Illinois 2023-2024 Regular Session

Illinois Senate Bill SB1255 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB1255 Introduced 2/3/2023, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/356z.26a new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 165/10 from Ch. 32, par. 604 Amends the Illinois Insurance Code. Provides that a health benefit plan amended, delivered, issued, or renewed on or after January 1, 2024 that provides prescription drug coverage or its contracted pharmacy benefit manager shall not engage in or require an enrollee to engage in specified prohibited acts. Provides that a clinician-administered drug supplied shall meet the supply chain security controls and chain of distribution set by the federal Drug Supply Chain Security Act. Provides that the Department of Insurance may adopt rules as necessary to implement the provisions. Defines terms. Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Voluntary Health Services Plans Act. LRB103 27845 BMS 54223 b STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB1255 Introduced 2/3/2023, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/356z.26a new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 165/10 from Ch. 32, par. 604 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/356z.26a new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 165/10 from Ch. 32, par. 604 Amends the Illinois Insurance Code. Provides that a health benefit plan amended, delivered, issued, or renewed on or after January 1, 2024 that provides prescription drug coverage or its contracted pharmacy benefit manager shall not engage in or require an enrollee to engage in specified prohibited acts. Provides that a clinician-administered drug supplied shall meet the supply chain security controls and chain of distribution set by the federal Drug Supply Chain Security Act. Provides that the Department of Insurance may adopt rules as necessary to implement the provisions. Defines terms. Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Voluntary Health Services Plans Act. LRB103 27845 BMS 54223 b LRB103 27845 BMS 54223 b STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB1255 Introduced 2/3/2023, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED:
3	3	5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/356z.26a new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 165/10 from Ch. 32, par. 604 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/356z.26a new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 165/10 from Ch. 32, par. 604
4	4	5 ILCS 375/6.11
5	5	55 ILCS 5/5-1069.3
6	6	65 ILCS 5/10-4-2.3
7	7	105 ILCS 5/10-22.3f
8	8	215 ILCS 5/356z.26a new
9	9	215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
10	10	215 ILCS 165/10 from Ch. 32, par. 604
11	11	Amends the Illinois Insurance Code. Provides that a health benefit plan amended, delivered, issued, or renewed on or after January 1, 2024 that provides prescription drug coverage or its contracted pharmacy benefit manager shall not engage in or require an enrollee to engage in specified prohibited acts. Provides that a clinician-administered drug supplied shall meet the supply chain security controls and chain of distribution set by the federal Drug Supply Chain Security Act. Provides that the Department of Insurance may adopt rules as necessary to implement the provisions. Defines terms. Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Voluntary Health Services Plans Act.
12	12	LRB103 27845 BMS 54223 b LRB103 27845 BMS 54223 b
13	13	LRB103 27845 BMS 54223 b
14	14	STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
15	15	STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
16	16	A BILL FOR
17	17	SB1255LRB103 27845 BMS 54223 b SB1255 LRB103 27845 BMS 54223 b
18	18	SB1255 LRB103 27845 BMS 54223 b
19	19	1 AN ACT concerning regulation.
20	20	2 Be it enacted by the People of the State of Illinois,
21	21	3 represented in the General Assembly:
22	22	4 Section 5. The State Employees Group Insurance Act of 1971
23	23	5 is amended by changing Section 6.11 as follows:
24	24	6 (5 ILCS 375/6.11)
25	25	7 (Text of Section before amendment by P.A. 102-768)
26	26	8 Sec. 6.11. Required health benefits; Illinois Insurance
27	27	9 Code requirements. The program of health benefits shall
28	28	10 provide the post-mastectomy care benefits required to be
29	29	11 covered by a policy of accident and health insurance under
30	30	12 Section 356t of the Illinois Insurance Code. The program of
31	31	13 health benefits shall provide the coverage required under
32	32	14 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
33	33	15 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
34	34	16 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
35	35	17 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
36	36	18 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
37	37	19 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and
38	38	20 356z.60 of the Illinois Insurance Code. The program of health
39	39	21 benefits must comply with Sections 155.22a, 155.37, 355b,
40	40	22 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois
41	41	23 Insurance Code. The Department of Insurance shall enforce the
42	42
43	43
44	44
45	45	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB1255 Introduced 2/3/2023, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED:
46	46	5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/356z.26a new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 165/10 from Ch. 32, par. 604 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/356z.26a new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 165/10 from Ch. 32, par. 604
47	47	5 ILCS 375/6.11
48	48	55 ILCS 5/5-1069.3
49	49	65 ILCS 5/10-4-2.3
50	50	105 ILCS 5/10-22.3f
51	51	215 ILCS 5/356z.26a new
52	52	215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
53	53	215 ILCS 165/10 from Ch. 32, par. 604
54	54	Amends the Illinois Insurance Code. Provides that a health benefit plan amended, delivered, issued, or renewed on or after January 1, 2024 that provides prescription drug coverage or its contracted pharmacy benefit manager shall not engage in or require an enrollee to engage in specified prohibited acts. Provides that a clinician-administered drug supplied shall meet the supply chain security controls and chain of distribution set by the federal Drug Supply Chain Security Act. Provides that the Department of Insurance may adopt rules as necessary to implement the provisions. Defines terms. Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Voluntary Health Services Plans Act.
