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1 | AN ACT concerning regulation. | |||||||||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois, | |||||||||||||||||||||||||||||||
3 | represented in the General Assembly: | |||||||||||||||||||||||||||||||
4 | Section 5. The Counties Code is amended by changing | |||||||||||||||||||||||||||||||
5 | Section 5-1069.3 as follows: | |||||||||||||||||||||||||||||||
6 | (55 ILCS 5/5-1069.3) | |||||||||||||||||||||||||||||||
7 | Sec. 5-1069.3. Required health benefits. If a county, | |||||||||||||||||||||||||||||||
8 | including a home rule county, is a self-insurer for purposes | |||||||||||||||||||||||||||||||
9 | of providing health insurance coverage for its employees, the | |||||||||||||||||||||||||||||||
10 | coverage shall include coverage for the post-mastectomy care | |||||||||||||||||||||||||||||||
11 | benefits required to be covered by a policy of accident and | |||||||||||||||||||||||||||||||
12 | health insurance under Section 356t and the coverage required | |||||||||||||||||||||||||||||||
13 | under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, | |||||||||||||||||||||||||||||||
14 | 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, | |||||||||||||||||||||||||||||||
15 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, | |||||||||||||||||||||||||||||||
16 | 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, | |||||||||||||||||||||||||||||||
17 | 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, | |||||||||||||||||||||||||||||||
18 | 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, | |||||||||||||||||||||||||||||||
19 | 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71 , | |||||||||||||||||||||||||||||||
20 | 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code. | |||||||||||||||||||||||||||||||
21 | The coverage shall comply with Sections 155.22a, 355b, | |||||||||||||||||||||||||||||||
22 | 356z.19, and 370c of the Illinois Insurance Code. The | |||||||||||||||||||||||||||||||
23 | Department of Insurance shall enforce the requirements of this |
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1 | Section. The requirement that health benefits be covered as | ||||||
2 | provided in this Section is an exclusive power and function of | ||||||
3 | the State and is a denial and limitation under Article VII, | ||||||
4 | Section 6, subsection (h) of the Illinois Constitution. A home | ||||||
5 | rule county to which this Section applies must comply with | ||||||
6 | every provision of this Section. | ||||||
7 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
8 | any, is conditioned on the rules being adopted in accordance | ||||||
9 | with all provisions of the Illinois Administrative Procedure | ||||||
10 | Act and all rules and procedures of the Joint Committee on | ||||||
11 | Administrative Rules; any purported rule not so adopted, for | ||||||
12 | whatever reason, is unauthorized. | ||||||
13 | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||||||
14 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
15 | 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | ||||||
16 | eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||||||
17 | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||||||
18 | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||||||
19 | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||||||
20 | 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. | ||||||
21 | 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, | ||||||
22 | eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; | ||||||
23 | revised 11-26-24.) | ||||||
24 | Section 10. The Illinois Municipal Code is amended by | ||||||
25 | changing Section 10-4-2.3 as follows: |
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1 | (65 ILCS 5/10-4-2.3) | ||||||
2 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
3 | municipality, including a home rule municipality, is a | ||||||
4 | self-insurer for purposes of providing health insurance | ||||||
5 | coverage for its employees, the coverage shall include | ||||||
6 | coverage for the post-mastectomy care benefits required to be | ||||||
7 | covered by a policy of accident and health insurance under | ||||||
8 | Section 356t and the coverage required under Sections 356g, | ||||||
9 | 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, | ||||||
10 | 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | ||||||
11 | 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, | ||||||
12 | 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, | ||||||
13 | 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, | ||||||
14 | 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, | ||||||
15 | 356z.67, 356z.68, and 356z.70, and 356z.71 , 356z.74, 356z.77, | ||||||
16 | and 356z.80 of the Illinois Insurance Code. The coverage shall | ||||||
17 | comply with Sections 155.22a, 355b, 356z.19, and 370c of the | ||||||
18 | Illinois Insurance Code. The Department of Insurance shall | ||||||
19 | enforce the requirements of this Section. The requirement that | ||||||
20 | health benefits be covered as provided in this is an exclusive | ||||||
