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96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010 HB5085
Introduced 1/29/2010, by Rep. Greg Harris SYNOPSIS AS INTRODUCED: |
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5 ILCS 375/6.11 |
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55 ILCS 5/5-1069.3 |
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65 ILCS 5/10-4-2.3 |
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105 ILCS 5/10-22.3f |
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215 ILCS 5/356z.19 new |
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215 ILCS 5/364.01 |
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215 ILCS 125/5-3 |
from Ch. 111 1/2, par. 1411.2 |
215 ILCS 165/10 |
from Ch. 32, par. 604 |
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Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Illinois Insurance Code, Health Maintenance Organization Act, and Voluntary Health Services Plans Act. Provides that accident and health insurance policies that provide coverage for prescription drugs or cancer chemotherapy treatment must provide coverage for prescribed orally-administered cancer medication used to kill or slow the growth of cancerous cells. Provides that an insurer shall ensure that the financial requirements and treatment limitations for orally-administered cancer medication coverage are no more restrictive than the requirements and limitations applied to intravenously administered cancer medications. Provides that accident and health insurance policies shall provide coverage to a qualified individual for participation in a qualified clinical cancer trial. Provides that an insurer shall not deny, limit, or impose additional conditions on the coverage of routine patient costs. Provides that the payment rate shall be at the agreed rate for covered items and services provided by a participating provider and at the usual and customary rate for covered items and services provided by a nonparticipating provider. Makes other changes. Contains a nonacceleration clause. Effective immediately.
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A BILL FOR
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HB5085 |
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LRB096 17984 RPM 33355 b |
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| 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 |
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| Code
requirements. The program of health
benefits shall provide |
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| the post-mastectomy care benefits required to be covered
by a |
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| policy of accident and health insurance under Section 356t of |
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| the Illinois
Insurance Code. The program of health benefits |
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| shall provide the coverage
required under Sections 356g, |
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| 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
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| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
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| 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17 356z.15 , |
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| 356z.19, and 364.01 of the
Illinois Insurance Code.
The program |
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| of health benefits must comply with Section 155.37 of the
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| Illinois Insurance Code.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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HB5085 |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (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; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, |
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| eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
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| 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
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| revised 10-22-09.) |
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| Section 10. The Counties Code is amended by changing |
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| 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, |
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| including a home
rule
county, is a self-insurer for purposes of |
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| providing health insurance coverage
for its employees, the |
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| coverage shall include coverage for the post-mastectomy
care |
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| benefits required to be covered by a policy of accident and |
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| health
insurance under Section 356t and the coverage required |
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| under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
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| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
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| 356z.13, and 356z.14, and 356z.15 356z.14 , 356z.19, and 364.01 |
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| of
the Illinois Insurance Code. The requirement that health |
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| benefits be covered
as provided in this Section is an
exclusive |
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| power and function of the State and is a denial and limitation |
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| under
Article VII, Section 6, subsection (h) of the Illinois |
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| Constitution. A home
rule county to which this Section applies |
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| must comply with every provision of
this Section.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (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; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
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| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
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| 96-328, eff. 8-11-09; revised 10-22-09.) |
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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 |
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| coverage for its employees, the coverage shall include coverage |
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| 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 |
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| and the coverage required
under Sections 356g, 356g.5, |
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| 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
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| 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15 |
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| 356z.14 , 356z.19, and 364.01 of the Illinois
Insurance
Code. |
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| The requirement that health
benefits be covered as provided in |
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| this is an exclusive power and function of
the State and is a |
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| denial and limitation under Article VII, Section 6,
subsection |
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| (h) of the Illinois Constitution. A home rule municipality to |
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| which
this Section applies must comply with every provision of |
