102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB4774

 

Introduced 1/27/2022, by Rep. Camille Y. Lilly

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.26a new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the Illinois Insurance Code. Provides that a health benefit plan amended, delivered, issued, or renewed on or after January 1, 2023 that provides prescription drug coverage or its contracted pharmacy benefit manager shall not engage in or require an enrollee to engage in specified prohibited acts. Provides that a clinician-administered drug supplied shall meet the supply chain security controls and chain of distribution set by the federal Drug Supply Chain Security Act. Provides that the Department of Insurance may adopt rules as necessary to implement the provisions. Defines terms. Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization, and the Voluntary Health Services Plans Act.


LRB102 24356 BMS 33590 b

STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT
MAY APPLY

 

 

A BILL FOR

 

HB4774LRB102 24356 BMS 33590 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall
9provide the post-mastectomy care benefits required to be
10covered by a policy of accident and health insurance under
11Section 356t of the Illinois Insurance Code. The program of
12health benefits shall provide the coverage required under
13Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
14356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
15356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
16356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
17356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
18and 356z.51 and 356z.43 of the Illinois Insurance Code. The
19program of health benefits must comply with Sections 155.22a,
20155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of
21the Illinois Insurance Code. The Department of Insurance shall
22enforce the requirements of this Section with respect to
23Sections 370c and 370c.1 of the Illinois Insurance Code; all

 

 

HB4774- 2 -LRB102 24356 BMS 33590 b

1other requirements of this Section shall be enforced by the
2Department of Central Management Services.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
10101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
111-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
12eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
13102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
1410-26-21.)
 
15    Section 10. The Counties Code is amended by changing
16Section 5-1069.3 as follows:
 
17    (55 ILCS 5/5-1069.3)
18    Sec. 5-1069.3. Required health benefits. If a county,
19including a home rule county, is a self-insurer for purposes
20of providing health insurance coverage for its employees, the
21coverage shall include coverage for the post-mastectomy care
22benefits required to be covered by a policy of accident and
23health insurance under Section 356t and the coverage required
24under Sections 356g, 356g.5, 356g.5-1, 356q, 356u, 356w, 356x,

 

 

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1356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
2356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.26a,
3356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40,
4356z.41, 356z.45, 356z.46, 356z.47, 356z.48, and 356z.51 and
5356z.43 of the Illinois Insurance Code. The coverage shall
6comply with Sections 155.22a, 355b, 356z.19, and 370c of the
7Illinois Insurance Code. The Department of Insurance shall
8enforce the requirements of this Section. The requirement that
9health benefits be covered as provided in this Section is an
10exclusive power and function of the State and is a denial and
11limitation under Article VII, Section 6, subsection (h) of the
12Illinois Constitution. A home rule county to which this
13Section applies must comply with every provision of this
14Section.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
22101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
231-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
24eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
25102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
2610-26-21.)
 

 

 

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1    Section 15. The Illinois Municipal Code is amended by
2changing Section 10-4-2.3 as follows:
 
3    (65 ILCS 5/10-4-2.3)
4    Sec. 10-4-2.3. Required health benefits. If a
5municipality, including a home rule municipality, is a
6self-insurer for purposes of providing health insurance
7coverage for its employees, the coverage shall include
8coverage for the post-mastectomy care benefits required to be
9covered by a policy of accident and health insurance under
10Section 356t and the coverage required under Sections 356g,
11356g.5, 356g.5-1, 356q, 356u, 356w, 356x, 356z.6, 356z.8,
12356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
13356z.22, 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a,
14356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46,
15356z.47, 356z.48, and 356z.51 and 356z.43 of the Illinois
16Insurance Code. The coverage shall comply with Sections
17155.22a, 355b, 356z.19, and 370c of the Illinois Insurance
18Code. The Department of Insurance shall enforce the
19requirements of this Section. The requirement that health
20benefits be covered as provided in this is an exclusive power
21and function of the State and is a denial and limitation under
22Article VII, Section 6, subsection (h) of the Illinois
23Constitution. A home rule municipality to which this Section
24applies must comply with every provision of this Section.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
8101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
91-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
10eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
11102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
1210-26-21.)
 
