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Sen. Andy Manar
Adopted in Senate on Oct 29, 2019
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1 | | AMENDMENT TO SENATE BILL 667
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2 | | AMENDMENT NO. ______. Amend Senate Bill 667 by replacing |
3 | | everything after the enacting clause with the following:
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4 | | "Section 1. Findings. The General Assembly finds and |
5 | | declares that: |
6 | | (1) Diabetes affects approximately 1,300,000 adults in |
7 | | Illinois (12.5% of the population); |
8 | | (2) Diabetes is the seventh leading cause of death |
9 | | nationally and in Illinois; |
10 | | (3) The toll on the U.S. economy has increased by more |
11 | | than 40% since 2007, costing the country $245,000,000,000 |
12 | | in 2012; |
13 | | (4) When someone has diabetes, the body either does not |
14 | | make enough insulin or is unable to use its own insulin, |
15 | | causing glucose levels to rise higher than normal in the |
16 | | blood; |
17 | | (5) For people with Type 1 diabetes, near-constant |
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1 | | self-management of glucose levels is essential to prevent |
2 | | life-threatening complications; |
3 | | (6) From 2012 to 2016, the average price of insulin |
4 | | increased from 13 cents per unit to 25 cents per unit; |
5 | | therefore, |
6 | | It is necessary for the State to enact laws to reduce the |
7 | | costs for Illinoisans with diabetes and increase their access |
8 | | to life-saving and life-sustaining insulin. |
9 | | Section 5. The State Employees Group Insurance Act of 1971 |
10 | | is amended by changing Section 6.11 as follows:
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11 | | (5 ILCS 375/6.11)
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12 | | Sec. 6.11. Required health benefits; Illinois Insurance |
13 | | Code
requirements. The program of health
benefits shall provide |
14 | | the post-mastectomy care benefits required to be covered
by a |
15 | | policy of accident and health insurance under Section 356t of |
16 | | the Illinois
Insurance Code. The program of health benefits |
17 | | shall provide the coverage
required under Sections 356g, |
18 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
19 | | 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, |
20 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, |
21 | | 356z.29, 356z.30a, 356z.32, and 356z.33 , 356z.36, and 356z.41 |
22 | | of the
Illinois Insurance Code.
The program of health benefits |
23 | | must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, |
24 | | and 370c.1 , and Article XXXIIB of the
Illinois Insurance Code. |
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1 | | The Department of Insurance shall enforce the requirements of |
2 | | this Section with respect to Sections 370c and 370c.1 of the |
3 | | Illinois Insurance Code; all other requirements of this Section |
4 | | shall be enforced by the Department of Central Management |
5 | | Services.
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6 | | Rulemaking authority to implement Public Act 95-1045, if |
7 | | any, is conditioned on the rules being adopted in accordance |
8 | | with all provisions of the Illinois Administrative Procedure |
9 | | Act and all rules and procedures of the Joint Committee on |
10 | | Administrative Rules; any purported rule not so adopted, for |
11 | | whatever reason, is unauthorized. |
12 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
13 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
14 | | 1-1-19; 100-1102, eff. 1-1-19; 100-1170, eff. 6-1-19; 101-13, |
15 | | eff. 6-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; |
16 | | 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; revised 10-16-19.) |
17 | | Section 10. The Attorney General Act is amended by adding |
18 | | Section 10 as follows: |
19 | | (15 ILCS 205/10 new) |
20 | | Sec. 10. Investigation of prescription insulin drug |
21 | | pricing; report. |
22 | | (a) The Attorney General shall investigate pricing of |
23 | | prescription insulin drugs made available to Illinois |
24 | | consumers to ensure adequate consumer protections in the |
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1 | | pricing of prescription insulin drugs and to determine whether |
2 | | additional consumer protections are needed. |
3 | | (b) As part of the investigation, the Attorney General |
4 | | shall gather, compile, and analyze information concerning the |
5 | | organization, business practices, pricing information, data, |
6 | | reports, or other information that the Attorney General finds |
7 | | necessary to fulfill the requirements of this Section from |
8 | | companies engaged in the manufacture or sale of prescription |
9 | | insulin drugs. |
10 | | If necessary to fulfill the reporting requirements of this |
11 | | Section, the Attorney General may issue a civil investigative |
12 | | demand requiring a State Agency, insurer, pharmacy benefit |
