|
|||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||
1 | AN ACT concerning pharmaceutical benefits.
| ||||||||||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois, | ||||||||||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||||||||||
4 | Section 5. The Illinois Insurance Code is amended by adding | ||||||||||||||||||||||||||||||||
5 | Section 356z.6
as follows:
| ||||||||||||||||||||||||||||||||
6 | (215 ILCS 5/356z.6 new)
| ||||||||||||||||||||||||||||||||
7 | Sec. 356z.6. Immunosuppressive agents. A group or | ||||||||||||||||||||||||||||||||
8 | individual policy of
accident and health insurance amended, | ||||||||||||||||||||||||||||||||
9 | delivered, issued, or renewed after the
effective date of this | ||||||||||||||||||||||||||||||||
10 | amendatory Act of the 93rd General Assembly that
provides | ||||||||||||||||||||||||||||||||
11 | coverage for organ transplants must provide coverage for
| ||||||||||||||||||||||||||||||||
12 | immunosuppressive agents (anti-rejection medications). If the | ||||||||||||||||||||||||||||||||
13 | policy provides
coverage for prescription drugs through the use | ||||||||||||||||||||||||||||||||
14 | of a drug formulary, the
generic immunosuppressive agents must | ||||||||||||||||||||||||||||||||
15 | be included with the drug formulary. If
the immunosuppressive | ||||||||||||||||||||||||||||||||
16 | agent is non-generic it must be included in the drug
formulary | ||||||||||||||||||||||||||||||||
17 | as the least expensive co-payment level higher than the | ||||||||||||||||||||||||||||||||
18 | co-payment
required for generic drugs.
| ||||||||||||||||||||||||||||||||
19 | Section 10. The Comprehensive Health Insurance Plan Act is | ||||||||||||||||||||||||||||||||
20 | amended by
changing
Section 8 as follows:
| ||||||||||||||||||||||||||||||||
21 | (215 ILCS 105/8) (from Ch. 73, par. 1308)
| ||||||||||||||||||||||||||||||||
22 | Sec. 8. Minimum benefits.
| ||||||||||||||||||||||||||||||||
23 | a. Availability. The Plan shall offer in an
annually | ||||||||||||||||||||||||||||||||
24 | renewable policy major medical expense coverage to every | ||||||||||||||||||||||||||||||||
25 | eligible
person who is not eligible for Medicare. Major medical
| ||||||||||||||||||||||||||||||||
26 | expense coverage offered by the Plan shall pay an eligible | ||||||||||||||||||||||||||||||||
27 | person's
covered expenses, subject to limit on the deductible | ||||||||||||||||||||||||||||||||
28 | and coinsurance
payments authorized under paragraph (4) of | ||||||||||||||||||||||||||||||||
29 | subsection d of this Section,
up to a lifetime benefit limit of | ||||||||||||||||||||||||||||||||
30 | $1,000,000 per covered
individual. The maximum
limit under this |
| |||||||
| |||||||
1 | subsection shall not be altered by the Board, and no
actuarial | ||||||
2 | equivalent benefit may be substituted by the Board.
Any person | ||||||
3 | who otherwise would qualify for coverage under the Plan, but
is | ||||||
4 | excluded because he or she is eligible for Medicare, shall be | ||||||
5 | eligible
for any separate Medicare supplement policy or | ||||||
6 | policies which the Board may
offer.
| ||||||
7 | b. Outline of benefits. Covered expenses shall be
limited | ||||||
8 | to the usual and customary charge, including negotiated fees, | ||||||
9 | in
the locality for the following services and articles when | ||||||
10 | prescribed by a
physician and determined by the Plan to be | ||||||
11 | medically necessary
for the following areas of services, | ||||||
12 | subject to such separate deductibles,
co-payments, exclusions, | ||||||
13 | and other limitations on benefits as the Board shall
establish | ||||||
14 | and approve, and the other provisions of this Section:
| ||||||
15 | (1) Hospital
services, except that
any services | ||||||
16 | provided by a hospital that is
located more than 75 miles | ||||||
17 | outside the State of Illinois shall be covered only
for a | ||||||
18 | maximum of 45 days in any calendar year. With respect to | ||||||
19 | covered
expenses incurred during any calendar year ending | ||||||
20 | on or after December 31,
1999, inpatient hospitalization of | ||||||
21 | an eligible person for the
treatment of mental illness at a | ||||||
22 | hospital located within the State of
Illinois
shall be | ||||||
23 | subject to the same terms and conditions as for any other | ||||||
24 | illness.
