95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
HB0385


 
Introduced 1/26/2007, by Rep. Mary E. Flowers
 
SYNOPSIS AS INTRODUCED:
 		





















5 ILCS 375/6.11





55 ILCS 5/5-1069.3





65 ILCS 5/10-4-2.3





105 ILCS 5/10-22.3f





215 ILCS 5/356z.9 new





215 ILCS 125/5-3
  from Ch. 111 1/2, par. 1411.2


215 ILCS 165/10
  from Ch. 32, par. 604







    Amends the State Employees Group Insurance Act of 1971, the Counties Code,
the
Illinois Municipal Code, the School Code, the Illinois Insurance Code, the Health Maintenance Organization Act, and the Voluntary Health Services Plans Act  to require coverage for all covered persons, including, but not limited to, pregnant women, women of childbearing potential, and children for non-occupational post-exposure prophylaxis to prevent HIV infection within 72 hours after exposure from sexual intercourse, sexual assault, rape, blood transfusion, injection drug use, or accidents.
















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FISCAL NOTE ACT MAY APPLY


HOME RULE NOTE ACT MAY APPLY


STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT
















 


 


A BILL FOR









 









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1
    AN ACT concerning insurance.

 
2
    Be it enacted by the People of the State of Illinois,
 
3
represented in the General Assembly:


 
4
    Section 5. The State Employees Group Insurance Act of 1971 
5
is amended  by changing Section 6.11 as follows:
 



6
    (5 ILCS 375/6.11)


7
    Sec. 6.11. Required health benefits; Illinois Insurance 
8
Code
requirements.  The program of health
benefits shall provide 
9
the post-mastectomy care benefits required to be covered
by a 
10
policy of accident and health insurance under Section 356t of 
11
the Illinois
Insurance Code.  The program of health benefits 
12
shall provide the coverage
required under Sections 356u, 356w, 
13
356x, 356z.2, 356z.4, and 356z.6, and 356z.9 of the
Illinois 
14
Insurance Code.
The program of health benefits must comply with 
15
Section 155.37 of the
Illinois Insurance Code.

16
(Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; 
17
93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)


 
18
    Section 10. The Counties Code is amended  by changing 
19
Section 5-1069.3 as follows:
 
20
    (55 ILCS 5/5-1069.3)

21
    Sec. 5-1069.3. Required health benefits.   If a county, 
 


 






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including a home
rule
county, is a self-insurer for purposes of 
2
providing health insurance coverage
for its employees, the 
3
coverage shall include coverage for the post-mastectomy
care 
4
benefits required to be covered by a policy of accident and 
5
health
insurance under Section 356t and the coverage required 
6
under Sections 356u,
356w, 356x,
and 356z.6, and 356z.9  of
the 
7
Illinois Insurance Code.  The requirement that health benefits 
8
be covered
as provided in this Section is an
exclusive power 
9
and function of the State and is a denial and limitation under

10
Article VII, Section 6, subsection (h) of the Illinois 
11
Constitution.  A home
rule county to which this Section applies 
12
must comply with every provision of
this Section.


13
(Source: P.A. 93-853, eff. 1-1-05.)


 
14
    Section 15. The Illinois Municipal Code is amended  by 
15
changing Section 10-4-2.3 as follows:
 
16
    (65 ILCS 5/10-4-2.3)

17
    Sec. 10-4-2.3. Required health benefits.   If a 
18
municipality, including a
home rule municipality, is a 
19
self-insurer for purposes of providing health
insurance 
20
coverage for its employees, the coverage shall include coverage 
21
for
the post-mastectomy care benefits required to be covered by 
22
a policy of
accident and health insurance under Section 356t 
23
and the coverage required
under Sections 356u, 356w, 356x,
and

24
356z.6, and 356z.9 of the Illinois
Insurance
Code.  The 
 


 






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1
requirement that health
benefits be covered as provided in this 
2
is an exclusive power and function of
the State and is a denial 
3
and limitation under Article VII, Section 6,
subsection (h) of 
4
the Illinois Constitution.  A home rule municipality to which

5
this Section applies must comply with every provision of this 
6
Section.


