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
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
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
LRB103 27845 BMS 54223 b
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
A BILL FOR
SB1255LRB103 27845 BMS 54223 b SB1255 LRB103 27845 BMS 54223 b
SB1255 LRB103 27845 BMS 54223 b
1 AN ACT concerning regulation.
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 1971
5 is amended by changing Section 6.11 as follows:
6 (5 ILCS 375/6.11)
7 (Text of Section before amendment by P.A. 102-768)
8 Sec. 6.11. Required health benefits; Illinois Insurance
9 Code requirements. The program of health benefits shall
10 provide the post-mastectomy care benefits required to be
11 covered by a policy of accident and health insurance under
12 Section 356t of the Illinois Insurance Code. The program of
13 health benefits shall provide the coverage required under
14 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
15 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
16 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
17 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
18 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
19 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and
20 356z.60 of the Illinois Insurance Code. The program of health
21 benefits must comply with Sections 155.22a, 155.37, 355b,
22 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois
23 Insurance Code. The Department of Insurance shall enforce the
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
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
LRB103 27845 BMS 54223 b
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
A BILL FOR
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
LRB103 27845 BMS 54223 b
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
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1 requirements of this Section with respect to Sections 370c and
2 370c.1 of the Illinois Insurance Code; all other requirements
3 of this Section shall be enforced by the Department of Central
4 Management Services.
5 Rulemaking authority to implement Public Act 95-1045, if
6 any, is conditioned on the rules being adopted in accordance
7 with all provisions of the Illinois Administrative Procedure
8 Act and all rules and procedures of the Joint Committee on
9 Administrative Rules; any purported rule not so adopted, for
10 whatever reason, is unauthorized.
11 (Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
12 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
13 1-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
14 eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
15 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
16 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816,
17 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
18 revised 12-13-22.)
19 (Text of Section after amendment by P.A. 102-768)
20 Sec. 6.11. Required health benefits; Illinois Insurance
21 Code requirements. The program of health benefits shall
22 provide the post-mastectomy care benefits required to be
23 covered by a policy of accident and health insurance under
24 Section 356t of the Illinois Insurance Code. The program of
25 health benefits shall provide the coverage required under
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1 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
2 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
3 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
4 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
5 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
6 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
7 and 356z.60 of the Illinois Insurance Code. The program of
8 health benefits must comply with Sections 155.22a, 155.37,
9 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the
10 Illinois Insurance Code. The Department of Insurance shall
11 enforce the requirements of this Section with respect to
12 Sections 370c and 370c.1 of the Illinois Insurance Code; all
13 other requirements of this Section shall be enforced by the
14 Department of Central Management Services.
15 Rulemaking authority to implement Public Act 95-1045, if
16 any, is conditioned on the rules being adopted in accordance
17 with all provisions of the Illinois Administrative Procedure
18 Act and all rules and procedures of the Joint Committee on
19 Administrative Rules; any purported rule not so adopted, for
20 whatever reason, is unauthorized.
21 (Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
22 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
23 1-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
24 eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
25 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
26 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813,
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1 eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23;
2 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
3 Section 10. The Counties Code is amended by changing
4 Section 5-1069.3 as follows:
5 (55 ILCS 5/5-1069.3)
6 Sec. 5-1069.3. Required health benefits. If a county,
7 including a home rule county, is a self-insurer for purposes
8 of providing health insurance coverage for its employees, the
9 coverage shall include coverage for the post-mastectomy care
10 benefits required to be covered by a policy of accident and
11 health insurance under Section 356t and the coverage required
12 under Sections 356g, 356g.5, 356g.5-1, 356q, 356u, 356w, 356x,
13 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
14 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
15 356z.26a, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36,
16 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
17 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and 356z.60 of
18 the Illinois Insurance Code. The coverage shall comply with
19 Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
20 Insurance Code. The Department of Insurance shall enforce the
21 requirements of this Section. The requirement that health
22 benefits be covered as provided in this Section is an
23 exclusive power and function of the State and is a denial and
24 limitation under Article VII, Section 6, subsection (h) of the
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1 Illinois Constitution. A home rule county to which this
2 Section applies must comply with every provision of this
3 Section.
4 Rulemaking authority to implement Public Act 95-1045, if
5 any, is conditioned on the rules being adopted in accordance
6 with all provisions of the Illinois Administrative Procedure
7 Act and all rules and procedures of the Joint Committee on
8 Administrative Rules; any purported rule not so adopted, for
9 whatever reason, is unauthorized.
10 (Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
11 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
12 1-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
13 eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
14 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
15 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816,
16 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
17 102-1117, eff. 1-13-23.)
