SB2744 Enrolled

LRB093 20224 SAS 45982 b






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    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 1971 
5
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 provide 
9
the post-mastectomy care benefits required to be covered
by a 
10
policy of accident and health insurance under Section 356t of 
11
the Illinois
Insurance Code.  The program of health benefits 
12
shall provide the coverage
required under Sections 356u, 356w, 
13
356x, 356z.2, and 356z.4, and 356z.6 of the
Illinois Insurance 
14
Code.
The program of health benefits must comply with Section 
15
155.37 of the
Illinois Insurance Code.

16
(Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; 
17
93-102, eff. 1-1-04.)



 
18
    Section 10. The Counties Code is amended by changing

19
Section 5-1069.3 as follows:


 
20
    (55 ILCS 5/5-1069.3)

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    Sec. 5-1069.3. Required health benefits.   If a county, 
22
including a home
rule
county, is a self-insurer for purposes of 
23
providing health insurance coverage
for its employees, the 
24
coverage shall include coverage for the post-mastectomy
care 
25
benefits required to be covered by a policy of accident and 
26
health
insurance under Section 356t and the coverage required 
27
under Sections 356u,
356w, and 356x and 356z.6  of
the Illinois 
28
Insurance Code.  The requirement that health benefits be covered

29
as provided in this Section is an
exclusive power and function 
30
of the State and is a denial and limitation under
Article VII, 
 


 






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Section 6, subsection (h) of the Illinois Constitution.  A home

2
rule county to which this Section applies must comply with 
3
every provision of
this Section.


4
(Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)


 
5
    Section 15. The Illinois Municipal Code is amended by 
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changing
Section 10-4-2.3 as follows:


 
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    (65 ILCS 5/10-4-2.3)

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    Sec. 10-4-2.3. Required health benefits.   If a 
9
municipality, including a
home rule municipality, is a 
10
self-insurer for purposes of providing health
insurance 
11
coverage for its employees, the coverage shall include coverage 
12
for
the post-mastectomy care benefits required to be covered by 
13
a policy of
accident and health insurance under Section 356t 
14
and the coverage required
under Sections 356u, 356w, and 356x 
15
and 356z.6 of the Illinois
Insurance
Code.  The requirement that 
16
health
benefits be covered as provided in this is an exclusive 
17
power and function of
the State and is a denial and limitation 
18
under Article VII, Section 6,
subsection (h) of the Illinois 
19
Constitution.  A home rule municipality to which
this Section 
20
applies must comply with every provision of this Section.


21
(Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)


 
22
    Section 20. The School Code is amended by changing
Section 
23
10-22.3f as follows:


 
24
    (105 ILCS 5/10-22.3f)

25
    Sec. 10-22.3f. Required health benefits.   Insurance 
26
protection and
benefits
for employees shall provide the 
27
post-mastectomy care benefits required to be
covered by a 
28
policy of accident and health insurance under Section 356t and 
29
the
coverage required under Sections 356u, 356w, and 356x and 
30
356z.6 of
the
Illinois Insurance Code.


31
(Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)


 
 


 






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    Section 25. The Illinois Insurance Code is amended by 
2
adding Section 356z.6
as
follows:


 
3
    (215 ILCS 5/356z.6 new)

4
    Sec. 356z.6. Bone mass measurement; osteoporosis.  A group 
5
or individual
policy of
accident and health insurance amended, 
6
delivered, issued,
or renewed after the effective date of this 
7
amendatory Act of the 93rd General
Assembly must
provide 
8
coverage for
medically necessary bone mass measurement and for 
9
the diagnosis and treatment
of osteoporosis on
the
same terms 
10
and conditions that are generally
applicable
to coverage for 
11
other
medical conditions.

 
12
    Section 30. The Health Maintenance Organization Act is 
13
amended by changing
Section 5-3 as follows:


 



14
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)



15
    Sec. 5-3. Insurance Code provisions. 

16
    (a) Health Maintenance Organizations
shall be subject to 
17
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
18
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
19
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
20
356y,
356z.2, 356z.4, 356z.5, 356z.6, 367.2, 367.2-5, 367i, 
21
368a, 368b, 368c, 368d, 368e,
401, 401.1, 402, 403, 403A,
408, 
22
408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection 
23
(2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, 
24
XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

25
    (b) For purposes of the Illinois Insurance Code, except for 
26
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
27
Maintenance Organizations in
the following categories are 
28
deemed to be "domestic companies":


29
        (1) a corporation authorized under the
Dental Service 
30
    Plan Act or the Voluntary Health Services Plans Act;


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        (2) a corporation organized under the laws of this 
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    State; or


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        (3) a corporation organized under the laws of another 
 


 






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    state, 30% or more
of the enrollees of which are residents 
2
    of this State, except a
corporation subject to 
3
    substantially the same requirements in its state of

4
    organization as is a "domestic company" under Article VIII 
5
    1/2 of the
Illinois Insurance Code.

