103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB3920

 

Introduced 2/17/2023, by Rep. Debbie Meyers-Martin

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.61 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003  from Ch. 73, par. 1504-3
215 ILCS 165/10  from Ch. 32, par. 604
305 ILCS 5/5-16.8

    Amends the Accident and Health Article of the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of the amendatory Act shall provide coverage for cranial prostheses when prescribed as part of a course of rehabilitative treatment by a physician licensed to practice medicine in all of its branches. Makes conforming changes in the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Voluntary Health Services Plans Act, and the Medical Assistance Article of the Illinois Public Aid Code.


LRB103 26433 BMS 52796 b

 

 

A BILL FOR

 

HB3920LRB103 26433 BMS 52796 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
5adding Section 356z.61 as follows:
 
6    (215 ILCS 5/356z.61 new)
7    Sec. 356z.61. Coverage for cranial prostheses. A group or
8individual policy of accident and health insurance or a
9managed care plan that is amended, delivered, issued, or
10renewed on or after the effective date of this amendatory Act
11of the 103rd General Assembly shall provide coverage for
12cranial prostheses when prescribed as part of a course of
13rehabilitative treatment by a physician licensed to practice
14medicine in all of its branches.
 
15    Section 10. The Health Maintenance Organization Act is
16amended by changing Section 5-3 as follows:
 
17    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
18    Sec. 5-3. Insurance Code provisions.
19    (a) Health Maintenance Organizations shall be subject to
20the provisions of Sections 133, 134, 136, 137, 139, 140,
21141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,

 

 

HB3920- 2 -LRB103 26433 BMS 52796 b

1154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
2355.3, 355b, 355c, 356g.5-1, 356m, 356q, 356v, 356w, 356x,
3356y, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
4356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
5356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
6356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
7356z.35, 356z.36, 356z.40, 356z.41, 356z.46, 356z.47, 356z.48,
8356z.50, 356z.51, 356z.53 256z.53, 356z.54, 356z.56, 356z.57,
9356z.59, 356z.60, 356z.61, 364, 364.01, 364.3, 367.2, 367.2-5,
10367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1,
11402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
12paragraph (c) of subsection (2) of Section 367, and Articles
13IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
14XXXIIB of the Illinois Insurance Code.
15    (b) For purposes of the Illinois Insurance Code, except
16for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
17Health Maintenance Organizations in the following categories
18are deemed 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

 

 

HB3920- 3 -LRB103 26433 BMS 52796 b

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
8    financial conditions of the acquired Health Maintenance
9    Organization after the merger, consolidation, or other
10    acquisition of 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

 

 

HB3920- 4 -LRB103 26433 BMS 52796 b

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
15to its 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,
20take into account the effect of the management contract or
21service agreement on the continuation of benefits to enrollees
22and the financial condition of the health maintenance
23organization to be managed or serviced, and (ii) need not take
24into account the effect of the management contract or service
25agreement on competition.
26    (f) Except for small employer groups as defined in the

 

 

HB3920- 5 -LRB103 26433 BMS 52796 b

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
4Health Maintenance Organization may by contract agree with a
5group or other enrollment unit to effect refunds or charge
6additional premiums 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
12    not 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

 

 

HB3920- 6 -LRB103 26433 BMS 52796 b

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
12the resulting 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
20accordance with all provisions of the Illinois Administrative
21Procedure Act and all rules and procedures of the Joint
22Committee on Administrative Rules; any purported rule not so
23adopted, for whatever reason, is unauthorized.
24(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
25101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
261-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,

 

 

HB3920- 7 -LRB103 26433 BMS 52796 b

1eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
2102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
31-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
4eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
5102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
61-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
7eff. 1-1-23; 102-1117, eff. 1-13-23; revised 1-22-23.)
 
