Full Text of HB2957 100th General Assembly
HB2957enr 100TH GENERAL ASSEMBLY |
| | HB2957 Enrolled | | LRB100 05656 SMS 15673 b |
|
| 1 | | 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 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, and 356z.22 , and 356z.25 of the
| 16 | | Illinois Insurance Code.
The program of health benefits must | 17 | | comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and | 18 | | 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 |
| | | HB2957 Enrolled | - 2 - | LRB100 05656 SMS 15673 b |
|
| 1 | | whatever reason, is unauthorized. | 2 | | (Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15; | 3 | | 99-480, eff. 9-9-15.) | 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, and 356z.22 , and 356z.25 of
the Illinois | 16 | | Insurance Code. The coverage shall comply with Sections | 17 | | 155.22a, 355b, 356z.19, and 370c of
the Illinois Insurance | 18 | | Code. The requirement that health benefits be covered
as | 19 | | provided in this Section is an
exclusive power and function of | 20 | | 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 |
| | | HB2957 Enrolled | - 3 - | LRB100 05656 SMS 15673 b |
|
| 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. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15; | 7 | | 99-480, eff. 9-9-15.) | 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, and 356z.22 , and | 20 | | 356z.25 of the Illinois
Insurance
Code. The coverage shall | 21 | | comply with Sections 155.22a, 355b, 356z.19, and 370c of
the | 22 | | Illinois Insurance Code. The requirement that health
benefits | 23 | | be covered as provided in this is an exclusive power and | 24 | | function of
the State and is a denial and limitation under |
| | | HB2957 Enrolled | - 4 - | LRB100 05656 SMS 15673 b |
|
| 1 | | 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. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15; | 11 | | 99-480, eff. 9-9-15.) | 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, and 356z.22 , and 356z.25 of
the
| 22 | | Illinois Insurance Code.
Insurance policies shall comply with | 23 | | Section 356z.19 of the Illinois Insurance Code. The coverage | 24 | | shall comply with Sections 155.22a and 355b of
the Illinois |
| | | HB2957 Enrolled | - 5 - | LRB100 05656 SMS 15673 b |
|
| 1 | | 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813, | 9 | | eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15 .) | 10 | | Section 25. The Illinois Insurance Code is amended by | 11 | | adding Section 356z.25 as follows: | 12 | | (215 ILCS 5/356z.25 new) | 13 | | Sec. 356z.25. Synchronization. | 14 | | (a) As used in this Section, "synchronization" means the | 15 | | coordination of medication refills for a patient taking 2 or | 16 | | more medications for one or more chronic conditions such that | 17 | | the patient's medications are refilled on the same schedule for | 18 | | a given time period. | 19 | | (b) Every policy of health and accident insurance amended, | 20 | | delivered, issued, or renewed after the effective date of this | 21 | | amendatory Act of the 100th General Assembly that provides | 22 | | coverage for prescription drugs shall provide for | 23 | | synchronization of prescription drug refills on at least one | 24 | | occasion per insured per year, provided all of the following |
| | | HB2957 Enrolled | - 6 - | LRB100 05656 SMS 15673 b |
|
| 1 | | conditions are met: | 2 | | (1) the prescription drugs are covered by the policy's | 3 | | clinical coverage policy or have been approved by a | 4 | | formulary exceptions process; | 5 | | (2) the prescription drugs are maintenance medications | 6 | | as defined by the policy and have available refill | 7 | | quantities at the time of synchronization; | 8 | | (3) the medications are not Schedule II, III, or IV | 9 | | controlled substances; | 10 | | (4) the insured meets all utilization management | 11 | | criteria specific to the prescription drugs at the time of | 12 | | synchronization; | 13 | | (5) the prescription drugs are of a formulation that | 14 | | can be safely split into short-fill periods to achieve | 15 | | synchronization; and | 16 | | (6) the prescription drugs do not have special handling | 17 | | or sourcing needs as determined by the policy, contract, or | 18 | | agreement that require a single, designated pharmacy to | 19 | | fill or refill the prescription. | 20 | | (c) When necessary to permit synchronization, the policy | 21 | | shall apply a prorated daily cost-sharing rate to any | 22 | | medication dispensed by a network pharmacy pursuant to this | 23 | | Section. No dispensing fees shall be prorated, and all | 24 | | dispensing fees shall be based on the number of prescriptions | 25 | | filled or refilled. | 26 | | |
| | | HB2957 Enrolled | - 7 - | LRB100 05656 SMS 15673 b |
|
| 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 | | (Text of Section before amendment by P.A. 99-761 ) | 5 | | Sec. 5-3. Insurance Code provisions.
