State of Illinois
92nd General Assembly
Legislation

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92_SB1052

 
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 1        AN  ACT  concerning insurance coverage relating to breast
 2    cancer risks.

 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,  and  356x,  and
14    356z.1 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 State Mandates Act is amended by adding
18    Section 8.25 as follows:

19        (30 ILCS 805/8.25 new)
20        Sec. 8.25. Exempt mandate.   Notwithstanding  Sections  6
21    and  8 of this Act, no reimbursement by the State is required
22    for  the  implementation  of  any  mandate  created  by  this
23    amendatory Act of the 92nd General Assembly.

24        Section 15.  The Counties Code  is  amended  by  changing
25    Section 5-1069.3 as follows:

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

15        Section  20.   The  Illinois Municipal Code is amended by
16    changing 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
19    municipality,  including  a  home  rule  municipality,  is  a
20    self-insurer  for  purposes  of  providing  health  insurance
21    coverage  for  its  employees,  the  coverage  shall  include
22    coverage for the post-mastectomy care benefits required to be
23    covered  by  a  policy of accident and health insurance under
24    Section 356t and the coverage required under  Sections  356u,
25    356w,  and  356x,  and 356z.1 of the Illinois Insurance Code.
26    The requirement that health benefits be covered  as  provided
27    in  this  is an exclusive power and function of the State and
28    is a denial and limitation  under  Article  VII,  Section  6,
29    subsection  (h)  of  the  Illinois Constitution.  A home rule
30    municipality to which this Section applies must  comply  with
31    every provision of this Section.
32    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
 
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 1        Section  25.  The  Illinois  Insurance Code is amended by
 2    adding Section 356z.1 as follows:

 3        (215 ILCS 5/356z.1 new)
 4        Sec. 356z.1.  Breast  cancer  family  history;  survivor;
 5    coverage.  After the effective date of this amendatory Act of
 6    the 92nd General Assembly, an issuer of a group or individual
 7    policy  of  accident  and  health  insurance  may  not cancel
 8    coverage, deny coverage, refuse to renew coverage, or include
 9    in any group or individual policy any exception or  exclusion
10    of benefits solely because the insured or proposed insured is
11    a survivor of breast cancer or has a family history of breast
12    cancer, or both.

13        Section  30.   The Health Maintenance Organization Act is
14    amended by changing Section 5-3 as follows:

15        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
16        Sec. 5-3.  Insurance Code provisions.
17        (a)  Health Maintenance Organizations shall be subject to
18    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
19    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
20    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
21    356y,  356z.1,  367i,  368a, 401, 401.1, 402, 403, 403A, 408,
22    408.2, 409, 412, 444, and 444.1, paragraph (c) of  subsection
23    (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
24    XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
25        (b)  For  purposes of the Illinois Insurance Code, except
26    for Sections 444 and 444.1 and Articles XIII  and  XIII  1/2,
27    Health  Maintenance Organizations in the following categories
28    are deemed to be "domestic companies":
29             (1)  a  corporation  authorized  under  the   Dental
30        Service  Plan  Act or the Voluntary Health Services Plans
31        Act;
 
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 1             (2)  a corporation organized under the laws of  this
 2        State; or
 3             (3)  a  corporation  organized  under  the  laws  of
 4        another  state, 30% or more of the enrollees of which are
 5        residents of this State, except a corporation subject  to
 6        substantially  the  same  requirements  in  its  state of
 7        organization as is a  "domestic  company"  under  Article
 8        VIII 1/2 of the Illinois Insurance Code.
 9        (c)  In  considering  the merger, consolidation, or other
10    acquisition of control of a Health  Maintenance  Organization
11    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
12             (1)  the  Director  shall give primary consideration
13        to the continuation of  benefits  to  enrollees  and  the
14        financial  conditions  of the acquired Health Maintenance
15        Organization after the merger,  consolidation,  or  other
16        acquisition of control takes effect;
17             (2)(i)  the  criteria specified in subsection (1)(b)
18        of Section 131.8 of the Illinois Insurance Code shall not
19        apply and (ii) the Director, in making his  determination
20        with  respect  to  the  merger,  consolidation,  or other
21        acquisition of control, need not take  into  account  the
22        effect  on  competition  of the merger, consolidation, or
23        other acquisition of control;
24             (3)  the Director shall have the  power  to  require
25        the following information:
26                  (A)  certification by an independent actuary of
27             the   adequacy   of   the  reserves  of  the  Health
28             Maintenance Organization sought to be acquired;
29                  (B)  pro forma financial statements  reflecting
30             the combined balance sheets of the acquiring company
31             and the Health Maintenance Organization sought to be
32             acquired  as of the end of the preceding year and as
33             of a date 90 days prior to the acquisition, as  well
34             as   pro   forma   financial  statements  reflecting
 
