093_HB0485eng

 
HB0485 Engrossed                     LRB093 05219 JLS 05279 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,  and  356z.2,  356z.4,  356z.5,
14    356z.6, 356z.7, and 356z.8 of the  Illinois  Insurance  Code.
15    The  program  of  health  benefits  must  comply with Section
16    155.37 of the Illinois Insurance Code.
17    (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03.)

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
23    of 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, 356z.4, 356z.5, 356z.6,
28    356z.7, and 356z.8  of  the  Illinois  Insurance  Code.   The
29    requirement  that  health  benefits be covered as provided in
 
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 1    this Section is an exclusive power and function of the  State
 2    and  is a denial and limitation under Article VII, Section 6,
 3    subsection (h) of the Illinois  Constitution.   A  home  rule
 4    county  to  which this Section applies must comply with every
 5    provision of this Section.
 6    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

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

 9        (65 ILCS 5/10-4-2.3)
10        Sec.   10-4-2.3.    Required   health   benefits.   If  a
11    municipality,  including  a  home  rule  municipality,  is  a
12    self-insurer  for  purposes  of  providing  health  insurance
13    coverage  for  its  employees,  the  coverage  shall  include
14    coverage for the post-mastectomy care benefits required to be
15    covered by a policy of accident and  health  insurance  under
16    Section  356t  and the coverage required under Sections 356u,
17    356w, and 356x, 356z.4, 356z.5, 356z.6, 356z.7, and 356z.8 of
18    the Illinois Insurance Code.   The  requirement  that  health
19    benefits be covered as provided in this is an exclusive power
20    and  function  of  the  State  and is a denial and limitation
21    under Article VII, Section 6, subsection (h) of the  Illinois
22    Constitution.  A home rule municipality to which this Section
23    applies must comply with every provision of this Section.
24    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

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

27        (105 ILCS 5/10-22.3f)
28        Sec.  10-22.3f.  Required  health  benefits.    Insurance
29    protection  and  benefits  for  employees  shall  provide the
30    post-mastectomy care benefits required to  be  covered  by  a
 
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 1    policy  of  accident  and health insurance under Section 356t
 2    and the coverage required  under  Sections  356u,  356w,  and
 3    356x,  356z.4,  356z.5,  356z.6,  356z.7,  and  356z.8 of the
 4    Illinois Insurance Code.
 5    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

 6        Section 25.  The Illinois Insurance Code  is  amended  by
 7    adding Sections 356z.4, 356z.5, 356z.6, 356z.7, and 356z.8 as
 8    follows:

 9        (215 ILCS 5/356z.4 new)
10        Sec.   356z.4.  Birth   control  coverage.   A  group  or
11    individual policy of accident and health insurance or managed
12    care plan amended, delivered, issued, or  renewed  after  the
13    effective  date  of  this  amendatory Act of the 93rd General
14    Assembly that provides coverage for prescribed drugs approved
15    by the federal Food and Drug Administration for the treatment
16    of impotence must also provide coverage for prescribed  drugs
17    approved  by the federal Food and Drug Administration for the
18    prevention of pregnancy on the same terms and conditions that
19    are generally applicable to  coverage  for  other  prescribed
20    drugs approved by the federal Food and Drug Administration.

21        (215 ILCS 5/356z.5 new)
22        Sec. 356z.5. AIDS vaccine.
23        (a)  A  group or individual policy of accident and health
24    insurance or managed care plan amended, delivered, issued, or
25    renewed after the effective date of this  amendatory  Act  of
26    the 93rd General Assembly must provide coverage for a vaccine
27    for  acquired  immune  deficiency  syndrome  (AIDS)  that  is
28    approved   for   marketing  by  the  federal  Food  and  Drug
29    Administration and that is recommended by the  United  States
30    Public Health Service.
31        (b)  This  Section  does not require a policy of accident
 
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 1    and health insurance to provide  coverage  for  any  clinical
 2    trials  relating  to  an AIDS vaccine or for any AIDS vaccine
 3    that  has  been  approved  by  the  federal  Food  and   Drug
 4    Administration  in  the  form  of an investigational new drug
 5    application.

 6        (215 ILCS 5/356z.6 new)
 7        Sec.  356z.6.  Prescription  nutritional  supplements.  A
 8    group or individual policy of accident and  health  insurance
 9    or  managed  care plan amended, delivered, issued, or renewed
10    after the effective date of this amendatory Act of  the  93rd
11    General  Assembly  that  provides  coverage  for prescription
12    drugs must provide coverage for reimbursement  for  medically
13    appropriate prescription nutritional supplements when ordered
14    by  a  physician  licensed  to  practice  medicine in all its
15    branches and  the  insured  suffers  from  a  condition  that
16    prevents  him  or her from taking sufficient oral nourishment
17    to sustain life.

