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1 | AN ACT concerning insurance coverage.
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2 | Be it enacted by the People of the State of Illinois, | ||||||||||||||||||||||||||||||||||||||||||||
3 | represented in the General Assembly:
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4 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||||||||||||||||||||||||||||||||||||||||
5 | is amended by
changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||||||||||||||||||||||||||||||||||||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||||||||||||||||||||||||||||||||||||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||||||||||||||||||||||||||||||||||||||||
10 | policy of accident and health insurance under Section 356t of | ||||||||||||||||||||||||||||||||||||||||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||||||||||||||||||||||||||||||||||||||||
12 | shall provide the coverage
required under Sections 356u, 356w, | ||||||||||||||||||||||||||||||||||||||||||||
13 | 356x, 356z.2, and 356z.4 , 356z.6,
356z.7, 356z.8, and 356z.9 of | ||||||||||||||||||||||||||||||||||||||||||||
14 | the Illinois Insurance Code.
The program of health benefits | ||||||||||||||||||||||||||||||||||||||||||||
15 | must comply with Section 155.37 of the
Illinois Insurance Code.
| ||||||||||||||||||||||||||||||||||||||||||||
16 | (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; | ||||||||||||||||||||||||||||||||||||||||||||
17 | 93-102, eff.
1-1-04.)
| ||||||||||||||||||||||||||||||||||||||||||||
18 | Section 10. The Counties Code is amended by changing | ||||||||||||||||||||||||||||||||||||||||||||
19 | Section 5-1069.3 as
follows:
| ||||||||||||||||||||||||||||||||||||||||||||
20 | (55 ILCS 5/5-1069.3)
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21 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||||||||||||||||||||||||||||||||||||||||
22 | including a home
rule
county, is a self-insurer for purposes of | ||||||||||||||||||||||||||||||||||||||||||||
23 | providing health insurance coverage
for its employees, the | ||||||||||||||||||||||||||||||||||||||||||||
24 | coverage shall include coverage for the post-mastectomy
care | ||||||||||||||||||||||||||||||||||||||||||||
25 | benefits required to be covered by a policy of accident and | ||||||||||||||||||||||||||||||||||||||||||||
26 | health
insurance under Section 356t and the coverage required | ||||||||||||||||||||||||||||||||||||||||||||
27 | under Sections 356u,
356w, and 356x , 356z.6, 356z.7,
356z.8, | ||||||||||||||||||||||||||||||||||||||||||||
28 | and 356z.9
of
the Illinois Insurance Code. The requirement that | ||||||||||||||||||||||||||||||||||||||||||||
29 | health benefits be covered
as provided in this Section is an
| ||||||||||||||||||||||||||||||||||||||||||||
30 | exclusive power and function of the State and is a denial and |
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| |||||||
1 | limitation under
Article VII, Section 6, subsection (h) of the | ||||||
2 | Illinois Constitution. A home
rule county to which this Section | ||||||
3 | applies must comply with every provision of
this Section.
| ||||||
4 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
| ||||||
5 | Section 15. The Illinois Municipal Code is amended by | ||||||
6 | changing Section
10-4-2.3 as follows:
| ||||||
7 | (65 ILCS 5/10-4-2.3)
| ||||||
8 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
9 | municipality, including a
home rule municipality, is a | ||||||
10 | self-insurer for purposes of providing health
insurance | ||||||
11 | coverage for its employees, the coverage shall include coverage | ||||||
12 | for
the post-mastectomy care benefits required to be covered by | ||||||
13 | a policy of
accident and health insurance under Section 356t | ||||||
14 | and the coverage required
under Sections 356u, 356w, and 356x , | ||||||
15 | 356z.6, 356z.7,
356z.8, and 356z.9
of the Illinois
Insurance
| ||||||
16 | Code. The requirement that health
benefits be covered as | ||||||
17 | provided in this is an exclusive power and function of
the | ||||||
18 | State and is a denial and limitation under Article VII, Section | ||||||
19 | 6,
subsection (h) of the Illinois Constitution. A home rule | ||||||
20 | municipality to which
this Section applies must comply with | ||||||
21 | every provision of this Section.
