Public Act 103-0758
 
SB2672 EnrolledLRB103 35845 RPS 65930 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois, 
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by 
adding Section 356z.71 as follows:
 
    (215 ILCS 5/356z.71 new)
    Sec. 356z.71. Coverage during a generic drug shortage.
    (a) As used in this Section:
    "Eligible prescription drug" means a prescription drug 
approved under 21 U.S.C. 355(c) that is not under patent.
    "Generic drug" means a drug that is approved pursuant to 
an application referencing an eligible prescription drug that 
is submitted under subsection (j) of Section 505 of the 
Federal Food, Drug, and Cosmetic Act, 21 U.S.C. 355(j). 
    "Unavailable" means being listed as Currently in Shortage 
or as a Discontinuation in the United States Food and Drug 
Administration's Drug Shortages Database. "Unavailable" does 
not include being listed as a Resolved Shortage in the United 
States Food and Drug Administration's Drug Shortages Database. 
    (b) If a generic drug or a therapeutic equivalent is 
unavailable due to a supply issue and dosage cannot be 
adjusted, a group or individual policy of accident and health 
insurance or a managed care plan that is amended, delivered, 
issued, or renewed after January 1, 2026 shall provide 
coverage for a brand name eligible prescription drug until 
supply of the generic drug or a therapeutic equivalent is 
available.
 
    Section 10. 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, 155.49, 
355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v, 
356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 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.20, 356z.21, 356z.22, 
356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 
356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35, 
356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, 356z.44, 
356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 
356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 
356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, 356z.68, 
356z.71, 364, 364.01, 364.3, 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, XXVI, and XXXIIB 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 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. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; 
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, 
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, 
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, 
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
    Section 15. 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, 155.49, 355.2, 
355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, 356z.21, 
356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 
356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 
356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, 356z.71, 
364.3, 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. 
Nothing in this Section shall require a limited health care 
plan to cover any service that is not a limited health service. 
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. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. 
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, 
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, 
eff. 1-1-24; revised 8-29-23.)
 
    Section 20. 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, 356q, 356r, 356t, 356u, 356v, 356w, 
356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 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, 356z.30, 356z.30a, 356z.32, 356z.33, 
356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 
356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 
356z.67, 356z.68, 356z.71, 364.01, 364.3, 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. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 
10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, 
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 
102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. 
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, 
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 
103-551, eff. 8-11-23; revised 8-29-23.)
 
    Section 25. 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, 356q, 356u, 356w, 356x, 356z.6, 
356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 
356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, and 
356z.61, 356z.64, 356z.67, and 356z.71 of the Illinois 
Insurance Code, (ii) be subject to the provisions of Sections 
356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the 
Illinois Insurance Code, and (iii) be subject to the 
provisions of subsection (d-5) of Section 10 of the Network 
Adequacy and Transparency Act.
    The Department, by rule, shall adopt a model similar to 
the requirements of Section 356z.39 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. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 
1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, 
eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 
1-1-24; 103-420, eff. 1-1-24; revised 12-15-23.)