State of Illinois
92nd General Assembly
Legislation

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[ House Amendment 001 ]


92_HB3933

                                               LRB9212968JSpc

 1        AN ACT concerning insurance coverage.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 5.  The State Employees Group  Insurance  Act  of
 5    1971 is amended by changing Section 6.11 as follows:

 6        (5 ILCS 375/6.11)
 7        Sec.  6.11.  Required health benefits; Illinois Insurance
 8    Code requirements.  The  program  of  health  benefits  shall
 9    provide  the  post-mastectomy  care  benefits  required to be
10    covered by a policy of accident and  health  insurance  under
11    Section  356t of the Illinois Insurance Code.  The program of
12    health benefits shall provide  the  coverage  required  under
13    Sections  356u,  356w,  and  356x, and 356z.2 of the Illinois
14    Insurance Code. The program of health  benefits  must  comply
15    with Section 155.37 of the Illinois Insurance Code.
16    (Source: P.A. 92-440, eff. 8-17-01.)

17        Section  10.  The  Counties  Code  is amended by changing
18    Section 5-1069.3 as follows:

19        (55 ILCS 5/5-1069.3)
20        Sec. 5-1069.3.  Required health benefits.  If  a  county,
21    including  a home rule county, is a self-insurer for purposes
22    of providing health insurance coverage for its employees, the
23    coverage shall include coverage for the post-mastectomy  care
24    benefits  required  to be covered by a policy of accident and
25    health insurance under Section 356t and the coverage required
26    under Sections 356u, 356w,  and  356x,  and  356z.2   of  the
27    Illinois   Insurance   Code.   The  requirement  that  health
28    benefits be  covered  as  provided  in  this  Section  is  an
29    exclusive power and function of the State and is a denial and
 
                            -2-                LRB9212968JSpc
 1    limitation  under  Article  VII, Section 6, subsection (h) of
 2    the Illinois Constitution.  A home rule county to which  this
 3    Section  applies  must  comply  with  every provision of this
 4    Section.
 5    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

 6        Section 15.  The Illinois Municipal Code  is  amended  by
 7    changing Section 10-4-2.3 as follows:

 8        (65 ILCS 5/10-4-2.3)
 9        Sec.   10-4-2.3.    Required   health   benefits.   If  a
10    municipality,  including  a  home  rule  municipality,  is  a
11    self-insurer  for  purposes  of  providing  health  insurance
12    coverage  for  its  employees,  the  coverage  shall  include
13    coverage for the post-mastectomy care benefits required to be
14    covered by a policy of accident and  health  insurance  under
15    Section  356t  and the coverage required under Sections 356u,
16    356w, and 356x, and 356z.2 of the  Illinois  Insurance  Code.
17    The  requirement  that health benefits be covered as provided
18    in this is an exclusive power and function of the  State  and
19    is  a  denial  and  limitation  under Article VII, Section 6,
20    subsection (h) of the Illinois  Constitution.   A  home  rule
21    municipality  to  which this Section applies must comply with
22    every provision of this Section.
23    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

24        Section 20.  The  School  Code  is  amended  by  changing
25    Section 10-22.3f as follows:

26        (105 ILCS 5/10-22.3f)
27        Sec.   10-22.3f.  Required  health  benefits.   Insurance
28    protection and  benefits  for  employees  shall  provide  the
29    post-mastectomy  care  benefits  required  to be covered by a
30    policy of accident and health insurance  under  Section  356t
 
                            -3-                LRB9212968JSpc
 1    and  the  coverage  required  under  Sections 356u, 356w, and
 2    356x, and 356z.2 of the Illinois Insurance Code.
 3    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

 4        Section 25.  The Illinois Insurance Code  is  amended  by
 5    adding Section 356z.2 as follows:

 6        (215 ILCS 5/356z.2 new)
 7        Sec.   356z.2.  Birth   control  coverage.   A  group  or
 8    individual policy of accident and health insurance or managed
 9    care plan amended, delivered, issued, or  renewed  after  the
10    effective  date  of  this  amendatory Act of the 92nd General
11    Assembly that provides coverage for prescribed drugs approved
12    by the federal Food and Drug Administration for the treatment
13    of impotence must also provide coverage for prescribed  drugs
14    approved  by the federal Food and Drug Administration for the
15    prevention of pregnancy on the same terms and conditions that
16    are generally applicable to  coverage  for  other  prescribed
17    drugs approved by the federal Food and Drug Administration.