18 Section 15. The Illinois Municipal Code is amended by
19 changing Section 10-4-2.3 as follows:
20 (65 ILCS 5/10-4-2.3)
21 Sec. 10-4-2.3. Required health benefits. If a
22 municipality, including a home rule municipality, is a
23 self-insurer for purposes of providing health insurance
24 coverage for its employees, the coverage shall include
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1 coverage for the post-mastectomy care benefits required to be
2 covered by a policy of accident and health insurance under
3 Section 356t and the coverage required under Sections 356g,
4 356g.5, 356g.5-1, 356q, 356u, 356w, 356x, 356z.4, 356z.4a,
5 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
6 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.26a,
7 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40,
8 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53,
9 356z.54, 356z.56, 356z.57, 356z.59, and 356z.60 of the
10 Illinois Insurance Code. The coverage shall comply with
11 Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
12 Insurance Code. The Department of Insurance shall enforce the
13 requirements of this Section. The requirement that health
14 benefits be covered as provided in this is an exclusive power
15 and function of the State and is a denial and limitation under
16 Article VII, Section 6, subsection (h) of the Illinois
17 Constitution. A home rule municipality to which this Section
18 applies must comply with every provision of this Section.
19 Rulemaking authority to implement Public Act 95-1045, if
20 any, is conditioned on the rules being adopted in accordance
21 with all provisions of the Illinois Administrative Procedure
22 Act and all rules and procedures of the Joint Committee on
23 Administrative Rules; any purported rule not so adopted, for
24 whatever reason, is unauthorized.
25 (Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
26 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
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1 1-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
2 eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
3 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
4 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816,
5 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
6 102-1117, eff. 1-13-23.)
7 Section 20. The School Code is amended by changing Section
8 10-22.3f as follows:
9 (105 ILCS 5/10-22.3f)
10 Sec. 10-22.3f. Required health benefits. Insurance
11 protection and benefits for employees shall provide the
12 post-mastectomy care benefits required to be covered by a
13 policy of accident and health insurance under Section 356t and
14 the coverage required under Sections 356g, 356g.5, 356g.5-1,
15 356q, 356u, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8,
16 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
17 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
18 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
19 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and
20 356z.60 of the Illinois Insurance Code. Insurance policies
21 shall comply with Section 356z.19 of the Illinois Insurance
22 Code. The coverage shall comply with Sections 155.22a, 355b,
23 and 370c of the Illinois Insurance Code. The Department of
24 Insurance shall enforce the requirements of this Section.
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1 Rulemaking authority to implement Public Act 95-1045, if
2 any, is conditioned on the rules being adopted in accordance
3 with all provisions of the Illinois Administrative Procedure
4 Act and all rules and procedures of the Joint Committee on
5 Administrative Rules; any purported rule not so adopted, for
6 whatever reason, is unauthorized.
7 (Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
8 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
9 1-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
10 eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22;
11 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, eff.
12 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860,
13 eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
14 Section 25. The Illinois Insurance Code is amended by
15 adding Section 356z.26a as follows:
16 (215 ILCS 5/356z.26a new)
17 Sec. 356z.26a. Clinician-administered drugs.
18 (a) As used in this Section:
19 "Clinician-administered drug" means a drug administered
20 pursuant to a valid prescription, other than a vaccine, that
21 cannot be reasonably self-administered by the patient or an
22 individual assisting the patient with self-administration and
23 is typically administered by a provider in an outpatient
24 hospital, physician's office, ambulatory infusion site, or
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1 other clinical setting.
2 "Health benefit plan" means an individual or group policy
3 of accident or health insurance, health care plan, or other
4 hospital or medical policy, certificate, or contract.
5 "Health care plan" has the meaning given to that term in
6 Section 1-2 of the Health Maintenance Organization Act.
7 "Health care plan" does not include a managed care
8 organization that provides, arranges, or reimburses for the
9 delivery of health care services to individuals who are
10 enrolled in medical assistance under the Illinois Public Aid
11 Code or under the Children's Health Insurance Program Act.
12 "Pharmacy" has the meaning given to that term in Section 3
13 of the Pharmacy Practice Act.
14 "Provider" has the meaning given to that term in Section
15 370g.
16 "Site of service" means the physical location where a
17 clinician-administered drug is administered, including, but
18 not limited to, an outpatient hospital, physician's office,
19 ambulatory infusion site, home-based site, or other setting.
