99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB1802

 

Introduced 2/20/2015, by Sen. Dan Kotowski

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Illinois Insurance Code, the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Voluntary Health Services Plans Act, and the Illinois Public Aid Code. Provides that government programs and accident and health insurance policies providing coverage for prescription drugs shall provide coverage for abuse-deterrent opioid analgesic drugs as preferred drugs on their formulary, preferred drug list, or other lists of similar construct. Prohibits cost sharing for abuse-deterrent opioid analgesic drugs that exceeds the lowest cost sharing level applied to prescription drugs. Prohibits insurers from requiring require that a covered individual first use an opioid analgesic drug product without abuse-deterrence labeling claims before providing coverage for an abuse-deterrent opioid analgesic product. Provides that any prior authorization requirements or other utilization review measures for opioid analgesic drug products, and any service denials made under those, shall not require first use of non-abuse-deterrent opioid analgesic drug products in order to access opioid analgesic drug products with abuse-deterrent properties.


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FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

SB1802LRB099 09955 MLM 30174 b

1    AN ACT concerning insurance.
 
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, and 356z.22, and 356z.23 of the
16Illinois Insurance Code. The program of health benefits must
17comply with Sections 155.22a, 155.37, 355b, and 356z.19 of the
18Illinois 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
3eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
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, and 356z.22, and 356z.23 of the Illinois
16Insurance Code. The coverage shall comply with Sections
17155.22a, 355b, and 356z.19 of the Illinois Insurance Code. The
18requirement that health benefits be covered as provided in this
19Section is an exclusive power and function of the State and is
20a denial and limitation under Article VII, Section 6,
21subsection (h) of the Illinois Constitution. A home rule county
22to which this Section applies must comply with every provision
23of 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
7eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
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, and 356z.22, and
20356z.23 of the Illinois Insurance Code. The coverage shall
21comply with Sections 155.22a, 355b, and 356z.19 of the Illinois
22Insurance Code. The requirement that health benefits be covered
23as provided in this is an exclusive power and function of the
24State and is a denial and limitation under Article VII, Section

 

 

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16, subsection (h) of the Illinois Constitution. A home rule
2municipality to which this Section applies must comply with
3every 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
11eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
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, and 356z.22, and 356z.23 of the
22Illinois Insurance Code. Insurance policies shall comply with
23Section 356z.19 of the Illinois Insurance Code. The coverage
24shall comply with Sections 155.22a and 355b of the Illinois

 

 

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1Insurance 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
9eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
10    Section 25. The Illinois Insurance Code is amended by
11adding Section 356z.23 as follows:
 
12    (215 ILCS 5/356z.23 new)
13    Sec. 356z.23. Access to opioid analgesics with
14abuse-deterrent properties.
15    (a) For purposes of this Section:
16    "Abuse-deterrent opioid analgesic drug product" means a
17brand or generic opioid analgesic drug product approved by the
18U.S. Food and Drug Administration with abuse-deterrence
19labeling claims that indicate the drug product is expected to
20result in a meaningful reduction in abuse.
21    "Covered individual" means an individual covered by an
22individual or group policy of accident and health insurance, as
23well as a beneficiary of any government health programs who is
24intended to be covered by the law.

 

 

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1    "Cost sharing" means any coverage limit, copayment,
2coinsurance, deductible, or other out-of-pocket expense
3requirements.
4    "Government health program" means all relevant government
5health care programs providing coverage for prescription drugs
6to beneficiaries.
7    "Health insurer" means all entities or companies licensed
8or authorized by the State to sell health insurance policies or
9that provide health care coverage, including any pharmacy
10benefit managers that administer the pharmacy benefit for an
11entity or company.
12    "Opioid analgesic drug product" means a drug product in the
13opioid analgesic drug class prescribed to treat moderate to
14severe pain or other conditions, whether in immediate-release
15or extended-release and long-acting form and whether or not
16combined with other drug substances to form a single drug
17product or dosage form.
18    (b) On or after the effective date of this amendatory Act
19of the 99th General Assembly, any government program and any
20health insurer that amends, delivers, issues, or renews group
21accident and health policies providing coverage for
22prescription drugs shall:
23        (1) provide coverage for abuse-deterrent opioid
24    analgesic drug product as preferred drugs on their
25    formulary, preferred drug list, or other lists of similar
26    construct;

 

 

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1        (2) not require cost sharing for abuse-deterrent
2    opioid analgesic drug product that exceeds the lowest cost
3    sharing level applied to prescription drugs;
4        (3) not increase patient cost sharing or impose other
5    disincentives for prescribers or dispensers in order to
6    comply with this Section; and
7        (4) not require that a covered individual first use an
8    opioid analgesic drug product without abuse-deterrence
9    labeling claims before providing coverage for an
10    abuse-deterrent opioid analgesic product.
11    (c) Any prior authorization requirements or other
12utilization review measures for opioid analgesic drug
13products, and any service denials, shall not require first use
14of non-abuse-deterrent opioid analgesic drug products in order
15to access opioid analgesic drug products with abuse-deterrent
16properties.
17    (d) This Section shall not be construed to prevent an
18insurer or health plan from applying prior authorization
19requirements to abuse-deterrent opioid analgesic drug
20products, provided those requirements are applied to
21non-abuse-deterrent versions of that opioid.
 
