Illinois-2021-HB2948-Introduced

102ND GENERAL ASSEMBLY State of Illinois 2021 and 2022 HB2948

Introduced , by Rep. Bob Morgan

SYNOPSIS AS INTRODUCED:

See Index

Amends the Illinois Insurance Code. Sets forth provisions concerning eligibility for health savings accounts. Provides that an HSA-eligible high deductible health plan is exempt from specified requirements but only until the deductible has been met and only to the extent necessary to allow the policy to satisfy specified federal criteria. Provides that for any HSA-eligible high deductible health plan issued, delivered, amended, or renewed on or after January 1, 2022, a company shall expressly identify the policy as HSA-eligible in all policy forms and in all sales and marketing materials. Provides that for high deductible non-HSA policies issued, delivered, amended, or renewed on or after January 1, 2022, the company shall use the term "non-HSA" in any name or title of the product found in its policy form, as well as in all sales and marketing materials. Provides that beginning January 1, 2022, if a company offers any HSA-eligible HDHP in the large group market, then it shall also offer in the same market at least one high-deductible non-HSA policy. Defines "HSA-eligible HDHP" and "high deductible non-HSA policy". In provisions concerning coverage for screening by low-dose mammography, provisions concerning coverage for contraceptives, and provisions concerning coverage for whole body skin examination, removes provisions stating that the mandates do not apply to required coverage to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to specified federal law. Makes a conforming change in the Health Maintenance Organization Act. Amends the Health Maintenance Organization Act and the Voluntary Health Services Plans Act to provide that health maintenance organizations and voluntary health services plans shall be subject to provisions of the Illinois Insurance Code concerning nonparticipating facility-based physicians and providers and provisions concerning eligibility for health savings accounts. Effective January 1, 2022.

LRB102 11004 BMS 16336 b

A BILL FOR

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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 Illinois Insurance Code is amended by

5 adding Section 355.5, by changing Sections 356g and 356z.4,

6 and by renumbering and changing Section 356z.33 as added by

7 Public Act 101-500 as follows:

8 (215 ILCS 5/355.5 new)

9 Sec. 355.5. Eligibility for health savings accounts.

10 (a) Definitions. As used in this Section:

11 "High deductible non-HSA policy" means a policy of

12 individual or group accident and health insurance coverage

13 that would have qualified as an HSA-eligible HDHP but for its

14 conformity with any of the Illinois statutes subject to

15 exemption under subsection (b).

16 "HSA-eligible HDHP" means a policy of individual or group

17 accident and health insurance coverage that satisfies the

18 criteria for a "high-deductible health plan" in 26 U.S.C. 223

19 as implemented and interpreted by the U.S. Department of the

20 Treasury in the regulations and guidance in effect at the time

21 of any transaction or occurrence addressed by this Section.

22 (b) Exemptions for an HSA-eligible HDHP.

23 (1) An HSA-eligible HDHP is exempt from the following

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1 provisions of Illinois law, but only until the deductible

2 has been met and only to the extent necessary to allow the

3 policy to satisfy the criteria for a "high-deductible

4 health plan" as implemented and interpreted by the U.S.

5 Department of the Treasury under 26 U.S.C. 223:

6 (A) the prohibition on cost-sharing requirements

7 for all coverages provided under subsection (a) of

8 Section 356g of this Code and subsection (a) of

9 Section 4-6.1 of the Health Maintenance Organization

10 Act;

11 (B) the prohibition on cost-sharing requirements

12 for coverage of voluntary male sterilization

13 procedures under paragraph (4) of subsection (a) of

14 Section 356z.4 of this Code;

15 (C) the prohibition on cost-sharing requirements

16 for coverage of whole body skin examinations provided

17 under Section 356z.37 of this Code;

18 (D) the requirements in subsection (d) of Section

19 30 of the Managed Care Reform and Patient Rights Act;

20 notwithstanding any other provision of this Section,

21 if any method of reducing an individual's

22 out-of-pocket expenses addressed in subsection (d) of

23 Section 30 does not fall within the scope of U.S.

24 Department of the Treasury regulations or guidance

25 about the criteria for a high deductible health plan

26 under 26 U.S.C. 223, or if such regulations or

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1 guidance indicate that the method of reduction is not

2 prohibited for such a plan, then an HSA-eligible HDHP

3 shall not be exempt from the requirements of

4 subsection (d) of Section 30 relating to that method

5 of reduction;

6 (E) other Illinois provisions that the Department

7 may identify by rule; for such an exemption to be

8 valid, the Department's rule must cite to the specific

9 federal statute, regulation, or guidance within or

10 under 26 U.S.C. 223 that would require a policy to be

11 exempt from the Illinois statute in order to be an

12 HSA-eligible HDHP; and

13 (F) other Illinois provisions that the Department

14 may acknowledge at a company's request during the

15 policy form filing process provided under Sections 143

16 and 355 of this Code. If a company requests an

17 exemption from a statutory provision under this

18 subparagraph, the Department may grant the exemption

19 only if the company has cited a specific federal

20 statute, regulation, or guidance within or under 26

21 U.S.C. 223 that would actually require such an

22 exemption for the policy to be an HSA-eligible HDHP.

