Bill Amendment: IL SB0667 | 2019-2020 | 101st General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: PRICING-PRESCRIPTION INSULIN
Status: 2020-01-24 - Public Act . . . . . . . . . 101-0625 [SB0667 Detail]
Download: Illinois-2019-SB0667-Senate_Amendment_002.html
Bill Title: PRICING-PRESCRIPTION INSULIN
Status: 2020-01-24 - Public Act . . . . . . . . . 101-0625 [SB0667 Detail]
Download: Illinois-2019-SB0667-Senate_Amendment_002.html
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1 | AMENDMENT TO SENATE BILL 667
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2 | AMENDMENT NO. ______. Amend Senate Bill 667 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 1. Findings. The General Assembly finds and | ||||||
5 | declares that: | ||||||
6 | (1) Diabetes affects approximately 1,300,000 adults in | ||||||
7 | Illinois (12.5% of the population); | ||||||
8 | (2) Diabetes is the seventh leading cause of death | ||||||
9 | nationally and in Illinois; | ||||||
10 | (3) The toll on the U.S. economy has increased by more | ||||||
11 | than 40% since 2007, costing the country $245,000,000,000 | ||||||
12 | in 2012; | ||||||
13 | (4) When someone has diabetes, the body either does not | ||||||
14 | make enough insulin or is unable to use its own insulin, | ||||||
15 | causing glucose levels to rise higher than normal in the | ||||||
16 | blood; | ||||||
17 | (5) For people with Type 1 diabetes, near-constant |
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1 | self-management of glucose levels is essential to prevent | ||||||
2 | life-threatening complications; | ||||||
3 | (6) From 2012 to 2016, the average price of insulin | ||||||
4 | increased from 13 cents per unit to 25 cents per unit; | ||||||
5 | therefore, | ||||||
6 | It is necessary for the State to enact laws to reduce the | ||||||
7 | costs for Illinoisans with diabetes and increase their access | ||||||
8 | to life-saving and life-sustaining insulin.
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9 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||
10 | is amended by changing Section 6.11 as follows:
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11 | (5 ILCS 375/6.11)
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12 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
13 | Code
requirements. The program of health
benefits shall provide | ||||||
14 | the post-mastectomy care benefits required to be covered
by a | ||||||
15 | policy of accident and health insurance under Section 356t of | ||||||
16 | the Illinois
Insurance Code. The program of health benefits | ||||||
17 | shall provide the coverage
required under Sections 356g, | ||||||
18 | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | ||||||
19 | 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||||||
20 | 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, | ||||||
21 | 356z.29, 356z.30a, 356z.32, and 356z.33 , 356z.36, and 356z.41 | ||||||
22 | of the
Illinois Insurance Code.
The program of health benefits | ||||||
23 | must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, | ||||||
24 | and 370c.1 , and Article XXXIIB of the
Illinois Insurance Code. |
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1 | The Department of Insurance shall enforce the requirements of | ||||||
2 | this Section with respect to Sections 370c and 370c.1 of the | ||||||
3 | Illinois Insurance Code; all other requirements of this Section | ||||||
4 | shall be enforced by the Department of Central Management | ||||||
5 | Services.
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6 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
7 | any, is conditioned on the rules being adopted in accordance | ||||||
8 | with all provisions of the Illinois Administrative Procedure | ||||||
9 | Act and all rules and procedures of the Joint Committee on | ||||||
10 | Administrative Rules; any purported rule not so adopted, for | ||||||
11 | whatever reason, is unauthorized. | ||||||
12 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
13 | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
14 | 1-1-19; 100-1102, eff. 1-1-19; 100-1170, eff. 6-1-19; 101-13, | ||||||
15 | eff. 6-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; | ||||||
16 | 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; revised 10-16-19.)