18        (215 ILCS 5/356z.7 new)
19        Sec.  356z.7.  Pain  medication  coverage.  A  group   or
20    individual policy of accident and health insurance or managed
21    care  plan  amended,  delivered, issued, or renewed after the
22    effective date of this amendatory Act  of  the  93rd  General
23    Assembly  that  provides coverage for prescription drugs must
24    provide  coverage  for  any  pain  medication  prescribed  or
25    ordered by the insured's treating physician.

26        (215 ILCS 5.356z.8 new)
27        Sec. 356z.8.  Intravenous feeding.  A group or individual
28    policy of accident and health insurance or managed care  plan
29    amended,  delivered,  issued,  or renewed after the effective
30    date of this amendatory Act of the 93rd General Assembly must
31    provide coverage for intravenous feeding.  The benefits under
 
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 1    this Section shall be at least  as  favorable  as  for  other
 2    coverages  under  the  policy  and may be subject to the same
 3    dollar   amount   limits,   deductibles,   and   co-insurance
 4    requirements applicable generally to  other  coverages  under
 5    the policy.

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

 8        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
 9        Sec. 5-3.  Insurance Code provisions.
10        (a)  Health Maintenance Organizations shall be subject to
11    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
12    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
13    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
14    356y,  356z.2,  356z.4,  356z.5, 356z.6, 356z.7, 356z.8 367i,
15    368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,  444,
16    and  444.1,  paragraph  (c) of subsection (2) of Section 367,
17    and Articles IIA, VIII 1/2, XII, XII  1/2,  XIII,  XIII  1/2,
18    XXV, and XXVI of the Illinois Insurance Code.
19        (b)  For  purposes of the Illinois Insurance Code, except
20    for Sections 444 and 444.1 and Articles XIII  and  XIII  1/2,
21    Health  Maintenance Organizations in the following categories
22    are deemed to be "domestic companies":
23             (1)  a  corporation  authorized  under  the   Dental
24        Service  Plan  Act or the Voluntary Health Services Plans
25        Act;
26             (2)  a corporation organized under the laws of  this
27        State; or
28             (3)  a  corporation  organized  under  the  laws  of
29        another  state, 30% or more of the enrollees of which are
30        residents of this State, except a corporation subject  to
31        substantially  the  same  requirements  in  its  state of
32        organization as is a  "domestic  company"  under  Article
 
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 1        VIII 1/2 of the Illinois Insurance Code.
 2        (c)  In  considering  the merger, consolidation, or other
 3    acquisition of control of a Health  Maintenance  Organization
 4    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
 5             (1)  the  Director  shall give primary consideration
 6        to the continuation of  benefits  to  enrollees  and  the
 7        financial  conditions  of the acquired Health Maintenance
 8        Organization after the merger,  consolidation,  or  other
 9        acquisition of control takes effect;
10             (2)(i)  the  criteria specified in subsection (1)(b)
11        of Section 131.8 of the Illinois Insurance Code shall not
12        apply and (ii) the Director, in making his  determination
13        with  respect  to  the  merger,  consolidation,  or other
14        acquisition of control, need not take  into  account  the
15        effect  on  competition  of the merger, consolidation, or
16        other acquisition of control;
17             (3)  the Director shall have the  power  to  require
18        the following information:
19                  (A)  certification by an independent actuary of
20             the   adequacy   of   the  reserves  of  the  Health
21             Maintenance Organization sought to be acquired;
22                  (B)  pro forma financial statements  reflecting
23             the combined balance sheets of the acquiring company
24             and the Health Maintenance Organization sought to be
25             acquired  as of the end of the preceding year and as
26             of a date 90 days prior to the acquisition, as  well
27             as   pro   forma   financial  statements  reflecting
28             projected combined  operation  for  a  period  of  2
29             years;
30                  (C)  a  pro  forma  business  plan detailing an
31             acquiring  party's  plans  with   respect   to   the
32             operation  of  the  Health  Maintenance Organization
33             sought to be acquired for a period of not less  than
34             3 years; and
 
