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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by adding | ||||||
5 | Section 356z.33 as follows: | ||||||
6 | (215 ILCS 5/356z.33 new) | ||||||
7 | Sec. 356z.33. Long-term antibiotic therapy for tick-borne | ||||||
8 | diseases. | ||||||
9 | (a) As used in this Section: | ||||||
10 | "Long-term antibiotic therapy" means the administration of | ||||||
11 | oral, intramuscular, or intravenous antibiotics singly or in | ||||||
12 | combination for periods of time in excess of 4 weeks. | ||||||
13 | "Tick-borne disease" means a disease caused when an | ||||||
14 | infected tick bites a person and the tick's saliva transmits an | ||||||
15 | infectious agent (bacteria, viruses, or parasites) that can | ||||||
16 | cause illness, including, but not limited to, the following: | ||||||
17 | (1) a severe infection with borrelia burgdorferi; | ||||||
18 | (2) a late stage, persistent, or chronic infection or | ||||||
19 | complications related to such an infection; | ||||||
20 | (3) an infection with other strains of borrelia or a | ||||||
21 | tick-borne disease that is recognized by the United States | ||||||
22 | Centers for Disease Control and Prevention; and | ||||||
23 | (4) the presence of signs or symptoms compatible with |
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1 | acute infection of borrelia or other tick-borne diseases. | ||||||
2 | (b) An individual or group policy of accident and health | ||||||
3 | insurance or managed care plan that is amended, delivered, | ||||||
4 | issued, or renewed on or after the effective date of this | ||||||
5 | amendatory Act of the 101st General Assembly shall provide | ||||||
6 | coverage for long-term antibiotic therapy, including necessary | ||||||
7 | office visits and ongoing testing, for a person with a | ||||||
8 | tick-borne disease when determined to be medically necessary | ||||||
9 | and ordered by a physician licensed to practice medicine in all | ||||||
10 | its branches after making a thorough evaluation of the person's | ||||||
11 | symptoms, diagnostic test results, or response to treatment. An | ||||||
12 | experimental drug shall be covered as a long-term antibiotic | ||||||
13 | therapy if it is approved for an indication by the United | ||||||
14 | States Food and Drug Administration. A drug, including an | ||||||
15 | experimental drug, shall be covered for an off-label use in the | ||||||
16 | treatment of a tick-borne disease if the drug has been approved | ||||||
17 | by the United States Food and Drug Administration. | ||||||
18 | Section 10. The Health Maintenance Organization Act is | ||||||
19 | amended by changing Section 5-3 as follows:
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20 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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21 | Sec. 5-3. Insurance Code provisions.
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22 | (a) Health Maintenance Organizations
shall be subject to | ||||||
23 | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
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24 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
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1 | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | ||||||
2 | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | ||||||
3 | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||||||
4 | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | ||||||
5 | 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, | ||||||
6 | 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | ||||||
7 | 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
8 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
9 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
10 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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11 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
12 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
13 | Maintenance Organizations in
the following categories are | ||||||
14 | deemed to be "domestic companies":
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15 | (1) a corporation authorized under the
Dental Service | ||||||
16 | Plan Act or the Voluntary Health Services Plans Act;
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17 | (2) a corporation organized under the laws of this | ||||||
18 | State; or
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19 | (3) a corporation organized under the laws of another | ||||||
20 | state, 30% or more
of the enrollees of which are residents | ||||||
21 | of this State, except a
corporation subject to | ||||||
22 | substantially the same requirements in its state of
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23 | organization as is a "domestic company" under Article VIII | ||||||
24 | 1/2 of the
Illinois Insurance Code.
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25 | (c) In considering the merger, consolidation, or other | ||||||
26 | acquisition of
control of a Health Maintenance Organization |
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1 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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2 | (1) the Director shall give primary consideration to | ||||||
3 | the continuation of
benefits to enrollees and the financial | ||||||
4 | conditions of the acquired Health
Maintenance Organization | ||||||
5 | after the merger, consolidation, or other
acquisition of | ||||||
6 | control takes effect;
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7 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
8 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
9 | apply and (ii) the Director, in making
his determination | ||||||
10 | with respect to the merger, consolidation, or other
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11 | acquisition of control, need not take into account the | ||||||
12 | effect on
competition of the merger, consolidation, or | ||||||
13 | other acquisition of control;
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14 | (3) the Director shall have the power to require the | ||||||
15 | following
information:
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16 | (A) certification by an independent actuary of the | ||||||
17 | adequacy
of the reserves of the Health Maintenance | ||||||
18 | Organization sought to be acquired;
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19 | (B) pro forma financial statements reflecting the | ||||||
20 | combined balance
sheets of the acquiring company and | ||||||
21 | the Health Maintenance Organization sought
to be | ||||||
22 | acquired as of the end of the preceding year and as of | ||||||
23 | a date 90 days
prior to the acquisition, as well as pro | ||||||
24 | forma financial statements
reflecting projected | ||||||
25 | combined operation for a period of 2 years;
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26 | (C) a pro forma business plan detailing an |
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1 | acquiring party's plans with
respect to the operation | ||||||
2 | of the Health Maintenance Organization sought to
be | ||||||
3 | acquired for a period of not less than 3 years; and
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4 | (D) such other information as the Director shall | ||||||
5 | require.
