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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 | ||||||
5 | adding Section 356z.43 as follows: | ||||||
6 | (215 ILCS 5/356z.43 new) | ||||||
7 | Sec. 356z.43. COVID-19 vaccine administrative cost. An | ||||||
8 | individual or group policy of accident and health insurance or | ||||||
9 | managed care plan in effect on and after March 9, 2020 must | ||||||
10 | provide coverage for the cost of administering a COVID-19 | ||||||
11 | vaccination without cost sharing. | ||||||
12 | Section 10. The Health Maintenance Organization Act is | ||||||
13 | amended by changing Section 5-3 as follows:
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14 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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15 | Sec. 5-3. Insurance Code provisions.
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16 | (a) Health Maintenance Organizations
shall be subject to | ||||||
17 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
18 | 141.1,
141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, | ||||||
19 | 154, 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, | ||||||
20 | 355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, | ||||||
21 | 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, |
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1 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, | ||||||
2 | 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | ||||||
3 | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41, | ||||||
4 | 356z.43, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
5 | 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, | ||||||
6 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||||||
7 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
8 | XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois | ||||||
9 | Insurance Code.
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10 | (b) For purposes of the Illinois Insurance Code, except | ||||||
11 | for Sections 444
and 444.1 and Articles XIII and XIII 1/2, | ||||||
12 | Health Maintenance Organizations in
the following categories | ||||||
13 | are deemed to be "domestic companies":
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14 | (1) a corporation authorized under the
Dental Service | ||||||
15 | Plan Act or the Voluntary Health Services Plans Act;
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16 | (2) a corporation organized under the laws of this | ||||||
17 | State; or
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18 | (3) a corporation organized under the laws of another | ||||||
19 | state, 30% or more
of the enrollees of which are residents | ||||||
20 | of this State, except a
corporation subject to | ||||||
21 | substantially the same requirements in its state of
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22 | organization as is a "domestic company" under Article VIII | ||||||
23 | 1/2 of the
Illinois Insurance Code.
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24 | (c) In considering the merger, consolidation, or other | ||||||
25 | acquisition of
control of a Health Maintenance Organization | ||||||
26 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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1 | (1) the Director shall give primary consideration to | ||||||
2 | the continuation of
benefits to enrollees and the | ||||||
3 | financial conditions of the acquired Health
Maintenance | ||||||
4 | Organization after the merger, consolidation, or other
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5 | acquisition of control takes effect;
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6 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
7 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
8 | apply and (ii) the Director, in making
his determination | ||||||
9 | with respect to the merger, consolidation, or other
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10 | acquisition of control, need not take into account the | ||||||
11 | effect on
competition of the merger, consolidation, or | ||||||
12 | other acquisition of control;
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13 | (3) the Director shall have the power to require the | ||||||
14 | following
information:
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15 | (A) certification by an independent actuary of the | ||||||
16 | adequacy
of the reserves of the Health Maintenance | ||||||
17 | Organization sought to be acquired;
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18 | (B) pro forma financial statements reflecting the | ||||||
19 | combined balance
sheets of the acquiring company and | ||||||
20 | the Health Maintenance Organization sought
to be | ||||||
21 | acquired as of the end of the preceding year and as of | ||||||
22 | a date 90 days
prior to the acquisition, as well as pro | ||||||
23 | forma financial statements
reflecting projected | ||||||
24 | combined operation for a period of 2 years;
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25 | (C) a pro forma business plan detailing an | ||||||
26 | acquiring party's plans with
respect to the operation |
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1 | of the Health Maintenance Organization sought to
be | ||||||
2 | acquired for a period of not less than 3 years; and
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3 | (D) such other information as the Director shall | ||||||
4 | require.
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5 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
6 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
7 | any health maintenance
organization of greater than 10% of its
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8 | enrollee population (including without limitation the health | ||||||
9 | maintenance
organization's right, title, and interest in and | ||||||
10 | to its health care
certificates).
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11 | (e) In considering any management contract or service | ||||||
12 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
13 | Code, the Director (i) shall, in
addition to the criteria | ||||||
14 | specified in Section 141.2 of the Illinois
Insurance Code, | ||||||
15 | take into account the effect of the management contract or
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16 | service agreement on the continuation of benefits to enrollees | ||||||
17 | and the
financial condition of the health maintenance | ||||||
18 | organization to be managed or
serviced, and (ii) need not take | ||||||
19 | into account the effect of the management
contract or service | ||||||
20 | agreement on competition.
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21 | (f) Except for small employer groups as defined in the | ||||||
22 | Small Employer
Rating, Renewability and Portability Health | ||||||
23 | Insurance Act and except for
medicare supplement policies as | ||||||
24 | defined in Section 363 of the Illinois
Insurance Code, a | ||||||
25 | Health Maintenance Organization may by contract agree with a
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26 | group or other enrollment unit to effect refunds or charge |
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1 | additional premiums
under the following terms and conditions:
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2 | (i) the amount of, and other terms and conditions with | ||||||
3 | respect to, the
refund or additional premium are set forth | ||||||
4 | in the group or enrollment unit
contract agreed in advance | ||||||
5 | of the period for which a refund is to be paid or
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6 | additional premium is to be charged (which period shall | ||||||
7 | not be less than one
year); and
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8 | (ii) the amount of the refund or additional premium | ||||||
9 | shall not exceed 20%
of the Health Maintenance | ||||||
10 | Organization's profitable or unprofitable experience
with | ||||||
11 | respect to the group or other enrollment unit for the | ||||||
12 | period (and, for
purposes of a refund or additional | ||||||
13 | premium, the profitable or unprofitable
experience shall | ||||||
14 | be calculated taking into account a pro rata share of the
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15 | Health Maintenance Organization's administrative and | ||||||
16 | marketing expenses, but
shall not include any refund to be | ||||||
17 | made or additional premium to be paid
pursuant to this | ||||||
18 | subsection (f)). The Health Maintenance Organization and | ||||||
19 | the
group or enrollment unit may agree that the profitable | ||||||
20 | or unprofitable
experience may be calculated taking into | ||||||
21 | account the refund period and the
immediately preceding 2 | ||||||
22 | plan years.
