Full Text of SB0773 103rd General Assembly
SB0773enr 103RD GENERAL ASSEMBLY | | | SB0773 Enrolled | | LRB103 03229 AMQ 48235 b |
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| 1 | | AN ACT concerning regulation. | 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 Sections 6.11 and 6.11B 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 | 9 | | provide the post-mastectomy care benefits required to be | 10 | | covered by a policy of accident and health insurance under | 11 | | Section 356t of the Illinois Insurance Code. The program of | 12 | | health benefits shall provide the coverage required under | 13 | | Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, | 14 | | 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, | 15 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, | 16 | | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | 17 | | 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, | 18 | | 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, | 19 | | and 356z.61, and 356z.62 , 356z.64, 356z.67, 356z.68, 356z.70, | 20 | | and 356z.71 of the Illinois Insurance Code. The program of | 21 | | health benefits must comply with Sections 155.22a, 155.37, | 22 | | 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the | 23 | | Illinois Insurance Code. The program of health benefits shall |
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| 1 | | provide the coverage required under Section 356m of the | 2 | | Illinois Insurance Code and, for the employees of the State | 3 | | Employee Group Insurance Program only, the coverage as also | 4 | | provided in Section 6.11B of this Act. The Department of | 5 | | Insurance shall enforce the requirements of this Section with | 6 | | respect to Sections 370c and 370c.1 of the Illinois Insurance | 7 | | Code; all other requirements of this Section shall be enforced | 8 | | by the Department of Central Management Services. | 9 | | Rulemaking authority to implement Public Act 95-1045, if | 10 | | any, is conditioned on the rules being adopted in accordance | 11 | | with all provisions of the Illinois Administrative Procedure | 12 | | Act and all rules and procedures of the Joint Committee on | 13 | | Administrative Rules; any purported rule not so adopted, for | 14 | | whatever reason, is unauthorized. | 15 | | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | 16 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. | 17 | | 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, | 18 | | eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | 19 | | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | 20 | | 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, | 21 | | eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; | 22 | | 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. | 23 | | 8-11-23; revised 8-29-23.) | 24 | | (5 ILCS 375/6.11B) | 25 | | Sec. 6.11B. Infertility coverage. |
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| 1 | | (a) Beginning on January 1, 2024, the State Employees | 2 | | Group Insurance Program shall provide coverage for the | 3 | | diagnosis and treatment of infertility, including, but not | 4 | | limited to, in vitro fertilization, uterine embryo lavage, | 5 | | embryo transfer, artificial insemination, gamete | 6 | | intrafallopian tube transfer, zygote intrafallopian tube | 7 | | transfer, and low tubal ovum transfer. The coverage required | 8 | | shall include procedures necessary to screen or diagnose a | 9 | | fertilized egg before implantation, including, but not limited | 10 | | to, preimplantation genetic diagnosis, preimplantation genetic | 11 | | screening, and prenatal genetic diagnosis. | 12 | | (b) Beginning on January 1, 2024, coverage under this | 13 | | Section for procedures for in vitro fertilization, gamete | 14 | | intrafallopian tube transfer, or zygote intrafallopian tube | 15 | | transfer shall be required only if the procedures: | 16 | | (1) are considered medically appropriate based on | 17 | | clinical guidelines or standards developed by the American | 18 | | Society for Reproductive Medicine, the American College of | 19 | | Obstetricians and Gynecologists, or the Society for | 20 | | Assisted Reproductive Technology; and | 21 | | (2) are performed at medical facilities or clinics | 22 | | that conform to the American College of Obstetricians and | 23 | | Gynecologists guidelines for in vitro fertilization or the | 24 | | American Society for Reproductive Medicine minimum | 25 | | standards for practices offering assisted reproductive | 26 | | technologies. |