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| this Section.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (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; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
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| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
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| 96-328, eff. 8-11-09; revised 10-23-09.) |
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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 |
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| policy of accident and health insurance under Section 356t and |
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| the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
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| 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
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| 356z.13, and 356z.14, and 356z.15 356z.14 , 356z.19, and 364.01 |
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| of
the
Illinois Insurance Code.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
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| 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
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| 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised |
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| 10-23-09.) |
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| Section 25. The Illinois Insurance Code is amended by |
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| adding Section 356z.19 and by changing Section 364.01 as |
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| follows: |
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| (215 ILCS 5/356z.19 new) |
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| Sec. 356z.19. Cancer drug parity. |
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| (a) As used in this Section: |
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| "Financial requirement" means deductibles, copayments, |
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| coinsurance, out-of-pocket expenses, aggregate lifetime |
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| limits, and annual limits. |
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| "Treatment limitation" means limits on the frequency of |
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| treatment, days of coverage, or other similar limits on the |
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| scope or duration of treatment. |
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| (b) An individual or group policy of accident and health |
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| insurance amended, delivered, issued, or renewed on or after |
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| the effective date of this amendatory Act of the 96th General |
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| Assembly that provides coverage for prescription drugs or |
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| cancer chemotherapy treatment must provide coverage for |
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| prescribed orally-administered cancer medication used to kill |
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| or slow the growth of cancerous cells. An insurer providing |
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| coverage under this Section shall ensure that: |
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| (1) the financial requirements applicable to such |
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| prescribed orally-administered cancer medications are no |
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| more restrictive than the financial requirements applied |
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| to intravenously administered or injected cancer |
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| medications that are covered by the policy and that there |
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| are no separate cost-sharing requirements that are |
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| applicable only with respect to such prescribed |
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| orally-administered cancer medications; and |
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| (2) the treatment limitations applicable to such |
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| prescribed orally-administered cancer medications are no |
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HB5085 |
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| more restrictive than the treatment limitations applied to |
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| intravenously administered or injected cancer medications |
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| that are covered by the policy and that there are no |
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| separate treatment limitations that are applicable only |
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| with respect to such prescribed orally-administered cancer |
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| medications. |
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| (215 ILCS 5/364.01) |
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| Sec. 364.01. Qualified clinical cancer trials. |
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| (a) No individual or group policy of accident and health |
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| insurance issued or renewed in this State may be cancelled or |
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| non-renewed for any individual based on that individual's |
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| participation in a qualified clinical cancer trial. |
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| (b) Qualified clinical cancer trials must meet the |
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| following criteria: |
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| (1) the effectiveness of the treatment has not been |
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| determined relative to established therapies; |
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| (2) the trial is under clinical investigation as part |
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| of an approved cancer research trial in Phase II, Phase |
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| III, or Phase IV of investigation; |
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| (3) the trial is: |
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| (A) approved by the Food and Drug Administration; |
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| or |
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| (B) approved and funded by the National Institutes |
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| of Health, the Centers for Disease Control and |
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| Prevention, the Agency for Healthcare Research and |
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| Quality, the United States Department of Defense, the |
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| United States Department of Veterans Affairs, or the |
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| United States Department of Energy in the form of an |
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| investigational new drug application, or a cooperative |
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| group or center of any entity described in this |
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| subdivision (B); and
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| (4) the patient's primary care physician, if any, is |
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| involved in the coordination of care.
