103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3225 Introduced 2/6/2024, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/356z.26a new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 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, 2025 that provides prescription drug coverage through a medical or pharmacy health benefit 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 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. Amends 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 to require policies under those Acts to comply with the provisions. LRB103 38466 RPS 68602 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3225 Introduced 2/6/2024, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/356z.26a new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 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, 2025 that provides prescription drug coverage through a medical or pharmacy health benefit 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 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. Amends 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 to require policies under those Acts to comply with the provisions. LRB103 38466 RPS 68602 b LRB103 38466 RPS 68602 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3225 Introduced 2/6/2024, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED:
5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/356z.26a new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 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, 2025 that provides prescription drug coverage through a medical or pharmacy health benefit 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 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. Amends 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 to require policies under those Acts to comply with the provisions.
LRB103 38466 RPS 68602 b LRB103 38466 RPS 68602 b
LRB103 38466 RPS 68602 b
A BILL FOR
SB3225LRB103 38466 RPS 68602 b SB3225 LRB103 38466 RPS 68602 b
SB3225 LRB103 38466 RPS 68602 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 Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall
9 provide the post-mastectomy care benefits required to be
10 covered by a policy of accident and health insurance under
11 Section 356t of the Illinois Insurance Code. The program of
12 health benefits shall provide the coverage required under
13 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
14 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
15 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
16 356z.25, 356z.26, 356z.26a, 356z.29, 356z.30a, 356z.32,
17 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
18 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
19 356z.60, and 356z.61, and 356z.62, 356z.64, 356z.67, 356z.68,
20 and 356z.70 of the Illinois Insurance Code. The program of
21 health benefits must comply with Sections 155.22a, 155.37,
22 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the
23 Illinois Insurance Code. The program of health benefits shall
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3225 Introduced 2/6/2024, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED:
5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/356z.26a new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2215 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, 2025 that provides prescription drug coverage through a medical or pharmacy health benefit 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 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. Amends 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 to require policies under those Acts to comply with the provisions.
LRB103 38466 RPS 68602 b LRB103 38466 RPS 68602 b
LRB103 38466 RPS 68602 b
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 38466 RPS 68602 b
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1 provide the coverage required under Section 356m of the
2 Illinois Insurance Code and, for the employees of the State
3 Employee Group Insurance Program only, the coverage as also
4 provided in Section 6.11B of this Act. The Department of
5 Insurance shall enforce the requirements of this Section with
6 respect to Sections 370c and 370c.1 of the Illinois Insurance
7 Code; all other requirements of this Section shall be enforced
8 by the Department of Central Management Services.
9 Rulemaking authority to implement Public Act 95-1045, if
10 any, is conditioned on the rules being adopted in accordance
11 with all provisions of the Illinois Administrative Procedure
12 Act and all rules and procedures of the Joint Committee on
13 Administrative Rules; any purported rule not so adopted, for
14 whatever reason, is unauthorized.
15 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
16 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
17 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
18 eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
19 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
20 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
21 eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
22 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
23 8-11-23; revised 8-29-23.)
24 Section 10. The Counties Code is amended by changing
25 Section 5-1069.3 as follows:
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1 (55 ILCS 5/5-1069.3)
2 Sec. 5-1069.3. Required health benefits. If a county,
3 including a home rule county, is a self-insurer for purposes
4 of providing health insurance coverage for its employees, the
5 coverage shall include coverage for the post-mastectomy care
6 benefits required to be covered by a policy of accident and
7 health insurance under Section 356t and the coverage required
8 under Sections 356g, 356g.5, 356g.5-1, 356q, 356u, 356w, 356x,
9 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
10 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
11 356z.26a, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36,
12 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
13 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, and
14 356z.61, and 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70
15 of the Illinois Insurance Code. The coverage shall comply with
16 Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
17 Insurance Code. The Department of Insurance shall enforce the
18 requirements of this Section. The requirement that health
19 benefits be covered as provided in this Section is an
20 exclusive power and function of the State and is a denial and
21 limitation under Article VII, Section 6, subsection (h) of the
22 Illinois Constitution. A home rule county to which this
23 Section applies must comply with every provision of this
24 Section.
25 Rulemaking authority to implement Public Act 95-1045, if
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1 any, is conditioned on the rules being adopted in accordance
2 with all provisions of the Illinois Administrative Procedure
3 Act and all rules and procedures of the Joint Committee on
4 Administrative Rules; any purported rule not so adopted, for
5 whatever reason, is unauthorized.
6 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
7 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
8 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
9 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
10 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
11 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
12 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
13 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; revised
14 8-29-23.)
