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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois, | ||||||||||||||||||||||||||||||||||||||||||
3 | represented in the General Assembly:
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4 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||||||||||||||||||||||||||||||||||||||
5 | is amended by
changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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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.9, 356z.10, and 356z.11
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14 | of the
Illinois Insurance Code.
The program of health benefits | ||||||||||||||||||||||||||||||||||||||||||
15 | must comply with Section 155.37 of the
Illinois Insurance Code.
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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.)
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18 | Section 10. The Counties Code is amended by changing | ||||||||||||||||||||||||||||||||||||||||||
19 | Section 5-1069.3 as
follows:
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20 | (55 ILCS 5/5-1069.3)
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21 | Sec. 5-1069.3. Required health benefits. If a county, |
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1 | including a home
rule
county, is a self-insurer for purposes of | ||||||
2 | providing health insurance coverage
for its employees, the | ||||||
3 | coverage shall include coverage for the post-mastectomy
care | ||||||
4 | benefits required to be covered by a policy of accident and | ||||||
5 | health
insurance under Section 356t and the coverage required | ||||||
6 | under Sections 356u,
356w, 356x ,
and 356z.6 , 356z.9, 356z.10, | ||||||
7 | and 356z.11 of
the Illinois Insurance Code. The requirement | ||||||
8 | that health benefits be covered
as provided in this Section is | ||||||
9 | an
exclusive power and function of the State and is a denial | ||||||
10 | and limitation under
Article VII, Section 6, subsection (h) of | ||||||
11 | the Illinois Constitution. A home
rule county to which this | ||||||
12 | Section applies must comply with every provision of
this | ||||||
13 | Section.
| ||||||
14 | (Source: P.A. 93-853, eff. 1-1-05.)
| ||||||
15 | Section 15. The Illinois Municipal Code is amended by | ||||||
16 | changing Section
10-4-2.3 as follows:
| ||||||
17 | (65 ILCS 5/10-4-2.3)
| ||||||
18 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
19 | municipality, including a
home rule municipality, is a | ||||||
20 | self-insurer for purposes of providing health
insurance | ||||||
21 | coverage for its employees, the coverage shall include coverage | ||||||
22 | for
the post-mastectomy care benefits required to be covered by | ||||||
23 | a policy of
accident and health insurance under Section 356t | ||||||
24 | and the coverage required
under Sections 356u, 356w, 356x ,
and
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| |||||||
1 | 356z.6 , 356z.9, 356z.10, and 356z.11 of the Illinois
Insurance
| ||||||
2 | Code. The requirement that health
benefits be covered as | ||||||
3 | provided in this is an exclusive power and function of
the | ||||||
4 | State and is a denial and limitation under Article VII, Section | ||||||
5 | 6,
subsection (h) of the Illinois Constitution. A home rule | ||||||
6 | municipality to which
this Section applies must comply with | ||||||
7 | every provision of this Section.
| ||||||
8 | (Source: P.A. 93-853, eff. 1-1-05.)
| ||||||
9 | Section 20. The School Code is amended by changing Section | ||||||
10 | 10-22.3f as
follows:
| ||||||
11 | (105 ILCS 5/10-22.3f)
| ||||||
12 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
13 | protection and
benefits
for employees shall provide the | ||||||
14 | post-mastectomy care benefits required to be
covered by a | ||||||
15 | policy of accident and health insurance under Section 356t and | ||||||
16 | the
coverage required under Sections 356u, 356w, 356x ,
and
| ||||||
17 | 356z.6 , 356z.9, 356z.10, and 356z.11 of
the
Illinois Insurance | ||||||
18 | Code.
| ||||||
19 | (Source: P.A. 93-853, eff. 1-1-05.)
