Full Text of SB0667 101st General Assembly
SB0667ham001 101ST GENERAL ASSEMBLY | Rep. Will Guzzardi Adopted in House Comm. on Nov 12, 2019
| | 10100SB0667ham001 | | LRB101 04428 BMS 64618 a |
|
| 1 | | AMENDMENT TO SENATE BILL 667
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 667 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Findings. The General Assembly finds and | 5 | | declares that: | 6 | | (1) Diabetes affects approximately 1,300,000 adults in | 7 | | Illinois (12.5% of the population); | 8 | | (2) Diabetes is the seventh leading cause of death | 9 | | nationally and in Illinois; | 10 | | (3) The toll on the U.S. economy has increased by more | 11 | | than 40% since 2007, costing the country $245,000,000,000 | 12 | | in 2012; | 13 | | (4) When someone has diabetes, the body either does not | 14 | | make enough insulin or is unable to use its own insulin, | 15 | | causing glucose levels to rise higher than normal in the | 16 | | blood; | 17 | | (5) For people with Type 1 diabetes, near-constant |
| | | 10100SB0667ham001 | - 2 - | LRB101 04428 BMS 64618 a |
|
| 1 | | self-management of glucose levels is essential to prevent | 2 | | life-threatening complications; | 3 | | (6) From 2012 to 2016, the average price of insulin | 4 | | increased from 13 cents per unit to 25 cents per unit; | 5 | | therefore, | 6 | | It is necessary for the State to enact laws to reduce the | 7 | | costs for Illinoisans with diabetes and increase their access | 8 | | to life-saving and life-sustaining insulin. | 9 | | Section 5. The State Employees Group Insurance Act of 1971 | 10 | | is amended by changing Section 6.11 as follows:
| 11 | | (5 ILCS 375/6.11)
| 12 | | Sec. 6.11. Required health benefits; Illinois Insurance | 13 | | Code
requirements. The program of health
benefits shall provide | 14 | | the post-mastectomy care benefits required to be covered
by a | 15 | | policy of accident and health insurance under Section 356t of | 16 | | the Illinois
Insurance Code. The program of health benefits | 17 | | shall provide the coverage
required under Sections 356g, | 18 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 19 | | 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 20 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, | 21 | | 356z.29, 356z.30a, 356z.32, and 356z.33 , 356z.36, and 356z.41 | 22 | | of the
Illinois Insurance Code.
The program of health benefits | 23 | | must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, | 24 | | and 370c.1 , and Article XXXIIB of the
Illinois Insurance Code. |
| | | 10100SB0667ham001 | - 3 - | LRB101 04428 BMS 64618 a |
|
| 1 | | The Department of Insurance shall enforce the requirements of | 2 | | this Section with respect to Sections 370c and 370c.1 of the | 3 | | Illinois Insurance Code; all other requirements of this Section | 4 | | shall be enforced by the Department of Central Management | 5 | | Services.
| 6 | | Rulemaking authority to implement Public Act 95-1045, if | 7 | | any, is conditioned on the rules being adopted in accordance | 8 | | with all provisions of the Illinois Administrative Procedure | 9 | | Act and all rules and procedures of the Joint Committee on | 10 | | Administrative Rules; any purported rule not so adopted, for | 11 | | whatever reason, is unauthorized. | 12 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 13 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 14 | | 1-1-19; 100-1102, eff. 1-1-19; 100-1170, eff. 6-1-19; 101-13, | 15 | | eff. 6-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; | 16 | | 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; revised 10-16-19.) | 17 | | Section 15. The Counties Code is amended by changing | 18 | | Section 5-1069.3 as follows: | 19 | | (55 ILCS 5/5-1069.3)
| 20 | | Sec. 5-1069.3. Required health benefits. If a county, | 21 | | including a home
rule
county, is a self-insurer for purposes of | 22 | | providing health insurance coverage
for its employees, the | 23 | | coverage shall include coverage for the post-mastectomy
care | 24 | | benefits required to be covered by a policy of accident and |
| | | 10100SB0667ham001 | - 4 - | LRB101 04428 BMS 64618 a |
|
| 1 | | health
insurance under Section 356t and the coverage required | 2 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 3 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 4 | | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | 5 | | 356z.30a, and 356z.32, and 356z.33 , 356z.36, and 356z.41 of
the | 6 | | Illinois Insurance Code. The coverage shall comply with | 7 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | 8 | | Insurance Code. The Department of Insurance shall enforce the | 9 | | requirements of this Section. The requirement that health | 10 | | benefits be covered
as provided in this Section is an
exclusive | 11 | | power and function of the State and is a denial and limitation | 12 | | under
Article VII, Section 6, subsection (h) of the Illinois | 13 | | Constitution. A home
rule county to which this Section applies | 14 | | must comply with every provision of
this Section.