7
(Source: P.A. 93-853, eff. 1-1-05.)


 
8
    Section 20. The School Code is amended  by changing Section 
9
10-22.3f as follows:
 
10
    (105 ILCS 5/10-22.3f)

11
    Sec. 10-22.3f. Required health benefits.   Insurance 
12
protection and
benefits
for employees shall provide the 
13
post-mastectomy care benefits required to be
covered by a 
14
policy of accident and health insurance under Section 356t and 
15
the
coverage required under Sections 356u, 356w, 356x,
and

16
356z.6, and 356z.9 of
the
Illinois Insurance Code.


17
(Source: P.A. 93-853, eff. 1-1-05.)


 
18
    Section 25. The Illinois Insurance Code is amended  by 
19
adding Section 356z.9 as follows:
 
20
    (215 ILCS 5/356z.9 new)

21
    Sec. 356z.9. Coverage for non-occupational post-exposure 
22
prophylaxis. An individual or group policy of accident and 
 


 






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health insurance or a managed care plan amended, delivered, 
2
issued, or renewed after the effective date of this amendatory 
3
Act of the 95th General Assembly shall provide coverage for all 
4
covered persons, including, but not limited to, pregnant women, 
5
women of childbearing potential, and children for 
6
non-occupational post-exposure prophylaxis (nPEP) pursuant to 
7
recommendations of the Centers for Disease Control and 
8
Prevention to prevent human immunodeficiency virus (HIV) 
9
infection within 72 hours after exposure to HIV through sexual 
10
intercourse, sexual assault, rape, blood transfusion, 
11
injection drug use, or accidents.
 
12
    Section 30. The Health Maintenance Organization Act is 
13
amended  by changing Section 5-3 as follows:
 



14
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


15
    Sec. 5-3. Insurance Code provisions. 

16
    (a) Health Maintenance Organizations
shall be subject to 
17
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
18
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
19
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
20
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 364.01, 
21
367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 
22
401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,

23
paragraph (c) of subsection (2) of Section 367, and Articles 
24
IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of 
 


 






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the Illinois Insurance Code.

2
    (b) For purposes of the Illinois Insurance Code, except for 
3
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
4
Maintenance Organizations in
the following categories are 
5
deemed to be "domestic companies":


6
        (1) a corporation authorized under the
Dental Service 
7
    Plan Act or the Voluntary Health Services Plans Act;


8
        (2) a corporation organized under the laws of this 
9
    State; or


10
        (3) a corporation organized under the laws of another 
11
    state, 30% or more
of the enrollees of which are residents 
12
    of this State, except a
corporation subject to 
13
    substantially the same requirements in its state of

14
    organization as is a "domestic company" under Article VIII 
15
    1/2 of the
Illinois Insurance Code.

16
    (c) In considering the merger, consolidation, or other 
17
acquisition of
control of a Health Maintenance Organization 
18
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


19
        (1) the Director shall give primary consideration to 
20
    the continuation of
benefits to enrollees and the financial 
21
    conditions of the acquired Health
Maintenance Organization 
22
    after the merger, consolidation, or other
acquisition of 
23
    control takes effect;


24
        (2)(i) the criteria specified in subsection (1)(b) of 
25
    Section 131.8 of
the Illinois Insurance Code shall not 
26
    apply and (ii) the Director, in making
his determination 
 


 






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    with respect to the merger, consolidation, or other

2
    acquisition of control, need not take into account the 
3
    effect on
competition of the merger, consolidation, or 
4
    other acquisition of control;


5
        (3) the Director shall have the power to require the 
6
    following
information:


7
            (A) certification by an independent actuary of the 
8
        adequacy
of the reserves of the Health Maintenance 
9
        Organization sought to be acquired;


10
            (B) pro forma financial statements reflecting the 
11
        combined balance
sheets of the acquiring company and 
12
        the Health Maintenance Organization sought
to be 
13
        acquired as of the end of the preceding year and as of 
14
        a date 90 days
prior to the acquisition, as well as pro 
15
        forma financial statements
reflecting projected 
16
        combined operation for a period of 2 years;


17
            (C) a pro forma business plan detailing an 
18
        acquiring party's plans with
respect to the operation 
19
        of the Health Maintenance Organization sought to
be 
20
        acquired for a period of not less than 3 years; and


21
            (D) such other information as the Director shall 
22
        require.