| 6 | | (a) Health Maintenance Organizations
shall be subject to | 7 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 8 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 9 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 10 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 11 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 12 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 13 | | 356z.22, 356z.25, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | 14 | | 368c, 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
| 15 | | 408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | 16 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
| 17 | | XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | 18 | | Insurance Code.
| 19 | | (b) For purposes of the Illinois Insurance Code, except for | 20 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 21 | | Maintenance Organizations in
the following categories are | 22 | | deemed to be "domestic companies":
| 23 | | (1) a corporation authorized under the
Dental Service | 24 | | Plan Act or the Voluntary Health Services Plans Act;
|
| | | HB2957 Enrolled | - 8 - | LRB100 05656 SMS 15673 b |
|
| 1 | | (2) a corporation organized under the laws of this | 2 | | State; or
| 3 | | (3) a corporation organized under the laws of another | 4 | | state, 30% or more
of the enrollees of which are residents | 5 | | of this State, except a
corporation subject to | 6 | | substantially the same requirements in its state of
| 7 | | organization as is a "domestic company" under Article VIII | 8 | | 1/2 of the
Illinois Insurance Code.
| 9 | | (c) In considering the merger, consolidation, or other | 10 | | acquisition of
control of a Health Maintenance Organization | 11 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 12 | | (1) the Director shall give primary consideration to | 13 | | the continuation of
benefits to enrollees and the financial | 14 | | conditions of the acquired Health
Maintenance Organization | 15 | | after the merger, consolidation, or other
acquisition of | 16 | | control takes effect;
| 17 | | (2)(i) the criteria specified in subsection (1)(b) of | 18 | | Section 131.8 of
the Illinois Insurance Code shall not | 19 | | apply and (ii) the Director, in making
his determination | 20 | | with respect to the merger, consolidation, or other
| 21 | | acquisition of control, need not take into account the | 22 | | effect on
competition of the merger, consolidation, or | 23 | | other acquisition of control;
| 24 | | (3) the Director shall have the power to require the | 25 | | following
information:
| 26 | | (A) certification by an independent actuary of the |
| | | HB2957 Enrolled | - 9 - | LRB100 05656 SMS 15673 b |
|
| 1 | | adequacy
of the reserves of the Health Maintenance | 2 | | Organization sought to be acquired;
| 3 | | (B) pro forma financial statements reflecting the | 4 | | combined balance
sheets of the acquiring company and | 5 | | the Health Maintenance Organization sought
to be | 6 | | acquired as of the end of the preceding year and as of | 7 | | a date 90 days
prior to the acquisition, as well as pro | 8 | | forma financial statements
reflecting projected | 9 | | combined operation for a period of 2 years;
| 10 | | (C) a pro forma business plan detailing an | 11 | | acquiring party's plans with
respect to the operation | 12 | | of the Health Maintenance Organization sought to
be | 13 | | acquired for a period of not less than 3 years; and
| 14 | | (D) such other information as the Director shall | 15 | | require.
| 16 | | (d) The provisions of Article VIII 1/2 of the Illinois | 17 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 18 | | any health maintenance
organization of greater than 10% of its
| 19 | | enrollee population (including without limitation the health | 20 | | maintenance
organization's right, title, and interest in and to | 21 | | its health care
certificates).
| 22 | | (e) In considering any management contract or service | 23 | | agreement subject
to Section 141.1 of the Illinois Insurance | 24 | | Code, the Director (i) shall, in
addition to the criteria | 25 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 26 | | into account the effect of the management contract or
service |
| | | HB2957 Enrolled | - 10 - | LRB100 05656 SMS 15673 b |
|
| 1 | | agreement on the continuation of benefits to enrollees and the
| 2 | | financial condition of the health maintenance organization to | 3 | | be managed or
serviced, and (ii) need not take into account the | 4 | | effect of the management
contract or service agreement on | 5 | | competition.
