(5 ILCS 375/1) (from Ch. 127, par. 521)
Sec. 1.
This Act shall be known and may be cited as the "State Employees Group
Insurance Act of 1971".
(Source: P.A. 77-476.)
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(5 ILCS 375/2) (from Ch. 127, par. 522)
Sec. 2. Purpose. The purpose of this Act is to provide a program of
group life insurance, a program of health benefits and other employee benefits
for persons in the service of the State of Illinois and certain of their dependents.
It is also the purpose of this Act to provide a program of health benefits
(i) for certain benefit recipients of the Teachers' Retirement System of
the State of Illinois and their dependent beneficiaries, (ii) for certain
eligible retired community college employees and their dependent
beneficiaries, and (iii) for employees of local governments, employees of rehabilitation facilities, employees of domestic violence shelters and services, and employees of child advocacy centers, and certain of their dependents.
(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/2.5) Sec. 2.5. Application to Regional Transportation Authority Board members. Notwithstanding any other provision of this Act to the contrary, this Act does not apply to any member of the Regional Transportation Authority Board who first becomes a member of that Board on or after July 23, 2013 (the effective date of Public Act 98-108) with respect to service of that Board.
(Source: P.A. 98-108, eff. 7-23-13; 98-756, eff. 7-16-14.) |
(5 ILCS 375/2.6) Sec. 2.6. Application to Suburban Bus Board members. Notwithstanding any other provision of this Act to the contrary, this Act does not apply to any member of the Suburban Bus Board who first becomes a member of that Board on or after the effective date of this amendatory Act of the 98th General Assembly with respect to service of that Board.
(Source: P.A. 98-108, eff. 7-23-13.) |
(5 ILCS 375/2.7) Sec. 2.7. Application to Commuter Rail Board members. Notwithstanding any other provision of this Act to the contrary, this Act does not apply to any member of the Commuter Rail Board who first becomes a member of that Board on or after the effective date of this amendatory Act of the 98th General Assembly with respect to service of that Board.
(Source: P.A. 98-108, eff. 7-23-13.) |
(5 ILCS 375/2.8) Sec. 2.8. Application to Chicago Transit Authority Board members. Notwithstanding any other provision of this Act to the contrary, this Act does not apply to any member of the Chicago Transit Authority Board who first becomes a member of that Board on or after the effective date of this amendatory Act of the 98th General Assembly with respect to service of that Board.
(Source: P.A. 98-108, eff. 7-23-13.) |
(5 ILCS 375/2.9) Sec. 2.9. State healthcare purchasing. On and after the date 6 months after August 16, 2013 (the effective date of Public Act 98-488), as provided in the Executive Order 1 (2012) Implementation Act, all of the powers, duties, rights, and responsibilities related to State healthcare purchasing under this Act that were transferred from the Department of Central Management Services to the Department of Healthcare and Family Services by Executive Order 3 (2005) are transferred back to the Department.
(Source: P.A. 98-488, eff. 8-16-13; 98-756, eff. 7-16-14.) |
(5 ILCS 375/3) (from Ch. 127, par. 523)
Sec. 3. Definitions. Unless the context otherwise requires, the
following words and phrases as used in this Act shall have the following
meanings. The Department may define these and other words and phrases
separately for the purpose of implementing specific programs providing benefits
under this Act.
(a) "Administrative service organization" means any person, firm or
corporation experienced in the handling of claims which is
fully qualified, financially sound and capable of meeting the service
requirements of a contract of administration executed with the Department.
(b) "Annuitant" means (1) an employee who retires, or has retired,
on or after January 1, 1966 on an immediate annuity under the provisions
of Articles 2, 14 (including an employee who has elected to receive an alternative retirement cancellation payment under Section 14-108.5 of the Illinois Pension Code in lieu of an annuity or who meets the criteria for retirement, but in lieu of receiving an annuity under that Article has elected to receive an accelerated pension benefit payment under Section 14-147.5 of that Article), 15 (including an employee who has retired under the optional
retirement program established under Section 15-158.2 or who meets the criteria for retirement but in lieu of receiving an annuity under that Article has elected to receive an accelerated pension benefit payment under Section 15-185.5 of the Article), paragraph
(2), (3), or (5) of Section 16-106 (including an employee who meets the criteria for retirement, but in lieu of receiving an annuity under that Article has elected to receive an accelerated pension benefit payment under Section 16-190.5 of the Illinois Pension Code), or
Article 18 of the Illinois Pension Code; (2) any person who was receiving
group insurance coverage under this Act as of March 31, 1978 by
reason of his status as an annuitant, even though the annuity in relation
to which such coverage was provided is a proportional annuity based on less
than the minimum period of service required for a retirement annuity in
the system involved; (3) any person not otherwise covered by this Act
who has retired as a participating member under Article 2 of the Illinois
Pension Code but is ineligible for the retirement annuity under Section
2-119 of the Illinois Pension Code; (4) the spouse of any person who
is receiving a retirement annuity under Article 18 of the Illinois Pension
Code and who is covered under a group health insurance program sponsored
by a governmental employer other than the State of Illinois and who has
irrevocably elected to waive his or her coverage under this Act and to have
his or her spouse considered as the "annuitant" under this Act and not as
a "dependent"; or (5) an employee who retires, or has retired, from a
qualified position, as determined according to rules promulgated by the
Director, under a qualified local government, a qualified rehabilitation
facility, a qualified domestic violence shelter or service, or a qualified child advocacy center. (For definition
of "retired employee", see (p) post).
(b-5) (Blank).
(b-6) (Blank).
(b-7) (Blank).
(c) "Carrier" means (1) an insurance company, a corporation organized
under the Limited Health Service Organization Act or the Voluntary Health
Services Plans Act, a partnership, or other nongovernmental organization,
which is authorized to do group life or group health insurance business in
Illinois, or (2) the State of Illinois as a self-insurer.
(d) "Compensation" means salary or wages payable on a regular
payroll by the State Treasurer on a warrant of the State Comptroller out
of any State, trust or federal fund, or by the Governor of the State
through a disbursing officer of the State out of a trust or out of
federal funds, or by any Department out of State, trust, federal or
other funds held by the State Treasurer or the Department, to any person
for personal services currently performed, and ordinary or accidental
disability benefits under Articles 2, 14, 15 (including ordinary or accidental
disability benefits under the optional retirement program established under
Section 15-158.2), paragraph (2), (3), or (5) of
Section 16-106, or Article 18 of the Illinois Pension Code, for disability
incurred after January 1, 1966, or benefits payable under the Workers'
Compensation or Occupational Diseases Act or benefits payable under a sick
pay plan established in accordance with Section 36 of the State Finance Act.
"Compensation" also means salary or wages paid to an employee of any
qualified local government, qualified rehabilitation facility,
qualified domestic violence shelter or service, or qualified child advocacy center.
(e) "Commission" means the State Employees Group Insurance Advisory
Commission authorized by this Act. Commencing July 1, 1984, "Commission"
as used in this Act means the Commission on Government Forecasting and Accountability as
established by the Legislative Commission Reorganization Act of 1984.
(f) "Contributory", when referred to as contributory coverage, shall
mean optional coverages or benefits elected by the member toward the cost of
which such member makes contribution, or which are funded in whole or in part
through the acceptance of a reduction in earnings or the foregoing of an
increase in earnings by an employee, as distinguished from noncontributory
coverage or benefits which are paid entirely by the State of Illinois
without reduction of the member's salary.
(g) "Department" means any department, institution, board,
commission, officer, court or any agency of the State government
receiving appropriations and having power to certify payrolls to the
Comptroller authorizing payments of salary and wages against such
appropriations as are made by the General Assembly from any State fund, or
against trust funds held by the State Treasurer and includes boards of
trustees of the retirement systems created by Articles 2, 14, 15, 16, and
18 of the Illinois Pension Code. "Department" also includes the Illinois
Comprehensive Health Insurance Board, the Board of Examiners established under
the Illinois Public Accounting Act, and the Illinois Finance Authority.
(h) "Dependent", when the term is used in the context of the health
and life plan, means a member's spouse and any child (1) from
birth to age 26 including an adopted child, a child who lives with the
member from the time of the placement for adoption until entry
of an order of adoption, a stepchild or adjudicated child, or a child who lives with the member
if such member is a court appointed guardian of the child or (2)
age 19 or over who has a mental or physical disability from a cause originating prior to the age of 19 (age 26 if enrolled as an adult child dependent). For
the health plan only, the term "dependent" also includes (1) any person
enrolled prior to the effective date of this Section who is dependent upon
the member to the extent that the member may claim such person as a
dependent for income tax deduction purposes and (2) any person who
has received after June 30, 2000 an organ transplant and who is financially
dependent upon the member and eligible to be claimed as a dependent for income
tax purposes. A member requesting to cover any dependent must provide documentation as requested by the Department of Central Management Services and file with the Department any and all forms required by the Department.
(i) "Director" means the Director of the Illinois Department of Central
Management Services.
(j) "Eligibility period" means the period of time a member has to
elect enrollment in programs or to select benefits without regard to
age, sex or health.
(k) "Employee" means and includes each officer or employee in the
service of a department who (1) receives his compensation for
service rendered to the department on a warrant issued pursuant to a payroll
certified by a department or on a warrant or check issued and drawn by a
department upon a trust, federal or other fund or on a warrant issued
pursuant to a payroll certified by an elected or duly appointed officer
of the State or who receives payment of the performance of personal
services on a warrant issued pursuant to a payroll certified by a
Department and drawn by the Comptroller upon the State Treasurer against
appropriations made by the General Assembly from any fund or against
trust funds held by the State Treasurer, and (2) is employed full-time or
part-time in a position normally requiring actual performance of duty
during not less than 1/2 of a normal work period, as established by the
Director in cooperation with each department, except that persons elected
by popular vote will be considered employees during the entire
term for which they are elected regardless of hours devoted to the
service of the State, and (3) except that "employee" does not include any
person who is not eligible by reason of such person's employment to
participate in one of the State retirement systems under Articles 2, 14, 15
(either the regular Article 15 system or the optional retirement program
established under Section 15-158.2), or 18, or under paragraph (2), (3), or
(5) of Section 16-106, of the Illinois
Pension Code, but such term does include persons who are employed during
the 6-month qualifying period under Article 14 of the Illinois Pension
Code. Such term also includes any person who (1) after January 1, 1966,
is receiving ordinary or accidental disability benefits under Articles
2, 14, 15 (including ordinary or accidental disability benefits under the
optional retirement program established under Section 15-158.2), paragraph
(2), (3), or (5) of Section 16-106, or Article 18 of the
Illinois Pension Code, for disability incurred after January 1, 1966, (2)
receives total permanent or total temporary disability under the Workers'
Compensation Act or Occupational Disease Act as a result of injuries
sustained or illness contracted in the course of employment with the
State of Illinois, or (3) is not otherwise covered under this Act and has
retired as a participating member under Article 2 of the Illinois Pension
Code but is ineligible for the retirement annuity under Section 2-119 of
the Illinois Pension Code. However, a person who satisfies the criteria
of the foregoing definition of "employee" except that such person is made
ineligible to participate in the State Universities Retirement System by
clause (4) of subsection (a) of Section 15-107 of the Illinois Pension
Code is also an "employee" for the purposes of this Act. "Employee" also
includes any person receiving or eligible for benefits under a sick pay
plan established in accordance with Section 36 of the State Finance Act.
"Employee" also includes (i) each officer or employee in the service of a
qualified local government, including persons appointed as trustees of
sanitary districts regardless of hours devoted to the service of the
sanitary district, (ii) each employee in the service of a qualified
rehabilitation facility, (iii) each full-time employee in the service of a
qualified domestic violence shelter or service, and (iv) each full-time employee in the service of a qualified child advocacy center, as determined according to
rules promulgated by the Director.
(l) "Member" means an employee, annuitant, retired employee, or survivor. In the case of an annuitant or retired employee who first becomes an annuitant or retired employee on or after January 13, 2012 (the effective date of Public Act 97-668), the individual must meet the minimum vesting requirements of the applicable retirement system in order to be eligible for group insurance benefits under that system. In the case of a survivor who is not entitled to occupational death benefits pursuant to an applicable retirement system or death benefits pursuant to the Illinois Workers' Compensation Act, and who first becomes a survivor on or after January 13, 2012 (the effective date of Public Act 97-668), the deceased employee, annuitant, or retired employee upon whom the annuity is based must have been eligible to participate in the group insurance system under the applicable retirement system in order for the survivor to be eligible for group insurance benefits under that system. In the case of a survivor who is entitled to occupational death benefits pursuant to the deceased employee's applicable retirement system or death benefits pursuant to the Illinois Workers' Compensation Act, and first becomes a survivor on or after January 1, 2022, the survivor is eligible for group health insurance benefits regardless of the deceased employee's minimum vesting requirements under the applicable retirement system, with a State contribution rate of 100%, until an unmarried child dependent reaches the age of 18, or the age of 22 if the dependent child is a full-time student, or until the adult survivor becomes eligible for benefits under the federal Medicare health insurance program (Title XVIII of the Social Security Act, as added by Public Law 89-97). In the case of a survivor currently receiving occupational death benefits pursuant to the deceased employee's applicable retirement system or has received death benefits pursuant to the Illinois Workers' Compensation Act, who first became a survivor prior to January 1, 2022, the survivor is eligible for group health insurance benefits regardless of the deceased employee's minimum vesting requirements under the applicable retirement system, with a State contribution rate of 100%, until an unmarried child dependent reaches the age of 18, or the age of 22 if the dependent child is a full-time student, or until the adult survivor becomes eligible for benefits under the federal Medicare health insurance program (Title XVIII of the Social Security Act, as added by Public Law 89-97). The changes made by this amendatory Act of the 102nd General Assembly with respect to survivors who first became survivors prior to January 1, 2022 shall apply upon request of the survivor on or after the effective date of this amendatory Act of the 102nd General Assembly.
