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093_HB3595
LRB093 09876 JLS 10124 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
5 adding Section 356z.4 as follows:
6 (215 ILCS 5/356z.4 new)
7 Sec. 356z.4. Immunosuppresive agents. A group or
8 individual policy of accident and health insurance amended,
9 delivered, issued, or renewed after the effective date of
10 this amendatory Act of the 93rd General Assembly that
11 provides coverage for organ transplants must provide coverage
12 for immunosuppresive agents (anti-rejection medications). If
13 the policy provides coverage for prescription drugs through
14 the use of a drug formulary, the generic immunosuppresive
15 agents must be included with the drug formulary. If the
16 immunosuppresive agent is non-generic it must be included in
17 the drug formulary as the least expensive co-payment level
18 higher than the co-payment required for generic drugs.
19 Section 10. The Comprehensive Health Insurance Plan Act
20 is 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
26 medical expense coverage offered by the Plan shall pay an
27 eligible person's covered expenses, subject to limit on the
28 deductible and coinsurance payments authorized under
29 paragraph (4) of subsection d of this Section, up to a
30 lifetime benefit limit of $1,000,000 per covered individual.
-2- LRB093 09876 JLS 10124 b
1 The maximum limit under this subsection shall not be altered
2 by the Board, and no actuarial equivalent benefit may be
3 substituted by the Board. Any person who otherwise would
4 qualify for coverage under the Plan, but is excluded because
5 he or she is eligible for Medicare, shall be eligible for any
6 separate Medicare supplement policy or policies which the
7 Board may offer.
8 b. Outline of benefits. Covered expenses shall be
9 limited to the usual and customary charge, including
10 negotiated fees, in the locality for the following services
11 and articles when prescribed by a physician and determined by
12 the Plan to be medically necessary for the following areas of
13 services, subject to such separate deductibles, co-payments,
14 exclusions, and other limitations on benefits as the Board
15 shall establish and approve, and the other provisions of this
16 Section:
17 (1) Hospital services, except that any services
18 provided by a hospital that is located more than 75 miles
19 outside the State of Illinois shall be covered only for a
20 maximum of 45 days in any calendar year. With respect to
21 covered expenses incurred during any calendar year ending
22 on or after December 31, 1999, inpatient hospitalization
23 of an eligible person for the treatment of mental illness
24 at a hospital located within the State of Illinois shall
25 be subject to the same terms and conditions as for any
26 other illness.
27 (2) Professional services for the diagnosis or
28 treatment of injuries, illnesses or conditions, other
29 than dental and mental and nervous disorders as described
30 in paragraph (17), which are rendered by a physician, or
31 by other licensed professionals at the physician's
32 direction. This includes reconstruction of the breast on
33 which a mastectomy was performed; surgery and
34 reconstruction of the other breast to produce a
-3- LRB093 09876 JLS 10124 b
1 symmetrical appearance; and prostheses and treatment of
2 physical complications at all stages of the mastectomy,
3 including lymphedemas.
4 (2.5) Professional services provided by a physician
5 to children under the age of 16 years for physical
6 examinations and age appropriate immunizations ordered by
7 a physician licensed to practice medicine in all its
8 branches.
9 (3) (Blank).
10 (4) Outpatient prescription drugs that by law
11 require a prescription written by a physician licensed to
12 practice medicine in all its branches subject to such
13 separate deductible, copayment, and other limitations or
14 restrictions as the Board shall approve, including the
15 use of a prescription drug card or any other program, or
16 both.
17 (5) Skilled nursing services of a licensed skilled
18 nursing facility for not more than 120 days during a
19 policy year.
20 (6) Services of a home health agency in accord with
21 a home health care plan, up to a maximum of 270 visits
22 per year.
23 (7) Services of a licensed hospice for not more
24 than 180 days during a policy year.
25 (8) Use of radium or other radioactive materials.
26 (9) Oxygen.
27 (10) Anesthetics.
28 (11) Orthoses and prostheses other than dental.
29 (12) Rental or purchase in accordance with Board
30 policies or procedures of durable medical equipment,
31 other than eyeglasses or hearing aids, for which there is
32 no personal use in the absence of the condition for which
33 it is prescribed.
34 (13) Diagnostic x-rays and laboratory tests.