13    Section 20. The School Code is amended by changing Section
1410-22.3f as follows:
 
15    (105 ILCS 5/10-22.3f)
16    Sec. 10-22.3f. Required health benefits. Insurance
17protection and benefits for employees shall provide the
18post-mastectomy care benefits required to be covered by a
19policy of accident and health insurance under Section 356t and
20the coverage required under Sections 356g, 356g.5, 356g.5-1,
21356q, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11,
22356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
23356z.26a, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36,
24356z.40, 356z.41, 356z.45, 356z.46, 356z.47, and 356z.51 and

 

 

HB4774- 6 -LRB102 24356 BMS 33590 b

1356z.43 of the Illinois Insurance Code. Insurance policies
2shall comply with Section 356z.19 of the Illinois Insurance
3Code. The coverage shall comply with Sections 155.22a, 355b,
4and 370c of the Illinois Insurance Code. The Department of
5Insurance shall enforce the requirements of this Section.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
13101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
141-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
15eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22;
16102-665, eff. 10-8-21; revised 10-27-21.)
 
17    Section 25. The Illinois Insurance Code is amended by
18adding Section 356z.26a as follows:
 
19    (215 ILCS 5/356z.26a new)
20    Sec. 356z.26a. Clinician-administered drugs.
21    (a) As used in this Section:
22    "Clinician-administered drug" means a drug administered
23pursuant to a valid prescription, other than a vaccine, that
24cannot be reasonably self-administered by the patient or an

 

 

HB4774- 7 -LRB102 24356 BMS 33590 b

1individual assisting the patient with self-administration and
2is typically administered by a provider in an outpatient
3hospital, physician's office, ambulatory infusion site, or
4other clinical setting.
5    "Health benefit plan" means an individual or group policy
6of accident or health insurance, health care plan, or other
7hospital or medical policy, certificate, or contract.
8    "Health care plan" has the meaning given to that term in
9Section 1-2 of the Health Maintenance Organization Act.
10"Health care plan" does not include a managed care
11organization that provides, arranges, or reimburses for the
12delivery of health care services to individuals who are
13enrolled in medical assistance under the Illinois Public Aid
14Code or under the Children's Health Insurance Program Act.
15    "Pharmacy" has the meaning given to that term in Section 3
16of the Pharmacy Practice Act.
17    "Provider" has the meaning given to that term in Section
18370g.
19    "Site of service" means the physical location where a
20clinician-administered drug is administered, including, but
21not limited to, an outpatient hospital, physician's office,
22ambulatory infusion site, home-based site, or other setting.
23    (b) To ensure access to safe and effective drug therapies,
24a health benefit plan amended, delivered, issued, or renewed
25on or after January 1, 2023 that provides prescription drug
26coverage or its contracted pharmacy benefit manager shall not:

 

 

HB4774- 8 -LRB102 24356 BMS 33590 b

1        (1) require an enrollee to obtain a covered
2    clinician-administered drug from a pharmacy selected by
3    the health benefit plan or pharmacy benefit manager with
4    the intent to transport the drug to another site of
5    service for administration;
6        (2) require an enrollee to obtain a covered
7    clinician-administered drug from a pharmacy selected by
8    the health benefit plan or pharmacy benefit manager;
9        (3) notwithstanding any other provision of law, steer
10    or offer financial or other incentives to induce an
11    enrollee to obtain a clinician-administered drug from a
12    pharmacy identified by the health benefit plan or pharmacy
13    benefit manager;
14        (4) condition, deny, restrict, refuse to authorize, or
15    otherwise limit benefits and coverage to an enrollee for
16    medically necessary clinician-administered drugs and
17    related services obtained from the provider that
18    administers the drug or from a pharmacy that is not
19    selected by the health benefit plan or pharmacy benefit
20    manager;
21        (5) condition, deny, restrict, refuse to authorize, or
22    otherwise limit reimbursement to a provider for covered
23    medically necessary clinician-administered drugs and
24    related services obtained from the provider that
25    administers the drug or from a pharmacy that is not
26    selected by the health benefit plan or pharmacy benefit

 

 