13 | | manager, or manufacturer of prescription insulin drugs that are |
14 | | made available in Illinois to furnish material, answers, data, |
15 | | or other relevant information. |
16 | | (c) A person or business shall not be compelled to provide |
17 | | trade secrets. |
18 | | (d) By November 1, 2020, the Attorney General shall issue |
19 | | and make available to the public a report detailing the |
20 | | findings from the investigation conducted pursuant to this |
21 | | Section. The Attorney General shall present the report to the |
22 | | Governor, the Department of Insurance, and the Judiciary |
23 | | Committees of the Senate and House of Representatives or their |
24 | | successor Committees. The report must include the following: |
25 | | (1) a summary of insulin pricing practices and |
26 | | variables that contribute to pricing of health coverage |
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1 | | plans; |
2 | | (2) public policy recommendations to control and |
3 | | prevent overpricing of prescription insulin drugs made |
4 | | available to Illinois consumers; |
5 | | (3) any recommendations for improvements to the |
6 | | Consumer Fraud and Deceptive Business Practices Act; and |
7 | | (4) any other information the Attorney General finds |
8 | | necessary. |
9 | | (e) This Section is repealed on December 1, 2020. |
10 | | Section 15. The Counties Code is amended by changing |
11 | | Section 5-1069.3 as follows: |
12 | | (55 ILCS 5/5-1069.3)
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13 | | Sec. 5-1069.3. Required health benefits. If a county, |
14 | | including a home
rule
county, is a self-insurer for purposes of |
15 | | providing health insurance coverage
for its employees, the |
16 | | coverage shall include coverage for the post-mastectomy
care |
17 | | benefits required to be covered by a policy of accident and |
18 | | health
insurance under Section 356t and the coverage required |
19 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
20 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
21 | | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, |
22 | | 356z.30a, and 356z.32, and 356z.33 , 356z.36, and 356z.41 of
the |
23 | | Illinois Insurance Code. The coverage shall comply with |
24 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois |
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1 | | Insurance Code. The Department of Insurance shall enforce the |
2 | | requirements of this Section. The requirement that health |
3 | | benefits be covered
as provided in this Section is an
exclusive |
4 | | power and function of the State and is a denial and limitation |
5 | | under
Article VII, Section 6, subsection (h) of the Illinois |
6 | | Constitution. A home
rule county to which this Section applies |
7 | | must comply with every provision of
this Section.
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8 | | Rulemaking authority to implement Public Act 95-1045, if |
9 | | any, is conditioned on the rules being adopted in accordance |
10 | | with all provisions of the Illinois Administrative Procedure |
11 | | Act and all rules and procedures of the Joint Committee on |
12 | | Administrative Rules; any purported rule not so adopted, for |
13 | | whatever reason, is unauthorized. |
14 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
15 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
16 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
17 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; |
18 | | revised 10-16-19.) |
19 | | Section 20. The Illinois Municipal Code is amended by |
20 | | changing Section 10-4-2.3 as follows: |
21 | | (65 ILCS 5/10-4-2.3)
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22 | | Sec. 10-4-2.3. Required health benefits. If a |
23 | | municipality, including a
home rule municipality, is a |
24 | | self-insurer for purposes of providing health
insurance |
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1 | | coverage for its employees, the coverage shall include coverage |
2 | | for
the post-mastectomy care benefits required to be covered by |
3 | | a policy of
accident and health insurance under Section 356t |
4 | | and the coverage required
under Sections 356g, 356g.5, |
5 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
6 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, |
7 | | 356z.26, 356z.29, 356z.30a, and 356z.32, and 356z.33 , 356z.36, |
8 | | and 356z.41 of the Illinois
Insurance
Code. The coverage shall |
9 | | comply with Sections 155.22a, 355b, 356z.19, and 370c of
the |
10 | | Illinois Insurance Code. The Department of Insurance shall |
11 | | enforce the requirements of this Section. The requirement that |
12 | | health
benefits be covered as provided in this is an exclusive |
13 | | power and function of
the State and is a denial and limitation |
14 | | under Article VII, Section 6,
subsection (h) of the Illinois |
15 | | Constitution. A home rule municipality to which
this Section |
16 | | applies must comply with every provision of this Section.
