|
|
Public Act 095-0978
|
| HB4602 Enrolled |
LRB095 16742 KBJ 42776 b |
|
|
AN ACT concerning regulation.
|
Be it enacted by the People of the State of Illinois,
|
represented in the General Assembly:
|
Section 5. The State Employees Group Insurance Act of 1971 |
is amended by changing Section 6.11 as follows:
|
(5 ILCS 375/6.11)
|
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.5,
|
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, |
and 356z.11
356z.9 of the
Illinois Insurance Code.
The program |
of health benefits must comply with Section 155.37 of the
|
Illinois Insurance Code.
|
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
95-520, eff. 8-28-07; revised 12-4-07.)
|
Section 10. The Counties Code is amended by changing |
Section 5-1069.3 as follows:
|
(55 ILCS 5/5-1069.3)
|
|
Sec. 5-1069.3. Required health benefits. If a county, |
including a home
rule
county, is a self-insurer for purposes of |
providing health insurance coverage
for its employees, the |
coverage shall include coverage for the post-mastectomy
care |
benefits required to be covered by a policy of accident and |
health
insurance under Section 356t and the coverage required |
under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, |
356z.10, and
356z.11 356z.9 of
the Illinois Insurance Code. The |
requirement that health benefits be covered
as provided in this |
Section is an
exclusive power and function of the State and is |
a denial and limitation under
Article VII, Section 6, |
subsection (h) of the Illinois Constitution. A home
rule county |
to which this Section applies must comply with every provision |
of
this Section.
|
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
95-520, eff. 8-28-07; revised 12-4-07.)
|
Section 15. The Illinois Municipal Code is amended by |
changing Section 10-4-2.3 as follows:
|
(65 ILCS 5/10-4-2.3)
|
Sec. 10-4-2.3. Required health benefits. If a |
municipality, including a
home rule municipality, is a |
self-insurer for purposes of providing health
insurance |
coverage for its employees, the coverage shall include coverage |
for
the post-mastectomy care benefits required to be covered by |
|
a policy of
accident and health insurance under Section 356t |
and the coverage required
under Sections 356g.5, 356u, 356w, |
356x, 356z.6, and 356z.9, 356z.10, and
356z.11 356z.9 of the |
Illinois
Insurance
Code. The requirement that health
benefits |
be covered as provided in this is an exclusive power and |
function of
the State and is a denial and limitation under |
Article VII, Section 6,
subsection (h) of the Illinois |
Constitution. A home rule municipality to which
this Section |
applies must comply with every provision of this Section.
|
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
95-520, eff. 8-28-07; revised 12-4-07.)
|
Section 20. The School Code is amended by changing Section |
10-22.3f as follows:
|
(105 ILCS 5/10-22.3f)
|
Sec. 10-22.3f. Required health benefits. Insurance |
protection and
benefits
for employees shall provide the |
post-mastectomy care benefits required to be
covered by a |
policy of accident and health insurance under Section 356t and |
the
coverage required under Sections 356g.5, 356u, 356w, 356x,
|
356z.6, and 356z.9, and 356z.11 of
the
Illinois Insurance Code.
|
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
revised 12-4-07.)
|
Section 25. The Illinois Insurance Code is amended by |
|
adding Section 356z.11 as follows:
|
(215 ILCS 5/356z.11 new) |
Sec. 356z.11. Shingles vaccine. A group or individual |
policy of accident and health insurance or managed care plan |
amended, delivered, issued, or renewed after the effective date |
of the amendatory Act of this 95th General Assembly must |
provide coverage for a vaccine for shingles that is approved |
for marketing by the federal Food and Drug Administration if |
the vaccine is ordered by a physician licensed to practice |
medicine in all its branches and the enrollee is 60 years of |
age or older.
|
Section 30. The Health Maintenance Organization Act is |
amended by changing Section 5-3 as follows:
|
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
|
Sec. 5-3. Insurance Code provisions.
|
(a) Health Maintenance Organizations
shall be subject to |
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, |
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, |
356z.11,
356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, |
368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, |
409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of |
|
Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, |
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
|
(b) For purposes of the Illinois Insurance Code, except for |
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
Maintenance Organizations in
the following categories are |
deemed to be "domestic companies":
|
(1) a corporation authorized under the
Dental Service |
Plan Act or the Voluntary Health Services Plans Act;
|
(2) a corporation organized under the laws of this |
State; or
|
(3) a corporation organized under the laws of another |
state, 30% or more
of the enrollees of which are residents |
of this State, except a
corporation subject to |
substantially the same requirements in its state of
|
organization as is a "domestic company" under Article VIII |
1/2 of the
Illinois Insurance Code.
