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91_HB0061eng HB0061 Engrossed LRB9100171JSgc 1 AN ACT concerning insurance coverage for pregnancy 2 prevention, amending named Acts. 3 Be it enacted by the People of the State of Illinois, 4 represented in the General Assembly: 5 Section 5. The State Employees Group Insurance Act of 6 1971 is amended by changing Section 6.11 as follows: 7 (5 ILCS 375/6.11) 8 Sec. 6.11. Required health benefits. The program of 9 health benefits shall provide the post-mastectomy care 10 benefits required to be covered by a policy of accident and 11 health insurance under Section 356t of the Illinois Insurance 12 Code. The program of health benefits shall provide the 13 coverage required under Sections 356u, 356w,and356x, and 14 356y of the Illinois Insurance Code. 15 (Source: P.A. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98; 16 90-741, eff. 1-1-99.) 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,and356x, and 356y 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 HB0061 Engrossed -2- LRB9100171JSgc 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,and356x, and 356y of the Illinois Insurance Code. The 17 requirement that health benefits be covered as provided in 18 this is an exclusive power and function of the State and is a 19 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 School Code is amended by changing 25 Section 10-22.3f as follows: 26 (105 ILCS 5/10-22.3f) 27 Sec. 10-22.3f. Required health benefits. Insurance 28 protection and benefits for employees shall provide the 29 post-mastectomy care benefits required to be covered by a 30 policy of accident and health insurance under Section 356t HB0061 Engrossed -3- LRB9100171JSgc 1 and the coverage required under Sections 356u, 356w,and356x 2 , and 356y of the Illinois Insurance Code. 3 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.) 4 Section 25. The Illinois Insurance Code is amended by 5 adding Section 356y as follows: 6 (215 ILCS 5/356y new) 7 Sec. 356y. Birth control coverage. A group or 8 individual policy of accident and health insurance or managed 9 care plan amended, delivered, issued, or renewed after the 10 effective date of this amendatory Act of 1999 that provides 11 coverage for prescribed drugs approved by the federal Food 12 and Drug Administration for the treatment of impotence must 13 also provide coverage for prescribed drugs approved by the 14 federal Food and Drug Administration for the prevention of 15 pregnancy on the same terms and conditions that are generally 16 applicable to coverage for other prescribed drugs approved by 17 the federal Food and Drug Administration. 18 Section 30. The Health Maintenance Organization Act is 19 amended by changing Section 5-3 as follows: 20 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) 21 Sec. 5-3. Insurance Code provisions. 22 (a) Health Maintenance Organizations shall be subject to 23 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2, 24 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 25 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 26 356y, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 27 444, and 444.1, paragraph (c) of subsection (2) of Section 28 367, and Articles VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, 29 XXV, and XXVI of the Illinois Insurance Code. 30 (b) For purposes of the Illinois Insurance Code, except HB0061 Engrossed -4- LRB9100171JSgc 1 for Sections 444 and 444.1 and Articles XIII and XIII 1/2, 2 Health Maintenance Organizations in the following categories 3 are deemed to be "domestic companies": 4 (1) a corporation authorized under the Dental 5 Service Plan Act or the Voluntary Health Services Plans 6 Act; 7 (2) a corporation organized under the laws of this 8 State; or 9 (3) a corporation organized under the laws of 10 another state, 30% or more of the enrollees of which are 11 residents of this State, except a corporation subject to 12 substantially the same requirements in its state of 13 organization as is a "domestic company" under Article 14 VIII 1/2 of the Illinois Insurance Code. 15 (c) In considering the merger, consolidation, or other 16 acquisition of control of a Health Maintenance Organization 17 pursuant to Article VIII 1/2 of the Illinois Insurance Code, 18 (1) the Director shall give primary consideration 19 to the continuation of benefits to enrollees and the 20 financial conditions of the acquired Health Maintenance 21 Organization after the merger, consolidation, or other 22 acquisition of control takes effect; 23 (2)(i) the criteria specified in subsection (1)(b) 24 of Section 131.8 of the Illinois Insurance Code shall not 25 apply and (ii) the Director, in making his determination 26 with respect to the merger, consolidation, or other 27 acquisition of control, need not take into account the 28 effect on competition of the merger, consolidation, or 29 other acquisition of control; 30 (3) the Director shall have the power to require 31 the following information: 32 (A) certification by an independent actuary of 33 the adequacy of the reserves of the Health 34 Maintenance Organization sought to be acquired; HB0061 Engrossed -5- LRB9100171JSgc 1 (B) pro forma financial statements reflecting 2 the combined balance sheets of the acquiring company 3 and the Health Maintenance Organization sought to be 4 acquired as of the end of the preceding year and as 5 of a date 90 days prior to the acquisition, as well 6 as pro forma financial statements reflecting 7 projected combined operation for a period of 2 8 years; 9 (C) a pro forma business plan detailing an 10 acquiring party's plans with respect to the 11 operation of the Health Maintenance Organization 12 sought to be acquired for a period of not less than 13 3 years; and 14 (D) such other information as the Director 15 shall require. 