23
    (d) The provisions of Article VIII 1/2 of the Illinois 
24
Insurance Code
and this Section 5-3 shall apply to the sale by 
25
any health maintenance
organization of greater than 10% of its

26
enrollee population (including without limitation the health 
 


 






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maintenance
organization's right, title, and interest in and to 
2
its health care
certificates).

3
    (e) In considering any management contract or service 
4
agreement subject
to Section 141.1 of the Illinois Insurance 
5
Code, the Director (i) shall, in
addition to the criteria 
6
specified in Section 141.2 of the Illinois
Insurance Code, take 
7
into account the effect of the management contract or
service 
8
agreement on the continuation of benefits to enrollees and the

9
financial condition of the health maintenance organization to 
10
be managed or
serviced, and (ii) need not take into account the 
11
effect of the management
contract or service agreement on 
12
competition.

13
    (f) Except for small employer groups as defined in the 
14
Small Employer
Rating, Renewability and Portability Health 
15
Insurance Act and except for
medicare supplement policies as 
16
defined in Section 363 of the Illinois
Insurance Code, a Health 
17
Maintenance Organization may by contract agree with a
group or 
18
other enrollment unit to effect refunds or charge additional 
19
premiums
under the following terms and conditions:


20
        (i) the amount of, and other terms and conditions with 
21
    respect to, the
refund or additional premium are set forth 
22
    in the group or enrollment unit
contract agreed in advance 
23
    of the period for which a refund is to be paid or

24
    additional premium is to be charged (which period shall not 
25
    be less than one
year); and


26
        (ii) the amount of the refund or additional premium 
 


 






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    shall not exceed 20%
of the Health Maintenance 
2
    Organization's profitable or unprofitable experience
with 
3
    respect to the group or other enrollment unit for the 
4
    period (and, for
purposes of a refund or additional 
5
    premium, the profitable or unprofitable
experience shall 
6
    be calculated taking into account a pro rata share of the

7
    Health Maintenance Organization's administrative and 
8
    marketing expenses, but
shall not include any refund to be 
9
    made or additional premium to be paid
pursuant to this 
10
    subsection (f)).  The Health Maintenance Organization and 
11
    the
group or enrollment unit may agree that the profitable 
12
    or unprofitable
experience may be calculated taking into 
13
    account the refund period and the
immediately preceding 2 
14
    plan years.

15
    The Health Maintenance Organization shall include a 
16
statement in the
evidence of coverage issued to each enrollee 
17
describing the possibility of a
refund or additional premium, 
18
and upon request of any group or enrollment unit,
provide to 
19
the group or enrollment unit a description of the method used 
20
to
calculate (1) the Health Maintenance Organization's 
21
profitable experience with
respect to the group or enrollment 
22
unit and the resulting refund to the group
or enrollment unit 
23
or (2) the Health Maintenance Organization's unprofitable

24
experience with respect to the group or enrollment unit and the 
25
resulting
additional premium to be paid by the group or 
26
enrollment unit.

 


 






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1
    In no event shall the Illinois Health Maintenance 
2
Organization
Guaranty Association be liable to pay any 
3
contractual obligation of an
insolvent organization to pay any 
4
refund authorized under this Section.

5
(Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, 
6
eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 
7
93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff. 
8
12-29-06; revised 1-5-07.)



 
9
    Section 35. The Voluntary Health Services Plans Act is 
10
amended  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 
13
services
plan corporations and all persons interested therein 
14
or dealing therewith
shall be subject to the provisions of 
15
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
16
149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, 
17
356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,

18
364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, 
19
and 412, and paragraphs (7) and (15) of Section 367 of the 
20
Illinois
Insurance Code.

21
(Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; 
22
93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. 
23
12-29-06.)