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| (c) An individual or group policy of accident and health |
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| insurance amended, delivered, issued, or renewed on or after |
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| the effective date of this amendatory Act of the 96th General |
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| Assembly shall provide coverage to a qualified individual for |
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| participation in a qualified clinical cancer trial. |
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| (d) An insurer providing coverage under this Section shall |
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| not: |
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| (1) deny the qualified individual participation in the |
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| qualified clinical cancer trial; |
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| (2) subject to subsection (f) of this Section, deny, |
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| limit, or impose additional conditions on the coverage of |
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| routine patient costs for items and services furnished in |
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| connection with participation in the qualified clinical |
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| cancer trial; or |
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| (3) discriminate against the qualified individual on |
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| the basis of the individual's participation in the |
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| qualified clinical cancer trial. |
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| (e) If one or more participating providers is participating |
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| in a qualified clinical cancer trial, nothing in subsections |
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| (c) or (d) of this Section shall be construed as preventing an |
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| insurer from requiring that a qualified individual participate |
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| in the trial through such a participating provider if the |
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| provider will accept the individual as a participant in the |
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| trial. |
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| (f) An insurer shall provide for payment for routine |
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| patient costs but is not required to pay for the costs of items |
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| and services that are customarily provided by the research |
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| sponsors free of charge for individuals participating in the |
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| qualified clinical cancer trial. In the case of covered items |
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| and services provided by a participating provider, the payment |
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| rate shall be at the agreed upon rate. In the case of covered |
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| items and services provided by a nonparticipating provider, the |
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| payment rate shall be at the usual and customary rate for |
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| comparable items and services provided by the participating |
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| provider. |
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| (g) As used in this Section: |
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| "Qualified individual" means an individual who is a |
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| participant or beneficiary in a group or individual policy of |
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| accident and health insurance and who meets the following |
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| conditions: |
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| (1) the individual has been diagnosed with cancer; |
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| (2) the individual is eligible to participate in a |
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| qualified clinical cancer trial according to the trial |
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| protocol with respect to treatment of such illness; and |
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| (3) one of the following circumstances exists: (A) the |
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| referring physician is a participating provider and has |
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| concluded that the individual's participation in the trial |
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| would be appropriate based upon the individual meeting the |
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| conditions described in items (1) and (2) of this |
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| definition or (B) the individual provides medical and |
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| scientific information establishing that the individual's |
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| participation in the trial would be appropriate based upon |
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| the individual meeting the conditions described in items |
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| (1) and (2) of this definition. |
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| "Routine patient costs" mean all items and services |
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| provided in the qualified cancer trial that are otherwise |
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| generally available to the qualified individual, except: |
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| (1) in the cases of items and services, the |
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| investigational item or service itself; or |
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| (2) items and services that are provided solely to |
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| satisfy data collection and analysis needs and that are not |
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| used in the direct clinical management of the patient. |
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| (h) Nothing in this Section shall be construed to limit an |
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| insurer's coverage with respect to clinical trials. |
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| (Source: P.A. 93-1000, eff. 1-1-05.) |
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| 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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| (Text of Section before amendment by P.A. 96-833 ) |
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| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to |
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| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
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| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
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| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
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| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
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| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , |
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| 356z.17 356z.15 , 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, |
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| 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, |
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| 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection |
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| (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, |
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| XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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| (b) For purposes of the Illinois Insurance Code, except for |
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| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
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| 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 |
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| 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 |
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| acquisition of
control of a Health Maintenance Organization |
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| 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 |
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| conditions of the acquired Health
Maintenance Organization |
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| after the merger, consolidation, or other
acquisition of |
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| 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 |
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| with respect to the merger, consolidation, or other
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| acquisition of control, need not take into account the |
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| effect on
competition of the merger, consolidation, or |
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| 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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HB5085 |
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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 |
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| Insurance Code
and this Section 5-3 shall apply to the sale by |
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| any health maintenance
organization of greater than 10% of its
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| enrollee population (including without limitation the health |
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| maintenance
organization's right, title, and interest in and to |
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| its health care
certificates).
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| (e) In considering any management contract or service |
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| agreement subject
to Section 141.1 of the Illinois Insurance |
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| Code, the Director (i) shall, in
addition to the criteria |
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| specified in Section 141.2 of the Illinois
Insurance Code, take |
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| into account the effect of the management contract or
service |
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| agreement on the continuation of benefits to enrollees and the
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| financial condition of the health maintenance organization to |
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| be managed or
serviced, and (ii) need not take into account the |
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| effect of the management
contract or service agreement on |
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| 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 |
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HB5085 |
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LRB096 17984 RPM 33355 b |
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| Insurance Act and except for
medicare supplement policies as |
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| defined in Section 363 of the Illinois
Insurance Code, a Health |
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| Maintenance Organization may by contract agree with a
group or |
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| other enrollment unit to effect refunds or charge additional |
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| premiums
under the following terms and conditions:
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| (i) the amount of, and other terms and conditions with |
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| 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 |
14 |
| Organization's profitable or unprofitable experience
with |
15 |
| respect to the group or other enrollment unit for the |
16 |
| period (and, for
purposes of a refund or additional |
17 |
| premium, the profitable or unprofitable
experience shall |
18 |
| be calculated taking into account a pro rata share of the
|
19 |
| Health Maintenance Organization's administrative and |
20 |
| marketing expenses, but
shall not include any refund to be |
21 |
| made or additional premium to be paid
pursuant to this |
22 |
| subsection (f)). The Health Maintenance Organization and |
23 |
| the
group or enrollment unit may agree that the profitable |
24 |
| or unprofitable
experience may be calculated taking into |
25 |
| account the refund period and the
immediately preceding 2 |
26 |
| plan years.
