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Public Act 104-0001
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| SB0126 Enrolled | LRB104 07411 BAB 17452 b |
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois, |
represented in the General Assembly:
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Section 5. The State Employees Group Insurance Act of 1971 |
is amended by changing Section 6.11 and by renumbering and |
changing 6.11D as added by Public Act 103-975 as follows:
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(5 ILCS 375/6.11) |
Sec. 6.11. Required health benefits; Illinois Insurance |
Code requirements. The program of health benefits shall |
provide the post-mastectomy care benefits required to be |
covered by a policy of accident and health insurance under |
Section 356t of the Illinois Insurance Code. The program of |
health benefits shall provide the coverage required under |
Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, |
356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, |
356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, |
356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, |
356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, |
356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, |
356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and |
356z.70, and 356z.71, 356z.74, 356z.76, 356z.77, and 356z.80 |
of the Illinois Insurance Code. The program of health benefits |
must comply with Sections 155.22a, 155.37, 355b, 356z.19, |
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370c, and 370c.1 and Article XXXIIB of the Illinois Insurance |
Code. The program of health benefits shall provide the |
coverage required under Section 356m of the Illinois Insurance |
Code and, for the employees of the State Employee Group |
Insurance Program only, the coverage as also provided in |
Section 6.11B of this Act. The Department of Insurance shall |
enforce the requirements of this Section with respect to |
Sections 370c and 370c.1 of the Illinois Insurance Code; all |
other requirements of this Section shall be enforced by the |
Department of Central Management Services. |
Rulemaking authority to implement Public Act 95-1045, if |
any, is conditioned on the rules being adopted in accordance |
with all provisions of the Illinois Administrative Procedure |
Act and all rules and procedures of the Joint Committee on |
Administrative Rules; any purported rule not so adopted, for |
whatever reason, is unauthorized. |
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; |
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. |
1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, |
eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; |
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. |
1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, |
eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; |
103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. |
8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751, |
eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25; |
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103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff. |
1-1-25; revised 11-26-24.)
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(5 ILCS 375/6.11E) |
Sec. 6.11E 6.11D. Coverage for treatments to slow the |
progression of Alzheimer's disease and related dementias. |
Beginning on July 1, 2025, the State Employees Group Insurance |
Program shall provide coverage for all medically necessary |
FDA-approved treatments or medications prescribed to slow the |
progression of Alzheimer's disease or another related |
dementia, as determined by a physician licensed to practice |
medicine in all its branches. Coverage for all FDA-approved |
treatments or medications prescribed to slow the progression |
of Alzheimer's disease or another related dementia shall not |
be subject to step therapy. Any diagnostic testing necessary |
for a physician to determine appropriate use of these |
treatments or medications shall be covered by the State |
Employees Group Insurance Program. This Section is repealed on |
July 1, 2027. |
(Source: P.A. 103-975, eff. 1-1-25; revised 12-1-24.)
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Section 10. The Counties Code is amended by changing |
Section 5-1069.3 as follows:
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(55 ILCS 5/5-1069.3) |
Sec. 5-1069.3. Required health benefits. If a county, |
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including a home rule county, is a self-insurer for purposes |
of providing health insurance coverage for its employees, the |
coverage shall include coverage for the post-mastectomy care |
benefits required to be covered by a policy of accident and |
health insurance under Section 356t and the coverage required |
under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, |
356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, |
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, |
356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, |
356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, |
356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, |
356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71, |
356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code. |
The coverage shall comply with Sections 155.22a, 355b, |
356z.19, and 370c of the Illinois Insurance Code. The |
Department of Insurance shall enforce the requirements of this |
Section. The requirement that health benefits be covered as |
provided in this Section is an exclusive power and function of |
the State and is a denial and limitation under Article VII, |
Section 6, subsection (h) of the Illinois Constitution. A home |
rule county to which this Section applies must comply with |
every provision of this Section. |
Rulemaking authority to implement Public Act 95-1045, if |
any, is conditioned on the rules being adopted in accordance |
with all provisions of the Illinois Administrative Procedure |
Act and all rules and procedures of the Joint Committee on |
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Administrative Rules; any purported rule not so adopted, for |
whatever reason, is unauthorized. |
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; |
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. |
1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, |
eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; |
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. |
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, |
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; |
103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. |
7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, |
eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; |
revised 11-26-24.)