18        Section  30.  The  Health Maintenance Organization Act is
19    amended 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
23    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
24    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
25    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
26    356y,  356z.2,  367i,  368a, 401, 401.1, 402, 403, 403A, 408,
27    408.2, 409, 412, 444, and 444.1, paragraph (c) of  subsection
28    (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
29    XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
30        (b)  For  purposes of the Illinois Insurance Code, except
 
                            -4-                LRB9212968JSpc
 1    for Sections 444 and 444.1 and Articles XIII  and  XIII  1/2,
 2    Health  Maintenance Organizations in the following categories
 3    are deemed to be "domestic companies":
 4             (1)  a  corporation  authorized  under  the   Dental
 5        Service  Plan  Act or the Voluntary Health Services Plans
 6        Act;
 7             (2)  a corporation organized under the laws of  this
 8        State; or
 9             (3)  a  corporation  organized  under  the  laws  of
10        another  state, 30% or more of the enrollees of which are
11        residents of this State, except a corporation subject  to
12        substantially  the  same  requirements  in  its  state of
13        organization as is a  "domestic  company"  under  Article
14        VIII 1/2 of the Illinois Insurance Code.
15        (c)  In  considering  the merger, consolidation, or other
16    acquisition of control of a Health  Maintenance  Organization
17    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
18             (1)  the  Director  shall give primary consideration
19        to the continuation of  benefits  to  enrollees  and  the
20        financial  conditions  of the acquired Health Maintenance
21        Organization after the merger,  consolidation,  or  other
22        acquisition of control takes effect;
23             (2)(i)  the  criteria specified in subsection (1)(b)
24        of Section 131.8 of the Illinois Insurance Code shall not
25        apply and (ii) the Director, in making his  determination
26        with  respect  to  the  merger,  consolidation,  or other
27        acquisition of control, need not take  into  account  the
28        effect  on  competition  of the merger, consolidation, or
29        other acquisition of control;
30             (3)  the Director shall have the  power  to  require
31        the following information:
32                  (A)  certification by an independent actuary of
33             the   adequacy   of   the  reserves  of  the  Health
34             Maintenance Organization sought to be acquired;
 
                            -5-                LRB9212968JSpc
 1                  (B)  pro forma financial statements  reflecting
 2             the combined balance sheets of the acquiring company
 3             and the Health Maintenance Organization sought to be
 4             acquired  as of the end of the preceding year and as
 5             of a date 90 days prior to the acquisition, as  well
 6             as   pro   forma   financial  statements  reflecting
 7             projected combined  operation  for  a  period  of  2
 8             years;
 9                  (C)  a  pro  forma  business  plan detailing an
10             acquiring  party's  plans  with   respect   to   the
11             operation  of  the  Health  Maintenance Organization
12             sought to be acquired for a period of not less  than
13             3 years; and
14                  (D)  such  other  information  as  the Director
15             shall require.
16        (d)  The provisions of Article VIII 1/2 of  the  Illinois
17    Insurance  Code  and this Section 5-3 shall apply to the sale
18    by any health maintenance organization of greater than 10% of
19    its enrollee population  (including  without  limitation  the
20    health  maintenance organization's right, title, and interest
21    in and to its health care certificates).
22        (e)  In considering any management  contract  or  service
23    agreement  subject to Section 141.1 of the Illinois Insurance
24    Code, the Director (i) shall, in  addition  to  the  criteria
25    specified  in  Section  141.2 of the Illinois Insurance Code,
26    take into account the effect of the  management  contract  or
27    service   agreement   on  the  continuation  of  benefits  to
28    enrollees  and  the  financial  condition   of   the   health
29    maintenance  organization to be managed or serviced, and (ii)
30    need not take into  account  the  effect  of  the  management
31    contract or service agreement on competition.
32        (f)  Except  for  small employer groups as defined in the
33    Small Employer Rating, Renewability  and  Portability  Health
34    Insurance  Act and except for medicare supplement policies as
 
