IL
Illinois House Bill HB1085

Illinois 2025-2026 Regular Session

Illinois House Bill HB1085 Compare Versions

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1-HB1085 EngrossedLRB104 05991 BAB 16024 b HB1085 Engrossed LRB104 05991 BAB 16024 b
2- HB1085 Engrossed LRB104 05991 BAB 16024 b
1+104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe 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 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately. LRB104 05991 BAB 16024 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe 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 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 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 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately. LRB104 05991 BAB 16024 b LRB104 05991 BAB 16024 b A BILL FOR
2+104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:
3+5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 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 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
4+5 ILCS 375/6.11
5+55 ILCS 5/5-1069.3
6+65 ILCS 5/10-4-2.3
7+105 ILCS 5/10-22.3f
8+215 ILCS 5/370c.3 new
9+215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
10+Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately.
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13+A BILL FOR
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15+ HB1085 LRB104 05991 BAB 16024 b
316 1 AN ACT concerning regulation.
417 2 Be it enacted by the People of the State of Illinois,
518 3 represented in the General Assembly:
6-4 Section 5. The Counties Code is amended by changing
7-5 Section 5-1069.3 as follows:
8-6 (55 ILCS 5/5-1069.3)
9-7 Sec. 5-1069.3. Required health benefits. If a county,
10-8 including a home rule county, is a self-insurer for purposes
11-9 of providing health insurance coverage for its employees, the
12-10 coverage shall include coverage for the post-mastectomy care
13-11 benefits required to be covered by a policy of accident and
14-12 health insurance under Section 356t and the coverage required
15-13 under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u,
16-14 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9,
17-15 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
18-16 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36,
19-17 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
20-18 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
21-19 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71,
22-20 356z.74, and 356z.77 of the Illinois Insurance Code. The
23-21 coverage shall comply with Sections 155.22a, 355b, 356z.19,
24-22 and 370c, and 370c.3 of the Illinois Insurance Code. The
25-23 Department of Insurance shall enforce the requirements of this
19+4 Section 5. The State Employees Group Insurance Act of 1971
20+5 is amended by changing Section 6.11 as follows:
21+6 (5 ILCS 375/6.11)
22+7 Sec. 6.11. Required health benefits; Illinois Insurance
23+8 Code requirements. The program of health benefits shall
24+9 provide the post-mastectomy care benefits required to be
25+10 covered by a policy of accident and health insurance under
26+11 Section 356t of the Illinois Insurance Code. The program of
27+12 health benefits shall provide the coverage required under
28+13 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10,
29+14 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
30+15 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
31+16 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
32+17 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
33+18 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
34+19 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and
35+20 356z.70, and 356z.71, 356z.74, 356z.76, 356z.77, and 356z.80
36+21 of the Illinois Insurance Code. The program of health benefits
37+22 must comply with Sections 155.22a, 155.37, 355b, 356z.19,
38+23 370c, and 370c.1, and 370c.3 and Article XXXIIB of the
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34-1 Section. The requirement that health benefits be covered as
35-2 provided in this Section is an exclusive power and function of
36-3 the State and is a denial and limitation under Article VII,
37-4 Section 6, subsection (h) of the Illinois Constitution. A home
38-5 rule county to which this Section applies must comply with
39-6 every provision of this Section.
40-7 Rulemaking authority to implement Public Act 95-1045, if
41-8 any, is conditioned on the rules being adopted in accordance
42-9 with all provisions of the Illinois Administrative Procedure
43-10 Act and all rules and procedures of the Joint Committee on
44-11 Administrative Rules; any purported rule not so adopted, for
45-12 whatever reason, is unauthorized.
46-13 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
47-14 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
48-15 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
49-16 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
50-17 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
51-18 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
52-19 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
53-20 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
54-21 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
55-22 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
56-23 revised 11-26-24.)
57-24 Section 10. The Illinois Municipal Code is amended by
58-25 changing Section 10-4-2.3 as follows:
42+104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:
43+5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 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 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
44+5 ILCS 375/6.11
45+55 ILCS 5/5-1069.3
46+65 ILCS 5/10-4-2.3
47+105 ILCS 5/10-22.3f
48+215 ILCS 5/370c.3 new
49+215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
50+Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately.
51+LRB104 05991 BAB 16024 b LRB104 05991 BAB 16024 b
52+ LRB104 05991 BAB 16024 b
53+A BILL FOR
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59+5 ILCS 375/6.11
60+55 ILCS 5/5-1069.3
61+65 ILCS 5/10-4-2.3
62+105 ILCS 5/10-22.3f
63+215 ILCS 5/370c.3 new
64+215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
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69-1 (65 ILCS 5/10-4-2.3)
70-2 Sec. 10-4-2.3. Required health benefits. If a
71-3 municipality, including a home rule municipality, is a
72-4 self-insurer for purposes of providing health insurance
73-5 coverage for its employees, the coverage shall include
74-6 coverage for the post-mastectomy care benefits required to be
75-7 covered by a policy of accident and health insurance under
76-8 Section 356t and the coverage required under Sections 356g,
77-9 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
78-10 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
79-11 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
80-12 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
81-13 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54,
82-14 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
83-15 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, and
84-16 356z.77 of the Illinois Insurance Code. The coverage shall
85-17 comply with Sections 155.22a, 355b, 356z.19, and 370c, and
86-18 370c.3 of the Illinois Insurance Code. The Department of
87-19 Insurance shall enforce the requirements of this Section. The
88-20 requirement that health benefits be covered as provided in
89-21 this is an exclusive power and function of the State and is a
90-22 denial and limitation under Article VII, Section 6, subsection
91-23 (h) of the Illinois Constitution. A home rule municipality to
92-24 which this Section applies must comply with every provision of
93-25 this Section.
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68+ LRB104 05991 BAB 16024 b
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99- HB1085 Engrossed - 3 - LRB104 05991 BAB 16024 b
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103- HB1085 Engrossed - 4 - LRB104 05991 BAB 16024 b
104-1 Rulemaking authority to implement Public Act 95-1045, if
105-2 any, is conditioned on the rules being adopted in accordance
106-3 with all provisions of the Illinois Administrative Procedure
107-4 Act and all rules and procedures of the Joint Committee on
108-5 Administrative Rules; any purported rule not so adopted, for
109-6 whatever reason, is unauthorized.
110-7 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
111-8 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
112-9 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
113-10 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
114-11 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
115-12 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
116-13 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
117-14 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
118-15 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
119-16 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
120-17 revised 11-26-24.)
121-18 Section 15. The School Code is amended by changing Section
122-19 10-22.3f as follows:
123-20 (105 ILCS 5/10-22.3f)
124-21 Sec. 10-22.3f. Required health benefits. Insurance
125-22 protection and benefits for employees shall provide the
126-23 post-mastectomy care benefits required to be covered by a
127-24 policy of accident and health insurance under Section 356t and
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83+1 Illinois Insurance Code. The program of health benefits shall
84+2 provide the coverage required under Section 356m of the
85+3 Illinois Insurance Code and, for the employees of the State
86+4 Employee Group Insurance Program only, the coverage as also
87+5 provided in Section 6.11B of this Act. The Department of
88+6 Insurance shall enforce the requirements of this Section with
89+7 respect to Sections 370c, and 370c.1, and 370c.3 of the
90+8 Illinois Insurance Code; all other requirements of this
91+9 Section shall be enforced by the Department of Central
92+10 Management Services.
93+11 Rulemaking authority to implement Public Act 95-1045, if
94+12 any, is conditioned on the rules being adopted in accordance
95+13 with all provisions of the Illinois Administrative Procedure
96+14 Act and all rules and procedures of the Joint Committee on
97+15 Administrative Rules; any purported rule not so adopted, for
98+16 whatever reason, is unauthorized.
99+17 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
100+18 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
101+19 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
102+20 eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
103+21 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
104+22 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
105+23 eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
106+24 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
107+25 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751,
108+26 eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25;
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114+ HB1085 - 2 - LRB104 05991 BAB 16024 b
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137- HB1085 Engrossed - 5 - LRB104 05991 BAB 16024 b
138-1 the coverage required under Sections 356g, 356g.5, 356g.5-1,
139-2 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,
140-3 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
141-4 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
142-5 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
143-6 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
144-7 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and
145-8 356z.71, 356z.74, and 356z.77 of the Illinois Insurance Code.
146-9 Insurance policies shall comply with Section 356z.19 of the
147-10 Illinois Insurance Code. The coverage shall comply with
148-11 Sections 155.22a, 355b, and 370c, and 370c.3 of the Illinois
149-12 Insurance Code. The Department of Insurance shall enforce the
150-13 requirements of this Section.
