HB0637 Engrossed LRB094 06857 LJB 36963 b

1     AN ACT concerning insurance.
 
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, 356z.4, and 356z.6, 356z.7, 356z.9, and 356z.10
14 of the Illinois Insurance Code. The program of health benefits
15 must comply with Section 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; 93-853, eff. 1-1-05.)
 
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, 356x, and 356z.6, 356z.7, 356z.9,
28 and 356z.10 of the Illinois Insurance Code. The requirement
29 that health benefits be covered as provided in this Section is
30 an exclusive power and function of the State and is a denial

 

 

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1 and limitation under Article VII, Section 6, subsection (h) of
2 the Illinois Constitution. A home rule county to which this
3 Section applies must comply with every provision of this
4 Section.
5 (Source: P.A. 93-853, eff. 1-1-05.)
 
6     Section 15. The Illinois Municipal Code is amended by
7 changing Section 10-4-2.3 as follows:
 
8     (65 ILCS 5/10-4-2.3)
9     Sec. 10-4-2.3. Required health benefits. If a
10 municipality, including a home rule municipality, is a
11 self-insurer for purposes of providing health insurance
12 coverage for its employees, the coverage shall include coverage
13 for the post-mastectomy care benefits required to be covered by
14 a policy of accident and health insurance under Section 356t
15 and the coverage required under Sections 356u, 356w, 356x, and
16 356z.6, 356z.7, 356z.9, and 356z.10 of the Illinois Insurance
17 Code. The requirement that health benefits be covered as
18 provided in this is an exclusive power and function of the
19 State and is a denial and limitation under Article VII, Section
20 6, subsection (h) of the Illinois Constitution. A home rule
21 municipality to which this Section applies must comply with
22 every provision of this Section.
23 (Source: P.A. 93-853, eff. 1-1-05.)
 
24     Section 20. The School Code is amended by changing Section
25 10-22.3f as follows:
 
26     (105 ILCS 5/10-22.3f)
27     Sec. 10-22.3f. Required health benefits. Insurance
28 protection and benefits for employees shall provide the
29 post-mastectomy care benefits required to be covered by a
30 policy of accident and health insurance under Section 356t and
31 the coverage required under Sections 356u, 356w, 356x, and
32 356z.6, 356z.7, 356z.9, and 356z.10 of the Illinois Insurance

 

 

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1 Code.
2 (Source: P.A. 93-853, eff. 1-1-05.)
 
3     Section 25. The Illinois Insurance Code is amended by
4 adding Sections 356z.7, 356z.9, and 356z.10 as follows:
 
5     (215 ILCS 5/356z.7 new)
6     Sec. 356z.7. Intravenous feeding. A group or individual
7 policy of accident and health insurance or managed care plan
8 amended, delivered, issued, or renewed after the effective date
9 of this amendatory Act of the 94th General Assembly must
10 provide coverage for intravenous feeding. The benefits under
11 this Section shall be at least as favorable as for other
12 coverages under the policy and may be subject to the same
13 dollar amount limits, deductibles, and co-insurance
14 requirements applicable generally to other coverages under the
15 policy.
 
16     (215 ILCS 5/356z.9 new)
17     Sec. 356z.9. Prescription nutritional supplements. A group
18 or individual policy of accident and health insurance or
19 managed care plan amended, delivered, issued, or renewed after
20 the effective date of this amendatory Act of the 94th General
21 Assembly that provides coverage for prescription drugs must
22 provide coverage for reimbursement for medically appropriate
23 prescription nutritional supplements when ordered by a
24 physician licensed to practice medicine in all its branches and
25 the insured suffers from a condition that prevents him or her
26 from taking sufficient oral nourishment to sustain life.
 
27     (215 ILCS 5/356z.10 new)
28     Sec. 356z.10. Pain medication coverage. A group or
29 individual policy of accident and health insurance or managed
30 care plan amended, delivered, issued, or renewed after the
31 effective date of this amendatory Act of the 94th General
32 Assembly that provides coverage for prescription drugs must

 

 

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1 provide coverage for any pain medication prescribed or ordered
2 by the insured's treating physician licensed to practice
3 medicine in all its branches.
 
4     Section 30. The Health Maintenance Organization Act is
5 amended by changing Section 5-3 as follows:
 
6     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
7     Sec. 5-3. Insurance Code provisions.
8     (a) Health Maintenance Organizations shall be subject to
9 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
10 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
11 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
12 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 356z.9, 356z.10,
13 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
14 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and
15 444.1, paragraph (c) of subsection (2) of Section 367, and
16 Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and
17 XXVI of the Illinois Insurance Code.
18     (b) For purposes of the Illinois Insurance Code, except for
19 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
20 Maintenance Organizations in the following categories are
21 deemed to be "domestic companies":
22         (1) a corporation authorized under the Dental Service
23     Plan Act or the Voluntary Health Services Plans Act;
24         (2) a corporation organized under the laws of this
25     State; or
26         (3) a corporation organized under the laws of another
27     state, 30% or more of the enrollees of which are residents
28     of this State, except a corporation subject to
29     substantially the same requirements in its state of
30     organization as is a "domestic company" under Article VIII
31     1/2 of the Illinois Insurance Code.
32     (c) In considering the merger, consolidation, or other
33 acquisition of control of a Health Maintenance Organization
34 pursuant to Article VIII 1/2 of the Illinois Insurance Code,