22    Section 30. The Health Maintenance Organization Act is
23amended by changing Section 5-3 as follows:
 
24    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)

 

 

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1    Sec. 5-3. Insurance Code provisions.
2    (a) Health Maintenance Organizations shall be subject to
3the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
4141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
5154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
6355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
7356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
8356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
9356z.22, 356z.23, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
10368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
11408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
12subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,
13XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
14Insurance Code.
15    (b) For purposes of the Illinois Insurance Code, except for
16Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
17Maintenance Organizations in the following categories are
18deemed to be "domestic companies":
19        (1) a corporation authorized under the Dental Service
20    Plan Act or the Voluntary Health Services Plans Act;
21        (2) a corporation organized under the laws of this
22    State; or
23        (3) a corporation organized under the laws of another
24    state, 30% or more of the enrollees of which are residents
25    of this State, except a corporation subject to
26    substantially the same requirements in its state of

 

 

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1    organization as is a "domestic company" under Article VIII
2    1/2 of the Illinois Insurance Code.
3    (c) In considering the merger, consolidation, or other
4acquisition of control of a Health Maintenance Organization
5pursuant to Article VIII 1/2 of the Illinois Insurance Code,
6        (1) the Director shall give primary consideration to
7    the continuation of benefits to enrollees and the financial
8    conditions of the acquired Health Maintenance Organization
9    after the merger, consolidation, or other acquisition of
10    control takes effect;
11        (2)(i) the criteria specified in subsection (1)(b) of
12    Section 131.8 of the Illinois Insurance Code shall not
13    apply and (ii) the Director, in making his determination
14    with respect to the merger, consolidation, or other
15    acquisition of control, need not take into account the
16    effect on competition of the merger, consolidation, or
17    other acquisition of control;
18        (3) the Director shall have the power to require the
19    following information:
20            (A) certification by an independent actuary of the
21        adequacy of the reserves of the Health Maintenance
22        Organization sought to be acquired;
23            (B) pro forma financial statements reflecting the
24        combined balance sheets of the acquiring company and
25        the Health Maintenance Organization sought to be
26        acquired as of the end of the preceding year and as of

 

 

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1        a date 90 days prior to the acquisition, as well as pro
2        forma financial statements reflecting projected
3        combined operation for a period of 2 years;
4            (C) a pro forma business plan detailing an
5        acquiring party's plans with respect to the operation
6        of the Health Maintenance Organization sought to be
7        acquired for a period of not less than 3 years; and
8            (D) such other information as the Director shall
9        require.
10    (d) The provisions of Article VIII 1/2 of the Illinois
11Insurance Code and this Section 5-3 shall apply to the sale by
12any health maintenance organization of greater than 10% of its
13enrollee population (including without limitation the health
14maintenance organization's right, title, and interest in and to
15its health care certificates).
16    (e) In considering any management contract or service
17agreement subject to Section 141.1 of the Illinois Insurance
18Code, the Director (i) shall, in addition to the criteria
19specified in Section 141.2 of the Illinois Insurance Code, take
20into account the effect of the management contract or service
21agreement on the continuation of benefits to enrollees and the
22financial condition of the health maintenance organization to
23be managed or serviced, and (ii) need not take into account the
24effect of the management contract or service agreement on
25competition.
26    (f) Except for small employer groups as defined in the

 

 

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1Small Employer Rating, Renewability and Portability Health
2Insurance Act and except for medicare supplement policies as
3defined in Section 363 of the Illinois Insurance Code, a Health
4Maintenance Organization may by contract agree with a group or
5other enrollment unit to effect refunds or charge additional
6premiums under the following terms and conditions:
7        (i) the amount of, and other terms and conditions with
8    respect to, the refund or additional premium are set forth
9    in the group or enrollment unit contract agreed in advance
10    of the period for which a refund is to be paid or
11    additional premium is to be charged (which period shall not
12    be less than one year); and
13        (ii) the amount of the refund or additional premium
14    shall not exceed 20% of the Health Maintenance
15    Organization's profitable or unprofitable experience with
16    respect to the group or other enrollment unit for the
17    period (and, for purposes of a refund or additional
18    premium, the profitable or unprofitable experience shall
19    be calculated taking into account a pro rata share of the
20    Health Maintenance Organization's administrative and
21    marketing expenses, but shall not include any refund to be
22    made or additional premium to be paid pursuant to this
23    subsection (f)). The Health Maintenance Organization and
24    the group or enrollment unit may agree that the profitable
25    or unprofitable experience may be calculated taking into
26    account the refund period and the immediately preceding 2