| 15 | | Rulemaking authority to implement Public Act 95-1045, if | 16 | | any, is conditioned on the rules being adopted in accordance | 17 | | with all provisions of the Illinois Administrative Procedure | 18 | | Act and all rules and procedures of the Joint Committee on | 19 | | Administrative Rules; any purported rule not so adopted, for | 20 | | whatever reason, is unauthorized. | 21 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 22 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 23 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 24 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 25 | | revised 10-16-19.) |
| | | 10100SB0667ham001 | - 5 - | LRB101 04428 BMS 64618 a |
|
| 1 | | Section 20. The Illinois Municipal Code is amended by | 2 | | changing Section 10-4-2.3 as follows: | 3 | | (65 ILCS 5/10-4-2.3)
| 4 | | Sec. 10-4-2.3. Required health benefits. If a | 5 | | municipality, including a
home rule municipality, is a | 6 | | self-insurer for purposes of providing health
insurance | 7 | | coverage for its employees, the coverage shall include coverage | 8 | | for
the post-mastectomy care benefits required to be covered by | 9 | | a policy of
accident and health insurance under Section 356t | 10 | | and the coverage required
under Sections 356g, 356g.5, | 11 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 12 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | 13 | | 356z.26, 356z.29, 356z.30a, and 356z.32, and 356z.33 , 356z.36, | 14 | | and 356z.41 of the Illinois
Insurance
Code. The coverage shall | 15 | | comply with Sections 155.22a, 355b, 356z.19, and 370c of
the | 16 | | Illinois Insurance Code. The Department of Insurance shall | 17 | | enforce the requirements of this Section. The requirement that | 18 | | health
benefits be covered as provided in this is an exclusive | 19 | | power and function of
the State and is a denial and limitation | 20 | | under Article VII, Section 6,
subsection (h) of the Illinois | 21 | | Constitution. A home rule municipality to which
this Section | 22 | | applies must comply with every provision of this Section.
| 23 | | Rulemaking authority to implement Public Act 95-1045, if | 24 | | any, is conditioned on the rules being adopted in accordance | 25 | | with all provisions of the Illinois Administrative Procedure |
| | | 10100SB0667ham001 | - 6 - | LRB101 04428 BMS 64618 a |
|
| 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. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 5 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 6 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 7 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 8 | | revised 10-16-19.) | 9 | | Section 25. The School Code is amended by changing Section | 10 | | 10-22.3f as follows: | 11 | | (105 ILCS 5/10-22.3f)
| 12 | | Sec. 10-22.3f. Required health benefits. Insurance | 13 | | protection and
benefits
for employees shall provide the | 14 | | post-mastectomy care benefits required to be
covered by a | 15 | | policy of accident and health insurance under Section 356t and | 16 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 17 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 18 | | 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | 19 | | 356z.30a, and 356z.32, and 356z.33 , 356z.36, and 356z.41 of
the
| 20 | | Illinois Insurance Code.
