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93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004 HB5091
Introduced 02/05/04, by Mary E. Flowers SYNOPSIS AS INTRODUCED: |
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215 ILCS 5/356z.6 new |
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215 ILCS 105/8 |
from Ch. 73, par. 1308 |
215 ILCS 125/5-3 |
from Ch. 111 1/2, par. 1411.2 |
215 ILCS 165/10 |
from Ch. 32, par. 604 |
320 ILCS 25/3.15 |
from Ch. 67 1/2, par. 403.15 |
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Amends the Illinois Insurance Code, the Comprehensive Health Insurance
Program
Act, the Health Maintenance Organization Act, the Voluntary Health Services
Plans Act, and the Senior Citizens and Disabled Persons Property Tax Relief and
Pharmaceutical Assistance Act to require coverage under those Acts for
immunosuppressive agents (anti-rejection medication).
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| FISCAL NOTE ACT MAY APPLY | |
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A BILL FOR
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HB5091 |
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LRB093 13635 SAS 40141 b |
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| AN ACT concerning pharmaceutical benefits.
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| Be it enacted by the People of the State of Illinois, |
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| represented in the General Assembly:
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| Section 5. The Illinois Insurance Code is amended by adding |
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| Section 356z.6
as follows:
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| (215 ILCS 5/356z.6 new)
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| Sec. 356z.6. Immunosuppressive agents. A group or |
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| individual policy of
accident and health insurance amended, |
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| delivered, issued, or renewed after the
effective date of this |
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| amendatory Act of the 93rd General Assembly that
provides |
11 |
| coverage for organ transplants must provide coverage for
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| immunosuppressive agents (anti-rejection medications). If the |
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| policy provides
coverage for prescription drugs through the use |
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| of a drug formulary, the
generic immunosuppressive agents must |
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| be included with the drug formulary. If
the immunosuppressive |
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| agent is non-generic it must be included in the drug
formulary |
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| as the least expensive co-payment level higher than the |
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| co-payment
required for generic drugs.
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| Section 10. The Comprehensive Health Insurance Plan Act is |
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| amended by
changing
Section 8 as follows:
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| (215 ILCS 105/8) (from Ch. 73, par. 1308)
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| Sec. 8. Minimum benefits.
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| a. Availability. The Plan shall offer in an
annually |
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| renewable policy major medical expense coverage to every |
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| eligible
person who is not eligible for Medicare. Major medical
|
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| expense coverage offered by the Plan shall pay an eligible |
27 |
| person's
covered expenses, subject to limit on the deductible |
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| and coinsurance
payments authorized under paragraph (4) of |
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| subsection d of this Section,
up to a lifetime benefit limit of |
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| $1,000,000 per covered
individual. The maximum
limit under this |
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HB5091 |
- 2 - |
LRB093 13635 SAS 40141 b |
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| subsection shall not be altered by the Board, and no
actuarial |
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| equivalent benefit may be substituted by the Board.
Any person |
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| who otherwise would qualify for coverage under the Plan, but
is |
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| excluded because he or she is eligible for Medicare, shall be |
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| eligible
for any separate Medicare supplement policy or |
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| policies which the Board may
offer.
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| b. Outline of benefits. Covered expenses shall be
limited |
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| to the usual and customary charge, including negotiated fees, |
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| in
the locality for the following services and articles when |
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| prescribed by a
physician and determined by the Plan to be |
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| medically necessary
for the following areas of services, |
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| subject to such separate deductibles,
co-payments, exclusions, |
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| and other limitations on benefits as the Board shall
establish |
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| and approve, and the other provisions of this Section:
|
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| (1) Hospital
services, except that
any services |
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| provided by a hospital that is
located more than 75 miles |
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| outside the State of Illinois shall be covered only
for a |
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| maximum of 45 days in any calendar year. With respect to |
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| covered
expenses incurred during any calendar year ending |
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| on or after December 31,
1999, inpatient hospitalization of |
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| an eligible person for the
treatment of mental illness at a |
22 |
| hospital located within the State of
Illinois
shall be |
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| subject to the same terms and conditions as for any other |
24 |
| illness.
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| (2) Professional services for the diagnosis or |
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| treatment of injuries,
illnesses or conditions, other than |
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| dental and mental
and
nervous disorders as
described in |
28 |
| paragraph (17), which are rendered by a physician, or by |
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| other
licensed professionals at the physician's
direction. |
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| This includes reconstruction of the breast on which a |
31 |
| mastectomy
was performed; surgery and reconstruction of |
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| the other breast to produce a
symmetrical appearance; and |
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| prostheses and treatment of physical complications
at all |
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| stages of the mastectomy, including lymphedemas.