23 Upon the first time granting the exemption to that

24 Illinois provision, the Department shall publish a

25 notification to companies indicating that it has done

26 so and identifying its specific basis for granting the

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1 exemption.

2 (2) Notwithstanding any other provision of this

3 Section, if the U.S. Department of the Treasury determines

4 by regulation or guidance that any coverage addressed by

5 one of the above Illinois statutes pertains to preventive

6 care as that term is used in 26 U.S.C. 223, an exemption

7 shall not apply with respect to that Illinois statute for

8 any HSA-eligible HDHP issued, delivered, amended, or

9 renewed while such regulation or guidance is effective.

10 (c) For any HSA-eligible HDHP issued, delivered, amended,

11 or renewed on or after January 1, 2022, a company shall

12 expressly identify the policy as HSA-eligible in all policy

13 forms and in all sales and marketing materials. Any name or

14 title of a product that is an HSA-eligible HDHP shall include

15 the term "HSA-eligible".

16 (d) For all policies issued, delivered, amended, or

17 renewed on or after January 1, 2022, unless the policy is an

18 HSA-eligible HDHP, no company shall use the terms

19 "HSA-eligible", "HSA", "for HSAs", "high deductible health

20 plan", "HDHP", or any substantially similar term or phrase, to

21 describe a policy of individual or group accident and health

22 insurance coverage in any policy form or related sales or

23 marketing materials. For all policies in effect on or after

24 the effective date of this amendatory Act of the 102nd General

25 Assembly, a company or producer shall not in any way represent

26 that a policy not satisfying the definition in subsection (a)

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1 is an HSA-eligible HDHP.

2 (e) For high deductible non-HSA policies issued,

3 delivered, amended, or renewed on or after January 1, 2022,

4 the company shall use the term "non-HSA" in any name or title

5 of the product found in its policy form, as well as in all

6 sales and marketing materials. Any policy, certificate,

7 evidence of coverage, or outline of coverage for a high

8 deductible non-HSA policy shall include a statement

9 substantially the same as the following within the first 2

10 pages of substantive text: "Pursuant to Section 355.5 of the

11 Illinois Insurance Code, we are required to disclose that the

12 coverage provided under this policy may not qualify as a

13 "high-deductible health plan" under 26 U.S.C. 223. As a

14 result, your enrollment under this policy may not qualify you

15 as an "eligible individual" to contribute to a health savings

16 account.".

17 (f) Beginning January 1, 2022, if a company offers any

18 HSA-eligible HDHP in the large group market, then it shall

19 also offer in the same market at least one high-deductible

20 non-HSA policy. If a company offers any HSA-eligible HDHP in

21 the individual or small group market, then it shall also offer

22 in the same market at least one high-deductible non-HSA policy

23 at each level of coverage defined in 45 CFR 156.140 for which

24 the company offers an HSA-eligible HDHP. A company is not

25 required to offer a high-deductible non-HSA policy version of

26 every HSA-eligible HDHP that it offers in a market unless the

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1 company only offers one HSA-eligible HDHP in the large group

2 market or one HSA-eligible HDHP in each applicable level of

3 coverage in the individual or small group market. No company

4 is required to offer an HSA-eligible HDHP merely because it

5 offers a high deductible non-HSA policy.

6 (g) If an applicant or policyholder obtains an

7 HSA-eligible HDHP, any successive policy shall not be deemed a

8 renewal policy unless it is issued as an HSA-eligible HDHP.

9 Nothing in this subsection shall prevent a company from

10 offering a policyholder a high deductible non-HSA policy as an

11 alternative to renewing their HSA-eligible HDHP, nor from

12 discontinuing to offer any HSA-eligible HDHP altogether in the

13 Illinois individual, small group, or large group market.

14 (h) This Section does not apply to short-term,

15 limited-duration health insurance coverage as defined in

16 Section 5 of the Short-Term, Limited-Duration Health Insurance

17 Coverage Act.

18 (215 ILCS 5/356g) (from Ch. 73, par. 968g)

19 Sec. 356g. Mammograms; mastectomies.

20 (a) Every insurer shall provide in each group or

21 individual policy, contract, or certificate of insurance

22 issued or renewed for persons who are residents of this State,

23 coverage for screening by low-dose mammography for all women

24 35 years of age or older for the presence of occult breast

25 cancer within the provisions of the policy, contract, or

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1 certificate. The coverage shall be as follows:

2 (1) A baseline mammogram for women 35 to 39 years of

3 age.

