Full Text of HB4821 100th General Assembly
HB4821enr 100TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 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 356g, | 13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 15 | | 356z.14, 356z.15, 356z.17, 356z.22, and 356z.25 , 356z.26, and | 16 | | 356z.29 of the
Illinois Insurance Code.
The program of health | 17 | | benefits must comply with Sections 155.22a, 155.37, 355b, | 18 | | 356z.19, 370c, and 370c.1 of the
Illinois Insurance Code.
| 19 | | Rulemaking authority to implement Public Act 95-1045, if | 20 | | any, is conditioned on the rules being adopted in accordance | 21 | | with all provisions of the Illinois Administrative Procedure | 22 | | Act and all rules and procedures of the Joint Committee on | 23 | | Administrative Rules; any purported rule not so adopted, for |
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| 1 | | whatever reason, is unauthorized. | 2 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 3 | | 100-138, eff. 8-18-17; revised 10-3-17.) | 4 | | Section 10. The Counties Code is amended by changing | 5 | | Section 5-1069.3 as follows: | 6 | | (55 ILCS 5/5-1069.3)
| 7 | | Sec. 5-1069.3. Required health benefits. If a county, | 8 | | including a home
rule
county, is a self-insurer for purposes of | 9 | | providing health insurance coverage
for its employees, the | 10 | | coverage shall include coverage for the post-mastectomy
care | 11 | | benefits required to be covered by a policy of accident and | 12 | | health
insurance under Section 356t and the coverage required | 13 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 15 | | 356z.14, 356z.15, 356z.22, and 356z.25 , 356z.26, and 356z.29 of
| 16 | | the Illinois Insurance Code. The coverage shall comply with | 17 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | 18 | | Insurance Code. The requirement that health benefits be covered
| 19 | | as provided in this Section is an
exclusive power and function | 20 | | of the State and is a denial and limitation under
Article VII, | 21 | | Section 6, subsection (h) of the Illinois Constitution. A home
| 22 | | rule county to which this Section applies must comply with | 23 | | every provision of
this Section.
| 24 | | Rulemaking authority to implement Public Act 95-1045, if |
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| 1 | | any, is conditioned on the rules being adopted in accordance | 2 | | with all provisions of the Illinois Administrative Procedure | 3 | | Act and all rules and procedures of the Joint Committee on | 4 | | Administrative Rules; any purported rule not so adopted, for | 5 | | whatever reason, is unauthorized. | 6 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 7 | | 100-138, eff. 8-18-17; revised 10-5-17.) | 8 | | Section 15. The Illinois Municipal Code is amended by | 9 | | changing 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 | 12 | | municipality, including a
home rule municipality, is a | 13 | | self-insurer for purposes of providing health
insurance | 14 | | coverage for its employees, the coverage shall include coverage | 15 | | for
the post-mastectomy care benefits required to be covered by | 16 | | a policy of
accident and health insurance under Section 356t | 17 | | and the coverage required
under Sections 356g, 356g.5, | 18 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 19 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and | 20 | | 356z.25 , 356z.26, and 356z.29 of the Illinois
Insurance
Code. | 21 | | The coverage shall comply with Sections 155.22a, 355b, 356z.19, | 22 | | and 370c of
the Illinois Insurance Code. The requirement that | 23 | | health
benefits be covered as provided in this is an exclusive | 24 | | power and function of
the State and is a denial and limitation |
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| 1 | | under Article VII, Section 6,
subsection (h) of the Illinois | 2 | | Constitution. A home rule municipality to which
this Section | 3 | | applies must comply with every provision of this Section.
| 4 | | Rulemaking authority to implement Public Act 95-1045, if | 5 | | any, is conditioned on the rules being adopted in accordance | 6 | | with all provisions of the Illinois Administrative Procedure | 7 | | Act and all rules and procedures of the Joint Committee on | 8 | | Administrative Rules; any purported rule not so adopted, for | 9 | | whatever reason, is unauthorized. | 10 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 11 | | 100-138, eff. 8-18-17; revised 10-5-17.) | 12 | | Section 20. The School Code is amended by changing Section | 13 | | 10-22.3f as follows: | 14 | | (105 ILCS 5/10-22.3f)
| 15 | | Sec. 10-22.3f. Required health benefits. Insurance | 16 | | protection and
benefits
for employees shall provide the | 17 | | post-mastectomy care benefits required to be
covered by a | 18 | | policy of accident and health insurance under Section 356t and | 19 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 20 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 21 | | 356z.13, 356z.14, 356z.15, 356z.22, and 356z.25 , 356z.26, and | 22 | | 356z.29 of
the
Illinois Insurance Code.