Insurance policies shall comply with | 21 | | Section 356z.19 of the Illinois Insurance Code. The coverage | 22 | | shall comply with Sections 155.22a, 355b, and 370c of
the | 23 | | Illinois Insurance Code. The Department of Insurance shall | 24 | | enforce the requirements of this Section.
|
| | | 10100SB0667ham001 | - 7 - | LRB101 04428 BMS 64618 a |
|
| 1 | | Rulemaking authority to implement Public Act 95-1045, if | 2 | | 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. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 8 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 9 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 10 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 11 | | revised 10-16-19.) | 12 | | Section 30. The Illinois Insurance Code is amended by | 13 | | changing Section 356w and by adding Sections 356z.41 and | 14 | | 356z.42 as follows:
| 15 | | (215 ILCS 5/356w)
| 16 | | Sec. 356w. Diabetes self-management training and | 17 | | education.
| 18 | | (a) A group policy of accident and health insurance that is | 19 | | amended,
delivered,
issued, or renewed after the
effective date | 20 | | of this amendatory Act of 1998 shall provide coverage for
| 21 | | outpatient self-management
training and education, equipment, | 22 | | and supplies, as set forth in this Section,
for the treatment | 23 | | of type 1 diabetes, type 2 diabetes, and gestational diabetes
| 24 | | mellitus.
|
| | | 10100SB0667ham001 | - 8 - | LRB101 04428 BMS 64618 a |
|
| 1 | | (b) As used in this Section:
| 2 | | "Diabetes self-management training"
means instruction in | 3 | | an outpatient setting
which enables a diabetic patient to | 4 | | understand the diabetic management process
and daily | 5 | | management of
diabetic therapy as a means of avoiding frequent | 6 | | hospitalization and
complications. Diabetes self-management | 7 | | training shall include
the content areas listed in the National | 8 | | Standards for Diabetes Self-Management
Education Programs as | 9 | | published by the American Diabetes Association, including
| 10 | | medical nutrition therapy and education programs, as defined by | 11 | | the contract of insurance, that allow the patient to maintain | 12 | | an A1c level within the range identified in nationally | 13 | | recognized standards of care.
| 14 | | "Medical nutrition therapy" shall have the meaning
| 15 | | ascribed to that term in the Dietitian Nutritionist
Practice | 16 | | Act.
| 17 | | "Physician" means a
physician licensed to practice | 18 | | medicine in all of
its branches providing care to the | 19 | | individual.
| 20 | | "Qualified provider" for an
individual that is enrolled in:
| 21 | | (1) a health maintenance organization that uses a
| 22 | | primary
care physician to
control access to specialty care | 23 | | means (A) the individual's primary care
physician licensed | 24 | | to practice
medicine in all of its branches, (B) a | 25 | | physician licensed to practice
medicine in all of its | 26 | | branches to
whom the individual has been referred by the |
| | | 10100SB0667ham001 | - 9 - | LRB101 04428 BMS 64618 a |
|
| 1 | | primary care physician, or (C) a
certified, registered, or
| 2 | | licensed network health care professional with expertise | 3 | | in diabetes management
to whom the individual
has been | 4 | | referred by the primary care physician.
| 5 | | (2) an insurance plan
means (A) a physician licensed to | 6 | | practice medicine in
all of its branches or (B) a
| 7 | | certified, registered, or licensed health care | 8 | | professional with expertise in
diabetes management to whom | 9 | | the individual has been referred by a physician.
| 10 | | (c) Coverage under this Section for diabetes | 11 | | self-management training,
including medical nutrition
| 12 | | education, shall be limited to the following:
| 13 | | (1) Up to 3 medically necessary visits to a qualified | 14 | | provider upon
initial diagnosis of diabetes
by the | 15 | | patient's
physician or, if diagnosis of diabetes was made | 16 | | within one year prior to the
effective date of
this | 17 | | amendatory Act
of 1998 where the insured was a covered | 18 | | individual, up to 3 medically necessary
visits to a | 19 | | qualified provider within one
year after that
effective
| 20 | | date.
| 21 | | (2) Up to 2 medically necessary visits to a qualified | 22 | | provider upon a
determination by a
patient's
physician that | 23 | | a significant change in the patient's symptoms or medical
| 24 | | condition has
occurred. A "significant change" in | 25 | | condition means symptomatic
hyperglycemia (greater than | 26 | | 250 mg/dl on repeated occasions), severe
hypoglycemia |
| | | 10100SB0667ham001 | - 10 - | LRB101 04428 BMS 64618 a |
|
| 1 | | (requiring the assistance of another person), onset or | 2 | | progression
of diabetes, or a significant change in medical | 3 | | condition that would require a
significantly different | 4 | | treatment regimen.
| 5 | | Payment by the insurer or health maintenance organization | 6 | | for the coverage
required for diabetes self-management | 7 | | training pursuant to the provisions of
this Section is only | 8 | | required to be made for services provided.