55	55	LRB103 27845 BMS 54223 b LRB103 27845 BMS 54223 b
56	56	LRB103 27845 BMS 54223 b
57	57	STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
58	58	STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
59	59	A BILL FOR
60	60
61	61
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63	63
64	64
65	65	5 ILCS 375/6.11
66	66	55 ILCS 5/5-1069.3
67	67	65 ILCS 5/10-4-2.3
68	68	105 ILCS 5/10-22.3f
69	69	215 ILCS 5/356z.26a new
70	70	215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
71	71	215 ILCS 165/10 from Ch. 32, par. 604
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73	73
74	74
75	75	LRB103 27845 BMS 54223 b
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77	77	STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
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94	94	1 requirements of this Section with respect to Sections 370c and
95	95	2 370c.1 of the Illinois Insurance Code; all other requirements
96	96	3 of this Section shall be enforced by the Department of Central
97	97	4 Management Services.
98	98	5 Rulemaking authority to implement Public Act 95-1045, if
99	99	6 any, is conditioned on the rules being adopted in accordance
100	100	7 with all provisions of the Illinois Administrative Procedure
101	101	8 Act and all rules and procedures of the Joint Committee on
102	102	9 Administrative Rules; any purported rule not so adopted, for
103	103	10 whatever reason, is unauthorized.
104	104	11 (Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
105	105	12 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
106	106	13 1-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
107	107	14 eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
108	108	15 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
109	109	16 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816,
110	110	17 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
111	111	18 revised 12-13-22.)
112	112	19 (Text of Section after amendment by P.A. 102-768)
113	113	20 Sec. 6.11. Required health benefits; Illinois Insurance
114	114	21 Code requirements. The program of health benefits shall
115	115	22 provide the post-mastectomy care benefits required to be
116	116	23 covered by a policy of accident and health insurance under
117	117	24 Section 356t of the Illinois Insurance Code. The program of
118	118	25 health benefits shall provide the coverage required under
119	119
120	120
121	121
122	122
123	123
124	124	SB1255 - 2 - LRB103 27845 BMS 54223 b
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128	128	SB1255 - 3 - LRB103 27845 BMS 54223 b
129	129	1 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
130	130	2 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
131	131	3 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
132	132	4 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
133	133	5 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
134	134	6 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
135	135	7 and 356z.60 of the Illinois Insurance Code. The program of
136	136	8 health benefits must comply with Sections 155.22a, 155.37,
137	137	9 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the
138	138	10 Illinois Insurance Code. The Department of Insurance shall
139	139	11 enforce the requirements of this Section with respect to
140	140	12 Sections 370c and 370c.1 of the Illinois Insurance Code; all
141	141	13 other requirements of this Section shall be enforced by the
142	142	14 Department of Central Management Services.
143	143	15 Rulemaking authority to implement Public Act 95-1045, if
144	144	16 any, is conditioned on the rules being adopted in accordance
145	145	17 with all provisions of the Illinois Administrative Procedure
146	146	18 Act and all rules and procedures of the Joint Committee on
147	147	19 Administrative Rules; any purported rule not so adopted, for
148	148	20 whatever reason, is unauthorized.