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17 | Section 10. The Attorney General Act is amended by adding | ||||||
18 | Section 10 as follows:
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19 | (15 ILCS 205/10 new) | ||||||
20 | Sec. 10. Investigation of prescription insulin drug | ||||||
21 | pricing; report. | ||||||
22 | (a) The Attorney General shall investigate pricing of | ||||||
23 | prescription insulin drugs made available to Illinois | ||||||
24 | consumers to ensure adequate consumer protections in the |
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1 | pricing of prescription insulin drugs and to determine whether | ||||||
2 | additional consumer protections are needed. | ||||||
3 | (b) As part of the investigation, the Attorney General | ||||||
4 | shall gather, compile, and analyze information concerning the | ||||||
5 | organization, business practices, pricing information, data, | ||||||
6 | reports, or other information that the Attorney General finds | ||||||
7 | necessary to fulfill the requirements of this Section from | ||||||
8 | companies engaged in the manufacture or sale of prescription | ||||||
9 | insulin drugs. | ||||||
10 | If necessary to fulfill the reporting requirements of this | ||||||
11 | Section, the Attorney General may issue a civil investigative | ||||||
12 | demand requiring a State Agency, insurer, pharmacy benefit | ||||||
13 | manager, or manufacturer of prescription insulin drugs that are | ||||||
14 | made available in Illinois to furnish material, answers, data, | ||||||
15 | or other relevant information. | ||||||
16 | (c) A person or business shall not be compelled to provide | ||||||
17 | trade secrets. | ||||||
18 | (d) By November 1, 2020, the Attorney General shall issue | ||||||
19 | and make available to the public a report detailing the | ||||||
20 | findings from the investigation conducted pursuant to this | ||||||
21 | Section. The Attorney General shall present the report to the | ||||||
22 | Governor, the Department of Insurance, and the Judiciary | ||||||
23 | Committees of the Senate and House of Representatives or their | ||||||
24 | successor Committees. The report must include the following: | ||||||
25 | (1) a summary of insulin pricing practices and | ||||||
26 | variables that contribute to pricing of health coverage |
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1 | plans; | ||||||
2 | (2) public policy recommendations to control and | ||||||
3 | prevent overpricing of prescription insulin drugs made | ||||||
4 | available to Illinois consumers; | ||||||
5 | (3) any recommendations for improvements to the | ||||||
6 | Consumer Fraud and Deceptive Business Practices Act; and | ||||||
7 | (4) any other information the Attorney General finds | ||||||
8 | necessary. | ||||||
9 | (e) This Section is repealed on December 1, 2020.
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10 | Section 15. The Counties Code is amended by changing | ||||||
11 | Section 5-1069.3 as follows:
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12 | (55 ILCS 5/5-1069.3)
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13 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
14 | including a home
rule
county, is a self-insurer for purposes of | ||||||
15 | providing health insurance coverage
for its employees, the | ||||||
16 | coverage shall include coverage for the post-mastectomy
care | ||||||
17 | benefits required to be covered by a policy of accident and | ||||||
18 | health
insurance under Section 356t and the coverage required | ||||||
19 | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | ||||||
20 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
21 | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | ||||||
22 | 356z.30a, and 356z.32, and 356z.33 , 356z.36, and 356z.41 of
the | ||||||
23 | Illinois Insurance Code. The coverage shall comply with | ||||||
24 | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois |
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1 | Insurance Code. The Department of Insurance shall enforce the | ||||||
2 | requirements of this Section. The requirement that health | ||||||
3 | benefits be covered
as provided in this Section is an
exclusive | ||||||
4 | power and function of the State and is a denial and limitation | ||||||
5 | under
Article VII, Section 6, subsection (h) of the Illinois | ||||||
6 | Constitution. A home
rule county to which this Section applies | ||||||
7 | must comply with every provision of
this Section.
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8 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
9 | any, is conditioned on the rules being adopted in accordance | ||||||
10 | with all provisions of the Illinois Administrative Procedure | ||||||
11 | Act and all rules and procedures of the Joint Committee on | ||||||
12 | Administrative Rules; any purported rule not so adopted, for | ||||||
13 | whatever reason, is unauthorized. | ||||||
14 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
15 | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
16 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
17 | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | ||||||
18 | revised 10-16-19.)
