Rep. Emily McAsey

Filed: 5/17/2016

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 2743

2    AMENDMENT NO. ______. Amend House Bill 2743 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, and 356z.24 of the
16Illinois Insurance Code. The program of health benefits must

 

 

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1comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and
2370c.1 of the Illinois 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. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
1099-480, eff. 9-9-15.)
 
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, and 356z.24 of the Illinois
23Insurance Code. The coverage shall comply with Sections
24155.22a, 355b, 356z.19, and 370c of the Illinois Insurance

 

 

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1Code. The requirement that health benefits be covered as
2provided in this Section is an exclusive power and function of
3the State and is a denial and limitation under Article VII,
4Section 6, subsection (h) of the Illinois Constitution. A home
5rule county to which this Section applies must comply with
6every provision of 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. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
1499-480, eff. 9-9-15.)
 
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, and
3356z.24 of the Illinois Insurance Code. The coverage shall
4comply with Sections 155.22a, 355b, 356z.19, and 370c of the
5Illinois Insurance Code. The requirement that health benefits
6be covered as provided in this is an exclusive power and
7function of the State and is a denial and limitation under
8Article VII, Section 6, subsection (h) of the Illinois
9Constitution. A home rule municipality to which this Section
10applies must comply with every 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. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
1899-480, eff. 9-9-15.)
 
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, and 356z.24 of the
5Illinois Insurance Code. Insurance policies shall comply with
6Section 356z.19 of the Illinois Insurance Code. The coverage
7shall comply with Sections 155.22a and 355b of the Illinois
8Insurance 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 356z.24 as follows:
 
19    (215 ILCS 5/356z.24 new)
20    Sec. 356z.24. Access to opioid analgesics with
21abuse-deterrent properties.
22    (a) For purposes of this Section:
23    "Abuse-deterrent opioid analgesic drug product" means a
24brand or generic opioid analgesic drug product approved by the

 

 

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1U.S. Food and Drug Administration with abuse-deterrence
2labeling claims that indicate the drug product is expected to
3result in a meaningful reduction in abuse.
4    "Covered individual" means an individual covered by an
5individual or group policy of accident and health insurance.
6    "Health insurer" means all entities or companies licensed
7or authorized by the State to sell health insurance policies or
8that provide health care coverage, including any pharmacy
9benefit managers that administer the pharmacy benefit for an
10entity or company.
11    "Opioid analgesic drug product" means a drug product in the
12opioid analgesic drug class prescribed to treat moderate to
13severe pain or other conditions, whether in immediate-release
14or extended-release and long-acting form and whether or not
15combined with other drug substances to form a single drug
16product or dosage form.
17    (b) On or after the effective date of this amendatory Act
18of the 99th General Assembly, any health insurer that amends,
19delivers, issues, or renews group accident and health policies
20providing coverage for prescription drugs shall:
21        (1) provide coverage for at least one abuse-deterrent
22    opioid analgesic drug product per opioid analgesic active
23    ingredient on their formulary, drug list, or other lists of
24    similar construct; and
25        (2) not require that a covered individual first use an
26    opioid analgesic drug product without abuse-deterrence

 

 

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1    labeling claims before providing coverage for an
2    abuse-deterrent opioid analgesic product.
3    (c) This Section shall not be construed to prevent an
4insurer or health plan from applying prior authorization
5requirements to abuse-deterrent opioid analgesic drug
6products, provided those requirements are applied to all opioid
7analgesic drug products with the same type of drug release,
8immediate or extended.
 
9    Section 30. The Health Maintenance Organization Act is
10amended by changing Section 5-3 as follows:
 
11    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
12    Sec. 5-3. Insurance Code provisions.
13    (a) Health Maintenance Organizations shall be subject to
14the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
15141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
16154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
17355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
18356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
19356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
20356z.22, 356z.24, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
21368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
22408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
23subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,
24XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois

 

 

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

 

 

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

 

 

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

 

 

