Rep. Seth Lewis

Filed: 4/20/2021





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2    AMENDMENT NO. ______. Amend House Bill 2109 by replacing
3everything after the enacting clause with the following:
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.



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1        (5) Tumor mutation burden.
2    "Prior authorization" means the process by which an
3insurer, or the insurer's designee, determines the medical
4necessity and medical appropriateness of otherwise covered
5health care services before the rendering of such health care
6services. "Prior authorization" includes any requirement that
7an enrollee, health care professional, or health care provider
8notify the insurer, or the insurer's designee, before, at the
9time of, or concurrently with providing a health care service.
10    "Testing of blood or constitutional tissue for cancer
11predisposition testing" includes, but is not limited to, the
12following forms of testing:
13        (1) Targeted cancer gene panels.
14        (2) Whole-exome genome testing.
15        (3) Whole-genome sequencing.
16    (b) An individual or group policy of accident and health
17insurance or managed care plan that is amended, delivered,
18issued, or renewed on or after the effective date of this
19amendatory Act of the 102nd General Assembly shall provide
20coverage for medically necessary comprehensive cancer testing
21and testing of blood or constitutional tissue for cancer
22predisposition testing as determined by a physician licensed
23to practice medicine in all of its branches.
24    (c) The coverage provided under this Section shall be
25provided without any prior authorization requirements.



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1    Section 10. The Health Maintenance Organization Act is
2amended by changing Section 5-3 as follows:
3    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
4    Sec. 5-3. Insurance Code provisions.
5    (a) Health Maintenance Organizations shall be subject to
6the provisions of Sections 133, 134, 136, 137, 139, 140,
7141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
8154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
9355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2,
10356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
11356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
12356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
13356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41,
14356z.43, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
15368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408,
16408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
17(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
18XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois
19Insurance Code.
20    (b) For purposes of the Illinois Insurance Code, except
21for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
22Health Maintenance Organizations in the following categories
23are deemed to be "domestic companies":
24        (1) a corporation authorized under the Dental Service
25    Plan Act or the Voluntary Health Services Plans 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 another
4    state, 30% or more of the enrollees of which are residents
5    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 VIII
8    1/2 of the Illinois Insurance Code.
9    (c) In considering the merger, consolidation, or other
10acquisition of control of a Health Maintenance Organization
11pursuant to Article VIII 1/2 of the Illinois Insurance Code,
12        (1) the Director shall give primary consideration to
13    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) of
18    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 the
25    following information:
26            (A) certification by an independent actuary of the



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



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



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1    marketing expenses, but shall not include any refund to be
2    made or additional premium to be paid pursuant to this
3    subsection (f)). The Health Maintenance Organization and
4    the group or enrollment unit may agree that the profitable
5    or unprofitable experience may be calculated taking into
6    account the refund period and the immediately preceding 2
7    plan years.
8    The Health Maintenance Organization shall include a
9statement in the evidence of coverage issued to each enrollee
10describing the possibility of a refund or additional premium,
11and upon request of any group or enrollment unit, provide to
12the group or enrollment unit a description of the method used
13to calculate (1) the Health Maintenance Organization's
14profitable experience with respect to the group or enrollment
15unit and the resulting refund to the group or enrollment unit
16or (2) the Health Maintenance Organization's unprofitable
17experience with respect to the group or enrollment unit and
18the resulting additional premium to be paid by the group or
19enrollment unit.
20    In no event shall the Illinois Health Maintenance
21Organization Guaranty Association be liable to pay any
22contractual obligation of an insolvent organization to pay any
23refund authorized under this Section.
24    (g) Rulemaking authority to implement Public Act 95-1045,
25if any, is conditioned on the rules being adopted in
26accordance with all provisions of the Illinois Administrative



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1Procedure Act and all rules and procedures of the Joint
2Committee on Administrative Rules; any purported rule not so
3adopted, for whatever reason, is unauthorized.
4(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
5100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
61-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
7eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20;
8101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
91-1-20; 101-625, eff. 1-1-21.)".