HB0637 Engrossed

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    AN ACT concerning insurance. 

 
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, 356z.4, and 356z.6, 356z.7, 356z.9, and 356z.10 
14
of the
Illinois Insurance Code.
The program of health benefits 
15
must comply with Section 155.37 of the
Illinois Insurance Code.

16
(Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; 
17
93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)


 
18
    Section 10. The Counties Code is amended by changing 
19
Section 5-1069.3 as
follows:


 
20
    (55 ILCS 5/5-1069.3)

21
    Sec. 5-1069.3. Required health benefits.   If a county, 
22
including a home
rule
county, is a self-insurer for purposes of 
23
providing health insurance coverage
for its employees, the 
24
coverage shall include coverage for the post-mastectomy
care 
25
benefits required to be covered by a policy of accident and 
26
health
insurance under Section 356t and the coverage required 
27
under Sections 356u,
356w, 356x,
and 356z.6, 356z.7, 356z.9, 
28
and 356z.10  of
the Illinois Insurance Code.  The requirement 
29
that health benefits be covered
as provided in this Section is 
30
an
exclusive power and function of the State and is a denial 
 


 






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and 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. 93-853, eff. 1-1-05.)


 
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 coverage 
13
for
the post-mastectomy care benefits required to be covered by 
14
a policy of
accident and health insurance under Section 356t 
15
and the coverage required
under Sections 356u, 356w, 356x,
and 
16
356z.6, 356z.7, 356z.9, and 356z.10 of the Illinois
Insurance

17
Code.  The requirement that health
benefits be covered as 
18
provided in this is an exclusive power and function of
the 
19
State and is a denial and limitation under Article VII, Section 
20
6,
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. 93-853, eff. 1-1-05.)


 
24
    Section 20. The School Code is amended by changing Section 
25
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 and 
31
the
coverage required under Sections 356u, 356w, 356x,
and 
32
356z.6, 356z.7, 356z.9, and 356z.10 of
the
Illinois Insurance 
 


 






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Code.


2
(Source: P.A. 93-853, eff. 1-1-05.)


 
3
    Section 25. The Illinois Insurance Code is amended by 
4
adding Sections
356z.7,
356z.9,
and 356z.10
as
follows:


 
5
    (215 ILCS 5/356z.7 new)

6
    Sec. 356z.7. Intravenous feeding.   A group or individual 
7
policy of
accident and health insurance or managed care plan 
8
amended, delivered, issued,
or renewed after the effective date 
9
of this amendatory Act of the 94th General
Assembly must 
10
provide coverage for intravenous feeding.  The benefits under

11
this Section shall be at least as favorable as for other 
12
coverages under the
policy and may be subject to the same 
13
dollar amount limits, deductibles, and
co-insurance 
14
requirements applicable generally to other coverages under the

15
policy.
 
16
    (215 ILCS 5/356z.9 new)

17
    Sec. 356z.9. Prescription nutritional supplements. A group 
18
or individual
policy of
accident and health insurance or 
19
managed care plan amended, delivered, issued,
or renewed
after 
20
the effective date of this amendatory Act of the 94th General 
21
Assembly
that provides
coverage for prescription drugs must 
22
provide coverage for reimbursement for
medically
appropriate 
23
prescription nutritional supplements when ordered by a 
24
physician
licensed to
practice medicine in all its branches and 
25
the insured suffers from a condition
that prevents
him or her 
26
from taking sufficient oral nourishment to sustain life.
 
27
    (215 ILCS 5/356z.10 new)

28
    Sec. 356z.10. Pain medication coverage. A group or 
29
individual policy
of accident and health insurance or managed 
30
care plan amended, delivered,
issued, or renewed after the 
31
effective date of this amendatory Act of the
94th General 
32
Assembly that provides coverage for prescription drugs must

 


 






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provide coverage for any pain medication prescribed or ordered 
2
by the
insured's treating physician licensed to practice 
3
medicine in all its branches.

 
4
    Section 30. The Health Maintenance Organization Act is 
5
amended by changing
Section 5-3 as follows:


 



6
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


7
    Sec. 5-3. Insurance Code provisions. 

8
    (a) Health Maintenance Organizations
shall be subject to 
9
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
10
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
11
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
12
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 356z.9, 356z.10, 
13
364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,

14
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and

15
444.1,
paragraph (c) of subsection (2) of Section 367, and 
16
Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and 
17
XXVI of the Illinois Insurance Code.

18
    (b) For purposes of the Illinois Insurance Code, except for 
19
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
20
Maintenance Organizations in
the following categories are 
21
deemed to be "domestic companies":


22
        (1) a corporation authorized under the
Dental Service 
23
    Plan Act or the Voluntary Health Services Plans Act;


24
        (2) a corporation organized under the laws of this 
25
    State; or


26
        (3) a corporation organized under the laws of another 
27
    state, 30% or more
of the enrollees of which are residents 
28
    of this State, except a
corporation subject to 
29
    substantially the same requirements in its state of

30
    organization as is a "domestic company" under Article VIII 
31
    1/2 of the
Illinois Insurance Code.

