93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB5091

 

Introduced 02/05/04, by Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.6 new
215 ILCS 105/8   from Ch. 73, par. 1308
215 ILCS 125/5-3   from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10   from Ch. 32, par. 604
320 ILCS 25/3.15   from Ch. 67 1/2, par. 403.15

    Amends the Illinois Insurance Code, the Comprehensive Health Insurance Program Act, the Health Maintenance Organization Act, the Voluntary Health Services Plans Act, and the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act to require coverage under those Acts for immunosuppressive agents (anti-rejection medication).


LRB093 13635 SAS 40141 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB5091 LRB093 13635 SAS 40141 b

1     AN ACT concerning pharmaceutical benefits.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by adding
5 Section 356z.6 as follows:
 
6     (215 ILCS 5/356z.6 new)
7     Sec. 356z.6. Immunosuppressive agents. A group or
8 individual policy of accident and health insurance amended,
9 delivered, issued, or renewed after the effective date of this
10 amendatory Act of the 93rd General Assembly that provides
11 coverage for organ transplants must provide coverage for
12 immunosuppressive agents (anti-rejection medications). If the
13 policy provides coverage for prescription drugs through the use
14 of a drug formulary, the generic immunosuppressive agents must
15 be included with the drug formulary. If the immunosuppressive
16 agent is non-generic it must be included in the drug formulary
17 as the least expensive co-payment level higher than the
18 co-payment required for generic drugs.
 
19     Section 10. The Comprehensive Health Insurance Plan Act is
20 amended by changing Section 8 as follows:
 
21     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
22     Sec. 8. Minimum benefits.
23     a. Availability. The Plan shall offer in an annually
24 renewable policy major medical expense coverage to every
25 eligible person who is not eligible for Medicare. Major medical
26 expense coverage offered by the Plan shall pay an eligible
27 person's covered expenses, subject to limit on the deductible
28 and coinsurance payments authorized under paragraph (4) of
29 subsection d of this Section, up to a lifetime benefit limit of
30 $1,000,000 per covered individual. The maximum limit under this

 

 

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1 subsection shall not be altered by the Board, and no actuarial
2 equivalent benefit may be substituted by the Board. Any person
3 who otherwise would qualify for coverage under the Plan, but is
4 excluded because he or she is eligible for Medicare, shall be
5 eligible for any separate Medicare supplement policy or
6 policies which the Board may offer.
7     b. Outline of benefits. Covered expenses shall be limited
8 to the usual and customary charge, including negotiated fees,
9 in the locality for the following services and articles when
10 prescribed by a physician and determined by the Plan to be
11 medically necessary for the following areas of services,
12 subject to such separate deductibles, co-payments, exclusions,
13 and other limitations on benefits as the Board shall establish
14 and approve, and the other provisions of this Section:
15         (1) Hospital services, except that any services
16     provided by a hospital that is located more than 75 miles
17     outside the State of Illinois shall be covered only for a
18     maximum of 45 days in any calendar year. With respect to
19     covered expenses incurred during any calendar year ending
20     on or after December 31, 1999, inpatient hospitalization of
21     an eligible person for the treatment of mental illness at a
22     hospital located within the State of Illinois shall be
23     subject to the same terms and conditions as for any other
24     illness.
25         (2) Professional services for the diagnosis or
26     treatment of injuries, illnesses or conditions, other than
27     dental and mental and nervous disorders as described in
28     paragraph (17), which are rendered by a physician, or by
29     other licensed professionals at the physician's direction.
30     This includes reconstruction of the breast on which a
31     mastectomy was performed; surgery and reconstruction of
32     the other breast to produce a symmetrical appearance; and
33     prostheses and treatment of physical complications at all
34     stages of the mastectomy, including lymphedemas.
35         (2.5) Professional services provided by a physician to
36     children under the age of 16 years for physical

 

 

