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SB0175 Enrolled LRB104 06566 BAB 16602 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
6 (5 ILCS 375/6.11)
7 Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall
9 provide the post-mastectomy care benefits required to be
10 covered by a policy of accident and health insurance under
11 Section 356t of the Illinois Insurance Code. The program of
12 health benefits shall provide the coverage required under
13 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10,
14 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
15 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
16 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
17 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
18 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
19 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and
20 356z.70, and 356z.71, 356z.74, 356z.76, 356z.77, and 356z.80
21 of the Illinois Insurance Code. The program of health benefits
22 must comply with Sections 155.22a, 155.37, 355b, 356z.19,
23 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance
SB0175 Enrolled -2- LRB104 06566 BAB 16602 b
1 Code. The program of health benefits shall provide the
2 coverage required under Section 356m of the Illinois Insurance
3 Code and, for the employees of the State Employee Group
4 Insurance Program only, the coverage as also provided in
5 Section 6.11B of this Act. The Department of Insurance shall
6 enforce the requirements of this Section with respect to
7 Sections 370c and 370c.1 of the Illinois Insurance Code; all
8 other requirements of this Section shall be enforced by the
9 Department of Central Management Services.
10 Rulemaking authority to implement Public Act 95-1045, if
11 any, is conditioned on the rules being adopted in accordance
12 with all provisions of the Illinois Administrative Procedure
13 Act and all rules and procedures of the Joint Committee on
14 Administrative Rules; any purported rule not so adopted, for
15 whatever reason, is unauthorized.
16 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
17 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
18 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
19 eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
20 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
21 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
22 eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
23 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
24 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751,
25 eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25;
26 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff.
SB0175 Enrolled -3- LRB104 06566 BAB 16602 b
1 1-1-25; revised 11-26-24.)
2 Section 10. The Counties Code is amended by changing
3 Section 5-1069.3 as follows:
4 (55 ILCS 5/5-1069.3)
5 Sec. 5-1069.3. Required health benefits. If a county,
6 including a home rule county, is a self-insurer for purposes
7 of providing health insurance coverage for its employees, the
8 coverage shall include coverage for the post-mastectomy care
9 benefits required to be covered by a policy of accident and
10 health insurance under Section 356t and the coverage required
11 under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u,
12 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9,
13 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
14 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36,
15 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
16 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
17 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71,
18 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code.
19 The coverage shall comply with Sections 155.22a, 355b,
20 356z.19, and 370c of the Illinois Insurance Code. The
21 Department of Insurance shall enforce the requirements of this
22 Section. The requirement that health benefits be covered as
23 provided in this Section is an exclusive power and function of
24 the State and is a denial and limitation under Article VII,
SB0175 Enrolled -4- LRB104 06566 BAB 16602 b
1 Section 6, subsection (h) of the Illinois Constitution. A home
2 rule county to which this Section applies must comply with
3 every provision of this Section.
4 Rulemaking authority to implement Public Act 95-1045, if
5 any, is conditioned on the rules being adopted in accordance
6 with all provisions of the Illinois Administrative Procedure
7 Act and all rules and procedures of the Joint Committee on
8 Administrative Rules; any purported rule not so adopted, for
9 whatever reason, is unauthorized.
10 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
11 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
12 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
13 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
14 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
15 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
16 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
17 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
18 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
19 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
20 revised 11-26-24.)
21 Section 15. The Illinois Municipal Code is amended by
22 changing Section 10-4-2.3 as follows:
23 (65 ILCS 5/10-4-2.3)
24 Sec. 10-4-2.3. Required health benefits. If a
SB0175 Enrolled -5- LRB104 06566 BAB 16602 b
1 municipality, including a home rule municipality, is a
2 self-insurer for purposes of providing health insurance
3 coverage for its employees, the coverage shall include
4 coverage for the post-mastectomy care benefits required to be
5 covered by a policy of accident and health insurance under
6 Section 356t and the coverage required under Sections 356g,
7 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
8 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
9 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
10 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
11 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54,
12 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
13 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77,
14 and 356z.80 of the Illinois Insurance Code. The coverage shall
15 comply with Sections 155.22a, 355b, 356z.19, and 370c of the
16 Illinois Insurance Code. The Department of Insurance shall
17 enforce the requirements of this Section. The requirement that
18 health benefits be covered as provided in this is an exclusive
19 power and function of the State and is a denial and limitation
20 under Article VII, Section 6, subsection (h) of the Illinois
21 Constitution. A home rule municipality to which this Section
22 applies must comply with every provision of this Section.