|
|
|
|
HB5085 |
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LRB096 17984 RPM 33355 b |
|
|
1 |
| The Health Maintenance Organization shall include a |
2 |
| statement in the
evidence of coverage issued to each enrollee |
3 |
| describing the possibility of a
refund or additional premium, |
4 |
| and upon request of any group or enrollment unit,
provide to |
5 |
| the group or enrollment unit a description of the method used |
6 |
| to
calculate (1) the Health Maintenance Organization's |
7 |
| profitable experience with
respect to the group or enrollment |
8 |
| unit and the resulting refund to the group
or enrollment unit |
9 |
| or (2) the Health Maintenance Organization's unprofitable
|
10 |
| experience with respect to the group or enrollment unit and the |
11 |
| resulting
additional premium to be paid by the group or |
12 |
| enrollment unit.
|
13 |
| In no event shall the Illinois Health Maintenance |
14 |
| Organization
Guaranty Association be liable to pay any |
15 |
| contractual obligation of an
insolvent organization to pay any |
16 |
| refund authorized under this Section.
|
17 |
| (g) Rulemaking authority to implement Public Act 95-1045 |
18 |
| this amendatory Act of the 95th General Assembly , if any, is |
19 |
| conditioned on the rules being adopted in accordance with all |
20 |
| provisions of the Illinois Administrative Procedure Act and all |
21 |
| rules and procedures of the Joint Committee on Administrative |
22 |
| Rules; any purported rule not so adopted, for whatever reason, |
23 |
| is unauthorized. |
24 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
25 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
26 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
|
|
|
HB5085 |
- 16 - |
LRB096 17984 RPM 33355 b |
|
|
1 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised |
2 |
| 10-23-09.) |
3 |
| (Text of Section after amendment by P.A. 96-833 ) |
4 |
| Sec. 5-3. Insurance Code provisions.
|
5 |
| (a) Health Maintenance Organizations
shall be subject to |
6 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
7 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
8 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
9 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
10 |
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, |
11 |
| 356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, |
12 |
| 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, |
13 |
| 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of |
14 |
| Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, |
15 |
| XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
|
16 |
| (b) For purposes of the Illinois Insurance Code, except for |
17 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
18 |
| Maintenance Organizations in
the following categories are |
19 |
| deemed to be "domestic companies":
|
20 |
| (1) a corporation authorized under the
Dental Service |
21 |
| Plan Act or the Voluntary Health Services Plans Act;
|
22 |
| (2) a corporation organized under the laws of this |
23 |
| State; or
|
24 |
| (3) a corporation organized under the laws of another |
25 |
| state, 30% or more
of the enrollees of which are residents |
|
|
|
HB5085 |
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LRB096 17984 RPM 33355 b |
|
|
1 |
| of this State, except a
corporation subject to |
2 |
| substantially the same requirements in its state of
|
3 |
| organization as is a "domestic company" under Article VIII |
4 |
| 1/2 of the
Illinois Insurance Code.