32
    (c) In considering the merger, consolidation, or other 
33
acquisition of
control of a Health Maintenance Organization 
34
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


 


 






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        (1) the Director shall give primary consideration to 
2
    the continuation of
benefits to enrollees and the financial 
3
    conditions of the acquired Health
Maintenance Organization 
4
    after the merger, consolidation, or other
acquisition of 
5
    control takes effect;


6
        (2)(i) the criteria specified in subsection (1)(b) of 
7
    Section 131.8 of
the Illinois Insurance Code shall not 
8
    apply and (ii) the Director, in making
his determination 
9
    with respect to the merger, consolidation, or other

10
    acquisition of control, need not take into account the 
11
    effect on
competition of the merger, consolidation, or 
12
    other acquisition of control;


13
        (3) the Director shall have the power to require the 
14
    following
information:


15
            (A) certification by an independent actuary of the 
16
        adequacy
of the reserves of the Health Maintenance 
17
        Organization sought to be acquired;


18
            (B) pro forma financial statements reflecting the 
19
        combined balance
sheets of the acquiring company and 
20
        the Health Maintenance Organization sought
to be 
21
        acquired as of the end of the preceding year and as of 
22
        a date 90 days
prior to the acquisition, as well as pro 
23
        forma financial statements
reflecting projected 
24
        combined operation for a period of 2 years;


25
            (C) a pro forma business plan detailing an 
26
        acquiring party's plans with
respect to the operation 
27
        of the Health Maintenance Organization sought to
be 
28
        acquired for a period of not less than 3 years; and


29
            (D) such other information as the Director shall 
30
        require.

31
    (d) The provisions of Article VIII 1/2 of the Illinois 
32
Insurance Code
and this Section 5-3 shall apply to the sale by 
33
any health maintenance
organization of greater than 10% of its

34
enrollee population (including without limitation the health 
35
maintenance
organization's right, title, and interest in and to 
36
its health care
certificates).

 


 






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    (e) In considering any management contract or service 
2
agreement subject
to Section 141.1 of the Illinois Insurance 
3
Code, the Director (i) shall, in
addition to the criteria 
4
specified in Section 141.2 of the Illinois
Insurance Code, take 
5
into account the effect of the management contract or
service 
6
agreement on the continuation of benefits to enrollees and the

7
financial condition of the health maintenance organization to 
8
be managed or
serviced, and (ii) need not take into account the 
9
effect of the management
contract or service agreement on 
10
competition.

11
    (f) Except for small employer groups as defined in the 
12
Small Employer
Rating, Renewability and Portability Health 
13
Insurance Act and except for
medicare supplement policies as 
14
defined in Section 363 of the Illinois
Insurance Code, a Health 
15
Maintenance Organization may by contract agree with a
group or 
16
other enrollment unit to effect refunds or charge additional 
17
premiums
under the following terms and conditions:


18
        (i) the amount of, and other terms and conditions with 
19
    respect to, the
refund or additional premium are set forth 
20
    in the group or enrollment unit
contract agreed in advance 
21
    of the period for which a refund is to be paid or

22
    additional premium is to be charged (which period shall not 
23
    be less than one
year); and


24
        (ii) the amount of the refund or additional premium 
25
    shall not exceed 20%
of the Health Maintenance 
26
    Organization's profitable or unprofitable experience
with 
27
    respect to the group or other enrollment unit for the 
28
    period (and, for
purposes of a refund or additional 
29
    premium, the profitable or unprofitable
experience shall 
30
    be calculated taking into account a pro rata share of the

31
    Health Maintenance Organization's administrative and 
32
    marketing expenses, but
shall not include any refund to be 
33
    made or additional premium to be paid
pursuant to this 
34
    subsection (f)).  The Health Maintenance Organization and 
35
    the
group or enrollment unit may agree that the profitable 
36
    or unprofitable
experience may be calculated taking into 
 


 






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    account the refund period and the
immediately preceding 2 
2
    plan years.

3
    The Health Maintenance Organization shall include a 
4
statement in the
evidence of coverage issued to each enrollee 
5
describing the possibility of a
refund or additional premium, 
6
and upon request of any group or enrollment unit,
provide to 
7
the group or enrollment unit a description of the method used 
8
to
calculate (1) the Health Maintenance Organization's 
9
profitable experience with
respect to the group or enrollment 
10
unit and the resulting refund to the group
or enrollment unit 
11
or (2) the Health Maintenance Organization's unprofitable

12
experience with respect to the group or enrollment unit and the 
13
resulting
additional premium to be paid by the group or 
14
enrollment unit.

15
    In no event shall the Illinois Health Maintenance 
16
Organization
Guaranty Association be liable to pay any 
17
contractual obligation of an
insolvent organization to pay any 
18
refund authorized under this Section.

19
(Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, 
20
eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, 
21
eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)



 
22
    Section 35. The Voluntary Health Services Plans Act is 
23
amended by changing
Section 10 as follows:


 



24
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


25
    Sec. 10. Application of Insurance Code provisions. Health 
26
services
plan corporations and all persons interested therein 
27
or dealing therewith
shall be subject to the provisions of 
28
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
29
149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, 
30
356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 356z.9, 
31
356z.10, 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,

32
408.2, and 412, and paragraphs (7) and (15) of Section 367 of 
33
the Illinois
Insurance Code.

34
(Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01; 
 


 






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92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 
2
93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 93-1000, eff. 
3
1-1-05; revised 10-14-04.)



 
4
    Section 90. The State Mandates Act is amended by adding 
5
Section 8.29 as
follows:


 
6
    (30 ILCS 805/8.29 new)

7
    Sec. 8.29. Exempt mandate. Notwithstanding Sections 6 and 8 
8
of this
Act, no reimbursement by the State is required for the 
9
implementation of
any mandate created by this amendatory Act of 
10
the 94th General Assembly.