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23 | The Health Maintenance Organization shall include a | ||||||
24 | statement in the
evidence of coverage issued to each enrollee | ||||||
25 | describing the possibility of a
refund or additional premium, | ||||||
26 | and upon request of any group or enrollment unit,
provide to |
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1 | the group or enrollment unit a description of the method used | ||||||
2 | to
calculate (1) the Health Maintenance Organization's | ||||||
3 | profitable experience with
respect to the group or enrollment | ||||||
4 | unit and the resulting refund to the group
or enrollment unit | ||||||
5 | or (2) the Health Maintenance Organization's unprofitable
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6 | experience with respect to the group or enrollment unit and | ||||||
7 | the resulting
additional premium to be paid by the group or | ||||||
8 | enrollment unit.
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9 | In no event shall the Illinois Health Maintenance | ||||||
10 | Organization
Guaranty Association be liable to pay any | ||||||
11 | contractual obligation of an
insolvent organization to pay any | ||||||
12 | refund authorized under this Section.
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13 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
14 | if any, is conditioned on the rules being adopted in | ||||||
15 | accordance with all provisions of the Illinois Administrative | ||||||
16 | Procedure Act and all rules and procedures of the Joint | ||||||
17 | Committee on Administrative Rules; any purported rule not so | ||||||
18 | adopted, for whatever reason, is unauthorized. | ||||||
19 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
20 | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | ||||||
21 | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | ||||||
22 | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | ||||||
23 | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | ||||||
24 | 1-1-20; 101-625, eff. 1-1-21 .) | ||||||
25 | Section 15. The Voluntary Health Services Plans Act is |
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1 | amended by changing Section 10 as follows:
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2 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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3 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
4 | services
plan corporations and all persons interested therein | ||||||
5 | or dealing therewith
shall be subject to the provisions of | ||||||
6 | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | ||||||
7 | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, | ||||||
8 | 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
9 | 356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, | ||||||
10 | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, | ||||||
11 | 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, | ||||||
12 | 356z.30, 356z.30a, 356z.32, 356z.33, 356z.41, 356z.43, 364.01, | ||||||
13 | 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, | ||||||
14 | and paragraphs (7) and (15) of Section 367 of the Illinois
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15 | Insurance Code.
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16 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
17 | any, is conditioned on the rules being adopted in accordance | ||||||
18 | with all provisions of the Illinois Administrative Procedure | ||||||
19 | Act and all rules and procedures of the Joint Committee on | ||||||
20 | Administrative Rules; any purported rule not so adopted, for | ||||||
21 | whatever reason, is unauthorized. | ||||||
22 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
23 | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | ||||||
24 | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | ||||||
25 | eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; |
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1 | 101-625, eff. 1-1-21 .) | ||||||
2 | Section 20. The Illinois Public Aid Code is amended by | ||||||
3 | changing Section 5-16.8 as follows:
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4 | (305 ILCS 5/5-16.8)
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5 | Sec. 5-16.8. Required health benefits. The medical | ||||||
6 | assistance program
shall
(i) provide the post-mastectomy care | ||||||
7 | benefits required to be covered by a policy of
accident and | ||||||
8 | health insurance under Section 356t and the coverage required
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9 | under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, | ||||||
10 | 356z.29, 356z.32, 356z.33, 356z.34, and 356z.35 , and 356z.43 | ||||||
11 | of the Illinois
Insurance Code and (ii) be subject to the | ||||||
12 | provisions of Sections 356z.19, 364.01, 370c, and 370c.1 of | ||||||
13 | the Illinois
Insurance Code.
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14 | The Department, by rule, shall adopt a model similar to | ||||||
15 | the requirements of Section 356z.39 of the Illinois Insurance | ||||||
16 | Code. | ||||||
17 | On and after July 1, 2012, the Department shall reduce any | ||||||
18 | rate of reimbursement for services or other payments or alter | ||||||
19 | any methodologies authorized by this Code to reduce any rate | ||||||
20 | of reimbursement for services or other payments in accordance | ||||||
21 | with Section 5-5e. | ||||||
22 | To ensure full access to the benefits set forth in this | ||||||
23 | Section, on and after January 1, 2016, the Department shall | ||||||
24 | ensure that provider and hospital reimbursement for |
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1 | post-mastectomy care benefits required under this Section are | ||||||
2 | no lower than the Medicare reimbursement rate. | ||||||
3 | (Source: P.A. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; | ||||||
4 | 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. | ||||||
5 | 7-12-19; 101-218, eff. 1-1-20; 101-281, eff. 1-1-20; 101-371, | ||||||
6 | eff. 1-1-20; 101-574, eff. 1-1-20; 101-649, eff. 7-7-20.)
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