Rep. Dan Brady

Filed: 3/10/2015

 

 


 

 


 
09900HB2711ham001LRB099 04229 MLM 31491 a

1
AMENDMENT TO HOUSE BILL 2711

2    AMENDMENT NO. ______. Amend House Bill 2711 by replacing
3everything after the enacting clause with the following:
 
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, and 356z.22 of the Illinois
16Insurance Code. The program of health benefits must comply with

 

 

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1Sections 155.22a, 155.37, 355b, and 356z.19, and 370b.1 of the
2Illinois Insurance 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
10eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
11    Section 10. The Counties Code is amended by changing
12Section 5-1069.3 as follows:
 
13    (55 ILCS 5/5-1069.3)
14    Sec. 5-1069.3. Required health benefits. If a county,
15including a home rule county, is a self-insurer for purposes of
16providing health insurance coverage for its employees, the
17coverage shall include coverage for the post-mastectomy care
18benefits required to be covered by a policy of accident and
19health insurance under Section 356t and the coverage required
20under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
21356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
22356z.14, 356z.15, and 356z.22 of the Illinois Insurance Code.
23The coverage shall comply with Sections 155.22a, 355b, and
24356z.19, and 370b.1 of the Illinois Insurance Code. The

 

 

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1requirement that health benefits be covered as provided in this
2Section is an exclusive power and function of the State and is
3a denial and limitation under Article VII, Section 6,
4subsection (h) of the Illinois Constitution. A home rule county
5to which this Section applies must comply with every provision
6of this Section.
7    Rulemaking authority to implement Public Act 95-1045, if
8any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
14eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
15    Section 15. The Illinois Municipal Code is amended by
16changing Section 10-4-2.3 as follows:
 
17    (65 ILCS 5/10-4-2.3)
18    Sec. 10-4-2.3. Required health benefits. If a
19municipality, including a home rule municipality, is a
20self-insurer for purposes of providing health insurance
21coverage for its employees, the coverage shall include coverage
22for the post-mastectomy care benefits required to be covered by
23a policy of accident and health insurance under Section 356t
24and the coverage required under Sections 356g, 356g.5,

 

 

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1356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
2356z.11, 356z.12, 356z.13, 356z.14, 356z.15, and 356z.22 of the
3Illinois Insurance Code. The coverage shall comply with
4Sections 155.22a, 355b, and 356z.19, and 370b.1 of the Illinois
5Insurance Code. The requirement that health benefits be covered
6as provided in this is an exclusive power and function of the
7State and is a denial and limitation under Article VII, Section
86, subsection (h) of the Illinois Constitution. A home rule
9municipality to which this Section applies must comply with
10every provision of this Section.
11    Rulemaking authority to implement Public Act 95-1045, if
12any, is conditioned on the rules being adopted in accordance
13with all provisions of the Illinois Administrative Procedure
14Act and all rules and procedures of the Joint Committee on
15Administrative Rules; any purported rule not so adopted, for
16whatever reason, is unauthorized.
17(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
18eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
19    Section 20. The School Code is amended by changing Section
2010-22.3f as follows:
 
21    (105 ILCS 5/10-22.3f)
22    Sec. 10-22.3f. Required health benefits. Insurance
23protection and benefits for employees shall provide the
24post-mastectomy care benefits required to be covered by a

 

 

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1policy of accident and health insurance under Section 356t and
2the coverage required under Sections 356g, 356g.5, 356g.5-1,
3356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
4356z.13, 356z.14, 356z.15, and 356z.22 of the Illinois
5Insurance Code. Insurance policies shall comply with Section
6356z.19 of the Illinois Insurance Code. The coverage shall
7comply with Sections 155.22a, and 355b, and 370b.1 of the
8Illinois Insurance Code.
9    Rulemaking authority to implement Public Act 95-1045, if
10any, is conditioned on the rules being adopted in accordance
11with all provisions of the Illinois Administrative Procedure
12Act and all rules and procedures of the Joint Committee on
13Administrative Rules; any purported rule not so adopted, for
14whatever reason, is unauthorized.
15(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
16eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
17    Section 25. The Illinois Insurance Code is amended by
18adding Section 370b.1 as follows:
 
19    (215 ILCS 5/370b.1 new)
20    Sec. 370b.1. Patient access to eye care.
21    (a) For purposes of this Section, "eye care" means those
22health care services and materials related to the care of the
23eye and related structures and vision care services which an
24insurer is obligated to pay for or provide to covered persons.