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| (2.5) Professional services provided by a physician to |
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| children under
the age of 16 years for physical |
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HB5091 |
- 3 - |
LRB093 13635 SAS 40141 b |
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| examinations and age appropriate
immunizations ordered by |
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| a physician licensed to practice medicine in all its
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| branches.
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| (3) (Blank).
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| (4) Outpatient prescription drugs that by law require
a
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| prescription
written by a physician licensed to practice |
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| medicine in all its branches
subject to such separate |
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| deductible, copayment, and other limitations or
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| restrictions as the Board shall approve, including the use |
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| of a prescription
drug card or any other program, or both.
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| (5) Skilled nursing services of a licensed
skilled
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| nursing facility for not more than 120 days during a policy |
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| year.
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| (6) Services of a home health agency in accord with a |
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| home health care
plan, up to a maximum of 270 visits per |
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| year.
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| (7) Services of a licensed hospice for not more than |
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| 180
days during a policy year.
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| (8) Use of radium or other radioactive materials.
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| (9) Oxygen.
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| (10) Anesthetics.
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| (11) Orthoses and prostheses other than dental.
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| (12) Rental or purchase in accordance with Board |
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| policies or
procedures of durable medical equipment, other |
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| than eyeglasses or hearing
aids, for which there is no |
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| personal use in the absence of the condition
for which it |
27 |
| is prescribed.
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| (13) Diagnostic x-rays and laboratory tests.
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| (14) Oral surgery (i) for excision of partially or |
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| completely unerupted
impacted teeth when not performed in
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| connection with the routine extraction or repair of teeth; |
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| (ii) for excision
of tumors or cysts of the jaws, cheeks, |
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| lips, tongue, and roof and floor of the
mouth; (iii) |
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| required for correction of cleft lip and palate
and
other |
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| craniofacial and maxillofacial birth defects; or (iv) for |
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| treatment of injuries to natural teeth or a fractured jaw |
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HB5091 |
- 4 - |
LRB093 13635 SAS 40141 b |
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| due to an accident.
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| (15) Physical, speech, and functional occupational |
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| therapy as
medically necessary and provided by appropriate |
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| licensed professionals.
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| (16) Emergency and other medically necessary |
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| transportation provided
by a licensed ambulance service to |
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| the
nearest health care facility qualified to treat a |
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| covered
illness, injury, or condition, subject to the |
9 |
| provisions of the
Emergency Medical Systems (EMS) Act.
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| (17) Outpatient services for
diagnosis and
treatment |
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| of mental and nervous disorders provided that a
covered |
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| person shall be required to make a copayment not to exceed |
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| 50% and that
the Plan's payment shall not exceed such |
14 |
| amounts as are established by the
Board.
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| (18) Human organ or tissue transplants specified by the |
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| Board that
are performed at a hospital designated by the |
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| Board as a participating
transplant center for that |
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| specific organ or tissue transplant , including |
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| immunosuppressive agents as required under Section 356z.6 |
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| of the
Illinois Insurance Code .
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| (19) Naprapathic services, as appropriate, provided by |
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| a licensed
naprapathic practitioner.
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| c. Exclusions. Covered expenses of the Plan shall not
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| include the following:
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| (1) Any charge for treatment for cosmetic purposes |
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| other than for
reconstructive surgery when the service is |
27 |
| incidental to or follows
surgery resulting from injury, |
28 |
| sickness or other diseases of the involved
part or surgery |
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| for the repair or treatment of a congenital bodily defect
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| to restore normal bodily functions.
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| (2) Any charge for care that is primarily for rest,
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| custodial, educational, or domiciliary purposes.
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| (3) Any charge for services in a private room to the |
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| extent it is in
excess of the institution's charge for its |
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| most common semiprivate room,
unless a private room is |
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| prescribed as medically necessary by a physician.
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HB5091 |
- 5 - |
LRB093 13635 SAS 40141 b |
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| (4) That part of any charge for room and board or for |
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| services
rendered or articles prescribed by a physician, |
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| dentist, or other health
care personnel that exceeds the |
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| reasonable and customary charge in the
locality or for any |
5 |
| services or supplies not medically necessary for the
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| diagnosed injury or illness.
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| (5) Any charge for services or articles the provision |
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| of which is not
within the scope of licensure of the |
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| institution or individual
providing the services or |
10 |
| articles.
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| (6) Any expense incurred prior to the effective date of |
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| coverage by the
Plan for the person on whose behalf the |
13 |
| expense is incurred.