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 1                  (D)  such  other  information  as  the Director
 2             shall require.
 3        (d)  The provisions of Article VIII 1/2 of  the  Illinois
 4    Insurance  Code  and this Section 5-3 shall apply to the sale
 5    by any health maintenance organization of greater than 10% of
 6    its enrollee population  (including  without  limitation  the
 7    health  maintenance organization's right, title, and interest
 8    in and to 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,
13    take into account the effect of the  management  contract  or
14    service   agreement   on  the  continuation  of  benefits  to
15    enrollees  and  the  financial  condition   of   the   health
16    maintenance  organization to be managed or serviced, and (ii)
17    need not take into  account  the  effect  of  the  management
18    contract or service agreement on 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
23    Health  Maintenance Organization may by contract agree with a
24    group or other enrollment unit to effect  refunds  or  charge
25    additional premiums under the following terms and conditions:
26             (i)  the  amount  of, and other terms and conditions
27        with respect to, the refund or additional premium are set
28        forth in the group or enrollment unit contract agreed  in
29        advance of the period for which a refund is to be paid or
30        additional  premium  is to be charged (which period shall
31        not be less than one year); and
32             (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
 
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 1        respect  to  the  group  or other enrollment unit for the
 2        period (and, for  purposes  of  a  refund  or  additional
 3        premium,  the profitable or unprofitable experience shall
 4        be calculated taking into account a pro rata share of the
 5        Health  Maintenance  Organization's  administrative   and
 6        marketing  expenses,  but shall not include any refund to
 7        be made or additional premium to be paid pursuant to this
 8        subsection (f)).  The Health Maintenance Organization and
 9        the  group  or  enrollment  unit  may  agree   that   the
10        profitable  or  unprofitable experience may be calculated
11        taking into account the refund period and the immediately
12        preceding 2 plan years.
13        The  Health  Maintenance  Organization  shall  include  a
14    statement in the evidence of coverage issued to each enrollee
15    describing the possibility of a refund or additional premium,
16    and upon request of any group or enrollment unit, provide  to
17    the group or enrollment unit a description of the method used
18    to   calculate  (1)  the  Health  Maintenance  Organization's
19    profitable experience with respect to the group or enrollment
20    unit and the resulting refund to the group or enrollment unit
21    or (2) the  Health  Maintenance  Organization's  unprofitable
22    experience  with  respect to the group or enrollment unit and
23    the resulting additional premium to be paid by the  group  or
24    enrollment unit.
25        In   no  event  shall  the  Illinois  Health  Maintenance
26    Organization  Guaranty  Association  be  liable  to  pay  any
27    contractual obligation of an insolvent  organization  to  pay
28    any refund authorized under this Section.
29    (Source: P.A.  91-357,  eff.  7-29-99;  91-406,  eff. 1-1-00;
30    91-549, eff. 8-14-99; 91-605,  eff.  12-14-99;  91-788,  eff.
31    6-9-00; 92-764, eff. 1-1-03.)

32        Section  35.  The  Voluntary Health Services Plans Act is
33    amended by changing Section 10 as follows:
 
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 1        (215 ILCS 165/10) (from Ch. 32, par. 604)
 2        Sec.  10.  Application  of  Insurance  Code   provisions.
 3    Health  services plan corporations and all persons interested
 4    therein  or  dealing  therewith  shall  be  subject  to   the
 5    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
 6    140,  143,  143c,  149, 155.37, 354, 355.2, 356r, 356t, 356u,
 7    356v, 356w,  356x,  356y,  356z.1,  356z.2,  356z.4,  356z.5,
 8    356z.6,  356z.7,  356z.8,  367.2, 368a, 401, 401.1, 402, 403,
 9    403A, 408, 408.2, and 412, and paragraphs  (7)  and  (15)  of
10    Section 367 of the Illinois Insurance Code.
11    (Source: P.A.  91-406,  eff.  1-1-00;  91-549,  eff. 8-14-99;
12    91-605, eff. 12-14-99;  91-788,  eff.  6-9-00;  92-130,  eff.
13    7-20-01;  92-440, eff. 8-17-01; 92-651, eff. 7-11-02; 92-764,
14    eff. 1-1-03.)

15        Section 90.  The State Mandates Act is amended by  adding
16    Section 8.27 as follows:

17        (30 ILCS 805/8.27 new)
18        Sec.  8.27.  Exempt  mandate.  Notwithstanding Sections 6
19    and 8 of this Act, no reimbursement by the State is  required
20    for  the  implementation  of  any  mandate  created  by  this
21    amendatory Act of the 93rd General Assembly.