15 Section 15. The Illinois Municipal Code is amended by
16 changing Section 10-4-2.3 as follows:
17 (65 ILCS 5/10-4-2.3)
18 Sec. 10-4-2.3. Required health benefits. If a
19 municipality, including a home rule municipality, is a
20 self-insurer for purposes of providing health insurance
21 coverage for its employees, the coverage shall include
22 coverage for the post-mastectomy care benefits required to be
23 covered by a policy of accident and health insurance under
24 Section 356t and the coverage required under Sections 356g,
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1 356g.5, 356g.5-1, 356q, 356u, 356w, 356x, 356z.4, 356z.4a,
2 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
3 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.26a,
4 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40,
5 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53,
6 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, and 356z.61, and
7 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70 of the
8 Illinois Insurance Code. The coverage shall comply with
9 Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
10 Insurance Code. The Department of Insurance shall enforce the
11 requirements of this Section. The requirement that health
12 benefits be covered as provided in this is an exclusive power
13 and function of the State and is a denial and limitation under
14 Article VII, Section 6, subsection (h) of the Illinois
15 Constitution. A home rule municipality to which this Section
16 applies must comply with every provision of this Section.
17 Rulemaking authority to implement Public Act 95-1045, if
18 any, is conditioned on the rules being adopted in accordance
19 with all provisions of the Illinois Administrative Procedure
20 Act and all rules and procedures of the Joint Committee on
21 Administrative Rules; any purported rule not so adopted, for
22 whatever reason, is unauthorized.
23 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
24 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
25 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
26 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
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1 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
2 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
3 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
4 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; revised
5 8-29-23.)
6 Section 20. The School Code is amended by changing Section
7 10-22.3f as follows:
8 (105 ILCS 5/10-22.3f)
9 Sec. 10-22.3f. Required health benefits. Insurance
10 protection and benefits for employees shall provide the
11 post-mastectomy care benefits required to be covered by a
12 policy of accident and health insurance under Section 356t and
13 the coverage required under Sections 356g, 356g.5, 356g.5-1,
14 356q, 356u, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8,
15 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
16 356z.25, 356z.26, 356z.26a 356z.29, 356z.30a, 356z.32,
17 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
18 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
19 and 356z.61, and 356z.62, 356z.64, 356z.67, 356z.68, and
20 356z.70 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. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
8 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
9 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
10 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
11 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
12 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
13 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
14 103-551, eff. 8-11-23; revised 8-29-23.)
15 Section 25. The Illinois Insurance Code is amended by
16 adding Section 356z.26a as follows:
17 (215 ILCS 5/356z.26a new)
18 Sec. 356z.26a. Clinician-administered drugs.
19 (a) As used in this Section:
20 "Clinician-administered drug" means an outpatient
21 prescription drug other than a vaccine that:
22 (1) cannot reasonably be self-administered by the
23 patient to whom the drug is prescribed or by an individual
24 assisting the patient with the self-administration; and
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1 (2) is typically administered:
2 (A) by a health care provider authorized under the
3 laws of this State to administer the drug, including a
4 health care provider acting under a physician's
5 delegation and supervision; and
6 (B) in a physician's office, hospital outpatient
7 infusion center, or other clinical setting.
8 "Health benefit plan" means an individual or group policy
9 of accident or health insurance, health care plan, or other
10 hospital or medical policy, certificate, or contract.
11 "Health care plan" has the meaning given to that term in
12 Section 1-2 of the Health Maintenance Organization Act.
13 "Health care plan" does not include a managed care
14 organization that provides, arranges, or reimburses for the
15 delivery of health care services to individuals who are
16 enrolled in the program of medical assistance under the
17 Illinois Public Aid Code or under the Children's Health
18 Insurance Program Act.
19 "Pharmacy" has the meaning given to that term in Section 3
20 of the Pharmacy Practice Act.
21 "Provider" has the meaning given to that term in Section
22 370g.
23 "Site of service" means the physical location where a
24 clinician-administered drug is administered, including, but
25 not limited to, an outpatient hospital, physician's office,
26 ambulatory infusion site, home-based site, or other clinical
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1 setting.