Insurance policies | 23 | | shall comply with Section 356z.19 of the Illinois Insurance | 24 | | Code. The coverage shall comply with Sections 155.22a and 355b |
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| 1 | | of
the Illinois Insurance Code.
| 2 | | Rulemaking authority to implement Public Act 95-1045, if | 3 | | any, is conditioned on the rules being adopted in accordance | 4 | | with all provisions of the Illinois Administrative Procedure | 5 | | Act and all rules and procedures of the Joint Committee on | 6 | | Administrative Rules; any purported rule not so adopted, for | 7 | | whatever reason, is unauthorized. | 8 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 9 | | revised 9-25-17.) | 10 | | Section 25. The Illinois Insurance Code is amended by | 11 | | adding 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 | 15 | | cancer" means cancer that has spread from the primary or | 16 | | original site of the cancer to nearby tissues, lymph nodes, or | 17 | | other areas or parts of the body. | 18 | | (b) No individual or group policy of accident and health | 19 | | insurance amended, issued, delivered, or renewed in this State | 20 | | after the effective date of this amendatory Act of the 100th | 21 | | General Assembly that, as a provision of hospital, medical, or | 22 | | surgical services, directly or indirectly covers the treatment | 23 | | of stage 4 advanced, metastatic cancer shall limit or exclude | 24 | | coverage for a drug approved by the United States Food and Drug |
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| 1 | | Administration by mandating that the insured shall first be | 2 | | required to fail to successfully respond to a different drug or | 3 | | prove a history of failure of the drug as long as the use of the | 4 | | drug is consistent with best practices for the treatment of | 5 | | stage 4 advanced, metastatic cancer and is supported by | 6 | | peer-reviewed medical literature. | 7 | | (c) If, at any time before or after the effective date of | 8 | | this amendatory Act of the 100th General Assembly, the | 9 | | Secretary of the United States Department of Health and Human | 10 | | Services, or its successor agency, promulgates rules or | 11 | | regulations to be published in the Federal Register, publishes | 12 | | a comment in the Federal Register, or issues an opinion, | 13 | | guidance, or other action that would require the State, | 14 | | pursuant to any provision of the Patient Protection and | 15 | | Affordable Care Act (Pub. L. 111–148), including, but not | 16 | | limited to, 42 U.S.C. 18031(d)(3)(B) or any successor | 17 | | provision, to defray the cost of the prohibition of coverage | 18 | | restrictions or exclusions contained in subsection (b) of this | 19 | | Section for the treatment of stage 4 advanced, metastatic | 20 | | cancer, then this Section is inoperative with respect to all | 21 | | such coverage other than that authorized under Section 1902 of | 22 | | the Social Security Act, 42 U.S.C. 1396a, and the State shall | 23 | | not assume any obligation for the cost of the prohibition of | 24 | | coverage restrictions or exclusions contained in subsection | 25 | | (b) of this Section for the treatment of stage 4 advanced, | 26 | | metastatic cancer. |
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| 1 | | Section 30. The Health Maintenance Organization Act is | 2 | | amended 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 | 6 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 7 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 8 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 9 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 10 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 11 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 12 | | 356z.22, 356z.25, 356z.26, 356z.29, 364, 364.01, 367.2, | 13 | | 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
370c.1, 401, | 14 | | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
| 15 | | paragraph (c) of subsection (2) of Section 367, and Articles | 16 | | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | 17 | | 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 |
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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 | 9 | | acquisition of
control of a Health Maintenance Organization | 10 | | pursuant 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 | 16 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 17 | | any health maintenance
organization of greater than 10% of its
| 18 | | enrollee population (including without limitation the health | 19 | | maintenance
organization's right, title, and interest in and to | 20 | | its health care
certificates).
| 21 | | (e) In considering any management contract or service | 22 | | agreement subject
to Section 141.1 of the Illinois Insurance | 23 | | Code, the Director (i) shall, in
addition to the criteria | 24 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 25 | | into account the effect of the management contract or
service | 26 | | agreement on the continuation of benefits to enrollees and the
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| 1 | | financial condition of the health maintenance organization to | 2 | | be managed or
serviced, and (ii) need not take into account the | 3 | | effect of the management
contract or service agreement on | 4 | | competition.