| 6 | | (f) Except for small employer groups as defined in the | 7 | | Small Employer
Rating, Renewability and Portability Health | 8 | | Insurance Act and except for
medicare supplement policies as | 9 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 10 | | Maintenance Organization may by contract agree with a
group or | 11 | | other enrollment unit to effect refunds or charge additional | 12 | | premiums
under the following terms and conditions:
| 13 | | (i) the amount of, and other terms and conditions with | 14 | | respect to, the
refund or additional premium are set forth | 15 | | in the group or enrollment unit
contract agreed in advance | 16 | | of the period for which a refund is to be paid or
| 17 | | additional premium is to be charged (which period shall not | 18 | | be less than one
year); and
| 19 | | (ii) the amount of the refund or additional premium | 20 | | shall not exceed 20%
of the Health Maintenance | 21 | | Organization's profitable or unprofitable experience
with | 22 | | respect to the group or other enrollment unit for the | 23 | | period (and, for
purposes of a refund or additional | 24 | | premium, the profitable or unprofitable
experience shall | 25 | | be calculated taking into account a pro rata share of the
| 26 | | Health Maintenance Organization's administrative and |
| | | HB2957 Enrolled | - 11 - | LRB100 05656 SMS 15673 b |
|
| 1 | | marketing expenses, but
shall not include any refund to be | 2 | | made or additional premium to be paid
pursuant to this | 3 | | subsection (f)). The Health Maintenance Organization and | 4 | | the
group or enrollment unit may agree that the profitable | 5 | | or unprofitable
experience may be calculated taking into | 6 | | account the refund period and the
immediately preceding 2 | 7 | | plan years.
| 8 | | The Health Maintenance Organization shall include a | 9 | | statement in the
evidence of coverage issued to each enrollee | 10 | | describing the possibility of a
refund or additional premium, | 11 | | and upon request of any group or enrollment unit,
provide to | 12 | | the group or enrollment unit a description of the method used | 13 | | to
calculate (1) the Health Maintenance Organization's | 14 | | profitable experience with
respect to the group or enrollment | 15 | | unit and the resulting refund to the group
or enrollment unit | 16 | | or (2) the Health Maintenance Organization's unprofitable
| 17 | | experience with respect to the group or enrollment unit and the | 18 | | resulting
additional premium to be paid by the group or | 19 | | enrollment unit.
| 20 | | In no event shall the Illinois Health Maintenance | 21 | | Organization
Guaranty Association be liable to pay any | 22 | | contractual obligation of an
insolvent organization to pay any | 23 | | refund authorized under this Section.
| 24 | | (g) Rulemaking authority to implement Public Act 95-1045, | 25 | | if any, is conditioned on the rules being adopted in accordance | 26 | | with all provisions of the Illinois Administrative Procedure |
| | | HB2957 Enrolled | - 12 - | LRB100 05656 SMS 15673 b |
|
| 1 | | Act and all rules and procedures of the Joint Committee on | 2 | | Administrative Rules; any purported rule not so adopted, for | 3 | | whatever reason, is unauthorized. | 4 | | (Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437, | 5 | | eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, | 6 | | eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; | 7 | | 98-1091, eff. 1-1-15 .) | 8 | | (Text of Section after amendment by P.A. 99-761 ) | 9 | | Sec. 5-3. Insurance Code provisions.
| 10 | | (a) Health Maintenance Organizations
shall be subject to | 11 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 12 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 13 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 14 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 15 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 16 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 17 | | 356z.22, 356z.25, 364, 364.01, 367.2, 367.2-5, 367i, 368a, | 18 | | 368b, 368c, 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, | 19 | | 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | 20 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
| 21 | | XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | 22 | | Insurance Code.
| 23 | | (b) For purposes of the Illinois Insurance Code, except for | 24 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 25 | | Maintenance Organizations in
the following categories are |
| | | HB2957 Enrolled | - 13 - | LRB100 05656 SMS 15673 b |
|
| 1 | | deemed to be "domestic companies":
| 2 | | (1) a corporation authorized under the
Dental Service | 3 | | Plan Act or the Voluntary Health Services Plans Act;
| 4 | | (2) a corporation organized under the laws of this | 5 | | State; or
| 6 | | (3) a corporation organized under the laws of another | 7 | | state, 30% or more
of the enrollees of which are residents | 8 | | of this State, except a
corporation subject to | 9 | | substantially the same requirements in its state of
| 10 | | organization as is a "domestic company" under Article VIII | 11 | | 1/2 of the
Illinois Insurance Code.
