HB2109 EngrossedLRB102 12330 BMS 17667 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 1. This Act may be referred to as Cal's Law.
5    Section 5. The Illinois Insurance Code is amended by
6adding Section 356z.43 as follows:
7    (215 ILCS 5/356z.43 new)
8    Sec. 356z.43. Comprehensive cancer testing.
9    (a) As used in this Section:
10    "Comprehensive cancer testing" includes, but is not
11limited to, the following forms of testing:
12        (1) Targeted cancer gene panels.
13        (2) Whole-exome genome testing.
14        (3) Whole-genome sequencing.
15        (4) RNA sequencing.
16        (5) Tumor mutation burden.
17    "Prior authorization" means the process by which an
18insurer, or the insurer's designee, determines the medical
19necessity and medical appropriateness of otherwise covered
20health care services before the rendering of such health care
21services. "Prior authorization" includes any requirement that
22an enrollee, health care professional, or health care provider



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1notify the insurer, or the insurer's designee, before, at the
2time of, or concurrently with providing a health care service.
3    "Testing of blood or constitutional tissue for cancer
4predisposition testing" includes, but is not limited to, the
5following forms of testing:
6        (1) Targeted cancer gene panels.
7        (2) Whole-exome genome testing.
8        (3) Whole-genome sequencing.
9    (b) An individual or group policy of accident and health
10insurance or managed care plan that is amended, delivered,
11issued, or renewed on or after the effective date of this
12amendatory Act of the 102nd General Assembly shall provide
13coverage for medically necessary comprehensive cancer testing
14and testing of blood or constitutional tissue for cancer
15predisposition testing as determined by a physician licensed
16to practice medicine in all of its branches.
17    (c) The coverage provided under this Section shall be
18provided without any prior authorization requirements.
19    Section 10. The Health Maintenance Organization Act is
20amended by changing Section 5-3 as follows:
21    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
22    Sec. 5-3. Insurance Code provisions.
23    (a) Health Maintenance Organizations shall be subject to
24the provisions of Sections 133, 134, 136, 137, 139, 140,



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1141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
2154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
3355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2,
4356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
5356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
6356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
7356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41,
8356z.43, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
9368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408,
10408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
11(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
12XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois
13Insurance Code.
14    (b) For purposes of the Illinois Insurance Code, except
15for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
16Health Maintenance Organizations in the following categories
17are deemed to be "domestic companies":
18        (1) a corporation authorized under the Dental Service
19    Plan Act or the Voluntary Health Services Plans Act;
20        (2) a corporation organized under the laws of this
21    State; or
22        (3) a corporation organized under the laws of another
23    state, 30% or more of the enrollees of which are residents
24    of this State, except a corporation subject to
25    substantially the same requirements in its state of
26    organization as is a "domestic company" under Article VIII



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



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



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1Insurance Act and except for medicare supplement policies as
2defined in Section 363 of the Illinois Insurance Code, a
3Health Maintenance Organization may by contract agree with a
4group or other enrollment unit to effect refunds or charge
5additional premiums under the following terms and conditions:
6        (i) the amount of, and other terms and conditions with
7    respect to, the refund or additional premium are set forth
8    in the group or enrollment unit contract agreed in advance
9    of the period for which a refund is to be paid or
10    additional premium is to be charged (which period shall
11    not be less than one year); and
12        (ii) the amount of the refund or additional premium
13    shall not exceed 20% of the Health Maintenance
14    Organization's profitable or unprofitable experience with
15    respect to the group or other enrollment unit for the
16    period (and, for purposes of a refund or additional
17    premium, the profitable or unprofitable experience shall
18    be calculated taking into account a pro rata share of the
19    Health Maintenance Organization's administrative and
20    marketing expenses, but shall not include any refund to be
21    made or additional premium to be paid pursuant to this
22    subsection (f)). The Health Maintenance Organization and
23    the group or enrollment unit may agree that the profitable
24    or unprofitable experience may be calculated taking into
25    account the refund period and the immediately preceding 2
26    plan years.



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1    The Health Maintenance Organization shall include a
2statement in the evidence of coverage issued to each enrollee
3describing the possibility of a refund or additional premium,
4and upon request of any group or enrollment unit, provide to
5the group or enrollment unit a description of the method used
6to calculate (1) the Health Maintenance Organization's
7profitable experience with respect to the group or enrollment
8unit and the resulting refund to the group or enrollment unit
9or (2) the Health Maintenance Organization's unprofitable
10experience with respect to the group or enrollment unit and
11the resulting additional premium to be paid by the group or
12enrollment unit.
13    In no event shall the Illinois Health Maintenance
14Organization Guaranty Association be liable to pay any
15contractual obligation of an insolvent organization to pay any
16refund authorized under this Section.
17    (g) Rulemaking authority to implement Public Act 95-1045,
18if any, is conditioned on the rules being adopted in
19accordance with all provisions of the Illinois Administrative
20Procedure Act and all rules and procedures of the Joint
21Committee on Administrative Rules; any purported rule not so
22adopted, for whatever reason, is unauthorized.
23(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
24100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
251-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
26eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20;



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1101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
21-1-20; 101-625, eff. 1-1-21.)