(m) "Optional coverages or benefits" means those coverages or
benefits available to the member on his or her voluntary election, and at
his or her own expense.
(n) "Program" means the group life insurance, health benefits and other
employee benefits designed and contracted for by the Director under this Act.
(o) "Health plan" means a health benefits
program offered
by the State of Illinois for persons eligible for the plan.
(p) "Retired employee" means any person who would be an annuitant as
that term is defined herein but for the fact that such person retired prior to
January 1, 1966. Such term also includes any person formerly employed by
the University of Illinois in the Cooperative Extension Service who would
be an annuitant but for the fact that such person was made ineligible to
participate in the State Universities Retirement System by clause (4) of
subsection (a) of Section 15-107 of the Illinois
Pension Code.
(q) "Survivor" means a person receiving an annuity as a survivor of an
employee or of an annuitant. "Survivor" also includes: (1) the surviving
dependent of a person who satisfies the definition of "employee" except that
such person is made ineligible to participate in the State Universities
Retirement System by clause (4) of subsection (a)
of Section 15-107 of the Illinois Pension Code; (2) the surviving
dependent of any person formerly employed by the University of Illinois in
the Cooperative Extension Service who would be an annuitant except for the
fact that such person was made ineligible to participate in the State
Universities Retirement System by clause (4) of subsection (a) of Section
15-107 of the Illinois Pension Code; (3) the surviving dependent of a person who was an annuitant under this Act by virtue of receiving an alternative retirement cancellation payment under Section 14-108.5 of the Illinois Pension Code; and (4) a person who would be receiving an annuity as a survivor of an annuitant except that the annuitant elected on or after June 4, 2018 to receive an accelerated pension benefit payment under Section 14-147.5, 15-185.5, or 16-190.5 of the Illinois Pension Code in lieu of receiving an annuity.
(q-2) "SERS" means the State Employees' Retirement System of Illinois, created under Article 14 of the Illinois Pension Code.
(q-3) "SURS" means the State Universities Retirement System, created under Article 15 of the Illinois Pension Code.
(q-4) "TRS" means the Teachers' Retirement System of the State of Illinois, created under Article 16 of the Illinois Pension Code.
(q-5) (Blank).
(q-6) (Blank).
(q-7) (Blank).
(r) "Medical services" means the services provided within the scope
of their licenses by practitioners in all categories licensed under the
Medical Practice Act of 1987.
(s) "Unit of local government" means any county, municipality,
township, school district (including a combination of school districts under
the Intergovernmental Cooperation Act), special district or other unit,
designated as a
unit of local government by law, which exercises limited governmental
powers or powers in respect to limited governmental subjects, any
not-for-profit association with a membership that primarily includes
townships and township officials, that has duties that include provision of
research service, dissemination of information, and other acts for the
purpose of improving township government, and that is funded wholly or
partly in accordance with Section 85-15 of the Township Code; any
not-for-profit corporation or association, with a membership consisting
primarily of municipalities, that operates its own utility system, and
provides research, training, dissemination of information, or other acts to
promote cooperation between and among municipalities that provide utility
services and for the advancement of the goals and purposes of its
membership;
the Southern Illinois Collegiate Common Market, which is a consortium of higher
education institutions in Southern Illinois; the Illinois Association of
Park Districts; and any hospital provider that is owned by a county that has 100 or fewer hospital beds and has not already joined the program. "Qualified
local government" means a unit of local government approved by the Director and
participating in a program created under subsection (i) of Section 10 of this
Act.
(t) "Qualified rehabilitation facility" means any not-for-profit
organization that is accredited by the Commission on Accreditation of
Rehabilitation Facilities or certified by the Department
of Human Services (as successor to the Department of Mental Health
and Developmental Disabilities) to provide services to persons with
disabilities
and which receives funds from the State of Illinois for providing those
services, approved by the Director and participating in a program created
under subsection (j) of Section 10 of this Act.
(u) "Qualified domestic violence shelter or service" means any Illinois
domestic violence shelter or service and its administrative offices funded
by the Department of Human Services (as successor to the Illinois Department of
Public Aid),
approved by the Director and
participating in a program created under subsection (k) of Section 10.
(v) "TRS benefit recipient" means a person who:
(1) is not a "member" as defined in this Section; and
(2) is receiving a monthly benefit or retirement | ||
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(3) either (i) has at least 8 years of creditable | ||
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(w) "TRS dependent beneficiary" means a person who:
(1) is not a "member" or "dependent" as defined in | ||
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(2) is a TRS benefit recipient's: (A) spouse, (B) | ||
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"TRS dependent beneficiary" does not include, as indicated under paragraph (2) of this subsection (w), a dependent of the survivor of a TRS benefit recipient who first becomes a dependent of a survivor of a TRS benefit recipient on or after January 13, 2012 (the effective date of Public Act 97-668) unless that dependent would have been eligible for coverage as a dependent of the deceased TRS benefit recipient upon whom the survivor benefit is based. (x) "Military leave" refers to individuals in basic
training for reserves, special/advanced training, annual training, emergency
call up, activation by the President of the United States, or any other training or duty in service to the United States Armed Forces.
(y) (Blank).
(z) "Community college benefit recipient" means a person who:
(1) is not a "member" as defined in this Section; and
(2) is receiving a monthly survivor's annuity or | ||
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(3) either (i) was a full-time employee of a | ||
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(aa) "Community college dependent beneficiary" means a person who:
(1) is not a "member" or "dependent" as defined in | ||
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(2) is a community college benefit recipient's: (A) | ||
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"Community college dependent beneficiary" does not include, as indicated under paragraph (2) of this subsection (aa), a dependent of the survivor of a community college benefit recipient who first becomes a dependent of a survivor of a community college benefit recipient on or after January 13, 2012 (the effective date of Public Act 97-668) unless that dependent would have been eligible for coverage as a dependent of the deceased community college benefit recipient upon whom the survivor annuity is based. (bb) "Qualified child advocacy center" means any Illinois child advocacy center and its administrative offices funded by the Department of Children and Family Services, as defined by the Children's Advocacy Center Act (55 ILCS 80/), approved by the Director and participating in a program created under subsection (n) of Section 10.
(cc) "Placement for adoption" means the assumption and retention by a member of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child's placement with the member terminates upon the termination of such legal obligation. (Source: P.A. 101-242, eff. 8-9-19; 102-558, eff. 8-20-21; 102-714, eff. 4-29-22; 102-813, eff 5-13-22.)
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(5 ILCS 375/4) (from Ch. 127, par. 524)
Sec. 4.
The Commission shall meet with the Department of
Central Management Services and advise the Department of Central Management
Services on all matters relating to policy and the administration of this Act.
(Source: P.A. 85-848.)
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(5 ILCS 375/5) (from Ch. 127, par. 525)
Sec. 5. Employee benefits; declaration of State policy.
The General Assembly declares that it is the policy of the State and in the best interest of the State to assure quality benefits to members and their dependents under this Act. The implementation of this policy depends upon, among other things, stability and continuity of coverage, care, and services under benefit programs for members and their dependents. Specifically, but without limitation, members should have continued access, on substantially similar terms and conditions, to trusted family health care providers with whom they have developed long-term relationships through a benefit program under this Act. Therefore, the Director must administer this Act consistent with that State policy, but may consider affordability, cost of coverage and care, and competition among health insurers and providers. All contracts for provision of employee benefits, including those portions of any proposed collective bargaining agreement that would require implementation through contracts entered into under this Act, are subject to the following requirements: (i) By April 1 of each year, the Director must report | ||
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(ii) Within 30 days after notice of the awarding or | ||
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(iii) Except as otherwise provided in this item | ||
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(iv) If the Director seeks to make any substantive | ||
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(v) By the date of the beginning of the annual | ||
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(vi) The Director must provide the reports, | ||
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All contracts entered into under this Section are subject to appropriation and shall comply with Section 20-60(b) of the Illinois Procurement Code (30 ILCS 500/20-60(b)).
The Director shall contract or otherwise make available group
life insurance, health benefits and other
employee benefits to eligible members and, where elected,
their eligible dependents. Any contract or, if
applicable, contracts or other arrangement for provision of benefits
shall be on terms consistent with State policy and
based on, but not limited to, such
criteria as administrative cost, service capabilities of the carrier
or other contractor and premiums, fees or charges as related to benefits.
Notwithstanding any other provisions of this Act, by January 1, 2014, the Department of Central Management Services, in consultation with and subject to the approval of the Chief Procurement Officer, shall contract or make otherwise available a program of group health benefits for Medicare-primary members and their Medicare-primary dependents. The Director may procure a single contract or multiple contracts that provide a program of group health benefits that is comparable in stability and continuity of coverage, care, and services to the program of health benefits offered to other members and their dependents under this Act. The initial procurement of a contract or contracts under this paragraph is not subject to the provisions of the Illinois Procurement Code, except for Sections 20-60, 20-65, 20-70, and 20-160 and Article 50 of that Code, provided that the Chief Procurement Officer may, in writing with justification, waive any certification required under Article 50. The Director may prepare and issue specifications
for group life insurance, health benefits, other employee benefits
and administrative services for the purpose of receiving proposals
from interested parties.
The Director is authorized to execute a contract, or
contracts, for the programs of group life insurance, health
benefits, other employee benefits and administrative services
authorized by this Act (including, without limitation, prescription drug benefits). All of the benefits provided under this Act may be
included in one or more contracts, or the benefits may be classified into
different types with each type included under one or more similar contracts
with the same or different companies.
The term of any contract may not extend beyond 5 fiscal years.
Upon recommendation of the Commission, the Director may exercise renewal
options of the same contract for up to a period of 5 years. Any
increases in premiums, fees or charges requested by a contractor whose
contract may be renewed pursuant to a renewal option contained therein,
must be justified on the basis of (1) audited experience data, (2)
increases in the costs of health care services provided under the contract,
(3) contractor performance, (4) increases in contractor responsibilities,
or (5) any combination thereof.
Any contractor shall agree to abide by all
requirements of this Act and Rules and Regulations promulgated and adopted
thereto; to submit such information and data as may from time to time be
deemed necessary by the Director for effective administration of the
provisions of this Act and the programs established
hereunder, and to fully cooperate in any audit.
(Source: P.A. 98-19, eff. 6-10-13.)
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(5 ILCS 375/6) (from Ch. 127, par. 526)
Sec. 6. Program of health benefits.
(a) The program of health benefits shall provide for protection
against the financial costs of health care expenses incurred in and out
of hospital including basic hospital-surgical-medical coverages. The program
may include, but shall not be limited to, such supplemental coverages as
out-patient diagnostic X-ray and laboratory expenses, prescription drugs,
dental services, hearing evaluations, hearing aids, the dispensing and
fitting
of hearing aids, and similar group benefits
as are now or may become available. The program may also include
coverage for those who rely on treatment by prayer or spiritual means
alone for healing in accordance with the tenets and practice of a
recognized religious denomination.
The program of health benefits shall be designed by the Director
(1) to provide a reasonable relationship between the benefits to be
included and the expected distribution of expenses of each such type to
be incurred by the covered members and dependents,
(2) to specify, as covered benefits and as optional benefits, the
medical services of practitioners in all categories licensed under the
Medical Practice Act of 1987, (3) to include
reasonable controls, which may include deductible and co-insurance
provisions, applicable to some or all of the benefits, or a coordination
of benefits provision, to prevent or minimize unnecessary utilization of
the various hospital, surgical and medical expenses to be provided and
to provide reasonable assurance of stability of the program, and (4) to
provide benefits to the extent possible to members throughout the
State, wherever located, on an equitable basis.
Notwithstanding any other provision of this Section or Act,
for all members or dependents who are eligible for benefits under Social
Security or the
Railroad Retirement system or who had sufficient Medicare-covered government
employment,
the
Department shall reduce benefits
which would otherwise be paid by Medicare, by the amount of benefits for
which the member or dependents are eligible
under Medicare, except that such reduction in benefits shall apply only to
those members or dependents who (1) first become
eligible for such medicare coverage on or after the effective date of this
amendatory Act of 1992; or (2) are Medicare-eligible members or dependents of
a local government unit which began participation in the program on or after
July 1, 1992; or (3) remain eligible for but no longer receive
Medicare coverage which they had been receiving on or after the effective date
of this amendatory Act of 1992.
Notwithstanding any other provisions of this Act, where a covered member or
dependents are eligible for benefits under the federal Medicare health
insurance program (Title XVIII of the Social Security Act as added by
Public Law 89-97, 89th Congress), benefits paid under the State of Illinois
program or plan will be reduced by the amount of benefits paid by Medicare.