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| 1 | | (c) As used in this Section, "infertility" means a | 2 | | disease, condition, or status characterized by: | 3 | | (1) a failure to establish a pregnancy or to carry a | 4 | | pregnancy to live birth after 12 months of regular, | 5 | | unprotected sexual intercourse if the woman is 35 years of | 6 | | age or younger, or after 6 months of regular, unprotected | 7 | | sexual intercourse if the woman is over 35 years of age; | 8 | | conceiving but having a miscarriage does not restart the | 9 | | 12-month or 6-month term for determining infertility; | 10 | | (2) a person's inability to reproduce either as a | 11 | | single individual or with a partner without medical | 12 | | intervention; or | 13 | | (3) a licensed physician's findings based on a | 14 | | patient's medical, sexual, and reproductive history, age, | 15 | | physical findings, or diagnostic testing. | 16 | | (d) The State Employees Group Insurance Program may not | 17 | | impose any exclusions, limitations, or other restrictions on | 18 | | coverage of fertility medications that are different from | 19 | | those imposed on any other prescription medications, nor may | 20 | | it impose any exclusions, limitations, or other restrictions | 21 | | on coverage of any fertility services based on a covered | 22 | | individual's participation in fertility services provided by | 23 | | or to a third party, nor may it impose deductibles, | 24 | | copayments, coinsurance, benefit maximums, waiting periods, or | 25 | | any other limitations on coverage for the diagnosis of | 26 | | infertility, treatment for infertility, and standard fertility |
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| 1 | | preservation services, except as provided in this Section, | 2 | | that are different from those imposed upon benefits for | 3 | | services not related to infertility. | 4 | | (e) This Section applies only to coverage provided on or | 5 | | after January 1, 2024 and before July 1, 2026. | 6 | | (f) This Section is repealed on July 1, 2026. | 7 | | (Source: P.A. 103-8, eff. 1-1-24 .) | 8 | | Section 10. The Counties Code is amended by changing | 9 | | Section 5-1069.3 as follows: | 10 | | (55 ILCS 5/5-1069.3) | 11 | | Sec. 5-1069.3. Required health benefits. If a county, | 12 | | including a home rule county, is a self-insurer for purposes | 13 | | of providing health insurance coverage for its employees, the | 14 | | coverage shall include coverage for 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 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, | 18 | | 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, | 19 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | 20 | | 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, | 21 | | 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, | 22 | | 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, and | 23 | | 356z.61, and 356z.62 , 356z.64, 356z.67, 356z.68, 356z.70, and | 24 | | 356z.71 of the Illinois Insurance Code. The coverage shall |
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| 1 | | comply with Sections 155.22a, 355b, 356z.19, and 370c of the | 2 | | Illinois Insurance Code. The Department of Insurance shall | 3 | | enforce the requirements of this Section. The requirement that | 4 | | health benefits be covered as provided in this Section is an | 5 | | exclusive power and function of the State and is a denial and | 6 | | limitation under Article VII, Section 6, subsection (h) of the | 7 | | Illinois Constitution. A home rule county to which this | 8 | | Section applies must comply with every provision of this | 9 | | Section. | 10 | | Rulemaking authority to implement Public Act 95-1045, if | 11 | | any, is conditioned on the rules being adopted in accordance | 12 | | with all provisions of the Illinois Administrative Procedure | 13 | | Act and all rules and procedures of the Joint Committee on | 14 | | Administrative Rules; any purported rule not so adopted, for | 15 | | whatever reason, is unauthorized. | 16 | | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | 17 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 18 | | 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | 19 | | eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | 20 | | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | 21 | | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | 22 | | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | 23 | | 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; revised | 24 | | 8-29-23.) | 25 | | Section 15. The Illinois Municipal Code is amended by |
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| 1 | | changing Section 10-4-2.3 as follows: | 2 | | (65 ILCS 5/10-4-2.3) | 3 | | Sec. 10-4-2.3. Required health benefits. If a | 4 | | municipality, including a home rule municipality, is a | 5 | | self-insurer for purposes of providing health insurance | 6 | | coverage for its employees, the coverage shall include | 7 | | coverage for the post-mastectomy care benefits required to be | 8 | | covered by a policy of accident and health insurance under | 9 | | Section 356t and the coverage required under Sections 356g, | 10 | | 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, 356z.4, | 11 | | 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 12 | | 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | 13 | | 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, | 14 | | 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, | 15 | | 356z.56, 356z.57, 356z.59, 356z.60, and 356z.61, and 356z.62 , | 16 | | 356z.64, 356z.67, 356z.68, 356z.70, and 356z.71 of the | 17 | | Illinois Insurance Code. The coverage shall comply with | 18 | | Sections 155.22a, 355b, 356z.19, and 370c of the Illinois | 19 | | Insurance Code. The Department of Insurance shall enforce the | 20 | | requirements of this Section. The requirement that health | 21 | | benefits be covered as provided in this is an exclusive power | 22 | | and function of the State and is a denial and limitation under | 23 | | Article VII, Section 6, subsection (h) of the Illinois | 24 | | Constitution. A home rule municipality to which this Section | 25 | | applies must comply with every provision of this Section. |