-4- LRB093 09876 JLS 10124 b
1 (14) Oral surgery (i) for excision of partially or
2 completely unerupted impacted teeth when not performed in
3 connection with the routine extraction or repair of
4 teeth; (ii) for excision of tumors or cysts of the jaws,
5 cheeks, lips, tongue, and roof and floor of the mouth;
6 (iii) required for correction of cleft lip and palate and
7 other craniofacial and maxillofacial birth defects; or
8 (iv) for treatment of injuries to natural teeth or a
9 fractured jaw due to an accident.
10 (15) Physical, speech, and functional occupational
11 therapy as medically necessary and provided by
12 appropriate licensed professionals.
13 (16) Emergency and other medically necessary
14 transportation provided by a licensed ambulance service
15 to the nearest health care facility qualified to treat a
16 covered illness, injury, or condition, subject to the
17 provisions of the Emergency Medical Systems (EMS) Act.
18 (17) Outpatient services for diagnosis and
19 treatment of mental and nervous disorders provided that a
20 covered person shall be required to make a copayment not
21 to exceed 50% and that the Plan's payment shall not
22 exceed such amounts as are established by the Board.
23 (18) Human organ or tissue transplants specified by
24 the Board that are performed at a hospital designated by
25 the Board as a participating transplant center for that
26 specific organ or tissue transplant, including
27 immunosuppresive agents as required under Section 356z.4
28 of the Illinois Insurance Code.
29 (19) Naprapathic services, as appropriate, provided
30 by a licensed naprapathic practitioner.
31 c. Exclusions. Covered expenses of the Plan shall not
32 include the following:
33 (1) Any charge for treatment for cosmetic purposes
34 other than for reconstructive surgery when the service is
-5- LRB093 09876 JLS 10124 b
1 incidental to or follows surgery resulting from injury,
2 sickness or other diseases of the involved part or
3 surgery for the repair or treatment of a congenital
4 bodily defect to restore normal bodily functions.
5 (2) Any charge for care that is primarily for rest,
6 custodial, educational, or domiciliary purposes.
7 (3) Any charge for services in a private room to
8 the extent it is in excess of the institution's charge
9 for its most common semiprivate room, unless a private
10 room is prescribed as medically necessary by a physician.
11 (4) That part of any charge for room and board or
12 for services rendered or articles prescribed by a
13 physician, dentist, or other health care personnel that
14 exceeds the reasonable and customary charge in the
15 locality or for any services or supplies not medically
16 necessary for the diagnosed injury or illness.
17 (5) Any charge for services or articles the
18 provision of which is not within the scope of licensure
19 of the institution or individual providing the services
20 or articles.
21 (6) Any expense incurred prior to the effective
22 date of coverage by the Plan for the person on whose
23 behalf the expense is incurred.
24 (7) Dental care, dental surgery, dental treatment,
25 any other dental procedure involving the teeth or
26 periodontium, or any dental appliances, including crowns,
27 bridges, implants, or partial or complete dentures,
28 except as specifically provided in paragraph (14) of
29 subsection b of this Section.
30 (8) Eyeglasses, contact lenses, hearing aids or
31 their fitting.
32 (9) Illness or injury due to acts of war.
33 (10) Services of blood donors and any fee for
34 failure to replace the first 3 pints of blood provided to
-6- LRB093 09876 JLS 10124 b
1 a covered person each policy year.
2 (11) Personal supplies or services provided by a
3 hospital or nursing home, or any other nonmedical or
4 nonprescribed supply or service.
5 (12) Routine maternity charges for a pregnancy,
6 except where added as optional coverage with payment of
7 an additional premium for pregnancy resulting from
8 conception occurring after the effective date of the
9 optional coverage.
10 (13) (Blank).
11 (14) Any expense or charge for services, drugs, or
12 supplies that are: (i) not provided in accord with
13 generally accepted standards of current medical practice;
14 (ii) for procedures, treatments, equipment, transplants,
15 or implants, any of which are investigational,
16 experimental, or for research purposes; (iii)
17 investigative and not proven safe and effective; or (iv)
18 for, or resulting from, a gender transformation
19 operation.
20 (15) Any expense or charge for routine physical
21 examinations or tests except as provided in item (2.5) of
22 subsection b of this Section.
23 (16) Any expense for which a charge is not made in
24 the absence of insurance or for which there is no legal
25 obligation on the part of the patient to pay.