For members or dependents
who are eligible for benefits under Social Security
or the Railroad Retirement system or who had sufficient Medicare-covered
government employment, benefits shall be reduced by the amount for which
the member or dependent is eligible under Medicare,
except that such reduction in benefits shall apply only to those
members or dependents who (1) first become eligible for such
Medicare coverage on or after the effective date of this amendatory Act
of 1992; or (2) are Medicare-eligible members or dependents of a local
government unit which began participation in the program on or after July 1,
1992; or (3) remain eligible for, but no longer receive Medicare
coverage which they had been receiving on or after the effective date of this
amendatory Act of 1992. Premiums may be adjusted, where applicable, to an
amount deemed by the Director to be reasonably consistent with any reduction
of benefits.
(b) A member, not otherwise covered by this Act, who has retired as a
participating member under Article 2 of the Illinois Pension Code
but is ineligible for the retirement annuity under Section 2-119 of the
Illinois
Pension Code, shall pay the premiums for coverage, not
exceeding the amount paid by the State for the non-contributory coverage for
other members, under the group health benefits program under this Act. The
Director shall determine the premiums to be paid
by a member under this subsection (b).
(Source: P.A. 100-538, eff. 1-1-18.)
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(5 ILCS 375/6.1) (from Ch. 127, par. 526.1)
Sec. 6.1.
The program of health benefits may offer as an alternative,
available on an optional basis, coverage through
health maintenance organizations or other managed care programs. That part of the premium for
such coverage which is in excess of the amount which would
otherwise be paid by the State for the program of health benefits shall
be paid by the member who elects such alternative coverage and shall
be collected as provided for premiums for other optional coverages.
(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/6.2) (from Ch. 127, par. 526.2)
Sec. 6.2.
When the Director, with the advice and consent of the
Commission, determines that it would be in the best interests of the State
and its employees, any program of health benefits under this Act may be
administered with the State as a self-insurer in whole or in part. The
State assumes the risks of any such program. The State may provide the
administrative services in connection with any self-insurance health plan
or purchase administrative services from an administrative service
organization. A plan of self-insurance may combine forms of re-insurance or
stop-loss insurance which limits the amount of State liability.
The program of health benefits shall provide a continuation and
conversion privilege for persons whose State employment is terminated and
a continuation privilege for members' spouses and dependent children who
are covered under the provisions of the program, consistent with the
requirements of federal law and Sections 367.2, 367e, and
367e.1 of the Illinois
Insurance Code.
(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/6.4) (from Ch. 127, par. 526.4)
Sec. 6.4. Prescription drugs; cancer treatment. If the program of
health benefits provides coverage for prescribed drugs approved by the
federal Food and Drug Administration for the treatment of certain types of
cancer, it may not exclude coverage of any drug on the basis that the drug
has been prescribed for the treatment of a type of cancer for which the
drug has not been approved by the federal Food and Drug Administration.
The drug, however, must be approved by the federal Food and Drug
Administration and must be recognized for the treatment of the specific
type of cancer for which the drug has been prescribed in
any one of the following established reference compendia:
(a) the American Hospital Formulary Service Drug | ||
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(b) National Comprehensive Cancer Network's Drugs & | ||
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(c) Thomson Micromedex's Drug Dex; (d) Elsevier Gold Standard's Clinical Pharmacology; or (e) other authoritative compendia as identified from | ||
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if not in the compendia, recommended for that particular type of cancer
in formal clinical studies, the results of which have been published in at
least two peer reviewed professional medical journals published in the
United States or Great Britain.
Any coverage required by this Section shall also include those medically
necessary services associated with the administration of a drug.
Despite the provisions of this Section, coverage shall
not be required for any experimental or investigational drugs or any drug
that the federal Food and Drug Administration has determined to be
contraindicated for treatment of the specific type of cancer for which the
drug has been prescribed. This Section shall apply only to cancer drugs.
Nothing in this Section shall be construed, expressly or by implication, to
create, impair, alter, limit, notify, enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any other disease or
condition.
(Source: P.A. 96-457, eff. 8-14-09.)
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(5 ILCS 375/6.5) Sec. 6.5. Health benefits for TRS benefit recipients and TRS dependent beneficiaries. (a) Purpose. It is the purpose of this amendatory Act of 1995 to transfer the administration of the program of health benefits established for benefit recipients and their dependent beneficiaries under Article 16 of the Illinois Pension Code to the Department of Central Management Services. (b) Transition provisions. The Board of Trustees of the Teachers' Retirement System shall continue to administer the health benefit program established under Article 16 of the Illinois Pension Code through December 31, 1995. Beginning January 1, 1996, the Department of Central Management Services shall be responsible for administering a program of health benefits for TRS benefit recipients and TRS dependent beneficiaries under this Section. The Department of Central Management Services and the Teachers' Retirement System shall cooperate in this endeavor and shall coordinate their activities so as to ensure a smooth transition and uninterrupted health benefit coverage. (c) Eligibility. All persons who were enrolled in the Article 16 program at the time of the transfer shall be eligible to participate in the program established under this Section without any interruption or delay in coverage or limitation as to pre-existing medical conditions. Eligibility to participate shall be determined by the Teachers' Retirement System. Eligibility information shall be communicated to the Department of Central Management Services in a format acceptable to the Department. Eligible TRS benefit recipients may enroll or re-enroll in the program of health benefits established under this Section during any applicable annual open enrollment period and as otherwise permitted by the Department of Central Management Services. A TRS benefit recipient shall not be deemed ineligible to participate solely by reason of the TRS benefit recipient having made a previous election to disenroll or otherwise not participate in the program of health benefits. A TRS dependent beneficiary who is a child age 19 or over and mentally or physically disabled does not become ineligible to participate by reason of (i) becoming ineligible to be claimed as a dependent for Illinois or federal income tax purposes or (ii) receiving earned income, so long as those earnings are insufficient for the child to be fully self-sufficient. (d) Coverage. The level of health benefits provided under this Section shall be similar to the level of benefits provided by the program previously established under Article 16 of the Illinois Pension Code. For plan years that begin on or after January 1, 2025, the health benefit program established under this Section shall include health, dental, and vision benefits. Group life insurance benefits are not included in the benefits to be provided to TRS benefit recipients and TRS dependent beneficiaries under this Act. The program of health benefits under this Section may include any or all of the benefit limitations, including but not limited to a reduction in benefits based on eligibility for federal Medicare benefits, that are provided under subsection (a) of Section 6 of this Act for other health benefit programs under this Act. (e) Insurance rates and premiums. The Director shall determine the insurance rates and premiums for TRS benefit recipients and TRS dependent beneficiaries, and shall present to the Teachers' Retirement System of the State of Illinois, by April 15 of each calendar year, the rate-setting methodology (including but not limited to utilization levels and costs) used to determine the amount of the health care premiums. For Fiscal Year 1996, the premium shall be equal to | ||
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For Fiscal Year 2003, the premium shall not exceed | ||
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For Fiscal Year 2004, the premium shall not exceed | ||
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For Fiscal Year 2005, the premium shall not exceed a | ||
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For Fiscal Year 2006, the premium shall not exceed a | ||
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For Fiscal Year 2007, the premium shall not exceed a | ||
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For Fiscal Year 2008 and thereafter, the premium in | ||
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In addition to the premium amount charged for the program of health benefits, in the initial plan year in which the dental and vision benefits are provided, an additional premium of not more than $7.11 per month for each TRS benefit recipient and $28.43 per month for each TRS dependent beneficiary shall be charged. The additional premium shall be used for the purpose of financing the dental and vision benefits for TRS benefit recipients and TRS dependent beneficiaries on and after the effective date of this amendatory Act of the 103rd General Assembly. Rates and premiums may be based in part on age and eligibility for federal medicare coverage. However, the cost of participation for a TRS dependent beneficiary who is an unmarried child age 19 or over and mentally or physically disabled shall not exceed the cost for a TRS dependent beneficiary who is an unmarried child under age 19 and participates in the same major medical or managed care program. The cost of health benefits under the program shall be paid as follows: (1) For a TRS benefit recipient selecting a managed | ||
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(2) For a TRS benefit recipient selecting the major | ||
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(3) For a TRS benefit recipient selecting the major | ||
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(3.1) For a TRS dependent beneficiary who is Medicare | ||
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(4) Except as otherwise provided in item (3.1), the | ||
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(5) If, for any month beginning on or after January | ||
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(f) Financing. Beginning July 1, 1995, all revenues arising from the administration of the health benefit programs established under Article 16 of the Illinois Pension Code or this Section shall be deposited into the Teacher Health Insurance Security Fund, which is hereby created as a nonappropriated trust fund to be held outside the State Treasury, with the State Treasurer as custodian. Any interest earned on moneys in the Teacher Health Insurance Security Fund shall be deposited into the Fund. Moneys in the Teacher Health Insurance Security Fund shall be used only to pay the costs of the health benefit program established under this Section, including associated administrative costs, and the costs associated with the health benefit program established under Article 16 of the Illinois Pension Code, as authorized in this Section. Beginning July 1, 1995, the Department of Central Management Services may make expenditures from the Teacher Health Insurance Security Fund for those costs. After other funds authorized for the payment of the costs of the health benefit program established under Article 16 of the Illinois Pension Code are exhausted and until January 1, 1996 (or such later date as may be agreed upon by the Director of Central Management Services and the Secretary of the Teachers' Retirement System), the Secretary of the Teachers' Retirement System may make expenditures from the Teacher Health Insurance Security Fund as necessary to pay up to 75% of the cost of providing health coverage to eligible benefit recipients (as defined in Sections 16-153.1 and 16-153.3 of the Illinois Pension Code) who are enrolled in the Article 16 health benefit program and to facilitate the transfer of administration of the health benefit program to the Department of Central Management Services. The Department of Central Management Services, or any successor agency designated to procure healthcare contracts pursuant to this Act, is authorized to establish funds, separate accounts provided by any bank or banks as defined by the Illinois Banking Act, or separate accounts provided by any savings and loan association or associations as defined by the Illinois Savings and Loan Act of 1985 to be held by the Director, outside the State treasury, for the purpose of receiving the transfer of moneys from the Teacher Health Insurance Security Fund. The Department may promulgate rules further defining the methodology for the transfers. Any interest earned by moneys in the funds or accounts shall inure to the Teacher Health Insurance Security Fund. The transferred moneys, and interest accrued thereon, shall be used exclusively for transfers to administrative service organizations or their financial institutions for payments of claims to claimants and providers under the self-insurance health plan. The transferred moneys, and interest accrued thereon, shall not be used for any other purpose including, but not limited to, reimbursement of administration fees due the administrative service organization pursuant to its contract or contracts with the Department. (g) Contract for benefits. The Director shall by contract, self-insurance, or otherwise make available the program of health benefits for TRS benefit recipients and their TRS dependent beneficiaries that is provided for in this Section. The contract or other arrangement for the provision of these health benefits shall be on terms deemed by the Director to be in the best interest of the State of Illinois and the TRS benefit recipients based on, but not limited to, such criteria as administrative cost, service capabilities of the carrier or other contractor, and the costs of the benefits. (g-5) Committee. A Teacher Retirement Insurance Program Committee shall be established, to consist of 10 persons appointed by the Governor. The Committee shall convene at least 4 times each year, and shall consider and make recommendations on issues affecting the program of health benefits provided under this Section. Recommendations of the Committee shall be based on a consensus of the members of the Committee. If the Teacher Health Insurance Security Fund experiences a deficit balance based upon the contribution and subsidy rates established in this Section and Section 6.6 for Fiscal Year 2008 or thereafter, the Committee shall make recommendations for adjustments to the funding sources established under these Sections. In addition, the Committee shall identify proposed solutions to the funding shortfalls that are affecting the Teacher Health Insurance Security Fund, and it shall report those solutions to the Governor and the General Assembly within 6 months after August 15, 2011 (the effective date of Public Act 97-386). (h) Continuation of program. It is the intention of the General Assembly that the program of health benefits provided under this Section be maintained on an ongoing, affordable basis. The program of health benefits provided under this Section may be amended by the State and is not intended to be a pension or retirement benefit subject to protection under Article XIII, Section 5 of the Illinois Constitution. (i) Repeal. (Blank).(Source: P.A. 102-210, eff. 7-30-21; 103-588, eff. 6-5-24.) |
(5 ILCS 375/6.6)
Sec. 6.6. Contributions to the Teacher Health Insurance Security Fund.
(a) Beginning July 1, 1995, all active contributors of the Teachers'
Retirement System (established under Article 16 of the Illinois Pension Code)
who are not employees of a department as defined in Section 3 of this Act
shall make contributions toward the cost of annuitant and survivor health
benefits. These contributions shall be at the following rates:
until January 1, 2002, 0.5% of salary;
beginning January 1, 2002, 0.65% of salary;
beginning July 1, 2003, 0.75% of salary; beginning July 1, 2005, 0.80% of salary;
beginning July 1, 2007, a percentage of salary to be determined by the Department of Central Management Services by rule, which in each fiscal year shall not exceed 105% of the percentage of salary actually required to be paid in the previous fiscal year.