149	149	21 (Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
150	150	22 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
151	151	23 1-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
152	152	24 eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
153	153	25 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
154	154	26 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813,
155	155
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160	160	SB1255 - 3 - LRB103 27845 BMS 54223 b
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163	163	SB1255- 4 -LRB103 27845 BMS 54223 b SB1255 - 4 - LRB103 27845 BMS 54223 b
164	164	SB1255 - 4 - LRB103 27845 BMS 54223 b
165	165	1 eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23;
166	166	2 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
167	167	3 Section 10. The Counties Code is amended by changing
168	168	4 Section 5-1069.3 as follows:
169	169	5 (55 ILCS 5/5-1069.3)
170	170	6 Sec. 5-1069.3. Required health benefits. If a county,
171	171	7 including a home rule county, is a self-insurer for purposes
172	172	8 of providing health insurance coverage for its employees, the
173	173	9 coverage shall include coverage for the post-mastectomy care
174	174	10 benefits required to be covered by a policy of accident and
175	175	11 health insurance under Section 356t and the coverage required
176	176	12 under Sections 356g, 356g.5, 356g.5-1, 356q, 356u, 356w, 356x,
177	177	13 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
178	178	14 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
179	179	15 356z.26a, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36,
180	180	16 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
181	181	17 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and 356z.60 of
182	182	18 the Illinois Insurance Code. The coverage shall comply with
183	183	19 Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
184	184	20 Insurance Code. The Department of Insurance shall enforce the
185	185	21 requirements of this Section. The requirement that health
186	186	22 benefits be covered as provided in this Section is an
187	187	23 exclusive power and function of the State and is a denial and
188	188	24 limitation under Article VII, Section 6, subsection (h) of the
189	189
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193	193
194	194	SB1255 - 4 - LRB103 27845 BMS 54223 b
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199	199	1 Illinois Constitution. A home rule county to which this
200	200	2 Section applies must comply with every provision of this
201	201	3 Section.
202	202	4 Rulemaking authority to implement Public Act 95-1045, if
203	203	5 any, is conditioned on the rules being adopted in accordance
204	204	6 with all provisions of the Illinois Administrative Procedure
205	205	7 Act and all rules and procedures of the Joint Committee on
206	206	8 Administrative Rules; any purported rule not so adopted, for
207	207	9 whatever reason, is unauthorized.
208	208	10 (Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
209	209	11 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
210	210	12 1-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
211	211	13 eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
212	212	14 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
213	213	15 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816,
214	214	16 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
215	215	17 102-1117, eff. 1-13-23.)
216	216	18 Section 15. The Illinois Municipal Code is amended by
217	217	19 changing Section 10-4-2.3 as follows:
218	218	20 (65 ILCS 5/10-4-2.3)
219	219	21 Sec. 10-4-2.3. Required health benefits. If a
220	220	22 municipality, including a home rule municipality, is a
221	221	23 self-insurer for purposes of providing health insurance
222	222	24 coverage for its employees, the coverage shall include
223	223
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233	233	1 coverage for the post-mastectomy care benefits required to be
234	234	2 covered by a policy of accident and health insurance under
235	235	3 Section 356t and the coverage required under Sections 356g,
236	236	4 356g.5, 356g.5-1, 356q, 356u, 356w, 356x, 356z.4, 356z.4a,
237	237	5 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
238	238	6 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.26a,
239	239	7 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40,
240	240	8 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53,
241	241	9 356z.54, 356z.56, 356z.57, 356z.59, and 356z.60 of the
242	242	10 Illinois Insurance Code. The coverage shall comply with
243	243	11 Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
244	244	12 Insurance Code. The Department of Insurance shall enforce the
245	245	13 requirements of this Section. The requirement that health
246	246	14 benefits be covered as provided in this is an exclusive power
247	247	15 and function of the State and is a denial and limitation under
248	248	16 Article VII, Section 6, subsection (h) of the Illinois
249	249	17 Constitution. A home rule municipality to which this Section
250	250	18 applies must comply with every provision of this Section.
251	251	19 Rulemaking authority to implement Public Act 95-1045, if
252	252	20 any, is conditioned on the rules being adopted in accordance
253	253	21 with all provisions of the Illinois Administrative Procedure
254	254	22 Act and all rules and procedures of the Joint Committee on
255	255	23 Administrative Rules; any purported rule not so adopted, for
256	256	24 whatever reason, is unauthorized.