21 | power and function of the State and is a denial and limitation | ||||||
22 | under Article VII, Section 6, subsection (h) of the Illinois | ||||||
23 | Constitution. A home rule municipality to which this Section | ||||||
24 | applies must comply with every provision of this Section. | ||||||
25 | Rulemaking authority to implement Public Act 95-1045, if |
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1 | any, is conditioned on the rules being adopted in accordance | ||||||
2 | with all provisions of the Illinois Administrative Procedure | ||||||
3 | Act and all rules and procedures of the Joint Committee on | ||||||
4 | Administrative Rules; any purported rule not so adopted, for | ||||||
5 | whatever reason, is unauthorized. | ||||||
6 | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||||||
7 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
8 | 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | ||||||
9 | eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||||||
10 | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||||||
11 | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||||||
12 | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||||||
13 | 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. | ||||||
14 | 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, | ||||||
15 | eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; | ||||||
16 | revised 11-26-24.) | ||||||
17 | Section 15. The School Code is amended by changing Section | ||||||
18 | 10-22.3f as follows: | ||||||
19 | (105 ILCS 5/10-22.3f) | ||||||
20 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
21 | protection and benefits for employees shall provide the | ||||||
22 | post-mastectomy care benefits required to be covered by a | ||||||
23 | policy of accident and health insurance under Section 356t and | ||||||
24 | the coverage required under Sections 356g, 356g.5, 356g.5-1, |
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1 | 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a, | ||||||
2 | 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, | ||||||
3 | 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, | ||||||
4 | 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, | ||||||
5 | 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, | ||||||
6 | 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and | ||||||
7 | 356z.71 , 356z.74, 356z.77, and 356z.80 of the Illinois | ||||||
8 | Insurance Code. Insurance policies shall comply with Section | ||||||
9 | 356z.19 of the Illinois Insurance Code. The coverage shall | ||||||
10 | comply with Sections 155.22a, 355b, and 370c of the Illinois | ||||||
11 | Insurance Code. The Department of Insurance shall enforce the | ||||||
12 | requirements of this Section. | ||||||
13 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
14 | any, is conditioned on the rules being adopted in accordance | ||||||
15 | with all provisions of the Illinois Administrative Procedure | ||||||
16 | Act and all rules and procedures of the Joint Committee on | ||||||
17 | Administrative Rules; any purported rule not so adopted, for | ||||||
18 | whatever reason, is unauthorized. | ||||||
19 | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||||||
20 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. | ||||||
21 | 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, | ||||||
22 | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||||||
23 | 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. | ||||||
24 | 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, | ||||||
25 | eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; | ||||||
26 | 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. |
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1 | 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, | ||||||
2 | eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.) | ||||||
3 | Section 20. The Illinois Insurance Code is amended by | ||||||
4 | adding Section 356z.80 as follows: | ||||||
5 | (215 ILCS 5/356z.80 new) | ||||||
6 | Sec. 356z.80. Coverage for treatments to slow the | ||||||
7 | progression of Alzheimer's disease and related dementias. A | ||||||
8 | group or individual policy of accident and health insurance or | ||||||
9 | a managed care plan that is amended, delivered, issued, or | ||||||
10 | renewed on or after January 1, 2027 shall provide coverage for | ||||||
11 | all medically necessary diagnostic testing and U.S. Food and | ||||||
12 | Drug Administration-approved treatments or medications | ||||||
13 | prescribed to slow the progression of Alzheimer's disease or | ||||||
14 | another related dementia, in accordance with the U.S. Food and | ||||||
15 | Drug Administration label, as determined by a physician | ||||||
16 | licensed to practice medicine in all its branches. Coverage of | ||||||
17 | U.S. Food and Drug Administration-approved treatments or | ||||||
18 | medications prescribed to slow the progression of Alzheimer's | ||||||
19 | disease or another related dementia pursuant to this Section | ||||||
20 | shall not be subject to step therapy. | ||||||
21 | Section 25. The Health Maintenance Organization Act is | ||||||