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1     examinations and age appropriate immunizations ordered by
2     a physician licensed to practice medicine in all its
3     branches.
4         (3) (Blank).
5         (4) Outpatient prescription drugs that by law require a
6     prescription written by a physician licensed to practice
7     medicine in all its branches subject to such separate
8     deductible, copayment, and other limitations or
9     restrictions as the Board shall approve, including the use
10     of a prescription drug card or any other program, or both.
11         (5) Skilled nursing services of a licensed skilled
12     nursing facility for not more than 120 days during a policy
13     year.
14         (6) Services of a home health agency in accord with a
15     home health care plan, up to a maximum of 270 visits per
16     year.
17         (7) Services of a licensed hospice for not more than
18     180 days during a policy year.
19         (8) Use of radium or other radioactive materials.
20         (9) Oxygen.
21         (10) Anesthetics.
22         (11) Orthoses and prostheses other than dental.
23         (12) Rental or purchase in accordance with Board
24     policies or procedures of durable medical equipment, other
25     than eyeglasses or hearing aids, for which there is no
26     personal use in the absence of the condition for which it
27     is prescribed.
28         (13) Diagnostic x-rays and laboratory tests.
29         (14) Oral surgery (i) for excision of partially or
30     completely unerupted impacted teeth when not performed in
31     connection with the routine extraction or repair of teeth;
32     (ii) for excision of tumors or cysts of the jaws, cheeks,
33     lips, tongue, and roof and floor of the mouth; (iii)
34     required for correction of cleft lip and palate and other
35     craniofacial and maxillofacial birth defects; or (iv) for
36     treatment of injuries to natural teeth or a fractured jaw

 

 

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1     due to an accident.
2         (15) Physical, speech, and functional occupational
3     therapy as medically necessary and provided by appropriate
4     licensed professionals.
5         (16) Emergency and other medically necessary
6     transportation provided by a licensed ambulance service to
7     the nearest health care facility qualified to treat a
8     covered illness, injury, or condition, subject to the
9     provisions of the Emergency Medical Systems (EMS) Act.
10         (17) Outpatient services for diagnosis and treatment
11     of mental and nervous disorders provided that a covered
12     person shall be required to make a copayment not to exceed
13     50% and that the Plan's payment shall not exceed such
14     amounts as are established by the Board.
15         (18) Human organ or tissue transplants specified by the
16     Board that are performed at a hospital designated by the
17     Board as a participating transplant center for that
18     specific organ or tissue transplant, including
19     immunosuppressive agents as required under Section 356z.6
20     of the Illinois Insurance Code.
21         (19) Naprapathic services, as appropriate, provided by
22     a licensed naprapathic practitioner.
23     c. Exclusions. Covered expenses of the Plan shall not
24 include the following:
25         (1) Any charge for treatment for cosmetic purposes
26     other than for reconstructive surgery when the service is
27     incidental to or follows surgery resulting from injury,
28     sickness or other diseases of the involved part or surgery
29     for the repair or treatment of a congenital bodily defect
30     to restore normal bodily functions.
31         (2) Any charge for care that is primarily for rest,
32     custodial, educational, or domiciliary purposes.
33         (3) Any charge for services in a private room to the
34     extent it is in excess of the institution's charge for its
35     most common semiprivate room, unless a private room is
36     prescribed as medically necessary by a physician.

 

 

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1         (4) That part of any charge for room and board or for
2     services rendered or articles prescribed by a physician,
3     dentist, or other health care personnel that exceeds the
4     reasonable and customary charge in the locality or for any
5     services or supplies not medically necessary for the
6     diagnosed injury or illness.
7         (5) Any charge for services or articles the provision
8     of which is not within the scope of licensure of the
9     institution or individual providing the services or
10     articles.
11         (6) Any expense incurred prior to the effective date of
12     coverage by the Plan for the person on whose behalf the
13     expense is incurred.
14         (7) Dental care, dental surgery, dental treatment, any
15     other dental procedure involving the teeth or
16     periodontium, or any dental appliances, including crowns,
17     bridges, implants, or partial or complete dentures, except
18     as specifically provided in paragraph (14) of subsection b
19     of this Section.
20         (8) Eyeglasses, contact lenses, hearing aids or their
21     fitting.
22         (9) Illness or injury due to acts of war.
23         (10) Services of blood donors and any fee for failure
24     to replace the first 3 pints of blood provided to a covered
25     person each policy year.
26         (11) Personal supplies or services provided by a
27     hospital or nursing home, or any other nonmedical or
28     nonprescribed supply or service.
29         (12) Routine maternity charges for a pregnancy, except
30     where added as optional coverage with payment of an
31     additional premium for pregnancy resulting from conception
32     occurring after the effective date of the optional
33     coverage.
34         (13) (Blank).
35         (14) Any expense or charge for services, drugs, or
36     supplies that are: (i) not provided in accord with

