| ||||
| Public Act 103-0751 | ||||
| ||||
AN ACT concerning regulation. | ||||
Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly: | ||||
Section 5. The State Employees Group Insurance Act of 1971 | ||||
is amended by changing Sections 6.11 and 6.11B as follows: | ||||
(5 ILCS 375/6.11) | ||||
Sec. 6.11. Required health benefits; Illinois Insurance | ||||
Code requirements. The program of health benefits shall | ||||
provide the post-mastectomy care benefits required to be | ||||
covered by a policy of accident and health insurance under | ||||
Section 356t of the Illinois Insurance Code. The program of | ||||
health benefits shall provide the coverage required under | ||||
Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, | ||||
356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, | ||||
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, | ||||
356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | ||||
356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, | ||||
356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, | ||||
and 356z.61, and 356z.62, 356z.64, 356z.67, 356z.68, 356z.70, | ||||
and 356z.71 of the Illinois Insurance Code. The program of | ||||
health benefits must comply with Sections 155.22a, 155.37, | ||||
355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the | ||||
Illinois Insurance Code. The program of health benefits shall | ||||
provide the coverage required under Section 356m of the | ||
Illinois Insurance Code and, for the employees of the State | ||
Employee Group Insurance Program only, the coverage as also | ||
provided in Section 6.11B of this Act. The Department of | ||
Insurance shall enforce the requirements of this Section with | ||
respect to Sections 370c and 370c.1 of the Illinois Insurance | ||
Code; all other requirements of this Section shall be enforced | ||
by the Department of Central Management Services. | ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. | ||
1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, | ||
eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||
1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, | ||
eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; | ||
103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. | ||
8-11-23; revised 8-29-23.) | ||
(5 ILCS 375/6.11B) | ||
Sec. 6.11B. Infertility coverage. | ||
(a) Beginning on January 1, 2024, the State Employees | ||
Group Insurance Program shall provide coverage for the | ||
diagnosis and treatment of infertility, including, but not | ||
limited to, in vitro fertilization, uterine embryo lavage, | ||
embryo transfer, artificial insemination, gamete | ||
intrafallopian tube transfer, zygote intrafallopian tube | ||
transfer, and low tubal ovum transfer. The coverage required | ||
shall include procedures necessary to screen or diagnose a | ||
fertilized egg before implantation, including, but not limited | ||
to, preimplantation genetic diagnosis, preimplantation genetic | ||
screening, and prenatal genetic diagnosis. | ||
(b) Beginning on January 1, 2024, coverage under this | ||
Section for procedures for in vitro fertilization, gamete | ||
intrafallopian tube transfer, or zygote intrafallopian tube | ||
transfer shall be required only if the procedures: | ||
(1) are considered medically appropriate based on | ||
clinical guidelines or standards developed by the American | ||
Society for Reproductive Medicine, the American College of | ||
Obstetricians and Gynecologists, or the Society for | ||
Assisted Reproductive Technology; and | ||
(2) are performed at medical facilities or clinics | ||
that conform to the American College of Obstetricians and | ||
Gynecologists guidelines for in vitro fertilization or the | ||
American Society for Reproductive Medicine minimum | ||
standards for practices offering assisted reproductive | ||
technologies. | ||
(c) As used in this Section, "infertility" means a | ||
disease, condition, or status characterized by: | ||
(1) a failure to establish a pregnancy or to carry a | ||
pregnancy to live birth after 12 months of regular, | ||
unprotected sexual intercourse if the woman is 35 years of | ||
age or younger, or after 6 months of regular, unprotected | ||
sexual intercourse if the woman is over 35 years of age; | ||
conceiving but having a miscarriage does not restart the | ||
12-month or 6-month term for determining infertility; | ||
(2) a person's inability to reproduce either as a | ||
single individual or with a partner without medical | ||
intervention; or | ||
(3) a licensed physician's findings based on a | ||
patient's medical, sexual, and reproductive history, age, | ||
physical findings, or diagnostic testing. | ||
(d) The State Employees Group Insurance Program may not | ||
impose any exclusions, limitations, or other restrictions on | ||
coverage of fertility medications that are different from | ||
those imposed on any other prescription medications, nor may | ||
it impose any exclusions, limitations, or other restrictions | ||
on coverage of any fertility services based on a covered | ||
individual's participation in fertility services provided by | ||
or to a third party, nor may it impose deductibles, | ||
copayments, coinsurance, benefit maximums, waiting periods, or | ||
any other limitations on coverage for the diagnosis of | ||
infertility, treatment for infertility, and standard fertility | ||
preservation services, except as provided in this Section, | ||
that are different from those imposed upon benefits for | ||
services not related to infertility. | ||
(e) This Section applies only to coverage provided on or | ||
after January 1, 2024 and before July 1, 2026. | ||
(f) This Section is repealed on July 1, 2026. | ||
(Source: P.A. 103-8, eff. 1-1-24.) | ||
