093_SB0419

 
                                     LRB093 07313 JLS 07474 b

 1        AN ACT concerning insurance coverage.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

 4        Section  5.  The  State  Employees Group Insurance Act of
 5    1971 is amended by changing Section 6.11 as follows:

 6        (5 ILCS 375/6.11)
 7        Sec. 6.11.  Required health benefits; Illinois  Insurance
 8    Code  requirements.   The  program  of  health benefits shall
 9    provide the post-mastectomy  care  benefits  required  to  be
10    covered  by  a  policy of accident and health insurance under
11    Section 356t of the Illinois Insurance Code.  The program  of
12    health  benefits  shall  provide  the coverage required under
13    Sections 356u, 356w, 356x, and  356z.2,  and  356z.4  of  the
14    Illinois  Insurance Code. The program of health benefits must
15    comply with Section 155.37 of the Illinois Insurance Code.
16    (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03.)

17        Section 10.  The Counties Code  is  amended  by  changing
18    Section 5-1069.3 as follows:

19        (55 ILCS 5/5-1069.3)
20        Sec.  5-1069.3.  Required  health benefits.  If a county,
21    including a home rule county, is a self-insurer for  purposes
22    of providing health insurance coverage for its employees, the
23    coverage  shall include coverage for the post-mastectomy care
24    benefits required to be covered by a policy of  accident  and
25    health insurance under Section 356t and the coverage required
26    under  Sections  356u,  356w,  and  356x,  and  356z.4 of the
27    Illinois  Insurance  Code.   The  requirement   that   health
28    benefits  be  covered  as  provided  in  this  Section  is an
29    exclusive power and function of the State and is a denial and
 
                            -2-      LRB093 07313 JLS 07474 b
 1    limitation under Article VII, Section 6,  subsection  (h)  of
 2    the  Illinois Constitution.  A home rule county to which this
 3    Section applies must comply  with  every  provision  of  this
 4    Section.
 5    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

 6        Section  15.  The  Illinois  Municipal Code is amended by
 7    changing Section 10-4-2.3 as follows:

 8        (65 ILCS 5/10-4-2.3)
 9        Sec.  10-4-2.3.   Required   health   benefits.    If   a
10    municipality,  including  a  home  rule  municipality,  is  a
11    self-insurer  for  purposes  of  providing  health  insurance
12    coverage  for  its  employees,  the  coverage  shall  include
13    coverage for the post-mastectomy care benefits required to be
14    covered  by  a  policy of accident and health insurance under
15    Section 356t and the coverage required under  Sections  356u,
16    356w,  and  356x,  and 356z.4 of the Illinois Insurance Code.
17    The requirement that health benefits be covered  as  provided
18    in  this  is an exclusive power and function of the State and
19    is a denial and limitation  under  Article  VII,  Section  6,
20    subsection  (h)  of  the  Illinois Constitution.  A home rule
21    municipality to which this Section applies must  comply  with
22    every provision of this Section.
23    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

24        Section  20.  The  Illinois  Insurance Code is amended by
25    adding Section 356z.4 as follows:

26        (215 ILCS 5/356z.4 new)
27        Sec. 356z.4.  Breast  cancer  family  history;  survivor;
28    coverage.  After the effective date of this amendatory Act of
29    the 93rd General Assembly, an issuer of a group or individual
30    policy  of  accident  and  health  insurance  may  not cancel
 
                            -3-      LRB093 07313 JLS 07474 b
 1    coverage, deny coverage, refuse to renew coverage, or include
 2    in any group or individual policy any exception or  exclusion
 3    of benefits solely because the insured or proposed insured is
 4    a survivor of breast cancer or has a family history of breast
 5    cancer, or both.