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| (7) Dental care, dental surgery, dental treatment, any |
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| other dental
procedure involving the teeth or |
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| periodontium, or any dental appliances,
including crowns, |
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| bridges, implants, or partial or complete dentures,
except
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| as specifically provided in paragraph
(14) of subsection b |
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| of this Section.
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| (8) Eyeglasses, contact lenses, hearing aids or their |
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| fitting.
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| (9) Illness or injury due to acts of war.
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| (10) Services of blood donors and any fee for failure |
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| to replace the
first 3 pints of blood
provided to a covered |
25 |
| person each policy year.
|
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| (11) Personal supplies or services provided by a |
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| hospital or nursing
home, or any other nonmedical or |
28 |
| nonprescribed supply or service.
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| (12) Routine maternity charges for a pregnancy, except |
30 |
| where added as
optional coverage with payment of an |
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| additional premium for pregnancy
resulting from conception |
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| occurring after the effective date of the
optional |
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| coverage.
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| (13) (Blank).
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| (14) Any expense or charge for services, drugs, or |
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| supplies that are:
(i) not provided in accord with |
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HB5091 |
- 6 - |
LRB093 13635 SAS 40141 b |
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| generally accepted standards of current
medical practice; |
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| (ii) for procedures, treatments, equipment, transplants,
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| or implants, any of which are investigational, |
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| experimental, or for
research purposes; (iii) |
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| investigative and not proven safe and effective;
or (iv) |
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| for, or resulting from, a gender
transformation operation.
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| (15) Any expense or charge for routine physical |
8 |
| examinations or tests
except as provided in item (2.5) of |
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| subsection b of this Section.
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| (16) Any expense for which a charge is not made in the |
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| absence of
insurance or for which there is no legal |
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| obligation on the part of the
patient to pay.
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| (17) Any expense incurred for benefits provided under |
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| the laws of the
United States and this State, including |
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| Medicare, Medicaid, and
other
medical assistance, maternal |
16 |
| and child health services and any other program
that is |
17 |
| administered or funded by the Department of Human Services, |
18 |
| Department
of Public Aid, or Department of Public Health, |
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| military service-connected
disability payments, medical
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20 |
| services provided for members of the armed forces and their |
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| dependents or
employees of the armed forces of the United |
22 |
| States, and medical services
financed on behalf of all |
23 |
| citizens by the United States.
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| (18) Any expense or charge for in vitro fertilization, |
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| artificial
insemination, or any other artificial means |
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| used to cause pregnancy.
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| (19) Any expense or charge for oral contraceptives used |
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| for birth
control or any other temporary birth control |
29 |
| measures.
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| (20) Any expense or charge for sterilization or |
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| sterilization reversals.
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| (21) Any expense or charge for weight loss programs, |
33 |
| exercise
equipment, or treatment of obesity, except when |
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| certified by a physician as
morbid obesity (at least 2 |
35 |
| times normal body weight).
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| (22) Any expense or charge for acupuncture treatment |
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HB5091 |
- 7 - |
LRB093 13635 SAS 40141 b |
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| unless used as an
anesthetic agent for a covered surgery.
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| (23) Any expense or charge for or related to organ or |
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| tissue
transplants other than those performed at a hospital |
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| with a Board approved
organ transplant program that has |
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| been designated by the Board as a
preferred or exclusive |
6 |
| provider organization for that specific organ or tissue
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| transplant.
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| (24) Any expense or charge for procedures, treatments, |
9 |
| equipment, or
services that are provided in special |
10 |
| settings for research purposes or in
a controlled |
11 |
| environment, are being studied for safety, efficiency, and
|
12 |
| effectiveness, and are awaiting endorsement by the |
13 |
| appropriate national
medical speciality college for |
14 |
| general use within the medical community.
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| d. Deductibles and coinsurance.
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| The Plan coverage defined in Section 6 shall provide for a |
17 |
| choice
of
deductibles per individual as authorized by the |
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| Board. If 2 individual members
of the same family
household, |
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| who are both covered persons under the Plan, satisfy the
same |
20 |
| applicable deductibles, no other member of that family who is
|
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| also a covered person under the Plan shall be
required to
meet |
22 |
| any deductibles for the balance of that calendar year. The
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| deductibles must be applied first to the authorized amount of |
24 |
| covered expenses
incurred by the
covered person. A mandatory |
25 |
| coinsurance requirement shall be imposed at
the rate authorized |
26 |
| by the Board in excess of the mandatory
deductible, the |
27 |
| coinsurance
in the aggregate not to exceed such amounts as are |
28 |
| authorized by the Board
per annum. At its discretion the Board |
29 |
| may, however, offer catastrophic
coverages or other policies |
30 |
| that provide for larger deductibles with or
without coinsurance |
31 |
| requirements. The deductibles and coinsurance
factors may be |
32 |
| adjusted annually according to the Medical Component of the
|
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| Consumer Price Index.