These contributions shall be deducted by the employer and paid to the System
as service agent for the Department of Central Management Services. The System
may use the same processes for collecting the contributions required by this
subsection that it uses to collect contributions received from school districts
and other covered employers under Sections 16-154 and 16-155 of the Illinois
Pension Code.
An employer may agree to pick up or pay the contributions required under
this subsection on behalf of the teacher; such contributions shall be deemed
to have to have been paid by the teacher. Beginning January 1, 2002, if
the employer does not directly pay the required member contribution, then the
employer shall reduce the member's salary by an amount equal to the required
contribution and shall then pay the contribution on behalf of the member.
This reduction shall not change the amounts reported as creditable earnings
to the Teachers' Retirement System.
A person who purchases optional service credit under Article 16 of the
Illinois Pension Code for a period after June 30, 1995 must also make a
contribution under this subsection for that optional credit, at the rate
provided in subsection (a), based on the salary used in
computing the optional service credit, plus interest on this employee
contribution. This contribution shall be collected by the System as service
agent for the Department of Central Management Services. The contribution
required under this subsection for the optional service credit must be paid
in full before any annuity based on that credit begins.
(a-5) Beginning January 1, 2002, every employer of a teacher (other than
an employer that is a department as defined in Section 3 of this Act) shall
pay an employer contribution toward the cost of annuitant and survivor health
benefits. These contributions shall be computed as follows:
(1) Beginning January 1, 2002 through June 30, 2003, | ||
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(2) Beginning July 1, 2003, the employer contribution | ||
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(3) Beginning July 1, 2005, the employer contribution | ||
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(4) Beginning July 1, 2007, the employer contribution | ||
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These contributions shall be paid by the employer to the System as service
agent for the Department of Central Management Services. The System may use
the same processes for collecting the contributions required by this subsection
that it uses to collect contributions received from school districts and other
covered employers under the Illinois Pension Code.
The school district or other employing unit may pay these employer
contributions out of any source of funding available for that purpose and
shall forward the contributions to the System on the schedule established
for the payment of member contributions.
(b) The Teachers' Retirement System shall promptly deposit all moneys
collected under subsections (a) and (a-5) of this
Section into the Teacher Health Insurance Security Fund created in Section 6.5
of this Act. The moneys collected under this Section shall be used only for
the purposes authorized in Section 6.5 of this Act and shall not be considered
to be assets of the Teachers' Retirement System. Contributions made under this
Section are not transferable to other pension funds or retirement systems and
are not refundable upon termination of service.
(c) On or before November 15 of each year, the Board of Trustees of the
Teachers' Retirement System shall certify to the Governor, the Director of
Central Management Services, and the State Comptroller its estimate of the
total amount of contributions to be paid under subsection (a) of this Section
6.6 for the next fiscal year. The amount certified shall be decreased or
increased each year by the amount that the actual active teacher contributions
either fell short of or exceeded the estimate used by the Board in making the
certification for the previous fiscal year. The certification shall include
a detailed explanation of the methods and information that the Board relied
upon in preparing its estimate. As soon as possible after the effective date
of this amendatory Act of the 92nd General Assembly, the Board
shall recalculate and recertify its certifications for fiscal years 2002 and
2003.
(d) Beginning in fiscal year 1996, on the first day of each month, or
as soon thereafter as may be practical, the State Treasurer and the State
Comptroller shall transfer from the General Revenue Fund to the Teacher Health
Insurance Security Fund 1/12 of the annual amount appropriated for that fiscal
year to the State Comptroller for deposit into the Teacher Health Insurance
Security Fund under Section 1.3 of the State Pension Funds Continuing
Appropriation Act.
(e) Except where otherwise specified in this Section, the definitions
that apply to Article 16 of the Illinois Pension Code apply to this Section.
(f) (Blank).
(Source: P.A. 92-505, eff. 12-20-01; 93-679, eff. 6-30-04.)
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(5 ILCS 375/6.7) Sec. 6.7. Access to obstetrical and gynecological care. The program of health benefits is subject to the provisions of Section 356r of the Illinois Insurance Code.(Source: P.A. 103-718, eff. 7-19-24.) |
(5 ILCS 375/6.8)
Sec. 6.8.
Post-parturition care.
The program of health
benefits shall provide the post-parturition care benefits required to be
covered by a policy of accident and health insurance under Section 356s of the
Illinois Insurance Code.
(Source: P.A. 89-513, eff. 7-17-96; 90-14, eff. 7-1-97.)
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(5 ILCS 375/6.9)
Sec. 6.9. Health benefits for community college benefit recipients and
community college dependent beneficiaries. (a) Purpose. It is the purpose of this amendatory Act of 1997 to establish
a uniform program of health benefits for community college benefit recipients
and their dependent beneficiaries under the administration of the Department of
Central Management Services.
(b) Creation of program. Beginning July 1, 1999, the Department of
Central Management Services shall be responsible for administering a program of
health benefits for community college benefit recipients and community college
dependent beneficiaries under this Section. The State Universities Retirement
System and the boards of trustees of the various community college districts
shall cooperate with the Department in this endeavor.
(c) Eligibility. All community college benefit recipients and community
college dependent beneficiaries shall be eligible to participate in the program
established under this Section, without any interruption or delay in coverage
or limitation as to pre-existing medical conditions. Eligibility to
participate shall be determined by the State Universities Retirement System.
Eligibility information shall be communicated to the Department of Central
Management Services in a format acceptable to the Department.
Eligible community college benefit recipients may enroll or re-enroll in the program of health benefits established under this Section during any applicable annual open enrollment period and as otherwise permitted by the Department of Central Management Services. A community college benefit recipient shall not be deemed ineligible to participate solely by reason of the community college benefit recipient having made a previous election to disenroll or otherwise not participate in the program of health benefits. (d) Coverage. The health benefit coverage provided under this Section
shall be a program of health, dental, and vision benefits.
The program of health benefits under this Section may include any or all of
the benefit limitations, including but not limited to a reduction in benefits
based on eligibility for federal Medicare benefits, that are provided under
subsection (a) of Section 6 of this Act for other health benefit programs under
this Act.
(e) Insurance rates and premiums. The Director shall determine the
insurance rates and premiums for community college benefit recipients and
community college dependent beneficiaries and shall present to the State Universities Retirement System, by April 15 of each calendar year, the rate-setting methodology (including, but not limited to, utilization levels and costs) used to determine the insurance rates and premiums. Rates and premiums may be based
in part on age and eligibility for federal Medicare coverage.
The Director shall also determine premiums that will allow for the
establishment of an actuarially sound reserve for this program.
The cost of health benefits under the program shall be paid as follows:
(1) For a community college benefit recipient, up to | ||
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(2) The balance of the rate of insurance, including | ||
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(f) Financing. All revenues arising from the administration of the health
benefit program established under this Section shall be deposited into the
Community College Health Insurance Security Fund, which is hereby created as a
nonappropriated trust fund to be held outside the State Treasury, with the
State Treasurer as custodian. Any interest earned on moneys in the Community
College Health Insurance Security Fund shall be deposited into the Fund.
Moneys in the Community College Health Insurance Security Fund shall be used
only to pay the costs of the health benefit program established under this
Section, including associated administrative costs and the establishment of a
program reserve. Beginning January 1, 1999,
the Department of Central Management Services may make expenditures from the
Community College Health Insurance Security Fund for those costs.
(g) Contract for benefits. The Director shall by contract, self-insurance,
or otherwise make available the program of health benefits for community
college benefit recipients and their community college dependent beneficiaries
that is provided for in this Section. The contract or other arrangement for
the provision of these health benefits shall be on terms deemed by the Director
to be in the best interest of the State of Illinois and the community college
benefit recipients based on, but not limited to, such criteria as
administrative cost, service capabilities of the carrier or other contractor,
and the costs of the benefits.
(h) Continuation of program. It is the intention of the General Assembly
that the program of health benefits provided under this Section be maintained
on an ongoing, affordable basis. The program of health benefits provided under
this Section may be amended by the State and is not intended to be a pension or
retirement benefit subject to protection under Article XIII, Section 5 of the
Illinois Constitution.
(i) Other health benefit plans. A health benefit plan provided by a
community college district (other than a community college district subject to
Article VII of the Public Community College Act) under the terms of a
collective bargaining agreement in effect on or prior to the effective date of
this amendatory Act of 1997 shall continue in force according to the terms of
that agreement, unless otherwise mutually agreed by the parties to that
agreement and the affected retiree.
A community college benefit recipient or community college dependent
beneficiary whose coverage under such a plan expires shall be eligible to begin
participating in the program established under this Section without any
interruption or delay in coverage or limitation as to pre-existing medical
conditions.
This Act does not prohibit any community college district from offering
additional health benefits for its retirees or their dependents or survivors.
(j) Committee. A Community College Insurance Program Committee shall be established and shall consist of the following 7 members who are appointed by the Governor: 2 members who represent organized labor and are each members of different unions; one member who represents community college retirees; one member who represents community college trustees; one member who represents community college presidents; one member who represents the Illinois Community College Board; and one ex officio member who represents the State Universities Retirement System. The Department of Central Management Services shall provide administrative support to the Committee. The Committee shall convene at least 4 times each year and shall review and make recommendations on program contribution rates once the program is forecasted to have satisfied the outstanding program debt existing on June 30, 2023 and is operating on a no-hold payment cycle. (Source: P.A. 103-8, eff. 6-7-23.)
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(5 ILCS 375/6.10)
Sec. 6.10. Contributions to the Community College Health Insurance
Security Fund. (a) Beginning January 1, 1999 and through June 30, 2023, every active contributor of the State
Universities Retirement System (established under Article 15 of the Illinois
Pension Code) who (1) is a full-time employee of a community college district
(other than a community college district subject to Article VII of the Public
Community College Act)
or an association of community college boards and (2) is not an employee as
defined in Section 3 of this Act shall make contributions toward the cost of
community college annuitant and survivor health benefits at the rate of 0.50%
of salary. Beginning July 1, 2023 and through June 30, 2024, the contribution rate shall be 0.75% of salary. Beginning July 1, 2024 and through June 30, 2026, the contribution rate shall be a percentage of salary to be determined by the Department of Central Management Services, which in each fiscal year shall not exceed a 0.1 percentage point increase in the amount of salary actually required to be contributed for the previous fiscal year. Beginning July 1, 2026, the contribution rate shall be a percentage of salary to be determined by the Department of Central Management Services, which in each fiscal year shall not exceed 105% of the percentage of salary actually required to be contributed for the previous fiscal year.
These contributions shall be deducted by the employer and paid to the State
Universities Retirement System as service agent for the Department of Central
Management Services. The System may use the same processes for collecting the
contributions required by this subsection that it uses to collect the
contributions received from those employees under Section 15-157 of the
Illinois Pension Code. An employer may agree to pick up or pay the
contributions required under this subsection on behalf of the employee;
such contributions shall be deemed to have been paid by the employee.
The State Universities Retirement System shall promptly deposit all moneys
collected under this subsection (a) into the Community College Health Insurance
Security Fund created in Section 6.9 of this Act. The moneys collected under
this Section shall be used only for the purposes authorized in Section 6.9 of
this Act and shall not be considered to be assets of the State Universities
Retirement System. Contributions made under this Section are not transferable
to other pension funds or retirement systems and are not refundable upon
termination of service.
(b) Beginning January 1, 1999 and through June 30, 2023, every community college district
(other than a community college district subject to Article VII of the Public
Community College Act) or association
of community college boards that is an employer under the State Universities
Retirement System shall contribute toward the cost of the community college
health benefits provided under Section 6.9 of this Act an amount equal to 0.50%
of the salary paid to its full-time employees who participate in the State
Universities Retirement System and are not members as defined in Section 3 of
this Act. Beginning July 1, 2023 and through June 30, 2024, the contribution rate shall be 0.75% of the salary. Beginning July 1, 2024 and through June 30, 2026, the contribution rate shall be a percentage of salary to be determined by the Department of Central Management Services, which in each fiscal year shall not exceed a 0.1 percentage point increase in the amount of salary actually required to be contributed for the previous fiscal year. Beginning July 1, 2026, the contribution rate shall be a percentage of salary to be determined by the Department of Central Management Services, which in each fiscal year shall not exceed 105% of the percentage of salary actually required to be contributed for the previous fiscal year.
These contributions shall be paid by the employer to the State Universities
Retirement System as service agent for the Department of Central Management
Services. The System may use the same processes for collecting the
contributions required by this subsection that it uses to collect the
contributions received from those employers under Section 15-155 of the
Illinois Pension Code.
The State Universities Retirement System shall promptly deposit all moneys
collected under this subsection (b) into the Community College Health Insurance
Security Fund created in Section 6.9 of this Act. The moneys collected under
this Section shall be used only for the purposes authorized in Section 6.9 of
this Act and shall not be considered to be assets of the State Universities
Retirement System. Contributions made under this Section are not transferable
to other pension funds or retirement systems and are not refundable upon
termination of service.