|
17 | | Rulemaking authority to implement Public Act 95-1045, if |
18 | | any, is conditioned on the rules being adopted in accordance |
19 | | with all provisions of the Illinois Administrative Procedure |
20 | | Act and all rules and procedures of the Joint Committee on |
21 | | Administrative Rules; any purported rule not so adopted, for |
22 | | whatever reason, is unauthorized. |
23 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
24 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
25 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
26 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; |
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1 | | revised 10-16-19.) |
2 | | Section 25. The School Code is amended by changing Section |
3 | | 10-22.3f as follows: |
4 | | (105 ILCS 5/10-22.3f)
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5 | | Sec. 10-22.3f. Required health benefits. Insurance |
6 | | protection and
benefits
for employees shall provide the |
7 | | post-mastectomy care benefits required to be
covered by a |
8 | | policy of accident and health insurance under Section 356t and |
9 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
10 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
11 | | 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, |
12 | | 356z.30a, and 356z.32, and 356z.33 , 356z.36, and 356z.41 of
the
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13 | | Illinois Insurance Code.
Insurance policies shall comply with |
14 | | Section 356z.19 of the Illinois Insurance Code. The coverage |
15 | | shall comply with Sections 155.22a, 355b, and 370c of
the |
16 | | Illinois Insurance Code. The Department of Insurance shall |
17 | | enforce the requirements of this Section.
|
18 | | Rulemaking authority to implement Public Act 95-1045, if |
19 | | any, is conditioned on the rules being adopted in accordance |
20 | | with all provisions of the Illinois Administrative Procedure |
21 | | Act and all rules and procedures of the Joint Committee on |
22 | | Administrative Rules; any purported rule not so adopted, for |
23 | | whatever reason, is unauthorized. |
24 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
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1 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
2 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
3 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; |
4 | | revised 10-16-19.) |
5 | | Section 30. The Illinois Insurance Code is amended changing |
6 | | Section 356w and by adding Section 356z.41 as follows:
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7 | | (215 ILCS 5/356w)
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8 | | Sec. 356w. Diabetes self-management training and |
9 | | education.
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10 | | (a) A group policy of accident and health insurance that is |
11 | | amended,
delivered,
issued, or renewed after the
effective date |
12 | | of this amendatory Act of 1998 shall provide coverage for
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13 | | outpatient self-management
training and education, equipment, |
14 | | and supplies, as set forth in this Section,
for the treatment |
15 | | of type 1 diabetes, type 2 diabetes, and gestational diabetes
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16 | | mellitus.
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17 | | (b) As used in this Section:
|
18 | | "Diabetes self-management training"
means instruction in |
19 | | an outpatient setting
which enables a diabetic patient to |
20 | | understand the diabetic management process
and daily |
21 | | management of
diabetic therapy as a means of avoiding frequent |
22 | | hospitalization and
complications. Diabetes self-management |
23 | | training shall include
the content areas listed in the National |
24 | | Standards for Diabetes Self-Management
Education Programs as |
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1 | | published by the American Diabetes Association, including
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2 | | medical nutrition therapy and education programs, as defined by |
3 | | the contract of insurance, that allow the patient to maintain |
4 | | an A1c level within the range identified in nationally |
5 | | recognized standards of care.
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6 | | "Medical nutrition therapy" shall have the meaning
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7 | | ascribed to that term in the Dietitian Nutritionist
Practice |
8 | | Act.
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9 | | "Physician" means a
physician licensed to practice |
10 | | medicine in all of
its branches providing care to the |
11 | | individual.