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| 1 | | Rulemaking authority to implement Public Act 95-1045, if | 2 | | any, is conditioned on the rules being adopted in accordance | 3 | | with all provisions of the Illinois Administrative Procedure | 4 | | Act and all rules and procedures of the Joint Committee on | 5 | | Administrative Rules; any purported rule not so adopted, for | 6 | | whatever reason, is unauthorized. | 7 | | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | 8 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 9 | | 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | 10 | | eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | 11 | | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | 12 | | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | 13 | | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | 14 | | 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; revised | 15 | | 8-29-23.) | 16 | | Section 20. The School Code is amended by changing Section | 17 | | 10-22.3f as follows: | 18 | | (105 ILCS 5/10-22.3f) | 19 | | Sec. 10-22.3f. Required health benefits. Insurance | 20 | | protection and benefits for employees shall provide the | 21 | | post-mastectomy care benefits required to be covered by a | 22 | | policy of accident and health insurance under Section 356t and | 23 | | the coverage required under Sections 356g, 356g.5, 356g.5-1, | 24 | | 356m, 356q, 356u, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, |
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| 1 | | 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, | 2 | | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | 3 | | 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, | 4 | | 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, and | 5 | | 356z.61, and 356z.62 , 356z.64, 356z.67, 356z.68, 356z.70, and | 6 | | 356z.71 of the Illinois Insurance Code. Insurance policies | 7 | | shall comply with Section 356z.19 of the Illinois Insurance | 8 | | Code. The coverage shall comply with Sections 155.22a, 355b, | 9 | | and 370c of the Illinois Insurance Code. The Department of | 10 | | Insurance shall enforce the requirements of this Section. | 11 | | Rulemaking authority to implement Public Act 95-1045, if | 12 | | any, is conditioned on the rules being adopted in accordance | 13 | | with all provisions of the Illinois Administrative Procedure | 14 | | Act and all rules and procedures of the Joint Committee on | 15 | | Administrative Rules; any purported rule not so adopted, for | 16 | | whatever reason, is unauthorized. | 17 | | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | 18 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. | 19 | | 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, | 20 | | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | 21 | | 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. | 22 | | 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, | 23 | | eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; | 24 | | 103-551, eff. 8-11-23; revised 8-29-23.) | 25 | | Section 25. The Illinois Insurance Code is amended by |
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| 1 | | changing Sections 356m and 356z.32 and by adding Section | 2 | | 356z.71 as follows: | 3 | | (215 ILCS 5/356m) (from Ch. 73, par. 968m) | 4 | | Sec. 356m. Infertility coverage. | 5 | | (a) No group policy of accident and health insurance | 6 | | providing coverage for more than 25 employees that provides | 7 | | pregnancy-related pregnancy related benefits may be issued, | 8 | | amended, delivered, or renewed in this State after January 1, | 9 | | 2016 and through December 31, 2025 the effective date of this | 10 | | amendatory Act of the 99th General Assembly unless the policy | 11 | | contains coverage for the diagnosis and treatment of | 12 | | infertility including, but not limited to, in vitro | 13 | | fertilization, uterine embryo lavage, embryo transfer, | 14 | | artificial insemination, gamete intrafallopian tube transfer, | 15 | | zygote intrafallopian tube transfer, and low tubal ovum | 16 | | transfer. | 17 | | (a-5) No group policy of accident and health insurance | 18 | | that provides pregnancy-related benefits may be issued, | 19 | | amended, delivered, or renewed in this State on or after | 20 | | January 1, 2026 unless the policy contains coverage for the | 21 | | diagnosis and treatment of infertility, including, but not | 22 | | limited to, in vitro fertilization, uterine embryo lavage, | 23 | | embryo transfer, artificial insemination, gamete | 24 | | intrafallopian tube transfer, zygote intrafallopian tube | 25 | | transfer, surgical sperm extraction procedures, and low tubal |