22 | amended by changing Section 5-3 as follows: |
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1 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||||||
2 | (Text of Section before amendment by P.A. 103-808 ) | ||||||
3 | Sec. 5-3. Insurance Code provisions. | ||||||
4 | (a) Health Maintenance Organizations shall be subject to | ||||||
5 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
6 | 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, | ||||||
7 | 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, | ||||||
8 | 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1, | ||||||
9 | 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a, | ||||||
10 | 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
11 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, | ||||||
12 | 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25, | ||||||
13 | 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33, | ||||||
14 | 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, | ||||||
15 | 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47, | ||||||
16 | 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55, | ||||||
17 | 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62, | ||||||
18 | 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69, | ||||||
19 | 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77, | ||||||
20 | 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
21 | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||||||
22 | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||||||
23 | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||||||
24 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
25 | Illinois Insurance Code. | ||||||
26 | (b) For purposes of the Illinois Insurance Code, except |
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1 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
2 | Health Maintenance Organizations in the following categories | ||||||
3 | are deemed to be "domestic companies": | ||||||
4 | (1) a corporation authorized under the Dental Service | ||||||
5 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
6 | (2) a corporation organized under the laws of this | ||||||
7 | State; or | ||||||
8 | (3) a corporation organized under the laws of another | ||||||
9 | state, 30% or more of the enrollees of which are residents | ||||||
10 | of this State, except a corporation subject to | ||||||
11 | substantially the same requirements in its state of | ||||||
12 | organization as is a "domestic company" under Article VIII | ||||||
13 | 1/2 of the Illinois Insurance Code. | ||||||
14 | (c) In considering the merger, consolidation, or other | ||||||
15 | acquisition of control of a Health Maintenance Organization | ||||||
16 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||||||
17 | (1) the Director shall give primary consideration to | ||||||
18 | the continuation of benefits to enrollees and the | ||||||
19 | financial conditions of the acquired Health Maintenance | ||||||
20 | Organization after the merger, consolidation, or other | ||||||
21 | acquisition of control takes effect; | ||||||
22 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
23 | Section 131.8 of the Illinois Insurance Code shall not | ||||||
24 | apply and (ii) the Director, in making his determination | ||||||
25 | with respect to the merger, consolidation, or other | ||||||
26 | acquisition of control, need not take into account the |
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1 | effect on competition of the merger, consolidation, or | ||||||
2 | other acquisition of control; | ||||||
3 | (3) the Director shall have the power to require the | ||||||
4 | following information: | ||||||
5 | (A) certification by an independent actuary of the | ||||||
6 | adequacy of the reserves of the Health Maintenance | ||||||
7 | Organization sought to be acquired; | ||||||
8 | (B) pro forma financial statements reflecting the | ||||||
9 | combined balance sheets of the acquiring company and | ||||||
10 | the Health Maintenance Organization sought to be | ||||||
11 | acquired as of the end of the preceding year and as of | ||||||
12 | a date 90 days prior to the acquisition, as well as pro | ||||||
13 | forma financial statements reflecting projected | ||||||
14 | combined operation for a period of 2 years; | ||||||
15 | (C) a pro forma business plan detailing an | ||||||
16 | acquiring party's plans with respect to the operation | ||||||
17 | of the Health Maintenance Organization sought to be | ||||||
18 | acquired for a period of not less than 3 years; and | ||||||
19 | (D) such other information as the Director shall | ||||||
20 | require. | ||||||
21 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
22 | Insurance Code and this Section 5-3 shall apply to the sale by | ||||||
23 | any health maintenance organization of greater than 10% of its | ||||||
24 | enrollee population (including, without limitation, the health | ||||||
25 | maintenance organization's right, title, and interest in and | ||||||
26 | to its health care certificates). |
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1 | (e) In considering any management contract or service | ||||||