151-14 Rulemaking authority to implement Public Act 95-1045, if
152-15 any, is conditioned on the rules being adopted in accordance
153-16 with all provisions of the Illinois Administrative Procedure
154-17 Act and all rules and procedures of the Joint Committee on
155-18 Administrative Rules; any purported rule not so adopted, for
156-19 whatever reason, is unauthorized.
157-20 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
158-21 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
159-22 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
160-23 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
161-24 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
162-25 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
163-26 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
117+HB1085- 3 -LRB104 05991 BAB 16024 b HB1085 - 3 - LRB104 05991 BAB 16024 b
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119+1 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff.
120+2 1-1-25; revised 11-26-24.)
121+3 Section 10. The Counties Code is amended by changing
122+4 Section 5-1069.3 as follows:
123+5 (55 ILCS 5/5-1069.3)
124+6 Sec. 5-1069.3. Required health benefits. If a county,
125+7 including a home rule county, is a self-insurer for purposes
126+8 of providing health insurance coverage for its employees, the
127+9 coverage shall include coverage for the post-mastectomy care
128+10 benefits required to be covered by a policy of accident and
129+11 health insurance under Section 356t and the coverage required
130+12 under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u,
131+13 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9,
132+14 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
133+15 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36,
134+16 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
135+17 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
136+18 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71,
137+19 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code.
138+20 The coverage shall comply with Sections 155.22a, 355b,
139+21 356z.19, and 370c, and 370c.3 of the Illinois Insurance Code.
140+22 The Department of Insurance shall enforce the requirements of
141+23 this Section. The requirement that health benefits be covered
142+24 as provided in this Section is an exclusive power and function
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174-1 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
175-2 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,
176-3 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
177-4 Section 20. The Illinois Insurance Code is amended by
178-5 adding Section 370c.3 as follows:
179-6 (215 ILCS 5/370c.3 new)
180-7 Sec. 370c.3. Mental health and substance use parity.
181-8 (a) In this Section:
182-9 "Application" means a person's or facility's application
183-10 to become a participating provider with an insurer in at least
184-11 one of the insurer's provider networks.
185-12 "Applying provider" means a provider or facility that has
186-13 submitted a completed application to become a participating
187-14 provider or facility with an insurer.
188-15 "Behavioral health trainee" means any person: (1) engaged
189-16 in the provision of mental health or substance use disorder
190-17 clinical services as part of that person's supervised course
191-18 of study while enrolled in a master's or doctoral psychology,
192-19 social work, counseling, or marriage or family therapy program
193-20 or as a postdoctoral graduate working toward licensure; and
194-21 (2) who is working toward clinical State licensure under the
195-22 clinical supervision of a fully licensed mental health or
196-23 substance use disorder treatment provider.
197-24 "Completed application" means a person's or facility's
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153+1 of the State and is a denial and limitation under Article VII,
154+2 Section 6, subsection (h) of the Illinois Constitution. A home
155+3 rule county to which this Section applies must comply with
156+4 every provision of this Section.
157+5 Rulemaking authority to implement Public Act 95-1045, if
158+6 any, is conditioned on the rules being adopted in accordance
159+7 with all provisions of the Illinois Administrative Procedure
160+8 Act and all rules and procedures of the Joint Committee on
161+9 Administrative Rules; any purported rule not so adopted, for
162+10 whatever reason, is unauthorized.
163+11 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
164+12 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
165+13 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
166+14 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
167+15 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
168+16 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
169+17 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
170+18 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
171+19 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
172+20 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
173+21 revised 11-26-24.)
174+22 Section 15. The Illinois Municipal Code is amended by
175+23 changing Section 10-4-2.3 as follows:
176+24 (65 ILCS 5/10-4-2.3)
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208-1 application to become a participating provider that has been
209-2 submitted to the insurer and includes all the required
210-3 information for the application to be considered by the
211-4 insurer according to the insurer's policies and procedures for
212-5 verifying a provider's or facility's credentials.
213-6 "Contracting process" means the process by which a mental
214-7 health or substance use disorder treatment provider or
215-8 facility makes a completed application with an insurer to
216-9 become a participating provider with the insurer until the
217-10 effective date of a final contract between the provider or
218-11 facility and the insurer. "Contracting process" includes the
219-12 process of verifying a provider's credentials.
220-13 "Participating provider" means any mental health or
221-14 substance use disorder treatment provider that has a contract
222-15 to provide mental health or substance use disorder services
223-16 with an insurer.
224-17 (b) For all group or individual policies of accident and
225-18 health insurance or managed care plans that are amended,
226-19 delivered, issued, or renewed on or after January 1, 2027, or
227-20 any contracted third party administering the behavioral health
228-21 benefits for the insurer, reimbursement for in-network mental
229-22 health and substance use disorder treatment services delivered
230-23 by Illinois providers and facilities must be equal to or
231-24 greater than 141% of the Medicare rate for the mental health or
232-25 substance use disorder service delivered. For services not
233-26 covered by Medicare, the reimbursement rates must be, on
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187+1 Sec. 10-4-2.3. Required health benefits. If a
188+2 municipality, including a home rule municipality, is a
189+3 self-insurer for purposes of providing health insurance
190+4 coverage for its employees, the coverage shall include
191+5 coverage for the post-mastectomy care benefits required to be
192+6 covered by a policy of accident and health insurance under
193+7 Section 356t and the coverage required under Sections 356g,
194+8 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
195+9 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
196+10 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
197+11 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
198+12 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54,
199+13 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
200+14 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77,
201+15 and 356z.80 of the Illinois Insurance Code. The coverage shall
202+16 comply with Sections 155.22a, 355b, 356z.19, and 370c, and
203+17 370c.3 of the Illinois Insurance Code. The Department of
204+18 Insurance shall enforce the requirements of this Section. The
205+19 requirement that health benefits be covered as provided in
206+20 this is an exclusive power and function of the State and is a
207+21 denial and limitation under Article VII, Section 6, subsection
208+22 (h) of the Illinois Constitution. A home rule municipality to
209+23 which this Section applies must comply with every provision of
210+24 this Section.
211+25 Rulemaking authority to implement Public Act 95-1045, if
212+26 any, is conditioned on the rules being adopted in accordance
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244-1 average, equal to or greater than 144% of the insurer's
245-2 in-network reimbursement rate for such service on the
246-3 effective date of this amendatory Act of the 104th General
247-4 Assembly. This Section applies to all covered office,
248-5 outpatient, inpatient, and residential mental health and
249-6 substance use disorder services. If at any time the average
250-7 reimbursement for in-network medical or surgical services
251-8 delivered by Illinois providers exceeds 141% of the Medicare
252-9 rate for such services, then the reimbursement for mental
253-10 health and substance use disorder treatment services must be
254-11 equal to or greater than that average.
255-12 (c) A group or individual policy of accident and health
256-13 insurance or managed care plan that is amended, delivered,
257-14 issued, or renewed on or after January 1, 2026, or contracted
258-15 third party administering the behavioral health benefits for
259-16 the insurer, shall cover all medically necessary mental health
260-17 or substance use disorder services received by the same
261-18 insured on the same day from the same or different mental
262-19 health or substance use provider or facility for both
263-20 outpatient and inpatient care.
264-21 (d) A group or individual policy of accident and health
265-22 insurance or managed care plan that is amended, delivered,
266-23 issued, or renewed on or after January 1, 2026, or any
267-24 contracted third party administering the behavioral health
268-25 benefits for the insurer, shall cover any medically necessary
269-26 mental health or substance use disorder service provided by a
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222+ HB1085 - 6 - LRB104 05991 BAB 16024 b
223+1 with all provisions of the Illinois Administrative Procedure
224+2 Act and all rules and procedures of the Joint Committee on
225+3 Administrative Rules; any purported rule not so adopted, for
226+4 whatever reason, is unauthorized.
227+5 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
228+6 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
229+7 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
230+8 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
231+9 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
232+10 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
233+11 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
234+12 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
235+13 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
236+14 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
237+15 revised 11-26-24.)
