093_SB1513

 
                                     LRB093 08144 EFG 08349 b

 1        AN ACT in relation to school employee health insurance.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 1. Short title.  This Act may  be  cited  as  the
 5    School Employee Health Insurance Act.

 6        Section 5. Findings.  The General Assembly finds that:
 7             (1)  There is no regulation or legislative oversight
 8        of  self-funded  health insurance plans covering Illinois
 9        school employees.
10             (2)  There  is  extensive  under-funding  of  health
11        insurance plans in the State public schools.
12             (3)  The escalating costs of health insurance  plans
13        are  burdensome  to  Illinois school employees and school
14        districts.
15             (4)  There is a continued shortfall in  funding  for
16        the  retired  certified Illinois school employees' health
17        plan (TRIP).
18             (5)  Non-certified retired Illinois school employees
19        receive no employer contribution toward the cost of their
20        health plan.
21             (6)  There is a vast  disparity  in  the  costs  and
22        benefits  of  the  health  plans  offered  by the various
23        Illinois school districts.
24             (7)  There is an urgent need for  the  establishment
25        of a statewide health plan for school employees.

26        Section  10. Access to group health plan.  All active and
27    retired employees of a participating school district who  are
28    either  currently  eligible for coverage under a local school
29    district  plan  or  eligible  for  the   Teacher   Retirement
30    Insurance  Program shall be eligible for participation in the
 
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 1    group health plan created under this Act.

 2        Section 15. Terms of group health plan.
 3        (a)  The group health plan created under this  Act  shall
 4    include, at a minimum, the following components:
 5             (1)  A   managed  care  major-medical  plan  with  a
 6        companion HMO option, with benefits  at  least  equal  to
 7        those described in Section 70.
 8             (2)  A standard dental component.
 9             (3)  A standard vision component.
10             (4)  A prescription drug program and card.
11        (b)  The  group  health plan shall include, at a minimum,
12    all benefits mandated under State and federal law.
13        (c)  The co-pays, deductibles,  out-of-pocket  stop  loss
14    levels,  and  monetary  caps  shall  be indexed each year for
15    medical and drug inflation as established by the U.S. Centers
16    for Medicare and Medicaid Services (formerly the Health  Care
17    Finance Administration).

18        Section 20. Applicability; purchasing pools.
19        (a)  All  school  districts  having  a population of less
20    than 500,000 are subject to this Act.
21        (b)  Each school district subject to this  Act  shall  be
22    assigned  to  a regional purchasing pool by the Department of
23    Central Management Services.  There shall be at least  5  and
24    no more than 6 regional purchasing pools.
25        (c)  Each  school  district  subject  to  this  Act shall
26    purchase  coverage  for  its  participating   employees   and
27    retirees  in  the  group  health  plan  through  its assigned
28    regional purchasing pool,  unless  the  school  district  has
29    opted out of participation under Section 45.

30        Section  25.  Administration  of  purchasing pools.  Each
31    regional purchasing pool shall be administered by a board  of
 
                            -3-      LRB093 08144 EFG 08349 b
 1    trustees  elected  by  the  employee,  retiree,  and employer
 2    participants in that pool.  The board  shall  consist  of  at
 3    least  20  trustees,  of  whom  half  shall be elected by the
 4    employee and retiree participants in that pool and half shall
 5    be elected by the employer participants in that pool.

 6        Section 30. Powers and duties of board.
 7        (a)  The  board  of  trustees  shall  have   all   powers
 8    necessary  and  convenient  for  the  administration  of  the
 9    regional purchasing pool.
10        (b)  The board of trustees shall:
11             (1)  Establish   and  maintain  appropriate  reserve
12        levels for the pool.
13             (2)  Establish and maintain  claims  administrators,
14        managed  care networks, prescription benefit managers for
15        retail and mail order programs, and  reinsurers,  all  as
16        the board deems appropriate.
17             (3)  Establish  initial and renewal premiums for the
18        plans offered.
19             (4)  Establish a claim appeal process.
20        (c)  The board of  trustees  shall  hire  consultants  to
21    represent  and  advise  the  board  as  to  rates,  networks,
22    vendors,  investment  of  the  reserves, and the claim appeal
23    process.  The consultants' fees shall be paid  by  the  pool.
24    The  trustees  representing  the  employer  and  the trustees
25    representing the employees and  retirees  may  hire  separate
26    consultants.  Rates shall be calculated, and vendor contracts
27    may  be  awarded,  based  upon  the  recommendations  of  the
28    consultants.