| ||||||
25 | (2) Professional services for the diagnosis or | ||||||
26 | treatment of injuries,
illnesses or conditions, other than | ||||||
27 | dental and mental
and
nervous disorders as
described in | ||||||
28 | paragraph (17), which are rendered by a physician, or by | ||||||
29 | other
licensed professionals at the physician's
direction. | ||||||
30 | This includes reconstruction of the breast on which a | ||||||
31 | mastectomy
was performed; surgery and reconstruction of | ||||||
32 | the other breast to produce a
symmetrical appearance; and | ||||||
33 | prostheses and treatment of physical complications
at all | ||||||
34 | stages of the mastectomy, including lymphedemas.
| ||||||
35 | (2.5) Professional services provided by a physician to | ||||||
36 | children under
the age of 16 years for physical |
| |||||||
| |||||||
1 | examinations and age appropriate
immunizations ordered by | ||||||
2 | a physician licensed to practice medicine in all its
| ||||||
3 | branches.
| ||||||
4 | (3) (Blank).
| ||||||
5 | (4) Outpatient prescription drugs that by law require
a
| ||||||
6 | prescription
written by a physician licensed to practice | ||||||
7 | medicine in all its branches
subject to such separate | ||||||
8 | deductible, copayment, and other limitations or
| ||||||
9 | restrictions as the Board shall approve, including the use | ||||||
10 | of a prescription
drug card or any other program, or both.
| ||||||
11 | (5) Skilled nursing services of a licensed
skilled
| ||||||
12 | nursing facility for not more than 120 days during a policy | ||||||
13 | year.
| ||||||
14 | (6) Services of a home health agency in accord with a | ||||||
15 | home health care
plan, up to a maximum of 270 visits per | ||||||
16 | year.
| ||||||
17 | (7) Services of a licensed hospice for not more than | ||||||
18 | 180
days during a policy year.
| ||||||
19 | (8) Use of radium or other radioactive materials.
| ||||||
20 | (9) Oxygen.
| ||||||
21 | (10) Anesthetics.
| ||||||
22 | (11) Orthoses and prostheses other than dental.
| ||||||
23 | (12) Rental or purchase in accordance with Board | ||||||
24 | policies or
procedures of durable medical equipment, other | ||||||
25 | than eyeglasses or hearing
aids, for which there is no | ||||||
26 | personal use in the absence of the condition
for which it | ||||||
27 | is prescribed.
| ||||||
28 | (13) Diagnostic x-rays and laboratory tests.
| ||||||
29 | (14) Oral surgery (i) for excision of partially or | ||||||
30 | completely unerupted
impacted teeth when not performed in
| ||||||
31 | connection with the routine extraction or repair of teeth; | ||||||
32 | (ii) for excision
of tumors or cysts of the jaws, cheeks, | ||||||
33 | lips, tongue, and roof and floor of the
mouth; (iii) | ||||||
34 | required for correction of cleft lip and palate
and
other | ||||||
35 | craniofacial and maxillofacial birth defects; or (iv) for | ||||||
36 | treatment of injuries to natural teeth or a fractured jaw |
| |||||||
| |||||||
1 | due to an accident.
| ||||||
2 | (15) Physical, speech, and functional occupational | ||||||
3 | therapy as
medically necessary and provided by appropriate | ||||||
4 | licensed professionals.
| ||||||
5 | (16) Emergency and other medically necessary | ||||||
6 | transportation provided
by a licensed ambulance service to | ||||||
7 | the
nearest health care facility qualified to treat a | ||||||
8 | covered
illness, injury, or condition, subject to the | ||||||
9 | provisions of the
Emergency Medical Systems (EMS) Act.