| ||||||
22 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
| ||||||
23 | Section 20. The School Code is amended by changing Section | ||||||
24 | 10-22.3f as
follows:
| ||||||
25 | (105 ILCS 5/10-22.3f)
| ||||||
26 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
27 | protection and
benefits
for employees shall provide the | ||||||
28 | post-mastectomy care benefits required to be
covered by a | ||||||
29 | policy of accident and health insurance under Section 356t and | ||||||
30 | the
coverage required under Sections 356u, 356w, and 356x , | ||||||
31 | 356z.6, 356z.7,
356z.8, and 356z.9
of
the
Illinois Insurance | ||||||
32 | Code.
|
| |||||||
| |||||||
1 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
| ||||||
2 | Section 25. The Illinois Insurance Code is amended by | ||||||
3 | adding Sections
356z.6, 356z.7, 356z.8, and 356z.9 as follows:
| ||||||
4 | (215 ILCS 5/356z.6 new)
| ||||||
5 | Sec. 356z.6. AIDS vaccine.
| ||||||
6 | (a) A group or individual policy of accident and health and | ||||||
7 | health
insurance or managed care plan amended, delivered, | ||||||
8 | issued, or renewed after
the effective date of this amendatory | ||||||
9 | Act of the 93rd General Assembly
must provide coverage for a | ||||||
10 | vaccine for acquired immune deficiency
syndrome (AIDS) that is | ||||||
11 | approved for marketing by the federal Food and
Drug | ||||||
12 | Administration and that is recommended by the United States | ||||||
13 | Public
Health Service.
| ||||||
14 | (b) This Section does not require a policy of accident and | ||||||
15 | health
insurance to provide coverage for any clinical trials | ||||||
16 | relating to an AIDS
vaccine or for any AIDS vaccine that has | ||||||
17 | been approved by the federal Food
and Drug Administration in | ||||||
18 | the form of an investigational new drug
application.
| ||||||
19 | (215 ILCS 5/356z.7 new)
| ||||||
20 | Sec. 356z.7. Prescription nutritional supplements. A group | ||||||
21 | or individual
policy of
accident and health insurance or | ||||||
22 | managed care plan amended, delivered, issued,
or renewed
after | ||||||
23 | the effective date of this amendatory Act of the 93rd General | ||||||
24 | Assembly
that provides
coverage for prescription drugs must | ||||||
25 | provide coverage for reimbursement for
medically
appropriate | ||||||
26 | prescription nutritional supplements when ordered by a | ||||||
27 | physician
licensed to
practice medicine in all its branches and | ||||||
28 | the insured suffers from a condition
that prevents
him or her | ||||||
29 | from taking sufficient oral nourishment to sustain life.
| ||||||
30 | (215 ILCS 5/356z.8 new)
| ||||||
31 | Sec. 356z.8. Pain medication coverage. A group or | ||||||
32 | individual policy
of accident and health insurance or managed |
| |||||||
| |||||||
1 | care plan amended, delivered,
issued, or renewed after the | ||||||
2 | effective date of this amendatory Act of the
93rd General | ||||||
3 | Assembly that provides coverage for prescription drugs must
| ||||||
4 | provide coverage for any pain medication prescribed or ordered | ||||||
5 | by the
insured's treating physician.
| ||||||
6 | (215 ILCS 5/356z.9 new)
| ||||||
7 | Sec. 356z.9. Intravenous feeding. A group or individual | ||||||
8 | policy of
accident and health insurance or managed care plan | ||||||
9 | amended, delivered, issued,
or renewed after the effective date | ||||||
10 | of this amendatory Act of the 93rd General
Assembly must | ||||||
11 | provide coverage for intravenous feeding. The benefits under
| ||||||
12 | this Section shall be at least as favorable as for other | ||||||
13 | coverages under the
policy and may be subject to the same | ||||||
14 | dollar amount limits, deductibles, and
co-insurance | ||||||
15 | requirements applicable generally to other coverages under the
| ||||||
16 | policy.