HB4774- 9 -LRB102 24356 BMS 33590 b

1    manager;
2        (6) assess higher deductibles, copayments,
3    coinsurance, or other cost-sharing amounts for
4    clinician-administered drugs obtained from the provider
5    that administers the drug or from a pharmacy that is not
6    selected by the health benefit plan or pharmacy benefit
7    manager;
8        (7) require an enrollee to use a home infusion
9    pharmacy to receive clinician-administered drugs in their
10    home or to use a site of service identified by the health
11    benefit plan or pharmacy benefit manager; or
12        (8) include the site of service in prior approval or
13    medical necessity criteria for clinician-administered
14    drugs.
15    (c) A clinician-administered drug shall meet the supply
16chain security controls and chain of distribution set by the
17federal Drug Supply Chain Security Act.
18    (d) The Department may adopt rules as necessary to
19implement the provisions of this Section.
 
20    Section 30. The Health Maintenance Organization Act is
21amended by changing Section 5-3 as follows:
 
22    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
23    Sec. 5-3. Insurance Code provisions.
24    (a) Health Maintenance Organizations shall be subject to

 

 

HB4774- 10 -LRB102 24356 BMS 33590 b

1the provisions of Sections 133, 134, 136, 137, 139, 140,
2141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
3154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
4355.3, 355b, 356g.5-1, 356m, 356q, 356v, 356w, 356x, 356y,
5356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
6356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
7356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,
8356z.26a, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
9356z.35, 356z.36, 356z.40, 356z.41, 356z.43, 356z.46, 356z.47,
10356z.48, 356z.50, 356z.51, 364, 364.01, 367.2, 367.2-5, 367i,
11368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402,
12403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
13of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
14XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
15Illinois Insurance Code.
16    (b) For purposes of the Illinois Insurance Code, except
17for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
18Health Maintenance Organizations in the following categories
19are deemed to be "domestic companies":
20        (1) a corporation authorized under the Dental Service
21    Plan Act or the Voluntary Health Services Plans Act;
22        (2) a corporation organized under the laws of this
23    State; or
24        (3) a corporation organized under the laws of another
25    state, 30% or more of the enrollees of which are residents
26    of this State, except a corporation subject to

 

 

HB4774- 11 -LRB102 24356 BMS 33590 b

1    substantially the same requirements in its state of
2    organization as is a "domestic company" under Article VIII
3    1/2 of the Illinois Insurance Code.
4    (c) In considering the merger, consolidation, or other
5acquisition of control of a Health Maintenance Organization
6pursuant to Article VIII 1/2 of the Illinois Insurance Code,
7        (1) the Director shall give primary consideration to
8    the continuation of benefits to enrollees and the
9    financial conditions of the acquired Health Maintenance
10    Organization after the merger, consolidation, or other
11    acquisition of control takes effect;
12        (2)(i) the criteria specified in subsection (1)(b) of
13    Section 131.8 of the Illinois Insurance Code shall not
14    apply and (ii) the Director, in making his determination
15    with respect to the merger, consolidation, or other
16    acquisition of control, need not take into account the
17    effect on competition of the merger, consolidation, or
18    other acquisition of control;
19        (3) the Director shall have the power to require the
20    following information:
21            (A) certification by an independent actuary of the
22        adequacy of the reserves of the Health Maintenance
23        Organization sought to be acquired;
24            (B) pro forma financial statements reflecting the
25        combined balance sheets of the acquiring company and
26        the Health Maintenance Organization sought to be

 

 

HB4774- 12 -LRB102 24356 BMS 33590 b

1        acquired as of the end of the preceding year and as of
2        a date 90 days prior to the acquisition, as well as pro
3        forma financial statements reflecting projected
4        combined operation for a period of 2 years;
5            (C) a pro forma business plan detailing an
6        acquiring party's plans with respect to the operation
7        of the Health Maintenance Organization sought to be
8        acquired for a period of not less than 3 years; and
9            (D) such other information as the Director shall
10        require.
11    (d) The provisions of Article VIII 1/2 of the Illinois
12Insurance Code and this Section 5-3 shall apply to the sale by
13any health maintenance organization of greater than 10% of its
14enrollee population (including without limitation the health
15maintenance organization's right, title, and interest in and
16to its health care certificates).
17    (e) In considering any management contract or service
18agreement subject to Section 141.1 of the Illinois Insurance
19Code, the Director (i) shall, in addition to the criteria
20specified in Section 141.2 of the Illinois Insurance Code,
21take into account the effect of the management contract or
22service agreement on the continuation of benefits to enrollees
23and the financial condition of the health maintenance
24organization to be managed or serviced, and (ii) need not take
25into account the effect of the management contract or service
26agreement on competition.

