HB1267 EngrossedLRB097 07252 RPM 47361 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.17, 356z.19, and 356z.20 of the
16Illinois Insurance Code. The program of health benefits must
17comply with Section 155.37 of the Illinois Insurance Code.
18    Rulemaking authority to implement Public Act 95-1045, if
19any, is conditioned on the rules being adopted in accordance
20with all provisions of the Illinois Administrative Procedure
21Act and all rules and procedures of the Joint Committee on
22Administrative Rules; any purported rule not so adopted, for
23whatever reason, is unauthorized.

 

 

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1(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
295-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
36-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044,
4eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
596-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
696-1000, eff. 7-2-10.)
 
7    Section 10. The Counties Code is amended by changing
8Section 5-1069.3 as follows:
 
9    (55 ILCS 5/5-1069.3)
10    Sec. 5-1069.3. Required health benefits. If a county,
11including a home rule county, is a self-insurer for purposes of
12providing health insurance coverage for its employees, the
13coverage shall include coverage for the post-mastectomy care
14benefits required to be covered by a policy of accident and
15health insurance under Section 356t and the coverage required
16under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
17356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
18356z.14, and 356z.15, 356z.19, and 356z.20 of the Illinois
19Insurance Code. The requirement that health benefits be covered
20as provided in this Section is an exclusive power and function
21of the State and is a denial and limitation under Article VII,
22Section 6, subsection (h) of the Illinois Constitution. A home
23rule county to which this Section applies must comply with
24every provision of this Section.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
895-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
96-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
10eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
1196-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
12    Section 15. The Illinois Municipal Code is amended by
13changing Section 10-4-2.3 as follows:
 
14    (65 ILCS 5/10-4-2.3)
15    Sec. 10-4-2.3. Required health benefits. If a
16municipality, including a home rule municipality, is a
17self-insurer for purposes of providing health insurance
18coverage for its employees, the coverage shall include coverage
19for the post-mastectomy care benefits required to be covered by
20a policy of accident and health insurance under Section 356t
21and the coverage required under Sections 356g, 356g.5,
22356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
23356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, 356z.19, and
24356z.20 of the Illinois Insurance Code. The requirement that

 

 

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1health benefits be covered as provided in this is an exclusive
2power and function of the State and is a denial and limitation
3under Article VII, Section 6, subsection (h) of the Illinois
4Constitution. A home rule municipality to which this Section
5applies must comply with every provision of this Section.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1395-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
146-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
15eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
1696-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
17    Section 20. The School Code is amended by changing Section
1810-22.3f as follows:
 
19    (105 ILCS 5/10-22.3f)
20    Sec. 10-22.3f. Required health benefits. Insurance
21protection and benefits for employees shall provide the
22post-mastectomy care benefits required to be covered by a
23policy of accident and health insurance under Section 356t and
24the coverage required under Sections 356g, 356g.5, 356g.5-1,

 

 

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1356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
2356z.13, 356z.14, and 356z.15, 356z.19, and 356z.20 of the
3Illinois Insurance Code.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1195-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
1295-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
131-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-1000,
14eff. 7-2-10.)
 
15    Section 25. The Illinois Insurance Code is amended by
16adding Sections 356z.19 and 356z.20 as follows:
 
17    (215 ILCS 5/356z.19 new)
18    Sec. 356z.19. Nutritional support and hydration.
19    (a) The General Assembly finds that people who are
20physically unable to swallow, digest, or absorb food and fluids
21taken by mouth are at risk of malnutrition and dehydration.
22Without nutritional support and hydration, such individuals
23will become increasingly weakened. As their immune system
24functioning is reduced, they may die from infections before

 

 

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1death can occur from malnutrition or dehydration.
2    (b) A group or individual policy of accident and health
3insurance or managed care plan amended, delivered, issued, or
4renewed after the effective date of this amendatory Act of the
597th General Assembly must provide coverage for intravenous
6feeding and for enteral or tube feeding. The benefits under
7this Section shall be at least as favorable as for other
8coverages under the policy and may be subject to the same
9dollar amount limits, deductibles, and co-insurance
10requirements applicable generally to other coverages under the
11policy.
12    (c) For the purpose of this Section, "enteral or tube
13feeding" means the process by which nutritional formulas are
14delivered via a tube into the digestive tract.
 
