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Public Act 100-1057
Public Act 1057 100TH GENERAL ASSEMBLY
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Public Act 100-1057
| | HB4821 Enrolled | LRB100 18480 SMS 33695 b |
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| AN ACT concerning regulation.
| Be it enacted by the People of the State of Illinois,
| represented in the General Assembly:
| Section 5. The State Employees Group Insurance Act of 1971 | is amended by changing Section 6.11 as follows:
| (5 ILCS 375/6.11)
| Sec. 6.11. Required health benefits; Illinois Insurance | Code
requirements. The program of health
benefits shall provide | the post-mastectomy care benefits required to be covered
by a | policy of accident and health insurance under Section 356t of | the Illinois
Insurance Code. The program of health benefits | shall provide the coverage
required under Sections 356g, | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 356z.14, 356z.15, 356z.17, 356z.22, and 356z.25, 356z.26, and | 356z.29 of the
Illinois Insurance Code.
The program of health | benefits must comply with Sections 155.22a, 155.37, 355b, | 356z.19, 370c, and 370c.1 of the
Illinois Insurance Code.
| Rulemaking authority to implement Public Act 95-1045, if | any, is conditioned on the rules being adopted in accordance | with all provisions of the Illinois Administrative Procedure | Act and all rules and procedures of the Joint Committee on | Administrative Rules; any purported rule not so adopted, for |
| whatever reason, is unauthorized. | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 100-138, eff. 8-18-17; revised 10-3-17.)
| Section 10. The Counties Code is amended by changing | Section 5-1069.3 as follows:
| (55 ILCS 5/5-1069.3)
| Sec. 5-1069.3. Required health benefits. If a county, | including a home
rule
county, is a self-insurer for purposes of | providing health insurance coverage
for its employees, the | coverage shall include coverage for the post-mastectomy
care | benefits required to be covered by a policy of accident and | health
insurance under Section 356t and the coverage required | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and 356z.29 of
| the Illinois Insurance Code. The coverage shall comply with | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | Insurance Code. The requirement that health benefits be covered
| as provided in this Section is an
exclusive power and function | of the State and is a denial and limitation under
Article VII, | Section 6, subsection (h) of the Illinois Constitution. A home
| rule county to which this Section applies must comply with | every provision of
this Section.
| Rulemaking authority to implement Public Act 95-1045, if |
| any, is conditioned on the rules being adopted in accordance | with all provisions of the Illinois Administrative Procedure | Act and all rules and procedures of the Joint Committee on | Administrative Rules; any purported rule not so adopted, for | whatever reason, is unauthorized. | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 100-138, eff. 8-18-17; revised 10-5-17.)
| Section 15. The Illinois Municipal Code is amended by | changing Section 10-4-2.3 as follows:
| (65 ILCS 5/10-4-2.3)
| Sec. 10-4-2.3. Required health benefits. If a | municipality, including a
home rule municipality, is a | self-insurer for purposes of providing health
insurance | coverage for its employees, the coverage shall include coverage | for
the post-mastectomy care benefits required to be covered by | a policy of
accident and health insurance under Section 356t | and the coverage required
under Sections 356g, 356g.5, | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and | 356z.25, 356z.26, and 356z.29 of the Illinois
Insurance
Code. | The coverage shall comply with Sections 155.22a, 355b, 356z.19, | and 370c of
the Illinois Insurance Code. The requirement that | health
benefits be covered as provided in this is an exclusive | power and function of
the State and is a denial and limitation |
| under Article VII, Section 6,
subsection (h) of the Illinois | Constitution. A home rule municipality to which
this Section | applies must comply with every provision of this Section.
| Rulemaking authority to implement Public Act 95-1045, if | any, is conditioned on the rules being adopted in accordance | with all provisions of the Illinois Administrative Procedure | Act and all rules and procedures of the Joint Committee on | Administrative Rules; any purported rule not so adopted, for | whatever reason, is unauthorized. | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 100-138, eff. 8-18-17; revised 10-5-17.)
| Section 20. The School Code is amended by changing Section | 10-22.3f as follows:
| (105 ILCS 5/10-22.3f)
| Sec. 10-22.3f. Required health benefits. Insurance | protection and
benefits
for employees shall provide the | post-mastectomy care benefits required to be
covered by a | policy of accident and health insurance under Section 356t and | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 356z.13, 356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and | 356z.29 of
the
Illinois Insurance Code.