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| 1 | | ovum transfer. The coverage required shall include procedures | 2 | | necessary to screen or diagnose a fertilized egg before | 3 | | implantation, including, but not limited to, preimplantation | 4 | | genetic testing for aneuploidy, preimplantation genetic | 5 | | testing for chromosome structural rearrangements, and | 6 | | preimplantation genetic testing for monogenic or single gene | 7 | | disorders. Coverage under this subsection for the diagnosis | 8 | | and treatment of infertility shall be required only if the | 9 | | procedures: | 10 | | (1) are considered medically appropriate by the | 11 | | patient's medical provider based on clinical guidelines or | 12 | | standards developed by the American Society for | 13 | | Reproductive Medicine, the American College of | 14 | | Obstetricians and Gynecologists, or the Society for | 15 | | Assisted Reproductive Technology; and | 16 | | (2) are performed at medical facilities or clinics | 17 | | that are members in good standing of the Society for | 18 | | Assisted Reproductive Technology. | 19 | | (b) The coverage required under subsection (a) for | 20 | | procedures for in vitro fertilization, gamete intrafallopian | 21 | | tube transfer, or zygote intrafallopian tube transfer shall be | 22 | | required only if is subject to the following conditions : | 23 | | (1) Coverage for procedures for in vitro | 24 | | fertilization, gamete intrafallopian tube transfer, or | 25 | | zygote intrafallopian tube transfer shall be required only | 26 | | if: |
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| 1 | | (1) (A) the covered individual has been unable to | 2 | | attain a viable pregnancy, maintain a viable pregnancy, or | 3 | | sustain a successful pregnancy through reasonable, less | 4 | | costly medically appropriate infertility treatments for | 5 | | which coverage is available under the policy, plan, or | 6 | | contract; | 7 | | (2) (B) the covered individual has not undergone 4 | 8 | | completed oocyte retrievals, except that if a live birth | 9 | | follows a completed oocyte retrieval, then 2 more | 10 | | completed oocyte retrievals shall be covered; and | 11 | | (3) (C) the procedures are performed at medical | 12 | | facilities that conform to the American College of | 13 | | Obstetric and Gynecology guidelines for in vitro | 14 | | fertilization clinics or to the American Fertility Society | 15 | | minimal standards for programs of in vitro fertilization. | 16 | | (2) The procedures required to be covered under this | 17 | | Section are not required to be contained in any policy or | 18 | | plan issued to or by a religious institution or | 19 | | organization or to or by an entity sponsored by a | 20 | | religious institution or organization that finds the | 21 | | procedures required to be covered under this Section to | 22 | | violate its religious and moral teachings and beliefs. | 23 | | (c) As used in this Section, "infertility" means a | 24 | | disease, condition, or status characterized by: | 25 | | (1) a failure to establish a pregnancy or to carry a | 26 | | pregnancy to live birth after 12 months of regular, |
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| 1 | | unprotected sexual intercourse if the woman is 35 years of | 2 | | age or younger, or after 6 months of regular, unprotected | 3 | | sexual intercourse if the woman is over 35 years of age; | 4 | | conceiving but having a miscarriage does not restart the | 5 | | 12-month or 6-month term for determining infertility; | 6 | | (2) a person's inability to reproduce either as a | 7 | | single individual or with a partner without medical | 8 | | intervention; or | 9 | | (3) a licensed physician's findings based on a | 10 | | patient's medical, sexual, and reproductive history, age, | 11 | | physical findings, or diagnostic testing. | 12 | | (d) A policy, contract, or certificate may not impose any | 13 | | exclusions, limitations, or other restrictions on coverage of | 14 | | fertility medications that are different from those imposed on | 15 | | any other prescription medications, nor may it impose any | 16 | | exclusions, limitations, or other restrictions on coverage of | 17 | | any fertility services based on a covered individual's | 18 | | participation in fertility services provided by or to a third | 19 | | party, nor may it impose deductibles, copayments, coinsurance, | 20 | | benefit maximums, waiting periods, or any other limitations on | 21 | | coverage for the diagnosis of infertility, treatment for | 22 | | infertility, and standard fertility preservation services, | 23 | | except as provided in this Section, that are different from | 24 | | those imposed upon benefits for services not related to | 25 | | infertility. | 26 | | (e) The procedures required to be covered under this |