20 (b) To ensure access to safe and effective drug therapies,
21 a health benefit plan amended, delivered, issued, or renewed
22 on or after January 1, 2024 that provides prescription drug
23 coverage or its contracted pharmacy benefit manager shall not:
24 (1) require an enrollee to obtain a covered
25 clinician-administered drug from a pharmacy selected by
26 the health benefit plan or pharmacy benefit manager with
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1 the intent to transport the drug to another site of
2 service for administration;
3 (2) require an enrollee to obtain a covered
4 clinician-administered drug from a pharmacy selected by
5 the health benefit plan or pharmacy benefit manager;
6 (3) notwithstanding any other provision of law, steer
7 or offer financial or other incentives to induce an
8 enrollee to obtain a clinician-administered drug from a
9 pharmacy identified by the health benefit plan or pharmacy
10 benefit manager;
11 (4) condition, deny, restrict, refuse to authorize, or
12 otherwise limit benefits and coverage to an enrollee for
13 medically necessary clinician-administered drugs and
14 related services obtained from the provider that
15 administers the drug or from a pharmacy that is not
16 selected by the health benefit plan or pharmacy benefit
17 manager;
18 (5) condition, deny, restrict, refuse to authorize, or
19 otherwise limit reimbursement to a provider for covered
20 medically necessary clinician-administered drugs and
21 related services obtained from the provider that
22 administers the drug or from a pharmacy that is not
23 selected by the health benefit plan or pharmacy benefit
24 manager;
25 (6) assess higher deductibles, copayments,
26 coinsurance, or other cost-sharing amounts for
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1 clinician-administered drugs obtained from the provider
2 that administers the drug or from a pharmacy that is not
3 selected by the health benefit plan or pharmacy benefit
4 manager;
5 (7) require an enrollee to use a home infusion
6 pharmacy to receive clinician-administered drugs in their
7 home or to use a site of service identified by the health
8 benefit plan or pharmacy benefit manager; or
9 (8) include the site of service in prior approval or
10 medical necessity criteria for clinician-administered
11 drugs.
12 (c) A clinician-administered drug shall meet the supply
13 chain security controls and chain of distribution set by the
14 federal Drug Supply Chain Security Act.
15 (d) The Department may adopt rules as necessary to
16 implement the provisions of this Section.
17 Section 30. The Health Maintenance Organization Act is
18 amended by changing Section 5-3 as follows:
19 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
20 Sec. 5-3. Insurance Code provisions.
21 (a) Health Maintenance Organizations shall be subject to
22 the provisions of Sections 133, 134, 136, 137, 139, 140,
23 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
24 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
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1 355.3, 355b, 355c, 356g.5-1, 356m, 356q, 356v, 356w, 356x,
2 356y, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
3 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
4 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
5 356z.26, 356z.26a, 356z.29, 356z.30, 356z.30a, 356z.32,
6 356z.33, 356z.35, 356z.36, 356z.40, 356z.41, 356z.46, 356z.47,
7 356z.48, 356z.50, 356z.51, 356z.53 256z.53, 356z.54, 356z.56,
8 356z.57, 356z.59, 356z.60, 364, 364.01, 364.3, 367.2, 367.2-5,
9 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1,
10 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
11 paragraph (c) of subsection (2) of Section 367, and Articles
12 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
13 XXXIIB of the Illinois Insurance Code.
14 (b) For purposes of the Illinois Insurance Code, except
15 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
16 Health Maintenance Organizations in the following categories
17 are deemed to be "domestic companies":
18 (1) a corporation authorized under the Dental Service
19 Plan Act or the Voluntary Health Services Plans Act;
20 (2) a corporation organized under the laws of this
21 State; or
22 (3) a corporation organized under the laws of another
23 state, 30% or more of the enrollees of which are residents
24 of this State, except a corporation subject to
25 substantially the same requirements in its state of
26 organization as is a "domestic company" under Article VIII
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1 1/2 of the Illinois Insurance Code.
2 (c) In considering the merger, consolidation, or other
3 acquisition of control of a Health Maintenance Organization
4 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
5 (1) the Director shall give primary consideration to
6 the continuation of benefits to enrollees and the
7 financial conditions of the acquired Health Maintenance
8 Organization after the merger, consolidation, or other
9 acquisition of control takes effect;
10 (2)(i) the criteria specified in subsection (1)(b) of
11 Section 131.8 of the Illinois Insurance Code shall not
12 apply and (ii) the Director, in making his determination
13 with respect to the merger, consolidation, or other
14 acquisition of control, need not take into account the
15 effect on competition of the merger, consolidation, or
16 other acquisition of control;
17 (3) the Director shall have the power to require the
18 following information:
19 (A) certification by an independent actuary of the
20 adequacy of the reserves of the Health Maintenance
21 Organization sought to be acquired;
22 (B) pro forma financial statements reflecting the
23 combined balance sheets of the acquiring company and
24 the Health Maintenance Organization sought to be
25 acquired as of the end of the preceding year and as of
26 a date 90 days prior to the acquisition, as well as pro
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1 forma financial statements reflecting projected
2 combined operation for a period of 2 years;
3 (C) a pro forma business plan detailing an
4 acquiring party's plans with respect to the operation
5 of the Health Maintenance Organization sought to be
6 acquired for a period of not less than 3 years; and
7 (D) such other information as the Director shall
8 require.