|
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| e. Scope of coverage.
|
35 |
| (1) In approving any of the benefit plans to be offered |
36 |
| by the Plan, the
Board shall establish such benefit levels, |
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HB5091 |
- 8 - |
LRB093 13635 SAS 40141 b |
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| deductibles, coinsurance factors,
exclusions, and |
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| limitations as it may deem appropriate and that it believes |
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| to
be generally reflective of and commensurate with health |
4 |
| insurance coverage that
is provided in the individual |
5 |
| market in this State.
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| (2) The benefit plans approved by the Board may also |
7 |
| provide for and
employ
various cost containment measures |
8 |
| and other requirements including, but not
limited to, |
9 |
| preadmission certification, prior approval, second |
10 |
| surgical
opinions, concurrent utilization review programs, |
11 |
| individual case management,
preferred provider |
12 |
| organizations, health maintenance organizations, and other
|
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| cost effective arrangements for paying for covered |
14 |
| expenses.
|
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| f. Preexisting conditions.
|
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| (1) Except for federally eligible individuals |
17 |
| qualifying for Plan
coverage under Section 15 of this Act
|
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| or eligible persons who qualify
for the waiver authorized |
19 |
| in paragraph (3) of this subsection,
plan coverage shall |
20 |
| exclude charges or expenses incurred
during the first 6 |
21 |
| months following the effective date of coverage as to
any |
22 |
| condition for which medical advice, care or treatment was |
23 |
| recommended or
received during the 6 month period
|
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| immediately preceding the effective date
of coverage.
|
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| (2) (Blank).
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| (3) Waiver: The preexisting condition exclusions as |
27 |
| set forth in
paragraph (1) of this subsection shall be |
28 |
| waived to the extent to which
the eligible person (a) has |
29 |
| satisfied similar exclusions under any prior
individual |
30 |
| health insurance policy that was involuntarily terminated
|
31 |
| because of the insolvency of the issuer of the policy and |
32 |
| (b) has applied
for Plan coverage within 90 days following |
33 |
| the involuntary
termination of that individual health |
34 |
| insurance coverage.
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| g. Other sources primary; nonduplication of benefits.
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| (1) The Plan shall be the last payor of benefits |
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HB5091 |
- 9 - |
LRB093 13635 SAS 40141 b |
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| whenever any other
benefit or source of third party payment |
2 |
| is available. Subject to the
provisions of subsection e of |
3 |
| Section 7, benefits
otherwise payable under Plan coverage |
4 |
| shall be reduced by
all amounts paid or payable by Medicare |
5 |
| or any other government program
or through any health |
6 |
| insurance coverage or group health plan,
whether by |
7 |
| insurance, reimbursement, or otherwise, or through
any |
8 |
| third party liability,
settlement, judgment, or award,
|
9 |
| regardless of the date of the settlement, judgment, or |
10 |
| award, whether the
settlement, judgment, or award is in the |
11 |
| form of a contract, agreement, or
trust on behalf of a |
12 |
| minor or otherwise and whether the settlement,
judgment, or |
13 |
| award is payable to the covered person, his or her |
14 |
| dependent,
estate, personal representative, or guardian in |
15 |
| a lump sum or over time,
and by all hospital or medical |
16 |
| expense benefits
paid or payable under any worker's |
17 |
| compensation coverage, automobile
medical payment, or |
18 |
| liability insurance, whether provided on the basis of
fault |
19 |
| or nonfault, and by any hospital or medical benefits paid |
20 |
| or payable
under or provided pursuant to any State or |
21 |
| federal law or program.
|
22 |
| (2) The Plan shall have a cause of action against any
|
23 |
| covered person or any other person or entity for
the |
24 |
| recovery of any amount paid to the extent
the amount was |
25 |
| for treatment, services, or supplies not covered in this
|
26 |
| Section or in excess of benefits as set forth in this |
27 |
| Section.
|
28 |
| (3) Whenever benefits are due from the Plan because of |
29 |
| sickness or
an injury to a covered person resulting from a |
30 |
| third party's wrongful act
or negligence and the covered |
31 |
| person has recovered or may recover damages
from a third |
32 |
| party or its insurer, the Plan shall have the right to |
33 |
| reduce
benefits or to refuse to pay benefits that otherwise |
34 |
| may be payable by the
amount of damages that the covered |
35 |
| person has recovered or may recover
regardless of the date |
36 |
| of the sickness or injury or the date of any
settlement, |
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HB5091 |
- 10 - |
LRB093 13635 SAS 40141 b |
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|
1 |
| judgment, or award resulting from that sickness or injury.