|
5 |
| (c) In considering the merger, consolidation, or other |
6 |
| acquisition of
control of a Health Maintenance Organization |
7 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
8 |
| (1) the Director shall give primary consideration to |
9 |
| the continuation of
benefits to enrollees and the financial |
10 |
| conditions of the acquired Health
Maintenance Organization |
11 |
| after the merger, consolidation, or other
acquisition of |
12 |
| control takes effect;
|
13 |
| (2)(i) the criteria specified in subsection (1)(b) of |
14 |
| Section 131.8 of
the Illinois Insurance Code shall not |
15 |
| apply and (ii) the Director, in making
his determination |
16 |
| with respect to the merger, consolidation, or other
|
17 |
| acquisition of control, need not take into account the |
18 |
| effect on
competition of the merger, consolidation, or |
19 |
| other acquisition of control;
|
20 |
| (3) the Director shall have the power to require the |
21 |
| following
information:
|
22 |
| (A) certification by an independent actuary of the |
23 |
| adequacy
of the reserves of the Health Maintenance |
24 |
| Organization sought to be acquired;
|
25 |
| (B) pro forma financial statements reflecting the |
26 |
| combined balance
sheets of the acquiring company and |
|
|
|
HB5085 |
- 18 - |
LRB096 17984 RPM 33355 b |
|
|
1 |
| the Health Maintenance Organization sought
to be |
2 |
| acquired as of the end of the preceding year and as of |
3 |
| a date 90 days
prior to the acquisition, as well as pro |
4 |
| forma financial statements
reflecting projected |
5 |
| combined operation for a period of 2 years;
|
6 |
| (C) a pro forma business plan detailing an |
7 |
| acquiring party's plans with
respect to the operation |
8 |
| of the Health Maintenance Organization sought to
be |
9 |
| acquired for a period of not less than 3 years; and
|
10 |
| (D) such other information as the Director shall |
11 |
| require.
|
12 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
13 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
14 |
| any health maintenance
organization of greater than 10% of its
|
15 |
| enrollee population (including without limitation the health |
16 |
| maintenance
organization's right, title, and interest in and to |
17 |
| its health care
certificates).
|
18 |
| (e) In considering any management contract or service |
19 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
20 |
| Code, the Director (i) shall, in
addition to the criteria |
21 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
22 |
| into account the effect of the management contract or
service |
23 |
| agreement on the continuation of benefits to enrollees and the
|
24 |
| financial condition of the health maintenance organization to |
25 |
| be managed or
serviced, and (ii) need not take into account the |
26 |
| effect of the management
contract or service agreement on |
|
|
|
HB5085 |
- 19 - |
LRB096 17984 RPM 33355 b |
|
|
1 |
| competition.
|
2 |
| (f) Except for small employer groups as defined in the |
3 |
| Small Employer
Rating, Renewability and Portability Health |
4 |
| Insurance Act and except for
medicare supplement policies as |
5 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
6 |
| Maintenance Organization may by contract agree with a
group or |
7 |
| other enrollment unit to effect refunds or charge additional |
8 |
| premiums
under the following terms and conditions:
|
9 |
| (i) the amount of, and other terms and conditions with |
10 |
| respect to, the
refund or additional premium are set forth |
11 |
| in the group or enrollment unit
contract agreed in advance |
12 |
| of the period for which a refund is to be paid or
|
13 |
| additional premium is to be charged (which period shall not |
14 |
| be less than one
year); and
|
15 |
| (ii) the amount of the refund or additional premium |
16 |
| shall not exceed 20%
of the Health Maintenance |
17 |
| Organization's profitable or unprofitable experience
with |
18 |
| respect to the group or other enrollment unit for the |
19 |
| period (and, for
purposes of a refund or additional |
20 |
| premium, the profitable or unprofitable
experience shall |
21 |
| be calculated taking into account a pro rata share of the
|
22 |
| Health Maintenance Organization's administrative and |
23 |
| marketing expenses, but
shall not include any refund to be |
24 |
| made or additional premium to be paid
pursuant to this |
25 |
| subsection (f)). The Health Maintenance Organization and |
26 |
| the
group or enrollment unit may agree that the profitable |
|
|
|
HB5085 |
- 20 - |
LRB096 17984 RPM 33355 b |
|
|
1 |
| or unprofitable
experience may be calculated taking into |
2 |
| account the refund period and the
immediately preceding 2 |
3 |
| plan years.