2 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
3 | Code, the Director (i) shall, in addition to the criteria | ||||||
4 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
5 | take into account the effect of the management contract or | ||||||
6 | service agreement on the continuation of benefits to enrollees | ||||||
7 | and the financial condition of the health maintenance | ||||||
8 | organization to be managed or serviced, and (ii) need not take | ||||||
9 | into account the effect of the management contract or service | ||||||
10 | agreement on competition. | ||||||
11 | (f) Except for small employer groups as defined in the | ||||||
12 | Small Employer Rating, Renewability and Portability Health | ||||||
13 | Insurance Act and except for medicare supplement policies as | ||||||
14 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
15 | Health Maintenance Organization may by contract agree with a | ||||||
16 | group or other enrollment unit to effect refunds or charge | ||||||
17 | additional premiums under the following terms and conditions: | ||||||
18 | (i) the amount of, and other terms and conditions with | ||||||
19 | respect to, the refund or additional premium are set forth | ||||||
20 | in the group or enrollment unit contract agreed in advance | ||||||
21 | of the period for which a refund is to be paid or | ||||||
22 | additional premium is to be charged (which period shall | ||||||
23 | not be less than one year); and | ||||||
24 | (ii) the amount of the refund or additional premium | ||||||
25 | shall not exceed 20% of the Health Maintenance | ||||||
26 | Organization's profitable or unprofitable experience with |
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1 | respect to the group or other enrollment unit for the | ||||||
2 | period (and, for purposes of a refund or additional | ||||||
3 | premium, the profitable or unprofitable experience shall | ||||||
4 | be calculated taking into account a pro rata share of the | ||||||
5 | Health Maintenance Organization's administrative and | ||||||
6 | marketing expenses, but shall not include any refund to be | ||||||
7 | made or additional premium to be paid pursuant to this | ||||||
8 | subsection (f)). The Health Maintenance Organization and | ||||||
9 | the group or enrollment unit may agree that the profitable | ||||||
10 | or unprofitable experience may be calculated taking into | ||||||
11 | account the refund period and the immediately preceding 2 | ||||||
12 | plan years. | ||||||
13 | The Health Maintenance Organization shall include a | ||||||
14 | statement in the evidence of coverage issued to each enrollee | ||||||
15 | describing the possibility of a refund or additional premium, | ||||||
16 | and upon request of any group or enrollment unit, provide to | ||||||
17 | the group or enrollment unit a description of the method used | ||||||
18 | to calculate (1) the Health Maintenance Organization's | ||||||
19 | profitable experience with respect to the group or enrollment | ||||||
20 | unit and the resulting refund to the group or enrollment unit | ||||||
21 | or (2) the Health Maintenance Organization's unprofitable | ||||||
22 | experience with respect to the group or enrollment unit and | ||||||
23 | the resulting additional premium to be paid by the group or | ||||||
24 | enrollment unit. | ||||||
25 | In no event shall the Illinois Health Maintenance | ||||||
26 | Organization Guaranty Association be liable to pay any |
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1 | contractual obligation of an insolvent organization to pay any | ||||||
2 | refund authorized under this Section. | ||||||
3 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
4 | if any, is conditioned on the rules being adopted in | ||||||
5 | accordance with all provisions of the Illinois Administrative | ||||||
6 | Procedure Act and all rules and procedures of the Joint | ||||||
7 | Committee on Administrative Rules; any purported rule not so | ||||||
8 | adopted, for whatever reason, is unauthorized. | ||||||
9 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
10 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
11 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
12 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
13 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
14 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
15 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
16 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||||||
17 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
18 | eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; | ||||||
19 | 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. | ||||||
20 | 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, | ||||||
21 | eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; | ||||||
22 | 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff. | ||||||
23 | 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.) | ||||||
24 | (Text of Section after amendment by P.A. 103-808 ) | ||||||
25 | Sec. 5-3. Insurance Code provisions. |
