Illinois General Assembly - Full Text of HB5254
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Full Text of HB5254  102nd General Assembly

HB5254eng 102ND GENERAL ASSEMBLY

  
  
  

 


 
HB5254 EngrossedLRB102 25494 BMS 34782 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
9provide the post-mastectomy care benefits required to be
10covered by a policy of accident and health insurance under
11Section 356t of the Illinois Insurance Code. The program of
12health benefits shall provide the coverage required under
13Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
14356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
15356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
16356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
17356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51,
18and 356z.53 and 356z.43 of the Illinois Insurance Code. The
19program of health benefits must comply with Sections 155.22a,
20155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of
21the Illinois Insurance Code. The Department of Insurance shall
22enforce the requirements of this Section with respect to
23Sections 370c and 370c.1 of the Illinois Insurance Code; all

 

 

HB5254 Engrossed- 2 -LRB102 25494 BMS 34782 b

1other requirements of this Section shall be enforced by the
2Department of Central Management Services.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
10101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
111-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
12eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
13102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
1410-26-21.)
 
15    Section 10. The Counties Code is amended by changing
16Section 5-1069.3 as follows:
 
17    (55 ILCS 5/5-1069.3)
18    Sec. 5-1069.3. Required health benefits. If a county,
19including a home rule county, is a self-insurer for purposes
20of providing health insurance coverage for its employees, the
21coverage shall include coverage for the post-mastectomy care
22benefits required to be covered by a policy of accident and
23health insurance under Section 356t and the coverage required
24under Sections 356g, 356g.5, 356g.5-1, 356q, 356u, 356w, 356x,

 

 

HB5254 Engrossed- 3 -LRB102 25494 BMS 34782 b

1356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
2356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
3356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
4356z.45, 356z.46, 356z.47, 356z.48, 356z.51, and 356z.53 and
5356z.43 of the Illinois Insurance Code. The coverage shall
6comply with Sections 155.22a, 355b, 356z.19, and 370c of the
7Illinois Insurance Code. The Department of Insurance shall
8enforce the requirements of this Section. The requirement that
9health benefits be covered as provided in this Section is an
10exclusive power and function of the State and is a denial and
11limitation under Article VII, Section 6, subsection (h) of the
12Illinois Constitution. A home rule county to which this
13Section applies must comply with every provision of this
14Section.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
22101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
231-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
24eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
25102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
2610-26-21.)
 

 

 

HB5254 Engrossed- 4 -LRB102 25494 BMS 34782 b

1    Section 15. The Illinois Municipal Code is amended by
2changing 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
5municipality, including a home rule municipality, is a
6self-insurer for purposes of providing health insurance
7coverage for its employees, the coverage shall include
8coverage for the post-mastectomy care benefits required to be
9covered by a policy of accident and health insurance under
10Section 356t and the coverage required under Sections 356g,
11356g.5, 356g.5-1, 356q, 356u, 356w, 356x, 356z.6, 356z.8,
12356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
13356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32,
14356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
15356z.48, 356z.51, and 356z.53 and 356z.43 of the Illinois
16Insurance Code. The coverage shall comply with Sections
17155.22a, 355b, 356z.19, and 370c of the Illinois Insurance
18Code. The Department of Insurance shall enforce the
19requirements of this Section. The requirement that health
20benefits be covered as provided in this is an exclusive power
21and function of the State and is a denial and limitation under
22Article VII, Section 6, subsection (h) of the Illinois
23Constitution. A home rule municipality to which this Section
24applies must comply with every provision of this Section.

 

 

HB5254 Engrossed- 5 -LRB102 25494 BMS 34782 b

1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
8101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
91-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
10eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
11102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
1210-26-21.)
 
13    Section 20. The School Code is amended by changing Section
1410-22.3f as follows:
 
15    (105 ILCS 5/10-22.3f)
16    Sec. 10-22.3f. Required health benefits. Insurance
17protection and benefits for employees shall provide the
18post-mastectomy care benefits required to be covered by a
19policy of accident and health insurance under Section 356t and
20the coverage required under Sections 356g, 356g.5, 356g.5-1,
21356q, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11,
22356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
23356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40,
24356z.41, 356z.45, 356z.46, 356z.47, 356z.51, and 356z.53 and

 

 

HB5254 Engrossed- 6 -LRB102 25494 BMS 34782 b

1356z.43 of the Illinois Insurance Code. Insurance policies
2shall comply with Section 356z.19 of the Illinois Insurance
3Code. The coverage shall comply with Sections 155.22a, 355b,
4and 370c of the Illinois Insurance Code. The Department of
5Insurance shall enforce the requirements of this Section.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
13101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
141-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
15eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22;
16102-665, eff. 10-8-21; revised 10-27-21.)
 
17    Section 25. The Illinois Insurance Code is amended by
18adding Section 356z.53 as follows:
 
19    (215 ILCS 5/356z.53 new)
20    Sec. 356z.53. Coverage for hormone therapy to treat
21menopause. A group or individual policy of accident and health
22insurance or a managed care plan that is amended, delivered,
23issued, or renewed on or after January 1, 2024 shall provide
24coverage for medically necessary hormone therapy treatment to

 

 

HB5254 Engrossed- 7 -LRB102 25494 BMS 34782 b

1treat menopause that has been induced by a hysterectomy.
 
