HB4602 Engrossed

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    AN ACT concerning regulation.

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


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


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    (5 ILCS 375/6.11)


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    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 356g.5,

13
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, 
14
and 356z.11
356z.9 of the
Illinois Insurance Code.
The program 
15
of health benefits must comply with Section 155.37 of the

16
Illinois Insurance Code.

17
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
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95-520, eff. 8-28-07; revised 12-4-07.)

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

 


 






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    Sec. 5-1069.3. Required health benefits.   If a county, 
2
including a home
rule
county, is a self-insurer for purposes of 
3
providing health insurance coverage
for its employees, the 
4
coverage shall include coverage for the post-mastectomy
care 
5
benefits required to be covered by a policy of accident and 
6
health
insurance under Section 356t and the coverage required 
7
under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, 
8
356z.10, and
356z.11 356z.9 of
the Illinois Insurance Code.  The 
9
requirement that health benefits be covered
as provided in this 
10
Section is an
exclusive power and function of the State and is 
11
a denial and limitation under
Article VII, Section 6, 
12
subsection (h) of the Illinois Constitution.  A home
rule county 
13
to which this Section applies must comply with every provision 
14
of
this Section.


15
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
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95-520, eff. 8-28-07; revised 12-4-07.)

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

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    Sec. 10-4-2.3. Required health benefits.   If a 
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municipality, including a
home rule municipality, is a 
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self-insurer for purposes of providing health
insurance 
23
coverage for its employees, the coverage shall include coverage 
24
for
the post-mastectomy care benefits required to be covered by 
 


 






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a policy of
accident and health insurance under Section 356t 
2
and the coverage required
under Sections 356g.5, 356u, 356w, 
3
356x, 356z.6, and 356z.9, 356z.10, and
356z.11 356z.9 of the 
4
Illinois
Insurance
Code.  The requirement that health
benefits 
5
be covered as provided in this is an exclusive power and 
6
function of
the State and is a denial and limitation under 
7
Article VII, Section 6,
subsection (h) of the Illinois 
8
Constitution.  A home rule municipality to which
this Section 
9
applies must comply with every provision of this Section.


10
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
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95-520, eff. 8-28-07; revised 12-4-07.)

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

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    Sec. 10-22.3f. Required health benefits.   Insurance 
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protection and
benefits
for employees shall provide the 
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post-mastectomy care benefits required to be
covered by a 
18
policy of accident and health insurance under Section 356t and 
19
the
coverage required under Sections 356g.5, 356u, 356w, 356x,


20
356z.6, and 356z.9, and 356z.11 of
the
Illinois Insurance Code.


21
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
22
revised 12-4-07.)

 
23
    Section 25. The Illinois Insurance Code is amended  by 
 


 






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adding Section 356z.11 as follows:
 
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    (215 ILCS 5/356z.11  new)
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    Sec. 356z.11. Shingles vaccine.  A group or individual 
4
policy of accident and health insurance or managed care plan 
5
amended, delivered, issued, or renewed after the effective date 
6
of the amendatory Act of this  95th General Assembly must 
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provide coverage for a vaccine for shingles that is approved 
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for marketing by the federal Food and Drug Administration if 
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the vaccine is ordered by a physician licensed to practice 
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medicine in all its branches and the enrollee is 60 years of 
11
age or older.
 
12
    Section 30. The Health Maintenance Organization Act is 
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amended  by changing Section 5-3 as follows:
 


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



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    Sec. 5-3. Insurance Code provisions. 

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    (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, 356z.10, 
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356z.11,
356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 
22
368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 
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409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of 
 


 






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Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, 
2
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

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


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        (1) a corporation authorized under the
Dental Service 
8
    Plan Act or the Voluntary Health Services Plans Act;


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


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

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

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    (c) In considering the merger, consolidation, or other 
18
acquisition of
control of a Health Maintenance Organization 
19
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


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        (1) the Director shall give primary consideration to 
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    the continuation of
benefits to enrollees and the financial 
22
    conditions of the acquired Health
Maintenance Organization 
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    after the merger, consolidation, or other
acquisition of 
24
    control takes effect;


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        (2)(i) the criteria specified in subsection (1)(b) of 
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    Section 131.8 of
the Illinois Insurance Code shall not 
 


 






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    apply and (ii) the Director, in making
his determination 
2
    with respect to the merger, consolidation, or other

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    acquisition of control, need not take into account the 
4
    effect on
competition of the merger, consolidation, or 
5
    other acquisition of control;


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


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


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


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


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

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    (d) The provisions of Article VIII 1/2 of the Illinois 
25
Insurance Code
and this Section 5-3 shall apply to the sale by 
26
any health maintenance
organization of greater than 10% of its

 


 






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enrollee population (including without limitation the health 
2
maintenance
organization's right, title, and interest in and to 
3
its health care
certificates).

4
    (e) In considering any management contract or service 
5
agreement subject
to Section 141.1 of the Illinois Insurance 
6
Code, the Director (i) shall, in
addition to the criteria 
7
specified in Section 141.2 of the Illinois
Insurance Code, take 
8
into account the effect of the management contract or
service 
9
agreement on the continuation of benefits to enrollees and the

10
financial condition of the health maintenance organization to 
11
be managed or
serviced, and (ii) need not take into account the 
12
effect of the management
contract or service agreement on 
13
competition.

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    (f) Except for small employer groups as defined in the 
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Small Employer
Rating, Renewability and Portability Health 
16
Insurance Act and except for
medicare supplement policies as 
17
defined in Section 363 of the Illinois
Insurance Code, a Health 
18
Maintenance Organization may by contract agree with a
group or 
19
other enrollment unit to effect refunds or charge additional 
20
premiums
under the following terms and conditions:


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

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


 


 






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

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

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

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


 






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enrollment unit.

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    In no event shall the Illinois Health Maintenance 
3
Organization
Guaranty Association be liable to pay any 
4
contractual obligation of an
insolvent organization to pay any 
5
refund authorized under this Section.

6
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
7
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)

 
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    Section 35. The Voluntary Health Services Plans Act is 
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amended  by changing Section 10 as follows:
 



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


11
    Sec. 10. Application of Insurance Code provisions. Health 
12
services
plan corporations and all persons interested therein 
13
or dealing therewith
shall be subject to the provisions of 
14
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
15
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
16
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
17
356z.9,
356z.10, 356z.11,
356z.9, 364.01, 367.2, 368a, 401, 
18
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
19
and (15) of Section 367 of the Illinois
Insurance Code.

20
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
21
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
22
8-28-07; revised 12-5-07.)