4 (2) An annual mammogram for women 40 years of age or

5 older.

6 (3) A mammogram at the age and intervals considered

7 medically necessary by the woman's health care provider

8 for women under 40 years of age and having a family history

9 of breast cancer, prior personal history of breast cancer,

10 positive genetic testing, or other risk factors.

11 (4) For an individual or group policy of accident and

12 health insurance or a managed care plan that is amended,

13 delivered, issued, or renewed on or after the effective

14 date of this amendatory Act of the 101st General Assembly,

15 a comprehensive ultrasound screening and MRI of an entire

16 breast or breasts if a mammogram demonstrates

17 heterogeneous or dense breast tissue or when medically

18 necessary as determined by a physician licensed to

19 practice medicine in all of its branches.

20 (5) A screening MRI when medically necessary, as

21 determined by a physician licensed to practice medicine in

22 all of its branches.

23 (6) For an individual or group policy of accident and

24 health insurance or a managed care plan that is amended,

25 delivered, issued, or renewed on or after the effective

26 date of this amendatory Act of the 101st General Assembly,

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1 a diagnostic mammogram when medically necessary, as

2 determined by a physician licensed to practice medicine in

3 all its branches, advanced practice registered nurse, or

4 physician assistant.

5 A policy subject to this subsection shall not impose a

6 deductible, coinsurance, copayment, or any other cost-sharing

7 requirement on the coverage provided~~; except that this~~

8 ~~sentence does not apply to coverage of diagnostic mammograms~~

9 ~~to the extent such coverage would disqualify a high-deductible~~

10 ~~health plan from eligibility for a health savings account~~

11 ~~pursuant to Section 223 of the Internal Revenue Code (26~~

12 ~~U.S.C. 223)~~.

13 For purposes of this Section:

14 "Diagnostic mammogram" means a mammogram obtained using

15 diagnostic mammography.

16 "Diagnostic mammography" means a method of screening that

17 is designed to evaluate an abnormality in a breast, including

18 an abnormality seen or suspected on a screening mammogram or a

19 subjective or objective abnormality otherwise detected in the

20 breast.

21 "Low-dose mammography" means the x-ray examination of the

22 breast using equipment dedicated specifically for mammography,

23 including the x-ray tube, filter, compression device, and

24 image receptor, with radiation exposure delivery of less than

25 1 rad per breast for 2 views of an average size breast. The

26 term also includes digital mammography and includes breast

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1 tomosynthesis. As used in this Section, the term "breast

2 tomosynthesis" means a radiologic procedure that involves the

3 acquisition of projection images over the stationary breast to

4 produce cross-sectional digital three-dimensional images of

5 the breast.

6 If, at any time, the Secretary of the United States

7 Department of Health and Human Services, or its successor

8 agency, promulgates rules or regulations to be published in

9 the Federal Register or publishes a comment in the Federal

10 Register or issues an opinion, guidance, or other action that

11 would require the State, pursuant to any provision of the

12 Patient Protection and Affordable Care Act (Public Law

13 111-148), including, but not limited to, 42 U.S.C.

14 18031(d)(3)(B) or any successor provision, to defray the cost

15 of any coverage for breast tomosynthesis outlined in this

16 subsection, then the requirement that an insurer cover breast

17 tomosynthesis is inoperative other than any such coverage

18 authorized under Section 1902 of the Social Security Act, 42

19 U.S.C. 1396a, and the State shall not assume any obligation

20 for the cost of coverage for breast tomosynthesis set forth in

21 this subsection.

22 (a-5) Coverage as described by subsection (a) shall be

23 provided at no cost to the insured and shall not be applied to

24 an annual or lifetime maximum benefit.

25 (a-10) When health care services are available through

26 contracted providers and a person does not comply with plan

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1 provisions specific to the use of contracted providers, the

2 requirements of subsection (a-5) are not applicable. When a

3 person does not comply with plan provisions specific to the

4 use of contracted providers, plan provisions specific to the

5 use of non-contracted providers must be applied without

6 distinction for coverage required by this Section and shall be

7 at least as favorable as for other radiological examinations

8 covered by the policy or contract.

9 (b) No policy of accident or health insurance that

10 provides for the surgical procedure known as a mastectomy

11 shall be issued, amended, delivered, or renewed in this State

12 unless that coverage also provides for prosthetic devices or

13 reconstructive surgery incident to the mastectomy. Coverage

14 for breast reconstruction in connection with a mastectomy

15 shall include:

16 (1) reconstruction of the breast upon which the

17 mastectomy has been performed;

18 (2) surgery and reconstruction of the other breast to

19 produce a symmetrical appearance; and

20 (3) prostheses and treatment for physical

21 complications at all stages of mastectomy, including

22 lymphedemas.