26 (17) Any expense incurred for benefits provided
27 under the laws of the United States and this State,
28 including Medicare, Medicaid, and other medical
29 assistance, maternal and child health services and any
30 other program that is administered or funded by the
31 Department of Human Services, Department of Public Aid,
32 or Department of Public Health, military
33 service-connected disability payments, medical services
34 provided for members of the armed forces and their
-7- LRB093 09876 JLS 10124 b
1 dependents or employees of the armed forces of the United
2 States, and medical services financed on behalf of all
3 citizens by the United States.
4 (18) Any expense or charge for in vitro
5 fertilization, artificial insemination, or any other
6 artificial means used to cause pregnancy.
7 (19) Any expense or charge for oral contraceptives
8 used for birth control or any other temporary birth
9 control measures.
10 (20) Any expense or charge for sterilization or
11 sterilization reversals.
12 (21) Any expense or charge for weight loss
13 programs, exercise equipment, or treatment of obesity,
14 except when certified by a physician as morbid obesity
15 (at least 2 times normal body weight).
16 (22) Any expense or charge for acupuncture
17 treatment unless used as an anesthetic agent for a
18 covered surgery.
19 (23) Any expense or charge for or related to organ
20 or tissue transplants other than those performed at a
21 hospital with a Board approved organ transplant program
22 that has been designated by the Board as a preferred or
23 exclusive provider organization for that specific organ
24 or tissue transplant.
25 (24) Any expense or charge for procedures,
26 treatments, equipment, or services that are provided in
27 special settings for research purposes or in a controlled
28 environment, are being studied for safety, efficiency,
29 and effectiveness, and are awaiting endorsement by the
30 appropriate national medical speciality college for
31 general use within the medical community.
32 d. Deductibles and coinsurance.
33 The Plan coverage defined in Section 6 shall provide for
34 a choice of deductibles per individual as authorized by the
-8- LRB093 09876 JLS 10124 b
1 Board. If 2 individual members of the same family household,
2 who are both covered persons under the Plan, satisfy the same
3 applicable deductibles, no other member of that family who is
4 also a covered person under the Plan shall be required to
5 meet any deductibles for the balance of that calendar year.
6 The deductibles must be applied first to the authorized
7 amount of covered expenses incurred by the covered person. A
8 mandatory coinsurance requirement shall be imposed at the
9 rate authorized by the Board in excess of the mandatory
10 deductible, the coinsurance in the aggregate not to exceed
11 such amounts as are authorized by the Board per annum. At
12 its discretion the Board may, however, offer catastrophic
13 coverages or other policies that provide for larger
14 deductibles with or without coinsurance requirements. The
15 deductibles and coinsurance factors may be adjusted annually
16 according to the Medical Component of the Consumer Price
17 Index.
18 e. Scope of coverage.
19 (1) In approving any of the benefit plans to be
20 offered by the Plan, the Board shall establish such
21 benefit levels, deductibles, coinsurance factors,
22 exclusions, and limitations as it may deem appropriate
23 and that it believes to be generally reflective of and
24 commensurate with health insurance coverage that is
25 provided in the individual market in this State.
26 (2) The benefit plans approved by the Board may
27 also provide for and employ various cost containment
28 measures and other requirements including, but not
29 limited to, preadmission certification, prior approval,
30 second surgical opinions, concurrent utilization review
31 programs, individual case management, preferred provider
32 organizations, health maintenance organizations, and
33 other cost effective arrangements for paying for covered
34 expenses.
-9- LRB093 09876 JLS 10124 b
1 f. Preexisting conditions.
2 (1) Except for federally eligible individuals
3 qualifying for Plan coverage under Section 15 of this Act
4 or eligible persons who qualify for the waiver authorized
5 in paragraph (3) of this subsection, plan coverage shall
6 exclude charges or expenses incurred during the first 6
7 months following the effective date of coverage as to any
8 condition for which medical advice, care or treatment was
9 recommended or received during the 6 month period
10 immediately preceding the effective date of coverage.
11 (2) (Blank).
12 (3) Waiver: The preexisting condition exclusions as
13 set forth in paragraph (1) of this subsection shall be
14 waived to the extent to which the eligible person (a) has
15 satisfied similar exclusions under any prior individual
16 health insurance policy that was involuntarily terminated
17 because of the insolvency of the issuer of the policy and
18 (b) has applied for Plan coverage within 90 days
19 following the involuntary termination of that individual
20 health insurance coverage.