 

 

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1     generally accepted standards of current medical practice;
2     (ii) for procedures, treatments, equipment, transplants,
3     or implants, any of which are investigational,
4     experimental, or for research purposes; (iii)
5     investigative and not proven safe and effective; or (iv)
6     for, or resulting from, a gender transformation operation.
7         (15) Any expense or charge for routine physical
8     examinations or tests except as provided in item (2.5) of
9     subsection b of this Section.
10         (16) Any expense for which a charge is not made in the
11     absence of insurance or for which there is no legal
12     obligation on the part of the patient to pay.
13         (17) Any expense incurred for benefits provided under
14     the laws of the United States and this State, including
15     Medicare, Medicaid, and other medical assistance, maternal
16     and child health services and any other program that is
17     administered or funded by the Department of Human Services,
18     Department of Public Aid, or Department of Public Health,
19     military service-connected disability payments, medical
20     services provided for members of the armed forces and their
21     dependents or employees of the armed forces of the United
22     States, and medical services financed on behalf of all
23     citizens by the United States.
24         (18) Any expense or charge for in vitro fertilization,
25     artificial insemination, or any other artificial means
26     used to cause pregnancy.
27         (19) Any expense or charge for oral contraceptives used
28     for birth control or any other temporary birth control
29     measures.
30         (20) Any expense or charge for sterilization or
31     sterilization reversals.
32         (21) Any expense or charge for weight loss programs,
33     exercise equipment, or treatment of obesity, except when
34     certified by a physician as morbid obesity (at least 2
35     times normal body weight).
36         (22) Any expense or charge for acupuncture treatment

 

 

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1     unless used as an anesthetic agent for a covered surgery.
2         (23) Any expense or charge for or related to organ or
3     tissue transplants other than those performed at a hospital
4     with a Board approved organ transplant program that has
5     been designated by the Board as a preferred or exclusive
6     provider organization for that specific organ or tissue
7     transplant.
8         (24) Any expense or charge for procedures, treatments,
9     equipment, or services that are provided in special
10     settings for research purposes or in a controlled
11     environment, are being studied for safety, efficiency, and
12     effectiveness, and are awaiting endorsement by the
13     appropriate national medical speciality college for
14     general use within the medical community.
15     d. Deductibles and coinsurance.
16     The Plan coverage defined in Section 6 shall provide for a
17 choice of deductibles per individual as authorized by the
18 Board. If 2 individual members of the same family household,
19 who are both covered persons under the Plan, satisfy the same
20 applicable deductibles, no other member of that family who is
21 also a covered person under the Plan shall be required to meet
22 any deductibles for the balance of that calendar year. The
23 deductibles must be applied first to the authorized amount of
24 covered expenses incurred by the covered person. A mandatory
25 coinsurance requirement shall be imposed at the rate authorized
26 by the Board in excess of the mandatory deductible, the
27 coinsurance in the aggregate not to exceed such amounts as are
28 authorized by the Board per annum. At its discretion the Board
29 may, however, offer catastrophic coverages or other policies
30 that provide for larger deductibles with or without coinsurance
31 requirements. The deductibles and coinsurance factors may be
32 adjusted annually according to the Medical Component of the
33 Consumer Price Index.
34     e. Scope of coverage.
35         (1) In approving any of the benefit plans to be offered
36     by the Plan, the Board shall establish such benefit levels,

 

 