2 (b) To ensure access to safe and effective drug therapies,
3 a health benefit plan amended, delivered, issued, or renewed
4 on or after January 1, 2025 that provides prescription drug
5 coverage through a medical or pharmacy health benefit or its
6 contracted pharmacy benefit manager shall not:
7 (1) require an enrollee to obtain a covered
8 clinician-administered drug from a pharmacy selected by
9 the health benefit plan or pharmacy benefit manager with
10 the intent to transport the drug to another site of
11 service for administration;
12 (2) require an enrollee to obtain a covered
13 clinician-administered drug from a pharmacy selected by
14 the health benefit plan or pharmacy benefit manager;
15 (3) notwithstanding any other provision of law, steer
16 or offer financial or other incentives to induce an
17 enrollee to obtain a clinician-administered drug from a
18 pharmacy identified by the health benefit plan or pharmacy
19 benefit manager;
20 (4) condition, deny, restrict, refuse to authorize, or
21 otherwise limit benefits and coverage to an enrollee for
22 medically necessary clinician-administered drugs and
23 related services obtained from the provider that
24 administers the drug or from a pharmacy that is not
25 selected by the health benefit plan or pharmacy benefit
26 manager;
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1 (5) condition, deny, restrict, refuse to authorize, or
2 otherwise limit reimbursement to a provider for covered
3 medically necessary clinician-administered drugs and
4 related services obtained from the provider that
5 administers the drug or from a pharmacy that is not
6 selected by the health benefit plan or pharmacy benefit
7 manager;
8 (6) assess higher deductibles, copayments,
9 coinsurance, or other cost-sharing amounts for
10 clinician-administered drugs obtained from the provider
11 that administers the drug or from a pharmacy that is not
12 selected by the health benefit plan or pharmacy benefit
13 manager;
14 (7) require an enrollee to use a home infusion
15 pharmacy to receive clinician-administered drugs in the
16 enrollee's home or to use a site of service identified by
17 the health benefit plan or pharmacy benefit manager;
18 (8) include the site of service in prior approval or
19 medical necessity criteria for clinician-administered
20 drugs;
21 (9) require an enrollee to use the pharmacy benefit
22 for specific clinician-administered drugs; or
23 (10) prohibit a provider from billing the health
24 benefit plan for reimbursement of clinician-administered
25 drugs.
26 (c) A clinician-administered drug shall meet the supply
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1 chain security controls and chain of distribution set by the
2 federal Drug Supply Chain Security Act.
3 (d) The Department may adopt rules as necessary to
4 implement the provisions of this Section.
5 Section 30. The Health Maintenance Organization Act is
6 amended by changing Section 5-3 as follows:
7 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
8 Sec. 5-3. Insurance Code provisions.
9 (a) Health Maintenance Organizations shall be subject to
10 the provisions of Sections 133, 134, 136, 137, 139, 140,
11 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
12 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
13 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v,
14 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
15 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
16 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22,
17 356z.23, 356z.24, 356z.25, 356z.26, 356z.26a, 356z.28,
18 356z.29, 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33,
19 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
20 356z.41, 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49,
21 356z.50, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57,
22 356z.58, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65,
23 356z.67, 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i,
24 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402,
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1 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
2 of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
3 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
4 Illinois Insurance Code.
5 (b) For purposes of the Illinois Insurance Code, except
6 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
7 Health Maintenance Organizations in the following categories
8 are deemed to be "domestic companies":
9 (1) a corporation authorized under the Dental Service
10 Plan Act or the Voluntary Health Services Plans Act;
11 (2) a corporation organized under the laws of this
12 State; or
13 (3) a corporation organized under the laws of another
14 state, 30% or more of the enrollees of which are residents
15 of this State, except a corporation subject to
16 substantially the same requirements in its state of
17 organization as is a "domestic company" under Article VIII
18 1/2 of the Illinois Insurance Code.
19 (c) In considering the merger, consolidation, or other
20 acquisition of control of a Health Maintenance Organization
21 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22 (1) the Director shall give primary consideration to
23 the continuation of benefits to enrollees and the
24 financial conditions of the acquired Health Maintenance
25 Organization after the merger, consolidation, or other
26 acquisition of control takes effect;
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1 (2)(i) the criteria specified in subsection (1)(b) of
2 Section 131.8 of the Illinois Insurance Code shall not
3 apply and (ii) the Director, in making his determination
4 with respect to the merger, consolidation, or other
5 acquisition of control, need not take into account the
6 effect on competition of the merger, consolidation, or
7 other acquisition of control;
8 (3) the Director shall have the power to require the
9 following information:
10 (A) certification by an independent actuary of the
11 adequacy of the reserves of the Health Maintenance
12 Organization sought to be acquired;
13 (B) pro forma financial statements reflecting the
14 combined balance sheets of the acquiring company and
15 the Health Maintenance Organization sought to be
16 acquired as of the end of the preceding year and as of
17 a date 90 days prior to the acquisition, as well as pro
18 forma financial statements reflecting projected
19 combined operation for a period of 2 years;
20 (C) a pro forma business plan detailing an
21 acquiring party's plans with respect to the operation
22 of the Health Maintenance Organization sought to be
23 acquired for a period of not less than 3 years; and
24 (D) such other information as the Director shall
25 require.