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19 | Section 20. The Illinois Municipal Code is amended by | ||||||
20 | changing Section 10-4-2.3 as follows:
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21 | (65 ILCS 5/10-4-2.3)
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22 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
23 | municipality, including a
home rule municipality, is a | ||||||
24 | self-insurer for purposes of providing health
insurance |
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1 | coverage for its employees, the coverage shall include coverage | ||||||
2 | for
the post-mastectomy care benefits required to be covered by | ||||||
3 | a policy of
accident and health insurance under Section 356t | ||||||
4 | and the coverage required
under Sections 356g, 356g.5, | ||||||
5 | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
6 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | ||||||
7 | 356z.26, 356z.29, 356z.30a, and 356z.32, and 356z.33 , 356z.36, | ||||||
8 | and 356z.41 of the Illinois
Insurance
Code. The coverage shall | ||||||
9 | comply with Sections 155.22a, 355b, 356z.19, and 370c of
the | ||||||
10 | Illinois Insurance Code. The Department of Insurance shall | ||||||
11 | enforce the requirements of this Section. The requirement that | ||||||
12 | health
benefits be covered as provided in this is an exclusive | ||||||
13 | power and function of
the State and is a denial and limitation | ||||||
14 | under Article VII, Section 6,
subsection (h) of the Illinois | ||||||
15 | Constitution. A home rule municipality to which
this Section | ||||||
16 | applies must comply with every provision of this Section.
| ||||||
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; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
25 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
26 | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; |
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1 | revised 10-16-19.)
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2 | Section 25. The School Code is amended by changing Section | ||||||
3 | 10-22.3f as follows:
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4 | (105 ILCS 5/10-22.3f)
| ||||||
5 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
6 | protection and
benefits
for employees shall provide the | ||||||
7 | post-mastectomy care benefits required to be
covered by a | ||||||
8 | policy of accident and health insurance under Section 356t and | ||||||
9 | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | ||||||
10 | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | ||||||
11 | 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | ||||||
12 | 356z.30a, and 356z.32, and 356z.33 , 356z.36, and 356z.41 of
the
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13 | Illinois Insurance Code.
Insurance policies shall comply with | ||||||
14 | Section 356z.19 of the Illinois Insurance Code. The coverage | ||||||
15 | shall comply with Sections 155.22a, 355b, and 370c of
the | ||||||
16 | Illinois Insurance Code. The Department of Insurance shall | ||||||
17 | enforce the requirements of this Section.
| ||||||
18 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
19 | any, is conditioned on the rules being adopted in accordance | ||||||
20 | with all provisions of the Illinois Administrative Procedure | ||||||
21 | Act and all rules and procedures of the Joint Committee on | ||||||
22 | Administrative Rules; any purported rule not so adopted, for | ||||||
23 | whatever reason, is unauthorized. | ||||||
24 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
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| |||||||
1 | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
2 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
3 | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | ||||||
4 | revised 10-16-19.)
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5 | Section 30. The Illinois Insurance Code is amended changing | ||||||
6 | Section 356w and by adding Section 356z.41 as follows:
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7 | (215 ILCS 5/356w)
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8 | Sec. 356w. Diabetes self-management training and | ||||||
9 | education.
| ||||||
10 | (a) A group policy of accident and health insurance that is | ||||||
11 | amended,
delivered,
issued, or renewed after the
effective date | ||||||
12 | of this amendatory Act of 1998 shall provide coverage for
| ||||||
13 | outpatient self-management
training and education, equipment, | ||||||
14 | and supplies, as set forth in this Section,
for the treatment | ||||||
15 | of type 1 diabetes, type 2 diabetes, and gestational diabetes
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16 | mellitus.
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17 | (b) As used in this Section:
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18 | "Diabetes self-management training"
means instruction in | ||||||
19 | an outpatient setting
which enables a diabetic patient to | ||||||
20 | understand the diabetic management process
and daily | ||||||
21 | management of
diabetic therapy as a means of avoiding frequent | ||||||
22 | hospitalization and
complications. Diabetes self-management | ||||||
23 | training shall include
the content areas listed in the National | ||||||
24 | Standards for Diabetes Self-Management
Education Programs as |
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1 | published by the American Diabetes Association, including
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2 | medical nutrition therapy and education programs, as defined by | ||||||
3 | the contract of insurance, that allow the patient to maintain | ||||||
4 | an A1c level within the range identified in nationally | ||||||
5 | recognized standards of care.
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6 | "Medical nutrition therapy" shall have the meaning
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7 | ascribed to that term in the Dietitian Nutritionist
Practice | ||||||
8 | Act.