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12 | | "Qualified provider" for an
individual that is enrolled in:
|
13 | | (1) a health maintenance organization that uses a
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14 | | primary
care physician to
control access to specialty care |
15 | | means (A) the individual's primary care
physician licensed |
16 | | to practice
medicine in all of its branches, (B) a |
17 | | physician licensed to practice
medicine in all of its |
18 | | branches to
whom the individual has been referred by the |
19 | | primary care physician, or (C) a
certified, registered, or
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20 | | licensed network health care professional with expertise |
21 | | in diabetes management
to whom the individual
has been |
22 | | referred by the primary care physician.
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23 | | (2) an insurance plan
means (A) a physician licensed to |
24 | | practice medicine in
all of its branches or (B) a
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25 | | certified, registered, or licensed health care |
26 | | professional with expertise in
diabetes management to whom |
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1 | | the individual has been referred by a physician.
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2 | | (c) Coverage under this Section for diabetes |
3 | | self-management training,
including medical nutrition
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4 | | education, shall be limited to the following:
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5 | | (1) Up to 3 medically necessary visits to a qualified |
6 | | provider upon
initial diagnosis of diabetes
by the |
7 | | patient's
physician or, if diagnosis of diabetes was made |
8 | | within one year prior to the
effective date of
this |
9 | | amendatory Act
of 1998 where the insured was a covered |
10 | | individual, up to 3 medically necessary
visits to a |
11 | | qualified provider within one
year after that
effective
|
12 | | date.
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13 | | (2) Up to 2 medically necessary visits to a qualified |
14 | | provider upon a
determination by a
patient's
physician that |
15 | | a significant change in the patient's symptoms or medical
|
16 | | condition has
occurred. A "significant change" in |
17 | | condition means symptomatic
hyperglycemia (greater than |
18 | | 250 mg/dl on repeated occasions), severe
hypoglycemia |
19 | | (requiring the assistance of another person), onset or |
20 | | progression
of diabetes, or a significant change in medical |
21 | | condition that would require a
significantly different |
22 | | treatment regimen.
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23 | | Payment by the insurer or health maintenance organization |
24 | | for the coverage
required for diabetes self-management |
25 | | training pursuant to the provisions of
this Section is only |
26 | | required to be made for services provided.
No coverage is |
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1 | | required for additional visits beyond those specified in items
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2 | | (1) and (2) of this subsection.
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3 | | Coverage under this subsection (c) for diabetes |
4 | | self-management training
shall
be subject to the same
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5 | | deductible, co-payment, and co-insurance provisions that apply |
6 | | to coverage
under
the policy for other
services provided by the |
7 | | same type of provider.
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8 | | (d) Coverage shall be provided for the following
equipment |
9 | | when medically necessary
and prescribed by a physician licensed |
10 | | to practice medicine in all
of its branches.
Coverage for the |
11 | | following items shall be subject to deductible, co-payment
and |
12 | | co-insurance provisions
provided for under the policy or a |
13 | | durable medical equipment rider to the
policy:
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14 | | (1) blood glucose monitors;
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15 | | (2) blood glucose monitors for the legally blind;
|
16 | | (3) cartridges for the legally blind; and
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17 | | (4) lancets and lancing devices.
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18 | | This subsection does not apply to a group policy of |
19 | | accident and health
insurance that does not provide a durable |
20 | | medical equipment benefit.
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21 | | (e) Coverage shall be provided for the following |
22 | | pharmaceuticals and
supplies when
medically necessary and |
23 | | prescribed by a physician licensed to
practice medicine in all |
24 | | of its
branches.
Coverage for the following items shall be |
25 | | subject to the same coverage,
deductible,
co-payment, and |
26 | | co-insurance
provisions under the policy or a drug rider to the |
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1 | | policy , except as otherwise provided for under Section 356z.41 :
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2 | | (1) insulin;
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3 | | (2) syringes and needles;
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4 | | (3) test strips for glucose monitors;
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5 | | (4) FDA approved oral agents used to control blood |
6 | | sugar; and
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7 | | (5) glucagon emergency kits.