257	257	25 (Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
258	258	26 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
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269	269	1 1-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
270	270	2 eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
271	271	3 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
272	272	4 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816,
273	273	5 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
274	274	6 102-1117, eff. 1-13-23.)
275	275	7 Section 20. The School Code is amended by changing Section
276	276	8 10-22.3f as follows:
277	277	9 (105 ILCS 5/10-22.3f)
278	278	10 Sec. 10-22.3f. Required health benefits. Insurance
279	279	11 protection and benefits for employees shall provide the
280	280	12 post-mastectomy care benefits required to be covered by a
281	281	13 policy of accident and health insurance under Section 356t and
282	282	14 the coverage required under Sections 356g, 356g.5, 356g.5-1,
283	283	15 356q, 356u, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8,
284	284	16 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
285	285	17 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
286	286	18 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
287	287	19 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and
288	288	20 356z.60 of the Illinois Insurance Code. Insurance policies
289	289	21 shall comply with Section 356z.19 of the Illinois Insurance
290	290	22 Code. The coverage shall comply with Sections 155.22a, 355b,
291	291	23 and 370c of the Illinois Insurance Code. The Department of
292	292	24 Insurance shall enforce the requirements of this Section.
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303	303	1 Rulemaking authority to implement Public Act 95-1045, if
304	304	2 any, is conditioned on the rules being adopted in accordance
305	305	3 with all provisions of the Illinois Administrative Procedure
306	306	4 Act and all rules and procedures of the Joint Committee on
307	307	5 Administrative Rules; any purported rule not so adopted, for
308	308	6 whatever reason, is unauthorized.
309	309	7 (Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
310	310	8 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
311	311	9 1-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
312	312	10 eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22;
313	313	11 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, eff.
314	314	12 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860,
315	315	13 eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
316	316	14 Section 25. The Illinois Insurance Code is amended by
317	317	15 adding Section 356z.26a as follows:
318	318	16 (215 ILCS 5/356z.26a new)
319	319	17 Sec. 356z.26a. Clinician-administered drugs.
320	320	18 (a) As used in this Section:
321	321	19 "Clinician-administered drug" means a drug administered
322	322	20 pursuant to a valid prescription, other than a vaccine, that
323	323	21 cannot be reasonably self-administered by the patient or an
324	324	22 individual assisting the patient with self-administration and
325	325	23 is typically administered by a provider in an outpatient
326	326	24 hospital, physician's office, ambulatory infusion site, or
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337	337	1 other clinical setting.
338	338	2 "Health benefit plan" means an individual or group policy
339	339	3 of accident or health insurance, health care plan, or other
340	340	4 hospital or medical policy, certificate, or contract.
341	341	5 "Health care plan" has the meaning given to that term in
342	342	6 Section 1-2 of the Health Maintenance Organization Act.
343	343	7 "Health care plan" does not include a managed care
344	344	8 organization that provides, arranges, or reimburses for the
345	345	9 delivery of health care services to individuals who are
346	346	10 enrolled in medical assistance under the Illinois Public Aid
347	347	11 Code or under the Children's Health Insurance Program Act.
348	348	12 "Pharmacy" has the meaning given to that term in Section 3
349	349	13 of the Pharmacy Practice Act.
350	350	14 "Provider" has the meaning given to that term in Section
351	351	15 370g.
352	352	16 "Site of service" means the physical location where a
353	353	17 clinician-administered drug is administered, including, but
354	354	18 not limited to, an outpatient hospital, physician's office,
355	355	19 ambulatory infusion site, home-based site, or other setting.