No coverage is | 9 | | required for additional visits beyond those specified in items
| 10 | | (1) and (2) of this subsection.
| 11 | | Coverage under this subsection (c) for diabetes | 12 | | self-management training
shall
be subject to the same
| 13 | | deductible, co-payment, and co-insurance provisions that apply | 14 | | to coverage
under
the policy for other
services provided by the | 15 | | same type of provider.
| 16 | | (d) Coverage shall be provided for the following
equipment | 17 | | when medically necessary
and prescribed by a physician licensed | 18 | | to practice medicine in all
of its branches.
Coverage for the | 19 | | following items shall be subject to deductible, co-payment
and | 20 | | co-insurance provisions
provided for under the policy or a | 21 | | durable medical equipment rider to the
policy:
| 22 | | (1) blood glucose monitors;
| 23 | | (2) blood glucose monitors for the legally blind;
| 24 | | (3) cartridges for the legally blind; and
| 25 | | (4) lancets and lancing devices.
| 26 | | This subsection does not apply to a group policy of |
| | | 10100SB0667ham001 | - 11 - | LRB101 04428 BMS 64618 a |
|
| 1 | | accident and health
insurance that does not provide a durable | 2 | | medical equipment benefit.
| 3 | | (e) Coverage shall be provided for the following | 4 | | pharmaceuticals and
supplies when
medically necessary and | 5 | | prescribed by a physician licensed to
practice medicine in all | 6 | | of its
branches.
Coverage for the following items shall be | 7 | | subject to the same coverage,
deductible,
co-payment, and | 8 | | co-insurance
provisions under the policy or a drug rider to the | 9 | | policy , except as otherwise provided for under Section 356z.41 :
| 10 | | (1) insulin;
| 11 | | (2) syringes and needles;
| 12 | | (3) test strips for glucose monitors;
| 13 | | (4) FDA approved oral agents used to control blood | 14 | | sugar; and
| 15 | | (5) glucagon emergency kits.
| 16 | | This subsection does not apply to a group policy of | 17 | | accident and health
insurance that does not provide a drug | 18 | | benefit.
| 19 | | (f) Coverage shall be provided for regular foot care exams | 20 | | by a
physician or by a
physician to whom a physician has | 21 | | referred the patient. Coverage
for regular foot care exams
| 22 | | shall be subject to the same deductible, co-payment, and | 23 | | co-insurance
provisions
that apply under the policy for
other | 24 | | services provided by the same type of provider.
| 25 | | (g) If authorized by a physician, diabetes self-management
| 26 | | training may be provided as a part of an office visit, group |
| | | 10100SB0667ham001 | - 12 - | LRB101 04428 BMS 64618 a |
|
| 1 | | setting, or home
visit.
| 2 | | (h) This Section shall not apply to agreements, contracts, | 3 | | or policies that
provide coverage for a specified diagnosis or | 4 | | other limited benefit coverage.
| 5 | | (Source: P.A. 97-281, eff. 1-1-12; 97-1141, eff. 12-28-12.)
