HB4821 EngrossedLRB100 18480 SMS 33695 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.17, 356z.22, and 356z.25, 356z.26, and
16356z.29 of the Illinois Insurance Code. The program of health
17benefits must comply with Sections 155.22a, 155.37, 355b,
18356z.19, 370c, and 370c.1 of the Illinois Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
3100-138, eff. 8-18-17; revised 10-3-17.)
 
4    Section 10. The Counties Code is amended by changing
5Section 5-1069.3 as follows:
 
6    (55 ILCS 5/5-1069.3)
7    Sec. 5-1069.3. Required health benefits. If a county,
8including a home rule county, is a self-insurer for purposes of
9providing health insurance coverage for its employees, the
10coverage shall include coverage for the post-mastectomy care
11benefits required to be covered by a policy of accident and
12health insurance under Section 356t and the coverage required
13under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and 356z.29 of
16the Illinois Insurance Code. The coverage shall comply with
17Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
18Insurance Code. The requirement that health benefits be covered
19as provided in this Section is an exclusive power and function
20of the State and is a denial and limitation under Article VII,
21Section 6, subsection (h) of the Illinois Constitution. A home
22rule county to which this Section applies must comply with
23every provision of this Section.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

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1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
7100-138, eff. 8-18-17; revised 10-5-17.)
 
8    Section 15. The Illinois Municipal Code is amended by
9changing Section 10-4-2.3 as follows:
 
10    (65 ILCS 5/10-4-2.3)
11    Sec. 10-4-2.3. Required health benefits. If a
12municipality, including a home rule municipality, is a
13self-insurer for purposes of providing health insurance
14coverage for its employees, the coverage shall include coverage
15for the post-mastectomy care benefits required to be covered by
16a policy of accident and health insurance under Section 356t
17and the coverage required under Sections 356g, 356g.5,
18356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
19356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and
20356z.25, 356z.26, and 356z.29 of the Illinois Insurance Code.
21The coverage shall comply with Sections 155.22a, 355b, 356z.19,
22and 370c of the Illinois Insurance Code. The requirement that
23health benefits be covered as provided in this is an exclusive
24power and function of the State and is a denial and limitation

 

 

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1under Article VII, Section 6, subsection (h) of the Illinois
2Constitution. A home rule municipality to which this Section
3applies must comply with every provision of this Section.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
11100-138, eff. 8-18-17; revised 10-5-17.)
 
12    Section 20. The School Code is amended by changing Section
1310-22.3f as follows:
 
14    (105 ILCS 5/10-22.3f)
15    Sec. 10-22.3f. Required health benefits. Insurance
16protection and benefits for employees shall provide the
17post-mastectomy care benefits required to be covered by a
18policy of accident and health insurance under Section 356t and
19the coverage required under Sections 356g, 356g.5, 356g.5-1,
20356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
21356z.13, 356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and
22356z.29 of the Illinois Insurance Code. Insurance policies
23shall comply with Section 356z.19 of the Illinois Insurance
24Code. The coverage shall comply with Sections 155.22a and 355b

 

 

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1of the Illinois Insurance Code.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
9revised 9-25-17.)
 
10    Section 25. The Illinois Insurance Code is amended by
11adding Section 356z.29 as follows:
 
12    (215 ILCS 5/356z.29 new)
13    Sec. 356z.29. Stage 4 advanced, metastatic cancer.
14    (a) As used in this Section, "stage 4 advanced, metastatic
15cancer" means cancer that has spread from the primary or
16original site of the cancer to nearby tissues, lymph nodes, or
17other areas or parts of the body.
18    (b) No individual or group policy of accident and health
19insurance amended, issued, delivered, or renewed in this State
20after the effective date of this amendatory Act of the 100th
21General Assembly that, as a provision of hospital, medical, or
22surgical services, directly or indirectly covers the treatment
23of stage 4 advanced, metastatic cancer shall limit or exclude
24coverage for a drug approved by the United States Food and Drug

 

 

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1Administration by mandating that the insured shall first be
2required to fail to successfully respond to a different drug or
3prove a history of failure of the drug as long as the use of the
4drug is consistent with best practices for the treatment of
5stage 4 advanced, metastatic cancer and is supported by
6peer-reviewed medical literature.
 