23 Rulemaking authority to implement Public Act 95-1045, if
24 any, is conditioned on the rules being adopted in accordance
25 with all provisions of the Illinois Administrative Procedure
26 Act and all rules and procedures of the Joint Committee on
SB0175 Enrolled -6- LRB104 06566 BAB 16602 b
1 Administrative Rules; any purported rule not so adopted, for
2 whatever reason, is unauthorized.
3 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
4 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
5 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
6 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
7 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
8 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
9 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
10 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
11 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
12 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
13 revised 11-26-24.)
14 Section 20. The School Code is amended by changing Section
15 10-22.3f as follows:
16 (105 ILCS 5/10-22.3f)
17 Sec. 10-22.3f. Required health benefits. Insurance
18 protection and benefits for employees shall provide the
19 post-mastectomy care benefits required to be covered by a
20 policy of accident and health insurance under Section 356t and
21 the coverage required under Sections 356g, 356g.5, 356g.5-1,
22 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,
23 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
24 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
SB0175 Enrolled -7- LRB104 06566 BAB 16602 b
1 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
2 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
3 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and
4 356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois
5 Insurance Code. Insurance policies shall comply with Section
6 356z.19 of the Illinois Insurance Code. The coverage shall
7 comply with Sections 155.22a, 355b, and 370c of the Illinois
8 Insurance Code. The Department of Insurance shall enforce the
9 requirements of this Section.
10 Rulemaking authority to implement Public Act 95-1045, if
11 any, is conditioned on the rules being adopted in accordance
12 with all provisions of the Illinois Administrative Procedure
13 Act and all rules and procedures of the Joint Committee on
14 Administrative Rules; any purported rule not so adopted, for
15 whatever reason, is unauthorized.
16 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
17 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
18 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
19 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
20 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
21 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
22 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
23 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
24 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,
25 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
SB0175 Enrolled -8- LRB104 06566 BAB 16602 b
1 Section 25. The Illinois Insurance Code is amended by
2 adding Section 356z.80 as follows:
3 (215 ILCS 5/356z.80 new)
4 Sec. 356z.80. Coverage for testing for Klinefelter
5 syndrome. A group or individual policy of accident and health
6 insurance or a managed care plan that is amended, delivered,
7 issued, or renewed on or after January 1, 2027 shall provide
8 coverage for a karyotype test or related hormone testing to
9 diagnose Klinefelter syndrome.
10 Section 30. The Health Maintenance Organization Act is
11 amended by changing Section 5-3 as follows:
12 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
13 (Text of Section before amendment by P.A. 103-808)
14 Sec. 5-3. Insurance Code provisions.
15 (a) Health Maintenance Organizations shall be subject to
16 the provisions of Sections 133, 134, 136, 137, 139, 140,
17 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
18 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
19 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
20 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
21 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
22 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
23 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
SB0175 Enrolled -9- LRB104 06566 BAB 16602 b
1 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
2 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
3 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
4 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
5 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
6 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
7 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
8 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
9 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
10 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
11 subsection (2) of Section 367, and Articles IIA, VIII 1/2,
12 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
13 Illinois Insurance Code.
14 (b) For purposes of the Illinois Insurance Code, except
15 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
16 Health Maintenance Organizations in the following categories
17 are deemed to be "domestic companies":
18 (1) a corporation authorized under the Dental Service
19 Plan Act or the Voluntary Health Services Plans Act;
20 (2) a corporation organized under the laws of this
21 State; or
22 (3) a corporation organized under the laws of another
23 state, 30% or more of the enrollees of which are residents
24 of this State, except a corporation subject to
25 substantially the same requirements in its state of
26 organization as is a "domestic company" under Article VIII
SB0175 Enrolled - 10 - LRB104 06566 BAB 16602 b
1 1/2 of the Illinois Insurance Code.