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1     deductibles, coinsurance factors, exclusions, and
2     limitations as it may deem appropriate and that it believes
3     to be generally reflective of and commensurate with health
4     insurance coverage that is provided in the individual
5     market in this State.
6         (2) The benefit plans approved by the Board may also
7     provide for and employ various cost containment measures
8     and other requirements including, but not limited to,
9     preadmission certification, prior approval, second
10     surgical opinions, concurrent utilization review programs,
11     individual case management, preferred provider
12     organizations, health maintenance organizations, and other
13     cost effective arrangements for paying for covered
14     expenses.
15     f. Preexisting conditions.
16         (1) Except for federally eligible individuals
17     qualifying for Plan coverage under Section 15 of this Act
18     or eligible persons who qualify for the waiver authorized
19     in paragraph (3) of this subsection, plan coverage shall
20     exclude charges or expenses incurred during the first 6
21     months following the effective date of coverage as to any
22     condition for which medical advice, care or treatment was
23     recommended or received during the 6 month period
24     immediately preceding the effective date of coverage.
25         (2) (Blank).
26         (3) Waiver: The preexisting condition exclusions as
27     set forth in paragraph (1) of this subsection shall be
28     waived to the extent to which the eligible person (a) has
29     satisfied similar exclusions under any prior individual
30     health insurance policy that was involuntarily terminated
31     because of the insolvency of the issuer of the policy and
32     (b) has applied for Plan coverage within 90 days following
33     the involuntary termination of that individual health
34     insurance coverage.
35     g. Other sources primary; nonduplication of benefits.
36         (1) The Plan shall be the last payor of benefits

 

 

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1     whenever any other benefit or source of third party payment
2     is available. Subject to the provisions of subsection e of
3     Section 7, benefits otherwise payable under Plan coverage
4     shall be reduced by all amounts paid or payable by Medicare
5     or any other government program or through any health
6     insurance coverage or group health plan, whether by
7     insurance, reimbursement, or otherwise, or through any
8     third party liability, settlement, judgment, or award,
9     regardless of the date of the settlement, judgment, or
10     award, whether the settlement, judgment, or award is in the
11     form of a contract, agreement, or trust on behalf of a
12     minor or otherwise and whether the settlement, judgment, or
13     award is payable to the covered person, his or her
14     dependent, estate, personal representative, or guardian in
15     a lump sum or over time, and by all hospital or medical
16     expense benefits paid or payable under any worker's
17     compensation coverage, automobile medical payment, or
18     liability insurance, whether provided on the basis of fault
19     or nonfault, and by any hospital or medical benefits paid
20     or payable under or provided pursuant to any State or
21     federal law or program.
22         (2) The Plan shall have a cause of action against any
23     covered person or any other person or entity for the
24     recovery of any amount paid to the extent the amount was
25     for treatment, services, or supplies not covered in this
26     Section or in excess of benefits as set forth in this
27     Section.
28         (3) Whenever benefits are due from the Plan because of
29     sickness or an injury to a covered person resulting from a
30     third party's wrongful act or negligence and the covered
31     person has recovered or may recover damages from a third
32     party or its insurer, the Plan shall have the right to
33     reduce benefits or to refuse to pay benefits that otherwise
34     may be payable by the amount of damages that the covered
35     person has recovered or may recover regardless of the date
36     of the sickness or injury or the date of any settlement,

 

 

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1     judgment, or award resulting from that sickness or injury.
2         During the pendency of any action or claim that is
3     brought by or on behalf of a covered person against a third
4     party or its insurer, any benefits that would otherwise be
5     payable except for the provisions of this paragraph (3)
6     shall be paid if payment by or for the third party has not
7     yet been made and the covered person or, if incapable, that
8     person's legal representative agrees in writing to pay back
9     promptly the benefits paid as a result of the sickness or
10     injury to the extent of any future payments made by or for
11     the third party for the sickness or injury. This agreement
12     is to apply whether or not liability for the payments is
13     established or admitted by the third party or whether those
14     payments are itemized.
15         Any amounts due the plan to repay benefits may be
16     deducted from other benefits payable by the Plan after
17     payments by or for the third party are made.
18         (4) Benefits due from the Plan may be reduced or
19     refused as an offset against any amount otherwise
20     recoverable under this Section.
21     h. Right of subrogation; recoveries.
22         (1) Whenever the Plan has paid benefits because of
23     sickness or an injury to any covered person resulting from
24     a third party's wrongful act or negligence, or for which an
25     insurer is liable in accordance with the provisions of any
26     policy of insurance, and the covered person has recovered
27     or may recover damages from a third party that is liable
28     for the damages, the Plan shall have the right to recover
29     the benefits it paid from any amounts that the covered
30     person has received or may receive regardless of the date
31     of the sickness or injury or the date of any settlement,
32     judgment, or award resulting from that sickness or injury.
33     The Plan shall be subrogated to any right of recovery the
34     covered person may have under the terms of any private or
35     public health care coverage or liability coverage,
36     including coverage under the Workers' Compensation Act or