 

 

HB4774- 13 -LRB102 24356 BMS 33590 b

1    (f) Except for small employer groups as defined in the
2Small Employer Rating, Renewability and Portability Health
3Insurance Act and except for medicare supplement policies as
4defined in Section 363 of the Illinois Insurance Code, a
5Health Maintenance Organization may by contract agree with a
6group or other enrollment unit to effect refunds or charge
7additional premiums under the following terms and conditions:
8        (i) the amount of, and other terms and conditions with
9    respect to, the refund or additional premium are set forth
10    in the group or enrollment unit contract agreed in advance
11    of the period for which a refund is to be paid or
12    additional premium is to be charged (which period shall
13    not be less than one year); and
14        (ii) the amount of the refund or additional premium
15    shall not exceed 20% of the Health Maintenance
16    Organization's profitable or unprofitable experience with
17    respect to the group or other enrollment unit for the
18    period (and, for purposes of a refund or additional
19    premium, the profitable or unprofitable experience shall
20    be calculated taking into account a pro rata share of the
21    Health Maintenance Organization's administrative and
22    marketing expenses, but shall not include any refund to be
23    made or additional premium to be paid pursuant to this
24    subsection (f)). The Health Maintenance Organization and
25    the group or enrollment unit may agree that the profitable
26    or unprofitable experience may be calculated taking into

 

 

HB4774- 14 -LRB102 24356 BMS 33590 b

1    account the refund period and the immediately preceding 2
2    plan years.
3    The Health Maintenance Organization shall include a
4statement in the evidence of coverage issued to each enrollee
5describing the possibility of a refund or additional premium,
6and upon request of any group or enrollment unit, provide to
7the group or enrollment unit a description of the method used
8to calculate (1) the Health Maintenance Organization's
9profitable experience with respect to the group or enrollment
10unit and the resulting refund to the group or enrollment unit
11or (2) the Health Maintenance Organization's unprofitable
12experience with respect to the group or enrollment unit and
13the resulting additional premium to be paid by the group or
14enrollment unit.
15    In no event shall the Illinois Health Maintenance
16Organization Guaranty Association be liable to pay any
17contractual obligation of an insolvent organization to pay any
18refund authorized under this Section.
19    (g) Rulemaking authority to implement Public Act 95-1045,
20if any, is conditioned on the rules being adopted in
21accordance with all provisions of the Illinois Administrative
22Procedure Act and all rules and procedures of the Joint
23Committee on Administrative Rules; any purported rule not so
24adopted, for whatever reason, is unauthorized.
25(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
26101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.

 

 

HB4774- 15 -LRB102 24356 BMS 33590 b

11-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
2eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
3102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
41-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
5eff. 10-8-21; revised 10-27-21.)
 
6    Section 35. The Voluntary Health Services Plans Act is
7amended by changing Section 10 as follows:
 
8    (215 ILCS 165/10)  (from Ch. 32, par. 604)
9    Sec. 10. Application of Insurance Code provisions. Health
10services plan corporations and all persons interested therein
11or dealing therewith shall be subject to the provisions of
12Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
13143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
14356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
15356x, 356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6,
16356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
17356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,
18356z.26a, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
19356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.43, 364.01,
20367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
21and paragraphs (7) and (15) of Section 367 of the Illinois
22Insurance Code.
23    Rulemaking authority to implement Public Act 95-1045, if
24any, is conditioned on the rules being adopted in accordance

 

 

HB4774- 16 -LRB102 24356 BMS 33590 b

1with all provisions of the Illinois Administrative Procedure
2Act and all rules and procedures of the Joint Committee on
3Administrative Rules; any purported rule not so adopted, for
4whatever reason, is unauthorized.
5(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
6101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
71-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
8eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
9revised 10-27-21.)