SB2744 Enrolled LRB093 20224 SAS 45982 b

1     AN ACT concerning insurance coverage.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
 
6     (5 ILCS 375/6.11)
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.
16 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03;
17 93-102, eff. 1-1-04.)
 
18     Section 10. The Counties Code is amended by changing
19 Section 5-1069.3 as follows:
 
20     (55 ILCS 5/5-1069.3)
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
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
2 rule county to which this Section applies must comply with
3 every provision of this Section.
4 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
 
5     Section 15. The Illinois Municipal Code is amended by
6 changing Section 10-4-2.3 as follows:
 
7     (65 ILCS 5/10-4-2.3)
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.
21 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
 
22     Section 20. The School Code is amended by changing Section
23 10-22.3f as follows:
 
24     (105 ILCS 5/10-22.3f)
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.
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:
 
3     (215 ILCS 5/356z.6 new)
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.
 
12     Section 30. The Health Maintenance Organization Act is
13 amended by changing Section 5-3 as follows:
 
14     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
15     Sec. 5-3. Insurance Code provisions.
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.
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":
29         (1) a corporation authorized under the Dental Service
30     Plan Act or the Voluntary Health Services Plans Act;
31         (2) a corporation organized under the laws of this
32     State; or
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
4     organization as is a "domestic company" under Article VIII
5     1/2 of the Illinois Insurance Code.
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,
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;
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
18     acquisition of control, need not take into account the
19     effect on competition of the merger, consolidation, or
20     other acquisition of control;
21         (3) the Director shall have the power to require the
22     following information:
23             (A) certification by an independent actuary of the
24         adequacy of the reserves of the Health Maintenance
25         Organization sought to be acquired;
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;
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.
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
6 enrollee population (including without limitation the health
7 maintenance organization's right, title, and interest in and to
8 its health care certificates).
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
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.
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:
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
30     additional premium is to be charged (which period shall not
31     be less than one year); and
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
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.
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
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.
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.
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.)
 
30     Section 35. The Voluntary Health Services Plans Act is
31 amended by changing Section 10 as follows:
 
32     (215 ILCS 165/10)  (from Ch. 32, par. 604)
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.
7 (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
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.)
 
10     Section 40. The Illinois Public Aid Code is amended by
11 changing Section 5-16.8 as follows:
 
12     (305 ILCS 5/5-16.8)
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
17 under Sections 356u, 356w, and 356x and 356z.6 of the Illinois
18 Insurance Code.
19 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)