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9 | "Physician" means a
physician licensed to practice | ||||||
10 | medicine in all of
its branches providing care to the | ||||||
11 | individual.
| ||||||
12 | "Qualified provider" for an
individual that is enrolled in:
| ||||||
13 | (1) a health maintenance organization that uses a
| ||||||
14 | primary
care physician to
control access to specialty care | ||||||
15 | means (A) the individual's primary care
physician licensed | ||||||
16 | to practice
medicine in all of its branches, (B) a | ||||||
17 | physician licensed to practice
medicine in all of its | ||||||
18 | branches to
whom the individual has been referred by the | ||||||
19 | primary care physician, or (C) a
certified, registered, or
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20 | licensed network health care professional with expertise | ||||||
21 | in diabetes management
to whom the individual
has been | ||||||
22 | referred by the primary care physician.
| ||||||
23 | (2) an insurance plan
means (A) a physician licensed to | ||||||
24 | practice medicine in
all of its branches or (B) a
| ||||||
25 | certified, registered, or licensed health care | ||||||
26 | professional with expertise in
diabetes management to whom |
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1 | the individual has been referred by a physician.
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2 | (c) Coverage under this Section for diabetes | ||||||
3 | self-management training,
including medical nutrition
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4 | education, shall be limited to the following:
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5 | (1) Up to 3 medically necessary visits to a qualified | ||||||
6 | provider upon
initial diagnosis of diabetes
by the | ||||||
7 | patient's
physician or, if diagnosis of diabetes was made | ||||||
8 | within one year prior to the
effective date of
this | ||||||
9 | amendatory Act
of 1998 where the insured was a covered | ||||||
10 | individual, up to 3 medically necessary
visits to a | ||||||
11 | qualified provider within one
year after that
effective
| ||||||
12 | date.
| ||||||
13 | (2) Up to 2 medically necessary visits to a qualified | ||||||
14 | provider upon a
determination by a
patient's
physician that | ||||||
15 | a significant change in the patient's symptoms or medical
| ||||||
16 | condition has
occurred. A "significant change" in | ||||||
17 | condition means symptomatic
hyperglycemia (greater than | ||||||
18 | 250 mg/dl on repeated occasions), severe
hypoglycemia | ||||||
19 | (requiring the assistance of another person), onset or | ||||||
20 | progression
of diabetes, or a significant change in medical | ||||||
21 | condition that would require a
significantly different | ||||||
22 | treatment regimen.
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23 | Payment by the insurer or health maintenance organization | ||||||
24 | for the coverage
required for diabetes self-management | ||||||
25 | training pursuant to the provisions of
this Section is only | ||||||
26 | required to be made for services provided.
No coverage is |
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1 | required for additional visits beyond those specified in items
| ||||||
2 | (1) and (2) of this subsection.
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3 | Coverage under this subsection (c) for diabetes | ||||||
4 | self-management training
shall
be subject to the same
| ||||||
5 | deductible, co-payment, and co-insurance provisions that apply | ||||||
6 | to coverage
under
the policy for other
services provided by the | ||||||
7 | same type of provider.
| ||||||
8 | (d) Coverage shall be provided for the following
equipment | ||||||
9 | when medically necessary
and prescribed by a physician licensed | ||||||
10 | to practice medicine in all
of its branches.
Coverage for the | ||||||
11 | following items shall be subject to deductible, co-payment
and | ||||||
12 | co-insurance provisions
provided for under the policy or a | ||||||
13 | durable medical equipment rider to the
policy:
| ||||||
14 | (1) blood glucose monitors;
| ||||||
15 | (2) blood glucose monitors for the legally blind;
| ||||||
16 | (3) cartridges for the legally blind; and
| ||||||
17 | (4) lancets and lancing devices.
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18 | This subsection does not apply to a group policy of | ||||||
19 | accident and health
insurance that does not provide a durable | ||||||
20 | medical equipment benefit.
| ||||||
21 | (e) Coverage shall be provided for the following | ||||||
22 | pharmaceuticals and
supplies when
medically necessary and | ||||||
23 | prescribed by a physician licensed to
practice medicine in all | ||||||
24 | of its
branches.