| ||||||
10 | (17) Outpatient services for
diagnosis and
treatment | ||||||
11 | of mental and nervous disorders provided that a
covered | ||||||
12 | person shall be required to make a copayment not to exceed | ||||||
13 | 50% and that
the Plan's payment shall not exceed such | ||||||
14 | amounts as are established by the
Board.
| ||||||
15 | (18) Human organ or tissue transplants specified by the | ||||||
16 | Board that
are performed at a hospital designated by the | ||||||
17 | Board as a participating
transplant center for that | ||||||
18 | specific organ or tissue transplant , including | ||||||
19 | immunosuppressive agents as required under Section 356z.6 | ||||||
20 | of the
Illinois Insurance Code .
| ||||||
21 | (19) Naprapathic services, as appropriate, provided by | ||||||
22 | a licensed
naprapathic practitioner.
| ||||||
23 | c. Exclusions. Covered expenses of the Plan shall not
| ||||||
24 | include the following:
| ||||||
25 | (1) Any charge for treatment for cosmetic purposes | ||||||
26 | 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 | ||||||
29 | for the repair or treatment of a congenital bodily defect
| ||||||
30 | to restore normal bodily functions.
| ||||||
31 | (2) Any charge for care that is primarily for rest,
| ||||||
32 | custodial, educational, or domiciliary purposes.
| ||||||
33 | (3) Any charge for services in a private room to the | ||||||
34 | extent it is in
excess of the institution's charge for its | ||||||
35 | most common semiprivate room,
unless a private room is | ||||||
36 | prescribed as medically necessary by a physician.
|
| |||||||
| |||||||
1 | (4) That part of any charge for room and board or for | ||||||
2 | services
rendered or articles prescribed by a physician, | ||||||
3 | dentist, or other health
care personnel that exceeds the | ||||||
4 | reasonable and customary charge in the
locality or for any | ||||||
5 | services or supplies not medically necessary for the
| ||||||
6 | diagnosed injury or illness.
| ||||||
7 | (5) Any charge for services or articles the provision | ||||||
8 | of which is not
within the scope of licensure of the | ||||||
9 | institution or individual
providing the services or | ||||||
10 | articles.
| ||||||
11 | (6) Any expense incurred prior to the effective date of | ||||||
12 | coverage by the
Plan for the person on whose behalf the | ||||||
13 | expense is incurred.
| ||||||
14 | (7) Dental care, dental surgery, dental treatment, any | ||||||
15 | other dental
procedure involving the teeth or | ||||||
16 | periodontium, or any dental appliances,
including crowns, | ||||||
17 | bridges, implants, or partial or complete dentures,
except
| ||||||
18 | as specifically provided in paragraph
(14) of subsection b | ||||||
19 | of this Section.
| ||||||
20 | (8) Eyeglasses, contact lenses, hearing aids or their | ||||||
21 | fitting.
| ||||||
22 | (9) Illness or injury due to acts of war.
| ||||||
23 | (10) Services of blood donors and any fee for failure | ||||||
24 | to replace the
first 3 pints of blood
provided to a covered | ||||||
25 | person each policy year.
| ||||||
26 | (11) Personal supplies or services provided by a | ||||||
27 | hospital or nursing
home, or any other nonmedical or | ||||||
28 | nonprescribed supply or service.
| ||||||
29 | (12) Routine maternity charges for a pregnancy, except | ||||||
30 | where added as
optional coverage with payment of an | ||||||
31 | additional premium for pregnancy
resulting from conception | ||||||
32 | occurring after the effective date of the
optional | ||||||
33 | coverage.
| ||||||
34 | (13) (Blank).