The Department of Central Management Services, or any successor agency designated to procure healthcare contracts pursuant to this Act, is authorized to establish funds, separate accounts provided by any bank or banks as defined by the Illinois Banking Act, or separate accounts provided by any savings and loan association or associations as defined by the Illinois Savings and Loan Act of 1985 to be held by the Director, outside the State treasury, for the purpose of receiving the transfer of moneys from the Community College Health Insurance Security Fund. The Department may promulgate rules further defining the methodology for the transfers. Any interest earned by moneys in the funds or accounts shall inure to the Community College Health Insurance Security Fund. The transferred moneys, and interest accrued thereon, shall be used exclusively for transfers to administrative service organizations or their financial institutions for payments of claims to claimants and providers under the self-insurance health plan. The transferred moneys, and interest accrued thereon, shall not be used for any other purpose including, but not limited to, reimbursement of administration fees due the administrative service organization pursuant to its contract or contracts with the Department.
(c) On or before November 15 of each year, the Board of Trustees of the
State Universities Retirement System shall certify to the Governor, the
Director of Central Management Services, and the State
Comptroller its estimate of the total amount of contributions to be paid under
subsection (a) of this Section for the next fiscal year. Beginning in fiscal year 2008, the amount certified shall be decreased or increased each year by the amount that the actual active employee contributions either fell short of or exceeded the estimate used by the Board in making the certification for the previous fiscal year. The State Universities Retirement System shall calculate the amount of actual active employee contributions in fiscal years 1999 through 2005. Based upon this calculation, the fiscal year 2008 certification shall include an amount equal to the cumulative amount that the actual active employee contributions either fell short of or exceeded the estimate used by the Board in making the certification for those fiscal years. The certification
shall include a detailed explanation of the methods and information that the
Board relied upon in preparing its estimate. As soon as possible after the
effective date of this Section, the Board shall submit its estimate for fiscal
year 1999.
On or after the effective date of the changes made to this Section by this amendatory Act of the 103rd General Assembly, but no later than June 30, 2023, the Board shall recalculate and recertify to the Governor, the Director of Central Management Services, and the State Comptroller its estimate of the total amount of contributions to be paid under subsection (a) for State fiscal year 2024, taking into account the changes in required employee contributions made by this amendatory Act of the 103rd General Assembly. (d) Beginning in fiscal year 1999, on the first day of each month, or as
soon thereafter as may be practical, the State Treasurer and the State
Comptroller shall transfer from the General Revenue Fund to the Community
College Health Insurance Security Fund 1/12 of the annual amount appropriated
for that fiscal year to the State Comptroller for deposit into the Community
College Health Insurance Security Fund under Section 1.4 of the State Pension
Funds Continuing Appropriation Act.
(e) Except where otherwise specified in this Section, the definitions
that apply to Article 15 of the Illinois Pension Code apply to this Section.
(Source: P.A. 103-8, eff. 6-7-23.)
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(5 ILCS 375/6.11) (Text of Section from P.A. 103-605) Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 of the Illinois Insurance Code; all other requirements of this Section shall be enforced by the Department of Central Management Services. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24.) (Text of Section from P.A. 103-718) Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 of the Illinois Insurance Code; all other requirements of this Section shall be enforced by the Department of Central Management Services. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-718, eff. 7-19-24.) (Text of Section from P.A. 103-751, 103-870, 103-918, and 103-1024) Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.70, and 356z.71 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 of the Illinois Insurance Code; all other requirements of this Section shall be enforced by the Department of Central Management Services. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-751, eff. 8-2-24; 103-870, eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25.) (Text of Section from P.A. 103-914) Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 of the Illinois Insurance Code; all other requirements of this Section shall be enforced by the Department of Central Management Services. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-914, eff. 1-1-25.) (Text of Section from P.A. 103-951) Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 of the Illinois Insurance Code; all other requirements of this Section shall be enforced by the Department of Central Management Services. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-951, eff. 1-1-25.) |
(5 ILCS 375/6.11A) Sec. 6.11A. Physical therapy and occupational therapy. (a) The program of health benefits provided under this Act shall provide coverage for medically necessary physical therapy and occupational therapy when that therapy is ordered for the treatment of autoimmune diseases or referred for the same purpose by (i) a physician licensed under the Medical Practice Act of 1987, (ii) a physician assistant licensed under the Physician Assistant Practice Act of 1987, or (iii) an advanced practice registered nurse licensed under the Nurse Practice Act. (b) For the purpose of this Section, "medically necessary" means any care, treatment, intervention, service, or item that will or is reasonably expected to: (i) prevent the onset of an illness, condition, | ||
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(ii) reduce or ameliorate the physical, mental, or | ||
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(iii) assist the achievement or maintenance of | ||
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(c) The coverage required under this Section shall be subject to the same deductible, coinsurance, waiting period, cost sharing limitation, treatment limitation, calendar year maximum, or other limitations as provided for other physical or rehabilitative or occupational therapy benefits covered by the policy. (d) Upon request of the reimbursing insurer, the provider of the physical therapy or occupational therapy shall furnish medical records, clinical notes, or other necessary data that substantiate that initial or continued treatment is medically necessary. When treatment is anticipated to require continued services to achieve demonstrable progress, the insurer may request a treatment plan consisting of the diagnosis, proposed treatment by type, proposed frequency of treatment, anticipated duration of treatment, anticipated outcomes stated as goals, and proposed frequency of updating the treatment plan. (e) When making a determination of medical necessity for treatment, an insurer must make the determination in a manner consistent with the manner in which that determination is made with respect to other diseases or illnesses covered under the policy, including an appeals process. During the appeals process, any challenge to medical necessity may be viewed as reasonable only if the review includes a licensed health care professional with the same category of license as the professional who ordered or referred the service in question and with expertise in the most current and effective treatment.
(Source: P.A. 99-581, eff. 1-1-17; 100-513, eff. 1-1-18.) |
(5 ILCS 375/6.11B) (Section scheduled to be repealed on July 1, 2026) Sec. 6.11B. Infertility coverage. (a) Beginning on January 1, 2024, the State Employees Group Insurance Program shall provide coverage for the diagnosis and treatment of infertility, including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer. The coverage required shall include procedures necessary to screen or diagnose a fertilized egg before implantation, including, but not limited to, preimplantation genetic diagnosis, preimplantation genetic screening, and prenatal genetic diagnosis. (b) Beginning on January 1, 2024, coverage under this Section for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if the procedures: (1) are considered medically appropriate based on | ||
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(2) are performed at medical facilities or clinics | ||
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(c) As used in this Section, "infertility" means a disease, condition, or status characterized by: (1) a failure to establish a pregnancy or to carry a | ||
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(2) a person's inability to reproduce either as a | ||
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(3) a licensed physician's findings based on a | ||
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(d) The State Employees Group Insurance Program may not impose any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on any other prescription medications, nor may it impose any exclusions, limitations, or other restrictions on coverage of any fertility services based on a covered individual's participation in fertility services provided by or to a third party, nor may it impose deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for the diagnosis of infertility, treatment for infertility, and standard fertility preservation services, except as provided in this Section, that are different from those imposed upon benefits for services not related to infertility. (e) This Section applies only to coverage provided on or after January 1, 2024 and before July 1, 2026. (f) This Section is repealed on July 1, 2026. (Source: P.A. 103-8, eff. 1-1-24; 103-751, eff. 8-2-24.) |
(5 ILCS 375/6.11C) Sec. 6.11C. Coverage for injectable medicines to improve glucose or weight loss. Beginning on July 1, 2024, the State Employees Group Insurance Program shall provide coverage for all types of medically necessary, as determined by a physician licensed to practice medicine in all its branches, injectable medicines prescribed on-label or off-label to improve glucose or weight loss for use by adults diagnosed or previously diagnosed with prediabetes, gestational diabetes, or obesity. To continue to qualify for coverage under this Section, the continued treatment must be medically necessary, and covered members must, if given advance, written notice, participate in a lifestyle management plan administered by their health plan. This Section does not apply to individuals covered by a Medicare Advantage Prescription Drug Plan.(Source: P.A. 103-8, eff. 1-1-24; 103-564, eff. 11-17-23.) |
(5 ILCS 375/6.11D) (Text of Section from P.A. 103-818) (This Section may contain text from a Public Act with a delayed effective date) Sec. 6.11D. Joint mental health therapy services. (a) The State Employees Group Insurance Program shall provide coverage for joint mental health therapy services for any Illinois State Police officer or police officer of an institution of higher education and any spouse or partner of the officer who resides with the officer. (b) The joint mental health therapy services provided under subsection (a) shall be performed by a physician licensed to practice medicine in all of its branches, a licensed clinical psychologist, a licensed clinical social worker, a licensed clinical professional counselor, a licensed marriage and family therapist, a licensed social worker, or a licensed professional counselor. (Source: P.A. 103-818, eff. 1-1-25.) (Text of Section from P.A. 103-975) (This Section may contain text from a Public Act with a delayed effective date) Sec. 6.11D. Coverage for treatments to slow the progression of Alzheimer's disease and related dementias. Beginning on July 1, 2025, the State Employees Group Insurance Program shall provide coverage for all medically necessary FDA-approved treatments or medications prescribed to slow the progression of Alzheimer's disease or another related dementia, as determined by a physician licensed to practice medicine in all its branches. Coverage for all FDA-approved treatments or medications prescribed to slow the progression of Alzheimer's disease or another related dementia shall not be subject to step therapy. Any diagnostic testing necessary for a physician to determine appropriate use of these treatments or medications shall be covered by the State Employees Group Insurance Program.(Source: P.A. 103-975, eff. 1-1-25.) |
(5 ILCS 375/6.12)
Sec. 6.12. Payment for services. The program of health benefits
is subject to the provisions of Sections 368a and 370a of the Illinois
Insurance Code, provided that, if a covered member or covered dependent assigns payments to a health care professional for covered services, then the health care professional shall only collect at point of service from that person the estimated amount not expected to be paid by the plan.
(Source: P.A. 97-1086, eff. 8-24-12.)
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(5 ILCS 375/6.13)
Sec. 6.13.
Managed Care Reform and Patient Rights Act.
The
program of
health
benefits
is subject to the provisions of the Managed Care Reform and Patient Rights
Act, except the fee for service program shall only be required to comply with
Section 85 and the definition of "emergency medical condition" in Section 10 of
the Managed Care Reform and Patient Rights Act.
(Source: P.A. 91-617, eff. 8-19-99; 92-16, eff. 6-28-01.)
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(5 ILCS 375/6.14)
Sec. 6.14.
Organ donor costs.
With respect to organ transplants occurring
after
June 30, 2000 when both a donor and donee are members of the same family and
are
both covered by the program of health benefits, the program of health benefits
shall pay
100% of the donor's expenses without the imposition of any deductible or
copayment.
(Source: P.A. 92-204, eff. 8-1-01.)
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(5 ILCS 375/6.15)
Sec. 6.15.
Retired teacher returning to service in shortage area.
Notwithstanding any other provision of this Act, the eligibility of an
annuitant or TRS benefit recipient to participate in the program of health
benefits established under Section 6 or 6.5 of this Act is suspended for any
period during which he or she is covered under a plan of group health benefits
for active teachers due to eligible employment as defined in Section 16-150.1
of the Illinois Pension Code. Upon termination of that coverage, eligibility
to participate in the program of health benefits established under Section 6 or
6.5 shall be immediately restored, without any interruption or delay in
coverage or limitation as to pre-existing medical condition.
(Source: P.A. 93-320, eff. 7-23-03.)
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(5 ILCS 375/6.16) Sec. 6.16. Human breast milk coverage. (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that | ||
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(2) the infant's mother is medically or physically | ||
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(3) the milk has been determined to be medically | ||
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(4) one or more of the following applies: (A) the infant's birth weight is below 1,500 | ||
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(B) the infant has a congenital or acquired | ||
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(C) the infant has infant hypoglycemia; (D) the infant has congenital heart disease; (E) the infant has had or will have an organ | ||
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(F) the infant has sepsis; or (G) the infant has any other serious congenital | ||
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(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that | ||
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(2) the child's mother is medically or physically | ||
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(3) the milk has been determined to be medically | ||
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(4) one or more of the following applies: (A) the child has spinal muscular atrophy; (B) the child's birth weight was below 1,500 | ||
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(C) the child has had or will have an organ | ||
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(D) the child has a congenital or acquired | ||
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(Source: P.A. 101-511, eff. 1-1-20.) |
(5 ILCS 375/7) (from Ch. 127, par. 527)
Sec. 7. Group life insurance program.
(a) The basic noncontributory group life insurance program shall
provide coverage as follows:
(1) employees shall be insured in an amount equal to | ||
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(2) annuitants shall be insured in the same manner as | ||
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(3) survivors whose coverage became effective prior | ||
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(4) retired employees shall not be eligible under the | ||
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(a-5) There shall also be available on an optional basis to employees,
annuitants whose retirement benefits begin within one year of their receipt of
final compensation, and survivors whose coverage became effective prior to
September 22, 1979, a contributory program of:
(1) supplemental life insurance in an amount not | ||
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(2) accidental death and dismemberment, with the | ||
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(3) dependent life insurance in an amount of $10,000 | ||
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(4) dependent life insurance in an amount of $10,000 | ||
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(b) A member, not otherwise covered by this Act, who has retired as a
participating member under Article 2 of the Illinois Pension
Code, but is ineligible for the retirement annuity under Section 2-119
of the Illinois Pension Code, shall pay the premiums for coverage under
the group life insurance program under this Act. The Director shall promulgate
rules and regulations to determine the premiums to be paid by a member
under this subsection (b).