Coverage for the following items shall be | ||||||
25 | subject to the same coverage,
deductible,
co-payment, and | ||||||
26 | co-insurance
provisions under the policy or a drug rider to the |
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| |||||||
1 | policy , except as otherwise provided for under Section 356z.41 :
| ||||||
2 | (1) insulin;
| ||||||
3 | (2) syringes and needles;
| ||||||
4 | (3) test strips for glucose monitors;
| ||||||
5 | (4) FDA approved oral agents used to control blood | ||||||
6 | sugar; and
| ||||||
7 | (5) glucagon emergency kits.
| ||||||
8 | This subsection does not apply to a group policy of | ||||||
9 | accident and health
insurance that does not provide a drug | ||||||
10 | benefit.
| ||||||
11 | (f) Coverage shall be provided for regular foot care exams | ||||||
12 | by a
physician or by a
physician to whom a physician has | ||||||
13 | referred the patient. Coverage
for regular foot care exams
| ||||||
14 | shall be subject to the same deductible, co-payment, and | ||||||
15 | co-insurance
provisions
that apply under the policy for
other | ||||||
16 | services provided by the same type of provider.
| ||||||
17 | (g) If authorized by a physician, diabetes self-management
| ||||||
18 | training may be provided as a part of an office visit, group | ||||||
19 | setting, or home
visit.
| ||||||
20 | (h) This Section shall not apply to agreements, contracts, | ||||||
21 | or policies that
provide coverage for a specified diagnosis or | ||||||
22 | other limited benefit coverage.
| ||||||
23 | (Source: P.A. 97-281, eff. 1-1-12; 97-1141, eff. 12-28-12.)
| ||||||
24 | (215 ILCS 5/356z.41 new) | ||||||
25 | Sec. 356z.41. Cost sharing in prescription insulin drugs; |
| |||||||
| |||||||
1 | limits; confidentiality of rebate information. | ||||||
2 | (a) As used in this Section, "prescription insulin drug" | ||||||
3 | means a prescription drug that contains insulin and is used to | ||||||
4 | treat diabetes. | ||||||
5 | (b) This Section applies to a group or individual policy of | ||||||
6 | accident and health insurance amended, delivered, issued, or | ||||||
7 | renewed on or after the effective date of this amendatory Act | ||||||
8 | of the 101st General Assembly. | ||||||
9 | (c) An insurer that provides coverage for prescription | ||||||
10 | insulin drugs pursuant to the terms of a health coverage plan | ||||||
11 | the insurer offers shall limit the total amount that an insured | ||||||
12 | is required to pay for a covered prescription insulin drug at | ||||||
13 | an amount not to exceed $100 per 30-day supply of insulin, | ||||||
14 | regardless of the amount or type of insulin needed to fill the | ||||||
15 | insured's prescription. | ||||||
16 | (d) Nothing in this Section prevents an insurer from | ||||||
17 | reducing an insured's cost sharing by an amount greater than | ||||||
18 | the amount specified in subsection (c). | ||||||
19 | (e) The Director may use any of the Director's enforcement | ||||||
20 | powers to obtain an insurer's compliance with this Section. | ||||||
21 | (f) The Department may adopt rules as necessary to | ||||||
22 | implement and administer this Section and to align it with | ||||||
23 | federal requirements.
| ||||||
24 | Section 35. The Health Maintenance Organization Act is | ||||||
25 | amended by changing Section 5-3 as follows:
|
| |||||||
| |||||||
1 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
2 | Sec. 5-3. Insurance Code provisions.
| ||||||
3 | (a) Health Maintenance Organizations
shall be subject to | ||||||
4 | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| ||||||
5 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | ||||||
6 | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | ||||||
7 | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | ||||||
8 | 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | ||||||
9 | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, | ||||||
10 | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | ||||||
11 | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41, 364, | ||||||
12 | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | ||||||
13 | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | ||||||
14 | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | ||||||
15 | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | ||||||
16 | XXVI, and XXXIIB of the Illinois Insurance Code.
| ||||||
17 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
18 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
19 | Maintenance Organizations in
the following categories are | ||||||
20 | deemed to be "domestic companies":
| ||||||
21 | (1) a corporation authorized under the
Dental Service | ||||||
22 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
23 | (2) a corporation organized under the laws of this | ||||||
24 | State; or
| ||||||
25 | (3) a corporation organized under the laws of another |
| |||||||
| |||||||
1 | state, 30% or more
of the enrollees of which are residents | ||||||
2 | of this State, except a
corporation subject to | ||||||
3 | substantially the same requirements in its state of
| ||||||
4 | organization as is a "domestic company" under Article VIII | ||||||
5 | 1/2 of the
Illinois Insurance Code.