21 g. Other sources primary; nonduplication of benefits.
22 (1) The Plan shall be the last payor of benefits
23 whenever any other benefit or source of third party
24 payment is available. Subject to the provisions of
25 subsection e of Section 7, benefits otherwise payable
26 under Plan coverage shall be reduced by all amounts paid
27 or payable by Medicare or any other government program or
28 through any health insurance coverage or group health
29 plan, whether by insurance, reimbursement, or otherwise,
30 or through any third party liability, settlement,
31 judgment, or award, regardless of the date of the
32 settlement, judgment, or award, whether the settlement,
33 judgment, or award is in the form of a contract,
34 agreement, or trust on behalf of a minor or otherwise and
-10- LRB093 09876 JLS 10124 b
1 whether the settlement, judgment, or award is payable to
2 the covered person, his or her dependent, estate,
3 personal representative, or guardian in a lump sum or
4 over time, and by all hospital or medical expense
5 benefits paid or payable under any worker's compensation
6 coverage, automobile medical payment, or liability
7 insurance, whether provided on the basis of fault or
8 nonfault, and by any hospital or medical benefits paid or
9 payable under or provided pursuant to any State or
10 federal law or program.
11 (2) The Plan shall have a cause of action against
12 any covered person or any other person or entity for the
13 recovery of any amount paid to the extent the amount was
14 for treatment, services, or supplies not covered in this
15 Section or in excess of benefits as set forth in this
16 Section.
17 (3) Whenever benefits are due from the Plan because
18 of sickness or an injury to a covered person resulting
19 from a third party's wrongful act or negligence and the
20 covered person has recovered or may recover damages from
21 a third party or its insurer, the Plan shall have the
22 right to reduce benefits or to refuse to pay benefits
23 that otherwise may be payable by the amount of damages
24 that the covered person has recovered or may recover
25 regardless of the date of the sickness or injury or the
26 date of any settlement, judgment, or award resulting from
27 that sickness or injury.
28 During the pendency of any action or claim that is
29 brought by or on behalf of a covered person against a
30 third party or its insurer, any benefits that would
31 otherwise be payable except for the provisions of this
32 paragraph (3) shall be paid if payment by or for the
33 third party has not yet been made and the covered person
34 or, if incapable, that person's legal representative
-11- LRB093 09876 JLS 10124 b
1 agrees in writing to pay back promptly the benefits paid
2 as a result of the sickness or injury to the extent of
3 any future payments made by or for the third party for
4 the sickness or injury. This agreement is to apply
5 whether or not liability for the payments is established
6 or admitted by the third party or whether those payments
7 are itemized.
8 Any amounts due the plan to repay benefits may be
9 deducted from other benefits payable by the Plan after
10 payments by or for the third party are made.
11 (4) Benefits due from the Plan may be reduced or
12 refused as an offset against any amount otherwise
13 recoverable under this Section.
14 h. Right of subrogation; recoveries.
15 (1) Whenever the Plan has paid benefits because of
16 sickness or an injury to any covered person resulting
17 from a third party's wrongful act or negligence, or for
18 which an insurer is liable in accordance with the
19 provisions of any policy of insurance, and the covered
20 person has recovered or may recover damages from a third
21 party that is liable for the damages, the Plan shall have
22 the right to recover the benefits it paid from any
23 amounts that the covered person has received or may
24 receive regardless of the date of the sickness or injury
25 or the date of any settlement, judgment, or award
26 resulting from that sickness or injury. The Plan shall
27 be subrogated to any right of recovery the covered person
28 may have under the terms of any private or public health
29 care coverage or liability coverage, including coverage
30 under the Workers' Compensation Act or the Workers'
31 Occupational Diseases Act, without the necessity of
32 assignment of claim or other authorization to secure the
33 right of recovery. To enforce its subrogation right, the
34 Plan may (i) intervene or join in an action or proceeding
-12- LRB093 09876 JLS 10124 b
1 brought by the covered person or his personal
2 representative, including his guardian, conservator,
3 estate, dependents, or survivors, against any third party
4 or the third party's insurer that may be liable or (ii)
5 institute and prosecute legal proceedings against any
6 third party or the third party's insurer that may be
7 liable for the sickness or injury in an appropriate court
8 either in the name of the Plan or in the name of the
9 covered person or his personal representative, including
10 his guardian, conservator, estate, dependents, or
11 survivors.