(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/7.1) (from Ch. 127, par. 527.1)
Sec. 7.1.
Any benefit received by an employee under this
Act pursuant to a collective bargaining agreement may be
extended by the Director to employees whose wages, hours and
other conditions of employment with the State are not subject
to a collective bargaining agreement. In addition, if any benefit
is offered by the Department of Central Management Services to
employees who are not members of a recognized bargaining unit,
then that benefit shall also be offered to all bargaining unit
members through their certified exclusive representative.
(Source: P.A. 85-848.)
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(5 ILCS 375/8) (from Ch. 127, par. 528)
Sec. 8. Eligibility.
(a) Each employee eligible under the provisions of this Act and any rules
and regulations promulgated and adopted hereunder by the Director shall
become immediately eligible and covered for all benefits available under
the programs. Employees electing coverage for eligible dependents shall have
the coverage effective immediately, provided that the election is properly
filed in accordance with required filing dates and procedures specified by
the Director, including the completion and submission of all documentation and forms required by the Director.
(1) Every member originally eligible to elect | ||
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(2) Members described above being transferred from | ||
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(3) Eligible and covered members that are eligible | ||
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(b) New employees shall be immediately insured for the basic group
life insurance and covered by the program of health benefits on the first
day of active State service. Optional life insurance coverage one to 4 times the basic amount, if elected
during the relevant eligibility period, will become effective on the date
of employment. Optional life insurance coverage exceeding 4 times the basic amount and all life insurance amounts applied for after the
eligibility period will be effective, subject to satisfactory evidence of
insurability when applicable, or other necessary qualifications, pursuant to
the requirements of the applicable benefit program, unless there is a change in
status that would confer new eligibility for change of enrollment under rules
established supplementing this Act, in which event application must be made
within the new eligibility period.
(c) As to the group health benefits program contracted to begin or
continue after June 30, 1973, each annuitant, survivor, and retired employee shall become immediately
eligible for all benefits available under that program. Each annuitant, survivor, and retired employee shall have coverage effective immediately, provided that the election is properly filed in accordance with the required filing dates and procedures specified by the Director, including the completion and submission of all documentation and forms required by the Director. Annuitants, survivors, and retired
employees may elect coverage for eligible dependents and shall have the
coverage effective immediately, provided that the election is properly
filed in accordance with required filing dates and procedures specified
by the Director, except that, for a survivor, the dependent sought to be added on or after the effective date of this amendatory Act of the 97th General Assembly must have been eligible for coverage as a dependent under the deceased member upon whom the survivor's annuity is based in order to be eligible for coverage under the survivor.
Except as otherwise provided in this Act, where husband and wife are
both eligible members, each shall be enrolled as a member and coverage on
their eligible dependent children, if any, may be under the enrollment and
election of either.
Regardless of other provisions herein regarding late enrollment or other
qualifications, as appropriate, the
Director may periodically authorize open enrollment periods for each of the
benefit programs at which time each member may elect enrollment or change
of enrollment without regard to age, sex, health, or other qualification
under the conditions as may be prescribed in rules and regulations
supplementing this Act. Special open enrollment periods may be declared by
the Director for certain members only when special circumstances occur that
affect only those members.
(d) Eligible
members may elect not to participate in the program of health benefits as
defined in this Act. The election must be made during the annual benefit
choice period or upon showing a qualifying change in status as defined in the U.S. Internal Revenue Code, subject to the conditions in this subsection.
(1) (Blank).
(2) Members may re-enroll in the Department of | ||
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(3) Members may also re-enroll in the program of | ||
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(4) Members who elect not to participate in the | ||
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(d-5) Beginning July 1, 2005, the Director may establish a program of financial incentives to encourage annuitants receiving a retirement annuity, but who are not eligible for benefits under the federal Medicare health insurance program (Title XVIII of the Social Security Act, as added by Public Law 89-97) to elect not to participate in the program of health benefits provided under this Act. The election by an annuitant not to participate under this program must be made in accordance with the requirements set forth under subsection (d). The financial incentives provided to these annuitants under the program may not exceed $150 per month for each annuitant electing not to participate in the program of health benefits provided under this Act.
(d-6) Beginning July 1, 2013, the Director may establish a program of financial incentives to encourage annuitants with 20 or more years of creditable service but who are not eligible for benefits under the federal Medicare health insurance program (Title XVIII of the Social Security Act, as added by Public Law 89-97) to elect not to participate in the program of health benefits provided under this Act. The election by an annuitant not to participate under this program must be made in accordance with the requirements set forth under subsection (d). The program established under this subsection (d-6) may include a prorated incentive for annuitants with fewer than 20 years of creditable service, as determined by the Director. The financial incentives provided to these annuitants under this program may not exceed $500 per month for each annuitant electing not to participate in the program of health benefits provided under this Act. (e) Notwithstanding any other provision of this Act or the rules adopted
under this Act, if a person participating in the program of health benefits as
the dependent spouse of an eligible member becomes an annuitant, the person may
elect, at the time of becoming an annuitant or during any subsequent annual
benefit choice period, to continue participation as a dependent rather than
as an eligible member for as long as the person continues to be an eligible
dependent. In order to be eligible to make such an election, the person must have been enrolled as a dependent under the program of health benefits for no less than one year prior to becoming an annuitant.
An eligible member who has elected to participate as a dependent may
re-enroll in the program of health benefits as an eligible member (i)
during any subsequent annual benefit choice period or (ii) upon showing a
qualifying change in status, as defined in the U.S. Internal Revenue Code,
without evidence of insurability and with no limitations on coverage for
pre-existing conditions.
A person who elects to participate in the program of health benefits as
a dependent rather than as an eligible member shall be furnished a written
explanation of the consequences of electing to participate as a dependent and
the conditions and procedures for re-enrolling as an eligible member. The
explanation shall also be included in the annual benefit choice options booklet
furnished to members.
(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/9) (from Ch. 127, par. 529)
Sec. 9.
(a) The eligible member shall be responsible for his or her
portion of the
premiums, charges or other fees for all elected coverages
or benefits, which shall be paid by means of the acceptance of a reduction
in earnings or the foregoing of an increase in earnings by an employee;
provided, however, subject to rules and regulations promulgated by the
Department, the eligible member may make personal payment of the premium,
charge or fee for any wellness programs implemented under the program of
health benefits.
All contributions and payments by the eligible members and the State for
all elected coverages and benefits shall be deposited in the
Health Insurance Reserve Fund. The Department may determine the aggregate
level of contribution required under this Section on the basis of actual
cost of services adjusted for age, sex or the geographical or other
demographic characteristics which affect costs of the benefit.
(b) If a member is not entitled to receive any salary, wages or other
compensation during a period in which premiums,
charges or other fees are due or does not receive compensation
sufficient to allow deduction of the required payment of the
premium, charge or other fee, such member may continue the contributory
benefit in effect by making personal payment of the premium, charge or
other fee for the period in such manner, in such amount, and
for such duration, as may be prescribed in rules and regulations promulgated
for the administration of this Act.
(Source: P.A. 91-390, eff. 7-30-99.)
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(5 ILCS 375/10) (from Ch. 127, par. 530)
Sec. 10. Contributions by the State and members.
(a) The State shall pay the cost of basic non-contributory group life
insurance and, subject to member paid contributions set by the Department or
required by this Section and except as provided in this Section, the basic program of group health benefits on each
eligible member, except a member, not otherwise
covered by this Act, who has retired as a participating member under Article 2
of the Illinois Pension Code but is ineligible for the retirement annuity under
Section 2-119 of the Illinois Pension Code, and part of each eligible member's
and retired member's premiums for health insurance coverage for enrolled
dependents as provided by Section 9. The State shall pay the cost of the basic
program of group health benefits only after benefits are reduced by the amount
of benefits covered by Medicare for all members and dependents
who are eligible for benefits under Social Security or
the Railroad Retirement system or who had sufficient Medicare-covered
government employment, except that such reduction in benefits shall apply only
to those members and dependents who (1) first become eligible
for such Medicare coverage on or after July 1, 1992; or (2) are
Medicare-eligible members or dependents of a local government unit which began
participation in the program on or after July 1, 1992; or (3) remain eligible
for, but no longer receive Medicare coverage which they had been receiving on
or after July 1, 1992. The Department may determine the aggregate level of the
State's contribution on the basis of actual cost of medical services adjusted
for age, sex or geographic or other demographic characteristics which affect
the costs of such programs.
The cost of participation in the basic program of group health benefits
for the dependent or survivor of a living or deceased retired employee who was
formerly employed by the University of Illinois in the Cooperative Extension
Service and would be an annuitant but for the fact that he or she was made
ineligible to participate in the State Universities Retirement System by clause
(4) of subsection (a) of Section 15-107 of the Illinois Pension Code shall not
be greater than the cost of participation that would otherwise apply to that
dependent or survivor if he or she were the dependent or survivor of an
annuitant under the State Universities Retirement System.
(a-1) (Blank).
(a-2) (Blank).
(a-3) (Blank).
(a-4) (Blank).
(a-5) (Blank).
(a-6) (Blank).
(a-7) (Blank).
(a-8) Any annuitant, survivor, or retired employee may waive or terminate coverage in
the program of group health benefits. Any such annuitant, survivor, or retired employee
who has waived or terminated coverage may enroll or re-enroll in the
program of group health benefits only during the annual benefit choice period,
as determined by the Director; except that in the event of termination of
coverage due to nonpayment of premiums, the annuitant, survivor, or retired employee
may not re-enroll in the program.
(a-8.5) Beginning on the effective date of this amendatory Act of the 97th General Assembly, the Director of Central Management Services shall, on an annual basis, determine the amount that the State shall contribute toward the basic program of group health benefits on behalf of annuitants (including individuals who (i) participated in the General Assembly Retirement System, the State Employees' Retirement System of Illinois, the State Universities Retirement System, the Teachers' Retirement System of the State of Illinois, or the Judges Retirement System of Illinois and (ii) qualify as annuitants under subsection (b) of Section 3 of this Act), survivors (including individuals who (i) receive an annuity as a survivor of an individual who participated in the General Assembly Retirement System, the State Employees' Retirement System of Illinois, the State Universities Retirement System, the Teachers' Retirement System of the State of Illinois, or the Judges Retirement System of Illinois and (ii) qualify as survivors under subsection (q) of Section 3 of this Act), and retired employees (as defined in subsection (p) of Section 3 of this Act). The remainder of the cost of coverage for each annuitant, survivor, or retired employee, as determined by the Director of Central Management Services, shall be the responsibility of that annuitant, survivor, or retired employee. Contributions required of annuitants, survivors, and retired employees shall be the same for all retirement systems and shall also be based on whether an individual has made an election under Section 15-135.1 of the Illinois Pension Code. Contributions may be based on annuitants', survivors', or retired employees' Medicare eligibility, but may not be based on Social Security eligibility. (a-9) No later than May 1 of each calendar year, the Director
of Central Management Services shall certify in writing to the Executive
Secretary of the State Employees' Retirement System of Illinois the amounts
of the Medicare supplement health care premiums and the amounts of the
health care premiums for all other retirees who are not Medicare eligible.
A separate calculation of the premiums based upon the actual cost of each
health care plan shall be so certified.
The Director of Central Management Services shall provide to the
Executive Secretary of the State Employees' Retirement System of
Illinois such information, statistics, and other data as he or she
may require to review the premium amounts certified by the Director
of Central Management Services.
The Department of Central Management Services, or any successor agency designated to procure healthcare contracts pursuant to this Act, is authorized to establish funds, separate accounts provided by any bank or banks as defined by the Illinois Banking Act, or separate accounts provided by any savings and loan association or associations as defined by the Illinois Savings and Loan Act of 1985 to be held by the Director, outside the State treasury, for the purpose of receiving the transfer of moneys from the Local Government Health Insurance Reserve Fund. The Department may promulgate rules further defining the methodology for the transfers. Any interest earned by moneys in the funds or accounts shall inure to the Local Government Health Insurance Reserve Fund. The transferred moneys, and interest accrued thereon, shall be used exclusively for transfers to administrative service organizations or their financial institutions for payments of claims to claimants and providers under the self-insurance health plan. The transferred moneys, and interest accrued thereon, shall not be used for any other purpose including, but not limited to, reimbursement of administration fees due the administrative service organization pursuant to its contract or contracts with the Department.
(a-10) To the extent that participation, benefits, or premiums under this Act are based on a person's service credit under an Article of the Illinois Pension Code, service credit terminated in exchange for an accelerated pension benefit payment under Section 14-147.5, 15-185.5, or 16-190.5 of that Code shall be included in determining a person's service credit for the purposes of this Act. (b) State employees who become eligible for this program on or after January
1, 1980 in positions normally requiring actual performance of duty not less
than 1/2 of a normal work period but not equal to that of a normal work period,
shall be given the option of participating in the available program. If the
employee elects coverage, the State shall contribute on behalf of such employee
to the cost of the employee's benefit and any applicable dependent supplement,
that sum which bears the same percentage as that percentage of time the
employee regularly works when compared to normal work period.
