Full Text of HB0889 101st General Assembly
HB0889enr 101ST GENERAL ASSEMBLY |
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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 Illinois Insurance Code is amended by adding | 5 | | Section 356z.33 as follows: | 6 | | (215 ILCS 5/356z.33 new) | 7 | | Sec. 356z.33. Long-term antibiotic therapy for tick-borne | 8 | | diseases. | 9 | | (a) As used in this Section: | 10 | | "Long-term antibiotic therapy" means the administration of | 11 | | oral, intramuscular, or intravenous antibiotics singly or in | 12 | | combination for periods of time in excess of 4 weeks. | 13 | | "Tick-borne disease" means a disease caused when an | 14 | | infected tick bites a person and the tick's saliva transmits an | 15 | | infectious agent (bacteria, viruses, or parasites) that can | 16 | | cause illness, including, but not limited to, the following: | 17 | | (1) a severe infection with borrelia burgdorferi; | 18 | | (2) a late stage, persistent, or chronic infection or | 19 | | complications related to such an infection; | 20 | | (3) an infection with other strains of borrelia or a | 21 | | tick-borne disease that is recognized by the United States | 22 | | Centers for Disease Control and Prevention; and | 23 | | (4) the presence of signs or symptoms compatible with |
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| 1 | | acute infection of borrelia or other tick-borne diseases. | 2 | | (b) An individual or group policy of accident and health | 3 | | insurance or managed care plan that is amended, delivered, | 4 | | issued, or renewed on or after the effective date of this | 5 | | amendatory Act of the 101st General Assembly shall provide | 6 | | coverage for long-term antibiotic therapy, including necessary | 7 | | office visits and ongoing testing, for a person with a | 8 | | tick-borne disease when determined to be medically necessary | 9 | | and ordered by a physician licensed to practice medicine in all | 10 | | its branches after making a thorough evaluation of the person's | 11 | | symptoms, diagnostic test results, or response to treatment. An | 12 | | experimental drug shall be covered as a long-term antibiotic | 13 | | therapy if it is approved for an indication by the United | 14 | | States Food and Drug Administration. A drug, including an | 15 | | experimental drug, shall be covered for an off-label use in the | 16 | | treatment of a tick-borne disease if the drug has been approved | 17 | | by the United States Food and Drug Administration. | 18 | | Section 10. The Health Maintenance Organization Act is | 19 | | amended by changing Section 5-3 as follows:
| 20 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 21 | | Sec. 5-3. Insurance Code provisions.
| 22 | | (a) Health Maintenance Organizations
shall be subject to | 23 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 24 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
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| 1 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 2 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 3 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 4 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 5 | | 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, | 6 | | 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | 7 | | 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, | 8 | | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | 9 | | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | 10 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| 11 | | (b) For purposes of the Illinois Insurance Code, except for | 12 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 13 | | Maintenance Organizations in
the following categories are | 14 | | deemed to be "domestic companies":
| 15 | | (1) a corporation authorized under the
Dental Service | 16 | | Plan Act or the Voluntary Health Services Plans Act;
| 17 | | (2) a corporation organized under the laws of this | 18 | | State; or
| 19 | | (3) a corporation organized under the laws of another | 20 | | state, 30% or more
of the enrollees of which are residents | 21 | | of this State, except a
corporation subject to | 22 | | substantially the same requirements in its state of
| 23 | | organization as is a "domestic company" under Article VIII | 24 | | 1/2 of the
Illinois Insurance Code.
| 25 | | (c) In considering the merger, consolidation, or other | 26 | | acquisition of
control of a Health Maintenance Organization |
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| 1 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 2 | | (1) the Director shall give primary consideration to | 3 | | the continuation of
benefits to enrollees and the financial | 4 | | conditions of the acquired Health
Maintenance Organization | 5 | | after the merger, consolidation, or other
acquisition of | 6 | | control takes effect;
| 7 | | (2)(i) the criteria specified in subsection (1)(b) of | 8 | | Section 131.8 of
the Illinois Insurance Code shall not | 9 | | apply and (ii) the Director, in making
his determination | 10 | | with respect to the merger, consolidation, or other
| 11 | | acquisition of control, need not take into account the | 12 | | effect on
competition of the merger, consolidation, or | 13 | | other acquisition of control;
| 14 | | (3) the Director shall have the power to require the | 15 | | following
information:
| 16 | | (A) certification by an independent actuary of the | 17 | | adequacy
of the reserves of the Health Maintenance | 18 | | Organization sought to be acquired;
| 19 | | (B) pro forma financial statements reflecting the | 20 | | combined balance
sheets of the acquiring company and | 21 | | the Health Maintenance Organization sought
to be | 22 | | acquired as of the end of the preceding year and as of | 23 | | a date 90 days
prior to the acquisition, as well as pro | 24 | | forma financial statements
reflecting projected | 25 | | combined operation for a period of 2 years;
| 26 | | (C) a pro forma business plan detailing an |
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| 1 | | acquiring party's plans with
respect to the operation | 2 | | of the Health Maintenance Organization sought to
be | 3 | | acquired for a period of not less than 3 years; and
| 4 | | (D) such other information as the Director shall | 5 | | require.