 

 

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1    plan years.
2    The Health Maintenance Organization shall include a
3statement in the evidence of coverage issued to each enrollee
4describing the possibility of a refund or additional premium,
5and upon request of any group or enrollment unit, provide to
6the group or enrollment unit a description of the method used
7to calculate (1) the Health Maintenance Organization's
8profitable experience with respect to the group or enrollment
9unit and the resulting refund to the group or enrollment unit
10or (2) the Health Maintenance Organization's unprofitable
11experience with respect to the group or enrollment unit and the
12resulting additional premium to be paid by the group or
13enrollment unit.
14    In no event shall the Illinois Health Maintenance
15Organization Guaranty Association be liable to pay any
16contractual obligation of an insolvent organization to pay any
17refund authorized under this Section.
18    (g) Rulemaking authority to implement Public Act 95-1045,
19if any, is conditioned on the rules being adopted in accordance
20with all provisions of the Illinois Administrative Procedure
21Act and all rules and procedures of the Joint Committee on
22Administrative Rules; any purported rule not so adopted, for
23whatever reason, is unauthorized.
24(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437,
25eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805,
26eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14;

 

 

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198-1091, eff. 1-1-15.)
 
2    Section 35. The Limited Health Service Organization Act is
3amended by changing Section 4003 as follows:
 
4    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
5    Sec. 4003. Illinois Insurance Code provisions. Limited
6health service organizations shall be subject to the provisions
7of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
8143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
9154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v,
10356z.10, 356z.21, 356z.22, 356z.23, 368a, 401, 401.1, 402, 403,
11403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA,
12VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the
13Illinois Insurance Code. For purposes of the Illinois Insurance
14Code, except for Sections 444 and 444.1 and Articles XIII and
15XIII 1/2, limited health service organizations in the following
16categories are deemed to be domestic companies:
17        (1) a corporation under the laws of this State; or
18        (2) a corporation organized under the laws of another
19    state, 30% of more of the enrollees of which are residents
20    of this State, except a corporation subject to
21    substantially the same requirements in its state of
22    organization as is a domestic company under Article VIII
23    1/2 of the Illinois Insurance Code.
24(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.

 

 

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11-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091,
2eff. 1-1-15.)
 
3    Section 40. The Voluntary Health Services Plans Act is
4amended by changing Section 10 as follows:
 
5    (215 ILCS 165/10)  (from Ch. 32, par. 604)
6    Sec. 10. Application of Insurance Code provisions. Health
7services plan corporations and all persons interested therein
8or dealing therewith shall be subject to the provisions of
9Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
10143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
11356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
12356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
13356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
14356z.19, 356z.21, 356z.22, 356z.23, 364.01, 367.2, 368a, 401,
15401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
16and (15) of Section 367 of the Illinois Insurance Code.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
24eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,

 

 

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1eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
2    Section 45. The Illinois Public Aid Code is amended by
3changing Section 5-16.8 as follows:
 
4    (305 ILCS 5/5-16.8)
5    Sec. 5-16.8. Required health benefits. The medical
6assistance program shall (i) provide the post-mastectomy care
7benefits required to be covered by a policy of accident and
8health insurance under Section 356t and the coverage required
9under Sections 356g.5, 356u, 356w, 356x, and 356z.6, and
10356z.23 of the Illinois Insurance Code and (ii) be subject to
11the provisions of Sections 356z.19 and 364.01 of the Illinois
12Insurance Code.
13    On and after July 1, 2012, the Department shall reduce any
14rate of reimbursement for services or other payments or alter
15any methodologies authorized by this Code to reduce any rate of
16reimbursement for services or other payments in accordance with
17Section 5-5e.
18(Source: P.A. 97-282, eff. 8-9-11; 97-689, eff. 6-14-12.)

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    5 ILCS 375/6.11
4    55 ILCS 5/5-1069.3
5    65 ILCS 5/10-4-2.3
6    105 ILCS 5/10-22.3f
7    215 ILCS 5/356z.23 new
8    215 ILCS 125/5-3from Ch. 111 1/2, par. 1411.2
9    215 ILCS 130/4003from Ch. 73, par. 1504-3
10    215 ILCS 165/10from Ch. 32, par. 604
11    305 ILCS 5/5-16.8