| 12 | | (c) In considering the merger, consolidation, or other | 13 | | acquisition of
control of a Health Maintenance Organization | 14 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 15 | | (1) the Director shall give primary consideration to | 16 | | the continuation of
benefits to enrollees and the financial | 17 | | conditions of the acquired Health
Maintenance Organization | 18 | | after the merger, consolidation, or other
acquisition of | 19 | | control takes effect;
| 20 | | (2)(i) the criteria specified in subsection (1)(b) of | 21 | | Section 131.8 of
the Illinois Insurance Code shall not | 22 | | apply and (ii) the Director, in making
his determination | 23 | | with respect to the merger, consolidation, or other
| 24 | | acquisition of control, need not take into account the | 25 | | effect on
competition of the merger, consolidation, or | 26 | | other acquisition of control;
|
| | | HB2957 Enrolled | - 14 - | LRB100 05656 SMS 15673 b |
|
| 1 | | (3) the Director shall have the power to require the | 2 | | following
information:
| 3 | | (A) certification by an independent actuary of the | 4 | | adequacy
of the reserves of the Health Maintenance | 5 | | Organization sought to be acquired;
| 6 | | (B) pro forma financial statements reflecting the | 7 | | combined balance
sheets of the acquiring company and | 8 | | the Health Maintenance Organization sought
to be | 9 | | acquired as of the end of the preceding year and as of | 10 | | a date 90 days
prior to the acquisition, as well as pro | 11 | | forma financial statements
reflecting projected | 12 | | combined operation for a period of 2 years;
| 13 | | (C) a pro forma business plan detailing an | 14 | | acquiring party's plans with
respect to the operation | 15 | | of the Health Maintenance Organization sought to
be | 16 | | acquired for a period of not less than 3 years; and
| 17 | | (D) such other information as the Director shall | 18 | | require.
| 19 | | (d) The provisions of Article VIII 1/2 of the Illinois | 20 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 21 | | any health maintenance
organization of greater than 10% of its
| 22 | | enrollee population (including without limitation the health | 23 | | maintenance
organization's right, title, and interest in and to | 24 | | its health care
certificates).
| 25 | | (e) In considering any management contract or service | 26 | | agreement subject
to Section 141.1 of the Illinois Insurance |
| | | HB2957 Enrolled | - 15 - | LRB100 05656 SMS 15673 b |
|
| 1 | | Code, the Director (i) shall, in
addition to the criteria | 2 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 3 | | into account the effect of the management contract or
service | 4 | | agreement on the continuation of benefits to enrollees and the
| 5 | | financial condition of the health maintenance organization to | 6 | | be managed or
serviced, and (ii) need not take into account the | 7 | | effect of the management
contract or service agreement on | 8 | | competition.
| 9 | | (f) Except for small employer groups as defined in the | 10 | | Small Employer
Rating, Renewability and Portability Health | 11 | | Insurance Act and except for
medicare supplement policies as | 12 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 13 | | Maintenance Organization may by contract agree with a
group or | 14 | | other enrollment unit to effect refunds or charge additional | 15 | | premiums
under the following terms and conditions:
| 16 | | (i) the amount of, and other terms and conditions with | 17 | | respect to, the
refund or additional premium are set forth | 18 | | in the group or enrollment unit
contract agreed in advance | 19 | | of the period for which a refund is to be paid or
| 20 | | additional premium is to be charged (which period shall not | 21 | | be less than one
year); and
| 22 | | (ii) the amount of the refund or additional premium | 23 | | shall not exceed 20%
of the Health Maintenance | 24 | | Organization's profitable or unprofitable experience
with | 25 | | respect to the group or other enrollment unit for the | 26 | | period (and, for
purposes of a refund or additional |
| | | HB2957 Enrolled | - 16 - | LRB100 05656 SMS 15673 b |
|
| 1 | | premium, the profitable or unprofitable
experience shall | 2 | | be calculated taking into account a pro rata share of the
| 3 | | Health Maintenance Organization's administrative and | 4 | | marketing expenses, but
shall not include any refund to be | 5 | | made or additional premium to be paid
pursuant to this | 6 | | subsection (f)). The Health Maintenance Organization and | 7 | | the
group or enrollment unit may agree that the profitable | 8 | | or unprofitable
experience may be calculated taking into | 9 | | account the refund period and the
immediately preceding 2 | 10 | | plan years.
| 11 | | The Health Maintenance Organization shall include a | 12 | | statement in the
evidence of coverage issued to each enrollee | 13 | | describing the possibility of a
refund or additional premium, | 14 | | and upon request of any group or enrollment unit,
provide to | 15 | | the group or enrollment unit a description of the method used | 16 | | to
calculate (1) the Health Maintenance Organization's | 17 | | profitable experience with
respect to the group or enrollment | 18 | | unit and the resulting refund to the group
or enrollment unit | 19 | | or (2) the Health Maintenance Organization's unprofitable
| 20 | | experience with respect to the group or enrollment unit and the | 21 | | resulting
additional premium to be paid by the group or | 22 | | enrollment unit.
| 23 | | In no event shall the Illinois Health Maintenance | 24 | | Organization
Guaranty Association be liable to pay any | 25 | | contractual obligation of an
insolvent organization to pay any | 26 | | refund authorized under this Section.