238+16 Section 20. The School Code is amended by changing Section
239+17 10-22.3f as follows:
240+18 (105 ILCS 5/10-22.3f)
241+19 Sec. 10-22.3f. Required health benefits. Insurance
242+20 protection and benefits for employees shall provide the
243+21 post-mastectomy care benefits required to be covered by a
244+22 policy of accident and health insurance under Section 356t and
245+23 the coverage required under Sections 356g, 356g.5, 356g.5-1,
246+24 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,
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280-1 behavioral health trainee when the trainee is working toward
281-2 clinical State licensure and is under the supervision of a
282-3 fully licensed mental health or substance use disorder
283-4 treatment provider, which is a physician licensed to practice
284-5 medicine in all its branches, licensed clinical psychologist,
285-6 licensed clinical social worker, licensed clinical
286-7 professional counselor, licensed marriage and family
287-8 therapist, licensed speech-language pathologist, or other
288-9 licensed or certified professional at a program licensed
289-10 pursuant to the Substance Use Disorder Act who is engaged in
290-11 treating mental, emotional, nervous, or substance use
291-12 disorders or conditions. Services provided by the trainee must
292-13 be billed under the supervising clinician's rendering National
293-14 Provider Identifier.
294-15 (e) A group or individual policy of accident and health
295-16 insurance or managed care plan that is amended, delivered,
296-17 issued, or renewed on or after January 1, 2026, or any
297-18 contracted third party administering the behavioral health
298-19 benefits for the insurer, shall:
299-20 (1) cover medically necessary 60-minute psychotherapy
300-21 billed using the CPT Code 90837 for Individual Therapy;
301-22 (2) not impose more onerous documentation requirements
302-23 on the provider than is required for other psychotherapy
303-24 CPT Codes; and
304-25 (3) not audit the use of CPT Code 90837 any more
305-26 frequently than audits for the use of other psychotherapy
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256+ HB1085 - 7 - LRB104 05991 BAB 16024 b
257+1 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
258+2 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
259+3 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
260+4 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
261+5 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and
262+6 356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois
263+7 Insurance Code. Insurance policies shall comply with Section
264+8 356z.19 of the Illinois Insurance Code. The coverage shall
265+9 comply with Sections 155.22a, 355b, and 370c, and 370c.3 of
266+10 the Illinois Insurance Code. The Department of Insurance shall
267+11 enforce the requirements of this Section.
268+12 Rulemaking authority to implement Public Act 95-1045, if
269+13 any, is conditioned on the rules being adopted in accordance
270+14 with all provisions of the Illinois Administrative Procedure
271+15 Act and all rules and procedures of the Joint Committee on
272+16 Administrative Rules; any purported rule not so adopted, for
273+17 whatever reason, is unauthorized.
274+18 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
275+19 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
276+20 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
277+21 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
278+22 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
279+23 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
280+24 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
281+25 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
282+26 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,
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316-1 CPT Codes.
317-2 (f)(1) Any group or individual policy of accident and
318-3 health insurance or managed care plan that is amended,
319-4 delivered, issued, or renewed on or after January 1, 2026, or
320-5 any contracted third party administering the behavioral health
321-6 benefits for the insurer, shall complete the contracting
322-7 process with a mental health or substance use disorder
323-8 treatment provider or facility for becoming a participating
324-9 provider in the insurer's network, including the verification
325-10 of the provider's credentials, within 60 days from the date of
326-11 a completed application to the insurer to become a
327-12 participating provider. Nothing in this paragraph (1),
328-13 however, presumes or establishes a contract between an insurer
329-14 and a provider.
330-15 (2) Any group or individual policy of accident and health
331-16 insurance or managed care plan that is amended, delivered,
332-17 issued, or renewed on or after January 1, 2026, or any
333-18 contracted third party administering the behavioral health
334-19 benefits for the insurer, shall reimburse a participating
335-20 mental health or substance use disorder treatment provider or
336-21 facility at the contracted reimbursement rate for any
337-22 medically necessary services provided to an insured from the
338-23 date of submission of the provider's or facility's completed
339-24 application to become a participating provider with the
340-25 insurer up to the effective date of the provider's contract.
341-26 The provider's claims for such services shall be reimbursed
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292+ HB1085 - 8 - LRB104 05991 BAB 16024 b
293+1 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
294+2 Section 25. The Illinois Insurance Code is amended by
295+3 adding Section 370c.3 as follows:
296+4 (215 ILCS 5/370c.3 new)
297+5 Sec. 370c.3. Mental health and substance use parity.
298+6 (a) In this Section:
299+7 "Application" means a person's or facility's application
300+8 to become a participating provider with an insurer in at least
301+9 one of the insurer's provider networks.
302+10 "Applying provider" means a provider or facility that has
303+11 submitted a completed application to become a participating
304+12 provider or facility with an insurer.
305+13 "Behavioral health trainee" means any person: (1) engaged
306+14 in the provision of mental health or substance use disorder
307+15 clinical services as part of that person's supervised course
308+16 of study while enrolled in a master's or doctoral psychology,
309+17 social work, counseling, or marriage or family therapy program
310+18 or as a postdoctoral graduate working toward licensure; and
311+19 (2) who is working toward clinical State licensure under the
312+20 clinical supervision of a fully licensed mental health or
313+21 substance use disorder treatment provider.
314+22 "Completed application" means a person's or facility's
315+23 application to become a participating provider that has been
316+24 submitted to the insurer and includes all the required
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352-1 only when submitted after the effective date of the provider's
353-2 contract with the insurer. This paragraph (2) does not apply
354-3 to a provider that does not have a completed contract with an
355-4 insurer. If a provider opts to submit claims for medically
356-5 necessary mental health or substance use disorder services
357-6 pursuant to this paragraph (2), the provider must notify the
358-7 insured following submission of the claims to the insurer that
359-8 the services provided to the insured may be treated as
360-9 in-network services.
361-10 (3) Any group or individual policy of accident and health
362-11 insurance or managed care plan that is amended, delivered,
363-12 issued, or renewed on or after January 1, 2026, or any
364-13 contracted third party administering the behavioral health
365-14 benefits for the insurer, shall cover any medically necessary
366-15 mental health or substance use disorder service provided by a
367-16 fully licensed mental health or substance use disorder
368-17 treatment provider affiliated with a mental health or
369-18 substance use disorder treatment group practice who has
370-19 submitted a completed application to become a participating
371-20 provider with an insurer who is delivering services under the
372-21 supervision of another fully licensed participating mental
373-22 health or substance use disorder treatment provider within the
374-23 same group practice up to the effective date of the applying
375-24 provider's contract with the insurer as a participating
376-25 provider. Services provided by the applying provider must be
377-26 billed under the supervising licensed provider's rendering
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327+1 information for the application to be considered by the
328+2 insurer according to the insurer's policies and procedures for
329+3 verifying a provider's or facility's credentials.
330+4 "Contracting process" means the process by which a mental
331+5 health or substance use disorder treatment provider or
332+6 facility makes a completed application with an insurer to
333+7 become a participating provider with the insurer until the
334+8 effective date of a final contract between the provider or
335+9 facility and the insurer. "Contracting process" includes the
336+10 process of verifying a provider's credentials.
337+11 "Participating provider" means any mental health or
338+12 substance use disorder treatment provider that has a contract
339+13 to provide mental health or substance use disorder services
340+14 with an insurer.
341+15 (b) For all group or individual policies of accident and
342+16 health insurance or managed care plans that are amended,
343+17 delivered, issued, or renewed on or after January 1, 2027, or
344+18 any contracted third party administering the behavioral health
345+19 benefits for the insurer, reimbursement for in-network mental
346+20 health and substance use disorder treatment services delivered
347+21 by Illinois providers and facilities must be equal to or
348+22 greater than 141% of the Medicare rate for the mental health or
349+23 substance use disorder service delivered. For services not
350+24 covered by Medicare, the reimbursement rates must be, on
351+25 average, equal to or greater than 144% of the insurer's
352+26 in-network reimbursement rate for such service on the
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388-1 National Provider Identifier.
389-2 (4) Upon request, an insurer, or any contracted third
390-3 party administering the behavioral health benefits for the
391-4 insurer, shall provide an applying provider with the insurer's
392-5 credentialing policies and procedures. An insurer, or any
393-6 contracted third party administering the behavioral health
394-7 benefits for the insurer, shall post the following
395-8 nonproprietary information on its website and make that
396-9 information available to all applicants:
397-10 (A) a list of the information required to be included
398-11 in an application;
399-12 (B) a checklist of the materials that must be
400-13 submitted in the credentialing process; and
401-14 (C) designated contact information of a network
402-15 representative, including a designated point of contact,
403-16 an email address, and a telephone number, to which an
404-17 applicant may address any credentialing inquiries.
405-18 (g) The Department has the same authority to enforce this
406-19 Section as it has to enforce compliance with Sections 370c and
407-20 370c.1. Additionally, if the Department determines that an
408-21 insurer or a contracted third party administering the
409-22 behavioral health benefits for the insurer has violated this
410-23 Section, the Department shall, after appropriate notice and
411-24 opportunity for hearing in accordance with Section 402, by
412-25 order assess a civil penalty of $1,000 for each violation. The
413-26 Department shall establish any processes or procedures
361+HB1085- 10 -LRB104 05991 BAB 16024 b HB1085 - 10 - LRB104 05991 BAB 16024 b
362+ HB1085 - 10 - LRB104 05991 BAB 16024 b
363+1 effective date of this amendatory Act of the 104th General
364+2 Assembly. This Section applies to all covered office,
365+3 outpatient, inpatient, and residential mental health and
366+4 substance use disorder services. If at any time the average
367+5 reimbursement for in-network medical or surgical services
368+6 delivered by Illinois providers exceeds 141% of the Medicare
369+7 rate for such services, then the reimbursement for mental
370+8 health and substance use disorder treatment services must be
371+9 equal to or greater than that average.
372+10 This Section applies to all covered office, outpatient,
373+11 inpatient, and residential mental health and substance use
374+12 disorder services.
375+13 This subsection does not apply to mental health or
376+14 substance use disorder services provided by a hospital when
377+15 the hospital has a contract with the insurer that provides for
378+16 reimbursement for such services based on achieving specified
379+17 patient health outcomes and other quality measures and
380+18 includes shared savings from lower health care costs.
381+19 (c) A group or individual policy of accident and health
382+20 insurance or managed care plan that is amended, delivered,
383+21 issued, or renewed on or after January 1, 2026, or contracted
384+22 third party administering the behavioral health benefits for
385+23 the insurer, shall cover all medically necessary mental health
386+24 or substance use disorder services received by the same
387+25 insured on the same day from the same or different mental
388+26 health or substance use provider or facility for both
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424-1 necessary to monitor compliance with this Section.
425-2 (h) At the end of 5 years, 10 years, and 15 years following
426-3 the implementation of subsection (b) of this Section, the
427-4 Department shall review the impact of this Section on network
428-5 adequacy for mental health and substance use disorder
429-6 treatment and access to affordable mental health and substance
430-7 use care. By no later than December 31, 2033, December 31,
431-8 2038, and December 31, 2043, the Department shall submit a
432-9 report in each of those years to the General Assembly that
433-10 includes its analyses and findings. For the purpose of
434-11 evaluating trends in network adequacy, the Department may
435-12 examine out-of-network utilization and out-of-pocket costs for
436-13 insureds for mental health and substance use treatment and
437-14 services for all plans to compare with in-network utilization.
438-15 (i) The Department shall adopt any rules necessary to
439-16 implement this Section by no later than May 1, 2026.
440-17 (j) This Section does not apply to a health care plan
441-18 serving Medicaid populations that provides, arranges for, pays
442-19 for, or reimburses the cost of any health care service for
443-20 persons who are enrolled under the Illinois Public Aid Code or
444-21 under the Children's Health Insurance Program Act.
445-22 Section 25. The Health Maintenance Organization Act is
446-23 amended by changing Section 5-3 as follows:
447-24 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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399+1 outpatient and inpatient care.
400+2 (d) A group or individual policy of accident and health
401+3 insurance or managed care plan that is amended, delivered,
402+4 issued, or renewed on or after January 1, 2026, or any
403+5 contracted third party administering the behavioral health
404+6 benefits for the insurer, shall cover any medically necessary
405+7 mental health or substance use disorder service provided by a
406+8 behavioral health trainee when the trainee is working toward
407+9 clinical State licensure and is under the supervision of a
408+10 fully licensed mental health or substance use disorder
409+11 treatment provider, which is a physician licensed to practice
410+12 medicine in all its branches, licensed clinical psychologist,
411+13 licensed clinical social worker, licensed clinical
412+14 professional counselor, licensed marriage and family
413+15 therapist, licensed speech-language pathologist, or other
414+16 licensed or certified professional at a program licensed
415+17 pursuant to the Substance Use Disorder Act who is engaged in
416+18 treating mental, emotional, nervous, or substance use
417+19 disorders or conditions. Services provided by the trainee must
418+20 be billed under the supervising clinician's rendering National
419+21 Provider Identifier.
420+22 (e) A group or individual policy of accident and health
421+23 insurance or managed care plan that is amended, delivered,
422+24 issued, or renewed on or after January 1, 2026, or any
423+25 contracted third party administering the behavioral health
424+26 benefits for the insurer, shall:
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458-1 (Text of Section before amendment by P.A. 103-808)
459-2 Sec. 5-3. Insurance Code provisions.
460-3 (a) Health Maintenance Organizations shall be subject to
461-4 the provisions of Sections 133, 134, 136, 137, 139, 140,
462-5 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
463-6 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
464-7 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
465-8 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
466-9 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
467-10 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
468-11 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
469-12 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
470-13 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
471-14 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
472-15 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
473-16 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
474-17 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
475-18 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
476-19 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
477-20 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403, 403A,
478-21 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
479-22 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
480-23 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
481-24 Illinois Insurance Code.
482-25 (b) For purposes of the Illinois Insurance Code, except
483-26 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
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434+ HB1085 - 12 - LRB104 05991 BAB 16024 b
435+1 (1) cover medically necessary 60-minute psychotherapy
436+2 billed using the CPT Code 90837 for Individual Therapy;
437+3 (2) not impose more onerous documentation requirements
438+4 on the provider than is required for other psychotherapy
439+5 CPT Codes; and
440+6 (3) not audit the use of CPT Code 90837 any more
441+7 frequently than audits for the use of other psychotherapy
442+8 CPT Codes.
443+9 (f)(1) Any group or individual policy of accident and
444+10 health insurance or managed care plan that is amended,
445+11 delivered, issued, or renewed on or after January 1, 2026, or
446+12 any contracted third party administering the behavioral health
447+13 benefits for the insurer, shall complete the contracting
448+14 process with a mental health or substance use disorder
449+15 treatment provider or facility for becoming a participating
450+16 provider in the insurer's network, including the verification
451+17 of the provider's credentials, within 60 days from the date of
452+18 a completed application to the insurer to become a
453+19 participating provider. Nothing in this paragraph (1),
454+20 however, presumes or establishes a contract between an insurer
455+21 and a provider.
456+22 (2) Any group or individual policy of accident and health
457+23 insurance or managed care plan that is amended, delivered,
458+24 issued, or renewed on or after January 1, 2026, or any
459+25 contracted third party administering the behavioral health
460+26 benefits for the insurer, shall reimburse a participating
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494-1 Health Maintenance Organizations in the following categories
495-2 are deemed to be "domestic companies":
496-3 (1) a corporation authorized under the Dental Service
497-4 Plan Act or the Voluntary Health Services Plans Act;
498-5 (2) a corporation organized under the laws of this
499-6 State; or
500-7 (3) a corporation organized under the laws of another
501-8 state, 30% or more of the enrollees of which are residents
502-9 of this State, except a corporation subject to
503-10 substantially the same requirements in its state of
504-11 organization as is a "domestic company" under Article VIII
505-12 1/2 of the Illinois Insurance Code.
506-13 (c) In considering the merger, consolidation, or other
507-14 acquisition of control of a Health Maintenance Organization
508-15 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
509-16 (1) the Director shall give primary consideration to
510-17 the continuation of benefits to enrollees and the
511-18 financial conditions of the acquired Health Maintenance
512-19 Organization after the merger, consolidation, or other
513-20 acquisition of control takes effect;
514-21 (2)(i) the criteria specified in subsection (1)(b) of
515-22 Section 131.8 of the Illinois Insurance Code shall not
516-23 apply and (ii) the Director, in making his determination
517-24 with respect to the merger, consolidation, or other
518-25 acquisition of control, need not take into account the
519-26 effect on competition of the merger, consolidation, or
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470+ HB1085 - 13 - LRB104 05991 BAB 16024 b
471+1 mental health or substance use disorder treatment provider or
472+2 facility at the contracted reimbursement rate for any
473+3 medically necessary services provided to an insured from the
474+4 date of submission of the provider's or facility's completed
475+5 application to become a participating provider with the
476+6 insurer up to the effective date of the provider's contract.
477+7 The provider's claims for such services shall be reimbursed
478+8 only when submitted after the effective date of the provider's
479+9 contract with the insurer. This paragraph (2) does not apply
480+10 to a provider that does not have a completed contract with an
481+11 insurer. If a provider opts to submit claims for medically
482+12 necessary mental health or substance use disorder services
483+13 pursuant to this paragraph (2), the provider must notify the
484+14 insured following submission of the claims to the insurer that
485+15 the services provided to the insured may be treated as
486+16 in-network services.
487+17 (3) Any group or individual policy of accident and health
488+18 insurance or managed care plan that is amended, delivered,
489+19 issued, or renewed on or after January 1, 2026, or any
490+20 contracted third party administering the behavioral health
491+21 benefits for the insurer, shall cover any medically necessary
492+22 mental health or substance use disorder service provided by a
493+23 fully licensed mental health or substance use disorder
494+24 treatment provider affiliated with a mental health or
495+25 substance use disorder treatment group practice who has
496+26 submitted a completed application to become a participating
520497
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530-1 other acquisition of control;
531-2 (3) the Director shall have the power to require the
532-3 following information:
533-4 (A) certification by an independent actuary of the
534-5 adequacy of the reserves of the Health Maintenance
535-6 Organization sought to be acquired;
536-7 (B) pro forma financial statements reflecting the
537-8 combined balance sheets of the acquiring company and
538-9 the Health Maintenance Organization sought to be
539-10 acquired as of the end of the preceding year and as of
540-11 a date 90 days prior to the acquisition, as well as pro
541-12 forma financial statements reflecting projected
542-13 combined operation for a period of 2 years;
543-14 (C) a pro forma business plan detailing an
544-15 acquiring party's plans with respect to the operation
545-16 of the Health Maintenance Organization sought to be
546-17 acquired for a period of not less than 3 years; and
547-18 (D) such other information as the Director shall
548-19 require.
549-20 (d) The provisions of Article VIII 1/2 of the Illinois
550-21 Insurance Code and this Section 5-3 shall apply to the sale by
551-22 any health maintenance organization of greater than 10% of its
552-23 enrollee population (including, without limitation, the health
553-24 maintenance organization's right, title, and interest in and
554-25 to its health care certificates).
555-26 (e) In considering any management contract or service
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506+ HB1085 - 14 - LRB104 05991 BAB 16024 b
507+1 provider with an insurer who is delivering services under the
508+2 supervision of another fully licensed participating mental
509+3 health or substance use disorder treatment provider within the
510+4 same group practice up to the effective date of the applying
511+5 provider's contract with the insurer as a participating
512+6 provider. Services provided by the applying provider must be
513+7 billed under the supervising licensed provider's rendering
514+8 National Provider Identifier.
515+9 (4) Upon request, an insurer, or any contracted third
516+10 party administering the behavioral health benefits for the
517+11 insurer, shall provide an applying provider with the insurer's
518+12 credentialing policies and procedures. An insurer, or any
519+13 contracted third party administering the behavioral health
520+14 benefits for the insurer, shall post the following
521+15 nonproprietary information on its website and make that
522+16 information available to all applicants:
523+17 (A) a list of the information required to be included
524+18 in an application;
525+19 (B) a checklist of the materials that must be
526+20 submitted in the credentialing process; and
527+21 (C) designated contact information of a network
528+22 representative, including a designated point of contact,
529+23 an email address, and a telephone number, to which an
530+24 applicant may address any credentialing inquiries.
531+25 (g) The Department has the same authority to enforce this
532+26 Section as it has to enforce compliance with Sections 370c and
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566-1 agreement subject to Section 141.1 of the Illinois Insurance
567-2 Code, the Director (i) shall, in addition to the criteria
568-3 specified in Section 141.2 of the Illinois Insurance Code,
569-4 take into account the effect of the management contract or
570-5 service agreement on the continuation of benefits to enrollees
571-6 and the financial condition of the health maintenance
572-7 organization to be managed or serviced, and (ii) need not take
573-8 into account the effect of the management contract or service
574-9 agreement on competition.
575-10 (f) Except for small employer groups as defined in the
576-11 Small Employer Rating, Renewability and Portability Health
577-12 Insurance Act and except for medicare supplement policies as
578-13 defined in Section 363 of the Illinois Insurance Code, a
579-14 Health Maintenance Organization may by contract agree with a
580-15 group or other enrollment unit to effect refunds or charge
581-16 additional premiums under the following terms and conditions:
582-17 (i) the amount of, and other terms and conditions with
583-18 respect to, the refund or additional premium are set forth
584-19 in the group or enrollment unit contract agreed in advance
585-20 of the period for which a refund is to be paid or
586-21 additional premium is to be charged (which period shall
587-22 not be less than one year); and
588-23 (ii) the amount of the refund or additional premium
589-24 shall not exceed 20% of the Health Maintenance
590-25 Organization's profitable or unprofitable experience with
591-26 respect to the group or other enrollment unit for the
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542+ HB1085 - 15 - LRB104 05991 BAB 16024 b
543+1 370c.1. Additionally, if the Department determines that an
544+2 insurer or a contracted third party administering the
545+3 behavioral health benefits for the insurer has violated this
546+4 Section, the Department shall, after appropriate notice and
547+5 opportunity for hearing in accordance with Section 402, by
548+6 order assess a civil penalty of $1,000 for each violation. The
549+7 Department shall establish any processes or procedures
550+8 necessary to monitor compliance with this Section.
551+9 (h) At the end of 5 years, 10 years, and 15 years following
552+10 the implementation of subsection (b) of this Section, the
553+11 Department shall review the impact of this Section on network
554+12 adequacy for mental health and substance use disorder
555+13 treatment and access to affordable mental health and substance
556+14 use care. By no later than December 31, 2033, December 31,
557+15 2038, and December 31, 2043, the Department shall submit a
558+16 report in each of those years to the General Assembly that
559+17 includes its analyses and findings. For the purpose of
560+18 evaluating trends in network adequacy, the Department may
561+19 examine out-of-network utilization and out-of-pocket costs for
562+20 insureds for mental health and substance use treatment and
563+21 services for all plans to compare with in-network utilization.
564+22 (i) The Department shall adopt any rules necessary to
565+23 implement this Section by no later than May 1, 2026.
566+24 (j) This Section does not apply to a health care plan
567+25 serving Medicaid populations that provides, arranges for, pays
568+26 for, or reimburses the cost of any health care service for
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601- HB1085 Engrossed - 18 - LRB104 05991 BAB 16024 b
602-1 period (and, for purposes of a refund or additional
603-2 premium, the profitable or unprofitable experience shall
604-3 be calculated taking into account a pro rata share of the
605-4 Health Maintenance Organization's administrative and
606-5 marketing expenses, but shall not include any refund to be
607-6 made or additional premium to be paid pursuant to this
608-7 subsection (f)). The Health Maintenance Organization and
609-8 the group or enrollment unit may agree that the profitable
610-9 or unprofitable experience may be calculated taking into
611-10 account the refund period and the immediately preceding 2
612-11 plan years.
613-12 The Health Maintenance Organization shall include a
614-13 statement in the evidence of coverage issued to each enrollee
615-14 describing the possibility of a refund or additional premium,
616-15 and upon request of any group or enrollment unit, provide to
617-16 the group or enrollment unit a description of the method used
618-17 to calculate (1) the Health Maintenance Organization's
619-18 profitable experience with respect to the group or enrollment
620-19 unit and the resulting refund to the group or enrollment unit
621-20 or (2) the Health Maintenance Organization's unprofitable
622-21 experience with respect to the group or enrollment unit and
623-22 the resulting additional premium to be paid by the group or
624-23 enrollment unit.
625-24 In no event shall the Illinois Health Maintenance
626-25 Organization Guaranty Association be liable to pay any
627-26 contractual obligation of an insolvent organization to pay any
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578+ HB1085 - 16 - LRB104 05991 BAB 16024 b
579+1 persons who are enrolled under the Illinois Public Aid Code or
580+2 under the Children's Health Insurance Program Act.
581+3 Section 30. The Health Maintenance Organization Act is
582+4 amended by changing Section 5-3 as follows:
583+5 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
584+6 (Text of Section before amendment by P.A. 103-808)
585+7 Sec. 5-3. Insurance Code provisions.
586+8 (a) Health Maintenance Organizations shall be subject to
587+9 the provisions of Sections 133, 134, 136, 137, 139, 140,
588+10 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
589+11 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
590+12 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
591+13 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
592+14 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
593+15 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
594+16 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
595+17 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
596+18 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
597+19 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
598+20 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
599+21 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
600+22 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
601+23 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
602+24 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
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638-1 refund authorized under this Section.
639-2 (g) Rulemaking authority to implement Public Act 95-1045,
640-3 if any, is conditioned on the rules being adopted in
641-4 accordance with all provisions of the Illinois Administrative
642-5 Procedure Act and all rules and procedures of the Joint
643-6 Committee on Administrative Rules; any purported rule not so
644-7 adopted, for whatever reason, is unauthorized.
645-8 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
646-9 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
647-10 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
648-11 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
649-12 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
650-13 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
651-14 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
652-15 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
653-16 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
654-17 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
655-18 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
656-19 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
657-20 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
658-21 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
659-22 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
660-23 (Text of Section after amendment by P.A. 103-808)
661-24 Sec. 5-3. Insurance Code provisions.
662-25 (a) Health Maintenance Organizations shall be subject to
611+HB1085- 17 -LRB104 05991 BAB 16024 b HB1085 - 17 - LRB104 05991 BAB 16024 b
612+ HB1085 - 17 - LRB104 05991 BAB 16024 b
613+1 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403,
614+2 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
615+3 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
616+4 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
617+5 Illinois Insurance Code.
618+6 (b) For purposes of the Illinois Insurance Code, except
619+7 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
620+8 Health Maintenance Organizations in the following categories
621+9 are deemed to be "domestic companies":
622+10 (1) a corporation authorized under the Dental Service
623+11 Plan Act or the Voluntary Health Services Plans Act;
624+12 (2) a corporation organized under the laws of this
625+13 State; or
626+14 (3) a corporation organized under the laws of another
627+15 state, 30% or more of the enrollees of which are residents
628+16 of this State, except a corporation subject to
629+17 substantially the same requirements in its state of
630+18 organization as is a "domestic company" under Article VIII
631+19 1/2 of the Illinois Insurance Code.
632+20 (c) In considering the merger, consolidation, or other
633+21 acquisition of control of a Health Maintenance Organization
634+22 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
635+23 (1) the Director shall give primary consideration to
636+24 the continuation of benefits to enrollees and the
637+25 financial conditions of the acquired Health Maintenance
638+26 Organization after the merger, consolidation, or other
663639
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673-1 the provisions of Sections 133, 134, 136, 137, 139, 140,
674-2 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
675-3 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
676-4 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
677-5 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
678-6 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
679-7 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
680-8 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
681-9 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
682-10 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
683-11 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
684-12 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
685-13 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
686-14 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
687-15 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
688-16 356z.77, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
689-17 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403,
690-18 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
691-19 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
692-20 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
693-21 Illinois Insurance Code.
694-22 (b) For purposes of the Illinois Insurance Code, except
695-23 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
696-24 Health Maintenance Organizations in the following categories
697-25 are deemed to be "domestic companies":
698-26 (1) a corporation authorized under the Dental Service
647+HB1085- 18 -LRB104 05991 BAB 16024 b HB1085 - 18 - LRB104 05991 BAB 16024 b
648+ HB1085 - 18 - LRB104 05991 BAB 16024 b
649+1 acquisition of control takes effect;
650+2 (2)(i) the criteria specified in subsection (1)(b) of
651+3 Section 131.8 of the Illinois Insurance Code shall not
652+4 apply and (ii) the Director, in making his determination
653+5 with respect to the merger, consolidation, or other
654+6 acquisition of control, need not take into account the
655+7 effect on competition of the merger, consolidation, or
656+8 other acquisition of control;
657+9 (3) the Director shall have the power to require the
658+10 following information:
659+11 (A) certification by an independent actuary of the
660+12 adequacy of the reserves of the Health Maintenance
661+13 Organization sought to be acquired;
662+14 (B) pro forma financial statements reflecting the
663+15 combined balance sheets of the acquiring company and
664+16 the Health Maintenance Organization sought to be
665+17 acquired as of the end of the preceding year and as of
666+18 a date 90 days prior to the acquisition, as well as pro
667+19 forma financial statements reflecting projected
668+20 combined operation for a period of 2 years;
669+21 (C) a pro forma business plan detailing an
670+22 acquiring party's plans with respect to the operation
671+23 of the Health Maintenance Organization sought to be
672+24 acquired for a period of not less than 3 years; and
673+25 (D) such other information as the Director shall
674+26 require.
699675
700676
701677
702678
703679
704- HB1085 Engrossed - 20 - LRB104 05991 BAB 16024 b
680+ HB1085 - 18 - LRB104 05991 BAB 16024 b
705681
706682
707-HB1085 Engrossed- 21 -LRB104 05991 BAB 16024 b HB1085 Engrossed - 21 - LRB104 05991 BAB 16024 b
708- HB1085 Engrossed - 21 - LRB104 05991 BAB 16024 b
709-1 Plan Act or the Voluntary Health Services Plans Act;
710-2 (2) a corporation organized under the laws of this
711-3 State; or
712-4 (3) a corporation organized under the laws of another
713-5 state, 30% or more of the enrollees of which are residents
714-6 of this State, except a corporation subject to
715-7 substantially the same requirements in its state of
716-8 organization as is a "domestic company" under Article VIII
717-9 1/2 of the Illinois Insurance Code.
718-10 (c) In considering the merger, consolidation, or other
719-11 acquisition of control of a Health Maintenance Organization
720-12 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
721-13 (1) the Director shall give primary consideration to
722-14 the continuation of benefits to enrollees and the
723-15 financial conditions of the acquired Health Maintenance
724-16 Organization after the merger, consolidation, or other
725-17 acquisition of control takes effect;
726-18 (2)(i) the criteria specified in subsection (1)(b) of
727-19 Section 131.8 of the Illinois Insurance Code shall not
728-20 apply and (ii) the Director, in making his determination
729-21 with respect to the merger, consolidation, or other
730-22 acquisition of control, need not take into account the
731-23 effect on competition of the merger, consolidation, or
732-24 other acquisition of control;
733-25 (3) the Director shall have the power to require the
734-26 following information:
683+HB1085- 19 -LRB104 05991 BAB 16024 b HB1085 - 19 - LRB104 05991 BAB 16024 b
684+ HB1085 - 19 - LRB104 05991 BAB 16024 b
685+1 (d) The provisions of Article VIII 1/2 of the Illinois
686+2 Insurance Code and this Section 5-3 shall apply to the sale by
687+3 any health maintenance organization of greater than 10% of its
688+4 enrollee population (including, without limitation, the health
689+5 maintenance organization's right, title, and interest in and
690+6 to its health care certificates).
691+7 (e) In considering any management contract or service
692+8 agreement subject to Section 141.1 of the Illinois Insurance
693+9 Code, the Director (i) shall, in addition to the criteria
694+10 specified in Section 141.2 of the Illinois Insurance Code,
695+11 take into account the effect of the management contract or
696+12 service agreement on the continuation of benefits to enrollees
697+13 and the financial condition of the health maintenance
698+14 organization to be managed or serviced, and (ii) need not take
699+15 into account the effect of the management contract or service
700+16 agreement on competition.
701+17 (f) Except for small employer groups as defined in the
702+18 Small Employer Rating, Renewability and Portability Health
703+19 Insurance Act and except for medicare supplement policies as
704+20 defined in Section 363 of the Illinois Insurance Code, a
705+21 Health Maintenance Organization may by contract agree with a
706+22 group or other enrollment unit to effect refunds or charge
707+23 additional premiums under the following terms and conditions:
708+24 (i) the amount of, and other terms and conditions with
709+25 respect to, the refund or additional premium are set forth
710+26 in the group or enrollment unit contract agreed in advance
735711
736712
737713
738714
739715
740- HB1085 Engrossed - 21 - LRB104 05991 BAB 16024 b
716+ HB1085 - 19 - LRB104 05991 BAB 16024 b
741717
742718
743-HB1085 Engrossed- 22 -LRB104 05991 BAB 16024 b HB1085 Engrossed - 22 - LRB104 05991 BAB 16024 b
744- HB1085 Engrossed - 22 - LRB104 05991 BAB 16024 b
745-1 (A) certification by an independent actuary of the
746-2 adequacy of the reserves of the Health Maintenance
747-3 Organization sought to be acquired;
748-4 (B) pro forma financial statements reflecting the
749-5 combined balance sheets of the acquiring company and
750-6 the Health Maintenance Organization sought to be
751-7 acquired as of the end of the preceding year and as of
752-8 a date 90 days prior to the acquisition, as well as pro
753-9 forma financial statements reflecting projected
754-10 combined operation for a period of 2 years;
755-11 (C) a pro forma business plan detailing an
756-12 acquiring party's plans with respect to the operation
757-13 of the Health Maintenance Organization sought to be
758-14 acquired for a period of not less than 3 years; and
759-15 (D) such other information as the Director shall
760-16 require.
761-17 (d) The provisions of Article VIII 1/2 of the Illinois
762-18 Insurance Code and this Section 5-3 shall apply to the sale by
763-19 any health maintenance organization of greater than 10% of its
764-20 enrollee population (including, without limitation, the health
765-21 maintenance organization's right, title, and interest in and
766-22 to its health care certificates).
767-23 (e) In considering any management contract or service
768-24 agreement subject to Section 141.1 of the Illinois Insurance
769-25 Code, the Director (i) shall, in addition to the criteria
770-26 specified in Section 141.2 of the Illinois Insurance Code,
719+HB1085- 20 -LRB104 05991 BAB 16024 b HB1085 - 20 - LRB104 05991 BAB 16024 b
720+ HB1085 - 20 - LRB104 05991 BAB 16024 b
721+1 of the period for which a refund is to be paid or
722+2 additional premium is to be charged (which period shall
723+3 not be less than one year); and
724+4 (ii) the amount of the refund or additional premium
725+5 shall not exceed 20% of the Health Maintenance
726+6 Organization's profitable or unprofitable experience with
727+7 respect to the group or other enrollment unit for the
728+8 period (and, for purposes of a refund or additional
729+9 premium, the profitable or unprofitable experience shall
730+10 be calculated taking into account a pro rata share of the
731+11 Health Maintenance Organization's administrative and
732+12 marketing expenses, but shall not include any refund to be
733+13 made or additional premium to be paid pursuant to this
734+14 subsection (f)). The Health Maintenance Organization and
735+15 the group or enrollment unit may agree that the profitable
736+16 or unprofitable experience may be calculated taking into
737+17 account the refund period and the immediately preceding 2
738+18 plan years.
739+19 The Health Maintenance Organization shall include a
740+20 statement in the evidence of coverage issued to each enrollee
741+21 describing the possibility of a refund or additional premium,
742+22 and upon request of any group or enrollment unit, provide to
743+23 the group or enrollment unit a description of the method used
744+24 to calculate (1) the Health Maintenance Organization's
745+25 profitable experience with respect to the group or enrollment
746+26 unit and the resulting refund to the group or enrollment unit
771747
772748
773749
774750
775751
776- HB1085 Engrossed - 22 - LRB104 05991 BAB 16024 b
752+ HB1085 - 20 - LRB104 05991 BAB 16024 b
777753
778754
779-HB1085 Engrossed- 23 -LRB104 05991 BAB 16024 b HB1085 Engrossed - 23 - LRB104 05991 BAB 16024 b
780- HB1085 Engrossed - 23 - LRB104 05991 BAB 16024 b
781-1 take into account the effect of the management contract or
782-2 service agreement on the continuation of benefits to enrollees
783-3 and the financial condition of the health maintenance
784-4 organization to be managed or serviced, and (ii) need not take
785-5 into account the effect of the management contract or service
786-6 agreement on competition.
787-7 (f) Except for small employer groups as defined in the
788-8 Small Employer Rating, Renewability and Portability Health
789-9 Insurance Act and except for medicare supplement policies as
790-10 defined in Section 363 of the Illinois Insurance Code, a
791-11 Health Maintenance Organization may by contract agree with a
792-12 group or other enrollment unit to effect refunds or charge
793-13 additional premiums under the following terms and conditions:
794-14 (i) the amount of, and other terms and conditions with
795-15 respect to, the refund or additional premium are set forth
796-16 in the group or enrollment unit contract agreed in advance
797-17 of the period for which a refund is to be paid or
798-18 additional premium is to be charged (which period shall
799-19 not be less than one year); and
800-20 (ii) the amount of the refund or additional premium
801-21 shall not exceed 20% of the Health Maintenance
802-22 Organization's profitable or unprofitable experience with
803-23 respect to the group or other enrollment unit for the
804-24 period (and, for purposes of a refund or additional
805-25 premium, the profitable or unprofitable experience shall
806-26 be calculated taking into account a pro rata share of the
755+HB1085- 21 -LRB104 05991 BAB 16024 b HB1085 - 21 - LRB104 05991 BAB 16024 b
756+ HB1085 - 21 - LRB104 05991 BAB 16024 b
757+1 or (2) the Health Maintenance Organization's unprofitable
758+2 experience with respect to the group or enrollment unit and
759+3 the resulting additional premium to be paid by the group or
760+4 enrollment unit.
761+5 In no event shall the Illinois Health Maintenance
762+6 Organization Guaranty Association be liable to pay any
763+7 contractual obligation of an insolvent organization to pay any
764+8 refund authorized under this Section.
765+9 (g) Rulemaking authority to implement Public Act 95-1045,
766+10 if any, is conditioned on the rules being adopted in
767+11 accordance with all provisions of the Illinois Administrative
768+12 Procedure Act and all rules and procedures of the Joint
769+13 Committee on Administrative Rules; any purported rule not so
770+14 adopted, for whatever reason, is unauthorized.
771+15 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
772+16 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
773+17 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
774+18 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
775+19 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
776+20 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
777+21 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
778+22 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
779+23 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
780+24 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
781+25 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
782+26 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
807783
808784
809785
810786
811787
812- HB1085 Engrossed - 23 - LRB104 05991 BAB 16024 b
788+ HB1085 - 21 - LRB104 05991 BAB 16024 b
813789
814790
815-HB1085 Engrossed- 24 -LRB104 05991 BAB 16024 b HB1085 Engrossed - 24 - LRB104 05991 BAB 16024 b
816- HB1085 Engrossed - 24 - LRB104 05991 BAB 16024 b
817-1 Health Maintenance Organization's administrative and
818-2 marketing expenses, but shall not include any refund to be
819-3 made or additional premium to be paid pursuant to this
820-4 subsection (f)). The Health Maintenance Organization and
821-5 the group or enrollment unit may agree that the profitable
822-6 or unprofitable experience may be calculated taking into
823-7 account the refund period and the immediately preceding 2
824-8 plan years.
825-9 The Health Maintenance Organization shall include a
826-10 statement in the evidence of coverage issued to each enrollee
827-11 describing the possibility of a refund or additional premium,
828-12 and upon request of any group or enrollment unit, provide to
829-13 the group or enrollment unit a description of the method used
830-14 to calculate (1) the Health Maintenance Organization's
831-15 profitable experience with respect to the group or enrollment
832-16 unit and the resulting refund to the group or enrollment unit
833-17 or (2) the Health Maintenance Organization's unprofitable
834-18 experience with respect to the group or enrollment unit and
835-19 the resulting additional premium to be paid by the group or
836-20 enrollment unit.
837-21 In no event shall the Illinois Health Maintenance
838-22 Organization Guaranty Association be liable to pay any
839-23 contractual obligation of an insolvent organization to pay any
840-24 refund authorized under this Section.
841-25 (g) Rulemaking authority to implement Public Act 95-1045,
842-26 if any, is conditioned on the rules being adopted in
791+HB1085- 22 -LRB104 05991 BAB 16024 b HB1085 - 22 - LRB104 05991 BAB 16024 b
792+ HB1085 - 22 - LRB104 05991 BAB 16024 b
793+1 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
794+2 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
795+3 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
796+4 (Text of Section after amendment by P.A. 103-808)
797+5 Sec. 5-3. Insurance Code provisions.
798+6 (a) Health Maintenance Organizations shall be subject to
799+7 the provisions of Sections 133, 134, 136, 137, 139, 140,
800+8 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
801+9 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
802+10 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
803+11 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
804+12 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
805+13 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
806+14 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
807+15 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
808+16 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
809+17 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
810+18 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
811+19 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
812+20 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
813+21 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
814+22 356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i,
815+23 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401,
816+24 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
817+25 paragraph (c) of subsection (2) of Section 367, and Articles
843818
844819
845820
846821
847822
848- HB1085 Engrossed - 24 - LRB104 05991 BAB 16024 b
823+ HB1085 - 22 - LRB104 05991 BAB 16024 b
849824
850825
851-HB1085 Engrossed- 25 -LRB104 05991 BAB 16024 b HB1085 Engrossed - 25 - LRB104 05991 BAB 16024 b
852- HB1085 Engrossed - 25 - LRB104 05991 BAB 16024 b
853-1 accordance with all provisions of the Illinois Administrative
854-2 Procedure Act and all rules and procedures of the Joint
855-3 Committee on Administrative Rules; any purported rule not so
856-4 adopted, for whatever reason, is unauthorized.
857-5 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
858-6 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
859-7 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
860-8 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
861-9 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
862-10 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
863-11 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
864-12 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
865-13 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
866-14 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
867-15 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
868-16 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
869-17 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
870-18 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
871-19 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
872-20 11-26-24.)
873-21 Section 95. No acceleration or delay. Where this Act makes
874-22 changes in a statute that is represented in this Act by text
875-23 that is not yet or no longer in effect (for example, a Section
876-24 represented by multiple versions), the use of that text does
877-25 not accelerate or delay the taking effect of (i) the changes
826+HB1085- 23 -LRB104 05991 BAB 16024 b HB1085 - 23 - LRB104 05991 BAB 16024 b
827+ HB1085 - 23 - LRB104 05991 BAB 16024 b
828+1 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
829+2 XXXIIB of the Illinois Insurance Code.
830+3 (b) For purposes of the Illinois Insurance Code, except
831+4 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
832+5 Health Maintenance Organizations in the following categories
833+6 are deemed to be "domestic companies":
834+7 (1) a corporation authorized under the Dental Service
835+8 Plan Act or the Voluntary Health Services Plans Act;
836+9 (2) a corporation organized under the laws of this
837+10 State; or
838+11 (3) a corporation organized under the laws of another
839+12 state, 30% or more of the enrollees of which are residents
840+13 of this State, except a corporation subject to
841+14 substantially the same requirements in its state of
842+15 organization as is a "domestic company" under Article VIII
843+16 1/2 of the Illinois Insurance Code.
844+17 (c) In considering the merger, consolidation, or other
845+18 acquisition of control of a Health Maintenance Organization
846+19 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
847+20 (1) the Director shall give primary consideration to
848+21 the continuation of benefits to enrollees and the
849+22 financial conditions of the acquired Health Maintenance
850+23 Organization after the merger, consolidation, or other
851+24 acquisition of control takes effect;
852+25 (2)(i) the criteria specified in subsection (1)(b) of
853+26 Section 131.8 of the Illinois Insurance Code shall not
878854
879855
880856
881857
882858
883- HB1085 Engrossed - 25 - LRB104 05991 BAB 16024 b
859+ HB1085 - 23 - LRB104 05991 BAB 16024 b
884860
885861
886-HB1085 Engrossed- 26 -LRB104 05991 BAB 16024 b HB1085 Engrossed - 26 - LRB104 05991 BAB 16024 b
887- HB1085 Engrossed - 26 - LRB104 05991 BAB 16024 b
888-1 made by this Act or (ii) provisions derived from any other
889-2 Public Act.
890-3 Section 99. Effective date. This Act takes effect upon
891-4 becoming law.
862+HB1085- 24 -LRB104 05991 BAB 16024 b HB1085 - 24 - LRB104 05991 BAB 16024 b
863+ HB1085 - 24 - LRB104 05991 BAB 16024 b
864+1 apply and (ii) the Director, in making his determination
865+2 with respect to the merger, consolidation, or other
866+3 acquisition of control, need not take into account the
867+4 effect on competition of the merger, consolidation, or
868+5 other acquisition of control;
869+6 (3) the Director shall have the power to require the
870+7 following information:
871+8 (A) certification by an independent actuary of the
872+9 adequacy of the reserves of the Health Maintenance
873+10 Organization sought to be acquired;
874+11 (B) pro forma financial statements reflecting the
875+12 combined balance sheets of the acquiring company and
876+13 the Health Maintenance Organization sought to be
877+14 acquired as of the end of the preceding year and as of
878+15 a date 90 days prior to the acquisition, as well as pro
879+16 forma financial statements reflecting projected
880+17 combined operation for a period of 2 years;
881+18 (C) a pro forma business plan detailing an
882+19 acquiring party's plans with respect to the operation
883+20 of the Health Maintenance Organization sought to be
884+21 acquired for a period of not less than 3 years; and
885+22 (D) such other information as the Director shall
886+23 require.
887+24 (d) The provisions of Article VIII 1/2 of the Illinois
888+25 Insurance Code and this Section 5-3 shall apply to the sale by
889+26 any health maintenance organization of greater than 10% of its
892890
893891
894892
895893
896894
897- HB1085 Engrossed - 26 - LRB104 05991 BAB 16024 b
895+ HB1085 - 24 - LRB104 05991 BAB 16024 b
896+
897+
898+HB1085- 25 -LRB104 05991 BAB 16024 b HB1085 - 25 - LRB104 05991 BAB 16024 b
899+ HB1085 - 25 - LRB104 05991 BAB 16024 b
900+1 enrollee population (including, without limitation, the health
901+2 maintenance organization's right, title, and interest in and
902+3 to its health care certificates).
903+4 (e) In considering any management contract or service
904+5 agreement subject to Section 141.1 of the Illinois Insurance
905+6 Code, the Director (i) shall, in addition to the criteria
906+7 specified in Section 141.2 of the Illinois Insurance Code,
907+8 take into account the effect of the management contract or
908+9 service agreement on the continuation of benefits to enrollees
909+10 and the financial condition of the health maintenance
910+11 organization to be managed or serviced, and (ii) need not take
911+12 into account the effect of the management contract or service
912+13 agreement on competition.
913+14 (f) Except for small employer groups as defined in the
914+15 Small Employer Rating, Renewability and Portability Health
915+16 Insurance Act and except for medicare supplement policies as
916+17 defined in Section 363 of the Illinois Insurance Code, a
917+18 Health Maintenance Organization may by contract agree with a
918+19 group or other enrollment unit to effect refunds or charge
919+20 additional premiums under the following terms and conditions:
920+21 (i) the amount of, and other terms and conditions with
921+22 respect to, the refund or additional premium are set forth
922+23 in the group or enrollment unit contract agreed in advance
923+24 of the period for which a refund is to be paid or
924+25 additional premium is to be charged (which period shall
925+26 not be less than one year); and
926+
927+
928+
929+
930+
931+ HB1085 - 25 - LRB104 05991 BAB 16024 b
932+
933+
934+HB1085- 26 -LRB104 05991 BAB 16024 b HB1085 - 26 - LRB104 05991 BAB 16024 b
935+ HB1085 - 26 - LRB104 05991 BAB 16024 b
936+1 (ii) the amount of the refund or additional premium
937+2 shall not exceed 20% of the Health Maintenance
938+3 Organization's profitable or unprofitable experience with
939+4 respect to the group or other enrollment unit for the
940+5 period (and, for purposes of a refund or additional
941+6 premium, the profitable or unprofitable experience shall
942+7 be calculated taking into account a pro rata share of the
943+8 Health Maintenance Organization's administrative and
944+9 marketing expenses, but shall not include any refund to be
945+10 made or additional premium to be paid pursuant to this
946+11 subsection (f)). The Health Maintenance Organization and
947+12 the group or enrollment unit may agree that the profitable
948+13 or unprofitable experience may be calculated taking into
949+14 account the refund period and the immediately preceding 2
950+15 plan years.
951+16 The Health Maintenance Organization shall include a
952+17 statement in the evidence of coverage issued to each enrollee
953+18 describing the possibility of a refund or additional premium,
954+19 and upon request of any group or enrollment unit, provide to
955+20 the group or enrollment unit a description of the method used
956+21 to calculate (1) the Health Maintenance Organization's
957+22 profitable experience with respect to the group or enrollment
958+23 unit and the resulting refund to the group or enrollment unit
959+24 or (2) the Health Maintenance Organization's unprofitable
960+25 experience with respect to the group or enrollment unit and
961+26 the resulting additional premium to be paid by the group or
962+
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972+1 enrollment unit.
973+2 In no event shall the Illinois Health Maintenance
974+3 Organization Guaranty Association be liable to pay any
975+4 contractual obligation of an insolvent organization to pay any
976+5 refund authorized under this Section.
977+6 (g) Rulemaking authority to implement Public Act 95-1045,
978+7 if any, is conditioned on the rules being adopted in
979+8 accordance with all provisions of the Illinois Administrative
980+9 Procedure Act and all rules and procedures of the Joint
981+10 Committee on Administrative Rules; any purported rule not so
982+11 adopted, for whatever reason, is unauthorized.
983+12 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
984+13 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
985+14 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
986+15 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
987+16 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
988+17 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
989+18 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
990+19 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
991+20 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
992+21 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
993+22 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
994+23 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
995+24 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
996+25 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
997+26 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
998+
999+
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1008+1 11-26-24.)
1009+2 Section 95. No acceleration or delay. Where this Act makes
1010+3 changes in a statute that is represented in this Act by text
1011+4 that is not yet or no longer in effect (for example, a Section
1012+5 represented by multiple versions), the use of that text does
1013+6 not accelerate or delay the taking effect of (i) the changes
1014+7 made by this Act or (ii) provisions derived from any other
1015+8 Public Act.
1016+
1017+
1018+
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1020+
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