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6 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
7 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
8 | any health maintenance
organization of greater than 10% of its
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9 | enrollee population (including without limitation the health | ||||||
10 | maintenance
organization's right, title, and interest in and to | ||||||
11 | its health care
certificates).
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12 | (e) In considering any management contract or service | ||||||
13 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
14 | Code, the Director (i) shall, in
addition to the criteria | ||||||
15 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
16 | into account the effect of the management contract or
service | ||||||
17 | agreement on the continuation of benefits to enrollees and the
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18 | financial condition of the health maintenance organization to | ||||||
19 | be managed or
serviced, and (ii) need not take into account the | ||||||
20 | effect of the management
contract or service agreement on | ||||||
21 | competition.
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22 | (f) Except for small employer groups as defined in the | ||||||
23 | Small Employer
Rating, Renewability and Portability Health | ||||||
24 | Insurance Act and except for
medicare supplement policies as | ||||||
25 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
26 | Maintenance Organization may by contract agree with a
group or |
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1 | other enrollment unit to effect refunds or charge additional | ||||||
2 | premiums
under the following terms and conditions:
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3 | (i) the amount of, and other terms and conditions with | ||||||
4 | respect to, the
refund or additional premium are set forth | ||||||
5 | in the group or enrollment unit
contract agreed in advance | ||||||
6 | of the period for which a refund is to be paid or
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7 | additional premium is to be charged (which period shall not | ||||||
8 | be less than one
year); and
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9 | (ii) the amount of the refund or additional premium | ||||||
10 | shall not exceed 20%
of the Health Maintenance | ||||||
11 | Organization's profitable or unprofitable experience
with | ||||||
12 | respect to the group or other enrollment unit for the | ||||||
13 | period (and, for
purposes of a refund or additional | ||||||
14 | premium, the profitable or unprofitable
experience shall | ||||||
15 | be calculated taking into account a pro rata share of the
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16 | Health Maintenance Organization's administrative and | ||||||
17 | marketing expenses, but
shall not include any refund to be | ||||||
18 | made or additional premium to be paid
pursuant to this | ||||||
19 | subsection (f)). The Health Maintenance Organization and | ||||||
20 | the
group or enrollment unit may agree that the profitable | ||||||
21 | or unprofitable
experience may be calculated taking into | ||||||
22 | account the refund period and the
immediately preceding 2 | ||||||
23 | plan years.
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24 | The Health Maintenance Organization shall include a | ||||||
25 | statement in the
evidence of coverage issued to each enrollee | ||||||
26 | describing the possibility of a
refund or additional premium, |
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1 | and upon request of any group or enrollment unit,
provide to | ||||||
2 | the group or enrollment unit a description of the method used | ||||||
3 | to
calculate (1) the Health Maintenance Organization's | ||||||
4 | profitable experience with
respect to the group or enrollment | ||||||
5 | unit and the resulting refund to the group
or enrollment unit | ||||||
6 | or (2) the Health Maintenance Organization's unprofitable
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7 | experience with respect to the group or enrollment unit and the | ||||||
8 | resulting
additional premium to be paid by the group or | ||||||
9 | enrollment unit.
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10 | In no event shall the Illinois Health Maintenance | ||||||
11 | Organization
Guaranty Association be liable to pay any | ||||||
12 | contractual obligation of an
insolvent organization to pay any | ||||||
13 | refund authorized under this Section.
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14 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
15 | if any, is conditioned on the rules being adopted in accordance | ||||||
16 | with all provisions of the Illinois Administrative Procedure | ||||||
17 | Act and all rules and procedures of the Joint Committee on | ||||||
18 | Administrative Rules; any purported rule not so adopted, for | ||||||
19 | whatever reason, is unauthorized. | ||||||
20 | (Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; | ||||||
21 | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff. | ||||||
22 | 8-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | ||||||
23 | 10-4-18.)
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24 | Section 15. The Illinois Public Aid Code is amended by | ||||||
25 | changing Section 5-16.8 as follows:
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1 | (305 ILCS 5/5-16.8)
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2 | Sec. 5-16.8. Required health benefits. The medical | ||||||
3 | assistance program
shall
(i) provide the post-mastectomy care | ||||||
4 | benefits required to be covered by a policy of
accident and | ||||||
5 | health insurance under Section 356t and the coverage required
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6 | under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and | ||||||
7 | 356z.29 , 356z.32, and 356z.33 of the Illinois
Insurance Code | ||||||
8 | and (ii) be subject to the provisions of Sections 356z.19, | ||||||
9 | 364.01, 370c, and 370c.1 of the Illinois
Insurance Code.
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10 | On and after July 1, 2012, the Department shall reduce any | ||||||
11 | rate of reimbursement for services or other payments or alter | ||||||
12 | any methodologies authorized by this Code to reduce any rate of | ||||||
13 | reimbursement for services or other payments in accordance with | ||||||
14 | Section 5-5e. | ||||||
15 | To ensure full access to the benefits set forth in this | ||||||
16 | Section, on and after January 1, 2016, the Department shall | ||||||
17 | ensure that provider and hospital reimbursement for | ||||||
18 | post-mastectomy care benefits required under this Section are | ||||||
19 | no lower than the Medicare reimbursement rate. | ||||||
20 | (Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; | ||||||
21 | 99-642, eff. 7-28-16; 100-138, eff. 8-18-17; 100-863, eff. | ||||||
22 | 8-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | ||||||
23 | 10-4-18.)
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