 

 

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1     the Workers' Occupational Diseases Act, without the
2     necessity of assignment of claim or other authorization to
3     secure the right of recovery. To enforce its subrogation
4     right, the Plan may (i) intervene or join in an action or
5     proceeding brought by the covered person or his personal
6     representative, including his guardian, conservator,
7     estate, dependents, or survivors, against any third party
8     or the third party's insurer that may be liable or (ii)
9     institute and prosecute legal proceedings against any
10     third party or the third party's insurer that may be liable
11     for the sickness or injury in an appropriate court either
12     in the name of the Plan or in the name of the covered
13     person or his personal representative, including his
14     guardian, conservator, estate, dependents, or survivors.
15         (2) If any action or claim is brought by or on behalf
16     of a covered person against a third party or the third
17     party's insurer, the covered person or his personal
18     representative, including his guardian, conservator,
19     estate, dependents, or survivors, shall notify the Plan by
20     personal service or registered mail of the action or claim
21     and of the name of the court in which the action or claim
22     is brought, filing proof thereof in the action or claim.
23     The Plan may, at any time thereafter, join in the action or
24     claim upon its motion so that all orders of court after
25     hearing and judgment shall be made for its protection. No
26     release or settlement of a claim for damages and no
27     satisfaction of judgment in the action shall be valid
28     without the written consent of the Plan to the extent of
29     its interest in the settlement or judgment and of the
30     covered person or his personal representative.
31         (3) In the event that the covered person or his
32     personal representative fails to institute a proceeding
33     against any appropriate third party before the fifth month
34     before the action would be barred, the Plan may, in its own
35     name or in the name of the covered person or personal
36     representative, commence a proceeding against any

 

 

HB5091 - 12 - LRB093 13635 SAS 40141 b

1     appropriate third party for the recovery of damages on
2     account of any sickness, injury, or death to the covered
3     person. The covered person shall cooperate in doing what is
4     reasonably necessary to assist the Plan in any recovery and
5     shall not take any action that would prejudice the Plan's
6     right to recovery. The Plan shall pay to the covered person
7     or his personal representative all sums collected from any
8     third party by judgment or otherwise in excess of amounts
9     paid in benefits under the Plan and amounts paid or to be
10     paid as costs, attorneys fees, and reasonable expenses
11     incurred by the Plan in making the collection or enforcing
12     the judgment.
13         (4) In the event that a covered person or his personal
14     representative, including his guardian, conservator,
15     estate, dependents, or survivors, recovers damages from a
16     third party for sickness or injury caused to the covered
17     person, the covered person or the personal representative
18     shall pay to the Plan from the damages recovered the amount
19     of benefits paid or to be paid on behalf of the covered
20     person.
21         (5) When the action or claim is brought by the covered
22     person alone and the covered person incurs a personal
23     liability to pay attorney's fees and costs of litigation,
24     the Plan's claim for reimbursement of the benefits provided
25     to the covered person shall be the full amount of benefits
26     paid to or on behalf of the covered person under this Act
27     less a pro rata share that represents the Plan's reasonable
28     share of attorney's fees paid by the covered person and
29     that portion of the cost of litigation expenses determined
30     by multiplying by the ratio of the full amount of the
31     expenditures to the full amount of the judgement, award, or
32     settlement.
33         (6) In the event of judgment or award in a suit or
34     claim against a third party or insurer, the court shall
35     first order paid from any judgement or award the reasonable
36     litigation expenses incurred in preparation and