23 Care shall be determined in consultation with the attending

24 physician and the patient. The offered coverage for prosthetic

25 devices and reconstructive surgery shall be subject to the

26 deductible and coinsurance conditions applied to the

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1 mastectomy, and all other terms and conditions applicable to

2 other benefits. When a mastectomy is performed and there is no

3 evidence of malignancy then the offered coverage may be

4 limited to the provision of prosthetic devices and

5 reconstructive surgery to within 2 years after the date of the

6 mastectomy. As used in this Section, "mastectomy" means the

7 removal of all or part of the breast for medically necessary

8 reasons, as determined by a licensed physician.

9 Written notice of the availability of coverage under this

10 Section shall be delivered to the insured upon enrollment and

11 annually thereafter. An insurer may not deny to an insured

12 eligibility, or continued eligibility, to enroll or to renew

13 coverage under the terms of the plan solely for the purpose of

14 avoiding the requirements of this Section. An insurer may not

15 penalize or reduce or limit the reimbursement of an attending

16 provider or provide incentives (monetary or otherwise) to an

17 attending provider to induce the provider to provide care to

18 an insured in a manner inconsistent with this Section.

19 (c) Rulemaking authority to implement Public Act 95-1045,

20 if any, is conditioned on the rules being adopted in

21 accordance with all provisions of the Illinois Administrative

22 Procedure Act and all rules and procedures of the Joint

23 Committee on Administrative Rules; any purported rule not so

24 adopted, for whatever reason, is unauthorized.

25 (Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)

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1 (215 ILCS 5/356z.4)

2 Sec. 356z.4. Coverage for contraceptives.

3 (a)(1) The General Assembly hereby finds and declares all

4 of the following:

5 (A) Illinois has a long history of expanding timely

6 access to birth control to prevent unintended pregnancy.

7 (B) The federal Patient Protection and Affordable Care

8 Act includes a contraceptive coverage guarantee as part of

9 a broader requirement for health insurance to cover key

10 preventive care services without out-of-pocket costs for

11 patients.

12 (C) The General Assembly intends to build on existing

13 State and federal law to promote gender equity and women's

14 health and to ensure greater contraceptive coverage equity

15 and timely access to all federal Food and Drug

16 Administration approved methods of birth control for all

17 individuals covered by an individual or group health

18 insurance policy in Illinois.

19 (D) Medical management techniques such as denials,

20 step therapy, or prior authorization in public and private

21 health care coverage can impede access to the most

22 effective contraceptive methods.

23 (2) As used in this subsection (a):

24 "Contraceptive services" includes consultations,

25 examinations, procedures, and medical services related to the

26 use of contraceptive methods (including natural family

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1 planning) to prevent an unintended pregnancy.

2 "Medical necessity", for the purposes of this subsection

3 (a), includes, but is not limited to, considerations such as

4 severity of side effects, differences in permanence and

5 reversibility of contraceptive, and ability to adhere to the

6 appropriate use of the item or service, as determined by the

7 attending provider.

8 "Therapeutic equivalent version" means drugs, devices, or

9 products that can be expected to have the same clinical effect

10 and safety profile when administered to patients under the

11 conditions specified in the labeling and satisfy the following

12 general criteria:

13 (i) they are approved as safe and effective;

14 (ii) they are pharmaceutical equivalents in that they

15 (A) contain identical amounts of the same active drug

16 ingredient in the same dosage form and route of

17 administration and (B) meet compendial or other applicable

18 standards of strength, quality, purity, and identity;

19 (iii) they are bioequivalent in that (A) they do not

20 present a known or potential bioequivalence problem and

21 they meet an acceptable in vitro standard or (B) if they do

22 present such a known or potential problem, they are shown

23 to meet an appropriate bioequivalence standard;

24 (iv) they are adequately labeled; and

25 (v) they are manufactured in compliance with Current

26 Good Manufacturing Practice regulations.

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1 (3) An individual or group policy of accident and health

2 insurance amended, delivered, issued, or renewed in this State

3 after the effective date of this amendatory Act of the 99th

4 General Assembly shall provide coverage for all of the

5 following services and contraceptive methods:

6 (A) All contraceptive drugs, devices, and other

7 products approved by the United States Food and Drug

8 Administration. This includes all over-the-counter

9 contraceptive drugs, devices, and products approved by the

10 United States Food and Drug Administration, excluding male

11 condoms. The following apply:

12 (i) If the United States Food and Drug

13 Administration has approved one or more therapeutic

14 equivalent versions of a contraceptive drug, device,

15 or product, a policy is not required to include all

16 such therapeutic equivalent versions in its formulary,

17 so long as at least one is included and covered without

18 cost-sharing and in accordance with this Section.