15    (215 ILCS 5/356z.20 new)
16    Sec. 356z.20. Prescription nutritional supplements. A
17group or individual policy of accident and health insurance or
18managed care plan amended, delivered, issued, or renewed after
19the effective date of this amendatory Act of the 97th General
20Assembly that provides coverage for prescription drugs must
21provide coverage for reimbursement for medically appropriate
22prescription nutritional supplements, limited to those
23products that are issued only by a physician's written order,
24when ordered by a physician licensed to practice medicine in
25all its branches and the insured suffers from a condition that

 

 

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1prevents him or her from taking sufficient oral nourishment to
2sustain life.
 
3    Section 30. The Health Maintenance Organization Act is
4amended by changing Section 5-3 as follows:
 
5    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
6    Sec. 5-3. Insurance Code provisions.
7    (a) Health Maintenance Organizations shall be subject to
8the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
9141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
10154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
11356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
12356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
13356z.18, 356z.19, 356z.20, 364.01, 367.2, 367.2-5, 367i, 368a,
14368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408,
15408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
16(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
17XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
18    (b) For purposes of the Illinois Insurance Code, except for
19Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
20Maintenance Organizations in the following categories are
21deemed to be "domestic companies":
22        (1) a corporation authorized under the Dental Service
23    Plan Act or the Voluntary Health Services Plans Act;
24        (2) a corporation organized under the laws of this

 

 

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1    State; or
2        (3) a corporation organized under the laws of another
3    state, 30% or more of the enrollees of which are residents
4    of this State, except a corporation subject to
5    substantially the same requirements in its state of
6    organization as is a "domestic company" under Article VIII
7    1/2 of the Illinois Insurance Code.
8    (c) In considering the merger, consolidation, or other
9acquisition of control of a Health Maintenance Organization
10pursuant to Article VIII 1/2 of the Illinois Insurance Code,
11        (1) the Director shall give primary consideration to
12    the continuation of benefits to enrollees and the financial
13    conditions of the acquired Health Maintenance Organization
14    after the merger, consolidation, or other acquisition of
15    control takes effect;
16        (2)(i) the criteria specified in subsection (1)(b) of
17    Section 131.8 of the Illinois Insurance Code shall not
18    apply and (ii) the Director, in making his determination
19    with respect to the merger, consolidation, or other
20    acquisition of control, need not take into account the
21    effect on competition of the merger, consolidation, or
22    other acquisition of control;
23        (3) the Director shall have the power to require the
24    following information:
25            (A) certification by an independent actuary of the
26        adequacy of the reserves of the Health Maintenance

 

 

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1        Organization sought to be acquired;
2            (B) pro forma financial statements reflecting the
3        combined balance sheets of the acquiring company and
4        the Health Maintenance Organization sought to be
5        acquired as of the end of the preceding year and as of
6        a date 90 days prior to the acquisition, as well as pro
7        forma financial statements reflecting projected
8        combined operation for a period of 2 years;
9            (C) a pro forma business plan detailing an
10        acquiring party's plans with respect to the operation
11        of the Health Maintenance Organization sought to be
12        acquired for a period of not less than 3 years; and
13            (D) such other information as the Director shall
14        require.
15    (d) The provisions of Article VIII 1/2 of the Illinois
16Insurance Code and this Section 5-3 shall apply to the sale by
17any health maintenance organization of greater than 10% of its
18enrollee population (including without limitation the health
19maintenance organization's right, title, and interest in and to
20its health care certificates).
21    (e) In considering any management contract or service
22agreement subject to Section 141.1 of the Illinois Insurance
23Code, the Director (i) shall, in addition to the criteria
24specified in Section 141.2 of the Illinois Insurance Code, take
25into account the effect of the management contract or service
26agreement on the continuation of benefits to enrollees and the