12 (2) If any action or claim is brought by or on
13 behalf of a covered person against a third party or the
14 third party's insurer, the covered person or his personal
15 representative, including his guardian, conservator,
16 estate, dependents, or survivors, shall notify the Plan
17 by personal service or registered mail of the action or
18 claim and of the name of the court in which the action or
19 claim is brought, filing proof thereof in the action or
20 claim. The Plan may, at any time thereafter, join in the
21 action or claim upon its motion so that all orders of
22 court after hearing and judgment shall be made for its
23 protection. No release or settlement of a claim for
24 damages and no satisfaction of judgment in the action
25 shall be valid without the written consent of the Plan to
26 the extent of its interest in the settlement or judgment
27 and of the covered person or his personal representative.
28 (3) In the event that the covered person or his
29 personal representative fails to institute a proceeding
30 against any appropriate third party before the fifth
31 month before the action would be barred, the Plan may, in
32 its own name or in the name of the covered person or
33 personal representative, commence a proceeding against
34 any appropriate third party for the recovery of damages
-13- LRB093 09876 JLS 10124 b
1 on account of any sickness, injury, or death to the
2 covered person. The covered person shall cooperate in
3 doing what is reasonably necessary to assist the Plan in
4 any recovery and shall not take any action that would
5 prejudice the Plan's right to recovery. The Plan shall
6 pay to the covered person or his personal representative
7 all sums collected from any third party by judgment or
8 otherwise in excess of amounts paid in benefits under the
9 Plan and amounts paid or to be paid as costs, attorneys
10 fees, and reasonable expenses incurred by the Plan in
11 making the collection or enforcing the judgment.
12 (4) In the event that a covered person or his
13 personal representative, including his guardian,
14 conservator, estate, dependents, or survivors, recovers
15 damages from a third party for sickness or injury caused
16 to the covered person, the covered person or the personal
17 representative shall pay to the Plan from the damages
18 recovered the amount of benefits paid or to be paid on
19 behalf of the covered person.
20 (5) When the action or claim is brought by the
21 covered person alone and the covered person incurs a
22 personal liability to pay attorney's fees and costs of
23 litigation, the Plan's claim for reimbursement of the
24 benefits provided to the covered person shall be the full
25 amount of benefits paid to or on behalf of the covered
26 person under this Act less a pro rata share that
27 represents the Plan's reasonable share of attorney's fees
28 paid by the covered person and that portion of the cost
29 of litigation expenses determined by multiplying by the
30 ratio of the full amount of the expenditures to the full
31 amount of the judgement, award, or settlement.
32 (6) In the event of judgment or award in a suit or
33 claim against a third party or insurer, the court shall
34 first order paid from any judgement or award the
-14- LRB093 09876 JLS 10124 b
1 reasonable litigation expenses incurred in preparation
2 and prosecution of the action or claim, together with
3 reasonable attorney's fees. After payment of those
4 expenses and attorney's fees, the court shall apply out
5 of the balance of the judgment or award an amount
6 sufficient to reimburse the Plan the full amount of
7 benefits paid on behalf of the covered person under this
8 Act, provided the court may reduce and apportion the
9 Plan's portion of the judgement proportionate to the
10 recovery of the covered person. The burden of producing
11 evidence sufficient to support the exercise by the court
12 of its discretion to reduce the amount of a proven charge
13 sought to be enforced against the recovery shall rest
14 with the party seeking the reduction. The court may
15 consider the nature and extent of the injury, economic
16 and non-economic loss, settlement offers, comparative
17 negligence as it applies to the case at hand, hospital
18 costs, physician costs, and all other appropriate costs.
19 The Plan shall pay its pro rata share of the attorney
20 fees based on the Plan's recovery as it compares to the
21 total judgment. Any reimbursement rights of the Plan
22 shall take priority over all other liens and charges
23 existing under the laws of this State with the exception
24 of any attorney liens filed under the Attorneys Lien Act.