19 (ii) If an individual's attending provider

20 recommends a particular service or item approved by

21 the United States Food and Drug Administration based

22 on a determination of medical necessity with respect

23 to that individual, the plan or issuer must cover that

24 service or item without cost sharing. The plan or

25 issuer must defer to the determination of the

26 attending provider.

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1 (iii) If a drug, device, or product is not

2 covered, plans and issuers must have an easily

3 accessible, transparent, and sufficiently expedient

4 process that is not unduly burdensome on the

5 individual or a provider or other individual acting as

6 a patient's authorized representative to ensure

7 coverage without cost sharing.

8 (iv) This coverage must provide for the dispensing

9 of 12 months' worth of contraception at one time.

10 (B) Voluntary sterilization procedures.

11 (C) Contraceptive services, patient education, and

12 counseling on contraception.

13 (D) Follow-up services related to the drugs, devices,

14 products, and procedures covered under this Section,

15 including, but not limited to, management of side effects,

16 counseling for continued adherence, and device insertion

17 and removal.

18 (4) Except as otherwise provided in this subsection (a), a

19 policy subject to this subsection (a) shall not impose a

20 deductible, coinsurance, copayment, or any other cost-sharing

21 requirement on the coverage provided. ~~The provisions of this~~

22 ~~paragraph do not apply to coverage of voluntary male~~

23 ~~sterilization procedures to the extent such coverage would~~

24 ~~disqualify a high-deductible health plan from eligibility for~~

25 ~~a health savings account pursuant to the federal Internal~~

26 ~~Revenue Code, 26 U.S.C. 223.~~

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1 (5) Except as otherwise authorized under this subsection

2 (a), a policy shall not impose any restrictions or delays on

3 the coverage required under this subsection (a).

4 (6) If, at any time, the Secretary of the United States

5 Department of Health and Human Services, or its successor

6 agency, promulgates rules or regulations to be published in

7 the Federal Register or publishes a comment in the Federal

8 Register or issues an opinion, guidance, or other action that

9 would require the State, pursuant to any provision of the

10 Patient Protection and Affordable Care Act (Public Law

11 111-148), including, but not limited to, 42 U.S.C.

12 18031(d)(3)(B) or any successor provision, to defray the cost

13 of any coverage outlined in this subsection (a), then this

14 subsection (a) is inoperative with respect to all coverage

15 outlined in this subsection (a) other than that authorized

16 under Section 1902 of the Social Security Act, 42 U.S.C.

17 1396a, and the State shall not assume any obligation for the

18 cost of the coverage set forth in this subsection (a).

19 (b) This subsection (b) shall become operative if and only

20 if subsection (a) becomes inoperative.

21 An individual or group policy of accident and health

22 insurance amended, delivered, issued, or renewed in this State

23 after the date this subsection (b) becomes operative that

24 provides coverage for outpatient services and outpatient

25 prescription drugs or devices must provide coverage for the

26 insured and any dependent of the insured covered by the policy

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1 for all outpatient contraceptive services and all outpatient

2 contraceptive drugs and devices approved by the Food and Drug

3 Administration. Coverage required under this Section may not

4 impose any deductible, coinsurance, waiting period, or other

5 cost-sharing or limitation that is greater than that required

6 for any outpatient service or outpatient prescription drug or

7 device otherwise covered by the policy.

8 Nothing in this subsection (b) shall be construed to

9 require an insurance company to cover services related to

10 permanent sterilization that requires a surgical procedure.

11 As used in this subsection (b), "outpatient contraceptive

12 service" means consultations, examinations, procedures, and

13 medical services, provided on an outpatient basis and related

14 to the use of contraceptive methods (including natural family

15 planning) to prevent an unintended pregnancy.

16 (c) (Blank).

17 (d) If a plan or issuer utilizes a network of providers,

18 nothing in this Section shall be construed to require coverage

19 or to prohibit the plan or issuer from imposing cost-sharing

20 for items or services described in this Section that are

21 provided or delivered by an out-of-network provider, unless

22 the plan or issuer does not have in its network a provider who

23 is able to or is willing to provide the applicable items or

24 services.

25 (Source: P.A. 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19.)