356	356	20 (b) To ensure access to safe and effective drug therapies,
357	357	21 a health benefit plan amended, delivered, issued, or renewed
358	358	22 on or after January 1, 2024 that provides prescription drug
359	359	23 coverage or its contracted pharmacy benefit manager shall not:
360	360	24 (1) require an enrollee to obtain a covered
361	361	25 clinician-administered drug from a pharmacy selected by
362	362	26 the health benefit plan or pharmacy benefit manager with
363	363
364	364
365	365
366	366
367	367
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369	369
370	370
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373	373	1 the intent to transport the drug to another site of
374	374	2 service for administration;
375	375	3 (2) require an enrollee to obtain a covered
376	376	4 clinician-administered drug from a pharmacy selected by
377	377	5 the health benefit plan or pharmacy benefit manager;
378	378	6 (3) notwithstanding any other provision of law, steer
379	379	7 or offer financial or other incentives to induce an
380	380	8 enrollee to obtain a clinician-administered drug from a
381	381	9 pharmacy identified by the health benefit plan or pharmacy
382	382	10 benefit manager;
383	383	11 (4) condition, deny, restrict, refuse to authorize, or
384	384	12 otherwise limit benefits and coverage to an enrollee for
385	385	13 medically necessary clinician-administered drugs and
386	386	14 related services obtained from the provider that
387	387	15 administers the drug or from a pharmacy that is not
388	388	16 selected by the health benefit plan or pharmacy benefit
389	389	17 manager;
390	390	18 (5) condition, deny, restrict, refuse to authorize, or
391	391	19 otherwise limit reimbursement to a provider for covered
392	392	20 medically necessary clinician-administered drugs and
393	393	21 related services obtained from the provider that
394	394	22 administers the drug or from a pharmacy that is not
395	395	23 selected by the health benefit plan or pharmacy benefit
396	396	24 manager;
397	397	25 (6) assess higher deductibles, copayments,
398	398	26 coinsurance, or other cost-sharing amounts for
399	399
400	400
401	401
402	402
403	403
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405	405
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409	409	1 clinician-administered drugs obtained from the provider
410	410	2 that administers the drug or from a pharmacy that is not
411	411	3 selected by the health benefit plan or pharmacy benefit
412	412	4 manager;
413	413	5 (7) require an enrollee to use a home infusion
414	414	6 pharmacy to receive clinician-administered drugs in their
415	415	7 home or to use a site of service identified by the health
416	416	8 benefit plan or pharmacy benefit manager; or
417	417	9 (8) include the site of service in prior approval or
418	418	10 medical necessity criteria for clinician-administered
419	419	11 drugs.
420	420	12 (c) A clinician-administered drug shall meet the supply
421	421	13 chain security controls and chain of distribution set by the
422	422	14 federal Drug Supply Chain Security Act.
423	423	15 (d) The Department may adopt rules as necessary to
424	424	16 implement the provisions of this Section.
425	425	17 Section 30. The Health Maintenance Organization Act is
426	426	18 amended by changing Section 5-3 as follows:
427	427	19 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
428	428	20 Sec. 5-3. Insurance Code provisions.
429	429	21 (a) Health Maintenance Organizations shall be subject to
430	430	22 the provisions of Sections 133, 134, 136, 137, 139, 140,
431	431	23 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
432	432	24 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
433	433
434	434
435	435
436	436
437	437
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439	439
440	440
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442	442	SB1255 - 12 - LRB103 27845 BMS 54223 b
443	443	1 355.3, 355b, 355c, 356g.5-1, 356m, 356q, 356v, 356w, 356x,
444	444	2 356y, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
445	445	3 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
446	446	4 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
447	447	5 356z.26, 356z.26a, 356z.29, 356z.30, 356z.30a, 356z.32,
448	448	6 356z.33, 356z.35, 356z.36, 356z.40, 356z.41, 356z.46, 356z.47,
449	449	7 356z.48, 356z.50, 356z.51, 356z.53 256z.53, 356z.54, 356z.56,
450	450	8 356z.57, 356z.59, 356z.60, 364, 364.01, 364.3, 367.2, 367.2-5,
451	451	9 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1,
452	452	10 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
453	453	11 paragraph (c) of subsection (2) of Section 367, and Articles
454	454	12 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
455	455	13 XXXIIB of the Illinois Insurance Code.
456	456	14 (b) For purposes of the Illinois Insurance Code, except
457	457	15 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
458	458	16 Health Maintenance Organizations in the following categories
459	459	17 are deemed to be "domestic companies":
460	460	18 (1) a corporation authorized under the Dental Service
461	461	19 Plan Act or the Voluntary Health Services Plans Act;
462	462	20 (2) a corporation organized under the laws of this
463	463	21 State; or
464	464	22 (3) a corporation organized under the laws of another
465	465	23 state, 30% or more of the enrollees of which are residents
466	466	24 of this State, except a corporation subject to
467	467	25 substantially the same requirements in its state of
468	468	26 organization as is a "domestic company" under Article VIII
469	469
470	470
471	471
472	472
473	473
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475	475
476	476
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479	479	1 1/2 of the Illinois Insurance Code.
