SB2672 EngrossedLRB103 35845 RPS 65930 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 Illinois Insurance Code is amended by
5adding Section 356z.71 as follows:
 
6    (215 ILCS 5/356z.71 new)
7    Sec. 356z.71. Coverage during a generic drug shortage.
8    (a) As used in this Section:
9    "Eligible prescription drug" means a prescription drug
10approved under 21 U.S.C. 355(c) that is not under patent.
11    "Generic drug" means a drug that is approved pursuant to
12an application referencing an eligible prescription drug that
13is submitted under subsection (j) of Section 505 of the
14Federal Food, Drug, and Cosmetic Act, 21 U.S.C. 355(j).
15    "Unavailable" means being listed as Currently in Shortage
16or as a Discontinuation in the United States Food and Drug
17Administration's Drug Shortages Database. "Unavailable" does
18not include being listed as a Resolved Shortage in the United
19States Food and Drug Administration's Drug Shortages Database.
20    (b) If a generic drug or a therapeutic equivalent is
21unavailable due to a supply issue and dosage cannot be
22adjusted, a group or individual policy of accident and health
23insurance or a managed care plan that is amended, delivered,

 

 

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1issued, or renewed after January 1, 2026 shall provide
2coverage for a brand name eligible prescription drug until
3supply of the generic drug or a therapeutic equivalent is
4available.
 
5    Section 10. The Health Maintenance Organization Act is
6amended by changing Section 5-3 as follows:
 
7    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
8    Sec. 5-3. Insurance Code provisions.
9    (a) Health Maintenance Organizations shall be subject to
10the provisions of Sections 133, 134, 136, 137, 139, 140,
11141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
12154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
13355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v,
14356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
15356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
16356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22,
17356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30,
18356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35,
19356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, 356z.44,
20356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51,
21356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59,
22356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, 356z.68,
23356z.71, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
24368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,

 

 

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1408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
2subsection (2) of Section 367, and Articles IIA, VIII 1/2,
3XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
4Illinois Insurance Code.
5    (b) For purposes of the Illinois Insurance Code, except
6for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
7Health Maintenance Organizations in the following categories
8are deemed to be "domestic companies":
9        (1) a corporation authorized under the Dental Service
10    Plan Act or the Voluntary Health Services Plans Act;
11        (2) a corporation organized under the laws of this
12    State; or
13        (3) a corporation organized under the laws of another
14    state, 30% or more of the enrollees of which are residents
15    of this State, except a corporation subject to
16    substantially the same requirements in its state of
17    organization as is a "domestic company" under Article VIII
18    1/2 of the Illinois Insurance Code.
19    (c) In considering the merger, consolidation, or other
20acquisition of control of a Health Maintenance Organization
21pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22        (1) the Director shall give primary consideration to
23    the continuation of benefits to enrollees and the
24    financial conditions of the acquired Health Maintenance
25    Organization after the merger, consolidation, or other
26    acquisition of control takes effect;

 

 

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1        (2)(i) the criteria specified in subsection (1)(b) of
2    Section 131.8 of the Illinois Insurance Code shall not
3    apply and (ii) the Director, in making his determination
4    with respect to the merger, consolidation, or other
5    acquisition of control, need not take into account the
6    effect on competition of the merger, consolidation, or
7    other acquisition of control;
8        (3) the Director shall have the power to require the
9    following information:
10            (A) certification by an independent actuary of the
11        adequacy of the reserves of the Health Maintenance
12        Organization sought to be acquired;
13            (B) pro forma financial statements reflecting the
14        combined balance sheets of the acquiring company and
15        the Health Maintenance Organization sought to be
16        acquired as of the end of the preceding year and as of
17        a date 90 days prior to the acquisition, as well as pro
18        forma financial statements reflecting projected
19        combined operation for a period of 2 years;
20            (C) a pro forma business plan detailing an
21        acquiring party's plans with respect to the operation
22        of the Health Maintenance Organization sought to be
23        acquired for a period of not less than 3 years; and
24            (D) such other information as the Director shall
25        require.
26    (d) The provisions of Article VIII 1/2 of the Illinois

 

 

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1Insurance Code and this Section 5-3 shall apply to the sale by
2any health maintenance organization of greater than 10% of its
3enrollee population (including, without limitation, the health
4maintenance organization's right, title, and interest in and
5to its health care certificates).
6    (e) In considering any management contract or service
7agreement subject to Section 141.1 of the Illinois Insurance
8Code, the Director (i) shall, in addition to the criteria
9specified in Section 141.2 of the Illinois Insurance Code,
10take into account the effect of the management contract or
11service agreement on the continuation of benefits to enrollees
12and the financial condition of the health maintenance
13organization to be managed or serviced, and (ii) need not take
14into account the effect of the management contract or service
15agreement on competition.
16    (f) Except for small employer groups as defined in the
17Small Employer Rating, Renewability and Portability Health
18Insurance Act and except for medicare supplement policies as
19defined in Section 363 of the Illinois Insurance Code, a
20Health Maintenance Organization may by contract agree with a
21group or other enrollment unit to effect refunds or charge
22additional premiums under the following terms and conditions:
23        (i) the amount of, and other terms and conditions with
24    respect to, the refund or additional premium are set forth
25    in the group or enrollment unit contract agreed in advance
26    of the period for which a refund is to be paid or