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8 | | This subsection does not apply to a group policy of |
9 | | accident and health
insurance that does not provide a drug |
10 | | benefit.
|
11 | | (f) Coverage shall be provided for regular foot care exams |
12 | | by a
physician or by a
physician to whom a physician has |
13 | | referred the patient. Coverage
for regular foot care exams
|
14 | | shall be subject to the same deductible, co-payment, and |
15 | | co-insurance
provisions
that apply under the policy for
other |
16 | | services provided by the same type of provider.
|
17 | | (g) If authorized by a physician, diabetes self-management
|
18 | | training may be provided as a part of an office visit, group |
19 | | setting, or home
visit.
|
20 | | (h) This Section shall not apply to agreements, contracts, |
21 | | or policies that
provide coverage for a specified diagnosis or |
22 | | other limited benefit coverage.
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23 | | (Source: P.A. 97-281, eff. 1-1-12; 97-1141, eff. 12-28-12.)
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24 | | (215 ILCS 5/356z.41 new) |
25 | | Sec. 356z.41. Cost sharing in prescription insulin drugs; |
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1 | | limits; confidentiality of rebate information. |
2 | | (a) As used in this Section, "prescription insulin drug" |
3 | | means a prescription drug that contains insulin and is used to |
4 | | treat diabetes. |
5 | | (b) This Section applies to a group or individual policy of |
6 | | accident and health insurance amended, delivered, issued, or |
7 | | renewed on or after the effective date of this amendatory Act |
8 | | of the 101st General Assembly. |
9 | | (c) An insurer that provides coverage for prescription |
10 | | insulin drugs pursuant to the terms of a health coverage plan |
11 | | the insurer offers shall limit the total amount that an insured |
12 | | is required to pay for a covered prescription insulin drug at |
13 | | an amount not to exceed $100 per 30-day supply of insulin, |
14 | | regardless of the amount or type of insulin needed to fill the |
15 | | insured's prescription. |
16 | | (d) Nothing in this Section prevents an insurer from |
17 | | reducing an insured's cost sharing by an amount greater than |
18 | | the amount specified in subsection (c). |
19 | | (e) The Director may use any of the Director's enforcement |
20 | | powers to obtain an insurer's compliance with this Section. |
21 | | (f) The Department may adopt rules as necessary to |
22 | | implement and administer this Section and to align it with |
23 | | federal requirements.
|
24 | | Section 35. The Health Maintenance Organization Act is |
25 | | amended by changing Section 5-3 as follows:
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1 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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2 | | Sec. 5-3. Insurance Code provisions.
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3 | | (a) Health Maintenance Organizations
shall be subject to |
4 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
|
5 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
6 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, |
7 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, |
8 | | 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, |
9 | | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, |
10 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, |
11 | | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41, 364, |
12 | | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, |
13 | | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, |
14 | | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, |
15 | | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, |
16 | | XXVI, and XXXIIB of the Illinois Insurance Code.
|
17 | | (b) For purposes of the Illinois Insurance Code, except for |
18 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
19 | | Maintenance Organizations in
the following categories are |
20 | | deemed to be "domestic companies":
|
21 | | (1) a corporation authorized under the
Dental Service |
22 | | Plan Act or the Voluntary Health Services Plans Act;
|
23 | | (2) a corporation organized under the laws of this |
24 | | State; or
|
25 | | (3) a corporation organized under the laws of another |
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1 | | state, 30% or more
of the enrollees of which are residents |
2 | | of this State, except a
corporation subject to |
3 | | substantially the same requirements in its state of
|
4 | | organization as is a "domestic company" under Article VIII |
5 | | 1/2 of the
Illinois Insurance Code.