| ||||||
20 | Section 25. The Illinois Insurance Code is amended by | ||||||
21 | adding Sections
356z.9,
356z.10,
and 356z.11
as
follows:
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22 | (215 ILCS 5/356z.9 new)
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1 | Sec. 356z.9. Intravenous feeding. A group or individual | ||||||
2 | policy of
accident and health insurance or managed care plan | ||||||
3 | amended, delivered, issued,
or renewed after the effective date | ||||||
4 | of this amendatory Act of the 95th General
Assembly must | ||||||
5 | provide coverage for intravenous feeding. The benefits under
| ||||||
6 | this Section shall be at least as favorable as for other | ||||||
7 | coverages under the
policy and may be subject to the same | ||||||
8 | dollar amount limits, deductibles, and
co-insurance | ||||||
9 | requirements applicable generally to other coverages under the
| ||||||
10 | policy. | ||||||
11 | (215 ILCS 5/356z.10 new)
| ||||||
12 | Sec. 356z.10. Prescription nutritional supplements. A | ||||||
13 | group or individual
policy of
accident and health insurance or | ||||||
14 | managed care plan amended, delivered, issued,
or renewed
after | ||||||
15 | the effective date of this amendatory Act of the 95th General | ||||||
16 | Assembly
that provides
coverage for prescription drugs must | ||||||
17 | provide coverage for reimbursement for
medically
appropriate | ||||||
18 | prescription nutritional supplements when ordered by a | ||||||
19 | physician
licensed to
practice medicine in all its branches and | ||||||
20 | the insured suffers from a condition
that prevents
him or her | ||||||
21 | from taking sufficient oral nourishment to sustain life. | ||||||
22 | (215 ILCS 5/356z.11 new)
| ||||||
23 | Sec. 356z.11. Pain medication coverage. A group or | ||||||
24 | individual policy
of accident and health insurance or managed |
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| |||||||
1 | care plan amended, delivered,
issued, or renewed after the | ||||||
2 | effective date of this amendatory Act of the
95th General | ||||||
3 | Assembly that provides coverage for prescription drugs must
| ||||||
4 | provide coverage for any pain medication prescribed or ordered | ||||||
5 | by the
insured's treating physician licensed to practice | ||||||
6 | medicine in all its branches.
| ||||||
7 | Section 30. The Health Maintenance Organization Act is | ||||||
8 | amended by changing
Section 5-3 as follows:
| ||||||
9 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
10 | Sec. 5-3. Insurance Code provisions.
| ||||||
11 | (a) Health Maintenance Organizations
shall be subject to | ||||||
12 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
13 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
14 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
15 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
16 | 356z.11, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | ||||||
17 | 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | ||||||
18 | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | ||||||
19 | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | ||||||
20 | and XXVI of the Illinois Insurance Code.
| ||||||
21 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
22 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
23 | Maintenance Organizations in
the following categories are | ||||||
24 | deemed to be "domestic companies":
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| |||||||
1 | (1) a corporation authorized under the
Dental Service | ||||||
2 | Plan Act or the Voluntary Health Services Plans Act;
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3 | (2) a corporation organized under the laws of this | ||||||
4 | State; or
| ||||||
5 | (3) a corporation organized under the laws of another | ||||||
6 | state, 30% or more
of the enrollees of which are residents | ||||||
7 | of this State, except a
corporation subject to | ||||||
8 | substantially the same requirements in its state of
| ||||||
9 | organization as is a "domestic company" under Article VIII | ||||||
10 | 1/2 of the
Illinois Insurance Code.
| ||||||
11 | (c) In considering the merger, consolidation, or other | ||||||
12 | acquisition of
control of a Health Maintenance Organization | ||||||
13 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
14 | (1) the Director shall give primary consideration to | ||||||
15 | the continuation of
benefits to enrollees and the financial | ||||||
16 | conditions of the acquired Health
Maintenance Organization | ||||||
17 | after the merger, consolidation, or other
acquisition of | ||||||
18 | control takes effect;
| ||||||
19 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
20 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
21 | apply and (ii) the Director, in making
his determination | ||||||
22 | with respect to the merger, consolidation, or other
| ||||||
23 | acquisition of control, need not take into account the | ||||||
24 | effect on
competition of the merger, consolidation, or | ||||||
25 | other acquisition of control;
| ||||||
26 | (3) the Director shall have the power to require the |
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1 | following
information:
| ||||||
2 | (A) certification by an independent actuary of the | ||||||
3 | adequacy
of the reserves of the Health Maintenance | ||||||
4 | Organization sought to be acquired;
| ||||||
5 | (B) pro forma financial statements reflecting the | ||||||
6 | combined balance
sheets of the acquiring company and | ||||||
7 | the Health Maintenance Organization sought
to be | ||||||
8 | acquired as of the end of the preceding year and as of | ||||||
9 | a date 90 days
prior to the acquisition, as well as pro | ||||||
10 | forma financial statements
reflecting projected | ||||||
11 | combined operation for a period of 2 years;
| ||||||
12 | (C) a pro forma business plan detailing an | ||||||
13 | acquiring party's plans with
respect to the operation | ||||||
14 | of the Health Maintenance Organization sought to
be | ||||||
15 | acquired for a period of not less than 3 years; and
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16 | (D) such other information as the Director shall | ||||||
17 | require.
| ||||||
18 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
19 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
20 | any health maintenance
organization of greater than 10% of its
| ||||||
21 | enrollee population (including without limitation the health | ||||||
22 | maintenance
organization's right, title, and interest in and to | ||||||
23 | its health care
certificates).
