093_SB0377eng SB377 Engrossed LRB093 03308 JLS 03325 b 1 AN ACT concerning insurance coverage. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 4 Section 5. The State Employees Group Insurance Act of 5 1971 is amended by changing Section 6.11 as follows: 6 (5 ILCS 375/6.11) 7 Sec. 6.11. Required health benefits; Illinois Insurance 8 Code requirements. The program of health benefits shall 9 provide the post-mastectomy care benefits required to be 10 covered by a policy of accident and health insurance under 11 Section 356t of the Illinois Insurance Code. The program of 12 health benefits shall provide the coverage required under 13 Sections 356u, 356w, 356x,and356z.2, and 356z.4 of the 14 Illinois Insurance Code. The program of health benefits must 15 comply with Section 155.37 of the Illinois Insurance Code. 16 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03.) 17 Section 10. The Counties Code is amended by changing 18 Section 5-1069.3 as follows: 19 (55 ILCS 5/5-1069.3) 20 Sec. 5-1069.3. Required health benefits. If a county, 21 including a home rule county, is a self-insurer for purposes 22 of providing health insurance coverage for its employees, the 23 coverage shall include coverage for the post-mastectomy care 24 benefits required to be covered by a policy of accident and 25 health insurance under Section 356t and the coverage required 26 under Sections 356u, 356w,and356x, and 356z.4 of the 27 Illinois Insurance Code. The requirement that health 28 benefits be covered as provided in this Section is an 29 exclusive power and function of the State and is a denial and SB377 Engrossed -2- LRB093 03308 JLS 03325 b 1 limitation under Article VII, Section 6, subsection (h) of 2 the Illinois Constitution. A home rule county to which this 3 Section applies must comply with every provision of this 4 Section. 5 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.) 6 Section 15. The Illinois Municipal Code is amended by 7 changing Section 10-4-2.3 as follows: 8 (65 ILCS 5/10-4-2.3) 9 Sec. 10-4-2.3. Required health benefits. If a 10 municipality, including a home rule municipality, is a 11 self-insurer for purposes of providing health insurance 12 coverage for its employees, the coverage shall include 13 coverage for the post-mastectomy care benefits required to be 14 covered by a policy of accident and health insurance under 15 Section 356t and the coverage required under Sections 356u, 16 356w,and356x, and 356z.4 of the Illinois Insurance Code. 17 The requirement that health benefits be covered as provided 18 in this is an exclusive power and function of the State and 19 is a denial and limitation under Article VII, Section 6, 20 subsection (h) of the Illinois Constitution. A home rule 21 municipality to which this Section applies must comply with 22 every provision of this Section. 23 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.) 24 Section 20. The School Code is amended by changing 25 Section 10-22.3f as follows: 26 (105 ILCS 5/10-22.3f) 27 Sec. 10-22.3f. Required health benefits. Insurance 28 protection and benefits for employees shall provide the 29 post-mastectomy care benefits required to be covered by a 30 policy of accident and health insurance under Section 356t SB377 Engrossed -3- LRB093 03308 JLS 03325 b 1 and the coverage required under Sections 356u, 356w,and2 356x, and 356z.4 of the Illinois Insurance Code. 3 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.) 4 Section 25. The Illinois Insurance Code is amended by 5 adding Section 356z.4 as follows: 6 (215 ILCS 5/356z.4 new) 7 Sec. 356z.4. Bone mass measurement; osteoporosis. A 8 group or individual policy of accident and health insurance 9 amended, delivered, issued, or renewed after the effective 10 date of this amendatory Act of the 93rd General Assembly must 11 provide coverage for medically necessary bone mass 12 measurement and for the diagnosis and treatment of 13 osteoporosis on the same terms and conditions that are 14 generally applicable to coverage for other medical 15 conditions. 16 Section 30. The Health Maintenance Organization Act is 17 amended by changing Section 5-3 as follows: 18 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) 19 Sec. 5-3. Insurance Code provisions. 20 (a) Health Maintenance Organizations shall be subject to 21 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2, 22 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 23 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 24 356y, 356z.2, 356z.4, 367i, 368a, 401, 401.1, 402, 403, 403A, 25 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of 26 subsection (2) of Section 367, and Articles IIA, VIII 1/2, 27 XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois 28 Insurance Code. 29 (b) For purposes of the Illinois Insurance Code, except 30 for Sections 444 and 444.1 and Articles XIII and XIII 1/2, SB377 Engrossed -4- LRB093 03308 JLS 03325 b 1 Health Maintenance Organizations in the following categories 2 are deemed to be "domestic companies": 3 (1) a corporation authorized under the Dental 4 Service Plan Act or the Voluntary Health Services Plans 5 Act; 6 (2) a corporation organized under the laws of this 7 State; or 8 (3) a corporation organized under the laws of 9 another state, 30% or more of the enrollees of which are 10 residents of this State, except a corporation subject to 11 substantially the same requirements in its state of 12 organization as is a "domestic company" under Article 13 VIII 1/2 of the Illinois Insurance Code. 14 (c) In considering the merger, consolidation, or other 15 acquisition of control of a Health Maintenance Organization 16 pursuant to Article VIII 1/2 of the Illinois Insurance Code, 17 (1) the Director shall give primary consideration 18 to the continuation of benefits to enrollees and the 19 financial conditions of the acquired Health Maintenance 20 Organization after the merger, consolidation, or other 21 acquisition of control takes effect; 22 (2)(i) the criteria specified in subsection (1)(b) 23 of Section 131.8 of the Illinois Insurance Code shall not 24 apply and (ii) the Director, in making his determination 25 with respect to the merger, consolidation, or