| 6 | | (215 ILCS 5/356z.41 new) | 7 | | Sec. 356z.41. Cost sharing in prescription insulin drugs; | 8 | | limits; confidentiality of rebate information. | 9 | | (a) As used in this Section, "prescription insulin drug" | 10 | | means a prescription drug that contains insulin and is used to | 11 | | control blood glucose levels to treat diabetes but does not | 12 | | include an insulin drug that is
administered to a patient | 13 | | intravenously. | 14 | | (b) This Section applies to a group or individual policy of | 15 | | accident and health insurance amended, delivered, issued, or | 16 | | renewed on or after the effective date of this amendatory Act | 17 | | of the 101st General Assembly. | 18 | | (c) An insurer that provides coverage for prescription | 19 | | insulin drugs pursuant to the terms of a health coverage plan | 20 | | the insurer offers shall limit the total amount that an insured | 21 | | is required to pay for a 30-day supply of covered prescription | 22 | | insulin drugs at an amount not to exceed $100, regardless of | 23 | | the quantity or type of covered prescription insulin drug used | 24 | | to fill the insured's prescription. | 25 | | (d) Nothing in this Section prevents an insurer from |
| | | 10100SB0667ham001 | - 13 - | LRB101 04428 BMS 64618 a |
|
| 1 | | reducing an insured's cost sharing by an amount greater than | 2 | | the amount specified in subsection (c). | 3 | | (e) The Director may use any of the Director's enforcement | 4 | | powers to obtain an insurer's compliance with this Section. | 5 | | (f) The Department may adopt rules as necessary to | 6 | | implement and administer this Section and to align it with | 7 | | federal requirements. | 8 | | (g) On January 1 of each year, the limit on the amount that | 9 | | an insured is required to pay for a 30-day supply of a covered | 10 | | prescription insulin drug shall increase by a percentage equal | 11 | | to the percentage change from the preceding year in the medical | 12 | | care component of the Consumer Price Index of the Bureau of | 13 | | Labor Statistics of the United States Department of Labor. | 14 | | (215 ILCS 5/356z.42 new) | 15 | | Sec. 356z.42. Insulin pricing report. By November 1, 2020, | 16 | | the Department of Insurance in conjunction with the Department | 17 | | of Human Services and the Department of Healthcare and Family | 18 | | Services shall make available to the public a report that | 19 | | details each Department's findings for the following: | 20 | | (1) a summary of insulin pricing practices and variables | 21 | | that contribute to pricing of health coverage plans; | 22 | | (2) public policy recommendations to control and prevent | 23 | | overpricing of prescription insulin drugs made available to | 24 | | Illinois consumers;
and | 25 | | (3) any other information the Department finds necessary. |
| | | 10100SB0667ham001 | - 14 - | LRB101 04428 BMS 64618 a |
|
| 1 | | This Section is repealed December 31, 2020.
| 2 | | Section 35. The Health Maintenance Organization Act is | 3 | | amended by changing Section 5-3 as follows:
| 4 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 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.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | 12 | | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, | 13 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | 14 | | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41, 364, | 15 | | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | 16 | | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | 17 | | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | 18 | | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | 19 | | XXVI, and XXXIIB of the Illinois Insurance Code.
| 20 | | (b) For purposes of the Illinois Insurance Code, except for | 21 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 22 | | Maintenance Organizations in
the following categories are | 23 | | deemed to be "domestic companies":
| 24 | | (1) a corporation authorized under the
Dental Service |
| | | 10100SB0667ham001 | - 15 - | LRB101 04428 BMS 64618 a |
|
| 1 | | Plan Act or the Voluntary Health Services Plans Act;
| 2 | | (2) a corporation organized under the laws of this | 3 | | State; or
| 4 | | (3) a corporation organized under the laws of another | 5 | | state, 30% or more
of the enrollees of which are residents | 6 | | of this State, except a
corporation subject to | 7 | | substantially the same requirements in its state of
| 8 | | organization as is a "domestic company" under Article VIII | 9 | | 1/2 of the
Illinois Insurance Code.