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Section 15. The Illinois Municipal Code is amended by |
changing Section 10-4-2.3 as follows:
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(65 ILCS 5/10-4-2.3) |
Sec. 10-4-2.3. Required health benefits. If a |
municipality, including a home rule municipality, is a |
self-insurer for purposes of providing health insurance |
coverage for its employees, the coverage shall include |
coverage for the post-mastectomy care benefits required to be |
covered by a policy of accident and health insurance under |
Section 356t and the coverage required under Sections 356g, |
356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, |
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356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, |
356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, |
356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, |
356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, |
356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, |
356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77, |
and 356z.80 of the Illinois Insurance Code. The coverage shall |
comply with Sections 155.22a, 355b, 356z.19, and 370c of the |
Illinois Insurance Code. The Department of Insurance shall |
enforce the requirements of this Section. The requirement that |
health benefits be covered as provided in this is an exclusive |
power and function of the State and is a denial and limitation |
under Article VII, Section 6, subsection (h) of the Illinois |
Constitution. A home rule municipality to which this Section |
applies must comply with every provision of this Section. |
Rulemaking authority to implement Public Act 95-1045, if |
any, is conditioned on the rules being adopted in accordance |
with all provisions of the Illinois Administrative Procedure |
Act and all rules and procedures of the Joint Committee on |
Administrative Rules; any purported rule not so adopted, for |
whatever reason, is unauthorized. |
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; |
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. |
1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, |
eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; |
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. |
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1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, |
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; |
103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. |
7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, |
eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; |
revised 11-26-24.)
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Section 20. The School Code is amended by changing Section |
10-22.3f as follows:
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(105 ILCS 5/10-22.3f) |
Sec. 10-22.3f. Required health benefits. Insurance |
protection and benefits for employees shall provide the |
post-mastectomy care benefits required to be covered by a |
policy of accident and health insurance under Section 356t and |
the coverage required under Sections 356g, 356g.5, 356g.5-1, |
356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a, |
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, |
356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, |
356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, |
356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, |
356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and |
356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois |
Insurance Code. Insurance policies shall comply with Section |
356z.19 of the Illinois Insurance Code. The coverage shall |
comply with Sections 155.22a, 355b, and 370c of the Illinois |
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Insurance Code. The Department of Insurance shall enforce the |
requirements of this Section. |
Rulemaking authority to implement Public Act 95-1045, if |
any, is conditioned on the rules being adopted in accordance |
with all provisions of the Illinois Administrative Procedure |
Act and all rules and procedures of the Joint Committee on |
Administrative Rules; any purported rule not so adopted, for |
whatever reason, is unauthorized. |
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; |
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. |
1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, |
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; |
102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. |
1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, |
eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; |
103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. |
7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, |
eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
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Section 25. The Illinois Insurance Code is amended by |
adding Section 356z.80 as follows:
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(215 ILCS 5/356z.80 new) |
Sec. 356z.80. Coverage for treatments to slow the |
progression of Alzheimer's disease and related dementias. |
(a) A group or individual policy of accident and health |
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insurance or a managed care plan that is amended, delivered, |
issued, or renewed on or after January 1, 2027 shall provide |
coverage for all medically necessary diagnostic testing and |
U.S. Food and Drug Administration-approved treatments or |
medications prescribed to slow the progression of Alzheimer's |
disease or another related dementia, in accordance with the |
U.S. Food and Drug Administration label, as determined by a |
physician licensed to practice medicine in all its branches. |
Coverage of U.S. Food and Drug Administration-approved |
treatments or medications prescribed to slow the progression |
of Alzheimer's disease or another related dementia pursuant to |
this Section shall not be subject to step therapy. |
(b) Nothing in this Section prohibits a group or |
individual policy of accident and health insurance or managed |
care plan, by contract, written policy, procedure, or any |
other agreement or course of conduct, from requiring a |
pharmacist to effect substitutions of prescription drugs |
consistent with Section 19.5 of the Pharmacy Practice Act, |
under which a pharmacist may substitute an interchangeable |
biologic for a prescribed biologic product, and Section 25 of |
the Pharmacy Practice Act, under which a pharmacist may select |
a generic drug determined to be therapeutically equivalent by |
the United States Food and Drug Administration and in |
accordance with the Illinois Food, Drug and Cosmetic Act. |
(c) The coverage required under this Section shall not |
apply to managed care plans that are under contract with the |
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Department of Healthcare and Family Services.