Section 10. The Counties Code is amended by changing | ||
Section 5-1069.3 as follows: | ||
(55 ILCS 5/5-1069.3) | ||
Sec. 5-1069.3. Required health benefits. If a county, | ||
including a home rule county, is a self-insurer for purposes | ||
of providing health insurance coverage for its employees, the | ||
coverage shall include coverage for the post-mastectomy care | ||
benefits required to be covered by a policy of accident and | ||
health insurance under Section 356t and the coverage required | ||
under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, | ||
356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, | ||
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | ||
356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, | ||
356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, | ||
356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, and | ||
356z.61, and 356z.62, 356z.64, 356z.67, 356z.68, 356z.70, and | ||
356z.71 of the Illinois Insurance Code. The coverage shall | ||
comply with Sections 155.22a, 355b, 356z.19, and 370c of the | ||
Illinois Insurance Code. The Department of Insurance shall | ||
enforce the requirements of this Section. The requirement that | ||
health benefits be covered as provided in this Section is an | ||
exclusive power and function of the State and is a denial and | ||
limitation under Article VII, Section 6, subsection (h) of the | ||
Illinois Constitution. A home rule county to which this | ||
Section applies must comply with every provision of this | ||
Section. | ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||
1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | ||
eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||
103-535, eff. 8-11-23; 103-551, eff. 8-11-23; revised | ||
8-29-23.) | ||
Section 15. The Illinois Municipal Code is amended by | ||
changing Section 10-4-2.3 as follows: | ||
(65 ILCS 5/10-4-2.3) | ||
Sec. 10-4-2.3. Required health benefits. If a | ||
municipality, including a home rule municipality, is a | ||
self-insurer for purposes of providing health insurance | ||
coverage for its employees, the coverage shall include | ||
coverage for the post-mastectomy care benefits required to be | ||
covered by a policy of accident and health insurance under | ||
Section 356t and the coverage required under Sections 356g, | ||
356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x, 356z.4, | ||
356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||
356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | ||
356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, | ||
356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, | ||
356z.56, 356z.57, 356z.59, 356z.60, and 356z.61, and 356z.62, | ||
356z.64, 356z.67, 356z.68, 356z.70, and 356z.71 of the | ||
Illinois Insurance Code. The coverage shall comply with | ||
Sections 155.22a, 355b, 356z.19, and 370c of the Illinois | ||
Insurance Code. The Department of Insurance shall enforce the | ||
requirements of this Section. The requirement that health | ||
benefits be covered as provided in this is an exclusive power | ||
and function of the State and is a denial and limitation under | ||
Article VII, Section 6, subsection (h) of the Illinois | ||
Constitution. A home rule municipality to which this Section | ||
applies must comply with every provision of this Section. | ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||
1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | ||
eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||
103-535, eff. 8-11-23; 103-551, eff. 8-11-23; revised | ||
8-29-23.) | ||
Section 20. The School Code is amended by changing Section | ||
10-22.3f as follows: | ||
(105 ILCS 5/10-22.3f) | ||
Sec. 10-22.3f. Required health benefits. Insurance | ||
protection and benefits for employees shall provide the | ||
post-mastectomy care benefits required to be covered by a | ||
policy of accident and health insurance under Section 356t and | ||
the coverage required under Sections 356g, 356g.5, 356g.5-1, | ||
356m, 356q, 356u, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, | ||
356z.9, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, | ||
356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | ||
356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, | ||
356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, and | ||
356z.61, and 356z.62, 356z.64, 356z.67, 356z.68, 356z.70, and | ||
356z.71 of the Illinois Insurance Code. Insurance policies | ||
shall comply with Section 356z.19 of the Illinois Insurance | ||
Code. The coverage shall comply with Sections 155.22a, 355b, | ||
and 370c of the Illinois Insurance Code. The Department of | ||
Insurance shall enforce the requirements of this Section. | ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. | ||
1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, | ||
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||
102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. | ||
1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, | ||
eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; | ||
103-551, eff. 8-11-23; revised 8-29-23.) | ||
Section 25. The Illinois Insurance Code is amended by | ||
changing Sections 356m and 356z.32 and by adding Section | ||
356z.71 as follows: | ||
(215 ILCS 5/356m) (from Ch. 73, par. 968m) | ||
Sec. 356m. Infertility coverage. | ||
(a) No group policy of accident and health insurance | ||
providing coverage for more than 25 employees that provides | ||
pregnancy-related pregnancy related benefits may be issued, | ||
amended, delivered, or renewed in this State after January 1, | ||
2016 and through December 31, 2025 the effective date of this | ||
amendatory Act of the 99th General Assembly unless the policy | ||