| ||||||
24 | (e) In considering any management contract or service | ||||||
25 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
26 | Code, the Director (i) shall, in
addition to the criteria |
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| |||||||
1 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
2 | into account the effect of the management contract or
service | ||||||
3 | agreement on the continuation of benefits to enrollees and the
| ||||||
4 | financial condition of the health maintenance organization to | ||||||
5 | be managed or
serviced, and (ii) need not take into account the | ||||||
6 | effect of the management
contract or service agreement on | ||||||
7 | competition.
| ||||||
8 | (f) Except for small employer groups as defined in the | ||||||
9 | Small Employer
Rating, Renewability and Portability Health | ||||||
10 | Insurance Act and except for
medicare supplement policies as | ||||||
11 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
12 | Maintenance Organization may by contract agree with a
group or | ||||||
13 | other enrollment unit to effect refunds or charge additional | ||||||
14 | premiums
under the following terms and conditions:
| ||||||
15 | (i) the amount of, and other terms and conditions with | ||||||
16 | respect to, the
refund or additional premium are set forth | ||||||
17 | in the group or enrollment unit
contract agreed in advance | ||||||
18 | of the period for which a refund is to be paid or
| ||||||
19 | additional premium is to be charged (which period shall not | ||||||
20 | be less than one
year); and
| ||||||
21 | (ii) the amount of the refund or additional premium | ||||||
22 | shall not exceed 20%
of the Health Maintenance | ||||||
23 | Organization's profitable or unprofitable experience
with | ||||||
24 | respect to the group or other enrollment unit for the | ||||||
25 | period (and, for
purposes of a refund or additional | ||||||
26 | premium, the profitable or unprofitable
experience shall |
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1 | be calculated taking into account a pro rata share of the
| ||||||
2 | Health Maintenance Organization's administrative and | ||||||
3 | marketing expenses, but
shall not include any refund to be | ||||||
4 | made or additional premium to be paid
pursuant to this | ||||||
5 | subsection (f)). The Health Maintenance Organization and | ||||||
6 | the
group or enrollment unit may agree that the profitable | ||||||
7 | or unprofitable
experience may be calculated taking into | ||||||
8 | account the refund period and the
immediately preceding 2 | ||||||
9 | plan years.
| ||||||
10 | The Health Maintenance Organization shall include a | ||||||
11 | statement in the
evidence of coverage issued to each enrollee | ||||||
12 | describing the possibility of a
refund or additional premium, | ||||||
13 | and upon request of any group or enrollment unit,
provide to | ||||||
14 | the group or enrollment unit a description of the method used | ||||||
15 | to
calculate (1) the Health Maintenance Organization's | ||||||
16 | profitable experience with
respect to the group or enrollment | ||||||
17 | unit and the resulting refund to the group
or enrollment unit | ||||||
18 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
19 | experience with respect to the group or enrollment unit and the | ||||||
20 | resulting
additional premium to be paid by the group or | ||||||
21 | enrollment unit.
| ||||||
22 | In no event shall the Illinois Health Maintenance | ||||||
23 | Organization
Guaranty Association be liable to pay any | ||||||
24 | contractual obligation of an
insolvent organization to pay any | ||||||
25 | refund authorized under this Section.
| ||||||
26 | (Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, |
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| |||||||
1 | eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; | ||||||
2 | 93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff. | ||||||
3 | 12-29-06; revised 1-5-07.)
| ||||||
4 | Section 35. The Voluntary Health Services Plans Act is | ||||||
5 | amended by changing
Section 10 as follows:
| ||||||
6 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
7 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
8 | services
plan corporations and all persons interested therein | ||||||
9 | or dealing therewith
shall be subject to the provisions of | ||||||
10 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
11 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
12 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
13 | 356z.10, 356z.11, 364.01, 367.2, 368a, 401, 401.1,
402,
403, | ||||||
14 | 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | ||||||
15 | Section 367 of the Illinois
Insurance Code.
| ||||||
16 | (Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; | ||||||
17 | 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. | ||||||
18 | 12-29-06.)
| ||||||
19 | Section 90. The State Mandates Act is amended by adding | ||||||
20 | Section 8.31 as follows: | ||||||
21 | (30 ILCS 805/8.31 new) | ||||||
22 | Sec. 8.31. Exempt mandate. Notwithstanding Sections 6 and 8 |
| |||||||
| |||||||
1 | of this Act, no reimbursement by the State is required for the | ||||||
2 | implementation of any mandate created by this amendatory Act of | ||||||
3 | the 95th General Assembly. |