|
4 |
| The Health Maintenance Organization shall include a |
5 |
| statement in the
evidence of coverage issued to each enrollee |
6 |
| describing the possibility of a
refund or additional premium, |
7 |
| and upon request of any group or enrollment unit,
provide to |
8 |
| the group or enrollment unit a description of the method used |
9 |
| to
calculate (1) the Health Maintenance Organization's |
10 |
| profitable experience with
respect to the group or enrollment |
11 |
| unit and the resulting refund to the group
or enrollment unit |
12 |
| or (2) the Health Maintenance Organization's unprofitable
|
13 |
| experience with respect to the group or enrollment unit and the |
14 |
| resulting
additional premium to be paid by the group or |
15 |
| enrollment unit.
|
16 |
| In no event shall the Illinois Health Maintenance |
17 |
| Organization
Guaranty Association be liable to pay any |
18 |
| contractual obligation of an
insolvent organization to pay any |
19 |
| refund authorized under this Section.
|
20 |
| (g) Rulemaking authority to implement Public Act 95-1045, |
21 |
| if any, is conditioned on the rules being adopted in accordance |
22 |
| with all provisions of the Illinois Administrative Procedure |
23 |
| Act and all rules and procedures of the Joint Committee on |
24 |
| Administrative Rules; any purported rule not so adopted, for |
25 |
| whatever reason, is unauthorized. |
26 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
|
|
|
HB5085 |
- 21 - |
LRB096 17984 RPM 33355 b |
|
|
1 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
2 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
3 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. |
4 |
| 6-1-10.) |
5 |
| Section 35. The Voluntary Health Services Plans Act is |
6 |
| amended by changing Section 10 as follows:
|
7 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
8 |
| (Text of Section before amendment by P.A. 96-833 ) |
9 |
| Sec. 10. Application of Insurance Code provisions. Health |
10 |
| services
plan corporations and all persons interested therein |
11 |
| or dealing therewith
shall be subject to the provisions of |
12 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
13 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
14 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
15 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
16 |
| 356z.14, 356z.15
356z.14 , 356z.19, 364.01, 367.2, 368a, 401, |
17 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
18 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
19 |
| Rulemaking authority to implement Public Act 95-1045
this |
20 |
| amendatory Act of the 95th General Assembly , if any, is |
21 |
| conditioned on the rules being adopted in accordance with all |
22 |
| provisions of the Illinois Administrative Procedure Act and all |
23 |
| rules and procedures of the Joint Committee on Administrative |
24 |
| Rules; any purported rule not so adopted, for whatever reason, |
|
|
|
HB5085 |
- 22 - |
LRB096 17984 RPM 33355 b |
|
|
1 |
| is unauthorized. |
2 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
3 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
4 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
5 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
6 |
| 96-328, eff. 8-11-09; revised 9-25-09.) |
7 |
| (Text of Section after amendment by P.A. 96-833 ) |
8 |
| Sec. 10. Application of Insurance Code provisions. Health |
9 |
| services
plan corporations and all persons interested therein |
10 |
| or dealing therewith
shall be subject to the provisions of |
11 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
12 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
13 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
14 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
15 |
| 356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401, |
16 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
17 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
18 |
| Rulemaking authority to implement Public Act 95-1045, if |
19 |
| any, is conditioned on the rules being adopted in accordance |
20 |
| with all provisions of the Illinois Administrative Procedure |
21 |
| Act and all rules and procedures of the Joint Committee on |
22 |
| Administrative Rules; any purported rule not so adopted, for |
23 |
| whatever reason, is unauthorized. |
24 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
25 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
|
|
|
HB5085 |
- 23 - |
LRB096 17984 RPM 33355 b |
|
|
1 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
2 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
3 |
| 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.) |
4 |
| Section 97. No acceleration or delay. Where this Act makes |
5 |
| changes in a statute that is represented in this Act by text |
6 |
| that is not yet or no longer in effect (for example, a Section |
7 |
| represented by multiple versions), the use of that text does |
8 |
| not accelerate or delay the taking effect of (i) the changes |
9 |
| made by this Act or (ii) provisions derived from any other |
10 |
| Public Act.
|
11 |
| Section 99. Effective date. This Act takes effect upon |
12 |
| becoming law.
|