| 6 | | (d) The provisions of Article VIII 1/2 of the Illinois | 7 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 8 | | any health maintenance
organization of greater than 10% of its
| 9 | | enrollee population (including without limitation the health | 10 | | maintenance
organization's right, title, and interest in and to | 11 | | its health care
certificates).
| 12 | | (e) In considering any management contract or service | 13 | | agreement subject
to Section 141.1 of the Illinois Insurance | 14 | | Code, the Director (i) shall, in
addition to the criteria | 15 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 16 | | into account the effect of the management contract or
service | 17 | | agreement on the continuation of benefits to enrollees and the
| 18 | | financial condition of the health maintenance organization to | 19 | | be managed or
serviced, and (ii) need not take into account the | 20 | | effect of the management
contract or service agreement on | 21 | | competition.
| 22 | | (f) Except for small employer groups as defined in the | 23 | | Small Employer
Rating, Renewability and Portability Health | 24 | | Insurance Act and except for
medicare supplement policies as | 25 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 26 | | Maintenance Organization may by contract agree with a
group or |
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| 1 | | other enrollment unit to effect refunds or charge additional | 2 | | premiums
under the following terms and conditions:
| 3 | | (i) the amount of, and other terms and conditions with | 4 | | respect to, the
refund or additional premium are set forth | 5 | | in the group or enrollment unit
contract agreed in advance | 6 | | of the period for which a refund is to be paid or
| 7 | | additional premium is to be charged (which period shall not | 8 | | be less than one
year); and
| 9 | | (ii) the amount of the refund or additional premium | 10 | | shall not exceed 20%
of the Health Maintenance | 11 | | Organization's profitable or unprofitable experience
with | 12 | | respect to the group or other enrollment unit for the | 13 | | period (and, for
purposes of a refund or additional | 14 | | premium, the profitable or unprofitable
experience shall | 15 | | be calculated taking into account a pro rata share of the
| 16 | | Health Maintenance Organization's administrative and | 17 | | marketing expenses, but
shall not include any refund to be | 18 | | made or additional premium to be paid
pursuant to this | 19 | | subsection (f)). The Health Maintenance Organization and | 20 | | the
group or enrollment unit may agree that the profitable | 21 | | or unprofitable
experience may be calculated taking into | 22 | | account the refund period and the
immediately preceding 2 | 23 | | plan years.
| 24 | | The Health Maintenance Organization shall include a | 25 | | statement in the
evidence of coverage issued to each enrollee | 26 | | describing the possibility of a
refund or additional premium, |
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| 1 | | and upon request of any group or enrollment unit,
provide to | 2 | | the group or enrollment unit a description of the method used | 3 | | to
calculate (1) the Health Maintenance Organization's | 4 | | profitable experience with
respect to the group or enrollment | 5 | | unit and the resulting refund to the group
or enrollment unit | 6 | | or (2) the Health Maintenance Organization's unprofitable
| 7 | | experience with respect to the group or enrollment unit and the | 8 | | resulting
additional premium to be paid by the group or | 9 | | enrollment unit.
| 10 | | In no event shall the Illinois Health Maintenance | 11 | | Organization
Guaranty Association be liable to pay any | 12 | | contractual obligation of an
insolvent organization to pay any | 13 | | refund authorized under this Section.
| 14 | | (g) Rulemaking authority to implement Public Act 95-1045, | 15 | | if any, is conditioned on the rules being adopted in accordance | 16 | | with all provisions of the Illinois Administrative Procedure | 17 | | Act and all rules and procedures of the Joint Committee on | 18 | | Administrative Rules; any purported rule not so adopted, for | 19 | | whatever reason, is unauthorized. | 20 | | (Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; | 21 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff. | 22 | | 8-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 23 | | 10-4-18.)
| 24 | | Section 15. The Illinois Public Aid Code is amended by | 25 | | changing Section 5-16.8 as follows:
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| 1 | | (305 ILCS 5/5-16.8)
| 2 | | Sec. 5-16.8. Required health benefits. The medical | 3 | | assistance program
shall
(i) provide the post-mastectomy care | 4 | | benefits required to be covered by a policy of
accident and | 5 | | health insurance under Section 356t and the coverage required
| 6 | | under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and | 7 | | 356z.29 , 356z.32, and 356z.33 of the Illinois
Insurance Code | 8 | | and (ii) be subject to the provisions of Sections 356z.19, | 9 | | 364.01, 370c, and 370c.1 of the Illinois
Insurance Code.
| 10 | | On and after July 1, 2012, the Department shall reduce any | 11 | | rate of reimbursement for services or other payments or alter | 12 | | any methodologies authorized by this Code to reduce any rate of | 13 | | reimbursement for services or other payments in accordance with | 14 | | Section 5-5e. | 15 | | To ensure full access to the benefits set forth in this | 16 | | Section, on and after January 1, 2016, the Department shall | 17 | | ensure that provider and hospital reimbursement for | 18 | | post-mastectomy care benefits required under this Section are | 19 | | no lower than the Medicare reimbursement rate. | 20 | | (Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; | 21 | | 99-642, eff. 7-28-16; 100-138, eff. 8-18-17; 100-863, eff. | 22 | | 8-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 23 | | 10-4-18.)
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