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| 1 | | Section are not required to be contained in any policy or plan | 2 | | issued to or by a religious institution or organization or to | 3 | | or by an entity sponsored by a religious institution or | 4 | | organization that finds the procedures required to be covered | 5 | | under this Section to violate its religious and moral | 6 | | teachings and beliefs. | 7 | | (Source: P.A. 102-170, eff. 1-1-22 .) | 8 | | (215 ILCS 5/356z.71 new) | 9 | | Sec. 356z.71. Coverage for annual menopause health visit. | 10 | | A group or individual policy of accident and health insurance | 11 | | providing coverage for more than 25 employees that is amended, | 12 | | delivered, issued, or renewed on or after January 1, 2026 | 13 | | shall provide, for individuals 45 years of age and older, | 14 | | coverage for an annual menopause health visit. A policy | 15 | | subject to this Section shall not impose a deductible, | 16 | | coinsurance, copayment, or any other cost-sharing requirement | 17 | | on the coverage provided; except that this Section does not | 18 | | apply to this coverage to the extent such coverage would | 19 | | disqualify a high-deductible health plan from eligibility for | 20 | | a health savings account pursuant to Section 223 of the | 21 | | Internal Revenue Code. | 22 | | Section 30. The Health Maintenance Organization Act is | 23 | | amended by changing Section 5-3 as follows: |
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| 1 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | 2 | | Sec. 5-3. Insurance Code provisions. | 3 | | (a) Health Maintenance Organizations shall be subject to | 4 | | the provisions of Sections 133, 134, 136, 137, 139, 140, | 5 | | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | 6 | | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | 7 | | 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v, | 8 | | 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, | 9 | | 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, | 10 | | 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, | 11 | | 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, | 12 | | 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35, | 13 | | 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, 356z.44, | 14 | | 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, | 15 | | 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, | 16 | | 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, 356z.68, | 17 | | 356z.71, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | 18 | | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | 19 | | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | 20 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | 21 | | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | 22 | | Illinois Insurance Code. | 23 | | (b) For purposes of the Illinois Insurance Code, except | 24 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | 25 | | Health Maintenance Organizations in the following categories | 26 | | are deemed to be "domestic companies": |
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| 1 | | (1) a corporation authorized under the Dental Service | 2 | | Plan Act or the Voluntary Health Services Plans Act; | 3 | | (2) a corporation organized under the laws of this | 4 | | State; or | 5 | | (3) a corporation organized under the laws of another | 6 | | state, 30% or more of the enrollees of which are residents | 7 | | of this State, except a corporation subject to | 8 | | substantially the same requirements in its state of | 9 | | organization as is a "domestic company" under Article VIII | 10 | | 1/2 of the Illinois Insurance Code. | 11 | | (c) In considering the merger, consolidation, or other | 12 | | acquisition of control of a Health Maintenance Organization | 13 | | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | 14 | | (1) the Director shall give primary consideration to | 15 | | the continuation of benefits to enrollees and the | 16 | | financial conditions of the acquired Health Maintenance | 17 | | Organization after the merger, consolidation, or other | 18 | | acquisition of control takes effect; | 19 | | (2)(i) the criteria specified in subsection (1)(b) of | 20 | | Section 131.8 of the Illinois Insurance Code shall not | 21 | | apply and (ii) the Director, in making his determination | 22 | | with respect to the merger, consolidation, or other | 23 | | acquisition of control, need not take into account the | 24 | | effect on competition of the merger, consolidation, or | 25 | | other acquisition of control; | 26 | | (3) the Director shall have the power to require the |