contains coverage for the diagnosis and treatment of | ||
infertility including, but not limited to, in vitro | ||
fertilization, uterine embryo lavage, embryo transfer, | ||
artificial insemination, gamete intrafallopian tube transfer, | ||
zygote intrafallopian tube transfer, and low tubal ovum | ||
transfer. | ||
(a-5) No group policy of accident and health insurance | ||
that provides pregnancy-related benefits may be issued, | ||
amended, delivered, or renewed in this State on or after | ||
January 1, 2026 unless the policy contains coverage for the | ||
diagnosis and treatment of infertility, including, but not | ||
limited to, in vitro fertilization, uterine embryo lavage, | ||
embryo transfer, artificial insemination, gamete | ||
intrafallopian tube transfer, zygote intrafallopian tube | ||
transfer, surgical sperm extraction procedures, and low tubal | ||
ovum transfer. The coverage required shall include procedures | ||
necessary to screen or diagnose a fertilized egg before | ||
implantation, including, but not limited to, preimplantation | ||
genetic testing for aneuploidy, preimplantation genetic | ||
testing for chromosome structural rearrangements, and | ||
preimplantation genetic testing for monogenic or single gene | ||
disorders. Coverage under this subsection for the diagnosis | ||
and treatment of infertility shall be required only if the | ||
procedures: | ||
(1) are considered medically appropriate by the | ||
patient's medical provider based on clinical guidelines or | ||
standards developed by the American Society for | ||
Reproductive Medicine, the American College of | ||
Obstetricians and Gynecologists, or the Society for | ||
Assisted Reproductive Technology; and | ||
(2) are performed at medical facilities or clinics | ||
that are members in good standing of the Society for | ||
Assisted Reproductive Technology. | ||
(b) The coverage required under subsection (a) for | ||
procedures for in vitro fertilization, gamete intrafallopian | ||
tube transfer, or zygote intrafallopian tube transfer shall be | ||
required only if is subject to the following conditions: | ||
(1) Coverage for procedures for in vitro | ||
fertilization, gamete intrafallopian tube transfer, or | ||
zygote intrafallopian tube transfer shall be required only | ||
if: | ||
(1) (A) the covered individual has been unable to | ||
attain a viable pregnancy, maintain a viable pregnancy, or | ||
sustain a successful pregnancy through reasonable, less | ||
costly medically appropriate infertility treatments for | ||
which coverage is available under the policy, plan, or | ||
contract; | ||
(2) (B) the covered individual has not undergone 4 | ||
completed oocyte retrievals, except that if a live birth | ||
follows a completed oocyte retrieval, then 2 more | ||
completed oocyte retrievals shall be covered; and | ||
(3) (C) the procedures are performed at medical | ||
facilities that conform to the American College of | ||
Obstetric and Gynecology guidelines for in vitro | ||
fertilization clinics or to the American Fertility Society | ||
minimal standards for programs of in vitro fertilization. | ||
(2) The procedures required to be covered under this | ||
Section are not required to be contained in any policy or | ||
plan issued to or by a religious institution or | ||
organization or to or by an entity sponsored by a | ||
religious institution or organization that finds the | ||
procedures required to be covered under this Section to | ||
violate its religious and moral teachings and beliefs. | ||
(c) As used in this Section, "infertility" means a | ||
disease, condition, or status characterized by: | ||
(1) a failure to establish a pregnancy or to carry a | ||
pregnancy to live birth after 12 months of regular, | ||
unprotected sexual intercourse if the woman is 35 years of | ||
age or younger, or after 6 months of regular, unprotected | ||
sexual intercourse if the woman is over 35 years of age; | ||
conceiving but having a miscarriage does not restart the | ||
12-month or 6-month term for determining infertility; | ||
(2) a person's inability to reproduce either as a | ||
single individual or with a partner without medical | ||
intervention; or | ||
(3) a licensed physician's findings based on a | ||
patient's medical, sexual, and reproductive history, age, | ||
physical findings, or diagnostic testing. | ||
(d) A policy, contract, or certificate may not impose any | ||
exclusions, limitations, or other restrictions on coverage of | ||
fertility medications that are different from those imposed on | ||
any other prescription medications, nor may it impose any | ||
exclusions, limitations, or other restrictions on coverage of | ||
any fertility services based on a covered individual's | ||
participation in fertility services provided by or to a third | ||
party, nor may it impose deductibles, copayments, coinsurance, | ||
benefit maximums, waiting periods, or any other limitations on | ||
coverage for the diagnosis of infertility, treatment for | ||
infertility, and standard fertility preservation services, | ||
except as provided in this Section, that are different from | ||
those imposed upon benefits for services not related to | ||
infertility. | ||
(e) The procedures required to be covered under this | ||
Section are not required to be contained in any policy or plan | ||
issued to or by a religious institution or organization or to | ||
or by an entity sponsored by a religious institution or | ||
organization that finds the procedures required to be covered | ||
under this Section to violate its religious and moral | ||
teachings and beliefs. | ||
(Source: P.A. 102-170, eff. 1-1-22.) | ||
(215 ILCS 5/356z.71 new) | ||
Sec. 356z.71. Coverage for annual menopause health visit. | ||
A group or individual policy of accident and health insurance | ||