 

 

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1financial condition of the health maintenance organization to
2be managed or serviced, and (ii) need not take into account the
3effect of the management contract or service agreement on
4competition.
5    (f) Except for small employer groups as defined in the
6Small Employer Rating, Renewability and Portability Health
7Insurance Act and except for medicare supplement policies as
8defined in Section 363 of the Illinois Insurance Code, a Health
9Maintenance Organization may by contract agree with a group or
10other enrollment unit to effect refunds or charge additional
11premiums under the following terms and conditions:
12        (i) the amount of, and other terms and conditions with
13    respect to, the refund or additional premium are set forth
14    in the group or enrollment unit contract agreed in advance
15    of the period for which a refund is to be paid or
16    additional premium is to be charged (which period shall not
17    be less than one year); and
18        (ii) the amount of the refund or additional premium
19    shall not exceed 20% of the Health Maintenance
20    Organization's profitable or unprofitable experience with
21    respect to the group or other enrollment unit for the
22    period (and, for purposes of a refund or additional
23    premium, the profitable or unprofitable experience shall
24    be calculated taking into account a pro rata share of the
25    Health Maintenance Organization's administrative and
26    marketing expenses, but shall not include any refund to be

 

 

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1    made or additional premium to be paid pursuant to this
2    subsection (f)). The Health Maintenance Organization and
3    the group or enrollment unit may agree that the profitable
4    or unprofitable experience may be calculated taking into
5    account the refund period and the immediately preceding 2
6    plan years.
7    The Health Maintenance Organization shall include a
8statement in the evidence of coverage issued to each enrollee
9describing the possibility of a refund or additional premium,
10and upon request of any group or enrollment unit, provide to
11the group or enrollment unit a description of the method used
12to calculate (1) the Health Maintenance Organization's
13profitable experience with respect to the group or enrollment
14unit and the resulting refund to the group or enrollment unit
15or (2) the Health Maintenance Organization's unprofitable
16experience with respect to the group or enrollment unit and the
17resulting additional premium to be paid by the group or
18enrollment unit.
19    In no event shall the Illinois Health Maintenance
20Organization Guaranty Association be liable to pay any
21contractual obligation of an insolvent organization to pay any
22refund authorized under this Section.
23    (g) Rulemaking authority to implement Public Act 95-1045,
24if any, is conditioned on the rules being adopted in accordance
25with all provisions of the Illinois Administrative Procedure
26Act and all rules and procedures of the Joint Committee on

 

 

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1Administrative Rules; any purported rule not so adopted, for
2whatever reason, is unauthorized.
3(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
495-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
595-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
61-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
76-1-10; 96-1000, eff. 7-2-10.)
 
8    Section 35. The Voluntary Health Services Plans Act is
9amended by changing Section 10 as follows:
 
10    (215 ILCS 165/10)  (from Ch. 32, par. 604)
11    Sec. 10. Application of Insurance Code provisions. Health
12services plan corporations and all persons interested therein
13or dealing therewith shall be subject to the provisions of
14Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
15149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
16356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
17356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
18356z.14, 356z.15, 356z.18, 356z.19, 356z.20, 364.01, 367.2,
19368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
20paragraphs (7) and (15) of Section 367 of the Illinois
21Insurance Code.
22    Rulemaking authority to implement Public Act 95-1045, if
23any, is conditioned on the rules being adopted in accordance
24with all provisions of the Illinois Administrative Procedure

 

 

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1Act and all rules and procedures of the Joint Committee on
2Administrative Rules; any purported rule not so adopted, for
3whatever reason, is unauthorized.
4(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
595-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
68-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
7eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
896-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff.
97-2-10.)
 
10    Section 90. The State Mandates Act is amended by adding
11Section 8.35 as follows:
 
12    (30 ILCS 805/8.35 new)
13    Sec. 8.35. Exempt mandate. Notwithstanding Sections 6 and 8
14of this Act, no reimbursement by the State is required for the
15implementation of any mandate created by this amendatory Act of
16the 97th General Assembly.