8    Section 15. The Limited Health Service Organization Act is
9amended by changing Section 4003 as follows:
 
10    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
11    Sec. 4003. Illinois Insurance Code provisions. Limited
12health service organizations shall be subject to the
13provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
14141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
15154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 355.2, 355.3,
16355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, 356z.21, 356z.22,
17356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
18356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.57,
19356z.59, 356z.61, 364.3, 368a, 401, 401.1, 402, 403, 403A,
20408, 408.2, 409, 412, 444, and 444.1 and Articles IIA, VIII
211/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the
22Illinois Insurance Code. Nothing in this Section shall require
23a limited health care plan to cover any service that is not a
24limited health service. For purposes of the Illinois Insurance

 

 

HB3920- 8 -LRB103 26433 BMS 52796 b

1Code, except for Sections 444 and 444.1 and Articles XIII and
2XIII 1/2, limited health service organizations in the
3following categories are deemed to be domestic companies:
4        (1) a corporation under the laws of this State; or
5        (2) a corporation organized under the laws of another
6    state, 30% or more of the enrollees of which are residents
7    of this State, except a corporation subject to
8    substantially the same requirements in its state of
9    organization as is a domestic company under Article VIII
10    1/2 of the Illinois Insurance Code.
11(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
12101-393, eff. 1-1-20; 101-625, eff. 1-1-21; 102-30, eff.
131-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642,
14eff. 1-1-22; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
15102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff.
161-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
 
17    Section 20. The Voluntary Health Services Plans Act is
18amended by changing Section 10 as follows:
 
19    (215 ILCS 165/10)  (from Ch. 32, par. 604)
20    Sec. 10. Application of Insurance Code provisions. Health
21services plan corporations and all persons interested therein
22or dealing therewith shall be subject to the provisions of
23Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
24143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,

 

 

HB3920- 9 -LRB103 26433 BMS 52796 b

1356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
2356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
3356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
4356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
5356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
6356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54,
7356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 364.01, 364.3,
8367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
9and paragraphs (7) and (15) of Section 367 of the Illinois
10Insurance Code.
11    Rulemaking authority to implement Public Act 95-1045, if
12any, is conditioned on the rules being adopted in accordance
13with all provisions of the Illinois Administrative Procedure
14Act and all rules and procedures of the Joint Committee on
15Administrative Rules; any purported rule not so adopted, for
16whatever reason, is unauthorized.
17(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
18101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
191-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
20eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
21102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, eff.
221-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860,
23eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. 1-1-23;
24102-1117, eff. 1-13-23.)
 
25    Section 25. The Illinois Public Aid Code is amended by

 

 

HB3920- 10 -LRB103 26433 BMS 52796 b

1changing Section 5-16.8 as follows:
 
2    (305 ILCS 5/5-16.8)
3    Sec. 5-16.8. Required health benefits. The medical
4assistance program shall (i) provide the post-mastectomy care
5benefits required to be covered by a policy of accident and
6health insurance under Section 356t and the coverage required
7under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6,
8356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46,
9356z.47, 356z.51, 356z.53, 356z.56, 356z.59, and 356z.60, and
10356z.61 of the Illinois Insurance Code, (ii) be subject to the
11provisions of Sections 356z.19, 356z.44, 356z.49, 364.01,
12370c, and 370c.1 of the Illinois Insurance Code, and (iii) be
13subject to the provisions of subsection (d-5) of Section 10 of
14the Network Adequacy and Transparency Act.
15    The Department, by rule, shall adopt a model similar to
16the requirements of Section 356z.39 of the Illinois Insurance
17Code.
18    On and after July 1, 2012, the Department shall reduce any
19rate of reimbursement for services or other payments or alter
20any methodologies authorized by this Code to reduce any rate
21of reimbursement for services or other payments in accordance
22with Section 5-5e.
23    To ensure full access to the benefits set forth in this
24Section, on and after January 1, 2016, the Department shall
25ensure that provider and hospital reimbursement for

 

 

HB3920- 11 -LRB103 26433 BMS 52796 b

1post-mastectomy care benefits required under this Section are
2no lower than the Medicare reimbursement rate.
3(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20;
4101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff.
51-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144,
6eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
7102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff.
81-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093,
9eff. 1-1-23; 102-1117, eff. 1-13-23.)