 

 

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1    additional premium is to be charged (which period shall
2    not be less than one year); and
3        (ii) the amount of the refund or additional premium
4    shall not exceed 20% of the Health Maintenance
5    Organization's profitable or unprofitable experience with
6    respect to the group or other enrollment unit for the
7    period (and, for purposes of a refund or additional
8    premium, the profitable or unprofitable experience shall
9    be calculated taking into account a pro rata share of the
10    Health Maintenance Organization's administrative and
11    marketing expenses, but shall not include any refund to be
12    made or additional premium to be paid pursuant to this
13    subsection (f)). The Health Maintenance Organization and
14    the group or enrollment unit may agree that the profitable
15    or unprofitable experience may be calculated taking into
16    account the refund period and the immediately preceding 2
17    plan years.
18    The Health Maintenance Organization shall include a
19statement in the evidence of coverage issued to each enrollee
20describing the possibility of a refund or additional premium,
21and upon request of any group or enrollment unit, provide to
22the group or enrollment unit a description of the method used
23to calculate (1) the Health Maintenance Organization's
24profitable experience with respect to the group or enrollment
25unit and the resulting refund to the group or enrollment unit
26or (2) the Health Maintenance Organization's unprofitable

 

 

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1experience with respect to the group or enrollment unit and
2the resulting additional premium to be paid by the group or
3enrollment unit.
4    In no event shall the Illinois Health Maintenance
5Organization Guaranty Association be liable to pay any
6contractual obligation of an insolvent organization to pay any
7refund authorized under this Section.
8    (g) Rulemaking authority to implement Public Act 95-1045,
9if any, is conditioned on the rules being adopted in
10accordance with all provisions of the Illinois Administrative
11Procedure Act and all rules and procedures of the Joint
12Committee on Administrative Rules; any purported rule not so
13adopted, for whatever reason, is unauthorized.
14(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
15102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
161-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
17eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
18102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
191-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
20eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
21103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
226-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
23eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
24    Section 15. The Limited Health Service Organization Act is
25amended by changing Section 4003 as follows:
 

 

 

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1    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
2    Sec. 4003. Illinois Insurance Code provisions. Limited
3health service organizations shall be subject to the
4provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
5141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
6154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2,
7355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, 356z.21,
8356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32,
9356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54,
10356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, 356z.71,
11364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
12444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
13XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
14Nothing in this Section shall require a limited health care
15plan to cover any service that is not a limited health service.
16For purposes of the Illinois Insurance Code, except for
17Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
18health service organizations in the following categories are
19deemed to be domestic companies:
20        (1) a corporation under the laws of this State; or
21        (2) a corporation organized under the laws of another
22    state, 30% or more of the enrollees of which are residents
23    of this State, except a corporation subject to
24    substantially the same requirements in its state of
25    organization as is a domestic company under Article VIII

 

 

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1    1/2 of the Illinois Insurance Code.
2(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
3102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
41-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
5eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
6102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
71-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
8eff. 1-1-24; revised 8-29-23.)
 
9    Section 20. The Voluntary Health Services Plans Act is
10amended by changing Section 10 as follows:
 
11    (215 ILCS 165/10)  (from Ch. 32, par. 604)
12    Sec. 10. Application of Insurance Code provisions. Health
13services plan corporations and all persons interested therein
14or dealing therewith shall be subject to the provisions of
15Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
16143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
17356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
18356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
19356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
20356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
21356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
22356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54,
23356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
24356z.67, 356z.68, 356z.71, 364.01, 364.3, 367.2, 368a, 401,

 

 

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1401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
2and (15) of Section 367 of the Illinois Insurance Code.
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. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
10102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
1110-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
12eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
13102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
141-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
15eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
16103-551, eff. 8-11-23; revised 8-29-23.)
 
17    Section 25. The Illinois Public Aid Code is amended by
18changing Section 5-16.8 as follows:
 
19    (305 ILCS 5/5-16.8)
20    Sec. 5-16.8. Required health benefits. The medical
21assistance program shall (i) provide 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.5, 356q, 356u, 356w, 356x, 356z.6,

 

 

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1356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46,
2356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, and
3356z.61, 356z.64, 356z.67, and 356z.71 of the Illinois
4Insurance Code, (ii) be subject to the provisions of Sections
5356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the
6Illinois 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. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22;
23102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff.
241-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813,
25eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23;
26102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.

 

 

SB2672 Engrossed- 12 -LRB103 35845 RPS 65930 b

11-1-24; 103-420, eff. 1-1-24; revised 12-15-23.)