|
| | | HB2957 Enrolled | - 17 - | LRB100 05656 SMS 15673 b |
|
| 1 | | (g) Rulemaking authority to implement Public Act 95-1045, | 2 | | if any, is conditioned on the rules being adopted in accordance | 3 | | with all provisions of the Illinois Administrative Procedure | 4 | | Act and all rules and procedures of the Joint Committee on | 5 | | Administrative Rules; any purported rule not so adopted, for | 6 | | whatever reason, is unauthorized. | 7 | | (Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15; | 8 | | 99-761, eff. 1-1-18.) | 9 | | Section 35. The Limited Health Service Organization Act is | 10 | | amended by changing Section 4003 as follows:
| 11 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| 12 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 13 | | health service
organizations shall be subject to the provisions | 14 | | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | 15 | | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | 16 | | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, | 17 | | 356z.10, 356z.21, 356z.22, 356z.25, 368a, 401, 401.1,
402,
403, | 18 | | 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles IIA, | 19 | | VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of the | 20 | | Illinois Insurance Code. For purposes of the
Illinois Insurance | 21 | | Code, except for Sections 444 and 444.1 and Articles XIII
and | 22 | | XIII 1/2, limited health service organizations in the following | 23 | | categories
are deemed to be domestic companies:
| 24 | | (1) a corporation under the laws of this State; or
|
| | | HB2957 Enrolled | - 18 - | LRB100 05656 SMS 15673 b |
|
| 1 | | (2) a corporation organized under the laws of another | 2 | | state, 30% or of more
of the enrollees of which are | 3 | | residents of this State, except a corporation
subject to | 4 | | substantially the same requirements in its state of | 5 | | organization as
is a domestic company under Article VIII | 6 | | 1/2 of the Illinois Insurance Code.
| 7 | | (Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff. | 8 | | 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, | 9 | | eff. 1-1-15; revised 10-5-16.)
| 10 | | Section 40. The Voluntary Health Services Plans Act is | 11 | | amended by changing Section 10 as follows:
| 12 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
| 13 | | Sec. 10. Application of Insurance Code provisions. Health | 14 | | services
plan corporations and all persons interested therein | 15 | | or dealing therewith
shall be subject to the provisions of | 16 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 17 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, | 18 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | 19 | | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| 20 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | 21 | | 356z.19, 356z.21, 356z.22, 356z.25, 364.01, 367.2, 368a, 401, | 22 | | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | 23 | | and (15) of Section 367 of the Illinois
Insurance Code.
| 24 | | Rulemaking authority to implement Public Act 95-1045, if |
| | | HB2957 Enrolled | - 19 - | LRB100 05656 SMS 15673 b |
|
| 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486, | 7 | | eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, | 8 | | eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15 .) | 9 | | Section 45. The Illinois Public Aid Code is amended by | 10 | | changing Section 5-16.8 as follows:
| 11 | | (305 ILCS 5/5-16.8)
| 12 | | Sec. 5-16.8. Required health benefits. The medical | 13 | | assistance program
shall
(i) provide the post-mastectomy care | 14 | | benefits required to be covered by a policy of
accident and | 15 | | health insurance under Section 356t and the coverage required
| 16 | | under Sections 356g.5, 356u, 356w, 356x, and 356z.6 , and | 17 | | 356z.25 of the Illinois
Insurance Code and (ii) be subject to | 18 | | the provisions of Sections 356z.19, 364.01, 370c, and 370c.1 of | 19 | | the Illinois
Insurance Code.
| 20 | | On and after July 1, 2012, the Department shall reduce any | 21 | | rate of reimbursement for services or other payments or alter | 22 | | any methodologies authorized by this Code to reduce any rate of | 23 | | reimbursement for services or other payments in accordance with | 24 | | Section 5-5e. |
| | | HB2957 Enrolled | - 20 - | LRB100 05656 SMS 15673 b |
|
| 1 | | To ensure full access to the benefits set forth in this | 2 | | Section, on and after January 1, 2016, the Department shall | 3 | | ensure that provider and hospital reimbursement for | 4 | | post-mastectomy care benefits required under this Section are | 5 | | no lower than the Medicare reimbursement rate. | 6 | | (Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; | 7 | | 99-642, eff. 7-28-16.)
| 8 | | Section 95. No acceleration or delay. Where this Act makes | 9 | | changes in a statute that is represented in this Act by text | 10 | | that is not yet or no longer in effect (for example, a Section | 11 | | represented by multiple versions), the use of that text does | 12 | | not accelerate or delay the taking effect of (i) the changes | 13 | | made by this Act or (ii) provisions derived from any other | 14 | | Public Act.
| 15 | | Section 99. Effective date. This Act takes effect upon | 16 | | becoming law.
|
|