                            -6-                LRB9212968JSpc
 1    defined in Section 363 of  the  Illinois  Insurance  Code,  a
 2    Health  Maintenance Organization may by contract agree with a
 3    group or other enrollment unit to effect  refunds  or  charge
 4    additional premiums under the following terms and conditions:
 5             (i)  the  amount  of, and other terms and conditions
 6        with respect to, the refund or additional premium are set
 7        forth in the group or enrollment unit contract agreed  in
 8        advance of the period for which a refund is to be paid or
 9        additional  premium  is to be charged (which period shall
10        not be less than one year); and
11             (ii)  the amount of the refund or additional premium
12        shall  not  exceed  20%   of   the   Health   Maintenance
13        Organization's profitable or unprofitable experience with
14        respect  to  the  group  or other enrollment unit for the
15        period (and, for  purposes  of  a  refund  or  additional
16        premium,  the profitable or unprofitable experience shall
17        be calculated taking into account a pro rata share of the
18        Health  Maintenance  Organization's  administrative   and
19        marketing  expenses,  but shall not include any refund to
20        be made or additional premium to be paid pursuant to this
21        subsection (f)).  The Health Maintenance Organization and
22        the  group  or  enrollment  unit  may  agree   that   the
23        profitable  or  unprofitable experience may be calculated
24        taking into account the refund period and the immediately
25        preceding 2 plan years.
26        The  Health  Maintenance  Organization  shall  include  a
27    statement in the evidence of coverage issued to each enrollee
28    describing the possibility of a refund or additional premium,
29    and upon request of any group or enrollment unit, provide  to
30    the group or enrollment unit a description of the method used
31    to   calculate  (1)  the  Health  Maintenance  Organization's
32    profitable experience with respect to the group or enrollment
33    unit and the resulting refund to the group or enrollment unit
34    or (2) the  Health  Maintenance  Organization's  unprofitable
 
                            -7-                LRB9212968JSpc
 1    experience  with  respect to the group or enrollment unit and
 2    the resulting additional premium to be paid by the  group  or
 3    enrollment unit.
 4        In   no  event  shall  the  Illinois  Health  Maintenance
 5    Organization  Guaranty  Association  be  liable  to  pay  any
 6    contractual obligation of an insolvent  organization  to  pay
 7    any refund authorized under this Section.
 8    (Source: P.A.  90-25,  eff.  1-1-98;  90-177,  eff.  7-23-97;
 9    90-372,  eff.  7-1-98;  90-583,  eff.  5-29-98;  90-655, eff.
10    7-30-98; 90-741, eff. 1-1-99; 91-357, eff.  7-29-99;  91-406,
11    eff.  1-1-00;  91-549,  eff.  8-14-99; 91-605, eff. 12-14-99;
12    91-788, eff. 6-9-00.)

13        Section 35.  The Voluntary Health Services Plans  Act  is
14    amended by changing Section 10 as follows:

15        (215 ILCS 165/10) (from Ch. 32, par. 604)
16        Sec.   10.  Application  of  Insurance  Code  provisions.
17    Health services plan corporations and all persons  interested
18    therein   or  dealing  therewith  shall  be  subject  to  the
19    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
20    140, 143, 143c, 149, 155.37, 354, 355.2,  356r,  356t,  356u,
21    356v,  356w,  356x,  356y,  356z.1, 356z.2, 367.2, 368a, 401,
22    401.1, 402, 403, 403A, 408, 408.2, and  412,  and  paragraphs
23    (7) and (15) of Section 367 of the Illinois Insurance Code.
24    (Source: P.A.  91-406,  eff.  1-1-00;  91-549,  eff. 8-14-99;
25    91-605, eff. 12-14-99;  91-788,  eff.  6-9-00;  92-130,  eff.
26    7-20-01; 92-440, eff. 8-17-01; revised 9-12-01.)

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