 

 

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1    (b) An individual or group policy of accident and health
2insurance amended, delivered, issued, or renewed in this State
3after the effective date of this amendatory Act of the 99th
4General Assembly that provides coverage for eye care, including
5benefits offered by managed care companies, limited health
6services organizations, and other similar entities:
7        (1) shall not set professional fees or reimbursement
8    for the same eye care services as defined by established
9    current procedural terminology codes in a manner that
10    discriminates against an individual eye care provider or a
11    class of eye care providers;
12        (2) shall not preclude a covered person who seeks eye
13    care from obtaining such service directly from a provider
14    affiliated with an insurer's plan who is licensed to
15    provide eye care;
16        (3) shall not promote or recommend any class of
17    providers to the detriment of any other class of providers
18    for the same eye care service;
19        (4) shall ensure that all eye care providers affiliated
20    with an insurer's plan are included on any publicly
21    accessible list of participating providers for the plan;
22        (5) shall include optometrists and ophthalmologists on
23    the list of participating providers for the plan in a
24    manner that ensures plan enrollees timely access and
25    geographic access;
26        (6) shall allow each eye care provider affiliated with

 

 

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1    an insurer's plan, without discrimination between classes
2    of eye care providers, to furnish covered eye care goods
3    and services to covered persons to the extent permitted by
4    such provider's licensure;
5        (7) shall not require any eye care provider to hold
6    hospital privileges or impose any other condition or
7    restriction for initial admittance to an insurer's plan not
8    necessary for the delivery of eye care upon such providers
9    which would have the effect of excluding an individual eye
10    care provider or class of eye care providers from
11    participation on the insurer's plan;
12        (8) shall not require any eye care provider or patient
13    to order or purchase covered goods, including, but not
14    limited to, ophthalmic lenses, from any source owned by,
15    controlled by, or in a common ownership scheme with the
16    benefits provider; and
17        (9) shall not set or create a policy which interferes
18    with the doctor-patient relationship, including the manner
19    in which a provider performs eye care services or chooses
20    to obtain covered eye care goods from commercially
21    reasonable vendors.
22    (c) A person adversely affected by a violation of this
23Section by an insurer may bring an action in a court of
24competent jurisdiction for injunctive relief against the
25insurer and, upon prevailing, in addition to any injunctive
26relief that may be granted, shall recover from the insurer

 

 

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1attorney's fees and costs.
2    (d) Nothing in this Section requires an individual or group
3policy of accident and health insurance to include eye care
4benefits.
 
5    Section 30. The Health Maintenance Organization Act is
6amended by changing Section 5-3 as follows:
 
7    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
8    Sec. 5-3. Insurance Code provisions.
9    (a) Health Maintenance Organizations shall be subject to
10the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
11141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
12154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
13355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
14356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
15356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
16356z.22, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
17368e, 370b.1, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408,
18408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
19(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
20XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
21    (b) For purposes of the Illinois Insurance Code, except for
22Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
23Maintenance Organizations in the following categories are
24deemed to be "domestic companies":

 

 

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

 

 

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1    following information:
2            (A) certification by an independent actuary of the
3        adequacy of the reserves of the Health Maintenance
4        Organization sought to be acquired;
5            (B) pro forma financial statements reflecting the
6        combined balance sheets of the acquiring company and
7        the Health Maintenance Organization sought to be
8        acquired as of the end of the preceding year and as of
9        a date 90 days prior to the acquisition, as well as pro
10        forma financial statements reflecting projected
11        combined operation for a period of 2 years;
12            (C) a pro forma business plan detailing an
13        acquiring party's plans with respect to the operation
14        of the Health Maintenance Organization sought to be
15        acquired for a period of not less than 3 years; and
16            (D) such other information as the Director shall
17        require.
18    (d) The provisions of Article VIII 1/2 of the Illinois
19Insurance Code and this Section 5-3 shall apply to the sale by
20any health maintenance organization of greater than 10% of its
21enrollee population (including without limitation the health
22maintenance organization's right, title, and interest in and to
23its health care certificates).
24    (e) In considering any management contract or service
25agreement subject to Section 141.1 of the Illinois Insurance
26Code, the Director (i) shall, in addition to the criteria