2 (c) In considering the merger, consolidation, or other
3 acquisition of control of a Health Maintenance Organization
4 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
5 (1) the Director shall give primary consideration to
6 the continuation of benefits to enrollees and the
7 financial conditions of the acquired Health Maintenance
8 Organization after the merger, consolidation, or other
9 acquisition of control takes effect;
10 (2)(i) the criteria specified in subsection (1)(b) of
11 Section 131.8 of the Illinois Insurance Code shall not
12 apply and (ii) the Director, in making his determination
13 with respect to the merger, consolidation, or other
14 acquisition of control, need not take into account the
15 effect on competition of the merger, consolidation, or
16 other acquisition of control;
17 (3) the Director shall have the power to require the
18 following information:
19 (A) certification by an independent actuary of the
20 adequacy of the reserves of the Health Maintenance
21 Organization sought to be acquired;
22 (B) pro forma financial statements reflecting the
23 combined balance sheets of the acquiring company and
24 the Health Maintenance Organization sought to be
25 acquired as of the end of the preceding year and as of
26 a date 90 days prior to the acquisition, as well as pro
SB0175 Enrolled - 11 - LRB104 06566 BAB 16602 b
1 forma financial statements reflecting projected
2 combined operation for a period of 2 years;
3 (C) a pro forma business plan detailing an
4 acquiring party's plans with respect to the operation
5 of the Health Maintenance Organization sought to be
6 acquired for a period of not less than 3 years; and
7 (D) such other information as the Director shall
8 require.
9 (d) The provisions of Article VIII 1/2 of the Illinois
10 Insurance Code and this Section 5-3 shall apply to the sale by
11 any health maintenance organization of greater than 10% of its
12 enrollee population (including, without limitation, the health
13 maintenance organization's right, title, and interest in and
14 to its health care certificates).
15 (e) In considering any management contract or service
16 agreement subject to Section 141.1 of the Illinois Insurance
17 Code, the Director (i) shall, in addition to the criteria
18 specified in Section 141.2 of the Illinois Insurance Code,
19 take into account the effect of the management contract or
20 service agreement on the continuation of benefits to enrollees
21 and the financial condition of the health maintenance
22 organization to be managed or serviced, and (ii) need not take
23 into account the effect of the management contract or service
24 agreement on competition.
25 (f) Except for small employer groups as defined in the
26 Small Employer Rating, Renewability and Portability Health
SB0175 Enrolled - 12 - LRB104 06566 BAB 16602 b
1 Insurance Act and except for medicare supplement policies as
2 defined in Section 363 of the Illinois Insurance Code, a
3 Health Maintenance Organization may by contract agree with a
4 group or other enrollment unit to effect refunds or charge
5 additional premiums under the following terms and conditions:
6 (i) the amount of, and other terms and conditions with
7 respect to, the refund or additional premium are set forth
8 in the group or enrollment unit contract agreed in advance
9 of the period for which a refund is to be paid or
10 additional premium is to be charged (which period shall
11 not be less than one year); and
12 (ii) the amount of the refund or additional premium
13 shall not exceed 20% of the Health Maintenance
14 Organization's profitable or unprofitable experience with
15 respect to the group or other enrollment unit for the
16 period (and, for purposes of a refund or additional
17 premium, the profitable or unprofitable experience shall
18 be calculated taking into account a pro rata share of the
19 Health Maintenance Organization's administrative and
20 marketing expenses, but shall not include any refund to be
21 made or additional premium to be paid pursuant to this
22 subsection (f)). The Health Maintenance Organization and
23 the group or enrollment unit may agree that the profitable
24 or unprofitable experience may be calculated taking into
25 account the refund period and the immediately preceding 2
26 plan years.
SB0175 Enrolled - 13 - LRB104 06566 BAB 16602 b
1 The Health Maintenance Organization shall include a
2 statement in the evidence of coverage issued to each enrollee
3 describing the possibility of a refund or additional premium,
4 and upon request of any group or enrollment unit, provide to
5 the group or enrollment unit a description of the method used
6 to calculate (1) the Health Maintenance Organization's
7 profitable experience with respect to the group or enrollment
8 unit and the resulting refund to the group or enrollment unit
9 or (2) the Health Maintenance Organization's unprofitable
10 experience with respect to the group or enrollment unit and
11 the resulting additional premium to be paid by the group or
12 enrollment unit.
