Illinois General Assembly - Full Text of HB4821
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Full Text of HB4821  100th General Assembly

HB4821enr 100TH GENERAL ASSEMBLY

  
  
  

 


 
HB4821 EnrolledLRB100 18480 SMS 33695 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.17, 356z.22, and 356z.25, 356z.26, and
16356z.29 of the Illinois Insurance Code. The program of health
17benefits must comply with Sections 155.22a, 155.37, 355b,
18356z.19, 370c, and 370c.1 of the Illinois Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
3100-138, eff. 8-18-17; revised 10-3-17.)
 
4    Section 10. The Counties Code is amended by changing
5Section 5-1069.3 as follows:
 
6    (55 ILCS 5/5-1069.3)
7    Sec. 5-1069.3. Required health benefits. If a county,
8including a home rule county, is a self-insurer for purposes of
9providing health insurance coverage for its employees, the
10coverage shall include coverage for the post-mastectomy care
11benefits required to be covered by a policy of accident and
12health insurance under Section 356t and the coverage required
13under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and 356z.29 of
16the Illinois Insurance Code. The coverage shall comply with
17Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
18Insurance Code. The requirement that health benefits be covered
19as provided in this Section is an exclusive power and function
20of the State and is a denial and limitation under Article VII,
21Section 6, subsection (h) of the Illinois Constitution. A home
22rule county to which this Section applies must comply with
23every provision of this Section.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

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1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
7100-138, eff. 8-18-17; revised 10-5-17.)
 
8    Section 15. The Illinois Municipal Code is amended by
9changing Section 10-4-2.3 as follows:
 
10    (65 ILCS 5/10-4-2.3)
11    Sec. 10-4-2.3. Required health benefits. If a
12municipality, including a home rule municipality, is a
13self-insurer for purposes of providing health insurance
14coverage for its employees, the coverage shall include coverage
15for the post-mastectomy care benefits required to be covered by
16a policy of accident and health insurance under Section 356t
17and the coverage required under Sections 356g, 356g.5,
18356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
19356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and
20356z.25, 356z.26, and 356z.29 of the Illinois Insurance Code.
21The coverage shall comply with Sections 155.22a, 355b, 356z.19,
22and 370c of the Illinois Insurance Code. The requirement that
23health benefits be covered as provided in this is an exclusive
24power and function of the State and is a denial and limitation

 

 

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1under Article VII, Section 6, subsection (h) of the Illinois
2Constitution. A home rule municipality to which this Section
3applies must comply with every provision of this Section.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
11100-138, eff. 8-18-17; revised 10-5-17.)
 
12    Section 20. The School Code is amended by changing Section
1310-22.3f as follows:
 
14    (105 ILCS 5/10-22.3f)
15    Sec. 10-22.3f. Required health benefits. Insurance
16protection and benefits for employees shall provide the
17post-mastectomy care benefits required to be covered by a
18policy of accident and health insurance under Section 356t and
19the coverage required under Sections 356g, 356g.5, 356g.5-1,
20356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
21356z.13, 356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and
22356z.29 of the Illinois Insurance Code. Insurance policies
23shall comply with Section 356z.19 of the Illinois Insurance
24Code. The coverage shall comply with Sections 155.22a and 355b

 

 

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1of the Illinois Insurance Code.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
9revised 9-25-17.)
 
10    Section 25. The Illinois Insurance Code is amended by
11adding Section 356z.29 as follows:
 
12    (215 ILCS 5/356z.29 new)
13    Sec. 356z.29. Stage 4 advanced, metastatic cancer.
14    (a) As used in this Section, "stage 4 advanced, metastatic
15cancer" means cancer that has spread from the primary or
16original site of the cancer to nearby tissues, lymph nodes, or
17other areas or parts of the body.
18    (b) No individual or group policy of accident and health
19insurance amended, issued, delivered, or renewed in this State
20after the effective date of this amendatory Act of the 100th
21General Assembly that, as a provision of hospital, medical, or
22surgical services, directly or indirectly covers the treatment
23of stage 4 advanced, metastatic cancer shall limit or exclude
24coverage for a drug approved by the United States Food and Drug

 

 