9 (d) The provisions of Article VIII 1/2 of the Illinois
10 Insurance Code and this Section 5-3 shall apply to the sale by
11 any health maintenance organization of greater than 10% of its
12 enrollee population (including without limitation the health
13 maintenance organization's right, title, and interest in and
14 to its health care certificates).
15 (e) In considering any management contract or service
16 agreement subject to Section 141.1 of the Illinois Insurance
17 Code, the Director (i) shall, in addition to the criteria
18 specified in Section 141.2 of the Illinois Insurance Code,
19 take into account the effect of the management contract or
20 service agreement on the continuation of benefits to enrollees
21 and the financial condition of the health maintenance
22 organization to be managed or serviced, and (ii) need not take
23 into account the effect of the management contract or service
24 agreement on competition.
25 (f) Except for small employer groups as defined in the
26 Small Employer Rating, Renewability and Portability Health
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1 Insurance Act and except for medicare supplement policies as
2 defined in Section 363 of the Illinois Insurance Code, a
3 Health Maintenance Organization may by contract agree with a
4 group or other enrollment unit to effect refunds or charge
5 additional premiums under the following terms and conditions:
6 (i) the amount of, and other terms and conditions with
7 respect to, the refund or additional premium are set forth
8 in the group or enrollment unit contract agreed in advance
9 of the period for which a refund is to be paid or
10 additional premium is to be charged (which period shall
11 not be less than one year); and
12 (ii) the amount of the refund or additional premium
13 shall not exceed 20% of the Health Maintenance
14 Organization's profitable or unprofitable experience with
15 respect to the group or other enrollment unit for the
16 period (and, for purposes of a refund or additional
17 premium, the profitable or unprofitable experience shall
18 be calculated taking into account a pro rata share of the
19 Health Maintenance Organization's administrative and
20 marketing expenses, but shall not include any refund to be
21 made or additional premium to be paid pursuant to this
22 subsection (f)). The Health Maintenance Organization and
23 the group or enrollment unit may agree that the profitable
24 or unprofitable experience may be calculated taking into
25 account the refund period and the immediately preceding 2
26 plan years.
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1 The Health Maintenance Organization shall include a
2 statement in the evidence of coverage issued to each enrollee
3 describing the possibility of a refund or additional premium,
4 and upon request of any group or enrollment unit, provide to
5 the group or enrollment unit a description of the method used
6 to calculate (1) the Health Maintenance Organization's
7 profitable experience with respect to the group or enrollment
8 unit and the resulting refund to the group or enrollment unit
9 or (2) the Health Maintenance Organization's unprofitable
10 experience with respect to the group or enrollment unit and
11 the resulting additional premium to be paid by the group or
12 enrollment unit.
13 In no event shall the Illinois Health Maintenance
14 Organization Guaranty Association be liable to pay any
15 contractual obligation of an insolvent organization to pay any
16 refund authorized under this Section.
17 (g) Rulemaking authority to implement Public Act 95-1045,
18 if any, is conditioned on the rules being adopted in
19 accordance with all provisions of the Illinois Administrative
20 Procedure Act and all rules and procedures of the Joint
21 Committee on Administrative Rules; any purported rule not so
22 adopted, for whatever reason, is unauthorized.
23 (Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
24 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
25 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
26 eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
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1 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
2 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
3 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
4 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
5 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
6 eff. 1-1-23; 102-1117, eff. 1-13-23; revised 1-22-23.)
7 Section 35. The Voluntary Health Services Plans Act is
8 amended by changing Section 10 as follows:
9 (215 ILCS 165/10) (from Ch. 32, par. 604)
10 Sec. 10. Application of Insurance Code provisions. Health
11 services plan corporations and all persons interested therein
12 or dealing therewith shall be subject to the provisions of
13 Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
14 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
15 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
16 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
17 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
18 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
19 356z.26, 356z.26a, 356z.29, 356z.30, 356z.30a, 356z.32,
20 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
21 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 364.01, 364.3,
22 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
23 and paragraphs (7) and (15) of Section 367 of the Illinois
24 Insurance Code.
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1 Rulemaking authority to implement Public Act 95-1045, if
2 any, is conditioned on the rules being adopted in accordance
3 with all provisions of the Illinois Administrative Procedure
4 Act and all rules and procedures of the Joint Committee on
5 Administrative Rules; any purported rule not so adopted, for
6 whatever reason, is unauthorized.
7 (Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
8 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
9 1-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
10 eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
11 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, eff.
12 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-860,
13 eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. 1-1-23;
14 102-1117, eff. 1-13-23.)
15 Section 95. No acceleration or delay. Where this Act makes
16 changes in a statute that is represented in this Act by text
17 that is not yet or no longer in effect (for example, a Section
18 represented by multiple versions), the use of that text does
19 not accelerate or delay the taking effect of (i) the changes
20 made by this Act or (ii) provisions derived from any other
21 Public Act.
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