13 In no event shall the Illinois Health Maintenance
14 Organization Guaranty Association be liable to pay any
15 contractual obligation of an insolvent organization to pay any
16 refund authorized under this Section.
17 (g) Rulemaking authority to implement Public Act 95-1045,
18 if any, is conditioned on the rules being adopted in
19 accordance with all provisions of the Illinois Administrative
20 Procedure Act and all rules and procedures of the Joint
21 Committee on Administrative Rules; any purported rule not so
22 adopted, for whatever reason, is unauthorized.
23 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
24 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
25 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
26 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
SB0175 Enrolled - 14 - LRB104 06566 BAB 16602 b
1 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
2 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
3 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
4 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
5 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
6 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
7 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
8 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
9 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
10 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
11 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
12 (Text of Section after amendment by P.A. 103-808)
13 Sec. 5-3. Insurance Code provisions.
14 (a) Health Maintenance Organizations shall be subject to
15 the provisions of Sections 133, 134, 136, 137, 139, 140,
16 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
17 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
18 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
19 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
20 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
21 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
22 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
23 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
24 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
25 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
SB0175 Enrolled - 15 - LRB104 06566 BAB 16602 b
1 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
2 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
3 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
4 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
5 356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i,
6 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402,
7 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
8 of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
9 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
10 Illinois Insurance Code.
11 (b) For purposes of the Illinois Insurance Code, except
12 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
13 Health Maintenance Organizations in the following categories
14 are deemed to be "domestic companies":
15 (1) a corporation authorized under the Dental Service
16 Plan Act or the Voluntary Health Services Plans Act;
17 (2) a corporation organized under the laws of this
18 State; or
19 (3) a corporation organized under the laws of another
20 state, 30% or more of the enrollees of which are residents
21 of this State, except a corporation subject to
22 substantially the same requirements in its state of
23 organization as is a "domestic company" under Article VIII
24 1/2 of the Illinois Insurance Code.
25 (c) In considering the merger, consolidation, or other
26 acquisition of control of a Health Maintenance Organization
SB0175 Enrolled - 16 - LRB104 06566 BAB 16602 b
1 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
2 (1) the Director shall give primary consideration to
3 the continuation of benefits to enrollees and the
4 financial conditions of the acquired Health Maintenance
5 Organization after the merger, consolidation, or other
6 acquisition of control takes effect;
7 (2)(i) the criteria specified in subsection (1)(b) of
8 Section 131.8 of the Illinois Insurance Code shall not
9 apply and (ii) the Director, in making his determination
10 with respect to the merger, consolidation, or other
11 acquisition of control, need not take into account the
12 effect on competition of the merger, consolidation, or
13 other acquisition of control;
14 (3) the Director shall have the power to require the
15 following information:
16 (A) certification by an independent actuary of the
17 adequacy of the reserves of the Health Maintenance
18 Organization sought to be acquired;
19 (B) pro forma financial statements reflecting the
20 combined balance sheets of the acquiring company and
21 the Health Maintenance Organization sought to be
22 acquired as of the end of the preceding year and as of
23 a date 90 days prior to the acquisition, as well as pro
24 forma financial statements reflecting projected
25 combined operation for a period of 2 years;
26 (C) a pro forma business plan detailing an
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1 acquiring party's plans with respect to the operation
2 of the Health Maintenance Organization sought to be
3 acquired for a period of not less than 3 years; and
4 (D) such other information as the Director shall
5 require.
6 (d) The provisions of Article VIII 1/2 of the Illinois
7 Insurance Code and this Section 5-3 shall apply to the sale by
8 any health maintenance organization of greater than 10% of its
9 enrollee population (including, without limitation, the health
10 maintenance organization's right, title, and interest in and
11 to its health care certificates).