| ||||||
17 | Section 30. The Health Maintenance Organization Act is | ||||||
18 | amended by changing
Section 5-3 as follows:
| ||||||
19 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
20 | Sec. 5-3. Insurance Code provisions.
| ||||||
21 | (a) Health Maintenance Organizations
shall be subject to | ||||||
22 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
23 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
24 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
25 | 356y,
356z.2, 356z.4, 356z.6, 356z.7, 356z.8, 356z.9, 367.2, | ||||||
26 | 367.2-5,
367i, 368a, 368b, 368c, 368d, 368e,
401, 401.1, 402, | ||||||
27 | 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) | ||||||
28 | of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
| ||||||
29 | XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | ||||||
30 | Insurance Code.
| ||||||
31 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
32 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
33 | Maintenance Organizations in
the following categories are |
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| |||||||
1 | deemed to be "domestic companies":
| ||||||
2 | (1) a corporation authorized under the
Dental Service | ||||||
3 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
4 | (2) a corporation organized under the laws of this | ||||||
5 | State; or
| ||||||
6 | (3) a corporation organized under the laws of another | ||||||
7 | state, 30% or more
of the enrollees of which are residents | ||||||
8 | of this State, except a
corporation subject to | ||||||
9 | substantially the same requirements in its state of
| ||||||
10 | organization as is a "domestic company" under Article VIII | ||||||
11 | 1/2 of the
Illinois Insurance Code.
| ||||||
12 | (c) In considering the merger, consolidation, or other | ||||||
13 | acquisition of
control of a Health Maintenance Organization | ||||||
14 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
15 | (1) the Director shall give primary consideration to | ||||||
16 | the continuation of
benefits to enrollees and the financial | ||||||
17 | conditions of the acquired Health
Maintenance Organization | ||||||
18 | after the merger, consolidation, or other
acquisition of | ||||||
19 | control takes effect;
| ||||||
20 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
21 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
22 | apply and (ii) the Director, in making
his determination | ||||||
23 | with respect to the merger, consolidation, or other
| ||||||
24 | acquisition of control, need not take into account the | ||||||
25 | effect on
competition of the merger, consolidation, or | ||||||
26 | other acquisition of control;
| ||||||
27 | (3) the Director shall have the power to require the | ||||||
28 | following
information:
| ||||||
29 | (A) certification by an independent actuary of the | ||||||
30 | adequacy
of the reserves of the Health Maintenance | ||||||
31 | Organization sought to be acquired;
| ||||||
32 | (B) pro forma financial statements reflecting the | ||||||
33 | combined balance
sheets of the acquiring company and | ||||||
34 | the Health Maintenance Organization sought
to be | ||||||
35 | acquired as of the end of the preceding year and as of | ||||||
36 | a date 90 days
prior to the acquisition, as well as pro |
| |||||||
| |||||||
1 | forma financial statements
reflecting projected | ||||||
2 | combined operation for a period of 2 years;
| ||||||
3 | (C) a pro forma business plan detailing an | ||||||
4 | acquiring party's plans with
respect to the operation | ||||||
5 | of the Health Maintenance Organization sought to
be | ||||||
6 | acquired for a period of not less than 3 years; and
| ||||||
7 | (D) such other information as the Director shall | ||||||
8 | require.
| ||||||
9 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
10 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
11 | any health maintenance
organization of greater than 10% of its
| ||||||
12 | enrollee population (including without limitation the health | ||||||
13 | maintenance
organization's right, title, and interest in and to | ||||||
14 | its health care
certificates).
| ||||||
15 | (e) In considering any management contract or service | ||||||
16 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
17 | Code, the Director (i) shall, in
addition to the criteria | ||||||
18 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
19 | into account the effect of the management contract or
service | ||||||
20 | agreement on the continuation of benefits to enrollees and the
| ||||||
21 | financial condition of the health maintenance organization to | ||||||
22 | be managed or
serviced, and (ii) need not take into account the | ||||||
23 | effect of the management
contract or service agreement on | ||||||
24 | competition.