 6        Section  25.  The  Health Maintenance Organization Act is
 7    amended by changing Section 5-3 as follows:

 8        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
 9        Sec. 5-3.  Insurance Code provisions.
10        (a)  Health Maintenance Organizations shall be subject to
11    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
12    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
13    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
14    356y, 356z.2, 356z.4, 367i, 368a, 401, 401.1, 402, 403, 403A,
15    408,  408.2,  409,  412,  444,  and  444.1,  paragraph (c) of
16    subsection (2) of Section 367, and Articles  IIA,  VIII  1/2,
17    XII,  XII  1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
18    Insurance Code.
19        (b)  For purposes of the Illinois Insurance Code,  except
20    for  Sections  444  and 444.1 and Articles XIII and XIII 1/2,
21    Health Maintenance Organizations in the following  categories
22    are deemed to be "domestic companies":
23             (1)  a   corporation  authorized  under  the  Dental
24        Service Plan Act or the Voluntary Health  Services  Plans
25        Act;
26             (2)  a  corporation organized under the laws of this
27        State; or
28             (3)  a  corporation  organized  under  the  laws  of
29        another state, 30% or more of the enrollees of which  are
30        residents  of this State, except a corporation subject to
31        substantially the  same  requirements  in  its  state  of
32        organization  as  is  a  "domestic company" under Article
 
                            -4-      LRB093 07313 JLS 07474 b
 1        VIII 1/2 of the Illinois Insurance Code.
 2        (c)  In considering the merger, consolidation,  or  other
 3    acquisition  of  control of a Health Maintenance Organization
 4    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
 5             (1)  the Director shall give  primary  consideration
 6        to  the  continuation  of  benefits  to enrollees and the
 7        financial conditions of the acquired  Health  Maintenance
 8        Organization  after  the  merger, consolidation, or other
 9        acquisition of control takes effect;
10             (2)(i)  the criteria specified in subsection  (1)(b)
11        of Section 131.8 of the Illinois Insurance Code shall not
12        apply  and (ii) the Director, in making his determination
13        with respect  to  the  merger,  consolidation,  or  other
14        acquisition  of  control,  need not take into account the
15        effect on competition of the  merger,  consolidation,  or
16        other acquisition of control;
17             (3)  the  Director  shall  have the power to require
18        the following information:
19                  (A)  certification by an independent actuary of
20             the  adequacy  of  the  reserves   of   the   Health
21             Maintenance Organization sought to be acquired;
22                  (B)  pro  forma financial statements reflecting
23             the combined balance sheets of the acquiring company
24             and the Health Maintenance Organization sought to be
25             acquired as of the end of the preceding year and  as
26             of  a date 90 days prior to the acquisition, as well
27             as  pro  forma   financial   statements   reflecting
28             projected  combined  operation  for  a  period  of 2
29             years;
30                  (C)  a pro forma  business  plan  detailing  an
31             acquiring   party's   plans   with  respect  to  the
32             operation of  the  Health  Maintenance  Organization
33             sought  to be acquired for a period of not less than
34             3 years; and
 
                            -5-      LRB093 07313 JLS 07474 b
 1                  (D)  such other  information  as  the  Director
 2             shall require.
 3        (d)  The  provisions  of Article VIII 1/2 of the Illinois
 4    Insurance Code and this Section 5-3 shall apply to  the  sale
 5    by any health maintenance organization of greater than 10% of
 6    its  enrollee  population  (including  without limitation the
 7    health maintenance organization's right, title, and  interest
 8    in and to its health care certificates).
 9        (e)  In  considering  any  management contract or service
10    agreement subject to Section 141.1 of the Illinois  Insurance
11    Code,  the  Director  (i)  shall, in addition to the criteria
12    specified in Section 141.2 of the  Illinois  Insurance  Code,
13    take  into  account  the effect of the management contract or
14    service  agreement  on  the  continuation  of   benefits   to
15    enrollees   and   the   financial  condition  of  the  health
16    maintenance organization to be managed or serviced, and  (ii)
17    need  not  take  into  account  the  effect of the management
18    contract or service agreement on competition.
19        (f)  Except for small employer groups as defined  in  the
20    Small  Employer  Rating,  Renewability and Portability Health
21    Insurance Act and except for medicare supplement policies  as
22    defined  in  Section  363  of  the Illinois Insurance Code, a
23    Health Maintenance Organization may by contract agree with  a
24    group  or  other  enrollment unit to effect refunds or charge
25    additional premiums under the following terms and conditions:
26             (i)  the amount of, and other terms  and  conditions
27        with respect to, the refund or additional premium are set
28        forth  in the group or enrollment unit contract agreed in
29        advance of the period for which a refund is to be paid or
30        additional premium is to be charged (which  period  shall
31        not be less than one year); and
32             (ii)  the amount of the refund or additional premium
33        shall   not   exceed   20%   of  the  Health  Maintenance
34        Organization's profitable or unprofitable experience with
 