 

 

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

 

 

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1    be calculated taking into account a pro rata share of the
2    Health Maintenance Organization's administrative and
3    marketing expenses, but shall not include any refund to be
4    made or additional premium to be paid pursuant to this
5    subsection (f)). The Health Maintenance Organization and
6    the group or enrollment unit may agree that the profitable
7    or unprofitable experience may be calculated taking into
8    account the refund period and the immediately preceding 2
9    plan years.
10    The Health Maintenance Organization shall include a
11statement in the evidence of coverage issued to each enrollee
12describing the possibility of a refund or additional premium,
13and upon request of any group or enrollment unit, provide to
14the group or enrollment unit a description of the method used
15to calculate (1) the Health Maintenance Organization's
16profitable experience with respect to the group or enrollment
17unit and the resulting refund to the group or enrollment unit
18or (2) the Health Maintenance Organization's unprofitable
19experience with respect to the group or enrollment unit and the
20resulting additional premium to be paid by the group or
21enrollment unit.
22    In no event shall the Illinois Health Maintenance
23Organization Guaranty Association be liable to pay any
24contractual obligation of an insolvent organization to pay any
25refund authorized under this Section.
26    (g) Rulemaking authority to implement Public Act 95-1045,

 

 

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1if any, 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437,
7eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805,
8eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14;
998-1091, eff. 1-1-15.)
 
10    Section 35. The Limited Health Service Organization Act is
11amended by changing Section 4003 as follows:
 
12    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
13    Sec. 4003. Illinois Insurance Code provisions. Limited
14health service organizations shall be subject to the provisions
15of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
16143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
17154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
18356z.10, 356z.21, 356z.22, 368a, 370b.1, 401, 401.1, 402, 403,
19403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA,
20VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the
21Illinois Insurance Code. For purposes of the Illinois Insurance
22Code, except for Sections 444 and 444.1 and Articles XIII and
23XIII 1/2, limited health service organizations in the following
24categories are deemed to be domestic companies:

 

 

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1        (1) a corporation under the laws of this State; or
2        (2) a corporation organized under the laws of another
3    state, 30% of more of the enrollees of which are residents
4    of this State, except a corporation subject to
5    substantially the same requirements in its state of
6    organization as is a domestic company under Article VIII
7    1/2 of the Illinois Insurance Code.
8(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.
91-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091,
10eff. 1-1-15.)
 
11    Section 40. The Voluntary Health Services Plans Act is
12amended by changing Section 10 as follows:
 
13    (215 ILCS 165/10)  (from Ch. 32, par. 604)
14    Sec. 10. Application of Insurance Code provisions. Health
15services plan corporations and all persons interested therein
16or dealing therewith shall be subject to the provisions of
17Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
18143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
19356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
20356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
21356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
22356z.19, 356z.21, 356z.22, 364.01, 367.2, 368a, 370b.1, 401,
23401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
24and (15) of Section 367 of the Illinois Insurance Code.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
8eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,
9eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
10    Section 45. The Illinois Public Aid Code is amended by
11changing Section 5-16.8 as follows:
 
12    (305 ILCS 5/5-16.8)
13    Sec. 5-16.8. Required health benefits. The medical
14assistance program shall (i) provide the post-mastectomy care
15benefits required to be covered by a policy of accident and
16health insurance under Section 356t and the coverage required
17under Sections 356g.5, 356u, 356w, 356x, and 356z.6 of the
18Illinois Insurance Code and (ii) be subject to the provisions
19of Sections 356z.19, and 364.01, and 370b.1 of the Illinois
20Insurance Code.
21    On and after July 1, 2012, the Department shall reduce any
22rate of reimbursement for services or other payments or alter
23any methodologies authorized by this Code to reduce any rate of
24reimbursement for services or other payments in accordance with

 

 

09900HB2711ham001- 16 -LRB099 04229 MLM 31491 a

1Section 5-5e.
2(Source: P.A. 97-282, eff. 8-9-11; 97-689, eff. 6-14-12.)".