providing coverage for more than 25 employees that is amended, | ||
delivered, issued, or renewed on or after January 1, 2026 | ||
shall provide, for individuals 45 years of age and older, | ||
coverage for an annual menopause health visit. A policy | ||
subject to this Section shall not impose a deductible, | ||
coinsurance, copayment, or any other cost-sharing requirement | ||
on the coverage provided; except that this Section does not | ||
apply to this coverage to the extent such coverage would | ||
disqualify a high-deductible health plan from eligibility for | ||
a health savings account pursuant to Section 223 of the | ||
Internal Revenue Code. | ||
Section 30. The Health Maintenance Organization Act is | ||
amended by changing Section 5-3 as follows: | ||
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||
Sec. 5-3. Insurance Code provisions. | ||
(a) Health Maintenance Organizations shall be subject to | ||
the provisions of Sections 133, 134, 136, 137, 139, 140, | ||
141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | ||
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | ||
355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v, | ||
356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, | ||
356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, | ||
356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, | ||
356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, | ||
356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35, | ||
356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, 356z.44, | ||
356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, | ||
356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, | ||
356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, 356z.68, | ||
356z.71, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||
368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||
408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||
subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||
Illinois Insurance Code. | ||
(b) For purposes of the Illinois Insurance Code, except | ||
for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||
Health Maintenance Organizations in the following categories | ||
are deemed to be "domestic companies": | ||
(1) a corporation authorized under the Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act; | ||
(2) a corporation organized under the laws of this | ||
State; or | ||
(3) a corporation organized under the laws of another | ||
state, 30% or more of the enrollees of which are residents | ||
of this State, except a corporation subject to | ||
substantially the same requirements in its state of | ||
organization as is a "domestic company" under Article VIII | ||
1/2 of the Illinois Insurance Code. | ||
(c) In considering the merger, consolidation, or other | ||
acquisition of control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||
(1) the Director shall give primary consideration to | ||
the continuation of benefits to enrollees and the | ||
financial conditions of the acquired Health Maintenance | ||
Organization after the merger, consolidation, or other | ||
acquisition of control takes effect; | ||
(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making his determination | ||
with respect to the merger, consolidation, or other | ||
acquisition of control, need not take into account the | ||
effect on competition of the merger, consolidation, or | ||
other acquisition of control; | ||
(3) the Director shall have the power to require the | ||
following information: | ||
(A) certification by an independent actuary of the | ||
adequacy of the reserves of the Health Maintenance | ||
Organization sought to be acquired; | ||
(B) pro forma financial statements reflecting the | ||
combined balance sheets of the acquiring company and | ||
the Health Maintenance Organization sought to be | ||
acquired as of the end of the preceding year and as of | ||
a date 90 days prior to the acquisition, as well as pro | ||
forma financial statements reflecting projected | ||
combined operation for a period of 2 years; | ||
(C) a pro forma business plan detailing an | ||
acquiring party's plans with respect to the operation | ||
of the Health Maintenance Organization sought to be | ||
acquired for a period of not less than 3 years; and | ||
(D) such other information as the Director shall | ||
require. | ||
(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code and this Section 5-3 shall apply to the sale by | ||
any health maintenance organization of greater than 10% of its | ||
enrollee population (including, without limitation, the health | ||
maintenance organization's right, title, and interest in and | ||
to its health care certificates). | ||
(e) In considering any management contract or service | ||
agreement subject to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in addition to the criteria | ||
specified in Section 141.2 of the Illinois Insurance Code, | ||
take into account the effect of the management contract or | ||
service agreement on the continuation of benefits to enrollees | ||
and the financial condition of the health maintenance | ||
organization to be managed or serviced, and (ii) need not take | ||
into account the effect of the management contract or service | ||
agreement on competition. | ||
(f) Except for small employer groups as defined in the | ||
Small Employer Rating, Renewability and Portability Health | ||
Insurance Act and except for medicare supplement policies as | ||
defined in Section 363 of the Illinois Insurance Code, a | ||
Health Maintenance Organization may by contract agree with a | ||
group or other enrollment unit to effect refunds or charge | ||
additional premiums under the following terms and conditions: | ||