|
2 |
| During the pendency of any action or claim that is |
3 |
| brought by or on
behalf of a covered person against a third |
4 |
| party or its insurer, any
benefits that would otherwise be |
5 |
| payable except for the provisions of this
paragraph (3) |
6 |
| shall be paid if payment by or for the third party has not |
7 |
| yet
been made and the covered person or, if incapable, that |
8 |
| person's legal
representative agrees in writing to pay back |
9 |
| promptly the benefits paid as
a result of the sickness or |
10 |
| injury to the extent of any future payments
made by or for |
11 |
| the third party for the sickness or injury. This agreement
|
12 |
| is to apply whether or not liability for the payments is |
13 |
| established or
admitted by the third party or whether those |
14 |
| payments are itemized.
|
15 |
| Any amounts due the plan to repay benefits may be |
16 |
| deducted from other
benefits payable by the Plan after |
17 |
| payments by or for the third party are made.
|
18 |
| (4) Benefits due from the Plan may be reduced or |
19 |
| refused as an offset
against any amount otherwise |
20 |
| recoverable under this Section.
|
21 |
| h. Right of subrogation; recoveries.
|
22 |
| (1) Whenever the Plan has paid benefits because of |
23 |
| sickness or an
injury to any covered person resulting from |
24 |
| a third party's wrongful act or
negligence, or for which an |
25 |
| insurer is liable in accordance with the
provisions of any |
26 |
| policy of insurance, and the covered person has recovered
|
27 |
| or may recover damages from a third party that is liable |
28 |
| for the damages,
the Plan shall have the right to recover |
29 |
| the benefits it paid from any
amounts that the covered |
30 |
| person has received or may receive regardless of
the date |
31 |
| of the sickness or injury or the date of any settlement, |
32 |
| judgment,
or award resulting from that sickness
or injury. |
33 |
| The Plan shall be subrogated to any right of recovery the
|
34 |
| covered person may have under the terms of any private or |
35 |
| public health
care coverage or liability coverage, |
36 |
| including coverage under the Workers'
Compensation Act or |
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HB5091 |
- 11 - |
LRB093 13635 SAS 40141 b |
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|
1 |
| the Workers' Occupational Diseases Act, without the
|
2 |
| necessity of assignment of claim or other authorization to |
3 |
| secure the right
of recovery. To enforce its subrogation |
4 |
| right, the Plan may (i) intervene
or join in an action or |
5 |
| proceeding brought by the covered person or his
personal |
6 |
| representative, including his guardian, conservator, |
7 |
| estate,
dependents, or survivors,
against any third party |
8 |
| or the third party's insurer that may be liable or
(ii) |
9 |
| institute and prosecute legal proceedings against any |
10 |
| third party or
the third party's insurer that may be liable |
11 |
| for the sickness or injury in
an appropriate court either |
12 |
| in the name of the Plan or in the name of the
covered |
13 |
| person or his personal representative, including his |
14 |
| guardian,
conservator, estate, dependents, or survivors.
|
15 |
| (2) If any action or claim is brought by or on behalf |
16 |
| of a covered
person against a third party or the third |
17 |
| party's insurer, the covered
person or his personal |
18 |
| representative, including his guardian,
conservator, |
19 |
| estate, dependents, or survivors, shall notify the Plan by
|
20 |
| personal service or registered mail of the action or claim |
21 |
| and of the name
of the court in which the action or claim |
22 |
| is brought, filing proof thereof
in the action or claim. |
23 |
| The Plan may, at any time thereafter, join in the
action or |
24 |
| claim upon its motion so that all orders of court after |
25 |
| hearing
and judgment shall be made for its protection. No |
26 |
| release or settlement of
a claim for damages and no |
27 |
| satisfaction of judgment in the action shall be
valid |
28 |
| without the written consent of the Plan to the extent of |
29 |
| its interest
in the settlement or judgment and of the |
30 |
| covered person or his
personal representative.