|
(c) In considering the merger, consolidation, or other |
acquisition of
control of a Health Maintenance Organization |
pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
(1) the Director shall give primary consideration to |
the continuation of
benefits to enrollees and the financial |
conditions of the acquired Health
Maintenance Organization |
after the merger, consolidation, or other
acquisition of |
control takes effect;
|
(2)(i) the criteria specified in subsection (1)(b) of |
Section 131.8 of
the Illinois Insurance Code shall not |
|
apply and (ii) the Director, in making
his determination |
with respect to the merger, consolidation, or other
|
acquisition of control, need not take into account the |
effect on
competition of the merger, consolidation, or |
other acquisition of control;
|
(3) the Director shall have the power to require the |
following
information:
|
(A) certification by an independent actuary of the |
adequacy
of the reserves of the Health Maintenance |
Organization sought to be acquired;
|
(B) pro forma financial statements reflecting the |
combined balance
sheets of the acquiring company and |
the Health Maintenance Organization sought
to be |
acquired as of the end of the preceding year and as of |
a date 90 days
prior to the acquisition, as well as pro |
forma financial statements
reflecting projected |
combined operation for a period of 2 years;
|
(C) a pro forma business plan detailing an |
acquiring party's plans with
respect to the operation |
of the Health Maintenance Organization sought to
be |
acquired for a period of not less than 3 years; and
|
(D) such other information as the Director shall |
require.
|
(d) The provisions of Article VIII 1/2 of the Illinois |
Insurance Code
and this Section 5-3 shall apply to the sale by |
any health maintenance
organization of greater than 10% of its
|
|
enrollee population (including without limitation the health |
maintenance
organization's right, title, and interest in and to |
its health care
certificates).
|
(e) In considering any management contract or service |
agreement subject
to Section 141.1 of the Illinois Insurance |
Code, the Director (i) shall, in
addition to the criteria |
specified in Section 141.2 of the Illinois
Insurance Code, take |
into account the effect of the management contract or
service |
agreement on the continuation of benefits to enrollees and the
|
financial condition of the health maintenance organization to |
be managed or
serviced, and (ii) need not take into account the |
effect of the management
contract or service agreement on |
competition.
|
(f) Except for small employer groups as defined in the |
Small Employer
Rating, Renewability and Portability Health |
Insurance Act and except for
medicare supplement policies as |
defined in Section 363 of the Illinois
Insurance Code, a Health |
Maintenance Organization may by contract agree with a
group or |
other enrollment unit to effect refunds or charge additional |
premiums
under the following terms and conditions:
|
(i) the amount of, and other terms and conditions with |
respect to, the
refund or additional premium are set forth |
in the group or enrollment unit
contract agreed in advance |
of the period for which a refund is to be paid or
|
additional premium is to be charged (which period shall not |
be less than one
year); and
|
|
(ii) the amount of the refund or additional premium |
shall not exceed 20%
of the Health Maintenance |
Organization's profitable or unprofitable experience
with |
respect to the group or other enrollment unit for the |
period (and, for
purposes of a refund or additional |
premium, the profitable or unprofitable
experience shall |
be calculated taking into account a pro rata share of the
|
Health Maintenance Organization's administrative and |
marketing expenses, but
shall not include any refund to be |
made or additional premium to be paid
pursuant to this |
subsection (f)). The Health Maintenance Organization and |
the
group or enrollment unit may agree that the profitable |
or unprofitable
experience may be calculated taking into |
account the refund period and the
immediately preceding 2 |
plan years.
|
The Health Maintenance Organization shall include a |
statement in the
evidence of coverage issued to each enrollee |
describing the possibility of a
refund or additional premium, |
and upon request of any group or enrollment unit,
provide to |
the group or enrollment unit a description of the method used |
to
calculate (1) the Health Maintenance Organization's |
profitable experience with
respect to the group or enrollment |
unit and the resulting refund to the group
or enrollment unit |
or (2) the Health Maintenance Organization's unprofitable
|
experience with respect to the group or enrollment unit and the |
resulting
additional premium to be paid by the group or |
|
enrollment unit.
|
In no event shall the Illinois Health Maintenance |
Organization
Guaranty Association be liable to pay any |
contractual obligation of an
insolvent organization to pay any |
refund authorized under this Section.
|
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; |
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
|
Section 35. The Voluntary Health Services Plans Act is |
amended by changing Section 10 as follows:
|
(215 ILCS 165/10) (from Ch. 32, par. 604)
|
Sec. 10. Application of Insurance Code provisions. Health |
services
plan corporations and all persons interested therein |
or dealing therewith
shall be subject to the provisions of |
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, |
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, |
356z.9,
356z.10, 356z.11,
356z.9, 364.01, 367.2, 368a, 401, |
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
and (15) of Section 367 of the Illinois
Insurance Code.
|
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; |
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. |
8-28-07; revised 12-5-07.)
|
Section 90. The State Mandates Act is amended by adding |