 

 

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1     prosecution of the action or claim, together with
2     reasonable attorney's fees. After payment of those
3     expenses and attorney's fees, the court shall apply out of
4     the balance of the judgment or award an amount sufficient
5     to reimburse the Plan the full amount of benefits paid on
6     behalf of the covered person under this Act, provided the
7     court may reduce and apportion the Plan's portion of the
8     judgement proportionate to the recovery of the covered
9     person. The burden of producing evidence sufficient to
10     support the exercise by the court of its discretion to
11     reduce the amount of a proven charge sought to be enforced
12     against the recovery shall rest with the party seeking the
13     reduction. The court may consider the nature and extent of
14     the injury, economic and non-economic loss, settlement
15     offers, comparative negligence as it applies to the case at
16     hand, hospital costs, physician costs, and all other
17     appropriate costs. The Plan shall pay its pro rata share of
18     the attorney fees based on the Plan's recovery as it
19     compares to the total judgment. Any reimbursement rights of
20     the Plan shall take priority over all other liens and
21     charges existing under the laws of this State with the
22     exception of any attorney liens filed under the Attorneys
23     Lien Act.
24         (7) The Plan may compromise or settle and release any
25     claim for benefits provided under this Act or waive any
26     claims for benefits, in whole or in part, for the
27     convenience of the Plan or if the Plan determines that
28     collection would result in undue hardship upon the covered
29     person.
30 (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00; 92-2,
31 eff. 5-1-01; 92-630, eff. 7-11-02.)
 
32     Section 15. The Health Maintenance Organization Act is
33 amended by changing Section 5-3 as follows:
 
34     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)

 

 

HB5091 - 14 - LRB093 13635 SAS 40141 b

1     Sec. 5-3. Insurance Code provisions.
2     (a) Health Maintenance Organizations shall be subject to
3 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
4 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
5 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
6 356y, 356z.2, 356z.4, 356z.6, 367.2, 367.2-5, 367i, 368a, 368b,
7 368c, 368d, 368e, 401, 401.1, 402, 403, 403A, 408, 408.2, 409,
8 412, 444, and 444.1, paragraph (c) of subsection (2) of Section
9 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
10 XXV, and XXVI of the Illinois Insurance Code.
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":
15         (1) a corporation authorized under the Dental Service
16     Plan Act or the Voluntary Health Services Plans Act;
17         (2) a corporation organized under the laws of this
18     State; or
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
23     organization as is a "domestic company" under Article VIII
24     1/2 of the Illinois Insurance Code.
25     (c) In considering the merger, consolidation, or other
26 acquisition of control of a Health Maintenance Organization
27 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
28         (1) the Director shall give primary consideration to
29     the continuation of benefits to enrollees and the financial
30     conditions of the acquired Health Maintenance Organization
31     after the merger, consolidation, or other acquisition of
32     control takes effect;
33         (2)(i) the criteria specified in subsection (1)(b) of
34     Section 131.8 of the Illinois Insurance Code shall not
35     apply and (ii) the Director, in making his determination
36     with respect to the merger, consolidation, or other

 

 

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1     acquisition of control, need not take into account the
2     effect on competition of the merger, consolidation, or
3     other acquisition of control;
4         (3) the Director shall have the power to require the
5     following information:
6             (A) certification by an independent actuary of the
7         adequacy of the reserves of the Health Maintenance
8         Organization sought to be acquired;
9             (B) pro forma financial statements reflecting the
10         combined balance sheets of the acquiring company and
11         the Health Maintenance Organization sought to be
12         acquired as of the end of the preceding year and as of
13         a date 90 days prior to the acquisition, as well as pro
14         forma financial statements reflecting projected
15         combined operation for a period of 2 years;
16             (C) a pro forma business plan detailing an
17         acquiring party's plans with respect to the operation
18         of the Health Maintenance Organization sought to be
19         acquired for a period of not less than 3 years; and
20             (D) such other information as the Director shall
21         require.
22     (d) The provisions of Article VIII 1/2 of the Illinois
23 Insurance Code and this Section 5-3 shall apply to the sale by
24 any health maintenance organization of greater than 10% of its
25 enrollee population (including without limitation the health
26 maintenance organization's right, title, and interest in and to
27 its health care certificates).
28     (e) In considering any management contract or service
29 agreement subject to Section 141.1 of the Illinois Insurance
30 Code, the Director (i) shall, in addition to the criteria
31 specified in Section 141.2 of the Illinois Insurance Code, take
32 into account the effect of the management contract or service
33 agreement on the continuation of benefits to enrollees and the
34 financial condition of the health maintenance organization to
35 be managed or serviced, and (ii) need not take into account the
36 effect of the management contract or service agreement on