(i) the amount of, and other terms and conditions with | ||
respect to, the refund or additional premium are set forth | ||
in the group or enrollment unit contract agreed in advance | ||
of the period for which a refund is to be paid or | ||
additional premium is to be charged (which period shall | ||
not be less than one year); and | ||
(ii) the amount of the refund or additional premium | ||
shall not exceed 20% of the Health Maintenance | ||
Organization's profitable or unprofitable experience with | ||
respect to the group or other enrollment unit for the | ||
period (and, for purposes of a refund or additional | ||
premium, the profitable or unprofitable experience shall | ||
be calculated taking into account a pro rata share of the | ||
Health Maintenance Organization's administrative and | ||
marketing expenses, but shall not include any refund to be | ||
made or additional premium to be paid pursuant to this | ||
subsection (f)). The Health Maintenance Organization and | ||
the group or enrollment unit may agree that the profitable | ||
or unprofitable experience may be calculated taking into | ||
account the refund period and the immediately preceding 2 | ||
plan years. | ||
The Health Maintenance Organization shall include a | ||
statement in the evidence of coverage issued to each enrollee | ||
describing the possibility of a refund or additional premium, | ||
and upon request of any group or enrollment unit, provide to | ||
the group or enrollment unit a description of the method used | ||
to calculate (1) the Health Maintenance Organization's | ||
profitable experience with respect to the group or enrollment | ||
unit and the resulting refund to the group or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable | ||
experience with respect to the group or enrollment unit and | ||
the resulting additional premium to be paid by the group or | ||
enrollment unit. | ||
In no event shall the Illinois Health Maintenance | ||
Organization Guaranty Association be liable to pay any | ||
contractual obligation of an insolvent organization to pay any | ||
refund authorized under this Section. | ||
(g) Rulemaking authority to implement Public Act 95-1045, | ||
if any, is conditioned on the rules being adopted in | ||
accordance with all provisions of the Illinois Administrative | ||
Procedure Act and all rules and procedures of the Joint | ||
Committee on Administrative Rules; any purported rule not so | ||
adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | ||
Section 35. The Limited Health Service Organization Act is | ||
amended by changing Section 4003 as follows: | ||
(215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | ||
Sec. 4003. Illinois Insurance Code provisions. Limited | ||
health service organizations shall be subject to the | ||
provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||
141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | ||
154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2, | ||
355.3, 355b, 356m, 356q, 356v, 356z.4, 356z.4a, 356z.10, | ||
356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | ||
356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||
356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | ||
356z.71, 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, | ||
409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII | ||
1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance | ||
Code. Nothing in this Section shall require a limited health | ||
care plan to cover any service that is not a limited health | ||
service. For purposes of the Illinois Insurance Code, except | ||
for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||
limited health service organizations in the following | ||
categories are deemed to be domestic companies: | ||
(1) a corporation under the laws of this State; or | ||
(2) a corporation organized under the laws of another | ||
state, 30% or more of the enrollees of which are residents | ||
of this State, except a corporation subject to | ||
substantially the same requirements in its state of | ||
organization as is a domestic company under Article VIII | ||
1/2 of the Illinois Insurance Code. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||
eff. 1-1-24; revised 8-29-23.) | ||
Section 40. The Voluntary Health Services Plans Act is | ||
amended by changing Section 10 as follows: | ||
(215 ILCS 165/10) (from Ch. 32, par. 604) | ||
Sec. 10. Application of Insurance Code provisions. Health | ||
services plan corporations and all persons interested therein | ||
or dealing therewith shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, | ||
143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, | ||
356g, 356g.5, 356g.5-1, 356m, 356q, 356r, 356t, 356u, 356v, | ||
356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, | ||
356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||
356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, | ||
356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, | ||
356z.32a, 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, | ||
356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, | ||
356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.71, 364.01, | ||
364.3, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, | ||
and 412, and paragraphs (7) and (15) of Section 367 of the | ||
Illinois Insurance Code. | ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. | ||
10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, | ||
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||
102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. | ||
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||
103-551, eff. 8-11-23; revised 8-29-23.) | ||
Section 99. Effective date. This Act takes effect upon | ||
becoming law. | ||