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1 | (a) Health Maintenance Organizations shall be subject to | ||||||
2 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
3 | 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, | ||||||
4 | 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, | ||||||
5 | 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g, | ||||||
6 | 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, | ||||||
7 | 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
8 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | ||||||
9 | 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, | ||||||
10 | 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, | ||||||
11 | 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, | ||||||
12 | 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, | ||||||
13 | 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, | ||||||
14 | 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, | ||||||
15 | 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, | ||||||
16 | 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, | ||||||
17 | 356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, | ||||||
18 | 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, | ||||||
19 | 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) | ||||||
20 | of subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||||||
21 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
22 | Illinois Insurance Code. | ||||||
23 | (b) For purposes of the Illinois Insurance Code, except | ||||||
24 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
25 | Health Maintenance Organizations in the following categories | ||||||
26 | are deemed to be "domestic companies": |
| |||||||
| |||||||
1 | (1) a corporation authorized under the Dental Service | ||||||
2 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
3 | (2) a corporation organized under the laws of this | ||||||
4 | State; or | ||||||
5 | (3) a corporation organized under the laws of another | ||||||
6 | state, 30% or more of the enrollees of which are residents | ||||||
7 | of this State, except a corporation subject to | ||||||
8 | substantially the same requirements in its state of | ||||||
9 | organization as is a "domestic company" under Article VIII | ||||||
10 | 1/2 of the Illinois Insurance Code. | ||||||
11 | (c) In considering the merger, consolidation, or other | ||||||
12 | acquisition of control of a Health Maintenance Organization | ||||||
13 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||||||
14 | (1) the Director shall give primary consideration to | ||||||
15 | the continuation of benefits to enrollees and the | ||||||
16 | financial conditions of the acquired Health Maintenance | ||||||
17 | Organization after the merger, consolidation, or other | ||||||
18 | acquisition of control takes effect; | ||||||
19 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
20 | Section 131.8 of the Illinois Insurance Code shall not | ||||||
21 | apply and (ii) the Director, in making his determination | ||||||
22 | with respect to the merger, consolidation, or other | ||||||
23 | acquisition of control, need not take into account the | ||||||
24 | effect on competition of the merger, consolidation, or | ||||||
25 | other acquisition of control; | ||||||
26 | (3) the Director shall have the power to require the |
| |||||||
| |||||||
1 | following information: | ||||||
2 | (A) certification by an independent actuary of the | ||||||
3 | adequacy of the reserves of the Health Maintenance | ||||||
4 | Organization sought to be acquired; | ||||||
5 | (B) pro forma financial statements reflecting the | ||||||
6 | combined balance sheets of the acquiring company and | ||||||
7 | the Health Maintenance Organization sought to be | ||||||
8 | acquired as of the end of the preceding year and as of | ||||||
9 | a date 90 days prior to the acquisition, as well as pro | ||||||
10 | forma financial statements reflecting projected | ||||||
11 | combined operation for a period of 2 years; | ||||||
12 | (C) a pro forma business plan detailing an | ||||||
13 | acquiring party's plans with respect to the operation | ||||||
14 | of the Health Maintenance Organization sought to be | ||||||
15 | acquired for a period of not less than 3 years; and | ||||||
16 | (D) such other information as the Director shall | ||||||
17 | require. | ||||||
18 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
19 | Insurance Code and this Section 5-3 shall apply to the sale by | ||||||
20 | any health maintenance organization of greater than 10% of its | ||||||
21 | enrollee population (including, without limitation, the health | ||||||
22 | maintenance organization's right, title, and interest in and | ||||||
23 | to its health care certificates). | ||||||
24 | (e) In considering any management contract or service | ||||||
25 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
26 | Code, the Director (i) shall, in addition to the criteria |
| |||||||
| |||||||
1 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
2 | take into account the effect of the management contract or | ||||||
3 | service agreement on the continuation of benefits to enrollees | ||||||
