97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB3411

 

Introduced 2/7/2012, by Sen. Ira I. Silverstein

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.22 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003  from Ch. 73, par. 1504-3
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Illinois Insurance Code, Health Maintenance Organization Act, Limited Health Service Organization Act, and Voluntary Health Services Plans Act. Provides that a policy of accident and health insurance or managed care plan that provides coverage for prescription drugs shall permit each participant to fill any mail order covered prescription, at his or her option, at any mail order pharmacy or network participating non-mail order retail pharmacy if the network participating non-mail order retail pharmacy offers to accept a price that is comparable to that of the mail order pharmacy. Provides that any policy or plan that provides coverage for prescription drugs shall not impose a co-payment fee or other condition on any insured who elects to purchase drugs from a network participating non-mail order retail pharmacy that is not also imposed on insureds electing to purchase drugs from a designated mail order pharmacy. Provides that the provisions concerning prescription drugs shall not supersede the terms of a collective bargaining agreement or apply to a policy that is the result of a collective bargaining agreement between an employer and a recognized or certified employee organization.


LRB097 19909 RPM 65199 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB3411LRB097 19909 RPM 65199 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.17 and 356z.19, and 356z.22 of the
16Illinois Insurance Code. The program of health benefits must
17comply with Sections 155.22a, and 155.37, and 356z.19 of the
18Illinois Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
396-639, eff. 1-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11;
497-343, eff. 1-1-12; revised 10-14-11.)
 
5    Section 10. The Counties Code is amended by changing
6Section 5-1069.3 as follows:
 
7    (55 ILCS 5/5-1069.3)
8    Sec. 5-1069.3. Required health benefits. If a county,
9including a home rule county, is a self-insurer for purposes of
10providing health insurance coverage for its employees, the
11coverage shall include coverage for the post-mastectomy care
12benefits required to be covered by a policy of accident and
13health insurance under Section 356t and the coverage required
14under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
15356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
16356z.14, and 356z.15, and 356z.22 of the Illinois Insurance
17Code. The coverage shall comply with Sections Section 155.22a
18and 356z.19 of the Illinois Insurance Code. The requirement
19that health benefits be covered as provided in this Section is
20an exclusive power and function of the State and is a denial
21and limitation under Article VII, Section 6, subsection (h) of
22the Illinois Constitution. A home rule county to which this
23Section applies must comply with every provision of this
24Section.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
896-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
9revised 10-14-11.)
 
10    Section 15. The Illinois Municipal Code is amended by
11changing Section 10-4-2.3 as follows:
 
12    (65 ILCS 5/10-4-2.3)
13    Sec. 10-4-2.3. Required health benefits. If a
14municipality, including a home rule municipality, is a
15self-insurer for purposes of providing health insurance
16coverage for its employees, the coverage shall include coverage
17for the post-mastectomy care benefits required to be covered by
18a policy of accident and health insurance under Section 356t
19and the coverage required under Sections 356g, 356g.5,
20356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
21356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, and 356z.22 of
22the Illinois Insurance Code. The coverage shall comply with
23Sections Section 155.22a and 356z.19 of the Illinois Insurance
24Code. The requirement that health benefits be covered as

 

 

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1provided in this is an exclusive power and function of the
2State and is a denial and limitation under Article VII, Section
36, subsection (h) of the Illinois Constitution. A home rule
4municipality to which this Section applies must comply with
5every provision of this Section.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
1396-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
14revised 10-14-11.)
 
15    Section 20. The School Code is amended by changing Section
1610-22.3f as follows:
 
17    (105 ILCS 5/10-22.3f)
18    Sec. 10-22.3f. Required health benefits. Insurance
19protection and benefits for employees shall provide the
20post-mastectomy care benefits required to be covered by a
21policy of accident and health insurance under Section 356t and
22the coverage required under Sections 356g, 356g.5, 356g.5-1,
23356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
24356z.13, 356z.14, and 356z.15, and 356z.22 of the Illinois

 

 

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1Insurance Code. Insurance policies shall comply with Section
2356z.19 of the Illinois Insurance Code. The coverage shall
3comply with Section 155.22a of the Illinois Insurance Code.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09;
1196-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
12revised 9-28-11.)
 