| 5 | | (f) Except for small employer groups as defined in the | 6 | | Small Employer
Rating, Renewability and Portability Health | 7 | | Insurance Act and except for
medicare supplement policies as | 8 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 9 | | Maintenance Organization may by contract agree with a
group or | 10 | | other enrollment unit to effect refunds or charge additional | 11 | | premiums
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 | 8 | | statement in the
evidence of coverage issued to each enrollee | 9 | | describing the possibility of a
refund or additional premium, | 10 | | and upon request of any group or enrollment unit,
provide to | 11 | | the group or enrollment unit a description of the method used | 12 | | to
calculate (1) the Health Maintenance Organization's | 13 | | profitable experience with
respect to the group or enrollment | 14 | | unit and the resulting refund to the group
or enrollment unit | 15 | | or (2) the Health Maintenance Organization's unprofitable
| 16 | | experience with respect to the group or enrollment unit and the | 17 | | resulting
additional premium to be paid by the group or | 18 | | enrollment unit.
| 19 | | In no event shall the Illinois Health Maintenance | 20 | | Organization
Guaranty Association be liable to pay any | 21 | | contractual obligation of an
insolvent organization to pay any | 22 | | refund authorized under this Section.
| 23 | | (g) Rulemaking authority to implement Public Act 95-1045, | 24 | | if any, is conditioned on the rules being adopted in accordance | 25 | | with all provisions of the Illinois Administrative Procedure | 26 | | Act and all rules and procedures of the Joint Committee on |
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| 1 | | Administrative Rules; any purported rule not so adopted, for | 2 | | whatever reason, is unauthorized. | 3 | | (Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; | 4 | | 100-138, eff. 8-18-17; revised 10-5-17.) | 5 | | Section 35. The Limited Health Service Organization Act is | 6 | | amended 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 | 9 | | health service
organizations shall be subject to the provisions | 10 | | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | 11 | | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | 12 | | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, | 13 | | 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 368a, | 14 | | 401, 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and | 15 | | 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, | 16 | | XXV, and XXVI of the Illinois Insurance Code. For purposes of | 17 | | the
Illinois Insurance Code, except for Sections 444 and 444.1 | 18 | | and Articles XIII
and XIII 1/2, limited health service | 19 | | organizations in the following categories
are deemed to be | 20 | | domestic 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; | 5 | | 100-201, eff. 8-18-17; revised 10-5-17.)
| 6 | | Section 40. The Voluntary Health Services Plans Act is | 7 | | amended 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 | 10 | | services
plan corporations and all persons interested therein | 11 | | or dealing therewith
shall be subject to the provisions of | 12 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 13 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, | 14 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | 15 | | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| 16 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | 17 | | 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 364.01, | 18 | | 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, | 19 | | and paragraphs (7) and (15) of Section 367 of the Illinois
| 20 | | Insurance Code.
| 21 | | Rulemaking authority to implement Public Act 95-1045, if | 22 | | any, is conditioned on the rules being adopted in accordance | 23 | | with all provisions of the Illinois Administrative Procedure | 24 | | Act and all rules and procedures of the Joint Committee on |
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| 1 | | Administrative Rules; any purported rule not so adopted, for | 2 | | whatever reason, is unauthorized. | 3 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 4 | | revised 10-5-17.) | 5 | | Section 45. The Illinois Public Aid Code is amended by | 6 | | changing Section 5-16.8 as follows:
| 7 | | (305 ILCS 5/5-16.8)
| 8 | | Sec. 5-16.8. Required health benefits. The medical | 9 | | assistance program
shall
(i) provide the post-mastectomy care | 10 | | benefits required to be covered by a policy of
accident and | 11 | | health insurance under Section 356t and the coverage required
| 12 | | under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and | 13 | | 356z.29 and 356z.25 of the Illinois
Insurance Code and (ii) be | 14 | | subject to the provisions of Sections 356z.19, 364.01, 370c, | 15 | | and 370c.1 of the Illinois
Insurance Code.
| 16 | | On and after July 1, 2012, the Department shall reduce any | 17 | | rate of reimbursement for services or other payments or alter | 18 | | any methodologies authorized by this Code to reduce any rate of | 19 | | reimbursement for services or other payments in accordance with | 20 | | Section 5-5e. | 21 | | To ensure full access to the benefits set forth in this | 22 | | Section, on and after January 1, 2016, the Department shall | 23 | | ensure that provider and hospital reimbursement for | 24 | | post-mastectomy care benefits required under this Section are |
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| 1 | | no lower than the Medicare reimbursement rate. | 2 | | (Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; | 3 | | 99-642, eff. 7-28-16; 100-138, eff. 8-18-17; revised 1-29-18.)
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