 

 

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1         (1) the Director shall give primary consideration to
2     the continuation of benefits to enrollees and the financial
3     conditions of the acquired Health Maintenance Organization
4     after the merger, consolidation, or other acquisition of
5     control takes effect;
6         (2)(i) the criteria specified in subsection (1)(b) of
7     Section 131.8 of the Illinois Insurance Code shall not
8     apply and (ii) the Director, in making his determination
9     with respect to the merger, consolidation, or other
10     acquisition of control, need not take into account the
11     effect on competition of the merger, consolidation, or
12     other acquisition of control;
13         (3) the Director shall have the power to require the
14     following information:
15             (A) certification by an independent actuary of the
16         adequacy of the reserves of the Health Maintenance
17         Organization sought to be acquired;
18             (B) pro forma financial statements reflecting the
19         combined balance sheets of the acquiring company and
20         the Health Maintenance Organization sought to be
21         acquired as of the end of the preceding year and as of
22         a date 90 days prior to the acquisition, as well as pro
23         forma financial statements reflecting projected
24         combined operation for a period of 2 years;
25             (C) a pro forma business plan detailing an
26         acquiring party's plans with respect to the operation
27         of the Health Maintenance Organization sought to be
28         acquired for a period of not less than 3 years; and
29             (D) such other information as the Director shall
30         require.
31     (d) The provisions of Article VIII 1/2 of the Illinois
32 Insurance Code and this Section 5-3 shall apply to the sale by
33 any health maintenance organization of greater than 10% of its
34 enrollee population (including without limitation the health
35 maintenance organization's right, title, and interest in and to
36 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, take
5 into account the effect of the management contract or service
6 agreement on the continuation of benefits to enrollees and the
7 financial condition of the health maintenance organization to
8 be managed or serviced, and (ii) need not take into account the
9 effect of the management contract or service agreement on
10 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 Health
15 Maintenance Organization may by contract agree with a group or
16 other enrollment unit to effect refunds or charge additional
17 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 not
23     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
27     respect to the group or other enrollment unit for the
28     period (and, for purposes of a refund or additional
29     premium, the profitable or unprofitable experience shall
30     be calculated taking into account a pro rata share of the
31     Health Maintenance Organization's administrative and
32     marketing expenses, but shall not include any refund to be
33     made or additional premium to be paid pursuant to this
34     subsection (f)). The Health Maintenance Organization and
35     the group or enrollment unit may agree that the profitable
36     or unprofitable experience may be calculated taking into

 

 

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1     account the refund period and the immediately preceding 2
2     plan years.
3     The Health Maintenance Organization shall include a
4 statement in the evidence of coverage issued to each enrollee
5 describing the possibility of a refund or additional premium,
6 and upon request of any group or enrollment unit, provide to
7 the group or enrollment unit a description of the method used
8 to calculate (1) the Health Maintenance Organization's
9 profitable experience with respect to the group or enrollment
10 unit and the resulting refund to the group or enrollment unit
11 or (2) the Health Maintenance Organization's unprofitable
12 experience with respect to the group or enrollment unit and the
13 resulting additional premium to be paid by the group or
14 enrollment unit.
15     In no event shall the Illinois Health Maintenance
16 Organization Guaranty Association be liable to pay any
17 contractual obligation of an insolvent organization to pay any
18 refund authorized under this Section.
19 (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261,
20 eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853,
21 eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)
 
22     Section 35. The Voluntary Health Services Plans Act is
23 amended by changing Section 10 as follows:
 
24     (215 ILCS 165/10)  (from Ch. 32, par. 604)
25     Sec. 10. Application of Insurance Code provisions. Health
26 services plan corporations and all persons interested therein
27 or dealing therewith shall be subject to the provisions of
28 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
29 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 356x,
30 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 356z.9,
31 356z.10, 364.01, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408,
32 408.2, and 412, and paragraphs (7) and (15) of Section 367 of
33 the Illinois Insurance Code.
34 (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;

 

 

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1 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04;
2 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 93-1000, eff.
3 1-1-05; revised 10-14-04.)
 
4     Section 90. The State Mandates Act is amended by adding
5 Section 8.29 as follows:
 
6     (30 ILCS 805/8.29 new)
7     Sec. 8.29. Exempt mandate. Notwithstanding Sections 6 and 8
8 of this Act, no reimbursement by the State is required for the
9 implementation of any mandate created by this amendatory Act of
10 the 94th General Assembly.