480	480	2 (c) In considering the merger, consolidation, or other
481	481	3 acquisition of control of a Health Maintenance Organization
482	482	4 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
483	483	5 (1) the Director shall give primary consideration to
484	484	6 the continuation of benefits to enrollees and the
485	485	7 financial conditions of the acquired Health Maintenance
486	486	8 Organization after the merger, consolidation, or other
487	487	9 acquisition of control takes effect;
488	488	10 (2)(i) the criteria specified in subsection (1)(b) of
489	489	11 Section 131.8 of the Illinois Insurance Code shall not
490	490	12 apply and (ii) the Director, in making his determination
491	491	13 with respect to the merger, consolidation, or other
492	492	14 acquisition of control, need not take into account the
493	493	15 effect on competition of the merger, consolidation, or
494	494	16 other acquisition of control;
495	495	17 (3) the Director shall have the power to require the
496	496	18 following information:
497	497	19 (A) certification by an independent actuary of the
498	498	20 adequacy of the reserves of the Health Maintenance
499	499	21 Organization sought to be acquired;
500	500	22 (B) pro forma financial statements reflecting the
501	501	23 combined balance sheets of the acquiring company and
502	502	24 the Health Maintenance Organization sought to be
503	503	25 acquired as of the end of the preceding year and as of
504	504	26 a date 90 days prior to the acquisition, as well as pro
505	505
506	506
507	507
508	508
509	509
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511	511
512	512
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515	515	1 forma financial statements reflecting projected
516	516	2 combined operation for a period of 2 years;
517	517	3 (C) a pro forma business plan detailing an
518	518	4 acquiring party's plans with respect to the operation
519	519	5 of the Health Maintenance Organization sought to be
520	520	6 acquired for a period of not less than 3 years; and
521	521	7 (D) such other information as the Director shall
522	522	8 require.
523	523	9 (d) The provisions of Article VIII 1/2 of the Illinois
524	524	10 Insurance Code and this Section 5-3 shall apply to the sale by
525	525	11 any health maintenance organization of greater than 10% of its
526	526	12 enrollee population (including without limitation the health
527	527	13 maintenance organization's right, title, and interest in and
528	528	14 to its health care certificates).
529	529	15 (e) In considering any management contract or service
530	530	16 agreement subject to Section 141.1 of the Illinois Insurance
531	531	17 Code, the Director (i) shall, in addition to the criteria
532	532	18 specified in Section 141.2 of the Illinois Insurance Code,
533	533	19 take into account the effect of the management contract or
534	534	20 service agreement on the continuation of benefits to enrollees
535	535	21 and the financial condition of the health maintenance
536	536	22 organization to be managed or serviced, and (ii) need not take
537	537	23 into account the effect of the management contract or service
538	538	24 agreement on competition.
539	539	25 (f) Except for small employer groups as defined in the
540	540	26 Small Employer Rating, Renewability and Portability Health
541	541
542	542
543	543
544	544
545	545
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547	547
548	548
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551	551	1 Insurance Act and except for medicare supplement policies as
552	552	2 defined in Section 363 of the Illinois Insurance Code, a
553	553	3 Health Maintenance Organization may by contract agree with a
554	554	4 group or other enrollment unit to effect refunds or charge
555	555	5 additional premiums under the following terms and conditions:
556	556	6 (i) the amount of, and other terms and conditions with
557	557	7 respect to, the refund or additional premium are set forth
558	558	8 in the group or enrollment unit contract agreed in advance
559	559	9 of the period for which a refund is to be paid or
560	560	10 additional premium is to be charged (which period shall
561	561	11 not be less than one year); and
562	562	12 (ii) the amount of the refund or additional premium
563	563	13 shall not exceed 20% of the Health Maintenance
564	564	14 Organization's profitable or unprofitable experience with
565	565	15 respect to the group or other enrollment unit for the
566	566	16 period (and, for purposes of a refund or additional
567	567	17 premium, the profitable or unprofitable experience shall
568	568	18 be calculated taking into account a pro rata share of the
569	569	19 Health Maintenance Organization's administrative and
570	570	20 marketing expenses, but shall not include any refund to be
571	571	21 made or additional premium to be paid pursuant to this
572	572	22 subsection (f)). The Health Maintenance Organization and
573	573	23 the group or enrollment unit may agree that the profitable
574	574	24 or unprofitable experience may be calculated taking into
575	575	25 account the refund period and the immediately preceding 2
576	576	26 plan years.