other 26 acquisition of control, need not take into account the 27 effect on competition of the merger, consolidation, or 28 other acquisition of control; 29 (3) the Director shall have the power to require 30 the following information: 31 (A) certification by an independent actuary of 32 the adequacy of the reserves of the Health 33 Maintenance Organization sought to be acquired; 34 (B) pro forma financial statements reflecting SB377 Engrossed -5- LRB093 03308 JLS 03325 b 1 the combined balance sheets of the acquiring company 2 and the Health Maintenance Organization sought to be 3 acquired as of the end of the preceding year and as 4 of a date 90 days prior to the acquisition, as well 5 as pro forma financial statements reflecting 6 projected combined operation for a period of 2 7 years; 8 (C) a pro forma business plan detailing an 9 acquiring party's plans with respect to the 10 operation of the Health Maintenance Organization 11 sought to be acquired for a period of not less than 12 3 years; and 13 (D) such other information as the Director 14 shall require. 15 (d) The provisions of Article VIII 1/2 of the Illinois 16 Insurance Code and this Section 5-3 shall apply to the sale 17 by any health maintenance organization of greater than 10% of 18 its enrollee population (including without limitation the 19 health maintenance organization's right, title, and interest 20 in and to its health care certificates). 21 (e) In considering any management contract or service 22 agreement subject to Section 141.1 of the Illinois Insurance 23 Code, the Director (i) shall, in addition to the criteria 24 specified in Section 141.2 of the Illinois Insurance Code, 25 take into account the effect of the management contract or 26 service agreement on the continuation of benefits to 27 enrollees and the financial condition of the health 28 maintenance organization to be managed or serviced, and (ii) 29 need not take into account the effect of the management 30 contract or service agreement on competition. 31 (f) Except for small employer groups as defined in the 32 Small Employer Rating, Renewability and Portability Health 33 Insurance Act and except for medicare supplement policies as 34 defined in Section 363 of the Illinois Insurance Code, a SB377 Engrossed -6- LRB093 03308 JLS 03325 b 1 Health Maintenance Organization may by contract agree with a 2 group or other enrollment unit to effect refunds or charge 3 additional premiums under the following terms and conditions: 4 (i) the amount of, and other terms and conditions 5 with respect to, the refund or additional premium are set 6 forth in the group or enrollment unit contract agreed in 7 advance of the period for which a refund is to be paid or 8 additional premium is to be charged (which period shall 9 not be less than one year); and 10 (ii) the amount of the refund or additional premium 11 shall not exceed 20% of the Health Maintenance 12 Organization's profitable or unprofitable experience with 13 respect to the group or other enrollment unit for the 14 period (and, for purposes of a refund or additional 15 premium, the profitable or unprofitable experience shall 16 be calculated taking into account a pro rata share of the 17 Health Maintenance Organization's administrative and 18 marketing expenses, but shall not include any refund to 19 be made or additional premium to be paid pursuant to this 20 subsection (f)). The Health Maintenance Organization and 21 the group or enrollment unit may agree that the 22 profitable or unprofitable experience may be calculated 23 taking into account the refund period and the immediately 24 preceding 2 plan years. 25 The Health Maintenance Organization shall include a 26 statement in the evidence of coverage issued to each enrollee 27 describing the possibility of a refund or additional premium, 28 and upon request of any group or enrollment unit, provide to 29 the group or enrollment unit a description of the method used 30 to calculate (1) the Health Maintenance Organization's 31 profitable experience with respect to the group or enrollment 32 unit and the resulting refund to the group or enrollment unit 33 or (2) the Health Maintenance Organization's unprofitable 34 experience with respect to the group or enrollment unit and SB377 Engrossed -7- LRB093 03308 JLS 03325 b 1 the resulting additional premium to be paid by the group or 2 enrollment unit. 3 In no event shall the Illinois Health Maintenance 4 Organization Guaranty Association be liable to pay any 5 contractual obligation of an insolvent organization to pay 6 any refund authorized under this Section. 7 (Source: P.A. 91-357, eff. 7-29-99; 91-406, eff. 1-1-00; 8 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; 91-788, eff. 9 6-9-00; 92-764, eff. 1-1-03.) 10 Section 35. The Voluntary Health Services Plans Act is 11 amended by changing Section 10 as follows: 12 (215 ILCS 165/10) (from Ch. 32, par. 604) 13 Sec. 10. Application of Insurance Code provisions. 14 Health services plan corporations and all persons interested 15 therein or dealing therewith shall be subject to the 16 provisions of Articles IIA and XII 1/2 and Sections 3.1, 133, 17 140, 143, 143c, 149, 155.37, 354, 355.2, 356r, 356t, 356u, 18 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 367.2, 368a, 19 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and 20 paragraphs (7) and (15) of Section 367 of the Illinois 21 Insurance Code. 22 (Source: P.A. 91-406, eff. 1-1-00; 91-549, eff. 8-14-99; 23 91-605, eff. 12-14-99; 91-788, eff. 6-9-00; 92-130, eff. 24 7-20-01; 92-440, eff. 8-17-01; 92-651, eff. 7-11-02; 92-764, 25 eff. 1-1-03.) 26 Section 40. The Illinois Public Aid Code is amended by 27 changing Section 5-16.8 as follows: 28 (305 ILCS 5/5-16.8) 29 Sec. 5-16.8. Required health benefits. The medical 30 assistance program shall provide the post-mastectomy care SB377 Engrossed -8- LRB093 03308 JLS 03325 b 1 benefits required to be covered by a policy of accident and 2 health insurance under Section 356t and the coverage required 3 under Sections 356u, 356w,and356x, and 356z.4 of the 4 Illinois Insurance Code. 5 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)