| 10 | | (c) In considering the merger, consolidation, or other | 11 | | acquisition of
control of a Health Maintenance Organization | 12 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 13 | | (1) the Director shall give primary consideration to | 14 | | the continuation of
benefits to enrollees and the financial | 15 | | conditions of the acquired Health
Maintenance Organization | 16 | | after the merger, consolidation, or other
acquisition of | 17 | | control takes effect;
| 18 | | (2)(i) the criteria specified in subsection (1)(b) of | 19 | | Section 131.8 of
the Illinois Insurance Code shall not | 20 | | apply and (ii) the Director, in making
his determination | 21 | | with respect to the merger, consolidation, or other
| 22 | | acquisition of control, need not take into account the | 23 | | effect on
competition of the merger, consolidation, or | 24 | | other acquisition of control;
| 25 | | (3) the Director shall have the power to require the | 26 | | following
information:
|
| | | 10100SB0667ham001 | - 16 - | LRB101 04428 BMS 64618 a |
|
| 1 | | (A) certification by an independent actuary of the | 2 | | adequacy
of the reserves of the Health Maintenance | 3 | | Organization sought to be acquired;
| 4 | | (B) pro forma financial statements reflecting the | 5 | | combined balance
sheets of the acquiring company and | 6 | | the Health Maintenance Organization sought
to be | 7 | | acquired as of the end of the preceding year and as of | 8 | | a date 90 days
prior to the acquisition, as well as pro | 9 | | forma financial statements
reflecting projected | 10 | | combined operation for a period of 2 years;
| 11 | | (C) a pro forma business plan detailing an | 12 | | acquiring party's plans with
respect to the operation | 13 | | of the Health Maintenance Organization sought to
be | 14 | | acquired for a period of not less than 3 years; and
| 15 | | (D) such other information as the Director shall | 16 | | require.
| 17 | | (d) The provisions of Article VIII 1/2 of the Illinois | 18 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 19 | | any health maintenance
organization of greater than 10% of its
| 20 | | enrollee population (including without limitation the health | 21 | | maintenance
organization's right, title, and interest in and to | 22 | | its health care
certificates).
| 23 | | (e) In considering any management contract or service | 24 | | agreement subject
to Section 141.1 of the Illinois Insurance | 25 | | Code, the Director (i) shall, in
addition to the criteria | 26 | | specified in Section 141.2 of the Illinois
Insurance Code, take |
| | | 10100SB0667ham001 | - 17 - | LRB101 04428 BMS 64618 a |
|
| 1 | | into account the effect of the management contract or
service | 2 | | agreement on the continuation of benefits to enrollees and the
| 3 | | financial condition of the health maintenance organization to | 4 | | be managed or
serviced, and (ii) need not take into account the | 5 | | effect of the management
contract or service agreement on | 6 | | competition.
| 7 | | (f) Except for small employer groups as defined in the | 8 | | Small Employer
Rating, Renewability and Portability Health | 9 | | Insurance Act and except for
medicare supplement policies as | 10 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 11 | | Maintenance Organization may by contract agree with a
group or | 12 | | other enrollment unit to effect refunds or charge additional | 13 | | premiums
under the following terms and conditions:
| 14 | | (i) the amount of, and other terms and conditions with | 15 | | respect to, the
refund or additional premium are set forth | 16 | | in the group or enrollment unit
contract agreed in advance | 17 | | of the period for which a refund is to be paid or
| 18 | | additional premium is to be charged (which period shall not | 19 | | be less than one
year); and
| 20 | | (ii) the amount of the refund or additional premium | 21 | | shall not exceed 20%
of the Health Maintenance | 22 | | Organization's profitable or unprofitable experience
with | 23 | | respect to the group or other enrollment unit for the | 24 | | period (and, for
purposes of a refund or additional | 25 | | premium, the profitable or unprofitable
experience shall | 26 | | be calculated taking into account a pro rata share of the
|
| | | 10100SB0667ham001 | - 18 - | LRB101 04428 BMS 64618 a |
|
| 1 | | Health Maintenance Organization's administrative and | 2 | | marketing expenses, but
shall not include any refund to be | 3 | | made or additional premium to be paid
pursuant to this | 4 | | subsection (f)). The Health Maintenance Organization and | 5 | | the
group or enrollment unit may agree that the profitable | 6 | | or unprofitable
experience may be calculated taking into | 7 | | account the refund period and the
immediately preceding 2 | 8 | | plan years.