2    Section 30. The Health Maintenance Organization Act is
3amended 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
7the provisions of Sections 133, 134, 136, 137, 139, 140,
8141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
9154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
10355.3, 355b, 356g.5-1, 356m, 356q, 356v, 356w, 356x, 356y,
11356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
12356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
13356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29,
14356z.30, 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36,
15356z.40, 356z.41, 356z.43, 356z.46, 356z.47, 356z.48, 356z.50,
16356z.51, 356z.53, 364, 364.01, 367.2, 367.2-5, 367i, 368a,
17368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403,
18403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
19subsection (2) of Section 367, and Articles IIA, VIII 1/2,
20XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
21Illinois Insurance Code.
22    (b) For purposes of the Illinois Insurance Code, except
23for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
24Health Maintenance Organizations in the following categories

 

 

HB5254 Engrossed- 8 -LRB102 25494 BMS 34782 b

1are 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
13acquisition of control of a Health Maintenance Organization
14pursuant 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
17    financial conditions of the acquired Health Maintenance
18    Organization after the merger, consolidation, or other
19    acquisition of 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;

 

 

HB5254 Engrossed- 9 -LRB102 25494 BMS 34782 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
20Insurance Code and this Section 5-3 shall apply to the sale by
21any health maintenance organization of greater than 10% of its
22enrollee population (including without limitation the health
23maintenance organization's right, title, and interest in and
24to its health care certificates).
25    (e) In considering any management contract or service
26agreement subject to Section 141.1 of the Illinois Insurance

 

 

HB5254 Engrossed- 10 -LRB102 25494 BMS 34782 b

1Code, the Director (i) shall, in addition to the criteria
2specified in Section 141.2 of the Illinois Insurance Code,
3take into account the effect of the management contract or
4service agreement on the continuation of benefits to enrollees
5and the financial condition of the health maintenance
6organization to be managed or serviced, and (ii) need not take
7into account the effect of the management contract or service
8agreement on competition.
9    (f) Except for small employer groups as defined in the
10Small Employer Rating, Renewability and Portability Health
11Insurance Act and except for medicare supplement policies as
12defined in Section 363 of the Illinois Insurance Code, a
13Health Maintenance Organization may by contract agree with a
14group or other enrollment unit to effect refunds or charge
15additional 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
21    not 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

 

 

HB5254 Engrossed- 11 -LRB102 25494 BMS 34782 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
12statement in the evidence of coverage issued to each enrollee
13describing the possibility of a refund or additional premium,
14and upon request of any group or enrollment unit, provide to
15the group or enrollment unit a description of the method used
16to calculate (1) the Health Maintenance Organization's
17profitable experience with respect to the group or enrollment
18unit and the resulting refund to the group or enrollment unit
19or (2) the Health Maintenance Organization's unprofitable
20experience with respect to the group or enrollment unit and
21the resulting additional premium to be paid by the group or
22enrollment unit.
23    In no event shall the Illinois Health Maintenance
24Organization Guaranty Association be liable to pay any
25contractual obligation of an insolvent organization to pay any
26refund authorized under this Section.

 

 

HB5254 Engrossed- 12 -LRB102 25494 BMS 34782 b

1    (g) Rulemaking authority to implement Public Act 95-1045,
2if any, is conditioned on the rules being adopted in
3accordance with all provisions of the Illinois Administrative
4Procedure Act and all rules and procedures of the Joint
5Committee on Administrative Rules; any purported rule not so
6adopted, for whatever reason, is unauthorized.
7(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
8101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
91-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
10eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
11102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
121-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
13eff. 10-8-21; revised 10-27-21.)
 
14    Section 35. The Voluntary Health Services Plans Act is
15amended 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
18services plan corporations and all persons interested therein
19or dealing therewith shall be subject to the provisions of
20Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
21143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
22356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
23356x, 356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6,
24356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,

 

 

HB5254 Engrossed- 13 -LRB102 25494 BMS 34782 b

1356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,
2356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, 356z.40,
3356z.41, 356z.46, 356z.47, 356z.51, 356z.53 356z.43, 364.01,
4367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
5and paragraphs (7) and (15) of Section 367 of the Illinois
6Insurance Code.
7    Rulemaking authority to implement Public Act 95-1045, if
8any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
14101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
151-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
16eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
17revised 10-27-21.)
 
18    Section 40. The Illinois Public Aid Code is amended by
19changing Section 5-16.8 as follows:
 
20    (305 ILCS 5/5-16.8)
21    Sec. 5-16.8. Required health benefits. The medical
22assistance program shall (i) provide the post-mastectomy care
23benefits required to be covered by a policy of accident and
24health insurance under Section 356t and the coverage required

 

 

HB5254 Engrossed- 14 -LRB102 25494 BMS 34782 b

1under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6,
2356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46,
3356z.47, 356z.51, and 356z.53 and 356z.43 of the Illinois
4Insurance Code, (ii) be subject to the provisions of Sections
5356z.19, 356z.43, 356z.44, 356z.49, 364.01, 370c, and 370c.1
6of the Illinois Insurance Code, and (iii) be subject to the
7provisions of subsection (d-5) of Section 10 of the Network
8Adequacy and Transparency Act.
9    The Department, by rule, shall adopt a model similar to
10the requirements of Section 356z.39 of the Illinois Insurance
11Code.
12    On and after July 1, 2012, the Department shall reduce any
13rate of reimbursement for services or other payments or alter
14any methodologies authorized by this Code to reduce any rate
15of reimbursement for services or other payments in accordance
16with Section 5-5e.
17    To ensure full access to the benefits set forth in this
18Section, on and after January 1, 2016, the Department shall
19ensure that provider and hospital reimbursement for
20post-mastectomy care benefits required under this Section are
21no lower than the Medicare reimbursement rate.
22(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20;
23101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff.
241-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144,
25eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
26102-530, eff. 1-1-22; 102-642, eff. 1-1-22; revised 10-27-21.)