Insurance policies | shall comply with Section 356z.19 of the Illinois Insurance | Code. The coverage shall comply with Sections 155.22a and 355b |
| of
the Illinois Insurance Code.
| Rulemaking authority to implement Public Act 95-1045, if | any, is conditioned on the rules being adopted in accordance | with all provisions of the Illinois Administrative Procedure | Act and all rules and procedures of the Joint Committee on | Administrative Rules; any purported rule not so adopted, for | whatever reason, is unauthorized. | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | revised 9-25-17.)
| Section 25. The Illinois Insurance Code is amended by | adding Section 356z.29 as follows:
| (215 ILCS 5/356z.29 new) | Sec. 356z.29. Stage 4 advanced, metastatic cancer. | (a) As used in this Section, "stage 4 advanced, metastatic | cancer" means cancer that has spread from the primary or | original site of the cancer to nearby tissues, lymph nodes, or | other areas or parts of the body. | (b) No individual or group policy of accident and health | insurance amended, issued, delivered, or renewed in this State | after the effective date of this amendatory Act of the 100th | General Assembly that, as a provision of hospital, medical, or | surgical services, directly or indirectly covers the treatment | of stage 4 advanced, metastatic cancer shall limit or exclude | coverage for a drug approved by the United States Food and Drug |
| Administration by mandating that the insured shall first be | required to fail to successfully respond to a different drug or | prove a history of failure of the drug as long as the use of the | drug is consistent with best practices for the treatment of | stage 4 advanced, metastatic cancer and is supported by | peer-reviewed medical literature. | (c) If, at any time before or after the effective date of | this amendatory Act of the 100th General Assembly, the | Secretary of the United States Department of Health and Human | Services, or its successor agency, promulgates rules or | regulations to be published in the Federal Register, publishes | a comment in the Federal Register, or issues an opinion, | guidance, or other action that would require the State, | pursuant to any provision of the Patient Protection and | Affordable Care Act (Pub. L. 111–148), including, but not | limited to, 42 U.S.C. 18031(d)(3)(B) or any successor | provision, to defray the cost of the prohibition of coverage | restrictions or exclusions contained in subsection (b) of this | Section for the treatment of stage 4 advanced, metastatic | cancer, then this Section is inoperative with respect to all | such coverage other than that authorized under Section 1902 of | the Social Security Act, 42 U.S.C. 1396a, and the State shall | not assume any obligation for the cost of the prohibition of | coverage restrictions or exclusions contained in subsection | (b) of this Section for the treatment of stage 4 advanced, | metastatic cancer.
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| Section 30. The Health Maintenance Organization Act is | amended by changing Section 5-3 as follows:
| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| Sec. 5-3. Insurance Code provisions.
| (a) Health Maintenance Organizations
shall be subject to | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 356z.22, 356z.25, 356z.26, 356z.29, 364, 364.01, 367.2, | 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
370c.1, 401, | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
| paragraph (c) of subsection (2) of Section 367, and Articles | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | the Illinois Insurance Code.
| (b) For purposes of the Illinois Insurance Code, except for | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | Maintenance Organizations in
the following categories are | deemed to be "domestic companies":
| (1) a corporation authorized under the
Dental Service | Plan Act or the Voluntary Health Services Plans Act;
| (2) a corporation organized under the laws of this |
| State; or
| (3) a corporation organized under the laws of another | state, 30% or more
of the enrollees of which are residents | of this State, except a
corporation subject to | substantially the same requirements in its state of
| organization as is a "domestic company" under Article VIII | 1/2 of the
Illinois Insurance Code.
| (c) In considering the merger, consolidation, or other | acquisition of
control of a Health Maintenance Organization | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| (1) the Director shall give primary consideration to | the continuation of
benefits to enrollees and the financial | conditions of the acquired Health
Maintenance Organization | after the merger, consolidation, or other
acquisition of | control takes effect;
| (2)(i) the criteria specified in subsection (1)(b) of | Section 131.8 of
the Illinois Insurance Code shall not | apply and (ii) the Director, in making
his determination | with respect to the merger, consolidation, or other
| acquisition of control, need not take into account the | effect on
competition of the merger, consolidation, or | other acquisition of control;
| (3) the Director shall have the power to require the | following
information:
| (A) certification by an independent actuary of the | adequacy
of the reserves of the Health Maintenance |
| Organization sought to be acquired;
| (B) pro forma financial statements reflecting the | combined balance
sheets of the acquiring company and | the Health Maintenance Organization sought
to be | acquired as of the end of the preceding year and as of | a date 90 days
prior to the acquisition, as well as pro | forma financial statements
reflecting projected | combined operation for a period of 2 years;
| (C) a pro forma business plan detailing an | acquiring party's plans with
respect to the operation | of the Health Maintenance Organization sought to
be | acquired for a period of not less than 3 years; and
| (D) such other information as the Director shall | require.
| (d) The provisions of Article VIII 1/2 of the Illinois | Insurance Code
and this Section 5-3 shall apply to the sale by | any health maintenance
organization of greater than 10% of its
| enrollee population (including without limitation the health | maintenance
organization's right, title, and interest in and to | its health care
certificates).
| (e) In considering any management contract or service | agreement subject
to Section 141.1 of the Illinois Insurance | Code, the Director (i) shall, in
addition to the criteria | specified in Section 141.2 of the Illinois
Insurance Code, take | into account the effect of the management contract or
service | agreement on the continuation of benefits to enrollees and the
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| financial condition of the health maintenance organization to | be managed or
serviced, and (ii) need not take into account the | effect of the management
contract or service agreement on | competition.