| 9 | | The Health Maintenance Organization shall include a | 10 | | statement in the
evidence of coverage issued to each enrollee | 11 | | describing the possibility of a
refund or additional premium, | 12 | | and upon request of any group or enrollment unit,
provide to | 13 | | the group or enrollment unit a description of the method used | 14 | | to
calculate (1) the Health Maintenance Organization's | 15 | | profitable experience with
respect to the group or enrollment | 16 | | unit and the resulting refund to the group
or enrollment unit | 17 | | or (2) the Health Maintenance Organization's unprofitable
| 18 | | experience with respect to the group or enrollment unit and the | 19 | | resulting
additional premium to be paid by the group or | 20 | | enrollment unit.
| 21 | | In no event shall the Illinois Health Maintenance | 22 | | Organization
Guaranty Association be liable to pay any | 23 | | contractual obligation of an
insolvent organization to pay any | 24 | | refund authorized under this Section.
| 25 | | (g) Rulemaking authority to implement Public Act 95-1045, | 26 | | if any, is conditioned on the rules being adopted in accordance |
| | | 10100SB0667ham001 | - 19 - | LRB101 04428 BMS 64618 a |
|
| 1 | | with all provisions of the Illinois Administrative Procedure | 2 | | Act and all rules and procedures of the Joint Committee on | 3 | | Administrative Rules; any purported rule not so adopted, for | 4 | | whatever reason, is unauthorized. | 5 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 6 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | 7 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | 8 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | 9 | | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | 10 | | 1-1-20; revised 10-16-19.) | 11 | | Section 40. The Limited Health Service Organization Act is | 12 | | amended by changing Section 4003 as follows:
| 13 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| 14 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 15 | | health service
organizations shall be subject to the provisions | 16 | | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | 17 | | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | 18 | | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, | 19 | | 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, | 20 | | 356z.30a, 356z.32, 356z.33, 356z.41, 368a, 401, 401.1,
402,
| 21 | | 403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles | 22 | | IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of | 23 | | the Illinois Insurance Code. For purposes of the
Illinois | 24 | | Insurance Code, except for Sections 444 and 444.1 and Articles |
| | | 10100SB0667ham001 | - 20 - | LRB101 04428 BMS 64618 a |
|
| 1 | | XIII
and XIII 1/2, limited health service organizations in the | 2 | | following categories
are deemed to be domestic companies:
| 3 | | (1) a corporation under the laws of this State; or
| 4 | | (2) a corporation organized under the laws of another | 5 | | state, 30% or more
of the enrollees of which are residents | 6 | | of this State, except a corporation
subject to | 7 | | substantially the same requirements in its state of | 8 | | organization as
is a domestic company under Article VIII | 9 | | 1/2 of the Illinois Insurance Code.
| 10 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 11 | | 100-201, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. | 12 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 13 | | eff. 1-1-20; 101-393, eff. 1-1-20; revised 10-16-19.)
| 14 | | Section 45. The Voluntary Health Services Plans Act is | 15 | | amended by changing Section 10 as follows:
| 16 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
| 17 | | Sec. 10. Application of Insurance Code provisions. Health | 18 | | services
plan corporations and all persons interested therein | 19 | | or dealing therewith
shall be subject to the provisions of | 20 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 21 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, | 22 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | 23 | | 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, | 24 | | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, |
| | | 10100SB0667ham001 | - 21 - | LRB101 04428 BMS 64618 a |
|
| 1 | | 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, | 2 | | 356z.30, 356z.30a, 356z.32, 356z.33, 356z.41, 364.01, 367.2, | 3 | | 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and | 4 | | paragraphs (7) and (15) of Section 367 of the Illinois
| 5 | | Insurance Code.
| 6 | | Rulemaking authority to implement Public Act 95-1045, if | 7 | | any, is conditioned on the rules being adopted in accordance | 8 | | with all provisions of the Illinois Administrative Procedure | 9 | | Act and all rules and procedures of the Joint Committee on | 10 | | Administrative Rules; any purported rule not so adopted, for | 11 | | whatever reason, is unauthorized. | 12 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 13 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | 14 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | 15 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; | 16 | | revised 10-16-19.) | 17 | | Section 99. Effective date. This Act takes effect January | 18 | | 1, 2021, except that Section 356z.42 and this Section take | 19 | | effect upon becoming law.".
|
|