29        Section   35.  Guidelines.   The  Department  of  Central
30    Management Services shall by rule adopt guidelines as to  (i)
31    appropriate  levels  of  reinsurance, rates, and reserves for
32    the pools, (ii) the establishment of benefits as  indexed  at
 
                            -4-      LRB093 08144 EFG 08349 b
 1    renewal, and (iii) appropriate investments of the reserves.

 2        Section  40. Supplemental plan of additional benefits.  A
 3    school  district  may,  through  its  collective   bargaining
 4    process or otherwise, offer a supplemental plan with a higher
 5    level  of  benefits.  The costs of any such supplemental plan
 6    shall be the responsibility of the school  district  and  the
 7    persons  insured  under  the  supplemental  plan, and not the
 8    responsibility of the State.

 9        Section 45. Opt out.  By duly adopted resolution  of  the
10    school  board,  a school district may opt out of its regional
11    purchasing pool in accordance with this  Section.   In  order
12    for  a  school  district  to opt out, it must provide its own
13    plan of health benefits for its employees  and  retirees  and
14    demonstrate  to the satisfaction of the Department of Central
15    Management Services that the district plan  is  at  least  as
16    economically efficient as to benefits, premiums, and reserves
17    as  the  assigned pool.  The Department of Central Management
18    Services shall by rule adopt guidelines for the opt-out of  a
19    school district.
20        A  school  district  that  opts  out of its assigned pool
21    shall not share in the State funding provided  under  Section
22    50.

23        Section  50.  Funding.   Funding  of  the  plan  shall be
24    derived from  employee  and  retiree  premiums  and  employer
25    contributions.    State,   employer,   and  employee  subsidy
26    contributions for retiree rate reduction  shall  continue  at
27    current  levels  and  shall  be  allocated  to pools based on
28    retiree participation.  Trustees shall direct premium dollars
29    to pay claims and costs and to maintain appropriate reserves.

30        Section 70. Minimum benefits.
 
                            -5-      LRB093 08144 EFG 08349 b
 1        (a)  The major-medical portion of the group  health  plan
 2    shall   include,  at  a  minimum,  the  following  levels  of
 3    coverage:

 4    Lifetime major medical: $3,000,000

 5                         IN NETWORK BENEFITS
 6    Single deductible: ..................................... $300
 7    Family deductible: ..................................... $600
 8    Maximum out-of-pocket: .......................... $1200/$2400
 9    Inpatient hospital services: ............................ 90%
10    Outpatient hospital services: ........................... 90%
11    Emergency care: ............................ 100% + $50 copay
12    Mental/Substance Abuse: ....................... 90% inpatient
13    Mental/Substance Abuse: ...................... 80% outpatient
14    Office visit: .......................... 100% + $10/$15 copay
15    Well care ($750/yr. max): .................. 100% + $10 copay
16    TMJ ($2500 lifetime max): ............................... 90%
17    Chiropractic ($2500/yr. max): ........................... 90%
18    Therapy ($5000/yr. max): ................................ 90%

19                       OUT OF NETWORK BENEFITS
20    Single deductible: ..................................... $900
21    Family deductible: .................................... $1800
22    Maximum out-of-pocket: .......................... $3600/$7200
23    Inpatient hospital services: ............................ 70%
24    Outpatient hospital services: ........................... 70%
25    Emergency care: ............................ 100% + $50 copay
26    Mental/Substance Abuse: ....................... 70% inpatient
27    Mental/Substance Abuse: ...................... 60% outpatient
28    Office visit: ........................... 70% + $10/$15 copay
29    Well care ($750/yr. max): ................... 70% + $10 copay
30    TMJ ($2500 lifetime max): ............................... 70%
31    Chiropractic ($2500/yr. max): ........................... 70%
32    Therapy ($5000/yr. max): ................................ 70%
 
                            -6-      LRB093 08144 EFG 08349 b
 1        (b)  The prescription drug program, at a  minimum,  shall
 2    include a prescription drug card, a mail order program, and 3
 3    levels of co-payments:
 4             generic drug ............................ $10 co-pay
 5             formulary brand ......................... $15 co-pay
 6             non-formulary brand ..................... $30 co-pay

 7        (c)  The  provisions  of  this  Section  are  subject  to
 8    interpretation  and  revision  by  the  Department of Central
 9    Management Services, by rule.

10        Section 90.  The State Mandates Act is amended by  adding
11    Section 8.27 as follows:

12        (30 ILCS 805/8.27 new)
13        Sec.  8.27.  Exempt  mandate.  Notwithstanding Sections 6
14    and 8 of this Act, no reimbursement by the State is  required
15    for  the  implementation  of  any  mandate  created  by  this
16    amendatory Act of the 93rd General Assembly.

17        Section  99.  Effective date.  This Act takes effect upon
18    becoming law.