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HB5085 Engrossed |
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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 Engrossed |
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LRB096 17984 RPM 33355 b |
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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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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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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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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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| 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
| 2 |
| 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 |
| 5 |
| this is an exclusive power and function of
the State and is a |
| 6 |
| 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 |
| 13 |
| provisions of the Illinois Administrative Procedure Act and all |
| 14 |
| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
| 16 |
| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
| 18 |
| 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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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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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 |
| 13 |
| 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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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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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 Engrossed |
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LRB096 17984 RPM 33355 b |
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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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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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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 |
| 11 |
| the effective date of this amendatory Act of the 96th General |
| 12 |
| 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 |
| 17 |
| 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 |
| 20 |
| routine patient costs for items and services furnished in |
| 21 |
| 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 |
| 25 |
| qualified clinical cancer trial. |
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| (e) If one or more participating providers is participating |
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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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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 |
| 9 |
| and services that are customarily provided by the research |
| 10 |
| sponsors free of charge for individuals participating in the |
| 11 |
| 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 |
| 16 |
| comparable items and services provided by the participating |
| 17 |
| provider. |
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| (g) As used in this Section: |
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| "Qualified individual" means an individual who is a |
| 20 |
| participant or beneficiary in a group or individual policy of |
| 21 |
| accident and health insurance and who meets the following |
| 22 |
| 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 |
| 25 |
| 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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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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| (3) one of the following circumstances exists: (A) the |
| 2 |
| 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 |
| 5 |
| conditions described in items (1) and (2) of this |
| 6 |
| definition or (B) the individual provides medical and |
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| scientific information establishing that the individual's |
| 8 |
| participation in the trial would be appropriate based upon |
| 9 |
| the individual meeting the conditions described in items |
| 10 |
| (1) and (2) of this definition. |
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| "Routine patient costs" mean all items and services |
| 12 |
| provided in the qualified cancer trial that are otherwise |
| 13 |
| generally available to the qualified individual, except: |
| 14 |
| (1) in the cases of items and services, the |
| 15 |
| investigational item or service itself; or |
| 16 |
| (2) items and services that are provided solely to |
| 17 |
| satisfy data collection and analysis needs and that are not |
| 18 |
| used in the direct clinical management of the patient. |
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| (h) Nothing in this Section shall be construed to limit an |
| 20 |
| insurer's coverage with respect to clinical trials. |
| 21 |
| (Source: P.A. 93-1000, eff. 1-1-05.) |
| 22 |
| 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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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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| 1 |
| (Text of Section before amendment by P.A. 96-833) |
| 2 |
| Sec. 5-3. Insurance Code provisions.
|
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| (a) Health Maintenance Organizations
shall be subject to |
| 4 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
| 5 |
| 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, |
| 7 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
| 8 |
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14, |
| 9 |
| 356z.17 356z.15, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, |
| 10 |
| 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 |
| 12 |
| (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 |
| 15 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
| 16 |
| Maintenance Organizations in
the following categories are |
| 17 |
| deemed to be "domestic companies":
|
| 18 |
| (1) a corporation authorized under the
Dental Service |
| 19 |
| Plan Act or the Voluntary Health Services Plans Act;
|
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| (2) a corporation organized under the laws of this |
| 21 |
| State; or
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| (3) a corporation organized under the laws of another |
| 23 |
| state, 30% or more
of the enrollees of which are residents |
| 24 |
| of this State, except a
corporation subject to |
| 25 |
| substantially the same requirements in its state of
|
| 26 |
| organization as is a "domestic company" under Article VIII |
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HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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| 1 |
| 1/2 of the
Illinois Insurance Code.
|
| 2 |
| (c) In considering the merger, consolidation, or other |
| 3 |
| acquisition of
control of a Health Maintenance Organization |
| 4 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
| 5 |
| (1) the Director shall give primary consideration to |
| 6 |
| the continuation of
benefits to enrollees and the financial |
| 7 |
| conditions of the acquired Health
Maintenance Organization |
| 8 |
| after the merger, consolidation, or other
acquisition of |
| 9 |
| control takes effect;
|
| 10 |
| (2)(i) the criteria specified in subsection (1)(b) of |
| 11 |
| Section 131.8 of
the Illinois Insurance Code shall not |
| 12 |
| apply and (ii) the Director, in making
his determination |
| 13 |
| with respect to the merger, consolidation, or other
|
| 14 |
| acquisition of control, need not take into account the |
| 15 |
| effect on
competition of the merger, consolidation, or |
| 16 |
| other acquisition of control;
|
| 17 |
| (3) the Director shall have the power to require the |
| 18 |
| following
information:
|
| 19 |
| (A) certification by an independent actuary of the |
| 20 |
| adequacy
of the reserves of the Health Maintenance |
| 21 |
| Organization sought to be acquired;
|
| 22 |
| (B) pro forma financial statements reflecting the |
| 23 |
| combined balance
sheets of the acquiring company and |
| 24 |
| the Health Maintenance Organization sought
to be |
| 25 |
| acquired as of the end of the preceding year and as of |
| 26 |
| a date 90 days
prior to the acquisition, as well as pro |
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|
HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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| 1 |
| forma financial statements
reflecting projected |
| 2 |
| combined operation for a period of 2 years;
|
| 3 |
| (C) a pro forma business plan detailing an |
| 4 |
| acquiring party's plans with
respect to the operation |
| 5 |
| of the Health Maintenance Organization sought to
be |
| 6 |
| acquired for a period of not less than 3 years; and
|
| 7 |
| (D) such other information as the Director shall |
| 8 |
| require.
|
| 9 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
| 10 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
| 11 |
| any health maintenance
organization of greater than 10% of its
|
| 12 |
| enrollee population (including without limitation the health |
| 13 |
| maintenance
organization's right, title, and interest in and to |
| 14 |
| its health care
certificates).
|
| 15 |
| (e) In considering any management contract or service |
| 16 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
| 17 |
| Code, the Director (i) shall, in
addition to the criteria |
| 18 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
| 19 |
| into account the effect of the management contract or
service |
| 20 |
| agreement on the continuation of benefits to enrollees and the
|
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| financial condition of the health maintenance organization to |
| 22 |
| be managed or
serviced, and (ii) need not take into account the |
| 23 |
| effect of the management
contract or service agreement on |
| 24 |
| competition.
|
| 25 |
| (f) Except for small employer groups as defined in the |
| 26 |
| Small Employer
Rating, Renewability and Portability Health |
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|
HB5085 Engrossed |
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LRB096 17984 RPM 33355 b |
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|
| 1 |
| Insurance Act and except for
medicare supplement policies as |
| 2 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
| 3 |
| Maintenance Organization may by contract agree with a
group or |
| 4 |
| other enrollment unit to effect refunds or charge additional |
| 5 |
| premiums
under the following terms and conditions:
|
| 6 |
| (i) the amount of, and other terms and conditions with |
| 7 |
| respect to, the
refund or additional premium are set forth |
| 8 |
| in the group or enrollment unit
contract agreed in advance |
| 9 |
| of the period for which a refund is to be paid or
|
| 10 |
| additional premium is to be charged (which period shall not |
| 11 |
| be less than one
year); and
|
| 12 |
| (ii) the amount of the refund or additional premium |
| 13 |
| 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 Engrossed |
- 15 - |
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 Engrossed |
- 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 Engrossed |
- 17 - |
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 Engrossed |
- 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 Engrossed |
- 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 Engrossed |
- 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 Engrossed |
- 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 Engrossed |
- 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 Engrossed |
- 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.
|