Illinois General Assembly Public Act 096-0833

HB2652 Enrolled LRB096 10389 RPM 20559 b

AN ACT concerning insurance.

Be it enacted by the People of the State of Illinois,

represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by

renumbering Section 356z.14 as added by Public Act 95-1005, by

changing and renumbering Section 356z.15 as added by Public Act

96-639, and by adding Section 356z.18 as follows:

(215 ILCS 5/356z.15)

Sec. 356z.15 356z.14. Habilitative services for children.

(a) As used in this Section, "habilitative services" means

occupational therapy, physical therapy, speech therapy, and

other services prescribed by the insured's treating physician

pursuant to a treatment plan to enhance the ability of a child

to function with a congenital, genetic, or early acquired

disorder. A congenital or genetic disorder includes, but is not

limited to, hereditary disorders. An early acquired disorder

refers to a disorder resulting from illness, trauma, injury, or

some other event or condition suffered by a child prior to that

child developing functional life skills such as, but not

limited to, walking, talking, or self-help skills. Congenital,

genetic, and early acquired disorders may include, but are not

limited to, autism or an autism spectrum disorder, cerebral

palsy, and other disorders resulting from early childhood

illness, trauma, or injury.

(b) A group or individual policy of accident and health

insurance or managed care plan amended, delivered, issued, or

renewed after the effective date of this amendatory Act of the

95th General Assembly must provide coverage for habilitative

services for children under 19 years of age with a congenital,

genetic, or early acquired disorder so long as all of the

following conditions are met:

(1) A physician licensed to practice medicine in all

its branches has diagnosed the child's congenital,

genetic, or early acquired disorder.

(2) The treatment is administered by a licensed

speech-language pathologist, licensed audiologist,

licensed occupational therapist, licensed physical

therapist, licensed physician, licensed nurse, licensed

optometrist, licensed nutritionist, licensed social

worker, or licensed psychologist upon the referral of a

physician licensed to practice medicine in all its

branches.

(3) The initial or continued treatment must be

medically necessary and therapeutic and not experimental

or investigational.

to other general exclusions and limitations of the policy,

including coordination of benefits, participating provider

requirements, restrictions on services provided by family or

household members, utilization review of health care services,

including review of medical necessity, case management,

experimental, and investigational treatments, and other

managed care provisions.

(d) Coverage under this Section does not apply to those

services that are solely educational in nature or otherwise

paid under State or federal law for purely educational

services. Nothing in this subsection (d) relieves an insurer or

similar third party from an otherwise valid obligation to

provide or to pay for services provided to a child with a

disability.

(e) Coverage under this Section for children under age 19

shall not apply to treatment of mental or emotional disorders

or illnesses as covered under Section 370 of this Code as well

as any other benefit based upon a specific diagnosis that may

be otherwise required by law.

(f) The provisions of this Section do not apply to

short-term travel, accident-only, limited, or specific disease

policies.

(g) Any denial of care for habilitative services shall be

subject to appeal and external independent review procedures as

provided by Section 45 of the Managed Care Reform and Patient

Rights Act.

(h) Upon request of the reimbursing insurer, the provider

under whose supervision the habilitative services are being

provided shall furnish medical records, clinical notes, or

other necessary data to allow the insurer to substantiate that

initial or continued medical treatment is medically necessary

and that the patient's condition is clinically improving. When

the treating provider anticipates that continued treatment is

or will be required to permit the patient to achieve

demonstrable progress, the insurer may request that the

provider furnish a treatment plan consisting of diagnosis,

proposed treatment by type, frequency, anticipated duration of

treatment, the anticipated goals of treatment, and how

frequently the treatment plan will be updated.

(i) Rulemaking authority to implement this amendatory Act

of the 95th General Assembly, if any, is conditioned on the

rules being adopted in accordance with all provisions of the

Illinois Administrative Procedure Act and all rules and

procedures of the Joint Committee on Administrative Rules; any

purported rule not so adopted, for whatever reason, is

unauthorized.