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1Administration by mandating that the insured shall first be
2required to fail to successfully respond to a different drug or
3prove a history of failure of the drug as long as the use of the
4drug is consistent with best practices for the treatment of
5stage 4 advanced, metastatic cancer and is supported by
6peer-reviewed medical literature.
7    (c) If, at any time before or after the effective date of
8this amendatory Act of the 100th General Assembly, the
9Secretary of the United States Department of Health and Human
10Services, or its successor agency, promulgates rules or
11regulations to be published in the Federal Register, publishes
12a comment in the Federal Register, or issues an opinion,
13guidance, or other action that would require the State,
14pursuant to any provision of the Patient Protection and
15Affordable Care Act (Pub. L. 111–148), including, but not
16limited to, 42 U.S.C. 18031(d)(3)(B) or any successor
17provision, to defray the cost of the prohibition of coverage
18restrictions or exclusions contained in subsection (b) of this
19Section for the treatment of stage 4 advanced, metastatic
20cancer, then this Section is inoperative with respect to all
21such coverage other than that authorized under Section 1902 of
22the Social Security Act, 42 U.S.C. 1396a, and the State shall
23not assume any obligation for the cost of the prohibition of
24coverage restrictions or exclusions contained in subsection
25(b) of this Section for the treatment of stage 4 advanced,
26metastatic cancer.
 

 

 

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1    Section 30. The Health Maintenance Organization Act is
2amended by changing Section 5-3 as follows:
 
3    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
4    Sec. 5-3. Insurance Code provisions.
5    (a) Health Maintenance Organizations shall be subject to
6the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
7141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
8154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
9355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
10356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
11356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
12356z.22, 356z.25, 356z.26, 356z.29, 364, 364.01, 367.2,
13367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401,
14401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
15paragraph (c) of subsection (2) of Section 367, and Articles
16IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
17the Illinois Insurance Code.
18    (b) For purposes of the Illinois Insurance Code, except for
19Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
20Maintenance Organizations in the following categories are
21deemed 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

 

 

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1    State; or
2        (3) a corporation organized under the laws of another
3    state, 30% or more of the enrollees of which are residents
4    of this State, except a corporation subject to
5    substantially the same requirements in its state of
6    organization as is a "domestic company" under Article VIII
7    1/2 of the Illinois Insurance Code.
8    (c) In considering the merger, consolidation, or other
9acquisition of control of a Health Maintenance Organization
10pursuant to Article VIII 1/2 of the Illinois Insurance Code,
11        (1) the Director shall give primary consideration to
12    the continuation of benefits to enrollees and the financial
13    conditions of the acquired Health Maintenance Organization
14    after the merger, consolidation, or other acquisition of
15    control takes effect;
16        (2)(i) the criteria specified in subsection (1)(b) of
17    Section 131.8 of the Illinois Insurance Code shall not
18    apply and (ii) the Director, in making his determination
19    with respect to the merger, consolidation, or other
20    acquisition of control, need not take into account the
21    effect on competition of the merger, consolidation, or
22    other acquisition of control;
23        (3) the Director shall have the power to require the
24    following information:
25            (A) certification by an independent actuary of the
26        adequacy of the reserves of the Health Maintenance

 

 

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1        Organization sought to be acquired;
2            (B) pro forma financial statements reflecting the
3        combined balance sheets of the acquiring company and
4        the Health Maintenance Organization sought to be
5        acquired as of the end of the preceding year and as of
6        a date 90 days prior to the acquisition, as well as pro
7        forma financial statements reflecting projected
8        combined operation for a period of 2 years;
9            (C) a pro forma business plan detailing an
10        acquiring party's plans with respect to the operation
11        of the Health Maintenance Organization sought to be
12        acquired for a period of not less than 3 years; and
13            (D) such other information as the Director shall
14        require.
15    (d) The provisions of Article VIII 1/2 of the Illinois
16Insurance Code and this Section 5-3 shall apply to the sale by
17any health maintenance organization of greater than 10% of its
18enrollee population (including without limitation the health
19maintenance organization's right, title, and interest in and to
20its health care certificates).
21    (e) In considering any management contract or service
22agreement subject to Section 141.1 of the Illinois Insurance
23Code, the Director (i) shall, in addition to the criteria
24specified in Section 141.2 of the Illinois Insurance Code, take
25into account the effect of the management contract or service
26agreement on the continuation of benefits to enrollees and the

 

 

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1financial condition of the health maintenance organization to
2be managed or serviced, and (ii) need not take into account the
3effect of the management contract or service agreement on
4competition.
5    (f) Except for small employer groups as defined in the
6Small Employer Rating, Renewability and Portability Health
7Insurance Act and except for medicare supplement policies as
8defined in Section 363 of the Illinois Insurance Code, a Health
9Maintenance Organization may by contract agree with a group or
10other enrollment unit to effect refunds or charge additional
11premiums under the following terms and conditions:
12        (i) the amount of, and other terms and conditions with
13    respect to, the refund or additional premium are set forth
14    in the group or enrollment unit contract agreed in advance
15    of the period for which a refund is to be paid or
16    additional premium is to be charged (which period shall not
17    be less than one year); and
18        (ii) the amount of the refund or additional premium
19    shall not exceed 20% of the Health Maintenance
20    Organization's profitable or unprofitable experience with
21    respect to the group or other enrollment unit for the
22    period (and, for purposes of a refund or additional
23    premium, the profitable or unprofitable experience shall
24    be calculated taking into account a pro rata share of the
25    Health Maintenance Organization's administrative and
26    marketing expenses, but shall not include any refund to be