|
6 | | (c) In considering the merger, consolidation, or other |
7 | | acquisition of
control of a Health Maintenance Organization |
8 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
9 | | (1) the Director shall give primary consideration to |
10 | | the continuation of
benefits to enrollees and the financial |
11 | | conditions of the acquired Health
Maintenance Organization |
12 | | after the merger, consolidation, or other
acquisition of |
13 | | control takes effect;
|
14 | | (2)(i) the criteria specified in subsection (1)(b) of |
15 | | Section 131.8 of
the Illinois Insurance Code shall not |
16 | | apply and (ii) the Director, in making
his determination |
17 | | with respect to the merger, consolidation, or other
|
18 | | acquisition of control, need not take into account the |
19 | | effect on
competition of the merger, consolidation, or |
20 | | other acquisition of control;
|
21 | | (3) the Director shall have the power to require the |
22 | | following
information:
|
23 | | (A) certification by an independent actuary of the |
24 | | adequacy
of the reserves of the Health Maintenance |
25 | | Organization sought to be acquired;
|
26 | | (B) pro forma financial statements reflecting the |
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1 | | combined balance
sheets of the acquiring company and |
2 | | the Health Maintenance Organization sought
to be |
3 | | acquired as of the end of the preceding year and as of |
4 | | a date 90 days
prior to the acquisition, as well as pro |
5 | | forma financial statements
reflecting projected |
6 | | combined operation for a period of 2 years;
|
7 | | (C) a pro forma business plan detailing an |
8 | | acquiring party's plans with
respect to the operation |
9 | | of the Health Maintenance Organization sought to
be |
10 | | acquired for a period of not less than 3 years; and
|
11 | | (D) such other information as the Director shall |
12 | | require.
|
13 | | (d) The provisions of Article VIII 1/2 of the Illinois |
14 | | Insurance Code
and this Section 5-3 shall apply to the sale by |
15 | | any health maintenance
organization of greater than 10% of its
|
16 | | enrollee population (including without limitation the health |
17 | | maintenance
organization's right, title, and interest in and to |
18 | | its health care
certificates).
|
19 | | (e) In considering any management contract or service |
20 | | agreement subject
to Section 141.1 of the Illinois Insurance |
21 | | Code, the Director (i) shall, in
addition to the criteria |
22 | | specified in Section 141.2 of the Illinois
Insurance Code, take |
23 | | into account the effect of the management contract or
service |
24 | | agreement on the continuation of benefits to enrollees and the
|
25 | | financial condition of the health maintenance organization to |
26 | | be managed or
serviced, and (ii) need not take into account the |
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1 | | effect of the management
contract or service agreement on |
2 | | competition.
|
3 | | (f) Except for small employer groups as defined in the |
4 | | Small Employer
Rating, Renewability and Portability Health |
5 | | Insurance Act and except for
medicare supplement policies as |
6 | | defined in Section 363 of the Illinois
Insurance Code, a Health |
7 | | Maintenance Organization may by contract agree with a
group or |
8 | | other enrollment unit to effect refunds or charge additional |
9 | | premiums
under the following terms and conditions:
|
10 | | (i) the amount of, and other terms and conditions with |
11 | | respect to, the
refund or additional premium are set forth |
12 | | in the group or enrollment unit
contract agreed in advance |
13 | | of the period for which a refund is to be paid or
|
14 | | additional premium is to be charged (which period shall not |
15 | | be less than one
year); and
|
16 | | (ii) the amount of the refund or additional premium |
17 | | shall not exceed 20%
of the Health Maintenance |
18 | | Organization's profitable or unprofitable experience
with |
19 | | respect to the group or other enrollment unit for the |
20 | | period (and, for
purposes of a refund or additional |
21 | | premium, the profitable or unprofitable
experience shall |
22 | | be calculated taking into account a pro rata share of the
|
23 | | Health Maintenance Organization's administrative and |
24 | | marketing expenses, but
shall not include any refund to be |
25 | | made or additional premium to be paid
pursuant to this |
26 | | subsection (f)). The Health Maintenance Organization and |
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1 | | the
group or enrollment unit may agree that the profitable |
2 | | or unprofitable
experience may be calculated taking into |
3 | | account the refund period and the
immediately preceding 2 |
4 | | plan years.