 

 

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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
27     or unprofitable experience may be calculated taking into
28     account the refund period and the immediately preceding 2
29     plan years.
30     The Health Maintenance Organization shall include a
31 statement in the evidence of coverage issued to each enrollee
32 describing the possibility of a refund or additional premium,
33 and upon request of any group or enrollment unit, provide to
34 the group or enrollment unit a description of the method used
35 to calculate (1) the Health Maintenance Organization's
36 profitable experience with respect to the group or enrollment

 

 

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1 unit and the resulting refund to the group or enrollment unit
2 or (2) the Health Maintenance Organization's unprofitable
3 experience with respect to the group or enrollment unit and the
4 resulting additional premium to be paid by the group or
5 enrollment unit.
6     In no event shall the Illinois Health Maintenance
7 Organization Guaranty Association be liable to pay any
8 contractual obligation of an insolvent organization to pay any
9 refund authorized under this Section.
10 (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261,
11 eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised
12 9-25-03.)
 
13     Section 20. The Voluntary Health Services Plans Act is
14 amended by changing Section 10 as follows:
 
15     (215 ILCS 165/10)  (from Ch. 32, par. 604)
16     Sec. 10. Application of Insurance Code provisions. Health
17 services plan corporations and all persons interested therein
18 or dealing therewith shall be subject to the provisions of
19 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
20 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 356x,
21 356y, 356z.1, 356z.2, 356z.4, 356z.6, 367.2, 368a, 401, 401.1,
22 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
23 (15) of Section 367 of the Illinois Insurance Code.
24 (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
25 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04;
26 93-529, eff. 8-14-03; revised 9-25-03.)
 
27     Section 25. The Senior Citizens and Disabled Persons
28 Property Tax Relief and Pharmaceutical Assistance Act is
29 amended by changing Section 3.15 as follows:
 
30     (320 ILCS 25/3.15)  (from Ch. 67 1/2, par. 403.15)
31     Sec. 3.15. "Covered prescription drug" means (1) any
32 cardiovascular agent or drug; (2) any insulin or other

 

 

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1 prescription drug used in the treatment of diabetes, including
2 syringe and needles used to administer the insulin; (3) any
3 prescription drug used in the treatment of arthritis, (4)
4 beginning on January 1, 2001, any prescription drug used in the
5 treatment of cancer, (5) beginning on January 1, 2001, any
6 prescription drug used in the treatment of Alzheimer's disease,
7 (6) beginning on January 1, 2001, any prescription drug used in
8 the treatment of Parkinson's disease, (7) beginning on January
9 1, 2001, any prescription drug used in the treatment of
10 glaucoma, (8) beginning on January 1, 2001, any prescription
11 drug used in the treatment of lung disease and smoking related
12 illnesses, (9) beginning on July 1, 2001, any prescription drug
13 used in the treatment of osteoporosis, and (10) beginning on
14 January 1, 2004, any prescription drug used in the treatment of
15 multiple sclerosis, and (11) beginning on January 1, 2005,
16 immunosuppressive agents (anti-rejection medication) used in
17 connection with organ transplants. The specific agents or
18 products to be included under such categories shall be listed
19 in a handbook to be prepared and distributed by the Department.
20 The general types of covered prescription drugs shall be
21 indicated by rule.
22 (Source: P.A. 92-10, eff. 6-11-01; 92-790, eff. 8-6-02; 93-528,
23 eff. 1-1-04.)