| ||||||
6 | (c) In considering the merger, consolidation, or other | ||||||
7 | acquisition of
control of a Health Maintenance Organization | ||||||
8 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
9 | (1) the Director shall give primary consideration to | ||||||
10 | the continuation of
benefits to enrollees and the financial | ||||||
11 | conditions of the acquired Health
Maintenance Organization | ||||||
12 | after the merger, consolidation, or other
acquisition of | ||||||
13 | control takes effect;
| ||||||
14 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
15 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
16 | apply and (ii) the Director, in making
his determination | ||||||
17 | with respect to the merger, consolidation, or other
| ||||||
18 | acquisition of control, need not take into account the | ||||||
19 | effect on
competition of the merger, consolidation, or | ||||||
20 | other acquisition of control;
| ||||||
21 | (3) the Director shall have the power to require the | ||||||
22 | following
information:
| ||||||
23 | (A) certification by an independent actuary of the | ||||||
24 | adequacy
of the reserves of the Health Maintenance | ||||||
25 | Organization sought to be acquired;
| ||||||
26 | (B) pro forma financial statements reflecting the |
| |||||||
| |||||||
1 | combined balance
sheets of the acquiring company and | ||||||
2 | the Health Maintenance Organization sought
to be | ||||||
3 | acquired as of the end of the preceding year and as of | ||||||
4 | a date 90 days
prior to the acquisition, as well as pro | ||||||
5 | forma financial statements
reflecting projected | ||||||
6 | combined operation for a period of 2 years;
| ||||||
7 | (C) a pro forma business plan detailing an | ||||||
8 | acquiring party's plans with
respect to the operation | ||||||
9 | of the Health Maintenance Organization sought to
be | ||||||
10 | acquired for a period of not less than 3 years; and
| ||||||
11 | (D) such other information as the Director shall | ||||||
12 | require.
| ||||||
13 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
14 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
15 | any health maintenance
organization of greater than 10% of its
| ||||||
16 | enrollee population (including without limitation the health | ||||||
17 | maintenance
organization's right, title, and interest in and to | ||||||
18 | its health care
certificates).
| ||||||
19 | (e) In considering any management contract or service | ||||||
20 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
21 | Code, the Director (i) shall, in
addition to the criteria | ||||||
22 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
23 | into account the effect of the management contract or
service | ||||||
24 | agreement on the continuation of benefits to enrollees and the
| ||||||
25 | financial condition of the health maintenance organization to | ||||||
26 | be managed or
serviced, and (ii) need not take into account the |
| |||||||
| |||||||
1 | effect of the management
contract or service agreement on | ||||||
2 | competition.
| ||||||
3 | (f) Except for small employer groups as defined in the | ||||||
4 | Small Employer
Rating, Renewability and Portability Health | ||||||
5 | Insurance Act and except for
medicare supplement policies as | ||||||
6 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
7 | Maintenance Organization may by contract agree with a
group or | ||||||
8 | other enrollment unit to effect refunds or charge additional | ||||||
9 | premiums
under the following terms and conditions:
| ||||||
10 | (i) the amount of, and other terms and conditions with | ||||||
11 | respect to, the
refund or additional premium are set forth | ||||||
12 | in the group or enrollment unit
contract agreed in advance | ||||||
13 | of the period for which a refund is to be paid or
| ||||||
14 | additional premium is to be charged (which period shall not | ||||||
15 | be less than one
year); and
| ||||||
16 | (ii) the amount of the refund or additional premium | ||||||
17 | shall not exceed 20%
of the Health Maintenance | ||||||
18 | Organization's profitable or unprofitable experience
with | ||||||
19 | respect to the group or other enrollment unit for the | ||||||
20 | period (and, for
purposes of a refund or additional | ||||||
21 | premium, the profitable or unprofitable
experience shall | ||||||
22 | be calculated taking into account a pro rata share of the
| ||||||
23 | Health Maintenance Organization's administrative and | ||||||
24 | marketing expenses, but
shall not include any refund to be | ||||||
25 | made or additional premium to be paid
pursuant to this | ||||||
26 | subsection (f)). The Health Maintenance Organization and |
| |||||||
| |||||||
1 | the
group or enrollment unit may agree that the profitable | ||||||
2 | or unprofitable
experience may be calculated taking into | ||||||
3 | account the refund period and the
immediately preceding 2 | ||||||
4 | plan years.