                            -6-      LRB093 07313 JLS 07474 b
 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
 7        be 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
10        profitable or unprofitable experience may  be  calculated
11        taking into account the refund period and the immediately
12        preceding 2 plan years.
13        The  Health  Maintenance  Organization  shall  include  a
14    statement in the evidence of coverage issued to each enrollee
15    describing the possibility of a refund or additional premium,
16    and  upon request of any group or enrollment unit, provide to
17    the group or enrollment unit a description of the method used
18    to  calculate  (1)  the  Health  Maintenance   Organization's
19    profitable experience with respect to the group or enrollment
20    unit and the resulting refund to the group or enrollment unit
21    or  (2)  the  Health  Maintenance Organization's unprofitable
22    experience with respect to the group or enrollment  unit  and
23    the  resulting  additional premium to be paid by the group or
24    enrollment unit.
25        In  no  event  shall  the  Illinois  Health   Maintenance
26    Organization  Guaranty  Association  be  liable  to  pay  any
27    contractual  obligation  of  an insolvent organization to pay
28    any refund authorized under this Section.
29    (Source: P.A. 91-357,  eff.  7-29-99;  91-406,  eff.  1-1-00;
30    91-549,  eff.  8-14-99;  91-605,  eff. 12-14-99; 91-788, eff.
31    6-9-00; 92-764, eff. 1-1-03.)

32        Section 30.  The Voluntary Health Services Plans  Act  is
33    amended by changing Section 10 as follows:
 
                            -7-      LRB093 07313 JLS 07474 b
 1        (215 ILCS 165/10) (from Ch. 32, par. 604)
 2        Sec.   10.  Application  of  Insurance  Code  provisions.
 3    Health services plan corporations and all persons  interested
 4    therein   or  dealing  therewith  shall  be  subject  to  the
 5    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
 6    140, 143, 143c, 149, 155.37, 354, 355.2,  356r,  356t,  356u,
 7    356v,  356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 367.2, 368a,
 8    401,  401.1,  402,  403,  403A,  408,  408.2,  and  412,  and
 9    paragraphs (7) and  (15)  of  Section  367  of  the  Illinois
10    Insurance Code.
11    (Source: P.A.  91-406,  eff.  1-1-00;  91-549,  eff. 8-14-99;
12    91-605, eff. 12-14-99;  91-788,  eff.  6-9-00;  92-130,  eff.
13    7-20-01;  92-440, eff. 8-17-01; 92-651, eff. 7-11-02; 92-764,
14    eff. 1-1-03.)

15        Section 90.  The State Mandates Act is amended by  adding
16    Section 8.27 as follows:

17        (30 ILCS 805/8.27 new)
18        Sec.  8.27.  Exempt  mandate.  Notwithstanding Sections 6
19    and 8 of this Act, no reimbursement by the State is  required
20    for  the  implementation  of  any  mandate  created  by  this
21    amendatory Act of the 93rd General Assembly.

22        Section  99.  Effective date.  This Act takes effect upon
23    becoming law.