7    Section 30. The Health Maintenance Organization Act is
8amended by changing Section 5-3 as follows:
 
9    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
10    Sec. 5-3. Insurance Code provisions.
11    (a) Health Maintenance Organizations shall be subject to
12the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
13141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
14154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
15355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
16356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
17356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
18356z.22, 356z.25, 356z.26, 356z.29, 364, 364.01, 367.2,
19367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401,
20401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
21paragraph (c) of subsection (2) of Section 367, and Articles
22IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
23the Illinois Insurance Code.
24    (b) For purposes of the Illinois Insurance Code, except for

 

 

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1Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
2Maintenance Organizations in the following categories are
3deemed to be "domestic companies":
4        (1) a corporation authorized under the Dental Service
5    Plan Act or the Voluntary Health Services Plans Act;
6        (2) a corporation organized under the laws of this
7    State; or
8        (3) a corporation organized under the laws of another
9    state, 30% or more of the enrollees of which are residents
10    of this State, except a corporation subject to
11    substantially the same requirements in its state of
12    organization as is a "domestic company" under Article VIII
13    1/2 of the Illinois Insurance Code.
14    (c) In considering the merger, consolidation, or other
15acquisition of control of a Health Maintenance Organization
16pursuant to Article VIII 1/2 of the Illinois Insurance Code,
17        (1) the Director shall give primary consideration to
18    the continuation of benefits to enrollees and the financial
19    conditions of the acquired Health Maintenance Organization
20    after the merger, consolidation, or other acquisition of
21    control takes effect;
22        (2)(i) the criteria specified in subsection (1)(b) of
23    Section 131.8 of the Illinois Insurance Code shall not
24    apply and (ii) the Director, in making his determination
25    with respect to the merger, consolidation, or other
26    acquisition of control, need not take into account the

 

 

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1    effect on competition of the merger, consolidation, or
2    other acquisition of control;
3        (3) the Director shall have the power to require the
4    following information:
5            (A) certification by an independent actuary of the
6        adequacy of the reserves of the Health Maintenance
7        Organization sought to be acquired;
8            (B) pro forma financial statements reflecting the
9        combined balance sheets of the acquiring company and
10        the Health Maintenance Organization sought to be
11        acquired as of the end of the preceding year and as of
12        a date 90 days prior to the acquisition, as well as pro
13        forma financial statements reflecting projected
14        combined operation for a period of 2 years;
15            (C) a pro forma business plan detailing an
16        acquiring party's plans with respect to the operation
17        of the Health Maintenance Organization sought to be
18        acquired for a period of not less than 3 years; and
19            (D) such other information as the Director shall
20        require.
21    (d) The provisions of Article VIII 1/2 of the Illinois
22Insurance Code and this Section 5-3 shall apply to the sale by
23any health maintenance organization of greater than 10% of its
24enrollee population (including without limitation the health
25maintenance organization's right, title, and interest in and to
26its health care certificates).

 

 

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1    (e) In considering any management contract or service
2agreement subject to Section 141.1 of the Illinois Insurance
3Code, the Director (i) shall, in addition to the criteria
4specified in Section 141.2 of the Illinois Insurance Code, take
5into account the effect of the management contract or service
6agreement on the continuation of benefits to enrollees and the
7financial condition of the health maintenance organization to
8be managed or serviced, and (ii) need not take into account the
9effect of the management contract or service agreement on
10competition.
11    (f) Except for small employer groups as defined in the
12Small Employer Rating, Renewability and Portability Health
13Insurance Act and except for medicare supplement policies as
14defined in Section 363 of the Illinois Insurance Code, a Health
15Maintenance Organization may by contract agree with a group or
16other enrollment unit to effect refunds or charge additional
17premiums under the following terms and conditions:
18        (i) the amount of, and other terms and conditions with
19    respect to, the refund or additional premium are set forth
20    in the group or enrollment unit contract agreed in advance
21    of the period for which a refund is to be paid or
22    additional premium is to be charged (which period shall not
23    be less than one year); and
24        (ii) the amount of the refund or additional premium
25    shall not exceed 20% of the Health Maintenance
26    Organization's profitable or unprofitable experience with