4 | and the financial condition of the health maintenance | ||||||
5 | organization to be managed or serviced, and (ii) need not take | ||||||
6 | into account the effect of the management contract or service | ||||||
7 | agreement on competition. | ||||||
8 | (f) Except for small employer groups as defined in the | ||||||
9 | Small Employer Rating, Renewability and Portability Health | ||||||
10 | Insurance Act and except for medicare supplement policies as | ||||||
11 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
12 | Health Maintenance Organization may by contract agree with a | ||||||
13 | group or other enrollment unit to effect refunds or charge | ||||||
14 | additional premiums under the following terms and conditions: | ||||||
15 | (i) the amount of, and other terms and conditions with | ||||||
16 | respect to, the refund or additional premium are set forth | ||||||
17 | in the group or enrollment unit contract agreed in advance | ||||||
18 | of the period for which a refund is to be paid or | ||||||
19 | additional premium is to be charged (which period shall | ||||||
20 | not be less than one year); and | ||||||
21 | (ii) the amount of the refund or additional premium | ||||||
22 | shall not exceed 20% of the Health Maintenance | ||||||
23 | Organization's profitable or unprofitable experience with | ||||||
24 | respect to the group or other enrollment unit for the | ||||||
25 | period (and, for purposes of a refund or additional | ||||||
26 | premium, the profitable or unprofitable experience shall |
| |||||||
| |||||||
1 | be calculated taking into account a pro rata share of the | ||||||
2 | Health Maintenance Organization's administrative and | ||||||
3 | marketing expenses, but shall not include any refund to be | ||||||
4 | made or additional premium to be paid pursuant to this | ||||||
5 | subsection (f)). The Health Maintenance Organization and | ||||||
6 | the group or enrollment unit may agree that the profitable | ||||||
7 | or unprofitable experience may be calculated taking into | ||||||
8 | account the refund period and the immediately preceding 2 | ||||||
9 | plan years. | ||||||
10 | The Health Maintenance Organization shall include a | ||||||
11 | statement in the evidence of coverage issued to each enrollee | ||||||
12 | describing the possibility of a refund or additional premium, | ||||||
13 | and upon request of any group or enrollment unit, provide to | ||||||
14 | the group or enrollment unit a description of the method used | ||||||
15 | to calculate (1) the Health Maintenance Organization's | ||||||
16 | profitable experience with respect to the group or enrollment | ||||||
17 | unit and the resulting refund to the group or enrollment unit | ||||||
18 | or (2) the Health Maintenance Organization's unprofitable | ||||||
19 | experience with respect to the group or enrollment unit and | ||||||
20 | the resulting additional premium to be paid by the group or | ||||||
21 | enrollment unit. | ||||||
22 | In no event shall the Illinois Health Maintenance | ||||||
23 | Organization Guaranty Association be liable to pay any | ||||||
24 | contractual obligation of an insolvent organization to pay any | ||||||
25 | refund authorized under this Section. | ||||||
26 | (g) Rulemaking authority to implement Public Act 95-1045, |
| |||||||
| |||||||
1 | if any, is conditioned on the rules being adopted in | ||||||
2 | accordance with all provisions of the Illinois Administrative | ||||||
3 | Procedure Act and all rules and procedures of the Joint | ||||||
4 | Committee on Administrative Rules; any purported rule not so | ||||||
5 | adopted, for whatever reason, is unauthorized. | ||||||
6 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
7 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
8 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
9 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
10 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
11 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
12 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
13 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||||||
14 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
15 | eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; | ||||||
16 | 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. | ||||||
17 | 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, | ||||||
18 | eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; | ||||||
19 | 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff. | ||||||
20 | 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised | ||||||
21 | 11-26-24.) | ||||||
22 | Section 30. The Limited Health Service Organization Act is | ||||||
23 | amended by changing Section 4003 as follows: | ||||||
24 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) |
| |||||||
| |||||||
1 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
2 | health service organizations shall be subject to the | ||||||
3 | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||||||
4 | 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153, | ||||||
5 | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, | ||||||