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1 (215 ILCS 5/356z.37)

2 Sec. 356z.37 ~~356z.33~~. Whole body skin examination. An

3 individual or group policy of accident and health insurance

4 shall cover, without imposing a deductible, coinsurance,

5 copayment, or any other cost-sharing requirement upon the

6 insured patient, one annual office visit, using appropriate

7 routine evaluation and management Current Procedural

8 Terminology codes or any successor codes, for a whole body

9 skin examination for lesions suspicious for skin cancer. The

10 whole body skin examination shall be indicated using an

11 appropriate International Statistical Classification of

12 Diseases and Related Health Problems code or any successor

13 codes. ~~The provisions of this Section do not apply to the~~

14 ~~extent such coverage would disqualify a high-deductible health~~

15 ~~plan from eligibility for a health savings account pursuant to~~

16 ~~26 U.S.C. 223.~~

17 (Source: P.A. 101-500, eff. 1-1-20; revised 10-16-19.)

18 Section 10. The Health Maintenance Organization Act is

19 amended by changing Sections 4-6.1 and 5-3 as follows:

20 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)

21 Sec. 4-6.1. Mammograms; mastectomies.

22 (a) Every contract or evidence of coverage issued by a

23 Health Maintenance Organization for persons who are residents

24 of this State shall contain coverage for screening by low-dose

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1 mammography for all women 35 years of age or older for the

2 presence of occult breast cancer. The coverage shall be as

3 follows:

4 (1) A baseline mammogram for women 35 to 39 years of

5 age.

6 (2) An annual mammogram for women 40 years of age or

7 older.

8 (3) A mammogram at the age and intervals considered

9 medically necessary by the woman's health care provider

10 for women under 40 years of age and having a family history

11 of breast cancer, prior personal history of breast cancer,

12 positive genetic testing, or other risk factors.

13 (4) For an individual or group policy of accident and

14 health insurance or a managed care plan that is amended,

15 delivered, issued, or renewed on or after the effective

16 date of this amendatory Act of the 101st General Assembly,

17 a comprehensive ultrasound screening and MRI of an entire

18 breast or breasts if a mammogram demonstrates

19 heterogeneous or dense breast tissue or when medically

20 necessary as determined by a physician licensed to

21 practice medicine in all of its branches.

22 (5) For an individual or group policy of accident and

23 health insurance or a managed care plan that is amended,

24 delivered, issued, or renewed on or after the effective

25 date of this amendatory Act of the 101st General Assembly,

26 a diagnostic mammogram when medically necessary, as

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1 determined by a physician licensed to practice medicine in

2 all its branches, advanced practice registered nurse, or

3 physician assistant.

4 A policy subject to this subsection shall not impose a

5 deductible, coinsurance, copayment, or any other cost-sharing

6 requirement on the coverage provided~~; except that this~~

7 ~~sentence does not apply to coverage of diagnostic mammograms~~

8 ~~to the extent such coverage would disqualify a high-deductible~~

9 ~~health plan from eligibility for a health savings account~~

10 ~~pursuant to Section 223 of the Internal Revenue Code (26~~

11 ~~U.S.C. 223)~~.

12 For purposes of this Section:

13 "Diagnostic mammogram" means a mammogram obtained using

14 diagnostic mammography.

15 "Diagnostic mammography" means a method of screening that

16 is designed to evaluate an abnormality in a breast, including

17 an abnormality seen or suspected on a screening mammogram or a

18 subjective or objective abnormality otherwise detected in the

19 breast.

20 "Low-dose mammography" means the x-ray examination of the

21 breast using equipment dedicated specifically for mammography,

22 including the x-ray tube, filter, compression device, and

23 image receptor, with radiation exposure delivery of less than

24 1 rad per breast for 2 views of an average size breast. The

25 term also includes digital mammography and includes breast

26 tomosynthesis.

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1 "Breast tomosynthesis" means a radiologic procedure that

2 involves the acquisition of projection images over the

3 stationary breast to produce cross-sectional digital

4 three-dimensional images of the breast.

5 If, at any time, the Secretary of the United States

6 Department of Health and Human Services, or its successor

7 agency, promulgates rules or regulations to be published in

8 the Federal Register or publishes a comment in the Federal

9 Register or issues an opinion, guidance, or other action that

10 would require the State, pursuant to any provision of the

11 Patient Protection and Affordable Care Act (Public Law

12 111-148), including, but not limited to, 42 U.S.C.

13 18031(d)(3)(B) or any successor provision, to defray the cost

14 of any coverage for breast tomosynthesis outlined in this

15 subsection, then the requirement that an insurer cover breast

16 tomosynthesis is inoperative other than any such coverage

17 authorized under Section 1902 of the Social Security Act, 42

18 U.S.C. 1396a, and the State shall not assume any obligation

19 for the cost of coverage for breast tomosynthesis set forth in

20 this subsection.

21 (a-5) Coverage as described in subsection (a) shall be

22 provided at no cost to the enrollee and shall not be applied to

23 an annual or lifetime maximum benefit.