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| 1 | | following information: | 2 | | (A) certification by an independent actuary of the | 3 | | adequacy of the reserves of the Health Maintenance | 4 | | Organization sought to be acquired; | 5 | | (B) pro forma financial statements reflecting the | 6 | | combined balance sheets of the acquiring company and | 7 | | the Health Maintenance Organization sought to be | 8 | | acquired as of the end of the preceding year and as of | 9 | | a date 90 days prior to the acquisition, as well as pro | 10 | | forma financial statements reflecting projected | 11 | | combined operation for a period of 2 years; | 12 | | (C) a pro forma business plan detailing an | 13 | | acquiring party's plans with respect to the operation | 14 | | of the Health Maintenance Organization sought to be | 15 | | acquired for a period of not less than 3 years; and | 16 | | (D) such other information as the Director shall | 17 | | require. | 18 | | (d) The provisions of Article VIII 1/2 of the Illinois | 19 | | Insurance Code and this Section 5-3 shall apply to the sale by | 20 | | any health maintenance organization of greater than 10% of its | 21 | | enrollee population (including , without limitation , the health | 22 | | maintenance organization's right, title, and interest in and | 23 | | to its health care certificates). | 24 | | (e) In considering any management contract or service | 25 | | agreement subject to Section 141.1 of the Illinois Insurance | 26 | | Code, the Director (i) shall, in addition to the criteria |
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| 1 | | specified in Section 141.2 of the Illinois Insurance Code, | 2 | | take into account the effect of the management contract or | 3 | | service agreement on the continuation of benefits to enrollees | 4 | | and the financial condition of the health maintenance | 5 | | organization to be managed or serviced, and (ii) need not take | 6 | | into account the effect of the management contract or service | 7 | | agreement on competition. | 8 | | (f) Except for small employer groups as defined in the | 9 | | Small Employer Rating, Renewability and Portability Health | 10 | | Insurance Act and except for medicare supplement policies as | 11 | | defined in Section 363 of the Illinois Insurance Code, a | 12 | | Health Maintenance Organization may by contract agree with a | 13 | | group or other enrollment unit to effect refunds or charge | 14 | | additional premiums under the following terms and conditions: | 15 | | (i) the amount of, and other terms and conditions with | 16 | | respect to, the refund or additional premium are set forth | 17 | | in the group or enrollment unit contract agreed in advance | 18 | | of the period for which a refund is to be paid or | 19 | | additional premium is to be charged (which period shall | 20 | | not be less than one year); and | 21 | | (ii) the amount of the refund or additional premium | 22 | | shall not exceed 20% of the Health Maintenance | 23 | | Organization's profitable or unprofitable experience with | 24 | | respect to the group or other enrollment unit for the | 25 | | period (and, for purposes of a refund or additional | 26 | | premium, the profitable or unprofitable experience shall |
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| 1 | | be calculated taking into account a pro rata share of the | 2 | | Health Maintenance Organization's administrative and | 3 | | marketing expenses, but shall not include any refund to be | 4 | | made or additional premium to be paid pursuant to this | 5 | | subsection (f)). The Health Maintenance Organization and | 6 | | the group or enrollment unit may agree that the profitable | 7 | | or unprofitable experience may be calculated taking into | 8 | | account the refund period and the immediately preceding 2 | 9 | | plan years. | 10 | | The Health Maintenance Organization shall include a | 11 | | statement in the evidence of coverage issued to each enrollee | 12 | | describing the possibility of a refund or additional premium, | 13 | | and upon request of any group or enrollment unit, provide to | 14 | | the group or enrollment unit a description of the method used | 15 | | to calculate (1) the Health Maintenance Organization's | 16 | | profitable experience with respect to the group or enrollment | 17 | | unit and the resulting refund to the group or enrollment unit | 18 | | or (2) the Health Maintenance Organization's unprofitable | 19 | | experience with respect to the group or enrollment unit and | 20 | | the resulting additional premium to be paid by the group or | 21 | | enrollment unit. | 22 | | In no event shall the Illinois Health Maintenance | 23 | | Organization Guaranty Association be liable to pay any | 24 | | contractual obligation of an insolvent organization to pay any | 25 | | refund authorized under this Section. | 26 | | (g) Rulemaking authority to implement Public Act 95-1045, |
