SB 935 — HEALTH-TECH

SB0935 EngrossedEnrolled LRB095 05753 KBJ 25843 b AN ACT concerning health.

If a county, SB0935 EngrossedEnrolled - 2 - LRB095 05753 KBJ 25843 b including a home rule county, is a self-insurer for purposes of providing health insurance coverage for its employees, the coverage shall include coverage for the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356u, 356w, 356x , and 356z.6, and 356z.9 of the Illinois Insurance Code.

The SB0935 EngrossedEnrolled - 3 - LRB095 05753 KBJ 25843 b requirement that health benefits be covered as provided in this is an exclusive power and function of the State and is a denial and limitation under Article VII, Section 6, subsection (h) of the Illinois Constitution.

(a) A group or individual policymajor ofmedical accident and health insurance policy 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 forand nonprescriptionreimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) milk protein allergies and intolerances, (ii) eosinophilic disorders, and (iii) impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility(ii) ofshort thebowel gastrointestinalsyndrome tract, when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessarynecessary. for the treatment of a SB0935 Engrossed - 4 - LRB095 05753 KBJ 25843 b disease or disorder and is the least restrictive and most cost-effective means for meeting the needs of the patient.

(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 specialized amino acid-based elemental formulas, regardless of delivery method, when the prescribing physician has issued a written order stating that such specialized amino acid-based elemental formula is medically necessary for the treatment of a disease or disorder and is the least restrictive and most cost-effective means for meeting the needs of the patient.

SB0935 Enrolled - 4 - LRB095 05753 KBJ 25843 b (215 ILCS 125/5-3) (from Ch.

(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, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 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 SB0935 Engrossed - 5 - LRB095 05753 KBJ 25843 b IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

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 SB0935 Enrolled - 5 - LRB095 05753 KBJ 25843 b 1/2 of the Illinois Insurance Code.

(2)(i) the criteria specified in subsection (1)(b) of Section 131.8 of the Illinois Insurance Code shall not SB0935 Engrossed - 6 - LRB095 05753 KBJ 25843 b 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;

(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 SB0935 Enrolled - 6 - LRB095 05753 KBJ 25843 b forma financial statements reflecting projected combined operation for a period of 2 years;

(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 SB0935 Engrossed - 7 - LRB095 05753 KBJ 25843 b enrollee population (including without limitation the health maintenance organization’s right, title, and interest in and to its health care certificates).

(f) Except for small employer groups as defined in the Small Employer Rating, Renewability and Portability Health SB0935 Enrolled - 7 - LRB095 05753 KBJ 25843 b 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:

and SB0935 Engrossed - 8 - LRB095 05753 KBJ 25843 b (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)).

SB0935 Enrolled - 8 - LRB095 05753 KBJ 25843 b 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 SB0935 Engrossed - 9 - LRB095 05753 KBJ 25843 b enrollment unit.

Limited SB0935 Enrolled - 9 - LRB095 05753 KBJ 25843 b health service 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, 155.37, 355.2, 356v, 356z.9, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

or SB0935 Engrossed - 10 - LRB095 05753 KBJ 25843 b (2) a corporation organized under the laws of another state, 30% of 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.

Health services plan corporations and all persons interested therein SB0935 Enrolled - 10 - LRB095 05753 KBJ 25843 b 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, 356r, 356t, 356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 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.

12-29-06.) SB0935 Engrossed - 11 - LRB095 05753 KBJ 25843 b Section 40.

(7) home health care SB0935 Enrolled - 11 - LRB095 05753 KBJ 25843 b services;

(15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual SB0935 Engrossed - 12 - LRB095 05753 KBJ 25843 b Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault;

The Illinois Department, by rule, shall prohibit any physician from providing medical assistance to anyone eligible therefor under SB0935 Enrolled - 12 - LRB095 05753 KBJ 25843 b this Code where such physician has been found guilty of performing an abortion procedure in a wilful and wanton manner upon a woman who was not pregnant at the time such abortion procedure was performed.

Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug administration shall be covered SB0935 Engrossed - 13 - LRB095 05753 KBJ 25843 b under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article.

The Illinois Department of Healthcare and Family Services Public Aid shall provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to SB0935 Enrolled - 13 - LRB095 05753 KBJ 25843 b the Department of Public Aid:

The Department of Healthcare and Family Services must provide coverage forand nonprescriptionreimbursement for amino acid-based SB0935 Engrossed - 14 - LRB095 05753 KBJ 25843 b elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) milk protein allergies and intolerances, (ii) eosinophilic disorders, and (iii) impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility(ii) ofshort thebowel gastrointestinalsyndrome tract, when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessarynecessary. for the treatment of a disease or disorder and is the least restrictive and most cost-effective means for meeting the needs of the patient.

The Department of Healthcare and Family Services must provide coverage for specialized amino acid-based elemental formulas, regardless of delivery method, when the prescribing physician has issued a written order stating that such specialized amino acid-based elemental formula is medically necessary for the treatment of a disease or disorder and is the least restrictive and most cost-effective means for meeting the needs of the patient.

All screenings shall include a physical breast exam, instruction on self-examination and SB0935 Engrossed - 15 - LRB095 05753 KBJ 25843 b information regarding the frequency of self-examination and its value as a preventative tool.

As used in this Section, SB0935 Enrolled - 14 - LRB095 05753 KBJ 25843 b "low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, image receptor, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with 2 views for each breast.

All medical providers providing medical assistance to pregnant women under this Code shall receive information from the Department on the availability of services under the Drug Free Families with a Future or any comparable program providing case management services for addicted women, including information on appropriate referrals for other social services SB0935 Engrossed - 16 - LRB095 05753 KBJ 25843 b that may be needed by addicted women in addition to treatment for addiction.

SB0935 Enrolled - 15 - LRB095 05753 KBJ 25843 b The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance.

SB0935 Engrossed - 17 - LRB095 05753 KBJ 25843 b Implementation of this Section may be by demonstration projects in certain geographic areas.

The Partnership shall be SB0935 Enrolled - 16 - LRB095 05753 KBJ 25843 b represented by a sponsor organization.

(3) Persons receiving medical services through Partnerships may receive medical and case management SB0935 Engrossed - 18 - LRB095 05753 KBJ 25843 b services above the level usually offered through the medical assistance program.

SB0935 Enrolled - 17 - LRB095 05753 KBJ 25843 b Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services.

The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under SB0935 Engrossed - 19 - LRB095 05753 KBJ 25843 b this Article.

The Illinois Department shall require health care providers to make available, when authorized by the patient, in SB0935 Enrolled - 18 - LRB095 05753 KBJ 25843 b writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article.

Within 90 days after the effective date of this amendatory Act of 1984, the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices SB0935 Engrossed - 20 - LRB095 05753 KBJ 25843 b and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such SB0935 Enrolled - 19 - LRB095 05753 KBJ 25843 b list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12.

The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which SB0935 Engrossed - 21 - LRB095 05753 KBJ 25843 b inquiries could indicate potential existence of claims or liens for the Illinois Department.

SB0935 Enrolled - 20 - LRB095 05753 KBJ 25843 b Enrollment of a vendor that provides non-emergency medical transportation, defined by the Department by rule, shall be conditional for 180 days.

The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the SB0935 Engrossed - 22 - LRB095 05753 KBJ 25843 b Department of Human Services and the Department on Aging, to effect the following:

(i) intake procedures and common SB0935 Enrolled - 21 - LRB095 05753 KBJ 25843 b eligibility criteria for those persons who are receiving non-institutional services;