25 (7) The Plan may compromise or settle and release
26 any claim for benefits provided under this Act or waive
27 any claims for benefits, in whole or in part, for the
28 convenience of the Plan or if the Plan determines that
29 collection would result in undue hardship upon the
30 covered person.
31 (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00;
32 92-2, eff. 5-1-01; 92-630, eff. 7-11-02.)
33 Section 15. The Health Maintenance Organization Act is
-15- LRB093 09876 JLS 10124 b
1 amended by changing Section 5-3 as follows:
2 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
3 Sec. 5-3. Insurance Code provisions.
4 (a) Health Maintenance Organizations shall be subject to
5 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
6 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
7 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
8 356y, 356z.2, 356z.4, 367i, 368a, 401, 401.1, 402, 403, 403A,
9 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
10 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
11 XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
12 Insurance Code.
13 (b) For purposes of the Illinois Insurance Code, except
14 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
15 Health Maintenance Organizations in the following categories
16 are deemed to be "domestic companies":
17 (1) a corporation authorized under the Dental
18 Service Plan Act or the Voluntary Health Services Plans
19 Act;
20 (2) a corporation organized under the laws of this
21 State; or
22 (3) a corporation organized under the laws of
23 another state, 30% or more of the enrollees of which are
24 residents of this State, except a corporation subject to
25 substantially the same requirements in its state of
26 organization as is a "domestic company" under Article
27 VIII 1/2 of the Illinois Insurance Code.
28 (c) In considering the merger, consolidation, or other
29 acquisition of control of a Health Maintenance Organization
30 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
31 (1) the Director shall give primary consideration
32 to the continuation of benefits to enrollees and the
33 financial conditions of the acquired Health Maintenance
-16- LRB093 09876 JLS 10124 b
1 Organization after the merger, consolidation, or other
2 acquisition of control takes effect;
3 (2)(i) the criteria specified in subsection (1)(b)
4 of Section 131.8 of the Illinois Insurance Code shall not
5 apply and (ii) the Director, in making his determination
6 with respect to the merger, consolidation, or other
7 acquisition of control, need not take into account the
8 effect on competition of the merger, consolidation, or
9 other acquisition of control;
10 (3) the Director shall have the power to require
11 the following information:
12 (A) certification by an independent actuary of
13 the adequacy of the reserves of the Health
14 Maintenance Organization sought to be acquired;
15 (B) pro forma financial statements reflecting
16 the combined balance sheets of the acquiring company
17 and the Health Maintenance Organization sought to be
18 acquired as of the end of the preceding year and as
19 of a date 90 days prior to the acquisition, as well
20 as pro forma financial statements reflecting
21 projected combined operation for a period of 2
22 years;
23 (C) a pro forma business plan detailing an
24 acquiring party's plans with respect to the
25 operation of the Health Maintenance Organization
26 sought to be acquired for a period of not less than
27 3 years; and
28 (D) such other information as the Director
29 shall require.
30 (d) The provisions of Article VIII 1/2 of the Illinois
31 Insurance Code and this Section 5-3 shall apply to the sale
32 by any health maintenance organization of greater than 10% of
33 its enrollee population (including without limitation the
34 health maintenance organization's right, title, and interest
-17- LRB093 09876 JLS 10124 b
1 in and to its health care certificates).
2 (e) In considering any management contract or service
3 agreement subject to Section 141.1 of the Illinois Insurance
4 Code, the Director (i) shall, in addition to the criteria
5 specified in Section 141.2 of the Illinois Insurance Code,
6 take into account the effect of the management contract or
7 service agreement on the continuation of benefits to
8 enrollees and the financial condition of the health
9 maintenance organization to be managed or serviced, and (ii)
10 need not take into account the effect of the management
11 contract or service agreement on competition.