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| 1 | | if any, is conditioned on the rules being adopted in | 2 | | accordance with all provisions of the Illinois Administrative | 3 | | Procedure Act and all rules and procedures of the Joint | 4 | | Committee on Administrative Rules; any purported rule not so | 5 | | adopted, for whatever reason, is unauthorized. | 6 | | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | 7 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 8 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | 9 | | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | 10 | | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | 11 | | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | 12 | | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | 13 | | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | 14 | | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 15 | | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | 16 | | Section 35. The Limited Health Service Organization Act is | 17 | | amended by changing Section 4003 as follows: | 18 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | 19 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 20 | | health service organizations shall be subject to the | 21 | | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | 22 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | 23 | | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2, | 24 | | 355.3, 355b, 356m, 356q, 356v, 356z.4, 356z.4a, 356z.10, |
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| 1 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | 2 | | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | 3 | | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | 4 | | 356z.71, 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, | 5 | | 409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII | 6 | | 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance | 7 | | Code. Nothing in this Section shall require a limited health | 8 | | care plan to cover any service that is not a limited health | 9 | | service. For purposes of the Illinois Insurance Code, except | 10 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | 11 | | limited health service organizations in the following | 12 | | categories are deemed to be domestic companies: | 13 | | (1) a corporation under the laws of this State; or | 14 | | (2) a corporation organized under the laws of another | 15 | | state, 30% or more of the enrollees of which are residents | 16 | | of this State, except a corporation subject to | 17 | | substantially the same requirements in its state of | 18 | | organization as is a domestic company under Article VIII | 19 | | 1/2 of the Illinois Insurance Code. | 20 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | 21 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | 22 | | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | 23 | | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | 24 | | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | 25 | | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 26 | | eff. 1-1-24; revised 8-29-23.) |
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| 1 | | Section 40. The Voluntary Health Services Plans Act is | 2 | | amended by changing Section 10 as follows: | 3 | | (215 ILCS 165/10) (from Ch. 32, par. 604) | 4 | | Sec. 10. Application of Insurance Code provisions. Health | 5 | | services plan corporations and all persons interested therein | 6 | | or dealing therewith shall be subject to the provisions of | 7 | | Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, | 8 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, | 9 | | 356g, 356g.5, 356g.5-1, 356m, 356q, 356r, 356t, 356u, 356v, | 10 | | 356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, | 11 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 12 | | 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, | 13 | | 356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, | 14 | | 356z.32a, 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, | 15 | | 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, | 16 | | 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.71, 364.01, | 17 | | 364.3, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, | 18 | | and 412, and paragraphs (7) and (15) of Section 367 of the | 19 | | Illinois Insurance Code. | 20 | | Rulemaking authority to implement Public Act 95-1045, if | 21 | | any, is conditioned on the rules being adopted in accordance | 22 | | with all provisions of the Illinois Administrative Procedure | 23 | | Act and all rules and procedures of the Joint Committee on | 24 | | Administrative Rules; any purported rule not so adopted, for |
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| 1 | | whatever reason, is unauthorized. | 2 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | 3 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. | 4 | | 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, | 5 | | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | 6 | | 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. | 7 | | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | 8 | | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | 9 | | 103-551, eff. 8-11-23; revised 8-29-23.) | 10 | | Section 99. Effective date. This Act takes effect upon | 11 | | becoming law. |
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