(Source: P.A. 95-1049, eff. 1-1-10; revised 10-23-09.)

(215 ILCS 5/356z.17)

Sec. 356z.17 356z.15. Wellness coverage.

(a) A group or individual policy of accident and health

insurance or managed care plan amended, delivered, issued, or

renewed after January 1, 2010 (the effective date of Public Act

96-639) this amendatory Act of the 96th General Assembly that

provides coverage for hospital or medical treatment on an

expense incurred basis may offer a reasonably designed program

for wellness coverage that allows for a reward, a contribution,

a reduction in premiums or reduced medical, prescription drug,

or equipment copayments, coinsurance, or deductibles, or a

combination of these incentives, for participation in any

health behavior wellness, maintenance, or improvement program

approved or offered by the insurer or managed care plan. The

insured or enrollee may be required to provide evidence of

participation in a program. Individuals unable to participate

in these incentives due to an adverse health factor shall not

be penalized based upon an adverse health status.

(b) For purposes of this Section, "wellness coverage" means

health care coverage with the primary purpose to engage and

motivate the insured or enrollee through: incentives;

provision of health education, counseling, and self-management

skills; identification of modifiable health risks; and other

activities to influence health behavior changes.

For the purposes of this Section, "reasonably designed

program" means a program of wellness coverage that has a

reasonable chance of improving health or preventing disease; is

not overly burdensome; does not discriminate based upon factors

of health; and is not otherwise contrary to law.

unique to the offering of wellness coverage and have no

application to any other required or optional health care

benefit.

(d) Such wellness coverage must satisfy the requirements

for an exception from the general prohibition against

discrimination based on a health factor under the federal

Health Insurance Portability and Accountability Act of 1996

(P.L. 104-191; 110 Stat. 1936), including any federal

regulations that are adopted pursuant to that Act.

(e) A plan offering wellness coverage must do the

following:

(i) give participants the opportunity to qualify for

offered incentives at least once a year;

(ii) allow a reasonable alternative to any individual

for whom it is unreasonably difficult, due to a medical

condition, to satisfy otherwise applicable wellness

program standards. Plans may seek physician verification

that health factors make it unreasonably difficult or

medically inadvisable for the participant to satisfy the

standards; and

(iii) not provide a total incentive that exceeds 20% of

the cost of employee-only coverage. The cost of

employee-only coverage includes both employer and employee

contributions. For plans offering family coverage, the 20%

limitation applies to cost of family coverage and applies

to the entire family.

(f) A reward, contribution, or reduction established under

this Section and included in the policy or certificate does not

violate Section 151 of this Code.

(Source: P.A. 96-639, eff. 1-1-10; revised 10-21-09.)

(215 ILCS 5/356z.18 new)

Sec. 356z.18. Prosthetic and customized orthotic devices.

(a) For the purposes of this Section:

"Customized orthotic device" means a supportive device for

the body or a part of the body, the head, neck, or extremities,

and includes the replacement or repair of the device based on

the patient's physical condition as medically necessary,

excluding foot orthotics defined as an in-shoe device designed

to support the structural components of the foot during

weight-bearing activities.

"Licensed provider" means a prosthetist, orthotist, or

pedorthist licensed to practice in this State.

"Prosthetic device" means an artificial device to replace,

in whole or in part, an arm or leg and includes accessories

essential to the effective use of the device and the

replacement or repair of the device based on the patient's

physical condition as medically necessary.

(b) This amendatory Act of the 96th General Assembly shall

provide benefits to any person covered thereunder for expenses

incurred in obtaining a prosthetic or custom orthotic device

from any Illinois licensed prosthetist, licensed orthotist, or

licensed pedorthist as required under the Orthotics,

Prosthetics, and Pedorthics Practice Act.

or health insurance or managed care plan or medical, health, or

hospital service corporation contract that provides coverage

for prosthetic or custom orthotic care and is amended,

delivered, issued, or renewed 6 months after the effective date

of this amendatory Act of the 96th General Assembly must

provide coverage for prosthetic and orthotic devices in

accordance with this subsection (c). The coverage required

under this Section shall be subject to the other general

exclusions, limitations, and financial requirements of the

policy, including coordination of benefits, participating

provider requirements, utilization review of health care

services, including review of medical necessity, case

management, and experimental and investigational treatments,

and other managed care provisions under terms and conditions

that are no less favorable than the terms and conditions that

apply to substantially all medical and surgical benefits

provided under the plan or coverage.