|
31 |
| (3) In the event that the covered person or his |
32 |
| personal
representative fails to institute a proceeding |
33 |
| against any appropriate
third party before the fifth month |
34 |
| before the action would be barred, the
Plan may, in its own |
35 |
| name or in the name of the covered person or personal
|
36 |
| representative, commence a proceeding against any |
|
|
|
HB5091 |
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LRB093 13635 SAS 40141 b |
|
|
1 |
| appropriate third party
for the recovery of damages on |
2 |
| account of any sickness, injury, or death to
the covered |
3 |
| person. The covered person shall cooperate in doing what is
|
4 |
| reasonably necessary to assist the Plan in any recovery and |
5 |
| shall not take
any action that would prejudice the Plan's |
6 |
| right to recovery. The Plan
shall pay to the covered person |
7 |
| or his personal representative all sums
collected from any |
8 |
| third party by judgment or otherwise in excess of
amounts |
9 |
| paid in benefits under the Plan and amounts paid or to be |
10 |
| paid as
costs, attorneys fees, and reasonable expenses |
11 |
| incurred by the Plan in
making the collection or enforcing |
12 |
| the judgment.
|
13 |
| (4) In the event that a covered person or his personal |
14 |
| representative,
including his guardian, conservator, |
15 |
| estate, dependents, or survivors,
recovers damages from a |
16 |
| third party for sickness or injury caused to the
covered |
17 |
| person, the covered person or the personal representative |
18 |
| shall pay to the Plan
from the damages recovered the amount |
19 |
| of benefits paid or to be paid on
behalf of the covered |
20 |
| person.
|
21 |
| (5) When the action or claim is brought by the covered |
22 |
| person alone
and the covered person incurs a personal |
23 |
| liability to pay attorney's fees
and costs of litigation, |
24 |
| the Plan's claim for reimbursement of the benefits
provided |
25 |
| to the covered person shall be the full amount of benefits |
26 |
| paid to
or on behalf of the covered person under this Act |
27 |
| less a pro rata share
that represents the Plan's reasonable |
28 |
| share of attorney's fees paid by the
covered person and |
29 |
| that portion of the cost of litigation expenses
determined |
30 |
| by multiplying by the ratio of the full amount of the
|
31 |
| expenditures to the full amount of the judgement, award, or |
32 |
| settlement.
|
33 |
| (6) In the event of judgment or award in a suit or |
34 |
| claim against a
third party or insurer, the court shall |
35 |
| first order paid from any judgement
or award the reasonable |
36 |
| litigation expenses incurred in preparation and
|
|
|
|
HB5091 |
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LRB093 13635 SAS 40141 b |
|
|
1 |
| prosecution of the action or claim, together with |
2 |
| reasonable attorney's
fees. After payment of those |
3 |
| expenses and attorney's fees, the court shall
apply out of |
4 |
| the balance of the judgment or award an amount sufficient |
5 |
| to
reimburse the Plan the full amount of benefits paid on |
6 |
| behalf of the
covered person under this Act, provided the |
7 |
| court may reduce and apportion
the Plan's portion of the |
8 |
| judgement proportionate to the recovery of the
covered |
9 |
| person. The burden of producing evidence sufficient to |
10 |
| support the
exercise by the court of its discretion to |
11 |
| reduce
the amount of a proven charge sought to be enforced |
12 |
| against the recovery
shall rest with the party seeking the |
13 |
| reduction. The court may consider
the nature and extent of |
14 |
| the injury, economic and non-economic loss,
settlement |
15 |
| offers, comparative negligence as it applies to the case at
|
16 |
| hand, hospital costs, physician costs, and all other |
17 |
| appropriate costs.
The Plan shall pay its pro rata share of |
18 |
| the attorney fees based on the
Plan's recovery as it |
19 |
| compares to the total judgment. Any reimbursement
rights of |
20 |
| the Plan shall take priority over all other liens and |
21 |
| charges
existing under the laws of this State with the |
22 |
| exception of any attorney
liens filed under the Attorneys |
23 |
| Lien Act.
|
24 |
| (7) The Plan may compromise or settle and release any |
25 |
| claim for
benefits provided under this Act or waive any |
26 |
| claims for benefits, in whole
or in part, for the |
27 |
| convenience of the Plan or if the Plan determines that
|
28 |
| collection would result in undue hardship upon the covered |
29 |
| person.
|
30 |
| (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00; 92-2, |
31 |
| eff.
5-1-01; 92-630, eff. 7-11-02.)
|
32 |
| Section 15. The Health Maintenance Organization Act is |
33 |
| amended by changing
Section 5-3 as follows:
|
34 |
| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
|
|
|
|
HB5091 |
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LRB093 13635 SAS 40141 b |
|
|
1 |
| Sec. 5-3. Insurance Code provisions.
|
2 |
| (a) Health Maintenance Organizations
shall be subject to |
3 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
4 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
5 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, |
6 |
| 356y,
356z.2, 356z.4, 356z.6, 367.2, 367.2-5, 367i, 368a, 368b, |
7 |
| 368c, 368d, 368e,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, |
8 |
| 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section |
9 |
| 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, |
10 |
| XXV, and XXVI of the Illinois Insurance Code.