12 (e) In considering any management contract or service
13 agreement subject to Section 141.1 of the Illinois Insurance
14 Code, the Director (i) shall, in addition to the criteria
15 specified in Section 141.2 of the Illinois Insurance Code,
16 take into account the effect of the management contract or
17 service agreement on the continuation of benefits to enrollees
18 and the financial condition of the health maintenance
19 organization to be managed or serviced, and (ii) need not take
20 into account the effect of the management contract or service
21 agreement on competition.
22 (f) Except for small employer groups as defined in the
23 Small Employer Rating, Renewability and Portability Health
24 Insurance Act and except for medicare supplement policies as
25 defined in Section 363 of the Illinois Insurance Code, a
26 Health Maintenance Organization may by contract agree with a
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1 group or other enrollment unit to effect refunds or charge
2 additional premiums under the following terms and conditions:
3 (i) the amount of, and other terms and conditions with
4 respect to, the refund or additional premium are set forth
5 in the group or enrollment unit contract agreed in advance
6 of the period for which a refund is to be paid or
7 additional premium is to be charged (which period shall
8 not be less than one year); and
9 (ii) the amount of the refund or additional premium
10 shall not exceed 20% of the Health Maintenance
11 Organization's profitable or unprofitable experience with
12 respect to the group or other enrollment unit for the
13 period (and, for purposes of a refund or additional
14 premium, the profitable or unprofitable experience shall
15 be calculated taking into account a pro rata share of the
16 Health Maintenance Organization's administrative and
17 marketing expenses, but shall not include any refund to be
18 made or additional premium to be paid pursuant to this
19 subsection (f)). The Health Maintenance Organization and
20 the group or enrollment unit may agree that the profitable
21 or unprofitable experience may be calculated taking into
22 account the refund period and the immediately preceding 2
23 plan years.
24 The Health Maintenance Organization shall include a
25 statement in the evidence of coverage issued to each enrollee
26 describing the possibility of a refund or additional premium,
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1 and upon request of any group or enrollment unit, provide to
2 the group or enrollment unit a description of the method used
3 to calculate (1) the Health Maintenance Organization's
4 profitable experience with respect to the group or enrollment
5 unit and the resulting refund to the group or enrollment unit
6 or (2) the Health Maintenance Organization's unprofitable
7 experience with respect to the group or enrollment unit and
8 the resulting additional premium to be paid by the group or
9 enrollment unit.
10 In no event shall the Illinois Health Maintenance
11 Organization Guaranty Association be liable to pay any
12 contractual obligation of an insolvent organization to pay any
13 refund authorized under this Section.
14 (g) Rulemaking authority to implement Public Act 95-1045,
15 if any, is conditioned on the rules being adopted in
16 accordance with all provisions of the Illinois Administrative
17 Procedure Act and all rules and procedures of the Joint
18 Committee on Administrative Rules; any purported rule not so
19 adopted, for whatever reason, is unauthorized.
20 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
21 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
22 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
23 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
24 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
25 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
26 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
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1 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
2 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
3 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
4 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
5 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
6 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
7 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
8 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
9 11-26-24.)
10 Section 35. The Limited Health Service Organization Act is
11 amended by changing Section 4003 as follows:
12 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
13 Sec. 4003. Illinois Insurance Code provisions. Limited
14 health service organizations shall be subject to the
15 provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
16 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153,
17 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c,
18 355.2, 355.3, 355b, 355d, 356m, 356q, 356v, 356z.4, 356z.4a,
19 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.32,
20 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54,
21 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, 356z.71,
22 356z.73, 356z.74, 356z.75, 356z.80, 364.3, 368a, 401, 401.1,
23 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and
24 Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and
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1 XXVI of the Illinois Insurance Code. Nothing in this Section
2 shall require a limited health care plan to cover any service
3 that is not a limited health service. For purposes of the
4 Illinois Insurance Code, except for Sections 444 and 444.1 and
5 Articles XIII and XIII 1/2, limited health service
6 organizations in the following categories are deemed to be
7 domestic companies:
8 (1) a corporation under the laws of this State; or
9 (2) a corporation organized under the laws of another
10 state, 30% or more of the enrollees of which are residents
11 of this State, except a corporation subject to
12 substantially the same requirements in its state of
13 organization as is a domestic company under Article VIII
14 1/2 of the Illinois Insurance Code.