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Section 30. The Health Maintenance Organization Act is |
amended by changing Section 5-3 as follows:
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(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) |
(Text of Section before amendment by P.A. 103-808) |
Sec. 5-3. Insurance Code provisions. |
(a) Health Maintenance Organizations shall be subject to |
the provisions of Sections 133, 134, 136, 137, 139, 140, |
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, |
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, |
155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1, |
356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a, |
356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, |
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, |
356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25, |
356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33, |
356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, |
356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47, |
356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55, |
356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62, |
356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69, |
356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77, |
356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, |
368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, |
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408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of |
subsection (2) of Section 367, and Articles IIA, VIII 1/2, |
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the |
Illinois Insurance Code. |
(b) For purposes of the Illinois Insurance Code, except |
for Sections 444 and 444.1 and Articles XIII and XIII 1/2, |
Health Maintenance Organizations in the following categories |
are deemed to be "domestic companies": |
(1) a corporation authorized under the Dental Service |
Plan Act or the Voluntary Health Services Plans Act; |
(2) a corporation organized under the laws of this |
State; or |
(3) a corporation organized under the laws of another |
state, 30% or more of the enrollees of which are residents |
of this State, except a corporation subject to |
substantially the same requirements in its state of |
organization as is a "domestic company" under Article VIII |
1/2 of the Illinois Insurance Code. |
(c) In considering the merger, consolidation, or other |
acquisition of control of a Health Maintenance Organization |
pursuant to Article VIII 1/2 of the Illinois Insurance Code, |
(1) the Director shall give primary consideration to |
the continuation of benefits to enrollees and the |
financial conditions of the acquired Health Maintenance |
Organization after the merger, consolidation, or other |
acquisition of control takes effect; |
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(2)(i) the criteria specified in subsection (1)(b) of |
Section 131.8 of the Illinois Insurance Code shall not |
apply and (ii) the Director, in making his determination |
with respect to the merger, consolidation, or other |
acquisition of control, need not take into account the |
effect on competition of the merger, consolidation, or |
other acquisition of control; |
(3) the Director shall have the power to require the |
following information: |
(A) certification by an independent actuary of the |
adequacy of the reserves of the Health Maintenance |
Organization sought to be acquired; |
(B) pro forma financial statements reflecting the |
combined balance sheets of the acquiring company and |
the Health Maintenance Organization sought to be |
acquired as of the end of the preceding year and as of |
a date 90 days prior to the acquisition, as well as pro |
forma financial statements reflecting projected |
combined operation for a period of 2 years; |
(C) a pro forma business plan detailing an |
acquiring party's plans with respect to the operation |
of the Health Maintenance Organization sought to be |
acquired for a period of not less than 3 years; and |
(D) such other information as the Director shall |
require. |
(d) The provisions of Article VIII 1/2 of the Illinois |
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Insurance Code and this Section 5-3 shall apply to the sale by |
any health maintenance organization of greater than 10% of its |
enrollee population (including, without limitation, the health |
maintenance organization's right, title, and interest in and |
to its health care certificates). |
(e) In considering any management contract or service |
agreement subject to Section 141.1 of the Illinois Insurance |
Code, the Director (i) shall, in addition to the criteria |
specified in Section 141.2 of the Illinois Insurance Code, |
take into account the effect of the management contract or |
service agreement on the continuation of benefits to enrollees |
and the financial condition of the health maintenance |
organization to be managed or serviced, and (ii) need not take |
into account the effect of the management contract or service |
agreement on competition. |
(f) Except for small employer groups as defined in the |
Small Employer Rating, Renewability and Portability Health |
Insurance Act and except for medicare supplement policies as |
defined in Section 363 of the Illinois Insurance Code, a |
Health Maintenance Organization may by contract agree with a |
group or other enrollment unit to effect refunds or charge |
additional premiums under the following terms and conditions: |
(i) the amount of, and other terms and conditions with |
respect to, the refund or additional premium are set forth |
in the group or enrollment unit contract agreed in advance |