| ||||||
5 | The Health Maintenance Organization shall include a | ||||||
6 | statement in the
evidence of coverage issued to each enrollee | ||||||
7 | describing the possibility of a
refund or additional premium, | ||||||
8 | and upon request of any group or enrollment unit,
provide to | ||||||
9 | the group or enrollment unit a description of the method used | ||||||
10 | to
calculate (1) the Health Maintenance Organization's | ||||||
11 | profitable experience with
respect to the group or enrollment | ||||||
12 | unit and the resulting refund to the group
or enrollment unit | ||||||
13 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
14 | experience with respect to the group or enrollment unit and the | ||||||
15 | resulting
additional premium to be paid by the group or | ||||||
16 | enrollment unit.
| ||||||
17 | In no event shall the Illinois Health Maintenance | ||||||
18 | Organization
Guaranty Association be liable to pay any | ||||||
19 | contractual obligation of an
insolvent organization to pay any | ||||||
20 | refund authorized under this Section.
| ||||||
21 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
22 | if any, is conditioned on the rules being adopted in accordance | ||||||
23 | with all provisions of the Illinois Administrative Procedure | ||||||
24 | Act and all rules and procedures of the Joint Committee on | ||||||
25 | Administrative Rules; any purported rule not so adopted, for | ||||||
26 | whatever reason, is unauthorized. |
| |||||||
| |||||||
1 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
2 | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | ||||||
3 | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | ||||||
4 | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | ||||||
5 | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | ||||||
6 | 1-1-20; revised 10-16-19.)
| ||||||
7 | Section 40. The Limited Health Service Organization Act is | ||||||
8 | amended by changing Section 4003 as follows:
| ||||||
9 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| ||||||
10 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
11 | health service
organizations shall be subject to the provisions | ||||||
12 | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | ||||||
13 | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | ||||||
14 | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, | ||||||
15 | 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, | ||||||
16 | 356z.30a, 356z.32, 356z.33, 356z.41, 368a, 401, 401.1,
402,
| ||||||
17 | 403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles | ||||||
18 | IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of | ||||||
19 | the Illinois Insurance Code. For purposes of the
Illinois | ||||||
20 | Insurance Code, except for Sections 444 and 444.1 and Articles | ||||||
21 | XIII
and XIII 1/2, limited health service organizations in the | ||||||
22 | following categories
are deemed to be domestic companies:
| ||||||
23 | (1) a corporation under the laws of this State; or
| ||||||
24 | (2) a corporation organized under the laws of another |
| |||||||
| |||||||
1 | state, 30% or more
of the enrollees of which are residents | ||||||
2 | of this State, except a corporation
subject to | ||||||
3 | substantially the same requirements in its state of | ||||||
4 | organization as
is a domestic company under Article VIII | ||||||
5 | 1/2 of the Illinois Insurance Code.
| ||||||
6 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
7 | 100-201, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. | ||||||
8 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
9 | eff. 1-1-20; 101-393, eff. 1-1-20; revised 10-16-19.)
| ||||||
10 | Section 45. The Voluntary Health Services Plans Act is | ||||||
11 | amended by changing Section 10 as follows:
| ||||||
12 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
13 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
14 | services
plan corporations and all persons interested therein | ||||||
15 | or dealing therewith
shall be subject to the provisions of | ||||||
16 | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | ||||||
17 | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, | ||||||
18 | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | ||||||
19 | 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, | ||||||
20 | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, | ||||||
21 | 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, | ||||||
22 | 356z.30, 356z.30a, 356z.32, 356z.33, 356z.41, 364.01, 367.2, | ||||||
23 | 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and | ||||||
24 | paragraphs (7) and (15) of Section 367 of the Illinois
|
| |||||||
| |||||||
1 | Insurance Code.
| ||||||
2 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
3 | any, is conditioned on the rules being adopted in accordance | ||||||
4 | with all provisions of the Illinois Administrative Procedure | ||||||
5 | Act and all rules and procedures of the Joint Committee on | ||||||
6 | Administrative Rules; any purported rule not so adopted, for | ||||||
7 | whatever reason, is unauthorized. | ||||||
8 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
9 | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | ||||||
10 | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | ||||||
11 | eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; | ||||||
12 | revised 10-16-19.)
| ||||||
13 | Section 99. Effective date. This Act takes effect January | ||||||
14 | 1, 2021, except that Section 10 and this Section take effect | ||||||
15 | upon becoming law.".
|