| (f) Except for small employer groups as defined in the | Small Employer
Rating, Renewability and Portability Health | Insurance Act and except for
medicare supplement policies as | defined in Section 363 of the Illinois
Insurance Code, a Health | Maintenance Organization may by contract agree with a
group or | other enrollment unit to effect refunds or charge additional | premiums
under the following terms and conditions:
| (i) the amount of, and other terms and conditions with | respect to, the
refund or additional premium are set forth | in the group or enrollment unit
contract agreed in advance | of the period for which a refund is to be paid or
| additional premium is to be charged (which period shall not | be less than one
year); and
| (ii) the amount of the refund or additional premium | shall not exceed 20%
of the Health Maintenance | Organization's profitable or unprofitable experience
with | respect to the group or other enrollment unit for the | period (and, for
purposes of a refund or additional | premium, the profitable or unprofitable
experience shall | be calculated taking into account a pro rata share of the
| Health Maintenance Organization's administrative and | marketing expenses, but
shall not include any refund to be |
| made or additional premium to be paid
pursuant to this | subsection (f)). The Health Maintenance Organization and | the
group or enrollment unit may agree that the profitable | or unprofitable
experience may be calculated taking into | account the refund period and the
immediately preceding 2 | plan years.
| The Health Maintenance Organization shall include a | statement in the
evidence of coverage issued to each enrollee | describing the possibility of a
refund or additional premium, | and upon request of any group or enrollment unit,
provide to | the group or enrollment unit a description of the method used | to
calculate (1) the Health Maintenance Organization's | profitable experience with
respect to the group or enrollment | unit and the resulting refund to the group
or enrollment unit | or (2) the Health Maintenance Organization's unprofitable
| experience with respect to the group or enrollment unit and the | resulting
additional premium to be paid by the group or | enrollment unit.
| In no event shall the Illinois Health Maintenance | Organization
Guaranty Association be liable to pay any | contractual obligation of an
insolvent organization to pay any | refund authorized under this Section.
| (g) Rulemaking authority to implement Public Act 95-1045, | if any, is conditioned on the rules being adopted in accordance | with all provisions of the Illinois Administrative Procedure | Act and all rules and procedures of the Joint Committee on |
| Administrative Rules; any purported rule not so adopted, for | whatever reason, is unauthorized. | (Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; | 100-138, eff. 8-18-17; revised 10-5-17.)
| Section 35. The Limited Health Service Organization Act is | amended by changing Section 4003 as follows:
| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| Sec. 4003. Illinois Insurance Code provisions. Limited | health service
organizations shall be subject to the provisions | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, | 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 368a, | 401, 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and | 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, | XXV, and XXVI of the Illinois Insurance Code. For purposes of | the
Illinois Insurance Code, except for Sections 444 and 444.1 | and Articles XIII
and XIII 1/2, limited health service | organizations in the following categories
are deemed to be | domestic companies:
| (1) a corporation under the laws of this State; or
| (2) a corporation organized under the laws of another | state, 30% or more
of the enrollees of which are residents | of this State, except a corporation
subject to |
| substantially the same requirements in its state of | organization as
is a domestic company under Article VIII | 1/2 of the Illinois Insurance Code.
| (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 100-201, eff. 8-18-17; revised 10-5-17.)
| Section 40. The Voluntary Health Services Plans Act is | amended by changing Section 10 as follows:
| (215 ILCS 165/10) (from Ch. 32, par. 604)
| Sec. 10. Application of Insurance Code provisions. Health | services
plan corporations and all persons interested therein | or dealing therewith
shall be subject to the provisions of | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 364.01, | 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, | and paragraphs (7) and (15) of Section 367 of the Illinois
| Insurance Code.
| Rulemaking authority to implement Public Act 95-1045, if | any, is conditioned on the rules being adopted in accordance | with all provisions of the Illinois Administrative Procedure | Act and all rules and procedures of the Joint Committee on |
| Administrative Rules; any purported rule not so adopted, for | whatever reason, is unauthorized. | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | revised 10-5-17.)
| Section 45. The Illinois Public Aid Code is amended by | changing Section 5-16.8 as follows:
| (305 ILCS 5/5-16.8)
| Sec. 5-16.8. Required health benefits. The medical | assistance program
shall
(i) provide the post-mastectomy care | benefits required to be covered by a policy of
accident and | health insurance under Section 356t and the coverage required
| under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and | 356z.29 and 356z.25 of the Illinois
Insurance Code and (ii) be | subject to the provisions of Sections 356z.19, 364.01, 370c, | and 370c.1 of the Illinois
Insurance Code.
| On and after July 1, 2012, the Department shall reduce any | rate of reimbursement for services or other payments or alter | any methodologies authorized by this Code to reduce any rate of | reimbursement for services or other payments in accordance with | Section 5-5e. | To ensure full access to the benefits set forth in this | Section, on and after January 1, 2016, the Department shall | ensure that provider and hospital reimbursement for | post-mastectomy care benefits required under this Section are |
| no lower than the Medicare reimbursement rate. | (Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; | 99-642, eff. 7-28-16; 100-138, eff. 8-18-17; revised 1-29-18.)
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Effective Date: 1/1/2019
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