of the period for which a refund is to be paid or |
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additional premium is to be charged (which period shall |
not be less than one year); and |
(ii) the amount of the refund or additional premium |
shall not exceed 20% of the Health Maintenance |
Organization's profitable or unprofitable experience with |
respect to the group or other enrollment unit for the |
period (and, for purposes of a refund or additional |
premium, the profitable or unprofitable experience shall |
be calculated taking into account a pro rata share of the |
Health Maintenance Organization's administrative and |
marketing expenses, but shall not include any refund to be |
made or additional premium to be paid pursuant to this |
subsection (f)). The Health Maintenance Organization and |
the group or enrollment unit may agree that the profitable |
or unprofitable experience may be calculated taking into |
account the refund period and the immediately preceding 2 |
plan years. |
The Health Maintenance Organization shall include a |
statement in the evidence of coverage issued to each enrollee |
describing the possibility of a refund or additional premium, |
and upon request of any group or enrollment unit, provide to |
the group or enrollment unit a description of the method used |
to calculate (1) the Health Maintenance Organization's |
profitable experience with respect to the group or enrollment |
unit and the resulting refund to the group or enrollment unit |
or (2) the Health Maintenance Organization's unprofitable |
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experience with respect to the group or enrollment unit and |
the resulting additional premium to be paid by the group or |
enrollment unit. |
In no event shall the Illinois Health Maintenance |
Organization Guaranty Association be liable to pay any |
contractual obligation of an insolvent organization to pay any |
refund authorized under this Section. |
(g) Rulemaking authority to implement Public Act 95-1045, |
if any, is conditioned on the rules being adopted in |
accordance with all provisions of the Illinois Administrative |
Procedure Act and all rules and procedures of the Joint |
Committee on Administrative Rules; any purported rule not so |
adopted, for whatever reason, is unauthorized. |
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; |
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. |
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, |
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; |
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. |
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, |
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; |
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. |
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; |
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. |
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, |
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; |
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103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff. |
1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
|
(Text of Section after amendment by P.A. 103-808) |
Sec. 5-3. Insurance Code provisions. |
(a) Health Maintenance Organizations shall be subject to |
the provisions of Sections 133, 134, 136, 137, 139, 140, |
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, |
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, |
155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g, |
356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, |
356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, |
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, |
356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, |
356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, |
356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, |
356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, |
356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, |
356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, |
356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, |
356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, |
356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, |
368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, |
403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) |
of subsection (2) of Section 367, and Articles IIA, VIII 1/2, |
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the |
|
Illinois Insurance Code. |
(b) For purposes of the Illinois Insurance Code, except |
for Sections 444 and 444.1 and Articles XIII and XIII 1/2, |
Health Maintenance Organizations in the following categories |
are deemed to be "domestic companies": |
(1) a corporation authorized under the Dental Service |
Plan Act or the Voluntary Health Services Plans Act; |
(2) a corporation organized under the laws of this |
State; or |
(3) a corporation organized under the laws of another |
state, 30% or more of the enrollees of which are residents |
of this State, except a corporation subject to |
substantially the same requirements in its state of |
organization as is a "domestic company" under Article VIII |
1/2 of the Illinois Insurance Code. |
(c) In considering the merger, consolidation, or other |
acquisition of control of a Health Maintenance Organization |
pursuant to Article VIII 1/2 of the Illinois Insurance Code, |
(1) the Director shall give primary consideration to |
the continuation of benefits to enrollees and the |
financial conditions of the acquired Health Maintenance |
Organization after the merger, consolidation, or other |
acquisition of control takes effect; |
(2)(i) the criteria specified in subsection (1)(b) of |