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1    shall not exceed 20% of the Health Maintenance
2    Organization's profitable or unprofitable experience with
3    respect to the group or other enrollment unit for the
4    period (and, for purposes of a refund or additional
5    premium, the profitable or unprofitable experience shall
6    be calculated taking into account a pro rata share of the
7    Health Maintenance Organization's administrative and
8    marketing expenses, but shall not include any refund to be
9    made or additional premium to be paid pursuant to this
10    subsection (f)). The Health Maintenance Organization and
11    the group or enrollment unit may agree that the profitable
12    or unprofitable experience may be calculated taking into
13    account the refund period and the immediately preceding 2
14    plan years.
15    The Health Maintenance Organization shall include a
16statement in the evidence of coverage issued to each enrollee
17describing the possibility of a refund or additional premium,
18and upon request of any group or enrollment unit, provide to
19the group or enrollment unit a description of the method used
20to calculate (1) the Health Maintenance Organization's
21profitable experience with respect to the group or enrollment
22unit and the resulting refund to the group or enrollment unit
23or (2) the Health Maintenance Organization's unprofitable
24experience with respect to the group or enrollment unit and the
25resulting additional premium to be paid by the group or
26enrollment unit.

 

 

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1    In no event shall the Illinois Health Maintenance
2Organization Guaranty Association be liable to pay any
3contractual obligation of an insolvent organization to pay any
4refund authorized under this Section.
5    (g) Rulemaking authority to implement Public Act 95-1045,
6if any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437,
12eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805,
13eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14;
1498-1091, eff. 1-1-15.)
 
15    Section 35. The Limited Health Service Organization Act is
16amended by changing Section 4003 as follows:
 
17    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
18    Sec. 4003. Illinois Insurance Code provisions. Limited
19health service organizations shall be subject to the provisions
20of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
21143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
22154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
23356z.10, 356z.21, 356z.22, 356z.24, 368a, 401, 401.1, 402, 403,
24403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA,

 

 

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1VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the
2Illinois Insurance Code. For purposes of the Illinois Insurance
3Code, except for Sections 444 and 444.1 and Articles XIII and
4XIII 1/2, limited health service organizations in the following
5categories are deemed to be domestic companies:
6        (1) a corporation under the laws of this State; or
7        (2) a corporation organized under the laws of another
8    state, 30% of more of the enrollees of which are residents
9    of this State, except a corporation subject to
10    substantially the same requirements in its state of
11    organization as is a domestic company under Article VIII
12    1/2 of the Illinois Insurance Code.
13(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.
141-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091,
15eff. 1-1-15.)
 
16    Section 40. The Voluntary Health Services Plans Act is
17amended by changing Section 10 as follows:
 
18    (215 ILCS 165/10)  (from Ch. 32, par. 604)
19    Sec. 10. Application of Insurance Code provisions. Health
20services plan corporations and all persons interested therein
21or dealing therewith shall be subject to the provisions of
22Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
23143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
24356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,

 

 

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1356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
2356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
3356z.19, 356z.21, 356z.22, 356z.24, 364.01, 367.2, 368a, 401,
4401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
5and (15) of Section 367 of the Illinois Insurance Code.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
13eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,
14eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
15    Section 45. The Illinois Public Aid Code is amended by
16changing Section 5-16.8 as follows:
 
17    (305 ILCS 5/5-16.8)
18    Sec. 5-16.8. Required health benefits. The medical
19assistance program shall (i) provide the post-mastectomy care
20benefits required to be covered by a policy of accident and
21health insurance under Section 356t and the coverage required
22under Sections 356g.5, 356u, 356w, 356x, and 356z.6, and
23356z.24 of the Illinois Insurance Code and (ii) be subject to
24the provisions of Sections 356z.19, 364.01, 370c, and 370c.1 of

 

 

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1the Illinois Insurance Code.
2    On and after July 1, 2012, the Department shall reduce any
3rate of reimbursement for services or other payments or alter
4any methodologies authorized by this Code to reduce any rate of
5reimbursement for services or other payments in accordance with
6Section 5-5e.
7    To ensure full access to the benefits set forth in this
8Section, on and after January 1, 2016, the Department shall
9ensure that provider and hospital reimbursement for
10post-mastectomy care benefits required under this Section are
11no lower than the Medicare reimbursement rate.
12(Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15;
13revised 10-21-15.)".