6 | 355.2, 355.3, 355b, 355d, 356m, 356q, 356v, 356z.4, 356z.4a, | ||||||
7 | 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.32, | ||||||
8 | 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, | ||||||
9 | 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, 356z.71, | ||||||
10 | 356z.73, 356z.74, 356z.75, 356z.80, 364.3, 368a, 401, 401.1, | ||||||
11 | 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and | ||||||
12 | Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and | ||||||
13 | XXVI of the Illinois Insurance Code. Nothing in this Section | ||||||
14 | shall require a limited health care plan to cover any service | ||||||
15 | that is not a limited health service. For purposes of the | ||||||
16 | Illinois Insurance Code, except for Sections 444 and 444.1 and | ||||||
17 | Articles XIII and XIII 1/2, limited health service | ||||||
18 | organizations in the following categories are deemed to be | ||||||
19 | domestic companies: | ||||||
20 | (1) a corporation under the laws of this State; or | ||||||
21 | (2) a corporation organized under the laws of another | ||||||
22 | state, 30% or more of the enrollees of which are residents | ||||||
23 | of this State, except a corporation subject to | ||||||
24 | substantially the same requirements in its state of | ||||||
25 | organization as is a domestic company under Article VIII | ||||||
26 | 1/2 of the Illinois Insurance Code. |
| |||||||
| |||||||
1 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||||||
2 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||||||
3 | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||||||
4 | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||||||
5 | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||||||
6 | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
7 | eff. 1-1-24; 103-605, eff. 7-1-24; 103-649, eff. 1-1-25; | ||||||
8 | 103-656, eff. 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. | ||||||
9 | 7-19-24; 103-751, eff. 8-2-24; 103-758, eff. 1-1-25; 103-832, | ||||||
10 | eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.) | ||||||
11 | Section 35. The Voluntary Health Services Plans Act is | ||||||
12 | amended by changing Section 10 as follows: | ||||||
13 | (215 ILCS 165/10) (from Ch. 32, par. 604) | ||||||
14 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
15 | services plan corporations and all persons interested therein | ||||||
16 | or dealing therewith shall be subject to the provisions of | ||||||
17 | Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, | ||||||
18 | 143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, | ||||||
19 | 355b, 355d, 356g, 356g.5, 356g.5-1, 356m, 356q, 356r, 356t, | ||||||
20 | 356u, 356u.10, 356v, 356w, 356x, 356y, 356z.1, 356z.2, | ||||||
21 | 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
22 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | ||||||
23 | 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | ||||||
24 | 356z.32, 356z.32a, 356z.33, 356z.40, 356z.41, 356z.46, |
| |||||||
| |||||||
1 | 356z.47, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, | ||||||
2 | 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.71, | ||||||
3 | 356z.72, 356z.74, 356z.75, 356z.77, 356z.80, 364.01, 364.3, | ||||||
4 | 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, | ||||||
5 | and paragraphs (7) and (15) of Section 367 of the Illinois | ||||||
6 | Insurance Code. | ||||||
7 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
8 | any, is conditioned on the rules being adopted in accordance | ||||||
9 | with all provisions of the Illinois Administrative Procedure | ||||||
10 | Act and all rules and procedures of the Joint Committee on | ||||||
11 | Administrative Rules; any purported rule not so adopted, for | ||||||
12 | whatever reason, is unauthorized. | ||||||
13 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||||||
14 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. | ||||||
15 | 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, | ||||||
16 | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||||||
17 | 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. | ||||||
18 | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||||||
19 | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||||||
20 | 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-656, eff. | ||||||
21 | 1-1-25; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-753, | ||||||
22 | eff. 8-2-24; 103-758, eff. 1-1-25; 103-832, eff. 1-1-25; | ||||||
23 | 103-914, eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. | ||||||
24 | 1-1-25; revised 11-26-24.) | ||||||
25 | Section 95. No acceleration or delay. Where this Act makes |
| |||||||
| |||||||
1 | changes in a statute that is represented in this Act by text | ||||||
2 | that is not yet or no longer in effect (for example, a Section | ||||||
3 | represented by multiple versions), the use of that text does | ||||||
4 | not accelerate or delay the taking effect of (i) the changes | ||||||
5 | made by this Act or (ii) provisions derived from any other | ||||||
6 | Public Act. | ||||||
7 | Section 99. Effective date. This Act takes effect upon | ||||||
8 | becoming law. |