Section 131.8 of the Illinois Insurance Code shall not |
apply and (ii) the Director, in making his determination |
|
with respect to the merger, consolidation, or other |
acquisition of control, need not take into account the |
effect on competition of the merger, consolidation, or |
other acquisition of control; |
(3) the Director shall have the power to require the |
following information: |
(A) certification by an independent actuary of the |
adequacy of the reserves of the Health Maintenance |
Organization sought to be acquired; |
(B) pro forma financial statements reflecting the |
combined balance sheets of the acquiring company and |
the Health Maintenance Organization sought to be |
acquired as of the end of the preceding year and as of |
a date 90 days prior to the acquisition, as well as pro |
forma financial statements reflecting projected |
combined operation for a period of 2 years; |
(C) a pro forma business plan detailing an |
acquiring party's plans with respect to the operation |
of the Health Maintenance Organization sought to be |
acquired for a period of not less than 3 years; and |
(D) such other information as the Director shall |
require. |
(d) The provisions of Article VIII 1/2 of the Illinois |
Insurance Code and this Section 5-3 shall apply to the sale by |
any health maintenance organization of greater than 10% of its |
enrollee population (including, without limitation, the health |
|
maintenance organization's right, title, and interest in and |
to its health care certificates). |
(e) In considering any management contract or service |
agreement subject to Section 141.1 of the Illinois Insurance |
Code, the Director (i) shall, in addition to the criteria |
specified in Section 141.2 of the Illinois Insurance Code, |
take into account the effect of the management contract or |
service agreement on the continuation of benefits to enrollees |
and the financial condition of the health maintenance |
organization to be managed or serviced, and (ii) need not take |
into account the effect of the management contract or service |
agreement on competition. |
(f) Except for small employer groups as defined in the |
Small Employer Rating, Renewability and Portability Health |
Insurance Act and except for medicare supplement policies as |
defined in Section 363 of the Illinois Insurance Code, a |
Health Maintenance Organization may by contract agree with a |
group or other enrollment unit to effect refunds or charge |
additional premiums under the following terms and conditions: |
(i) the amount of, and other terms and conditions with |
respect to, the refund or additional premium are set forth |
in the group or enrollment unit contract agreed in advance |
of the period for which a refund is to be paid or |
additional premium is to be charged (which period shall |
not be less than one year); and |
(ii) the amount of the refund or additional premium |
|
shall not exceed 20% of the Health Maintenance |
Organization's profitable or unprofitable experience with |
respect to the group or other enrollment unit for the |
period (and, for purposes of a refund or additional |
premium, the profitable or unprofitable experience shall |
be calculated taking into account a pro rata share of the |
Health Maintenance Organization's administrative and |
marketing expenses, but shall not include any refund to be |
made or additional premium to be paid pursuant to this |
subsection (f)). The Health Maintenance Organization and |
the group or enrollment unit may agree that the profitable |
or unprofitable experience may be calculated taking into |
account the refund period and the immediately preceding 2 |
plan years. |
The Health Maintenance Organization shall include a |
statement in the evidence of coverage issued to each enrollee |
describing the possibility of a refund or additional premium, |
and upon request of any group or enrollment unit, provide to |
the group or enrollment unit a description of the method used |
to calculate (1) the Health Maintenance Organization's |
profitable experience with respect to the group or enrollment |
unit and the resulting refund to the group or enrollment unit |
or (2) the Health Maintenance Organization's unprofitable |
experience with respect to the group or enrollment unit and |
the resulting additional premium to be paid by the group or |
enrollment unit. |
|
In no event shall the Illinois Health Maintenance |
Organization Guaranty Association be liable to pay any |
contractual obligation of an insolvent organization to pay any |
refund authorized under this Section. |
(g) Rulemaking authority to implement Public Act 95-1045, |
if any, is conditioned on the rules being adopted in |
accordance with all provisions of the Illinois Administrative |
Procedure Act and all rules and procedures of the Joint |
Committee on Administrative Rules; any purported rule not so |
adopted, for whatever reason, is unauthorized. |
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; |
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. |
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, |
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; |
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. |
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, |
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; |
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. |
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; |
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. |
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, |
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; |
103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff. |
1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised |
11-26-24.)