|
11 |
| (b) For purposes of the Illinois Insurance Code, except for |
12 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
13 |
| Maintenance Organizations in
the following categories are |
14 |
| deemed to be "domestic companies":
|
15 |
| (1) a corporation authorized under the
Dental Service |
16 |
| Plan Act or the Voluntary Health Services Plans Act;
|
17 |
| (2) a corporation organized under the laws of this |
18 |
| State; or
|
19 |
| (3) a corporation organized under the laws of another |
20 |
| state, 30% or more
of the enrollees of which are residents |
21 |
| of this State, except a
corporation subject to |
22 |
| substantially the same requirements in its state of
|
23 |
| organization as is a "domestic company" under Article VIII |
24 |
| 1/2 of the
Illinois Insurance Code.
|
25 |
| (c) In considering the merger, consolidation, or other |
26 |
| acquisition of
control of a Health Maintenance Organization |
27 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
28 |
| (1) the Director shall give primary consideration to |
29 |
| the continuation of
benefits to enrollees and the financial |
30 |
| conditions of the acquired Health
Maintenance Organization |
31 |
| after the merger, consolidation, or other
acquisition of |
32 |
| control takes effect;
|
33 |
| (2)(i) the criteria specified in subsection (1)(b) of |
34 |
| Section 131.8 of
the Illinois Insurance Code shall not |
35 |
| apply and (ii) the Director, in making
his determination |
36 |
| with respect to the merger, consolidation, or other
|
|
|
|
HB5091 |
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LRB093 13635 SAS 40141 b |
|
|
1 |
| acquisition of control, need not take into account the |
2 |
| effect on
competition of the merger, consolidation, or |
3 |
| other acquisition of control;
|
4 |
| (3) the Director shall have the power to require the |
5 |
| following
information:
|
6 |
| (A) certification by an independent actuary of the |
7 |
| adequacy
of the reserves of the Health Maintenance |
8 |
| Organization sought to be acquired;
|
9 |
| (B) pro forma financial statements reflecting the |
10 |
| combined balance
sheets of the acquiring company and |
11 |
| the Health Maintenance Organization sought
to be |
12 |
| acquired as of the end of the preceding year and as of |
13 |
| a date 90 days
prior to the acquisition, as well as pro |
14 |
| forma financial statements
reflecting projected |
15 |
| combined operation for a period of 2 years;
|
16 |
| (C) a pro forma business plan detailing an |
17 |
| acquiring party's plans with
respect to the operation |
18 |
| of the Health Maintenance Organization sought to
be |
19 |
| acquired for a period of not less than 3 years; and
|
20 |
| (D) such other information as the Director shall |
21 |
| require.
|
22 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
23 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
24 |
| any health maintenance
organization of greater than 10% of its
|
25 |
| enrollee population (including without limitation the health |
26 |
| maintenance
organization's right, title, and interest in and to |
27 |
| its health care
certificates).
|
28 |
| (e) In considering any management contract or service |
29 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
30 |
| Code, the Director (i) shall, in
addition to the criteria |
31 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
32 |
| into account the effect of the management contract or
service |
33 |
| agreement on the continuation of benefits to enrollees and the
|
34 |
| financial condition of the health maintenance organization to |
35 |
| be managed or
serviced, and (ii) need not take into account the |
36 |
| effect of the management
contract or service agreement on |
|
|
|
HB5091 |
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LRB093 13635 SAS 40141 b |
|
|
1 |
| competition.
|
2 |
| (f) Except for small employer groups as defined in the |
3 |
| Small Employer
Rating, Renewability and Portability Health |
4 |
| Insurance Act and except for
medicare supplement policies as |
5 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
6 |
| Maintenance Organization may by contract agree with a
group or |
7 |
| other enrollment unit to effect refunds or charge additional |
8 |
| premiums
under the following terms and conditions:
|
9 |
| (i) the amount of, and other terms and conditions with |
10 |
| respect to, the
refund or additional premium are set forth |
11 |
| in the group or enrollment unit
contract agreed in advance |
12 |
| of the period for which a refund is to be paid or
|
13 |
| additional premium is to be charged (which period shall not |
14 |
| be less than one
year); and
|
15 |
| (ii) the amount of the refund or additional premium |
16 |
| shall not exceed 20%
of the Health Maintenance |
17 |
| Organization's profitable or unprofitable experience
with |
18 |
| respect to the group or other enrollment unit for the |
19 |
| period (and, for
purposes of a refund or additional |
20 |
| premium, the profitable or unprofitable
experience shall |
21 |
| be calculated taking into account a pro rata share of the
|
22 |
| Health Maintenance Organization's administrative and |
23 |
| marketing expenses, but
shall not include any refund to be |
24 |
| made or additional premium to be paid
pursuant to this |
25 |
| subsection (f)). The Health Maintenance Organization and |
26 |
| the
group or enrollment unit may agree that the profitable |
27 |
| or unprofitable
experience may be calculated taking into |
28 |
| account the refund period and the
immediately preceding 2 |
29 |
| plan years.