| ||||||
25 | (f) Except for small employer groups as defined in the | ||||||
26 | Small Employer
Rating, Renewability and Portability Health | ||||||
27 | Insurance Act and except for
medicare supplement policies as | ||||||
28 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
29 | Maintenance Organization may by contract agree with a
group or | ||||||
30 | other enrollment unit to effect refunds or charge additional | ||||||
31 | premiums
under the following terms and conditions:
| ||||||
32 | (i) the amount of, and other terms and conditions with | ||||||
33 | respect to, the
refund or additional premium are set forth | ||||||
34 | in the group or enrollment unit
contract agreed in advance | ||||||
35 | of the period for which a refund is to be paid or
| ||||||
36 | additional premium is to be charged (which period shall not |
| |||||||
| |||||||
1 | be less than one
year); and
| ||||||
2 | (ii) the amount of the refund or additional premium | ||||||
3 | shall not exceed 20%
of the Health Maintenance | ||||||
4 | Organization's profitable or unprofitable experience
with | ||||||
5 | respect to the group or other enrollment unit for the | ||||||
6 | period (and, for
purposes of a refund or additional | ||||||
7 | premium, the profitable or unprofitable
experience shall | ||||||
8 | be calculated taking into account a pro rata share of the
| ||||||
9 | Health Maintenance Organization's administrative and | ||||||
10 | marketing expenses, but
shall not include any refund to be | ||||||
11 | made or additional premium to be paid
pursuant to this | ||||||
12 | subsection (f)). The Health Maintenance Organization and | ||||||
13 | the
group or enrollment unit may agree that the profitable | ||||||
14 | or unprofitable
experience may be calculated taking into | ||||||
15 | account the refund period and the
immediately preceding 2 | ||||||
16 | plan years.
| ||||||
17 | The Health Maintenance Organization shall include a | ||||||
18 | statement in the
evidence of coverage issued to each enrollee | ||||||
19 | describing the possibility of a
refund or additional premium, | ||||||
20 | and upon request of any group or enrollment unit,
provide to | ||||||
21 | the group or enrollment unit a description of the method used | ||||||
22 | to
calculate (1) the Health Maintenance Organization's | ||||||
23 | profitable experience with
respect to the group or enrollment | ||||||
24 | unit and the resulting refund to the group
or enrollment unit | ||||||
25 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
26 | experience with respect to the group or enrollment unit and the | ||||||
27 | resulting
additional premium to be paid by the group or | ||||||
28 | enrollment unit.
| ||||||
29 | In no event shall the Illinois Health Maintenance | ||||||
30 | Organization
Guaranty Association be liable to pay any | ||||||
31 | contractual obligation of an
insolvent organization to pay any | ||||||
32 | refund authorized under this Section.
| ||||||
33 | (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, | ||||||
34 | eff. 1-1-04;
93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised | ||||||
35 | 9-25-03.)
|
| |||||||
| |||||||
1 | Section 35. The Voluntary Health Services Plans Act is | ||||||
2 | amended by changing
Section 10 as follows:
| ||||||
3 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
4 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
5 | services
plan corporations and all persons interested therein | ||||||
6 | or dealing therewith
shall be subject to the provisions of | ||||||
7 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
8 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
9 | 356y, 356z.1, 356z.2, 356z.4, 356z.6, 356z.7, 356z.8, 356z.9,
| ||||||
10 | 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, | ||||||
11 | and paragraphs (7) and (15) of Section 367 of the Illinois
| ||||||
12 | Insurance Code.
| ||||||
13 | (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
| ||||||
14 | 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; | ||||||
15 | 93-529, eff.
8-14-03; revised 9-25-03.)
| ||||||
16 | Section 90. The State Mandates Act is amended by adding | ||||||
17 | Section 8.28 as
follows:
| ||||||
18 | (30 ILCS 805/8.28 new)
| ||||||
19 | Sec. 8.28. Exempt mandate. Notwithstanding Sections 6 and | ||||||
20 | 8 of this
Act, no reimbursement by the State is required for | ||||||
21 | the implementation of
any mandate created by this amendatory | ||||||
22 | Act of the 93rd General Assembly.
|