(d) The policy or plan or contract may require prior

authorization for the prosthetic or orthotic devices in the

same manner that prior authorization is required for any other

covered benefit.

(e) Repairs and replacements of prosthetic and orthotic

devices are also covered, subject to the co-payments and

deductibles, unless necessitated by misuse or loss.

(f) A policy or plan or contract may require that, if

coverage is provided through a managed care plan, the benefits

mandated pursuant to this Section shall be covered benefits

only if the prosthetic or orthotic devices are provided by a

licensed provider employed by a provider service who contracts

with or is designated by the carrier, to the extent that the

carrier provides in-network and out-of-network service, the

coverage for the prosthetic or orthotic device shall be offered

no less extensively.

(g) The policy or plan or contract shall also meet adequacy

requirements as established by the Health Care Reimbursement

Reform Act of 1985 of the Illinois Insurance Code.

(h) This Section shall not apply to accident only,

specified disease, short-term hospital or medical, hospital

confinement indemnity, credit, dental, vision, Medicare

supplement, long-term care, basic hospital and

medical-surgical expense coverage, disability income insurance

coverage, coverage issued as a supplement to liability

insurance, workers' compensation insurance, or automobile

medical payment insurance.

Section 10. The Health Maintenance Organization Act is

amended by changing Section 5-3 as follows:

(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)

Sec. 5-3. Insurance Code provisions.

(a) Health Maintenance Organizations shall be subject to

the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,

141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,

154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,

356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,

356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14,

356z.17 356z.15, 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a,

368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408,

408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection

(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,

XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

(b) For purposes of the Illinois Insurance Code, except for

Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health

Maintenance Organizations in the following categories are

deemed to be "domestic companies":

(1) a corporation authorized under the Dental Service

Plan Act or the Voluntary Health Services Plans Act;

(2) a corporation organized under the laws of this

State; or

(3) a corporation organized under the laws of another

state, 30% or more of the enrollees of which are residents

of this State, except a corporation subject to

substantially the same requirements in its state of

organization as is a "domestic company" under Article VIII

1/2 of the Illinois Insurance Code.

acquisition of control of a Health Maintenance Organization

pursuant to Article VIII 1/2 of the Illinois Insurance Code,

(1) the Director shall give primary consideration to

the continuation of benefits to enrollees and the financial

conditions of the acquired Health Maintenance Organization

after the merger, consolidation, or other acquisition of

control takes effect;

(2)(i) the criteria specified in subsection (1)(b) of

Section 131.8 of the Illinois Insurance Code shall not

apply and (ii) the Director, in making his determination

with respect to the merger, consolidation, or other

acquisition of control, need not take into account the

effect on competition of the merger, consolidation, or

other acquisition of control;

(3) the Director shall have the power to require the

following information:

(A) certification by an independent actuary of the

adequacy of the reserves of the Health Maintenance

Organization sought to be acquired;

(B) pro forma financial statements reflecting the

combined balance sheets of the acquiring company and

the Health Maintenance Organization sought to be

acquired as of the end of the preceding year and as of

a date 90 days prior to the acquisition, as well as pro

forma financial statements reflecting projected

combined operation for a period of 2 years;

acquiring party's plans with respect to the operation

of the Health Maintenance Organization sought to be

acquired for a period of not less than 3 years; and

(D) such other information as the Director shall

require.

(d) The provisions of Article VIII 1/2 of the Illinois

Insurance Code and this Section 5-3 shall apply to the sale by

any health maintenance organization of greater than 10% of its

enrollee population (including without limitation the health

maintenance organization's right, title, and interest in and to

its health care certificates).