(c) The basic non-contributory coverage from the basic program of
group health benefits shall be continued for each employee not in pay status or
on active service by reason of (1) leave of absence due to illness or injury,
(2) authorized educational leave of absence or sabbatical leave, or (3)
military leave. This coverage shall continue until
expiration of authorized leave and return to active service, but not to exceed
24 months for leaves under item (1) or (2). This 24-month limitation and the
requirement of returning to active service shall not apply to persons receiving
ordinary or accidental disability benefits or retirement benefits through the
appropriate State retirement system or benefits under the Workers' Compensation
or Occupational Disease Act.
(d) The basic group life insurance coverage shall continue, with
full State contribution, where such person is (1) absent from active
service by reason of disability arising from any cause other than
self-inflicted, (2) on authorized educational leave of absence or
sabbatical leave, or (3) on military leave.
(e) Where the person is in non-pay status for a period in excess of
30 days or on leave of absence, other than by reason of disability,
educational or sabbatical leave, or military leave, such
person may continue coverage only by making personal
payment equal to the amount normally contributed by the State on such person's
behalf. Such payments and coverage may be continued: (1) until such time as
the person returns to a status eligible for coverage at State expense, but not
to exceed 24 months or (2) until such person's employment or annuitant status
with the State is terminated (exclusive of any additional service imposed pursuant to law).
(f) The Department shall establish by rule the extent to which other
employee benefits will continue for persons in non-pay status or who are
not in active service.
(g) The State shall not pay the cost of the basic non-contributory
group life insurance, program of health benefits and other employee benefits
for members who are survivors as defined by paragraphs (1) and (2) of
subsection (q) of Section 3 of this Act. The costs of benefits for these
survivors shall be paid by the survivors or by the University of Illinois
Cooperative Extension Service, or any combination thereof.
However, the State shall pay the amount of the reduction in the cost of
participation, if any, resulting from the amendment to subsection (a) made
by this amendatory Act of the 91st General Assembly.
(h) Those persons occupying positions with any department as a result
of emergency appointments pursuant to Section 8b.8 of the Personnel Code
who are not considered employees under this Act shall be given the option
of participating in the programs of group life insurance, health benefits and
other employee benefits. Such persons electing coverage may participate only
by making payment equal to the amount normally contributed by the State for
similarly situated employees. Such amounts shall be determined by the
Director. Such payments and coverage may be continued until such time as the
person becomes an employee pursuant to this Act or such person's appointment is
terminated.
(i) Any unit of local government within the State of Illinois
may apply to the Director to have its employees, annuitants, and their
dependents provided group health coverage under this Act on a non-insured
basis. To participate, a unit of local government must agree to enroll
all of its employees, who may select coverage under any group
health benefits plan made available by the Department under the health benefits program established under this Section or a health maintenance organization that has
contracted with the State to be available as a health care provider for
employees as defined in this Act. A unit of local government must remit the
entire cost of providing coverage under the health benefits program established under this Section
or, for coverage under a health maintenance organization, an amount determined
by the Director based on an analysis of the sex, age, geographic location, or
other relevant demographic variables for its employees, except that the unit of
local government shall not be required to enroll those of its employees who are
covered spouses or dependents under the State group health benefits plan or another group policy or plan
providing health benefits as long as (1) an appropriate official from the unit
of local government attests that each employee not enrolled is a covered spouse
or dependent under this plan or another group policy or plan, and (2) at least
50% of the employees are enrolled and the unit of local government remits
the entire cost of providing coverage to those employees, except that a
participating school district must have enrolled at least 50% of its full-time
employees who have not waived coverage under the district's group health
plan by participating in a component of the district's cafeteria plan. A
participating school district is not required to enroll a full-time employee
who has waived coverage under the district's health plan, provided that an
appropriate official from the participating school district attests that the
full-time employee has waived coverage by participating in a component of the
district's cafeteria plan. For the purposes of this subsection, "participating
school district" includes a unit of local government whose primary purpose is
education as defined by the Department's rules.
Employees of a participating unit of local government who are not enrolled
due to coverage under another group health policy or plan may enroll in
the event of a qualifying change in status, special enrollment, special
circumstance as defined by the Director, or during the annual Benefit Choice
Period. A participating unit of local government may also elect to cover its
annuitants. Dependent coverage shall be offered on an optional basis, with the
costs paid by the unit of local government, its employees, or some combination
of the two as determined by the unit of local government. The unit of local
government shall be responsible for timely collection and transmission of
dependent premiums.
The Director shall annually determine monthly rates of payment, subject
to the following constraints:
(1) In the first year of coverage, the rates shall be | ||
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(2) In subsequent years, a further adjustment shall | ||
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In the case of coverage of local government employees under a health
maintenance organization, the Director shall annually determine for each
participating unit of local government the maximum monthly amount the unit
may contribute toward that coverage, based on an analysis of (i) the age,
sex, geographic location, and other relevant demographic variables of the
unit's employees and (ii) the cost to cover those employees under the State
group health benefits plan. The Director may similarly determine the
maximum monthly amount each unit of local government may contribute toward
coverage of its employees' dependents under a health maintenance organization.
Monthly payments by the unit of local government or its employees for
group health benefits plan or health maintenance organization coverage shall
be deposited in the Local Government Health Insurance Reserve Fund.
The Local Government Health Insurance Reserve Fund is hereby created as a nonappropriated trust fund to be held outside the State Treasury, with the State Treasurer as custodian. The Local Government Health Insurance Reserve Fund shall be a continuing
fund not subject to fiscal year limitations. The Local Government Health Insurance Reserve Fund is not subject to administrative charges or charge-backs, including but not limited to those authorized under Section 8h of the State Finance Act. All revenues arising from the administration of the health benefits program established under this Section shall be deposited into the Local Government Health Insurance Reserve Fund. Any interest earned on moneys in the Local Government Health Insurance Reserve Fund shall be deposited into the Fund. All expenditures from this Fund
shall be used for payments for health care benefits for local government and rehabilitation facility
employees, annuitants, and dependents, and to reimburse the Department or
its administrative service organization for all expenses incurred in the
administration of benefits. No other State funds may be used for these
purposes.
A local government employer's participation or desire to participate
in a program created under this subsection shall not limit that employer's
duty to bargain with the representative of any collective bargaining unit
of its employees.
(j) Any rehabilitation facility within the State of Illinois may apply
to the Director to have its employees, annuitants, and their eligible
dependents provided group health coverage under this Act on a non-insured
basis. To participate, a rehabilitation facility must agree to enroll all
of its employees and remit the entire cost of providing such coverage for
its employees, except that the rehabilitation facility shall not be
required to enroll those of its employees who are covered spouses or
dependents under this plan or another group policy or plan providing health
benefits as long as (1) an appropriate official from the rehabilitation
facility attests that each employee not enrolled is a covered spouse or
dependent under this plan or another group policy or plan, and (2) at least
50% of the employees are enrolled and the rehabilitation facility remits
the entire cost of providing coverage to those employees. Employees of a
participating rehabilitation facility who are not enrolled due to coverage
under another group health policy or plan may enroll
in the event of a qualifying change in status, special enrollment, special
circumstance as defined by the Director, or during the annual Benefit Choice
Period. A participating rehabilitation facility may also elect
to cover its annuitants. Dependent coverage shall be offered on an optional
basis, with the costs paid by the rehabilitation facility, its employees, or
some combination of the 2 as determined by the rehabilitation facility. The
rehabilitation facility shall be responsible for timely collection and
transmission of dependent premiums.
The Director shall annually determine quarterly rates of payment, subject
to the following constraints:
(1) In the first year of coverage, the rates shall be | ||
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(2) In subsequent years, a further adjustment shall | ||
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Monthly payments by the rehabilitation facility or its employees for
group health benefits shall be deposited in the Local Government Health
Insurance Reserve Fund.
(k) Any domestic violence shelter or service within the State of Illinois
may apply to the Director to have its employees, annuitants, and their
dependents provided group health coverage under this Act on a non-insured
basis. To participate, a domestic violence shelter or service must agree to
enroll all of its employees and pay the entire cost of providing such coverage
for its employees. The domestic violence shelter shall not be required to enroll those of its employees who are covered spouses or dependents under this plan or another group policy or plan providing health benefits as long as (1) an appropriate official from the domestic violence shelter attests that each employee not enrolled is a covered spouse or dependent under this plan or another group policy or plan and (2) at least 50% of the employees are enrolled and the domestic violence shelter remits the entire cost of providing coverage to those employees. Employees of a participating domestic violence shelter who are not enrolled due to coverage under another group health policy or plan may enroll in the event of a qualifying change in status, special enrollment, or special circumstance as defined by the Director or during the annual Benefit Choice Period. A participating domestic violence shelter may also elect
to cover its annuitants. Dependent coverage shall be offered on an optional
basis, with
employees, or some combination of the 2 as determined by the domestic violence
shelter or service. The domestic violence shelter or service shall be
responsible for timely collection and transmission of dependent premiums.
The Director shall annually determine rates of payment,
subject to the following constraints:
(1) In the first year of coverage, the rates shall be | ||
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(2) In subsequent years, a further adjustment shall | ||
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Monthly payments by the domestic violence shelter or service or its employees
for group health insurance shall be deposited in the Local Government Health
Insurance Reserve Fund.
(l) A public community college or entity organized pursuant to the
Public Community College Act may apply to the Director initially to have
only annuitants not covered prior to July 1, 1992 by the district's health
plan provided health coverage under this Act on a non-insured basis. The
community college must execute a 2-year contract to participate in the
Local Government Health Plan.
Any annuitant may enroll in the event of a qualifying change in status, special
enrollment, special circumstance as defined by the Director, or during the
annual Benefit Choice Period.
The Director shall annually determine monthly rates of payment subject to
the following constraints: for those community colleges with annuitants
only enrolled, first year rates shall be equal to the average cost to cover
claims for a State member adjusted for demographics, Medicare
participation, and other factors; and in the second year, a further adjustment
of rates shall be made to reflect the actual first year's claims experience
of the covered annuitants.
(l-5) The provisions of subsection (l) become inoperative on July 1, 1999.
(m) The Director shall adopt any rules deemed necessary for
implementation of this amendatory Act of 1989 (Public Act 86-978).
(n) Any child advocacy center within the State of Illinois may apply to the Director to have its employees, annuitants, and their dependents provided group health coverage under this Act on a non-insured basis. To participate, a child advocacy center must agree to enroll all of its employees and pay the entire cost of providing coverage for its employees. The child
advocacy center shall not be required to enroll those of its
employees who are covered spouses or dependents under this plan
or another group policy or plan providing health benefits as
long as (1) an appropriate official from the child advocacy
center attests that each employee not enrolled is a covered
spouse or dependent under this plan or another group policy or
plan and (2) at least 50% of the employees are enrolled and the child advocacy center remits the entire cost of providing coverage to those employees. Employees of a participating child advocacy center who are not enrolled due to coverage under another group health policy or plan may enroll in the event of a qualifying change in status, special enrollment, or special circumstance as defined by the Director or during the annual Benefit Choice Period. A participating child advocacy center may also elect to cover its annuitants. Dependent coverage shall be offered on an optional basis, with the costs paid by the child advocacy center, its employees, or some combination of the 2 as determined by the child advocacy center. The child advocacy center shall be responsible for timely collection and transmission of dependent premiums. The Director shall annually determine rates of payment, subject to the following constraints: (1) In the first year of coverage, the rates shall be | ||
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(2) In subsequent years, a further adjustment shall | ||
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Monthly payments by the child advocacy center or its employees for group health insurance shall be deposited into the Local Government Health Insurance Reserve Fund.(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/11) (from Ch. 127, par. 531) Sec. 11. The amount of contribution in any fiscal year from funds other than the General Revenue Fund or the Road Fund shall be at the same contribution rate as the General Revenue Fund or the Road Fund. Contributions and payments for life insurance shall be deposited in the Group Insurance Premium Fund. Contributions and payments for health coverages and other benefits shall be deposited in the Health Insurance Reserve Fund. Federal funds which are available for cooperative extension purposes shall also be charged for the contributions which are made for retired employees formerly employed in the Cooperative Extension Service. In the case of departments or any division thereof receiving a fraction of its requirements for administration from the Federal Government, the contributions hereunder shall be such fraction of the amount determined under the provisions hereof and the remainder shall be contributed by the State. Every department which has members paid from funds other than the General Revenue Fund shall cooperate with the Department of Central Management Services and the Governor's Office of Management and Budget in order to assure that the specified proportion of the State's cost for group life insurance, the program of health benefits and other employee benefits is paid by such funds; except that contributions under this Act need not be paid from any other fund where both the Director of Central Management Services and the Director of the Governor's Office of Management and Budget have designated in writing that the necessary contributions are included in the General Revenue Fund contribution amount. Universities having employees who are compensated out of the following funds or sources are not required to submit the contribution described in this Section for such employees: (1) income funds, as described in Sections 6a-1, | ||
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(2) local auxiliary funds, as described in the | ||
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(i) funds from auxiliary enterprises, which are | ||
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(ii) funds from auxiliary activities, which are | ||
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(3) the Agricultural Premium Fund as established by | ||
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(4) appropriations from the General Revenue Fund, | ||
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(5) funds to the University of Illinois Hospital for | ||
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(6) funds designated for the Cooperative Extension | ||
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If an employee of a university is partially compensated from the funds or sources of funds identified in paragraphs (1) through (6) above, universities shall be required to submit a pro rata contribution for the portion of the employee's compensation that is derived out of funds or sources other than those identified in paragraphs (1) through (6) above. The Department of Central Management Services may conduct a post-payment review of university reimbursements to assess or address any discrepancies. Universities shall cooperate with the Department of Central Management Services during any post-payment review, that may require universities to provide documentation to support payment calculations or funding sources used for calculating reimbursements. The Department of Central Management Services reserves the right to reconcile any discrepancies in reimbursement subtotals or total obligations and to notify universities of all final reconciliations, which shall include the Department of Central Management Services calculations and the amount of any credits or obligations that may be due. For each employee of the Illinois Toll Highway Authority covered under this Act whose eligibility for such coverage is as an annuitant, the Authority shall annually contribute an amount, as determined by the Director of the Department of Central Management Services, that represents the average employer's share of the cost of retiree coverage per participating employee in the State Employees Group Insurance Program.(Source: P.A. 102-1071, eff. 6-10-22; 102-1115, eff. 1-9-23; 103-616, eff. 7-1-24.) |
(5 ILCS 375/12) (from Ch. 127, par. 532)
Sec. 12. (a) Any surplus resulting from favorable experience of those
portions of the group life insurance and group health program shall be
refunded to the State of Illinois for deposit, respectively, in the Group Insurance
Premium Fund or Health Insurance Reserve Fund established under this Act.