 

 

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1    respect to the group or other enrollment unit for the
2    period (and, for purposes of a refund or additional
3    premium, the profitable or unprofitable experience shall
4    be calculated taking into account a pro rata share of the
5    Health Maintenance Organization's administrative and
6    marketing expenses, but shall not include any refund to be
7    made or additional premium to be paid pursuant to this
8    subsection (f)). The Health Maintenance Organization and
9    the group or enrollment unit may agree that the profitable
10    or unprofitable experience may be calculated taking into
11    account the refund period and the immediately preceding 2
12    plan years.
13    The Health Maintenance Organization shall include a
14statement in the evidence of coverage issued to each enrollee
15describing the possibility of a refund or additional premium,
16and upon request of any group or enrollment unit, provide to
17the group or enrollment unit a description of the method used
18to calculate (1) the Health Maintenance Organization's
19profitable experience with respect to the group or enrollment
20unit and the resulting refund to the group or enrollment unit
21or (2) the Health Maintenance Organization's unprofitable
22experience with respect to the group or enrollment unit and the
23resulting additional premium to be paid by the group or
24enrollment unit.
25    In no event shall the Illinois Health Maintenance
26Organization Guaranty Association be liable to pay any

 

 

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1contractual obligation of an insolvent organization to pay any
2refund authorized under this Section.
3    (g) Rulemaking authority to implement Public Act 95-1045,
4if any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
10100-138, eff. 8-18-17; revised 10-5-17.)
 
11    Section 35. The Limited Health Service Organization Act is
12amended by changing Section 4003 as follows:
 
13    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
14    Sec. 4003. Illinois Insurance Code provisions. Limited
15health service organizations shall be subject to the provisions
16of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
17143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
18154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
19356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 368a,
20401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and
21444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
22XXV, and XXVI of the Illinois Insurance Code. For purposes of
23the Illinois Insurance Code, except for Sections 444 and 444.1
24and Articles XIII and XIII 1/2, limited health service

 

 

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1organizations in the following categories are deemed to be
2domestic companies:
3        (1) a corporation under the laws of this State; or
4        (2) a corporation organized under the laws of another
5    state, 30% or more of the enrollees of which are residents
6    of this State, except a corporation subject to
7    substantially the same requirements in its state of
8    organization as is a domestic company under Article VIII
9    1/2 of the Illinois Insurance Code.
10(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
11100-201, eff. 8-18-17; revised 10-5-17.)
 
12    Section 40. The Voluntary Health Services Plans Act is
13amended by changing Section 10 as follows:
 
14    (215 ILCS 165/10)  (from Ch. 32, par. 604)
15    Sec. 10. Application of Insurance Code provisions. Health
16services plan corporations and all persons interested therein
17or dealing therewith shall be subject to the provisions of
18Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
19143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
20356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
21356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
22356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
23356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 364.01,
24367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,

 

 

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1and paragraphs (7) and (15) of Section 367 of the Illinois
2Insurance Code.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
10revised 10-5-17.)
 
11    Section 45. The Illinois Public Aid Code is amended by
12changing Section 5-16.8 as follows:
 
13    (305 ILCS 5/5-16.8)
14    Sec. 5-16.8. Required health benefits. The medical
15assistance program shall (i) provide the post-mastectomy care
16benefits required to be covered by a policy of accident and
17health insurance under Section 356t and the coverage required
18under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and
19356z.29 and 356z.25 of the Illinois Insurance Code and (ii) be
20subject to the provisions of Sections 356z.19, 364.01, 370c,
21and 370c.1 of the Illinois Insurance Code.
22    On and after July 1, 2012, the Department shall reduce any
23rate of reimbursement for services or other payments or alter
24any methodologies authorized by this Code to reduce any rate of

 

 

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1reimbursement for services or other payments in accordance with
2Section 5-5e.
3    To ensure full access to the benefits set forth in this
4Section, on and after January 1, 2016, the Department shall
5ensure that provider and hospital reimbursement for
6post-mastectomy care benefits required under this Section are
7no lower than the Medicare reimbursement rate.
8(Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15;
999-642, eff. 7-28-16; 100-138, eff. 8-18-17; revised 1-29-18.)