13    Section 25. The Illinois Insurance Code is amended by
14adding Section 356z.22 as follows:
 
15    (215 ILCS 5/356z.22 new)
16    Sec. 356z.22. Prescription drugs. A group or individual
17policy of accident and health insurance or managed care plan
18amended, delivered, issued, or renewed after the effective date
19of this amendatory Act of the 97th General Assembly that
20provides coverage for prescription drugs shall permit each
21participant to fill any mail order covered prescription, at his
22or her option, at any mail order pharmacy or network
23participating non-mail order retail pharmacy if the network
24participating non-mail order retail pharmacy offers to accept a

 

 

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1price that is comparable to that of the mail order pharmacy.
2Any policy or plan that provides coverage for prescription
3drugs shall not impose a co-payment fee or other condition on
4any insured who elects to purchase drugs from a network
5participating non-mail order retail pharmacy that is not also
6imposed on insureds electing to purchase drugs from a
7designated mail order pharmacy. The provisions of this Section
8shall not supersede the terms of a collective bargaining
9agreement or apply to a policy that is the result of a
10collective bargaining agreement between an employer and a
11recognized or certified employee organization.
 
12    Section 30. The Health Maintenance Organization Act is
13amended 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
17the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
18141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
19154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 356g.5-1,
20356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6,
21356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
22356z.15, 356z.17, 356z.18, 356z.19, 356z.21 356z.19, 356z.22,
23364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
24370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,

 

 

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1444, and 444.1, paragraph (c) of subsection (2) of Section 367,
2and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
3and XXVI of the Illinois Insurance Code.
4    (b) For purposes of the Illinois Insurance Code, except for
5Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
6Maintenance Organizations in the following categories are
7deemed to be "domestic companies":
8        (1) a corporation authorized under the Dental Service
9    Plan Act or the Voluntary Health Services Plans Act;
10        (2) a corporation organized under the laws of this
11    State; or
12        (3) a corporation organized under the laws of another
13    state, 30% or more of the enrollees of which are residents
14    of this State, except a corporation subject to
15    substantially the same requirements in its state of
16    organization as is a "domestic company" under Article VIII
17    1/2 of the Illinois Insurance Code.
18    (c) In considering the merger, consolidation, or other
19acquisition of control of a Health Maintenance Organization
20pursuant to Article VIII 1/2 of the Illinois Insurance Code,
21        (1) the Director shall give primary consideration to
22    the continuation of benefits to enrollees and the financial
23    conditions of the acquired Health Maintenance Organization
24    after the merger, consolidation, or other acquisition of
25    control takes effect;
26        (2)(i) the criteria specified in subsection (1)(b) of

 

 

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1    Section 131.8 of the Illinois Insurance Code shall not
2    apply and (ii) the Director, in making his determination
3    with respect to the merger, consolidation, or other
4    acquisition of control, need not take into account the
5    effect on competition of the merger, consolidation, or
6    other acquisition of control;
7        (3) the Director shall have the power to require the
8    following information:
9            (A) certification by an independent actuary of the
10        adequacy of the reserves of the Health Maintenance
11        Organization sought to be acquired;
12            (B) pro forma financial statements reflecting the
13        combined balance sheets of the acquiring company and
14        the Health Maintenance Organization sought to be
15        acquired as of the end of the preceding year and as of
16        a date 90 days prior to the acquisition, as well as pro
17        forma financial statements reflecting projected
18        combined operation for a period of 2 years;
19            (C) a pro forma business plan detailing an
20        acquiring party's plans with respect to the operation
21        of the Health Maintenance Organization sought to be
22        acquired for a period of not less than 3 years; and
23            (D) such other information as the Director shall
24        require.
25    (d) The provisions of Article VIII 1/2 of the Illinois
26Insurance Code and this Section 5-3 shall apply to the sale by

 

 