12 (f) Except for small employer groups as defined in the
13 Small Employer Rating, Renewability and Portability Health
14 Insurance Act and except for medicare supplement policies as
15 defined in Section 363 of the Illinois Insurance Code, a
16 Health Maintenance Organization may by contract agree with a
17 group or other enrollment unit to effect refunds or charge
18 additional premiums under the following terms and conditions:
19 (i) the amount of, and other terms and conditions
20 with respect to, the refund or additional premium are set
21 forth in the group or enrollment unit contract agreed in
22 advance of the period for which a refund is to be paid or
23 additional premium is to be charged (which period shall
24 not be less than one year); and
25 (ii) the amount of the refund or additional premium
26 shall not exceed 20% of the Health Maintenance
27 Organization's profitable or unprofitable experience with
28 respect to the group or other enrollment unit for the
29 period (and, for purposes of a refund or additional
30 premium, the profitable or unprofitable experience shall
31 be calculated taking into account a pro rata share of the
32 Health Maintenance Organization's administrative and
33 marketing expenses, but shall not include any refund to
34 be made or additional premium to be paid pursuant to this
-18- LRB093 09876 JLS 10124 b
1 subsection (f)). The Health Maintenance Organization and
2 the group or enrollment unit may agree that the
3 profitable or unprofitable experience may be calculated
4 taking into account the refund period and the immediately
5 preceding 2 plan years.
6 The Health Maintenance Organization shall include a
7 statement in the evidence of coverage issued to each enrollee
8 describing the possibility of a refund or additional premium,
9 and upon request of any group or enrollment unit, provide to
10 the group or enrollment unit a description of the method used
11 to calculate (1) the Health Maintenance Organization's
12 profitable experience with respect to the group or enrollment
13 unit and the resulting refund to the group or enrollment unit
14 or (2) the Health Maintenance Organization's unprofitable
15 experience with respect to the group or enrollment unit and
16 the resulting additional premium to be paid by the group or
17 enrollment unit.
18 In no event shall the Illinois Health Maintenance
19 Organization Guaranty Association be liable to pay any
20 contractual obligation of an insolvent organization to pay
21 any refund authorized under this Section.
22 (Source: P.A. 91-357, eff. 7-29-99; 91-406, eff. 1-1-00;
23 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; 91-788, eff.
24 6-9-00; 92-764, eff. 1-1-03.)
25 Section 20. The Voluntary Health Services Plans Act is
26 amended by changing Section 10 as follows:
27 (215 ILCS 165/10) (from Ch. 32, par. 604)
28 Sec. 10. Application of Insurance Code provisions.
29 Health services plan corporations and all persons interested
30 therein or dealing therewith shall be subject to the
31 provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
32 140, 143, 143c, 149, 155.37, 354, 355.2, 356r, 356t, 356u,
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1 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 367.2, 368a,
2 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
3 paragraphs (7) and (15) of Section 367 of the Illinois
4 Insurance Code.
5 (Source: P.A. 91-406, eff. 1-1-00; 91-549, eff. 8-14-99;
6 91-605, eff. 12-14-99; 91-788, eff. 6-9-00; 92-130, eff.
7 7-20-01; 92-440, eff. 8-17-01; 92-651, eff. 7-11-02; 92-764,
8 eff. 1-1-03.)
9 Section 25. The Senior Citizens and Disabled Persons
10 Property Tax Relief and Pharmaceutical Assistance Act is
11 amended by changing Section 3.15 as follows:
12 (320 ILCS 25/3.15) (from Ch. 67 1/2, par. 403.15)
13 Sec. 3.15. "Covered prescription drug" means (1) any
14 cardiovascular agent or drug; (2) any insulin or other
15 prescription drug used in the treatment of diabetes,
16 including syringe and needles used to administer the insulin;
17 (3) any prescription drug used in the treatment of arthritis,
18 (4) beginning on January 1, 2001, any prescription drug used
19 in the treatment of cancer, (5) beginning on January 1, 2001,
20 any prescription drug used in the treatment of Alzheimer's
21 disease, (6) beginning on January 1, 2001, any prescription
22 drug used in the treatment of Parkinson's disease, (7)
23 beginning on January 1, 2001, any prescription drug used in
24 the treatment of glaucoma, (8) beginning on January 1, 2001,
25 any prescription drug used in the treatment of lung disease
26 and smoking related illnesses, and (9) beginning on July 1,
27 2001, any prescription drug used in the treatment of
28 osteoporosis, and (10) beginning January 1, 2004,
29 immunosuppresive agents (anti-rejection medication) used in
30 connection with organ transplants. The specific agents or
31 products to be included under such categories shall be listed
32 in a handbook to be prepared and distributed by the
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1 Department. The general types of covered prescription drugs
2 shall be indicated by rule.
3 (Source: P.A. 91-699, eff. 1-1-01; 92-10, eff. 6-11-01;
4 92-790, eff. 8-6-02.)
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