577	577
578	578
579	579
580	580
581	581
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583	583
584	584
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587	587	1 The Health Maintenance Organization shall include a
588	588	2 statement in the evidence of coverage issued to each enrollee
589	589	3 describing the possibility of a refund or additional premium,
590	590	4 and upon request of any group or enrollment unit, provide to
591	591	5 the group or enrollment unit a description of the method used
592	592	6 to calculate (1) the Health Maintenance Organization's
593	593	7 profitable experience with respect to the group or enrollment
594	594	8 unit and the resulting refund to the group or enrollment unit
595	595	9 or (2) the Health Maintenance Organization's unprofitable
596	596	10 experience with respect to the group or enrollment unit and
597	597	11 the resulting additional premium to be paid by the group or
598	598	12 enrollment unit.
599	599	13 In no event shall the Illinois Health Maintenance
600	600	14 Organization Guaranty Association be liable to pay any
601	601	15 contractual obligation of an insolvent organization to pay any
602	602	16 refund authorized under this Section.
603	603	17 (g) Rulemaking authority to implement Public Act 95-1045,
604	604	18 if any, is conditioned on the rules being adopted in
605	605	19 accordance with all provisions of the Illinois Administrative
606	606	20 Procedure Act and all rules and procedures of the Joint
607	607	21 Committee on Administrative Rules; any purported rule not so
608	608	22 adopted, for whatever reason, is unauthorized.
609	609	23 (Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
610	610	24 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
611	611	25 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
612	612	26 eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
613	613
614	614
615	615
616	616
617	617
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619	619
620	620
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623	623	1 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
624	624	2 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
625	625	3 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
626	626	4 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
627	627	5 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
628	628	6 eff. 1-1-23; 102-1117, eff. 1-13-23; revised 1-22-23.)
629	629	7 Section 35. The Voluntary Health Services Plans Act is
630	630	8 amended by changing Section 10 as follows:
631	631	9 (215 ILCS 165/10) (from Ch. 32, par. 604)
632	632	10 Sec. 10. Application of Insurance Code provisions. Health
633	633	11 services plan corporations and all persons interested therein
634	634	12 or dealing therewith shall be subject to the provisions of
635	635	13 Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
636	636	14 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
637	637	15 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
638	638	16 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
639	639	17 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
640	640	18 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
641	641	19 356z.26, 356z.26a, 356z.29, 356z.30, 356z.30a, 356z.32,
642	642	20 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
643	643	21 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 364.01, 364.3,
644	644	22 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
645	645	23 and paragraphs (7) and (15) of Section 367 of the Illinois
646	646	24 Insurance Code.
647	647
648	648
649	649
650	650
651	651
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653	653
654	654
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657	657	1 Rulemaking authority to implement Public Act 95-1045, if
658	658	2 any, is conditioned on the rules being adopted in accordance
659	659	3 with all provisions of the Illinois Administrative Procedure
660	660	4 Act and all rules and procedures of the Joint Committee on
661	661	5 Administrative Rules; any purported rule not so adopted, for
662	662	6 whatever reason, is unauthorized.
663	663	7 (Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
664	664	8 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
665	665	9 1-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
666	666	10 eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
667	667	11 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, eff.
668	668	12 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860,
669	669	13 eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. 1-1-23;
670	670	14 102-1117, eff. 1-13-23.)
671	671	15 Section 95. No acceleration or delay. Where this Act makes
672	672	16 changes in a statute that is represented in this Act by text
673	673	17 that is not yet or no longer in effect (for example, a Section
674	674	18 represented by multiple versions), the use of that text does
675	675	19 not accelerate or delay the taking effect of (i) the changes
676	676	20 made by this Act or (ii) provisions derived from any other
677	677	21 Public Act.
678	678
679	679
680	680
681	681
682	682
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