15 (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
16 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
17 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
18 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
19 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
20 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
21 eff. 1-1-24; 103-605, eff. 7-1-24; 103-649, eff. 1-1-25;
22 103-656, eff. 1-1-25; 103-700, eff. 1-1-25; 103-718, eff.
23 7-19-24; 103-751, eff. 8-2-24; 103-758, eff. 1-1-25; 103-832,
24 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
25 Section 40. The Voluntary Health Services Plans Act is
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1 amended by changing Section 10 as follows:
2 (215 ILCS 165/10) (from Ch. 32, par. 604)
3 Sec. 10. Application of Insurance Code provisions. Health
4 services plan corporations and all persons interested therein
5 or dealing therewith shall be subject to the provisions of
6 Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
7 143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3,
8 355b, 355d, 356g, 356g.5, 356g.5-1, 356m, 356q, 356r, 356t,
9 356u, 356u.10, 356v, 356w, 356x, 356y, 356z.1, 356z.2,
10 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
11 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
12 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
13 356z.32, 356z.32a, 356z.33, 356z.40, 356z.41, 356z.46,
14 356z.47, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59,
15 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.71,
16 356z.72, 356z.74, 356z.75, 356z.77, 356z.80, 364.01, 364.3,
17 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
18 and paragraphs (7) and (15) of Section 367 of the Illinois
19 Insurance Code.
20 Rulemaking authority to implement Public Act 95-1045, if
21 any, is conditioned on the rules being adopted in accordance
22 with all provisions of the Illinois Administrative Procedure
23 Act and all rules and procedures of the Joint Committee on
24 Administrative Rules; any purported rule not so adopted, for
25 whatever reason, is unauthorized.
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1 (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
2 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
3 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
4 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
5 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
6 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
7 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
8 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-656, eff.
9 1-1-25; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-753,
10 eff. 8-2-24; 103-758, eff. 1-1-25; 103-832, eff. 1-1-25;
11 103-914, eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff.
12 1-1-25; revised 11-26-24.)
13 Section 45. The Illinois Public Aid Code is amended by
14 changing Section 5-16.8 as follows:
15 (305 ILCS 5/5-16.8)
16 Sec. 5-16.8. Required health benefits. The medical
17 assistance program shall (i) provide the post-mastectomy care
18 benefits required to be covered by a policy of accident and
19 health insurance under Section 356t and the coverage required
20 under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6,
21 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46,
22 356z.47, 356z.51, 356z.53, 356z.59, 356z.60, 356z.61, 356z.64,
23 and 356z.67, and 356z.71, 356z.75, and 356z.80 of the Illinois
24 Insurance Code, (ii) be subject to the provisions of Sections
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1 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the
2 Illinois Insurance Code, and (iii) be subject to the
3 provisions of subsection (d-5) of Section 10 of the Network
4 Adequacy and Transparency Act.
5 The Department, by rule, shall adopt a model similar to
6 the requirements of Section 356z.39 of the Illinois Insurance
7 Code.
8 On and after July 1, 2012, the Department shall reduce any
9 rate of reimbursement for services or other payments or alter
10 any methodologies authorized by this Code to reduce any rate
11 of reimbursement for services or other payments in accordance
12 with Section 5-5e.
13 To ensure full access to the benefits set forth in this
14 Section, on and after January 1, 2016, the Department shall
15 ensure that provider and hospital reimbursement for
16 post-mastectomy care benefits required under this Section are
17 no lower than the Medicare reimbursement rate.
18 (Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22;
19 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff.
20 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813,
21 eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23;
22 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
23 1-1-24; 103-420, eff. 1-1-24; 103-605, eff. 7-1-24; 103-703,
24 eff. 1-1-25; 103-758, eff. 1-1-25; 103-1024, eff. 1-1-25;
25 revised 11-26-24.)
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1 Section 95. No acceleration or delay. Where this Act makes
2 changes in a statute that is represented in this Act by text
3 that is not yet or no longer in effect (for example, a Section
4 represented by multiple versions), the use of that text does
5 not accelerate or delay the taking effect of (i) the changes
6 made by this Act or (ii) provisions derived from any other
7 Public Act.Every fact on this page links to its source, starting with the official bill record.