| ||||||
35 | (14) Any expense or charge for services, drugs, or | ||||||
36 | supplies that are:
(i) not provided in accord with |
| |||||||
| |||||||
1 | generally accepted standards of current
medical practice; | ||||||
2 | (ii) for procedures, treatments, equipment, transplants,
| ||||||
3 | or implants, any of which are investigational, | ||||||
4 | experimental, or for
research purposes; (iii) | ||||||
5 | investigative and not proven safe and effective;
or (iv) | ||||||
6 | for, or resulting from, a gender
transformation operation.
| ||||||
7 | (15) Any expense or charge for routine physical | ||||||
8 | examinations or tests
except as provided in item (2.5) of | ||||||
9 | subsection b of this Section.
| ||||||
10 | (16) Any expense for which a charge is not made in the | ||||||
11 | absence of
insurance or for which there is no legal | ||||||
12 | obligation on the part of the
patient to pay.
| ||||||
13 | (17) Any expense incurred for benefits provided under | ||||||
14 | the laws of the
United States and this State, including | ||||||
15 | 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, | ||||||
19 | military service-connected
disability payments, medical
| ||||||
20 | services provided for members of the armed forces and their | ||||||
21 | 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.
| ||||||
24 | (18) Any expense or charge for in vitro fertilization, | ||||||
25 | artificial
insemination, or any other artificial means | ||||||
26 | used to cause pregnancy.
| ||||||
27 | (19) Any expense or charge for oral contraceptives used | ||||||
28 | for birth
control or any other temporary birth control | ||||||
29 | measures.
| ||||||
30 | (20) Any expense or charge for sterilization or | ||||||
31 | sterilization reversals.
| ||||||
32 | (21) Any expense or charge for weight loss programs, | ||||||
33 | exercise
equipment, or treatment of obesity, except when | ||||||
34 | certified by a physician as
morbid obesity (at least 2 | ||||||
35 | times normal body weight).
| ||||||
36 | (22) Any expense or charge for acupuncture treatment |
| |||||||
| |||||||
1 | unless used as an
anesthetic agent for a covered surgery.
| ||||||
2 | (23) Any expense or charge for or related to organ or | ||||||
3 | tissue
transplants other than those performed at a hospital | ||||||
4 | with a Board approved
organ transplant program that has | ||||||
5 | been designated by the Board as a
preferred or exclusive | ||||||
6 | provider organization for that specific organ or tissue
| ||||||
7 | transplant.
| ||||||
8 | (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.
| ||||||
15 | d. Deductibles and coinsurance.
| ||||||
16 | The Plan coverage defined in Section 6 shall provide for a | ||||||
17 | choice
of
deductibles per individual as authorized by the | ||||||
18 | Board. If 2 individual members
of the same family
household, | ||||||
19 | who are both covered persons under the Plan, satisfy the
same | ||||||
20 | applicable deductibles, no other member of that family who is
| ||||||
21 | also a covered person under the Plan shall be
required to
meet | ||||||
22 | any deductibles for the balance of that calendar year. The
| ||||||
23 | 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
| ||||||
33 | Consumer Price Index.
| ||||||
34 | 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, |
| |||||||
| |||||||
1 | deductibles, coinsurance factors,
exclusions, and | ||||||
2 | limitations as it may deem appropriate and that it believes | ||||||
3 | to
be generally reflective of and commensurate with health | ||||||
4 | insurance coverage that
is provided in the individual | ||||||
5 | market in this State.
| ||||||
6 | (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
| ||||||
13 | cost effective arrangements for paying for covered | ||||||
14 | expenses.
| ||||||
15 | f. Preexisting conditions.
| ||||||
16 | (1) Except for federally eligible individuals | ||||||
17 | qualifying for Plan
coverage under Section 15 of this Act
| ||||||
18 | 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
| ||||||
24 | immediately preceding the effective date
of coverage.
| ||||||
25 | (2) (Blank).
| ||||||
26 | (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.
| ||||||
35 | g. Other sources primary; nonduplication of benefits.
| ||||||
36 | (1) The Plan shall be the last payor of benefits |
| |||||||
| |||||||
1 | 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, |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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
|
| |||||||
| |||||||
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)
|
| |||||||
| |||||||
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
|
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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.)
|