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1 | AN ACT concerning insurance coverage.
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2 | Be it enacted by the People of the State of Illinois, | ||||||
3 | represented in the General Assembly:
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4 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by
changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||
10 | policy of accident and health insurance under Section 356t of | ||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||
12 | shall provide the coverage
required under Sections 356u, 356w, | ||||||
13 | 356x, 356z.2, and 356z.4 , and 356z.6 of the
Illinois Insurance | ||||||
14 | Code.
The program of health benefits must comply with Section | ||||||
15 | 155.37 of the
Illinois Insurance Code.
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16 | (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03; | ||||||
17 | 93-102, eff. 1-1-04.)
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18 | Section 10. The Counties Code is amended by changing
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19 | Section 5-1069.3 as follows:
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20 | (55 ILCS 5/5-1069.3)
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21 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
22 | including a home
rule
county, is a self-insurer for purposes of | ||||||
23 | providing health insurance coverage
for its employees, the | ||||||
24 | coverage shall include coverage for the post-mastectomy
care | ||||||
25 | benefits required to be covered by a policy of accident and | ||||||
26 | health
insurance under Section 356t and the coverage required | ||||||
27 | under Sections 356u,
356w, and 356x and 356z.6 of
the Illinois | ||||||
28 | Insurance Code. The requirement that health benefits be covered
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29 | as provided in this Section is an
exclusive power and function | ||||||
30 | of the State and is a denial and limitation under
Article VII, |
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1 | Section 6, subsection (h) of the Illinois Constitution. A home
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2 | rule county to which this Section applies must comply with | ||||||
3 | every provision of
this Section.
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4 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
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5 | Section 15. The Illinois Municipal Code is amended by | ||||||
6 | changing
Section 10-4-2.3 as follows:
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7 | (65 ILCS 5/10-4-2.3)
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8 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
9 | municipality, including a
home rule municipality, is a | ||||||
10 | self-insurer for purposes of providing health
insurance | ||||||
11 | coverage for its employees, the coverage shall include coverage | ||||||
12 | for
the post-mastectomy care benefits required to be covered by | ||||||
13 | a policy of
accident and health insurance under Section 356t | ||||||
14 | and the coverage required
under Sections 356u, 356w, and 356x | ||||||
15 | and 356z.6 of the Illinois
Insurance
Code. The requirement that | ||||||
16 | health
benefits be covered as provided in this is an exclusive | ||||||
17 | power and function of
the State and is a denial and limitation | ||||||
18 | under Article VII, Section 6,
subsection (h) of the Illinois | ||||||
19 | Constitution. A home rule municipality to which
this Section | ||||||
20 | applies must comply with every provision of this Section.
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21 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
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22 | Section 20. The School Code is amended by changing
Section | ||||||
23 | 10-22.3f as follows:
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24 | (105 ILCS 5/10-22.3f)
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25 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
26 | protection and
benefits
for employees shall provide the | ||||||
27 | post-mastectomy care benefits required to be
covered by a | ||||||
28 | policy of accident and health insurance under Section 356t and | ||||||
29 | the
coverage required under Sections 356u, 356w, and 356x and | ||||||
30 | 356z.6 of
the
Illinois Insurance Code.
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31 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
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1 | Section 25. The Illinois Insurance Code is amended by | ||||||
2 | adding Section 356z.6
as
follows:
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3 | (215 ILCS 5/356z.6 new)
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4 | Sec. 356z.6. Bone mass measurement; osteoporosis. A group | ||||||
5 | or individual
policy of
accident and health insurance amended, | ||||||
6 | delivered, issued,
or renewed after the effective date of this | ||||||
7 | amendatory Act of the 93rd General
Assembly must
provide | ||||||
8 | coverage for
medically necessary bone mass measurement and for | ||||||
9 | the diagnosis and treatment
of osteoporosis on
the
same terms | ||||||
10 | and conditions that are generally
applicable
to coverage for | ||||||
11 | other
medical conditions.
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12 | Section 30. 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, 137, 140, 141.1,
141.2, | ||||||
18 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
19 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
20 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 367.2, 367.2-5, 367i, | ||||||
21 | 368a, 368b, 368c, 368d, 368e,
401, 401.1, 402, 403, 403A,
408, | ||||||
22 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||||||
23 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
24 | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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25 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
26 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
27 | Maintenance Organizations in
the following categories are | ||||||
28 | deemed to be "domestic companies":
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29 | (1) a corporation authorized under the
Dental Service | ||||||
30 | Plan Act or the Voluntary Health Services Plans Act;
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31 | (2) a corporation organized under the laws of this | ||||||
32 | State; or
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33 | (3) a corporation organized under the laws of another |
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1 | state, 30% or more
of the enrollees of which are residents | ||||||
2 | of this State, except a
corporation subject to | ||||||
3 | substantially the same requirements in its state of
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4 | organization as is a "domestic company" under Article VIII | ||||||
5 | 1/2 of the
Illinois Insurance Code.