 

 

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1    made or additional premium to be paid pursuant to this
2    subsection (f)). The Health Maintenance Organization and
3    the group or enrollment unit may agree that the profitable
4    or unprofitable experience may be calculated taking into
5    account the refund period and the immediately preceding 2
6    plan years.
7    The Health Maintenance Organization shall include a
8statement in the evidence of coverage issued to each enrollee
9describing the possibility of a refund or additional premium,
10and upon request of any group or enrollment unit, provide to
11the group or enrollment unit a description of the method used
12to calculate (1) the Health Maintenance Organization's
13profitable experience with respect to the group or enrollment
14unit and the resulting refund to the group or enrollment unit
15or (2) the Health Maintenance Organization's unprofitable
16experience with respect to the group or enrollment unit and the
17resulting additional premium to be paid by the group or
18enrollment unit.
19    In no event shall the Illinois Health Maintenance
20Organization Guaranty Association be liable to pay any
21contractual obligation of an insolvent organization to pay any
22refund authorized under this Section.
23    (g) Rulemaking authority to implement Public Act 95-1045,
24if any, is conditioned on the rules being adopted in accordance
25with all provisions of the Illinois Administrative Procedure
26Act and all rules and procedures of the Joint Committee on

 

 

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1Administrative Rules; any purported rule not so adopted, for
2whatever reason, is unauthorized.
3(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
4100-138, eff. 8-18-17; revised 10-5-17.)
 
5    Section 35. The Limited Health Service Organization Act is
6amended by changing Section 4003 as follows:
 
7    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
8    Sec. 4003. Illinois Insurance Code provisions. Limited
9health service organizations shall be subject to the provisions
10of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
11143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
12154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
13356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 368a,
14401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and
15444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
16XXV, and XXVI of the Illinois Insurance Code. For purposes of
17the Illinois Insurance Code, except for Sections 444 and 444.1
18and Articles XIII and XIII 1/2, limited health service
19organizations in the following categories are deemed to be
20domestic companies:
21        (1) a corporation under the laws of this State; or
22        (2) a corporation organized under the laws of another
23    state, 30% or more of the enrollees of which are residents
24    of this State, except a corporation subject to

 

 

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1    substantially the same requirements in its state of
2    organization as is a domestic company under Article VIII
3    1/2 of the Illinois Insurance Code.
4(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
5100-201, eff. 8-18-17; revised 10-5-17.)
 
6    Section 40. The Voluntary Health Services Plans Act is
7amended by changing Section 10 as follows:
 
8    (215 ILCS 165/10)  (from Ch. 32, par. 604)
9    Sec. 10. Application of Insurance Code provisions. Health
10services plan corporations and all persons interested therein
11or dealing therewith shall be subject to the provisions of
12Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
13143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
14356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
15356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
16356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
17356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 364.01,
18367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
19and paragraphs (7) and (15) of Section 367 of the Illinois
20Insurance Code.
21    Rulemaking authority to implement Public Act 95-1045, if
22any, is conditioned on the rules being adopted in accordance
23with all provisions of the Illinois Administrative Procedure
24Act and all rules and procedures of the Joint Committee on

 

 

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1Administrative Rules; any purported rule not so adopted, for
2whatever reason, is unauthorized.
3(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
4revised 10-5-17.)
 
5    Section 45. The Illinois Public Aid Code is amended by
6changing Section 5-16.8 as follows:
 
7    (305 ILCS 5/5-16.8)
8    Sec. 5-16.8. Required health benefits. The medical
9assistance program shall (i) provide the post-mastectomy care
10benefits required to be covered by a policy of accident and
11health insurance under Section 356t and the coverage required
12under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and
13356z.29 and 356z.25 of the Illinois Insurance Code and (ii) be
14subject to the provisions of Sections 356z.19, 364.01, 370c,
15and 370c.1 of the Illinois Insurance Code.
16    On and after July 1, 2012, the Department shall reduce any
17rate of reimbursement for services or other payments or alter
18any methodologies authorized by this Code to reduce any rate of
19reimbursement for services or other payments in accordance with
20Section 5-5e.
21    To ensure full access to the benefits set forth in this
22Section, on and after January 1, 2016, the Department shall
23ensure that provider and hospital reimbursement for
24post-mastectomy care benefits required under this Section are

 

 

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1no lower than the Medicare reimbursement rate.
2(Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15;
399-642, eff. 7-28-16; 100-138, eff. 8-18-17; revised 1-29-18.)