|
5 | | The Health Maintenance Organization shall include a |
6 | | statement in the
evidence of coverage issued to each enrollee |
7 | | describing the possibility of a
refund or additional premium, |
8 | | and upon request of any group or enrollment unit,
provide to |
9 | | the group or enrollment unit a description of the method used |
10 | | to
calculate (1) the Health Maintenance Organization's |
11 | | profitable experience with
respect to the group or enrollment |
12 | | unit and the resulting refund to the group
or enrollment unit |
13 | | or (2) the Health Maintenance Organization's unprofitable
|
14 | | experience with respect to the group or enrollment unit and the |
15 | | resulting
additional premium to be paid by the group or |
16 | | enrollment unit.
|
17 | | In no event shall the Illinois Health Maintenance |
18 | | Organization
Guaranty Association be liable to pay any |
19 | | contractual obligation of an
insolvent organization to pay any |
20 | | refund authorized under this Section.
|
21 | | (g) Rulemaking authority to implement Public Act 95-1045, |
22 | | if any, is conditioned on the rules being adopted in accordance |
23 | | with all provisions of the Illinois Administrative Procedure |
24 | | Act and all rules and procedures of the Joint Committee on |
25 | | Administrative Rules; any purported rule not so adopted, for |
26 | | whatever reason, is unauthorized. |
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1 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
2 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. |
3 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, |
4 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; |
5 | | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. |
6 | | 1-1-20; revised 10-16-19.) |
7 | | Section 40. The Limited Health Service Organization Act is |
8 | | amended by changing Section 4003 as follows:
|
9 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
|
10 | | Sec. 4003. Illinois Insurance Code provisions. Limited |
11 | | health service
organizations shall be subject to the provisions |
12 | | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, |
13 | | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, |
14 | | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, |
15 | | 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, |
16 | | 356z.30a, 356z.32, 356z.33, 356z.41, 368a, 401, 401.1,
402,
|
17 | | 403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles |
18 | | IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of |
19 | | the Illinois Insurance Code. For purposes of the
Illinois |
20 | | Insurance Code, except for Sections 444 and 444.1 and Articles |
21 | | XIII
and XIII 1/2, limited health service organizations in the |
22 | | following categories
are deemed to be domestic companies:
|
23 | | (1) a corporation under the laws of this State; or
|
24 | | (2) a corporation organized under the laws of another |
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1 | | state, 30% or more
of the enrollees of which are residents |
2 | | of this State, except a corporation
subject to |
3 | | substantially the same requirements in its state of |
4 | | organization as
is a domestic company under Article VIII |
5 | | 1/2 of the Illinois Insurance Code.
|
6 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
7 | | 100-201, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. |
8 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
9 | | eff. 1-1-20; 101-393, eff. 1-1-20; revised 10-16-19.)
|
10 | | Section 45. The Voluntary Health Services Plans Act is |
11 | | amended by changing Section 10 as follows:
|
12 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
|
13 | | Sec. 10. Application of Insurance Code provisions. Health |
14 | | services
plan corporations and all persons interested therein |
15 | | or dealing therewith
shall be subject to the provisions of |
16 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, |
17 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, |
18 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, |
19 | | 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, |
20 | | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, |
21 | | 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, |
22 | | 356z.30, 356z.30a, 356z.32, 356z.33, 356z.41, 364.01, 367.2, |
23 | | 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and |
24 | | paragraphs (7) and (15) of Section 367 of the Illinois
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1 | | Insurance Code.
|
2 | | Rulemaking authority to implement Public Act 95-1045, if |
3 | | any, is conditioned on the rules being adopted in accordance |
4 | | with all provisions of the Illinois Administrative Procedure |
5 | | Act and all rules and procedures of the Joint Committee on |
6 | | Administrative Rules; any purported rule not so adopted, for |
7 | | whatever reason, is unauthorized. |
8 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
9 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. |
10 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, |
11 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; |
12 | | revised 10-16-19.) |
13 | | Section 99. Effective date. This Act takes effect January |
14 | | 1, 2021, except that Section 10 and this Section take effect |
15 | | upon becoming law.".
|