Such funds may be applied to reduce member premiums, charges or fees or
increase benefits, or both, in accordance with Subsection (b) of this Section.
(b) Surplus resulting from favorable experience may be applied to
any current or future contract made under authority of this Act. With respect to any surplus relating to the Group Insurance Premium Fund, the surplus shall be deposited into the Group Insurance Premium Fund and may be applied either
towards the reduction of the cost of optional life insurance or the provision of additional life insurance as determined by the Director. With respect to any surplus relating to the Health Insurance Reserve Fund, the surplus shall be deposited into the Health Insurance Reserve Fund and may be applied towards
contributions to the
program of health benefits or other benefits or towards providing
additional health or other benefits, or both, as determined
by the Director.
(Source: P.A. 95-632, eff. 9-25-07.)
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(5 ILCS 375/13) (from Ch. 127, par. 533)
Sec. 13. There is established a Group Insurance Premium Fund
administered by the Director which shall include: (1) amounts paid by covered
members for optional life insurance and (2)
refunds which may be received from (a) the group carrier or carriers which
may result from favorable experience as described in Section 12 herein or
(b) from any other source from which the State is reasonably and properly
entitled to refund as a result of the life insurance
program. The Group Insurance Premium Fund shall be a continuing fund not
subject to fiscal year limitations.
The State of Illinois shall at least once each month make payment on behalf
of each member, except one who is a member by virtue of participation in a
program created under subsection (i), (j), (k), or (l) of Section 10 of this
Act, to the appropriate carrier or, if applicable, carriers insuring State
members under the contracted group life insurance program authorized by this Act.
Refunds to members for premiums paid for optional life insurance coverage
may be paid from the Group Insurance Premium Fund without regard to the
fact that the premium being refunded may have been paid in a different
fiscal year.
(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/13.1) (from Ch. 127, par. 533.1)
Sec. 13.1. (a) All contributions, appropriations, interest, and dividend
payments to fund the program of health benefits and other employee benefits, and all other revenues arising from the administration of any employee health benefits program,
shall be deposited in a trust fund outside the State Treasury, with the State
Treasurer as ex-officio custodian, to be known as the Health Insurance Reserve
Fund.
(b) Upon the adoption of a self-insurance health plan, any monies
attributable to the group health insurance program shall be deposited in or
transferred to the Health Insurance Reserve Fund for use by the Department.
As of the effective date of this amendatory Act of 1986, the Department
shall certify to the Comptroller the amount of money in the Group Insurance
Premium Fund attributable to the State group health insurance program and the
Comptroller shall transfer such money from the Group Insurance Premium Fund
to the Health Insurance Reserve Fund. Contributions by the State to the
Health Insurance Reserve Fund to meet the requirements of this Act, as
established by the Director, from the General Revenue Fund and the Road
Fund to the Health Insurance Reserve Fund shall be by annual
appropriations, and all other contributions to meet the requirements of the
programs of health benefits or other employee benefits shall be deposited
in the Health Insurance Reserve Fund. The Department shall draw the
appropriation from the General Revenue Fund and the Road Fund from time to
time as necessary to make expenditures authorized under this Act.
The Director may employ such assistance and services and may purchase
such goods as may be necessary for the proper development and
administration of any of the benefit programs authorized by this Act. The
Director may promulgate rules and regulations in regard to the
administration of these programs.
All monies received by the Department for deposit in or transfer to the
Health Insurance Reserve Fund, through appropriation or otherwise, shall be
used to provide for the making of payments to claimants and providers and
to reimburse the Department for all expenses directly incurred relating to
Department development and administration of the program of health benefits
and other employee benefits.
Any administrative service organization administering any self-insurance
health plan and paying claims and benefits under authority of this Act may
receive, pursuant to written authorization and direction of the Director,
an initial transfer and periodic transfers of funds from the Health
Insurance Reserve Fund in amounts determined by the Director who may
consider the amount recommended by the administrative service organization.
Notwithstanding any other statute, such transferred funds shall be
retained by the administrative service organization in a separate
account provided by any bank as defined by the Illinois Banking
Act. The Department may promulgate regulations further defining the banks
authorized to accept such funds and all methodology for transfer of such
funds. Any interest earned by monies in such
account shall inure to the Health Insurance Reserve Fund, shall remain
in such account and shall be used exclusively to pay claims and benefits
under this Act. Such transferred funds shall be used exclusively for
administrative service organization payment of claims to claimants and
providers under the self-insurance health plan by the drawing of checks
against such account. The administrative service organization may not use
such transferred funds, or interest accrued thereon, for any other purpose
including, but not limited to, reimbursement of administrative expenses or
payments of administration fees due the organization pursuant to its
contract or contracts with the Department of Central Management Services.
The account of the administrative service organization established under
this Section, any transfers from the Health Insurance Reserve Fund to
such account and the use of such account and funds shall be subject
to (1) audit by the Department or private contractor authorized by the
Department to conduct audits, and (2) post audit pursuant to the
Illinois State Auditing Act.
The Department of Central Management Services, or any successor agency designated to procure healthcare contracts pursuant to this Act, is authorized to establish funds, separate accounts provided by any bank or banks as defined by the Illinois Banking Act, or separate accounts provided by any savings and loan association or associations as defined by the Illinois Savings and Loan Act of 1985 to be held by the Director, outside the State treasury, for the purpose of receiving the transfer of moneys from the Health Insurance Reserve Fund. The Department may promulgate rules further defining the methodology for the transfers. Any interest earned by monies in the funds or accounts shall inure to the Health Insurance Reserve Fund. The transferred moneys, and interest accrued thereon, shall be used exclusively for transfers to administrative service organizations or their financial institutions for payments of claims to claimants and providers under the self-insurance health plan. The transferred moneys, and interest accrued thereon, shall not be used for any other purpose including, but not limited to, reimbursement of administration fees due the administrative service organization pursuant to its contract or contracts with the Department.
(c) The Director, with the advice and consent of the Commission, shall
establish premiums for optional coverage for dependents of eligible members
for the health plans. The eligible members
shall be responsible for their portion of such optional
premium. The State shall
contribute an amount per month for each eligible member who has
enrolled one or more dependents under the health plans. Such contribution
shall be made directly to the Health Insurance
Reserve Fund. Those employees described in subsection (b) of Section 9 of this
Act shall be allowed to continue in the health plan by
making personal payments with the premiums to be deposited
in the Health Insurance Reserve Fund.
(d) The Health Insurance Reserve Fund shall be a continuing fund not subject
to fiscal year limitations. All expenditures from that fund shall be at
the direction of the Director and shall be only for the purpose of:
(1) the payment of administrative expenses incurred | ||
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(2) the payment of administrative expenses incurred | ||
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(3) the payment of health benefits;
(3.5) the payment of medical expenses incurred by the | ||
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(4) refunds to employees for erroneous payments of | ||
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(5) payment of premium for stop-loss or re-insurance;
(6) payment of premium to health maintenance | ||
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(7) payment of adoption program benefits; and
(8) payment of other benefits offered to members and | ||
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(Source: P.A. 102-19, eff. 7-1-21.)
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(5 ILCS 375/13.2) (from Ch. 127, par. 533.2)
Sec. 13.2.
Insurance reserve funds; investments.
All amounts held in
the Health Insurance Reserve Fund, the Group Insurance Premium Fund, and
the Local Government Health
Insurance Reserve Fund shall be invested, at interest, by the State
Treasurer. The investments shall be subject to terms, conditions, and
limitations imposed by the laws of Illinois on State funds. All income
derived from the investments shall accrue and be deposited to the
respective funds no less frequently than quarterly. The Health Insurance
Reserve Fund and the Local Government Health Insurance Reserve Fund shall
be administered by the Director.
(Source: P.A. 91-390, eff. 7-30-99.)
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(5 ILCS 375/15) (from Ch. 127, par. 535)
Sec. 15. Administration; rules; audit; review.
(a) The Director shall administer this Act and shall prescribe
such rules and regulations as are necessary to give full effect to the
purposes of this Act. To facilitate the maintenance of the program of group health benefits provided to annuitants, survivors, and retired employees under this Act, rules adopted by the Director to alter the contributions to be paid by the State, annuitants, survivors, retired employees, or any combination of those entities, for that program of group health benefits, shall be adopted as emergency rules in accordance with Section 5-45 of the Illinois Administrative Procedure Act.
(b) These rules may fix reasonable standards for the group life and
group health programs and other benefit programs offered under this
Act, and for the contractors providing them.
(c) These rules shall specify that covered and optional medical
services of the program are services provided within the scope of their
licenses by practitioners in all categories licensed under the Medical
Practice Act of 1987 and shall provide that all eligible persons be
fully informed of this specification.
(d) These rules shall establish eligibility requirements for
members and dependents as may be necessary to supplement
or clarify requirements contained in this Act.
(e) Each affected department of the State, the State Universities
Retirement System, the Teachers' Retirement System, and each qualified local
government, rehabilitation facility, domestic violence shelter or service,
or child advocacy center, shall keep such records, make such certifications, and furnish the Director
such information as may be necessary for the administration of this Act,
including information concerning number and total amounts of payroll of
employees of the department who are paid from trust funds or federal funds.
(f) Each member, each community college benefit recipient to whom this Act
applies, and each TRS benefit recipient to whom this Act applies shall
furnish the Director, in such form as may be required, any
information that may be necessary to enroll such member
or benefit recipient and, if applicable, his or her
dependents or dependent beneficiaries under the programs or
plan, including such data as may be required to allow the Director to
accumulate statistics on data normally considered in actuarial studies of
employee groups. Information about community college benefit recipients and
community college dependent beneficiaries shall be furnished through the State
Universities Retirement System. Information about TRS benefit recipients and
TRS dependent beneficiaries shall be furnished through the Teachers' Retirement
System.
(g) There shall be audits and reports
on the programs authorized and established by this Act prepared by the Director
with the assistance of a qualified, independent accounting firm. The
reports shall provide information on the experience, and
administrative effectiveness
and adequacy of the program including, when applicable, recommendations on
up-grading of benefits and improvement of the program.
(h) Any final order, decision or other determination made, issued or
executed by the Director under the provisions of this Act whereby any
contractor or person is aggrieved shall be subject to review in accordance
with the provisions of the Administrative Review Law and all amendments
and modifications thereof, and the rules adopted pursuant thereto, shall
apply to and govern all proceedings for the judicial review of final
administrative decisions of the Director.
(Source: P.A. 97-695, eff. 7-1-12.)
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(5 ILCS 375/15.1) (from Ch. 127, par. 535.1)
Sec. 15.1.
Every group health insurance program or self-insurance health
plan which provides coverage for services coming within
the practice of optometry as defined in the Illinois Optometric
Practice Act of 1987, as now or hereafter amended, shall provide to each member a
written notice that such member may elect for optometric services received
to be reimbursed to either a physician licensed to practice medicine in all
its branches or to an optometrist licensed in this State.
This Section applies only to persons who become covered by such group insurance
program or self-insurance health plan after the effective date of this
amendatory Act of 1979.
(Source: P.A. 85-1440.)
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(5 ILCS 375/16) (from Ch. 127, par. 536)
Sec. 16.
If any provision of this Act or application thereof to any person or
circumstance is held invalid, such invalidity does not affect other
provisions or applications of this Act which can be given effect without
the invalid application or provision, and to this end the provisions of
this Act are declared to be severable.
The Department is authorized to interpret and implement this Act so as
not to conflict with required provisions of the federal Medicare law
and rules.
(Source: P.A. 87-860.)
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(5 ILCS 375/17) (from Ch. 127, par. 537)
Sec. 17.
The provisions of this Act with regard to the initiation of planning
and other provisions in respect to the administration of this Act shall
become effective July 1, 1971. Provisions regarding initiation of the program
of group life and group health insurance and State contributions authorized
herein shall become effective January 1, 1972.
(Source: P.A. 77-476.)
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