(e) In considering any management contract or service

agreement subject to Section 141.1 of the Illinois Insurance

Code, the Director (i) shall, in addition to the criteria

specified in Section 141.2 of the Illinois Insurance Code, take

into account the effect of the management contract or service

agreement on the continuation of benefits to enrollees and the

financial condition of the health maintenance organization to

be managed or serviced, and (ii) need not take into account the

effect of the management contract or service agreement on

competition.

(f) Except for small employer groups as defined in the

Small Employer Rating, Renewability and Portability Health

Insurance Act and except for medicare supplement policies as

defined in Section 363 of the Illinois Insurance Code, a Health

Maintenance Organization may by contract agree with a group or

other enrollment unit to effect refunds or charge additional

premiums under the following terms and conditions:

(i) the amount of, and other terms and conditions with

respect to, the refund or additional premium are set forth

in the group or enrollment unit contract agreed in advance

of the period for which a refund is to be paid or

additional premium is to be charged (which period shall not

be less than one year); and

(ii) the amount of the refund or additional premium

shall not exceed 20% of the Health Maintenance

Organization's profitable or unprofitable experience with

respect to the group or other enrollment unit for the

period (and, for purposes of a refund or additional

premium, the profitable or unprofitable experience shall

be calculated taking into account a pro rata share of the

Health Maintenance Organization's administrative and

marketing expenses, but shall not include any refund to be

made or additional premium to be paid pursuant to this

subsection (f)). The Health Maintenance Organization and

the group or enrollment unit may agree that the profitable

or unprofitable experience may be calculated taking into

account the refund period and the immediately preceding 2

plan years.

The Health Maintenance Organization shall include a

statement in the evidence of coverage issued to each enrollee

describing the possibility of a refund or additional premium,

and upon request of any group or enrollment unit, provide to

the group or enrollment unit a description of the method used

to calculate (1) the Health Maintenance Organization's

profitable experience with respect to the group or enrollment

unit and the resulting refund to the group or enrollment unit

or (2) the Health Maintenance Organization's unprofitable

experience with respect to the group or enrollment unit and the

resulting additional premium to be paid by the group or

enrollment unit.

In no event shall the Illinois Health Maintenance

Organization Guaranty Association be liable to pay any

contractual obligation of an insolvent organization to pay any

refund authorized under this Section.

(g) Rulemaking authority to implement Public Act 95-1045

this amendatory Act of the 95th General Assembly, if any, is

conditioned on the rules being adopted in accordance with all

provisions of the Illinois Administrative Procedure Act and all

rules and procedures of the Joint Committee on Administrative

Rules; any purported rule not so adopted, for whatever reason,

is unauthorized.

(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;

95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;

95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.

1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised

10-23-09.)

Section 15. The Voluntary Health Services Plans Act is

amended by changing Section 10 as follows:

(215 ILCS 165/10) (from Ch. 32, par. 604)

Sec. 10. Application of Insurance Code provisions. Health

services plan corporations and all persons interested therein

or dealing therewith shall be subject to the provisions of

Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,

149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,

356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,

356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,

356z.14, 356z.15 356z.14, 356z.18, 364.01, 367.2, 368a, 401,

401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)

and (15) of Section 367 of the Illinois Insurance Code.

Rulemaking authority to implement Public Act 95-1045 this

amendatory Act of the 95th General Assembly, if any, is

conditioned on the rules being adopted in accordance with all

provisions of the Illinois Administrative Procedure Act and all

rules and procedures of the Joint Committee on Administrative

Rules; any purported rule not so adopted, for whatever reason,

is unauthorized.

(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;

95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.

8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,

eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;

96-328, eff. 8-11-09; revised 9-25-09.)

Section 95. No acceleration or delay. Where this Act makes

changes in a statute that is represented in this Act by text

that is not yet or no longer in effect (for example, a Section

represented by multiple versions), the use of that text does

not accelerate or delay the taking effect of (i) the changes

made by this Act or (ii) provisions derived from any other

Public Act.

Effective Date: 6/1/2010

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