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1any health maintenance organization of greater than 10% of its
2enrollee population (including without limitation the health
3maintenance organization's right, title, and interest in and to
4its health care certificates).
5    (e) In considering any management contract or service
6agreement subject to Section 141.1 of the Illinois Insurance
7Code, the Director (i) shall, in addition to the criteria
8specified in Section 141.2 of the Illinois Insurance Code, take
9into account the effect of the management contract or service
10agreement on the continuation of benefits to enrollees and the
11financial condition of the health maintenance organization to
12be managed or serviced, and (ii) need not take into account the
13effect of the management contract or service agreement on
14competition.
15    (f) Except for small employer groups as defined in the
16Small Employer Rating, Renewability and Portability Health
17Insurance Act and except for medicare supplement policies as
18defined in Section 363 of the Illinois Insurance Code, a Health
19Maintenance Organization may by contract agree with a group or
20other enrollment unit to effect refunds or charge additional
21premiums under the following terms and conditions:
22        (i) the amount of, and other terms and conditions with
23    respect to, the refund or additional premium are set forth
24    in the group or enrollment unit contract agreed in advance
25    of the period for which a refund is to be paid or
26    additional premium is to be charged (which period shall not

 

 

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1    be less than one year); and
2        (ii) the amount of the refund or additional premium
3    shall not exceed 20% of the Health Maintenance
4    Organization's profitable or unprofitable experience with
5    respect to the group or other enrollment unit for the
6    period (and, for purposes of a refund or additional
7    premium, the profitable or unprofitable experience shall
8    be calculated taking into account a pro rata share of the
9    Health Maintenance Organization's administrative and
10    marketing expenses, but shall not include any refund to be
11    made or additional premium to be paid pursuant to this
12    subsection (f)). The Health Maintenance Organization and
13    the group or enrollment unit may agree that the profitable
14    or unprofitable experience may be calculated taking into
15    account the refund period and the immediately preceding 2
16    plan years.
17    The Health Maintenance Organization shall include a
18statement in the evidence of coverage issued to each enrollee
19describing the possibility of a refund or additional premium,
20and upon request of any group or enrollment unit, provide to
21the group or enrollment unit a description of the method used
22to calculate (1) the Health Maintenance Organization's
23profitable experience with respect to the group or enrollment
24unit and the resulting refund to the group or enrollment unit
25or (2) the Health Maintenance Organization's unprofitable
26experience with respect to the group or enrollment unit and the

 

 

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1resulting additional premium to be paid by the group or
2enrollment unit.
3    In no event shall the Illinois Health Maintenance
4Organization Guaranty Association be liable to pay any
5contractual obligation of an insolvent organization to pay any
6refund authorized under this Section.
7    (g) Rulemaking authority to implement Public Act 95-1045,
8if any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
1496-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11;
1597-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12;
1697-592, eff. 1-1-12; revised 10-13-11.)
 
17    Section 35. The Limited Health Service Organization Act is
18amended by changing Section 4003 as follows:
 
19    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
20    Sec. 4003. Illinois Insurance Code provisions. Limited
21health service organizations shall be subject to the provisions
22of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
23143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
24154.7, 154.8, 155.04, 155.37, 355.2, 356v, 356z.10, 356z.21

 

 

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1356z.19, 356z.22, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2,
2409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII
31/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance
4Code. For purposes of the Illinois Insurance Code, except for
5Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
6health service organizations in the following categories are
7deemed to be domestic companies:
8        (1) a corporation under the laws of this State; or
9        (2) a corporation organized under the laws of another
10    state, 30% of more of the enrollees of which are residents
11    of this State, except a corporation subject to
12    substantially the same requirements in its state of
13    organization as is a domestic company under Article VIII
14    1/2 of the Illinois Insurance Code.
15(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; revised
1610-13-11.)
 
17    Section 40. The Voluntary Health Services Plans Act is
18amended by changing Section 10 as follows:
 
19    (215 ILCS 165/10)  (from Ch. 32, par. 604)
20    Sec. 10. Application of Insurance Code provisions. Health
21services plan corporations and all persons interested therein
22or dealing therewith shall be subject to the provisions of
23Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
24143, 143c, 149, 155.22a, 155.37, 354, 355.2, 356g, 356g.5,

 

 

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1356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y, 356z.1,
2356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
3356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, 356z.19,
4356z.21 356z.19, 356z.22, 364.01, 367.2, 368a, 401, 401.1, 402,
5403, 403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
6Section 367 of the Illinois Insurance Code.
7    Rulemaking authority to implement Public Act 95-1045, if
8any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10;
1496-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
1597-486, eff. 1-1-12; 97-592, eff. 1-1-12; revised 10-13-11.)