6
    (c) In considering the merger, consolidation, or other 
7
acquisition of
control of a Health Maintenance Organization 
8
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


9
        (1) the Director shall give primary consideration to 
10
    the continuation of
benefits to enrollees and the financial 
11
    conditions of the acquired Health
Maintenance Organization 
12
    after the merger, consolidation, or other
acquisition of 
13
    control takes effect;


14
        (2)(i) the criteria specified in subsection (1)(b) of 
15
    Section 131.8 of
the Illinois Insurance Code shall not 
16
    apply and (ii) the Director, in making
his determination 
17
    with respect to the merger, consolidation, or other

18
    acquisition of control, need not take into account the 
19
    effect on
competition of the merger, consolidation, or 
20
    other acquisition of control;


21
        (3) the Director shall have the power to require the 
22
    following
information:


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            (A) certification by an independent actuary of the 
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        adequacy
of the reserves of the Health Maintenance 
25
        Organization sought to be acquired;


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            (B) pro forma financial statements reflecting the 
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        combined balance
sheets of the acquiring company and 
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        the Health Maintenance Organization sought
to be 
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        acquired as of the end of the preceding year and as of 
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        a date 90 days
prior to the acquisition, as well as pro 
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        forma financial statements
reflecting projected 
32
        combined operation for a period of 2 years;


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            (C) a pro forma business plan detailing an 
34
        acquiring party's plans with
respect to the operation 
35
        of the Health Maintenance Organization sought to
be 
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        acquired for a period of not less than 3 years; and


 


 






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            (D) such other information as the Director shall 
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        require.

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    (d) The provisions of Article VIII 1/2 of the Illinois 
4
Insurance Code
and this Section 5-3 shall apply to the sale by 
5
any health maintenance
organization of greater than 10% of its

6
enrollee population (including without limitation the health 
7
maintenance
organization's right, title, and interest in and to 
8
its health care
certificates).

9
    (e) In considering any management contract or service 
10
agreement subject
to Section 141.1 of the Illinois Insurance 
11
Code, the Director (i) shall, in
addition to the criteria 
12
specified in Section 141.2 of the Illinois
Insurance Code, take 
13
into account the effect of the management contract or
service 
14
agreement on the continuation of benefits to enrollees and the

15
financial condition of the health maintenance organization to 
16
be managed or
serviced, and (ii) need not take into account the 
17
effect of the management
contract or service agreement on 
18
competition.

19
    (f) Except for small employer groups as defined in the 
20
Small Employer
Rating, Renewability and Portability Health 
21
Insurance Act and except for
medicare supplement policies as 
22
defined in Section 363 of the Illinois
Insurance Code, a Health 
23
Maintenance Organization may by contract agree with a
group or 
24
other enrollment unit to effect refunds or charge additional 
25
premiums
under the following terms and conditions:


26
        (i) the amount of, and other terms and conditions with 
27
    respect to, the
refund or additional premium are set forth 
28
    in the group or enrollment unit
contract agreed in advance 
29
    of the period for which a refund is to be paid or

30
    additional premium is to be charged (which period shall not 
31
    be less than one
year); and


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        (ii) the amount of the refund or additional premium 
33
    shall not exceed 20%
of the Health Maintenance 
34
    Organization's profitable or unprofitable experience
with 
35
    respect to the group or other enrollment unit for the 
36
    period (and, for
purposes of a refund or additional 
 


 






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    premium, the profitable or unprofitable
experience shall 
2
    be calculated taking into account a pro rata share of the

3
    Health Maintenance Organization's administrative and 
4
    marketing expenses, but
shall not include any refund to be 
5
    made or additional premium to be paid
pursuant to this 
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    subsection (f)).  The Health Maintenance Organization and 
7
    the
group or enrollment unit may agree that the profitable 
8
    or unprofitable
experience may be calculated taking into 
9
    account the refund period and the
immediately preceding 2 
10
    plan years.

11
    The Health Maintenance Organization shall include a 
12
statement in the
evidence of coverage issued to each enrollee 
13
describing the possibility of a
refund or additional premium, 
14
and upon request of any group or enrollment unit,
provide to 
15
the group or enrollment unit a description of the method used 
16
to
calculate (1) the Health Maintenance Organization's 
17
profitable experience with
respect to the group or enrollment 
18
unit and the resulting refund to the group
or enrollment unit 
19
or (2) the Health Maintenance Organization's unprofitable

20
experience with respect to the group or enrollment unit and the 
21
resulting
additional premium to be paid by the group or 
22
enrollment unit.

23
    In no event shall the Illinois Health Maintenance 
24
Organization
Guaranty Association be liable to pay any 
25
contractual obligation of an
insolvent organization to pay any 
26
refund authorized under this Section.

27
(Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, 
28
eff. 1-1-04;
93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised 
29
9-25-03.)


 
30
    Section 35. The Voluntary Health Services Plans Act is 
31
amended by changing
Section 10 as follows:


 



32
    (215 ILCS 165/10)  (from Ch. 32, par. 604)



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    Sec. 10. Application of Insurance Code provisions. Health 
34
services
plan corporations and all persons interested therein 
 


 






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or dealing therewith
shall be subject to the provisions of 
2
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
3
149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, 
4
356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 367.2, 368a, 401, 
5
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
6
and (15) of Section 367 of the Illinois
Insurance Code.

7
(Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;

8
92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 
9
93-529, eff.
8-14-03; revised 9-25-03.)


 
10
    Section 40. The Illinois Public Aid Code is amended by 
11
changing
Section 5-16.8 as follows:


 
12
    (305 ILCS 5/5-16.8)

13
    Sec. 5-16.8. Required health benefits.   The medical 
14
assistance program
shall
provide the post-mastectomy care 
15
benefits required to be covered by a policy of
accident and 
16
health insurance under Section 356t and the coverage required

17
under Sections 356u, 356w, and 356x and 356z.6 of the Illinois

18
Insurance Code.


19
(Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)