26 (d) The provisions of Article VIII 1/2 of the Illinois
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1 Insurance Code and this Section 5-3 shall apply to the sale by
2 any health maintenance organization of greater than 10% of its
3 enrollee population (including, without limitation, the health
4 maintenance organization's right, title, and interest in and
5 to its health care certificates).
6 (e) In considering any management contract or service
7 agreement subject to Section 141.1 of the Illinois Insurance
8 Code, the Director (i) shall, in addition to the criteria
9 specified in Section 141.2 of the Illinois Insurance Code,
10 take into account the effect of the management contract or
11 service agreement on the continuation of benefits to enrollees
12 and the financial condition of the health maintenance
13 organization to be managed or serviced, and (ii) need not take
14 into account the effect of the management contract or service
15 agreement on competition.
16 (f) Except for small employer groups as defined in the
17 Small Employer Rating, Renewability and Portability Health
18 Insurance Act and except for medicare supplement policies as
19 defined in Section 363 of the Illinois Insurance Code, a
20 Health Maintenance Organization may by contract agree with a
21 group or other enrollment unit to effect refunds or charge
22 additional premiums under the following terms and conditions:
23 (i) the amount of, and other terms and conditions with
24 respect to, the refund or additional premium are set forth
25 in the group or enrollment unit contract agreed in advance
26 of the period for which a refund is to be paid or
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1 additional premium is to be charged (which period shall
2 not be less than one year); and
3 (ii) the amount of the refund or additional premium
4 shall not exceed 20% of the Health Maintenance
5 Organization's profitable or unprofitable experience with
6 respect to the group or other enrollment unit for the
7 period (and, for purposes of a refund or additional
8 premium, the profitable or unprofitable experience shall
9 be calculated taking into account a pro rata share of the
10 Health Maintenance Organization's administrative and
11 marketing expenses, but shall not include any refund to be
12 made or additional premium to be paid pursuant to this
13 subsection (f)). The Health Maintenance Organization and
14 the group or enrollment unit may agree that the profitable
15 or unprofitable experience may be calculated taking into
16 account the refund period and the immediately preceding 2
17 plan years.
18 The Health Maintenance Organization shall include a
19 statement in the evidence of coverage issued to each enrollee
20 describing the possibility of a refund or additional premium,
21 and upon request of any group or enrollment unit, provide to
22 the group or enrollment unit a description of the method used
23 to calculate (1) the Health Maintenance Organization's
24 profitable experience with respect to the group or enrollment
25 unit and the resulting refund to the group or enrollment unit
26 or (2) the Health Maintenance Organization's unprofitable
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1 experience with respect to the group or enrollment unit and
2 the resulting additional premium to be paid by the group or
3 enrollment unit.
4 In no event shall the Illinois Health Maintenance
5 Organization Guaranty Association be liable to pay any
6 contractual obligation of an insolvent organization to pay any
7 refund authorized under this Section.
8 (g) Rulemaking authority to implement Public Act 95-1045,
9 if any, is conditioned on the rules being adopted in
10 accordance with all provisions of the Illinois Administrative
11 Procedure Act and all rules and procedures of the Joint
12 Committee on Administrative Rules; any purported rule not so
13 adopted, for whatever reason, is unauthorized.
14 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
15 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
16 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
17 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
18 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
19 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
20 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
21 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
22 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
23 eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
24 Section 35. The Voluntary Health Services Plans Act is
25 amended by changing Section 10 as follows:
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1 (215 ILCS 165/10) (from Ch. 32, par. 604)
2 Sec. 10. Application of Insurance Code provisions. Health
3 services plan corporations and all persons interested therein
4 or dealing therewith shall be subject to the provisions of
5 Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
6 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
7 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
8 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
9 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
10 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
11 356z.26, 356z.26a, 356z.29, 356z.30, 356z.30a, 356z.32,
12 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
13 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
14 356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
15 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
16 and (15) of Section 367 of the Illinois Insurance Code.
17 Rulemaking authority to implement Public Act 95-1045, if
18 any, is conditioned on the rules being adopted in accordance
19 with all provisions of the Illinois Administrative Procedure
20 Act and all rules and procedures of the Joint Committee on
21 Administrative Rules; any purported rule not so adopted, for
22 whatever reason, is unauthorized.
23 (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
24 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
25 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
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