24 (b) No contract or evidence of coverage issued by a health

25 maintenance organization that provides for the surgical

26 procedure known as a mastectomy shall be issued, amended,

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1 delivered, or renewed in this State on or after the effective

2 date of this amendatory Act of the 92nd General Assembly

3 unless that coverage also provides for prosthetic devices or

4 reconstructive surgery incident to the mastectomy, providing

5 that the mastectomy is performed after the effective date of

6 this amendatory Act. Coverage for breast reconstruction in

7 connection with a mastectomy shall include:

8 (1) reconstruction of the breast upon which the

9 mastectomy has been performed;

10 (2) surgery and reconstruction of the other breast to

11 produce a symmetrical appearance; and

12 (3) prostheses and treatment for physical

13 complications at all stages of mastectomy, including

14 lymphedemas.

15 Care shall be determined in consultation with the attending

16 physician and the patient. The offered coverage for prosthetic

17 devices and reconstructive surgery shall be subject to the

18 deductible and coinsurance conditions applied to the

19 mastectomy and all other terms and conditions applicable to

20 other benefits. When a mastectomy is performed and there is no

21 evidence of malignancy, then the offered coverage may be

22 limited to the provision of prosthetic devices and

23 reconstructive surgery to within 2 years after the date of the

24 mastectomy. As used in this Section, "mastectomy" means the

25 removal of all or part of the breast for medically necessary

26 reasons, as determined by a licensed physician.

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1 Written notice of the availability of coverage under this

2 Section shall be delivered to the enrollee upon enrollment and

3 annually thereafter. A health maintenance organization may not

4 deny to an enrollee eligibility, or continued eligibility, to

5 enroll or to renew coverage under the terms of the plan solely

6 for the purpose of avoiding the requirements of this Section.

7 A health maintenance organization may not penalize or reduce

8 or limit the reimbursement of an attending provider or provide

9 incentives (monetary or otherwise) to an attending provider to

10 induce the provider to provide care to an insured in a manner

11 inconsistent with this Section.

12 (c) Rulemaking authority to implement this amendatory Act

13 of the 95th General Assembly, if any, is conditioned on the

14 rules being adopted in accordance with all provisions of the

15 Illinois Administrative Procedure Act and all rules and

16 procedures of the Joint Committee on Administrative Rules; any

17 purported rule not so adopted, for whatever reason, is

18 unauthorized.

19 (Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)

20 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)

21 Sec. 5-3. Insurance Code provisions.

22 (a) Health Maintenance Organizations shall be subject to

23 the provisions of Sections 133, 134, 136, 137, 139, 140,

24 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,

25 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,

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1 355.3, 355.5,355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,

2 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,

3 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,

4 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,

5 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, 356z.35,

6 356z.36, 356z.41, 364, 364.01, 367.2, 367.2-5, 367i, 368a,

7 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403,

8 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of

9 subsection (2) of Section 367, and Articles IIA, VIII 1/2,

10 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the

11 Illinois Insurance Code.

12 (b) For purposes of the Illinois Insurance Code, except

13 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,

14 Health Maintenance Organizations in the following categories

15 are deemed to be "domestic companies":

16 (1) a corporation authorized under the Dental Service

17 Plan Act or the Voluntary Health Services Plans Act;

18 (2) a corporation organized under the laws of this

19 State; or

20 (3) a corporation organized under the laws of another

21 state, 30% or more of the enrollees of which are residents

22 of this State, except a corporation subject to

23 substantially the same requirements in its state of

24 organization as is a "domestic company" under Article VIII

25 1/2 of the Illinois Insurance Code.

26 (c) In considering the merger, consolidation, or other

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1 acquisition of control of a Health Maintenance Organization

2 pursuant to Article VIII 1/2 of the Illinois Insurance Code,

3 (1) the Director shall give primary consideration to

4 the continuation of benefits to enrollees and the

5 financial conditions of the acquired Health Maintenance

6 Organization after the merger, consolidation, or other

7 acquisition of control takes effect;

8 (2)(i) the criteria specified in subsection (1)(b) of

9 Section 131.8 of the Illinois Insurance Code shall not

10 apply and (ii) the Director, in making his determination

11 with respect to the merger, consolidation, or other

12 acquisition of control, need not take into account the

13 effect on competition of the merger, consolidation, or

14 other acquisition of control;

15 (3) the Director shall have the power to require the

16 following information:

17 (A) certification by an independent actuary of the

18 adequacy of the reserves of the Health Maintenance

19 Organization sought to be acquired;

20 (B) pro forma financial statements reflecting the

21 combined balance sheets of the acquiring company and

22 the Health Maintenance Organization sought to be

23 acquired as of the end of the preceding year and as of

24 a date 90 days prior to the acquisition, as well as pro

25 forma financial statements reflecting projected

26 combined operation for a period of 2 years;

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1 (C) a pro forma business plan detailing an

2 acquiring party's plans with respect to the operation

3 of the Health Maintenance Organization sought to be

4 acquired for a period of not less than 3 years; and

5 (D) such other information as the Director shall

6 require.