|
30 |
| The Health Maintenance Organization shall include a |
31 |
| statement in the
evidence of coverage issued to each enrollee |
32 |
| describing the possibility of a
refund or additional premium, |
33 |
| and upon request of any group or enrollment unit,
provide to |
34 |
| the group or enrollment unit a description of the method used |
35 |
| to
calculate (1) the Health Maintenance Organization's |
36 |
| profitable experience with
respect to the group or enrollment |
|
|
|
HB5091 |
- 17 - |
LRB093 13635 SAS 40141 b |
|
|
1 |
| unit and the resulting refund to the group
or enrollment unit |
2 |
| or (2) the Health Maintenance Organization's unprofitable
|
3 |
| experience with respect to the group or enrollment unit and the |
4 |
| resulting
additional premium to be paid by the group or |
5 |
| enrollment unit.
|
6 |
| In no event shall the Illinois Health Maintenance |
7 |
| Organization
Guaranty Association be liable to pay any |
8 |
| contractual obligation of an
insolvent organization to pay any |
9 |
| refund authorized under this Section.
|
10 |
| (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, |
11 |
| eff. 1-1-04;
93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised |
12 |
| 9-25-03.)
|
13 |
| Section 20. The Voluntary Health Services Plans Act is |
14 |
| amended by changing
Section 10 as follows:
|
15 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
16 |
| Sec. 10. Application of Insurance Code provisions. Health |
17 |
| services
plan corporations and all persons interested therein |
18 |
| or dealing therewith
shall be subject to the provisions of |
19 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
20 |
| 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, |
21 |
| 356y, 356z.1, 356z.2, 356z.4, 356z.6, 367.2, 368a, 401, 401.1,
|
22 |
| 402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) and |
23 |
| (15) of Section 367 of the Illinois
Insurance Code.
|
24 |
| (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
|
25 |
| 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; |
26 |
| 93-529, eff.
8-14-03; revised 9-25-03.)
|
27 |
| Section 25. The Senior Citizens and Disabled Persons |
28 |
| Property Tax Relief and
Pharmaceutical Assistance Act is |
29 |
| amended by changing
Section 3.15 as follows:
|
30 |
| (320 ILCS 25/3.15) (from Ch. 67 1/2, par. 403.15)
|
31 |
| Sec. 3.15. "Covered prescription drug" means (1) any |
32 |
| cardiovascular agent
or drug; (2) any insulin or other |
|
|
|
HB5091 |
- 18 - |
LRB093 13635 SAS 40141 b |
|
|
1 |
| prescription drug used in the treatment of
diabetes, including |
2 |
| syringe and needles used to administer the insulin; (3)
any |
3 |
| prescription drug used in the treatment of arthritis, (4) |
4 |
| beginning on
January 1, 2001, any prescription drug used in the |
5 |
| treatment of cancer, (5)
beginning on January 1, 2001, any |
6 |
| prescription drug used in the treatment of
Alzheimer's disease, |
7 |
| (6) beginning on January 1, 2001, any prescription drug
used in |
8 |
| the treatment of Parkinson's disease, (7) beginning on January |
9 |
| 1,
2001, any prescription drug used in the treatment of |
10 |
| glaucoma, (8)
beginning on January 1, 2001, any prescription |
11 |
| drug used in the treatment of
lung disease and smoking related |
12 |
| illnesses, (9) beginning on July 1,
2001, any prescription drug |
13 |
| used in the treatment
of osteoporosis, and
(10) beginning
on |
14 |
| January 1, 2004, any
prescription drug used in the treatment of |
15 |
| multiple sclerosis , and (11) beginning on January 1, 2005,
|
16 |
| immunosuppressive agents (anti-rejection medication) used in
|
17 |
| connection with organ transplants .
The
specific agents or |
18 |
| products to be included under such categories shall be
listed |
19 |
| in a handbook to be prepared and distributed by the Department. |
20 |
| The
general types of covered prescription drugs shall be |
21 |
| indicated by rule.
|
22 |
| (Source: P.A. 92-10, eff. 6-11-01; 92-790, eff. 8-6-02; 93-528, |
23 |
| eff.
1-1-04.)
|