16 (d) The provisions of Article VIII 1/2 of the Illinois 17 Insurance Code and this Section 5-3 shall apply to the sale 18 by any health maintenance organization of greater than 10% of 19 its enrollee population (including without limitation the 20 health maintenance organization's right, title, and interest 21 in and to its health care certificates). 22 (e) In considering any management contract or service 23 agreement subject to Section 141.1 of the Illinois Insurance 24 Code, the Director (i) shall, in addition to the criteria 25 specified in Section 141.2 of the Illinois Insurance Code, 26 take into account the effect of the management contract or 27 service agreement on the continuation of benefits to 28 enrollees and the financial condition of the health 29 maintenance organization to be managed or serviced, and (ii) 30 need not take into account the effect of the management 31 contract or service agreement on competition. 32 (f) Except for small employer groups as defined in the 33 Small Employer Rating, Renewability and Portability Health 34 Insurance Act and except for medicare supplement policies as HB0061 Engrossed -6- LRB9100171JSgc 1 defined in Section 363 of the Illinois Insurance Code, a 2 Health Maintenance Organization may by contract agree with a 3 group or other enrollment unit to effect refunds or charge 4 additional premiums under the following terms and conditions: 5 (i) the amount of, and other terms and conditions 6 with respect to, the refund or additional premium are set 7 forth in the group or enrollment unit contract agreed in 8 advance of the period for which a refund is to be paid or 9 additional premium is to be charged (which period shall 10 not be less than one year); and 11 (ii) the amount of the refund or additional premium 12 shall not exceed 20% of the Health Maintenance 13 Organization's profitable or unprofitable experience with 14 respect to the group or other enrollment unit for the 15 period (and, for purposes of a refund or additional 16 premium, the profitable or unprofitable experience shall 17 be calculated taking into account a pro rata share of the 18 Health Maintenance Organization's administrative and 19 marketing expenses, but shall not include any refund to 20 be made or additional premium to be paid pursuant to this 21 subsection (f)). The Health Maintenance Organization and 22 the group or enrollment unit may agree that the 23 profitable or unprofitable experience may be calculated 24 taking into account the refund period and the immediately 25 preceding 2 plan years. 26 The Health Maintenance Organization shall include a 27 statement in the evidence of coverage issued to each enrollee 28 describing the possibility of a refund or additional premium, 29 and upon request of any group or enrollment unit, provide to 30 the group or enrollment unit a description of the method used 31 to calculate (1) the Health Maintenance Organization's 32 profitable experience with respect to the group or enrollment 33 unit and the resulting refund to the group or enrollment unit 34 or (2) the Health Maintenance Organization's unprofitable HB0061 Engrossed -7- LRB9100171JSgc 1 experience with respect to the group or enrollment unit and 2 the resulting additional premium to be paid by the group or 3 enrollment unit. 4 In no event shall the Illinois Health Maintenance 5 Organization Guaranty Association be liable to pay any 6 contractual obligation of an insolvent organization to pay 7 any refund authorized under this Section. 8 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98; 9 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; 90-583, eff. 10 5-29-98; 90-655, eff. 7-30-98; 90-741, eff. 1-1-99; revised 11 9-8-98.) 12 Section 35. The Voluntary Health Services Plans Act is 13 amended by changing Section 10 as follows: 14 (215 ILCS 165/10) (from Ch. 32, par. 604) 15 Sec. 10. Application of Insurance Code provisions. 16 Health services plan corporations and all persons interested 17 therein or dealing therewith shall be subject to the 18 provisions of Article XII 1/2 and Sections 3.1, 133, 140, 19 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 20 356x, 356y, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, 21 and 412, and paragraphs (7) and (15) of Section 367 of the 22 Illinois Insurance Code. 23 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97; 24 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 90-741, eff. 25 1-1-99.)