|
|
Section 35. The Limited Health Service Organization Act is |
amended by changing Section 4003 as follows:
|
(215 ILCS 130/4003) (from Ch. 73, par. 1504-3) |
Sec. 4003. Illinois Insurance Code provisions. Limited |
health service organizations shall be subject to the |
provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, |
141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153, |
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, |
355.2, 355.3, 355b, 355d, 356m, 356q, 356v, 356z.4, 356z.4a, |
356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.32, |
356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, |
356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, 356z.71, |
356z.73, 356z.74, 356z.75, 356z.80, 364.3, 368a, 401, 401.1, |
402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and |
Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and |
XXVI of the Illinois Insurance Code. Nothing in this Section |
shall require a limited health care plan to cover any service |
that is not a limited health service. For purposes of the |
Illinois Insurance Code, except for Sections 444 and 444.1 and |
Articles XIII and XIII 1/2, limited health service |
organizations in the following categories are deemed to be |
domestic companies: |
(1) a corporation under the laws of this State; or |
(2) a corporation organized under the laws of another |
|
state, 30% or more of the enrollees of which are residents |
of this State, except a corporation subject to |
substantially the same requirements in its state of |
organization as is a domestic company under Article VIII |
1/2 of the Illinois Insurance Code. |
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; |
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. |
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, |
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; |
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. |
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
eff. 1-1-24; 103-605, eff. 7-1-24; 103-649, eff. 1-1-25; |
103-656, eff. 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. |
7-19-24; 103-751, eff. 8-2-24; 103-758, eff. 1-1-25; 103-832, |
eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
|
Section 40. The Voluntary Health Services Plans Act is |
amended by changing Section 10 as follows:
|
(215 ILCS 165/10) (from Ch. 32, par. 604) |
Sec. 10. Application of Insurance Code provisions. Health |
services plan corporations and all persons interested therein |
or dealing therewith shall be subject to the provisions of |
Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, |
143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, |
355b, 355d, 356g, 356g.5, 356g.5-1, 356m, 356q, 356r, 356t, |
|
356u, 356u.10, 356v, 356w, 356x, 356y, 356z.1, 356z.2, |
356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, |
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, |
356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, |
356z.32, 356z.32a, 356z.33, 356z.40, 356z.41, 356z.46, |
356z.47, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, |
356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.71, |
356z.72, 356z.74, 356z.75, 356z.77, 356z.80, 364.01, 364.3, |
367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, |
and paragraphs (7) and (15) of Section 367 of the Illinois |
Insurance Code. |
Rulemaking authority to implement Public Act 95-1045, if |
any, is conditioned on the rules being adopted in accordance |
with all provisions of the Illinois Administrative Procedure |
Act and all rules and procedures of the Joint Committee on |
Administrative Rules; any purported rule not so adopted, for |
whatever reason, is unauthorized. |
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; |
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. |
10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, |
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; |
102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. |
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, |
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; |
103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-656, eff. |
1-1-25; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-753, |