7 (d) The provisions of Article VIII 1/2 of the Illinois

8 Insurance Code and this Section 5-3 shall apply to the sale by

9 any health maintenance organization of greater than 10% of its

10 enrollee population (including without limitation the health

11 maintenance organization's right, title, and interest in and

12 to its health care certificates).

13 (e) In considering any management contract or service

14 agreement subject to Section 141.1 of the Illinois Insurance

15 Code, the Director (i) shall, in addition to the criteria

16 specified in Section 141.2 of the Illinois Insurance Code,

17 take into account the effect of the management contract or

18 service agreement on the continuation of benefits to enrollees

19 and the financial condition of the health maintenance

20 organization to be managed or serviced, and (ii) need not take

21 into account the effect of the management contract or service

22 agreement on competition.

23 (f) Except for small employer groups as defined in the

24 Small Employer Rating, Renewability and Portability Health

25 Insurance Act and except for medicare supplement policies as

26 defined in Section 363 of the Illinois Insurance Code, a

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LRB102 11004 BMS 16336 b

1 Health Maintenance Organization may by contract agree with a

2 group or other enrollment unit to effect refunds or charge

3 additional premiums under the following terms and conditions:

4 (i) the amount of, and other terms and conditions with

5 respect to, the refund or additional premium are set forth

6 in the group or enrollment unit contract agreed in advance

7 of the period for which a refund is to be paid or

8 additional premium is to be charged (which period shall

9 not be less than one year); and

10 (ii) the amount of the refund or additional premium

11 shall not exceed 20% of the Health Maintenance

12 Organization's profitable or unprofitable experience with

13 respect to the group or other enrollment unit for the

14 period (and, for purposes of a refund or additional

15 premium, the profitable or unprofitable experience shall

16 be calculated taking into account a pro rata share of the

17 Health Maintenance Organization's administrative and

18 marketing expenses, but shall not include any refund to be

19 made or additional premium to be paid pursuant to this

20 subsection (f)). The Health Maintenance Organization and

21 the group or enrollment unit may agree that the profitable

22 or unprofitable experience may be calculated taking into

23 account the refund period and the immediately preceding 2

24 plan years.

25 The Health Maintenance Organization shall include a

26 statement in the evidence of coverage issued to each enrollee

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1 describing the possibility of a refund or additional premium,

2 and upon request of any group or enrollment unit, provide to

3 the group or enrollment unit a description of the method used

4 to calculate (1) the Health Maintenance Organization's

5 profitable experience with respect to the group or enrollment

6 unit and the resulting refund to the group or enrollment unit

7 or (2) the Health Maintenance Organization's unprofitable

8 experience with respect to the group or enrollment unit and

9 the resulting additional premium to be paid by the group or

10 enrollment unit.

11 In no event shall the Illinois Health Maintenance

12 Organization Guaranty Association be liable to pay any

13 contractual obligation of an insolvent organization to pay any

14 refund authorized under this Section.

15 (g) Rulemaking authority to implement Public Act 95-1045,

16 if any, is conditioned on the rules being adopted in

17 accordance with all provisions of the Illinois Administrative

18 Procedure Act and all rules and procedures of the Joint

19 Committee on Administrative Rules; any purported rule not so

20 adopted, for whatever reason, is unauthorized.

21 (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;

22 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.

23 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,

24 eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20;

25 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.

26 1-1-20; 101-625, eff. 1-1-21.)

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1 Section 15. The Voluntary Health Services Plans Act is

2 amended by changing Section 10 as follows:

3 (215 ILCS 165/10) (from Ch. 32, par. 604)

4 Sec. 10. Application of Insurance Code provisions. Health

5 services plan corporations and all persons interested therein

6 or dealing therewith shall be subject to the provisions of

7 Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,

8 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355.5,

9 355b, 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w,

10 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,

11 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,

12 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,

13 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,

14 356z.41, 364.01, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408,

15 408.2, and 412, and paragraphs (7) and (15) of Section 367 of

16 the Illinois Insurance Code.

17 Rulemaking authority to implement Public Act 95-1045, if

18 any, is conditioned on the rules being adopted in accordance

19 with all provisions of the Illinois Administrative Procedure

20 Act and all rules and procedures of the Joint Committee on

21 Administrative Rules; any purported rule not so adopted, for

22 whatever reason, is unauthorized.

23 (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;

24 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.

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1 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,

2 eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20;

3 101-625, eff. 1-1-21.)

4 Section 99. Effective date. This Act takes effect January

5 1, 2022.

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INDEX

Statutes amended in order of appearance