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 1             projected combined  operation  for  a  period  of  2
 2             years;
 3                  (C)  a  pro  forma  business  plan detailing an
 4             acquiring  party's  plans  with   respect   to   the
 5             operation  of  the  Health  Maintenance Organization
 6             sought to be acquired for a period of not less  than
 7             3 years; and
 8                  (D)  such  other  information  as  the Director
 9             shall require.
10        (d)  The provisions of Article VIII 1/2 of  the  Illinois
11    Insurance  Code  and this Section 5-3 shall apply to the sale
12    by any health maintenance organization of greater than 10% of
13    its enrollee population  (including  without  limitation  the
14    health  maintenance organization's right, title, and interest
15    in and to its health care certificates).
16        (e)  In considering any management  contract  or  service
17    agreement  subject to Section 141.1 of the Illinois Insurance
18    Code, the Director (i) shall, in  addition  to  the  criteria
19    specified  in  Section  141.2 of the Illinois Insurance Code,
20    take into account the effect of the  management  contract  or
21    service   agreement   on  the  continuation  of  benefits  to
22    enrollees  and  the  financial  condition   of   the   health
23    maintenance  organization to be managed or serviced, and (ii)
24    need not take into  account  the  effect  of  the  management
25    contract or service agreement on competition.
26        (f)  Except  for  small employer groups as defined in the
27    Small Employer Rating, Renewability  and  Portability  Health
28    Insurance  Act and except for medicare supplement policies as
29    defined in Section 363 of  the  Illinois  Insurance  Code,  a
30    Health  Maintenance Organization may by contract agree with a
31    group or other enrollment unit to effect  refunds  or  charge
32    additional premiums under the following terms and conditions:
33             (i)  the  amount  of, and other terms and conditions
34        with respect to, the refund or additional premium are set
 
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 1        forth in the group or enrollment unit contract agreed  in
 2        advance of the period for which a refund is to be paid or
 3        additional  premium  is to be charged (which period shall
 4        not be less than one year); and
 5             (ii)  the amount of the refund or additional premium
 6        shall  not  exceed  20%   of   the   Health   Maintenance
 7        Organization's profitable or unprofitable experience with
 8        respect  to  the  group  or other enrollment unit for the
 9        period (and, for  purposes  of  a  refund  or  additional
10        premium,  the profitable or unprofitable experience shall
11        be calculated taking into account a pro rata share of the
12        Health  Maintenance  Organization's  administrative   and
13        marketing  expenses,  but shall not include any refund to
14        be made or additional premium to be paid pursuant to this
15        subsection (f)).  The Health Maintenance Organization and
16        the  group  or  enrollment  unit  may  agree   that   the
17        profitable  or  unprofitable experience may be calculated
18        taking into account the refund period and the immediately
19        preceding 2 plan years.
20        The  Health  Maintenance  Organization  shall  include  a
21    statement in the evidence of coverage issued to each enrollee
22    describing the possibility of a refund or additional premium,
23    and upon request of any group or enrollment unit, provide  to
24    the group or enrollment unit a description of the method used
25    to   calculate  (1)  the  Health  Maintenance  Organization's
26    profitable experience with respect to the group or enrollment
27    unit and the resulting refund to the group or enrollment unit
28    or (2) the  Health  Maintenance  Organization's  unprofitable
29    experience  with  respect to the group or enrollment unit and
30    the resulting additional premium to be paid by the  group  or
31    enrollment unit.
32        In   no  event  shall  the  Illinois  Health  Maintenance
33    Organization  Guaranty  Association  be  liable  to  pay  any
34    contractual obligation of an insolvent  organization  to  pay
 
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 1    any refund authorized under this Section.
 2    (Source: P.A.  90-25,  eff.  1-1-98;  90-177,  eff.  7-23-97;
 3    90-372,  eff.  7-1-98;  90-583,  eff.  5-29-98;  90-655, eff.
 4    7-30-98; 90-741, eff. 1-1-99; 91-357, eff.  7-29-99;  91-406,
 5    eff.  1-1-00;  91-549,  eff.  8-14-99; 91-605, eff. 12-14-99;
 6    91-788, eff. 6-9-00.)

 7        Section 35.  The Voluntary Health Services Plans  Act  is
 8    amended by changing Section 10 as follows:

 9        (215 ILCS 165/10) (from Ch. 32, par. 604)
10        Sec.   10.  Application  of  Insurance  Code  provisions.
11    Health services plan corporations and all persons  interested
12    therein   or  dealing  therewith  shall  be  subject  to  the
13    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
14    140, 143, 143c, 149, 354,  355.2,  356r,  356t,  356u,  356v,
15    356w,  356x, 356y, 356z.1, 367.2, 368a, 401, 401.1, 402, 403,
16    403A, 408, 408.2, and 412, and paragraphs  (7)  and  (15)  of
17    Section 367 of the Illinois Insurance Code.
18    (Source: P.A. 90-7, eff. 6-10-97; 90-25, eff. 1-1-98; 90-655,
19    eff.  7-30-98;  90-741,  eff.  1-1-99;  91-406,  eff. 1-1-00;
20    91-549, eff. 8-14-99; 91-605,  eff.  12-14-99;  91-788,  eff.
21    6-9-00.)

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