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6 | (c) In considering the merger, consolidation, or other | ||||||
7 | acquisition of
control of a Health Maintenance Organization | ||||||
8 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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9 | (1) the Director shall give primary consideration to | ||||||
10 | the continuation of
benefits to enrollees and the financial | ||||||
11 | conditions of the acquired Health
Maintenance Organization | ||||||
12 | after the merger, consolidation, or other
acquisition of | ||||||
13 | control takes effect;
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14 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
15 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
16 | apply and (ii) the Director, in making
his determination | ||||||
17 | with respect to the merger, consolidation, or other
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18 | acquisition of control, need not take into account the | ||||||
19 | effect on
competition of the merger, consolidation, or | ||||||
20 | other acquisition of control;
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21 | (3) the Director shall have the power to require the | ||||||
22 | following
information:
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23 | (A) certification by an independent actuary of the | ||||||
24 | adequacy
of the reserves of the Health Maintenance | ||||||
25 | Organization sought to be acquired;
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26 | (B) pro forma financial statements reflecting the | ||||||
27 | combined balance
sheets of the acquiring company and | ||||||
28 | the Health Maintenance Organization sought
to be | ||||||
29 | acquired as of the end of the preceding year and as of | ||||||
30 | a date 90 days
prior to the acquisition, as well as pro | ||||||
31 | forma financial statements
reflecting projected | ||||||
32 | combined operation for a period of 2 years;
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33 | (C) a pro forma business plan detailing an | ||||||
34 | acquiring party's plans with
respect to the operation | ||||||
35 | of the Health Maintenance Organization sought to
be | ||||||
36 | acquired for a period of not less than 3 years; and
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1 | (D) such other information as the Director shall | ||||||
2 | require.
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3 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
4 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
5 | any health maintenance
organization of greater than 10% of its
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6 | enrollee population (including without limitation the health | ||||||
7 | maintenance
organization's right, title, and interest in and to | ||||||
8 | its health care
certificates).
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9 | (e) In considering any management contract or service | ||||||
10 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
11 | Code, the Director (i) shall, in
addition to the criteria | ||||||
12 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
13 | into account the effect of the management contract or
service | ||||||
14 | agreement on the continuation of benefits to enrollees and the
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15 | financial condition of the health maintenance organization to | ||||||
16 | be managed or
serviced, and (ii) need not take into account the | ||||||
17 | effect of the management
contract or service agreement on | ||||||
18 | competition.
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19 | (f) Except for small employer groups as defined in the | ||||||
20 | Small Employer
Rating, Renewability and Portability Health | ||||||
21 | Insurance Act and except for
medicare supplement policies as | ||||||
22 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
23 | Maintenance Organization may by contract agree with a
group or | ||||||
24 | other enrollment unit to effect refunds or charge additional | ||||||
25 | premiums
under the following terms and conditions:
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26 | (i) the amount of, and other terms and conditions with | ||||||
27 | respect to, the
refund or additional premium are set forth | ||||||
28 | in the group or enrollment unit
contract agreed in advance | ||||||
29 | of the period for which a refund is to be paid or
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30 | additional premium is to be charged (which period shall not | ||||||
31 | be less than one
year); and
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32 | (ii) the amount of the refund or additional premium | ||||||
33 | shall not exceed 20%
of the Health Maintenance | ||||||
34 | Organization's profitable or unprofitable experience
with | ||||||
35 | respect to the group or other enrollment unit for the | ||||||
36 | period (and, for
purposes of a refund or additional |
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1 | premium, the profitable or unprofitable
experience shall | ||||||
2 | be calculated taking into account a pro rata share of the
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3 | Health Maintenance Organization's administrative and | ||||||
4 | marketing expenses, but
shall not include any refund to be | ||||||
5 | made or additional premium to be paid
pursuant to this | ||||||
6 | subsection (f)). The Health Maintenance Organization and | ||||||
7 | the
group or enrollment unit may agree that the profitable | ||||||
8 | or unprofitable
experience may be calculated taking into | ||||||
9 | account the refund period and the
immediately preceding 2 | ||||||
10 | plan years.
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11 | The Health Maintenance Organization shall include a | ||||||
12 | statement in the
evidence of coverage issued to each enrollee | ||||||
13 | describing the possibility of a
refund or additional premium, | ||||||
14 | and upon request of any group or enrollment unit,
provide to | ||||||
15 | the group or enrollment unit a description of the method used | ||||||
16 | to
calculate (1) the Health Maintenance Organization's | ||||||
17 | profitable experience with
respect to the group or enrollment | ||||||
18 | unit and the resulting refund to the group
or enrollment unit | ||||||
19 | or (2) the Health Maintenance Organization's unprofitable
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20 | experience with respect to the group or enrollment unit and the | ||||||
21 | resulting
additional premium to be paid by the group or | ||||||
22 | enrollment unit.
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23 | In no event shall the Illinois Health Maintenance | ||||||
24 | Organization
Guaranty Association be liable to pay any | ||||||
25 | contractual obligation of an
insolvent organization to pay any | ||||||
26 | refund authorized under this Section.
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27 | (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, | ||||||
28 | eff. 1-1-04;
93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised | ||||||
29 | 9-25-03.)
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30 | Section 35. The Voluntary Health Services Plans Act is | ||||||
31 | amended by changing
Section 10 as follows:
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32 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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33 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
34 | services
plan corporations and all persons interested therein |
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1 | or dealing therewith
shall be subject to the provisions of | ||||||
2 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
3 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
4 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 367.2, 368a, 401, | ||||||
5 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
6 | and (15) of Section 367 of the Illinois
Insurance Code.
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7 | (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
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8 | 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; | ||||||
9 | 93-529, eff.
8-14-03; revised 9-25-03.)
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10 | Section 40. The Illinois Public Aid Code is amended by | ||||||
11 | changing
Section 5-16.8 as follows:
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12 | (305 ILCS 5/5-16.8)
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13 | Sec. 5-16.8. Required health benefits. The medical | ||||||
14 | assistance program
shall
provide the post-mastectomy care | ||||||
15 | benefits required to be covered by a policy of
accident and | ||||||
16 | health insurance under Section 356t and the coverage required
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17 | under Sections 356u, 356w, and 356x and 356z.6 of the Illinois
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18 | Insurance Code.
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19 | (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
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