State of Illinois
2019 and 2020


Introduced , by Rep. Daniel Swanson


215 ILCS 5/356z.33 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
305 ILCS 5/5-16.8

    Amends the Illinois Insurance Code. Requires an individual or group policy of accident and health insurance or managed care plan to provide coverage for long-term antibiotic therapy for a person with a tick-borne disease. Makes conforming changes in the Health Maintenance Organization Act and the Illinois Public Aid Code.

LRB101 04337 SMS 51168 b






HB0889LRB101 04337 SMS 51168 b

1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 356z.33 as follows:
6    (215 ILCS 5/356z.33 new)
7    Sec. 356z.33. Long-term antibiotic therapy for tick-borne
9    (a) As used in this Section:
10    "Long-term antibiotic therapy" means the administration of
11oral, intramuscular, or intravenous antibiotics singly or in
12combination for periods of time in excess of 4 weeks.
13    "Tick-borne disease" means a disease caused when an
14infected tick bites a person and the tick's saliva transmits an
15infectious agent (bacteria, viruses, or parasites) that can
16cause illness, including, but not limited to, the following:
17        (1) a severe infection with borrelia burgdorferi;
18        (2) a late stage, persistent, or chronic infection or
19    complications related to such an infection;
20        (3) an infection with other strains of borrelia or a
21    tick-borne disease that is recognized by the United States
22    Centers for Disease Control and Prevention; and
23        (4) the presence of signs or symptoms compatible with



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1    acute infection of borrelia or other tick-borne diseases.
2    (b) An individual or group policy of accident and health
3insurance or managed care plan that is amended, delivered,
4issued, or renewed on or after the effective date of this
5amendatory Act of the 101st General Assembly shall provide
6coverage for long-term antibiotic therapy, including necessary
7office visits and ongoing testing, for a person with a
8tick-borne disease when determined to be medically necessary
9and ordered by a physician licensed to practice medicine in all
10its branches after making a thorough evaluation of the person's
11symptoms, diagnostic test results, or response to treatment. An
12experimental drug shall be covered as a long-term antibiotic
13therapy if it is approved for an indication by the United
14States Food and Drug Administration. A drug, including an
15experimental drug, shall be covered for an off-label use in the
16treatment of a tick-borne disease if the drug has been approved
17by the United States Food and Drug Administration.
18    Section 10. The Health Maintenance Organization Act is
19amended 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
23the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
24141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,



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1154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
2355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
3356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
4356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
5356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33,
6364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
7368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2,
8409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
9Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
10XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
11    (b) For purposes of the Illinois Insurance Code, except for
12Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
13Maintenance Organizations in the following categories are
14deemed to be "domestic companies":
15        (1) a corporation authorized under the Dental Service
16    Plan Act or the Voluntary Health Services Plans Act;
17        (2) a corporation organized under the laws of this
18    State; or
19        (3) a corporation organized under the laws of another
20    state, 30% or more of the enrollees of which are residents
21    of this State, except a corporation subject to
22    substantially the same requirements in its state of
23    organization as is a "domestic company" under Article VIII
24    1/2 of the Illinois Insurance Code.
25    (c) In considering the merger, consolidation, or other
26acquisition of control of a Health Maintenance Organization



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1pursuant to Article VIII 1/2 of the Illinois Insurance Code,
2        (1) the Director shall give primary consideration to
3    the continuation of benefits to enrollees and the financial
4    conditions of the acquired Health Maintenance Organization
5    after the merger, consolidation, or other acquisition of
6    control takes effect;
7        (2)(i) the criteria specified in subsection (1)(b) of
8    Section 131.8 of the Illinois Insurance Code shall not
9    apply and (ii) the Director, in making his determination
10    with respect to the merger, consolidation, or other
11    acquisition of control, need not take into account the
12    effect on competition of the merger, consolidation, or
13    other acquisition of control;
14        (3) the Director shall have the power to require the
15    following information:
16            (A) certification by an independent actuary of the
17        adequacy of the reserves of the Health Maintenance
18        Organization sought to be acquired;
19            (B) pro forma financial statements reflecting the
20        combined balance sheets of the acquiring company and
21        the Health Maintenance Organization sought to be
22        acquired as of the end of the preceding year and as of
23        a date 90 days prior to the acquisition, as well as pro
24        forma financial statements reflecting projected
25        combined operation for a period of 2 years;
26            (C) a pro forma business plan detailing an



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1        acquiring party's plans with respect to the operation
2        of the Health Maintenance Organization sought to be
3        acquired for a period of not less than 3 years; and
4            (D) such other information as the Director shall
5        require.
6    (d) The provisions of Article VIII 1/2 of the Illinois
7Insurance Code and this Section 5-3 shall apply to the sale by
8any health maintenance organization of greater than 10% of its
9enrollee population (including without limitation the health
10maintenance organization's right, title, and interest in and to
11its health care certificates).
12    (e) In considering any management contract or service
13agreement subject to Section 141.1 of the Illinois Insurance
14Code, the Director (i) shall, in addition to the criteria
15specified in Section 141.2 of the Illinois Insurance Code, take
16into account the effect of the management contract or service
17agreement on the continuation of benefits to enrollees and the
18financial condition of the health maintenance organization to
19be managed or serviced, and (ii) need not take into account the
20effect of the management contract or service agreement on
22    (f) Except for small employer groups as defined in the
23Small Employer Rating, Renewability and Portability Health
24Insurance Act and except for medicare supplement policies as
25defined in Section 363 of the Illinois Insurance Code, a Health
26Maintenance Organization may by contract agree with a group or



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



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1and upon request of any group or enrollment unit, provide to
2the group or enrollment unit a description of the method used
3to calculate (1) the Health Maintenance Organization's
4profitable experience with respect to the group or enrollment
5unit and the resulting refund to the group or enrollment unit
6or (2) the Health Maintenance Organization's unprofitable
7experience with respect to the group or enrollment unit and the
8resulting additional premium to be paid by the group or
9enrollment unit.
10    In no event shall the Illinois Health Maintenance
11Organization Guaranty Association be liable to pay any
12contractual obligation of an insolvent organization to pay any
13refund authorized under this Section.
14    (g) Rulemaking authority to implement Public Act 95-1045,
15if any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
21100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff.
228-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
24    Section 15. The Illinois Public Aid Code is amended by
25changing Section 5-16.8 as follows:



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1    (305 ILCS 5/5-16.8)
2    Sec. 5-16.8. Required health benefits. The medical
3assistance program shall (i) provide the post-mastectomy care
4benefits required to be covered by a policy of accident and
5health insurance under Section 356t and the coverage required
6under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and
7356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code
8and (ii) be subject to the provisions of Sections 356z.19,
9364.01, 370c, and 370c.1 of the Illinois Insurance Code.
10    On and after July 1, 2012, the Department shall reduce any
11rate of reimbursement for services or other payments or alter
12any methodologies authorized by this Code to reduce any rate of
13reimbursement for services or other payments in accordance with
14Section 5-5e.
15    To ensure full access to the benefits set forth in this
16Section, on and after January 1, 2016, the Department shall
17ensure that provider and hospital reimbursement for
18post-mastectomy care benefits required under this Section are
19no lower than the Medicare reimbursement rate.
20(Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15;
2199-642, eff. 7-28-16; 100-138, eff. 8-18-17; 100-863, eff.
228-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised