Illinois 2025-2026 Regular Session

Illinois Senate Bill SB0055 Compare Versions

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

Old	New	Differences
1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB0055 Introduced 1/13/2025, by Sen. Karina Villa 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 05904 BAB 15935 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB0055 Introduced 1/13/2025, by Sen. Karina Villa 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 05904 BAB 15935 b LRB104 05904 BAB 15935 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB0055 Introduced 1/13/2025, by Sen. Karina Villa SYNOPSIS AS INTRODUCED:
3	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	4	5 ILCS 375/6.11
5	5	55 ILCS 5/5-1069.3
6	6	65 ILCS 5/10-4-2.3
7	7	105 ILCS 5/10-22.3f
8	8	215 ILCS 5/370c.3 new
9	9	215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
10	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.
11	11	LRB104 05904 BAB 15935 b LRB104 05904 BAB 15935 b
12	12	LRB104 05904 BAB 15935 b
13	13	A BILL FOR
14	14	SB0055LRB104 05904 BAB 15935 b SB0055 LRB104 05904 BAB 15935 b
15	15	SB0055 LRB104 05904 BAB 15935 b
16	16	1 AN ACT concerning regulation.
17	17	2 Be it enacted by the People of the State of Illinois,
18	18	3 represented in the General Assembly:
19	19	4 Section 5. The State Employees Group Insurance Act of 1971
20	20	5 is amended by changing Section 6.11 as follows:
21	21	6 (5 ILCS 375/6.11)
22	22	7 Sec. 6.11. Required health benefits; Illinois Insurance
23	23	8 Code requirements. The program of health benefits shall
24	24	9 provide the post-mastectomy care benefits required to be
25	25	10 covered by a policy of accident and health insurance under
26	26	11 Section 356t of the Illinois Insurance Code. The program of
27	27	12 health benefits shall provide the coverage required under
28	28	13 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10,
29	29	14 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
30	30	15 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
31	31	16 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
32	32	17 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
33	33	18 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
34	34	19 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and
35	35	20 356z.70, and 356z.71, 356z.74, 356z.76, 356z.77, and 356z.80
36	36	21 of the Illinois Insurance Code. The program of health benefits
37	37	22 must comply with Sections 155.22a, 155.37, 355b, 356z.19,
38	38	23 370c, and 370c.1, and 370c.3 and Article XXXIIB of the
39	39
40	40
41	41
42	42	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 SB0055 Introduced 1/13/2025, by Sen. Karina Villa SYNOPSIS AS INTRODUCED:
43	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	44	5 ILCS 375/6.11
45	45	55 ILCS 5/5-1069.3
46	46	65 ILCS 5/10-4-2.3
47	47	105 ILCS 5/10-22.3f
48	48	215 ILCS 5/370c.3 new
49	49	215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
50	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	51	LRB104 05904 BAB 15935 b LRB104 05904 BAB 15935 b
52	52	LRB104 05904 BAB 15935 b
53	53	A BILL FOR
54	54
55	55
56	56
57	57
58	58
59	59	5 ILCS 375/6.11
60	60	55 ILCS 5/5-1069.3
61	61	65 ILCS 5/10-4-2.3
62	62	105 ILCS 5/10-22.3f
63	63	215 ILCS 5/370c.3 new
64	64	215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
65	65
66	66
67	67
68	68	LRB104 05904 BAB 15935 b
69	69
70	70
71	71
72	72
73	73
74	74
75	75
76	76
77	77
78	78	SB0055 LRB104 05904 BAB 15935 b
79	79
80	80
81	81	SB0055- 2 -LRB104 05904 BAB 15935 b SB0055 - 2 - LRB104 05904 BAB 15935 b
82	82	SB0055 - 2 - LRB104 05904 BAB 15935 b
83	83	1 Illinois Insurance Code. The program of health benefits shall
84	84	2 provide the coverage required under Section 356m of the
85	85	3 Illinois Insurance Code and, for the employees of the State
86	86	4 Employee Group Insurance Program only, the coverage as also
87	87	5 provided in Section 6.11B of this Act. The Department of
88	88	6 Insurance shall enforce the requirements of this Section with
89	89	7 respect to Sections 370c, and 370c.1, and 370c.3 of the
90	90	8 Illinois Insurance Code; all other requirements of this
91	91	9 Section shall be enforced by the Department of Central
92	92	10 Management Services.
93	93	11 Rulemaking authority to implement Public Act 95-1045, if
94	94	12 any, is conditioned on the rules being adopted in accordance
95	95	13 with all provisions of the Illinois Administrative Procedure
96	96	14 Act and all rules and procedures of the Joint Committee on
97	97	15 Administrative Rules; any purported rule not so adopted, for
98	98	16 whatever reason, is unauthorized.
99	99	17 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
100	100	18 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
101	101	19 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
102	102	20 eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
103	103	21 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
104	104	22 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
105	105	23 eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
106	106	24 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
107	107	25 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751,
108	108	26 eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25;
109	109
110	110
111	111
112	112
113	113
114	114	SB0055 - 2 - LRB104 05904 BAB 15935 b
115	115
116	116
117	117	SB0055- 3 -LRB104 05904 BAB 15935 b SB0055 - 3 - LRB104 05904 BAB 15935 b
118	118	SB0055 - 3 - LRB104 05904 BAB 15935 b
119	119	1 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff.
120	120	2 1-1-25; revised 11-26-24.)
121	121	3 Section 10. The Counties Code is amended by changing
122	122	4 Section 5-1069.3 as follows:
123	123	5 (55 ILCS 5/5-1069.3)
124	124	6 Sec. 5-1069.3. Required health benefits. If a county,
125	125	7 including a home rule county, is a self-insurer for purposes
126	126	8 of providing health insurance coverage for its employees, the
127	127	9 coverage shall include coverage for the post-mastectomy care
128	128	10 benefits required to be covered by a policy of accident and
129	129	11 health insurance under Section 356t and the coverage required
130	130	12 under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u,
131	131	13 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9,
132	132	14 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
133	133	15 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36,
134	134	16 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
135	135	17 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
136	136	18 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71,
137	137	19 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code.
138	138	20 The coverage shall comply with Sections 155.22a, 355b,
139	139	21 356z.19, and 370c, and 370c.3 of the Illinois Insurance Code.
140	140	22 The Department of Insurance shall enforce the requirements of
141	141	23 this Section. The requirement that health benefits be covered
142	142	24 as provided in this Section is an exclusive power and function
143	143
144	144
145	145
146	146
147	147
148	148	SB0055 - 3 - LRB104 05904 BAB 15935 b
149	149
150	150
151	151	SB0055- 4 -LRB104 05904 BAB 15935 b SB0055 - 4 - LRB104 05904 BAB 15935 b
152	152	SB0055 - 4 - LRB104 05904 BAB 15935 b
153	153	1 of the State and is a denial and limitation under Article VII,
154	154	2 Section 6, subsection (h) of the Illinois Constitution. A home
155	155	3 rule county to which this Section applies must comply with
156	156	4 every provision of this Section.
157	157	5 Rulemaking authority to implement Public Act 95-1045, if
158	158	6 any, is conditioned on the rules being adopted in accordance
159	159	7 with all provisions of the Illinois Administrative Procedure
160	160	8 Act and all rules and procedures of the Joint Committee on
161	161	9 Administrative Rules; any purported rule not so adopted, for
162	162	10 whatever reason, is unauthorized.
163	163	11 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
164	164	12 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
165	165	13 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
166	166	14 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
167	167	15 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
168	168	16 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
169	169	17 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
170	170	18 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
171	171	19 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
172	172	20 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
173	173	21 revised 11-26-24.)
174	174	22 Section 15. The Illinois Municipal Code is amended by
175	175	23 changing Section 10-4-2.3 as follows:
176	176	24 (65 ILCS 5/10-4-2.3)
177	177
178	178
179	179
180	180
181	181
182	182	SB0055 - 4 - LRB104 05904 BAB 15935 b
183	183
184	184
185	185	SB0055- 5 -LRB104 05904 BAB 15935 b SB0055 - 5 - LRB104 05904 BAB 15935 b
186	186	SB0055 - 5 - LRB104 05904 BAB 15935 b
187	187	1 Sec. 10-4-2.3. Required health benefits. If a
188	188	2 municipality, including a home rule municipality, is a
189	189	3 self-insurer for purposes of providing health insurance
190	190	4 coverage for its employees, the coverage shall include
191	191	5 coverage for the post-mastectomy care benefits required to be
192	192	6 covered by a policy of accident and health insurance under
193	193	7 Section 356t and the coverage required under Sections 356g,
194	194	8 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
195	195	9 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
196	196	10 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
197	197	11 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
198	198	12 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54,
199	199	13 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
200	200	14 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77,
201	201	15 and 356z.80 of the Illinois Insurance Code. The coverage shall
202	202	16 comply with Sections 155.22a, 355b, 356z.19, and 370c, and
203	203	17 370c.3 of the Illinois Insurance Code. The Department of
204	204	18 Insurance shall enforce the requirements of this Section. The
205	205	19 requirement that health benefits be covered as provided in
206	206	20 this is an exclusive power and function of the State and is a
207	207	21 denial and limitation under Article VII, Section 6, subsection
208	208	22 (h) of the Illinois Constitution. A home rule municipality to
209	209	23 which this Section applies must comply with every provision of
210	210	24 this Section.
211	211	25 Rulemaking authority to implement Public Act 95-1045, if
212	212	26 any, is conditioned on the rules being adopted in accordance
213	213
214	214
215	215
216	216
217	217
218	218	SB0055 - 5 - LRB104 05904 BAB 15935 b
219	219
220	220
221	221	SB0055- 6 -LRB104 05904 BAB 15935 b SB0055 - 6 - LRB104 05904 BAB 15935 b
222	222	SB0055 - 6 - LRB104 05904 BAB 15935 b
223	223	1 with all provisions of the Illinois Administrative Procedure
224	224	2 Act and all rules and procedures of the Joint Committee on
225	225	3 Administrative Rules; any purported rule not so adopted, for
226	226	4 whatever reason, is unauthorized.
227	227	5 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
228	228	6 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
229	229	7 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
230	230	8 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
231	231	9 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
232	232	10 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
233	233	11 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
234	234	12 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
235	235	13 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
236	236	14 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
237	237	15 revised 11-26-24.)
238	238	16 Section 20. The School Code is amended by changing Section
239	239	17 10-22.3f as follows:
240	240	18 (105 ILCS 5/10-22.3f)
241	241	19 Sec. 10-22.3f. Required health benefits. Insurance
242	242	20 protection and benefits for employees shall provide the
243	243	21 post-mastectomy care benefits required to be covered by a
244	244	22 policy of accident and health insurance under Section 356t and
245	245	23 the coverage required under Sections 356g, 356g.5, 356g.5-1,
246	246	24 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,
247	247
248	248
249	249
250	250
251	251
252	252	SB0055 - 6 - LRB104 05904 BAB 15935 b
253	253
254	254
255	255	SB0055- 7 -LRB104 05904 BAB 15935 b SB0055 - 7 - LRB104 05904 BAB 15935 b
256	256	SB0055 - 7 - LRB104 05904 BAB 15935 b
257	257	1 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
258	258	2 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
259	259	3 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
260	260	4 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
261	261	5 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and
262	262	6 356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois
263	263	7 Insurance Code. Insurance policies shall comply with Section
264	264	8 356z.19 of the Illinois Insurance Code. The coverage shall
265	265	9 comply with Sections 155.22a, 355b, and 370c, and 370c.3 of
266	266	10 the Illinois Insurance Code. The Department of Insurance shall
267	267	11 enforce the requirements of this Section.
268	268	12 Rulemaking authority to implement Public Act 95-1045, if
269	269	13 any, is conditioned on the rules being adopted in accordance
270	270	14 with all provisions of the Illinois Administrative Procedure
271	271	15 Act and all rules and procedures of the Joint Committee on
272	272	16 Administrative Rules; any purported rule not so adopted, for
273	273	17 whatever reason, is unauthorized.
274	274	18 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
275	275	19 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
276	276	20 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
277	277	21 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
278	278	22 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
279	279	23 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
280	280	24 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
281	281	25 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
282	282	26 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,
283	283
284	284
285	285
286	286
287	287
288	288	SB0055 - 7 - LRB104 05904 BAB 15935 b
289	289
290	290
291	291	SB0055- 8 -LRB104 05904 BAB 15935 b SB0055 - 8 - LRB104 05904 BAB 15935 b
292	292	SB0055 - 8 - LRB104 05904 BAB 15935 b
293	293	1 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
294	294	2 Section 25. The Illinois Insurance Code is amended by
295	295	3 adding Section 370c.3 as follows:
296	296	4 (215 ILCS 5/370c.3 new)
297	297	5 Sec. 370c.3. Mental health and substance use parity.
298	298	6 (a) In this Section:
299	299	7 "Application" means a person's or facility's application
300	300	8 to become a participating provider with an insurer in at least
301	301	9 one of the insurer's provider networks.
302	302	10 "Applying provider" means a provider or facility that has
303	303	11 submitted a completed application to become a participating
304	304	12 provider or facility with an insurer.
305	305	13 "Behavioral health trainee" means any person: (1) engaged
306	306	14 in the provision of mental health or substance use disorder
307	307	15 clinical services as part of that person's supervised course
308	308	16 of study while enrolled in a master's or doctoral psychology,
309	309	17 social work, counseling, or marriage or family therapy program
310	310	18 or as a postdoctoral graduate working toward licensure; and
311	311	19 (2) who is working toward clinical State licensure under the
312	312	20 clinical supervision of a fully licensed mental health or
313	313	21 substance use disorder treatment provider.
314	314	22 "Completed application" means a person's or facility's
315	315	23 application to become a participating provider that has been
316	316	24 submitted to the insurer and includes all the required
317	317
318	318
319	319
320	320
321	321
322	322	SB0055 - 8 - LRB104 05904 BAB 15935 b
323	323
324	324
325	325	SB0055- 9 -LRB104 05904 BAB 15935 b SB0055 - 9 - LRB104 05904 BAB 15935 b
326	326	SB0055 - 9 - LRB104 05904 BAB 15935 b
327	327	1 information for the application to be considered by the
328	328	2 insurer according to the insurer's policies and procedures for
329	329	3 verifying a provider's or facility's credentials.
330	330	4 "Contracting process" means the process by which a mental
331	331	5 health or substance use disorder treatment provider or
332	332	6 facility makes a completed application with an insurer to
333	333	7 become a participating provider with the insurer until the
334	334	8 effective date of a final contract between the provider or
335	335	9 facility and the insurer. "Contracting process" includes the
336	336	10 process of verifying a provider's credentials.
337	337	11 "Participating provider" means any mental health or
338	338	12 substance use disorder treatment provider that has a contract
339	339	13 to provide mental health or substance use disorder services
340	340	14 with an insurer.
341	341	15 (b) For all group or individual policies of accident and
342	342	16 health insurance or managed care plans that are amended,
343	343	17 delivered, issued, or renewed on or after January 1, 2027, or
344	344	18 any contracted third party administering the behavioral health
345	345	19 benefits for the insurer, reimbursement for in-network mental
346	346	20 health and substance use disorder treatment services delivered
347	347	21 by Illinois providers and facilities must be equal to or
348	348	22 greater than 141% of the Medicare rate for the mental health or
349	349	23 substance use disorder service delivered. For services not
350	350	24 covered by Medicare, the reimbursement rates must be, on
351	351	25 average, equal to or greater than 144% of the insurer's
352	352	26 in-network reimbursement rate for such service on the
353	353
354	354
355	355
356	356
357	357
358	358	SB0055 - 9 - LRB104 05904 BAB 15935 b
359	359
360	360
361	361	SB0055- 10 -LRB104 05904 BAB 15935 b SB0055 - 10 - LRB104 05904 BAB 15935 b
362	362	SB0055 - 10 - LRB104 05904 BAB 15935 b
363	363	1 effective date of this amendatory Act of the 104th General
364	364	2 Assembly. This Section applies to all covered office,
365	365	3 outpatient, inpatient, and residential mental health and
366	366	4 substance use disorder services. If at any time the average
367	367	5 reimbursement for in-network medical or surgical services
368	368	6 delivered by Illinois providers exceeds 141% of the Medicare
369	369	7 rate for such services, then the reimbursement for mental
370	370	8 health and substance use disorder treatment services must be
371	371	9 equal to or greater than that average.
372	372	10 This Section applies to all covered office, outpatient,
373	373	11 inpatient, and residential mental health and substance use
374	374	12 disorder services.
375	375	13 This subsection does not apply to mental health or
376	376	14 substance use disorder services provided by a hospital when
377	377	15 the hospital has a contract with the insurer that provides for
378	378	16 reimbursement for such services based on achieving specified
379	379	17 patient health outcomes and other quality measures and
380	380	18 includes shared savings from lower health care costs.
381	381	19 (c) A group or individual policy of accident and health
382	382	20 insurance or managed care plan that is amended, delivered,
383	383	21 issued, or renewed on or after January 1, 2026, or contracted
384	384	22 third party administering the behavioral health benefits for
385	385	23 the insurer, shall cover all medically necessary mental health
386	386	24 or substance use disorder services received by the same
387	387	25 insured on the same day from the same or different mental
388	388	26 health or substance use provider or facility for both
389	389
390	390
391	391
392	392
393	393
394	394	SB0055 - 10 - LRB104 05904 BAB 15935 b
395	395
396	396
397	397	SB0055- 11 -LRB104 05904 BAB 15935 b SB0055 - 11 - LRB104 05904 BAB 15935 b
398	398	SB0055 - 11 - LRB104 05904 BAB 15935 b
399	399	1 outpatient and inpatient care.
400	400	2 (d) A group or individual policy of accident and health
401	401	3 insurance or managed care plan that is amended, delivered,
402	402	4 issued, or renewed on or after January 1, 2026, or any
403	403	5 contracted third party administering the behavioral health
404	404	6 benefits for the insurer, shall cover any medically necessary
405	405	7 mental health or substance use disorder service provided by a
406	406	8 behavioral health trainee when the trainee is working toward
407	407	9 clinical State licensure and is under the supervision of a
408	408	10 fully licensed mental health or substance use disorder
409	409	11 treatment provider, which is a physician licensed to practice
410	410	12 medicine in all its branches, licensed clinical psychologist,
411	411	13 licensed clinical social worker, licensed clinical
412	412	14 professional counselor, licensed marriage and family
413	413	15 therapist, licensed speech-language pathologist, or other
414	414	16 licensed or certified professional at a program licensed
415	415	17 pursuant to the Substance Use Disorder Act who is engaged in
416	416	18 treating mental, emotional, nervous, or substance use
417	417	19 disorders or conditions. Services provided by the trainee must
418	418	20 be billed under the supervising clinician's rendering National
419	419	21 Provider Identifier.
420	420	22 (e) A group or individual policy of accident and health
421	421	23 insurance or managed care plan that is amended, delivered,
422	422	24 issued, or renewed on or after January 1, 2026, or any
423	423	25 contracted third party administering the behavioral health
424	424	26 benefits for the insurer, shall:
425	425
426	426
427	427
428	428
429	429
430	430	SB0055 - 11 - LRB104 05904 BAB 15935 b
431	431
432	432
433	433	SB0055- 12 -LRB104 05904 BAB 15935 b SB0055 - 12 - LRB104 05904 BAB 15935 b
434	434	SB0055 - 12 - LRB104 05904 BAB 15935 b
435	435	1 (1) cover medically necessary 60-minute psychotherapy
436	436	2 billed using the CPT Code 90837 for Individual Therapy;
437	437	3 (2) not impose more onerous documentation requirements
438	438	4 on the provider than is required for other psychotherapy
439	439	5 CPT Codes; and
440	440	6 (3) not audit the use of CPT Code 90837 any more
441	441	7 frequently than audits for the use of other psychotherapy
442	442	8 CPT Codes.
443	443	9 (f)(1) Any group or individual policy of accident and
444	444	10 health insurance or managed care plan that is amended,
445	445	11 delivered, issued, or renewed on or after January 1, 2026, or
446	446	12 any contracted third party administering the behavioral health
447	447	13 benefits for the insurer, shall complete the contracting
448	448	14 process with a mental health or substance use disorder
449	449	15 treatment provider or facility for becoming a participating
450	450	16 provider in the insurer's network, including the verification
451	451	17 of the provider's credentials, within 60 days from the date of
452	452	18 a completed application to the insurer to become a
453	453	19 participating provider. Nothing in this paragraph (1),
454	454	20 however, presumes or establishes a contract between an insurer
455	455	21 and a provider.
456	456	22 (2) Any group or individual policy of accident and health
457	457	23 insurance or managed care plan that is amended, delivered,
458	458	24 issued, or renewed on or after January 1, 2026, or any
459	459	25 contracted third party administering the behavioral health
460	460	26 benefits for the insurer, shall reimburse a participating
461	461
462	462
463	463
464	464
465	465
466	466	SB0055 - 12 - LRB104 05904 BAB 15935 b
467	467
468	468
469	469	SB0055- 13 -LRB104 05904 BAB 15935 b SB0055 - 13 - LRB104 05904 BAB 15935 b
470	470	SB0055 - 13 - LRB104 05904 BAB 15935 b
471	471	1 mental health or substance use disorder treatment provider or
472	472	2 facility at the contracted reimbursement rate for any
473	473	3 medically necessary services provided to an insured from the
474	474	4 date of submission of the provider's or facility's completed
475	475	5 application to become a participating provider with the
476	476	6 insurer up to the effective date of the provider's contract.
477	477	7 The provider's claims for such services shall be reimbursed
478	478	8 only when submitted after the effective date of the provider's
479	479	9 contract with the insurer. This paragraph (2) does not apply
480	480	10 to a provider that does not have a completed contract with an
481	481	11 insurer. If a provider opts to submit claims for medically
482	482	12 necessary mental health or substance use disorder services
483	483	13 pursuant to this paragraph (2), the provider must notify the
484	484	14 insured following submission of the claims to the insurer that
485	485	15 the services provided to the insured may be treated as
486	486	16 in-network services.
487	487	17 (3) Any group or individual policy of accident and health
488	488	18 insurance or managed care plan that is amended, delivered,
489	489	19 issued, or renewed on or after January 1, 2026, or any
490	490	20 contracted third party administering the behavioral health
491	491	21 benefits for the insurer, shall cover any medically necessary
492	492	22 mental health or substance use disorder service provided by a
493	493	23 fully licensed mental health or substance use disorder
494	494	24 treatment provider affiliated with a mental health or
495	495	25 substance use disorder treatment group practice who has
496	496	26 submitted a completed application to become a participating
497	497
498	498
499	499
500	500
501	501
502	502	SB0055 - 13 - LRB104 05904 BAB 15935 b
503	503
504	504
505	505	SB0055- 14 -LRB104 05904 BAB 15935 b SB0055 - 14 - LRB104 05904 BAB 15935 b
506	506	SB0055 - 14 - LRB104 05904 BAB 15935 b
507	507	1 provider with an insurer who is delivering services under the
508	508	2 supervision of another fully licensed participating mental
509	509	3 health or substance use disorder treatment provider within the
510	510	4 same group practice up to the effective date of the applying
511	511	5 provider's contract with the insurer as a participating
512	512	6 provider. Services provided by the applying provider must be
513	513	7 billed under the supervising licensed provider's rendering
514	514	8 National Provider Identifier.
515	515	9 (4) Upon request, an insurer, or any contracted third
516	516	10 party administering the behavioral health benefits for the
517	517	11 insurer, shall provide an applying provider with the insurer's
518	518	12 credentialing policies and procedures. An insurer, or any
519	519	13 contracted third party administering the behavioral health
520	520	14 benefits for the insurer, shall post the following
521	521	15 nonproprietary information on its website and make that
522	522	16 information available to all applicants:
523	523	17 (A) a list of the information required to be included
524	524	18 in an application;
525	525	19 (B) a checklist of the materials that must be
526	526	20 submitted in the credentialing process; and
527	527	21 (C) designated contact information of a network
528	528	22 representative, including a designated point of contact,
529	529	23 an email address, and a telephone number, to which an
530	530	24 applicant may address any credentialing inquiries.
531	531	25 (g) The Department has the same authority to enforce this
532	532	26 Section as it has to enforce compliance with Sections 370c and
533	533
534	534
535	535
536	536
537	537
538	538	SB0055 - 14 - LRB104 05904 BAB 15935 b
539	539
540	540
541	541	SB0055- 15 -LRB104 05904 BAB 15935 b SB0055 - 15 - LRB104 05904 BAB 15935 b
542	542	SB0055 - 15 - LRB104 05904 BAB 15935 b
543	543	1 370c.1. Additionally, if the Department determines that an
544	544	2 insurer or a contracted third party administering the
545	545	3 behavioral health benefits for the insurer has violated this
546	546	4 Section, the Department shall, after appropriate notice and
547	547	5 opportunity for hearing in accordance with Section 402, by
548	548	6 order assess a civil penalty of $1,000 for each violation. The
549	549	7 Department shall establish any processes or procedures
550	550	8 necessary to monitor compliance with this Section.
551	551	9 (h) At the end of 5 years, 10 years, and 15 years following
552	552	10 the implementation of subsection (b) of this Section, the
553	553	11 Department shall review the impact of this Section on network
554	554	12 adequacy for mental health and substance use disorder
555	555	13 treatment and access to affordable mental health and substance
556	556	14 use care. By no later than December 31, 2033, December 31,
557	557	15 2038, and December 31, 2043, the Department shall submit a
558	558	16 report in each of those years to the General Assembly that
559	559	17 includes its analyses and findings. For the purpose of
560	560	18 evaluating trends in network adequacy, the Department may
561	561	19 examine out-of-network utilization and out-of-pocket costs for
562	562	20 insureds for mental health and substance use treatment and
563	563	21 services for all plans to compare with in-network utilization.
564	564	22 (i) The Department shall adopt any rules necessary to
565	565	23 implement this Section by no later than May 1, 2026.
566	566	24 (j) This Section does not apply to a health care plan
567	567	25 serving Medicaid populations that provides, arranges for, pays
568	568	26 for, or reimburses the cost of any health care service for
569	569
570	570
571	571
572	572
573	573
574	574	SB0055 - 15 - LRB104 05904 BAB 15935 b
575	575
576	576
577	577	SB0055- 16 -LRB104 05904 BAB 15935 b SB0055 - 16 - LRB104 05904 BAB 15935 b
578	578	SB0055 - 16 - LRB104 05904 BAB 15935 b
579	579	1 persons who are enrolled under the Illinois Public Aid Code or
580	580	2 under the Children's Health Insurance Program Act.
581	581	3 Section 30. The Health Maintenance Organization Act is
582	582	4 amended by changing Section 5-3 as follows:
583	583	5 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
584	584	6 (Text of Section before amendment by P.A. 103-808)
585	585	7 Sec. 5-3. Insurance Code provisions.
586	586	8 (a) Health Maintenance Organizations shall be subject to
587	587	9 the provisions of Sections 133, 134, 136, 137, 139, 140,
588	588	10 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
589	589	11 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
590	590	12 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
591	591	13 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
592	592	14 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
593	593	15 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
594	594	16 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
595	595	17 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
596	596	18 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
597	597	19 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
598	598	20 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
599	599	21 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
600	600	22 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
601	601	23 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
602	602	24 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
603	603
604	604
605	605
606	606
607	607
608	608	SB0055 - 16 - LRB104 05904 BAB 15935 b
609	609
610	610
611	611	SB0055- 17 -LRB104 05904 BAB 15935 b SB0055 - 17 - LRB104 05904 BAB 15935 b
612	612	SB0055 - 17 - LRB104 05904 BAB 15935 b
613	613	1 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403,
614	614	2 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
615	615	3 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
616	616	4 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
617	617	5 Illinois Insurance Code.
618	618	6 (b) For purposes of the Illinois Insurance Code, except
619	619	7 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
620	620	8 Health Maintenance Organizations in the following categories
621	621	9 are deemed to be "domestic companies":
622	622	10 (1) a corporation authorized under the Dental Service
623	623	11 Plan Act or the Voluntary Health Services Plans Act;
624	624	12 (2) a corporation organized under the laws of this
625	625	13 State; or
626	626	14 (3) a corporation organized under the laws of another
627	627	15 state, 30% or more of the enrollees of which are residents
628	628	16 of this State, except a corporation subject to
629	629	17 substantially the same requirements in its state of
630	630	18 organization as is a "domestic company" under Article VIII
631	631	19 1/2 of the Illinois Insurance Code.
632	632	20 (c) In considering the merger, consolidation, or other
633	633	21 acquisition of control of a Health Maintenance Organization
634	634	22 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
635	635	23 (1) the Director shall give primary consideration to
636	636	24 the continuation of benefits to enrollees and the
637	637	25 financial conditions of the acquired Health Maintenance
638	638	26 Organization after the merger, consolidation, or other
639	639
640	640
641	641
642	642
643	643
644	644	SB0055 - 17 - LRB104 05904 BAB 15935 b
645	645
646	646
647	647	SB0055- 18 -LRB104 05904 BAB 15935 b SB0055 - 18 - LRB104 05904 BAB 15935 b
648	648	SB0055 - 18 - LRB104 05904 BAB 15935 b
649	649	1 acquisition of control takes effect;
650	650	2 (2)(i) the criteria specified in subsection (1)(b) of
651	651	3 Section 131.8 of the Illinois Insurance Code shall not
652	652	4 apply and (ii) the Director, in making his determination
653	653	5 with respect to the merger, consolidation, or other
654	654	6 acquisition of control, need not take into account the
655	655	7 effect on competition of the merger, consolidation, or
656	656	8 other acquisition of control;
657	657	9 (3) the Director shall have the power to require the
658	658	10 following information:
659	659	11 (A) certification by an independent actuary of the
660	660	12 adequacy of the reserves of the Health Maintenance
661	661	13 Organization sought to be acquired;
662	662	14 (B) pro forma financial statements reflecting the
663	663	15 combined balance sheets of the acquiring company and
664	664	16 the Health Maintenance Organization sought to be
665	665	17 acquired as of the end of the preceding year and as of
666	666	18 a date 90 days prior to the acquisition, as well as pro
667	667	19 forma financial statements reflecting projected
668	668	20 combined operation for a period of 2 years;
669	669	21 (C) a pro forma business plan detailing an
670	670	22 acquiring party's plans with respect to the operation
671	671	23 of the Health Maintenance Organization sought to be
672	672	24 acquired for a period of not less than 3 years; and
673	673	25 (D) such other information as the Director shall
674	674	26 require.
675	675
676	676
677	677
678	678
679	679
680	680	SB0055 - 18 - LRB104 05904 BAB 15935 b
681	681
682	682
683	683	SB0055- 19 -LRB104 05904 BAB 15935 b SB0055 - 19 - LRB104 05904 BAB 15935 b
684	684	SB0055 - 19 - LRB104 05904 BAB 15935 b
685	685	1 (d) The provisions of Article VIII 1/2 of the Illinois
686	686	2 Insurance Code and this Section 5-3 shall apply to the sale by
687	687	3 any health maintenance organization of greater than 10% of its
688	688	4 enrollee population (including, without limitation, the health
689	689	5 maintenance organization's right, title, and interest in and
690	690	6 to its health care certificates).
691	691	7 (e) In considering any management contract or service
692	692	8 agreement subject to Section 141.1 of the Illinois Insurance
693	693	9 Code, the Director (i) shall, in addition to the criteria
694	694	10 specified in Section 141.2 of the Illinois Insurance Code,
695	695	11 take into account the effect of the management contract or
696	696	12 service agreement on the continuation of benefits to enrollees
697	697	13 and the financial condition of the health maintenance
698	698	14 organization to be managed or serviced, and (ii) need not take
699	699	15 into account the effect of the management contract or service
700	700	16 agreement on competition.
701	701	17 (f) Except for small employer groups as defined in the
702	702	18 Small Employer Rating, Renewability and Portability Health
703	703	19 Insurance Act and except for medicare supplement policies as
704	704	20 defined in Section 363 of the Illinois Insurance Code, a
705	705	21 Health Maintenance Organization may by contract agree with a
706	706	22 group or other enrollment unit to effect refunds or charge
707	707	23 additional premiums under the following terms and conditions:
708	708	24 (i) the amount of, and other terms and conditions with
709	709	25 respect to, the refund or additional premium are set forth
710	710	26 in the group or enrollment unit contract agreed in advance
711	711
712	712
713	713
714	714
715	715
716	716	SB0055 - 19 - LRB104 05904 BAB 15935 b
717	717
718	718
719	719	SB0055- 20 -LRB104 05904 BAB 15935 b SB0055 - 20 - LRB104 05904 BAB 15935 b
720	720	SB0055 - 20 - LRB104 05904 BAB 15935 b
721	721	1 of the period for which a refund is to be paid or
722	722	2 additional premium is to be charged (which period shall
723	723	3 not be less than one year); and
724	724	4 (ii) the amount of the refund or additional premium
725	725	5 shall not exceed 20% of the Health Maintenance
726	726	6 Organization's profitable or unprofitable experience with
727	727	7 respect to the group or other enrollment unit for the
728	728	8 period (and, for purposes of a refund or additional
729	729	9 premium, the profitable or unprofitable experience shall
730	730	10 be calculated taking into account a pro rata share of the
731	731	11 Health Maintenance Organization's administrative and
732	732	12 marketing expenses, but shall not include any refund to be
733	733	13 made or additional premium to be paid pursuant to this
734	734	14 subsection (f)). The Health Maintenance Organization and
735	735	15 the group or enrollment unit may agree that the profitable
736	736	16 or unprofitable experience may be calculated taking into
737	737	17 account the refund period and the immediately preceding 2
738	738	18 plan years.
739	739	19 The Health Maintenance Organization shall include a
740	740	20 statement in the evidence of coverage issued to each enrollee
741	741	21 describing the possibility of a refund or additional premium,
742	742	22 and upon request of any group or enrollment unit, provide to
743	743	23 the group or enrollment unit a description of the method used
744	744	24 to calculate (1) the Health Maintenance Organization's
745	745	25 profitable experience with respect to the group or enrollment
746	746	26 unit and the resulting refund to the group or enrollment unit
747	747
748	748
749	749
750	750
751	751
752	752	SB0055 - 20 - LRB104 05904 BAB 15935 b
753	753
754	754
755	755	SB0055- 21 -LRB104 05904 BAB 15935 b SB0055 - 21 - LRB104 05904 BAB 15935 b
756	756	SB0055 - 21 - LRB104 05904 BAB 15935 b
757	757	1 or (2) the Health Maintenance Organization's unprofitable
758	758	2 experience with respect to the group or enrollment unit and
759	759	3 the resulting additional premium to be paid by the group or
760	760	4 enrollment unit.
761	761	5 In no event shall the Illinois Health Maintenance
762	762	6 Organization Guaranty Association be liable to pay any
763	763	7 contractual obligation of an insolvent organization to pay any
764	764	8 refund authorized under this Section.
765	765	9 (g) Rulemaking authority to implement Public Act 95-1045,
766	766	10 if any, is conditioned on the rules being adopted in
767	767	11 accordance with all provisions of the Illinois Administrative
768	768	12 Procedure Act and all rules and procedures of the Joint
769	769	13 Committee on Administrative Rules; any purported rule not so
770	770	14 adopted, for whatever reason, is unauthorized.
771	771	15 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
772	772	16 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
773	773	17 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
774	774	18 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
775	775	19 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
776	776	20 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
777	777	21 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
778	778	22 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
779	779	23 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
780	780	24 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
781	781	25 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
782	782	26 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
783	783
784	784
785	785
786	786
787	787
788	788	SB0055 - 21 - LRB104 05904 BAB 15935 b
789	789
790	790
791	791	SB0055- 22 -LRB104 05904 BAB 15935 b SB0055 - 22 - LRB104 05904 BAB 15935 b
792	792	SB0055 - 22 - LRB104 05904 BAB 15935 b
793	793	1 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
794	794	2 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
795	795	3 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
796	796	4 (Text of Section after amendment by P.A. 103-808)
797	797	5 Sec. 5-3. Insurance Code provisions.
798	798	6 (a) Health Maintenance Organizations shall be subject to
799	799	7 the provisions of Sections 133, 134, 136, 137, 139, 140,
800	800	8 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
801	801	9 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
802	802	10 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
803	803	11 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
804	804	12 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
805	805	13 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
806	806	14 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
807	807	15 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
808	808	16 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
809	809	17 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
810	810	18 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
811	811	19 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
812	812	20 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
813	813	21 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
814	814	22 356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i,
815	815	23 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401,
816	816	24 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
817	817	25 paragraph (c) of subsection (2) of Section 367, and Articles
818	818
819	819
820	820
821	821
822	822
823	823	SB0055 - 22 - LRB104 05904 BAB 15935 b
824	824
825	825
826	826	SB0055- 23 -LRB104 05904 BAB 15935 b SB0055 - 23 - LRB104 05904 BAB 15935 b
827	827	SB0055 - 23 - LRB104 05904 BAB 15935 b
828	828	1 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
829	829	2 XXXIIB of the Illinois Insurance Code.
830	830	3 (b) For purposes of the Illinois Insurance Code, except
831	831	4 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
832	832	5 Health Maintenance Organizations in the following categories
833	833	6 are deemed to be "domestic companies":
834	834	7 (1) a corporation authorized under the Dental Service
835	835	8 Plan Act or the Voluntary Health Services Plans Act;
836	836	9 (2) a corporation organized under the laws of this
837	837	10 State; or
838	838	11 (3) a corporation organized under the laws of another
839	839	12 state, 30% or more of the enrollees of which are residents
840	840	13 of this State, except a corporation subject to
841	841	14 substantially the same requirements in its state of
842	842	15 organization as is a "domestic company" under Article VIII
843	843	16 1/2 of the Illinois Insurance Code.
844	844	17 (c) In considering the merger, consolidation, or other
845	845	18 acquisition of control of a Health Maintenance Organization
846	846	19 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
847	847	20 (1) the Director shall give primary consideration to
848	848	21 the continuation of benefits to enrollees and the
849	849	22 financial conditions of the acquired Health Maintenance
850	850	23 Organization after the merger, consolidation, or other
851	851	24 acquisition of control takes effect;
852	852	25 (2)(i) the criteria specified in subsection (1)(b) of
853	853	26 Section 131.8 of the Illinois Insurance Code shall not
854	854
855	855
856	856
857	857
858	858
859	859	SB0055 - 23 - LRB104 05904 BAB 15935 b
860	860
861	861
862	862	SB0055- 24 -LRB104 05904 BAB 15935 b SB0055 - 24 - LRB104 05904 BAB 15935 b
863	863	SB0055 - 24 - LRB104 05904 BAB 15935 b
864	864	1 apply and (ii) the Director, in making his determination
865	865	2 with respect to the merger, consolidation, or other
866	866	3 acquisition of control, need not take into account the
867	867	4 effect on competition of the merger, consolidation, or
868	868	5 other acquisition of control;
869	869	6 (3) the Director shall have the power to require the
870	870	7 following information:
871	871	8 (A) certification by an independent actuary of the
872	872	9 adequacy of the reserves of the Health Maintenance
873	873	10 Organization sought to be acquired;
874	874	11 (B) pro forma financial statements reflecting the
875	875	12 combined balance sheets of the acquiring company and
876	876	13 the Health Maintenance Organization sought to be
877	877	14 acquired as of the end of the preceding year and as of
878	878	15 a date 90 days prior to the acquisition, as well as pro
879	879	16 forma financial statements reflecting projected
880	880	17 combined operation for a period of 2 years;
881	881	18 (C) a pro forma business plan detailing an
882	882	19 acquiring party's plans with respect to the operation
883	883	20 of the Health Maintenance Organization sought to be
884	884	21 acquired for a period of not less than 3 years; and
885	885	22 (D) such other information as the Director shall
886	886	23 require.
887	887	24 (d) The provisions of Article VIII 1/2 of the Illinois
888	888	25 Insurance Code and this Section 5-3 shall apply to the sale by
889	889	26 any health maintenance organization of greater than 10% of its
890	890
891	891
892	892
893	893
894	894
895	895	SB0055 - 24 - LRB104 05904 BAB 15935 b
896	896
897	897
898	898	SB0055- 25 -LRB104 05904 BAB 15935 b SB0055 - 25 - LRB104 05904 BAB 15935 b
899	899	SB0055 - 25 - LRB104 05904 BAB 15935 b
900	900	1 enrollee population (including, without limitation, the health
901	901	2 maintenance organization's right, title, and interest in and
902	902	3 to its health care certificates).
903	903	4 (e) In considering any management contract or service
904	904	5 agreement subject to Section 141.1 of the Illinois Insurance
905	905	6 Code, the Director (i) shall, in addition to the criteria
906	906	7 specified in Section 141.2 of the Illinois Insurance Code,
907	907	8 take into account the effect of the management contract or
908	908	9 service agreement on the continuation of benefits to enrollees
909	909	10 and the financial condition of the health maintenance
910	910	11 organization to be managed or serviced, and (ii) need not take
911	911	12 into account the effect of the management contract or service
912	912	13 agreement on competition.
913	913	14 (f) Except for small employer groups as defined in the
914	914	15 Small Employer Rating, Renewability and Portability Health
915	915	16 Insurance Act and except for medicare supplement policies as
916	916	17 defined in Section 363 of the Illinois Insurance Code, a
917	917	18 Health Maintenance Organization may by contract agree with a
918	918	19 group or other enrollment unit to effect refunds or charge
919	919	20 additional premiums under the following terms and conditions:
920	920	21 (i) the amount of, and other terms and conditions with
921	921	22 respect to, the refund or additional premium are set forth
922	922	23 in the group or enrollment unit contract agreed in advance
923	923	24 of the period for which a refund is to be paid or
924	924	25 additional premium is to be charged (which period shall
925	925	26 not be less than one year); and
926	926
927	927
928	928
929	929
930	930
931	931	SB0055 - 25 - LRB104 05904 BAB 15935 b
932	932
933	933
934	934	SB0055- 26 -LRB104 05904 BAB 15935 b SB0055 - 26 - LRB104 05904 BAB 15935 b
935	935	SB0055 - 26 - LRB104 05904 BAB 15935 b
936	936	1 (ii) the amount of the refund or additional premium
937	937	2 shall not exceed 20% of the Health Maintenance
938	938	3 Organization's profitable or unprofitable experience with
939	939	4 respect to the group or other enrollment unit for the
940	940	5 period (and, for purposes of a refund or additional
941	941	6 premium, the profitable or unprofitable experience shall
942	942	7 be calculated taking into account a pro rata share of the
943	943	8 Health Maintenance Organization's administrative and
944	944	9 marketing expenses, but shall not include any refund to be
945	945	10 made or additional premium to be paid pursuant to this
946	946	11 subsection (f)). The Health Maintenance Organization and
947	947	12 the group or enrollment unit may agree that the profitable
948	948	13 or unprofitable experience may be calculated taking into
949	949	14 account the refund period and the immediately preceding 2
950	950	15 plan years.
951	951	16 The Health Maintenance Organization shall include a
952	952	17 statement in the evidence of coverage issued to each enrollee
953	953	18 describing the possibility of a refund or additional premium,
954	954	19 and upon request of any group or enrollment unit, provide to
955	955	20 the group or enrollment unit a description of the method used
956	956	21 to calculate (1) the Health Maintenance Organization's
957	957	22 profitable experience with respect to the group or enrollment
958	958	23 unit and the resulting refund to the group or enrollment unit
959	959	24 or (2) the Health Maintenance Organization's unprofitable
960	960	25 experience with respect to the group or enrollment unit and
961	961	26 the resulting additional premium to be paid by the group or
962	962
963	963
964	964
965	965
966	966
967	967	SB0055 - 26 - LRB104 05904 BAB 15935 b
968	968
969	969
970	970	SB0055- 27 -LRB104 05904 BAB 15935 b SB0055 - 27 - LRB104 05904 BAB 15935 b
971	971	SB0055 - 27 - LRB104 05904 BAB 15935 b
972	972	1 enrollment unit.
973	973	2 In no event shall the Illinois Health Maintenance
974	974	3 Organization Guaranty Association be liable to pay any
975	975	4 contractual obligation of an insolvent organization to pay any
976	976	5 refund authorized under this Section.
977	977	6 (g) Rulemaking authority to implement Public Act 95-1045,
978	978	7 if any, is conditioned on the rules being adopted in
979	979	8 accordance with all provisions of the Illinois Administrative
980	980	9 Procedure Act and all rules and procedures of the Joint
981	981	10 Committee on Administrative Rules; any purported rule not so
982	982	11 adopted, for whatever reason, is unauthorized.
983	983	12 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
984	984	13 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
985	985	14 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
986	986	15 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
987	987	16 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
988	988	17 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
989	989	18 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
990	990	19 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
991	991	20 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
992	992	21 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
993	993	22 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
994	994	23 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
995	995	24 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
996	996	25 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
997	997	26 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
998	998
999	999
1000	1000
1001	1001
1002	1002
1003	1003	SB0055 - 27 - LRB104 05904 BAB 15935 b
1004	1004
1005	1005
1006	1006	SB0055- 28 -LRB104 05904 BAB 15935 b SB0055 - 28 - LRB104 05904 BAB 15935 b
1007	1007	SB0055 - 28 - LRB104 05904 BAB 15935 b
1008	1008	1 11-26-24.)
1009	1009	2 Section 95. No acceleration or delay. Where this Act makes
1010	1010	3 changes in a statute that is represented in this Act by text
1011	1011	4 that is not yet or no longer in effect (for example, a Section
1012	1012	5 represented by multiple versions), the use of that text does
1013	1013	6 not accelerate or delay the taking effect of (i) the changes
1014	1014	7 made by this Act or (ii) provisions derived from any other
1015	1015	8 Public Act.
1016	1016
1017	1017
1018	1018
1019	1019
1020	1020
1021	1021	SB0055 - 28 - LRB104 05904 BAB 15935 b