Bill Text: IL HB2948 | 2021-2022 | 102nd General Assembly | Introduced


Bill Title: 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.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2021-04-23 - Rule 19(a) / Re-referred to Rules Committee [HB2948 Detail]

Download: Illinois-2021-HB2948-Introduced.html


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.
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A BILL FOR

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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5adding Section 355.5, by changing Sections 356g and 356z.4,
6and by renumbering and changing Section 356z.33 as added by
7Public 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
12individual or group accident and health insurance coverage
13that would have qualified as an HSA-eligible HDHP but for its
14conformity with any of the Illinois statutes subject to
15exemption under subsection (b).
16 "HSA-eligible HDHP" means a policy of individual or group
17accident and health insurance coverage that satisfies the
18criteria for a "high-deductible health plan" in 26 U.S.C. 223
19as implemented and interpreted by the U.S. Department of the
20Treasury in the regulations and guidance in effect at the time
21of 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,
11or renewed on or after January 1, 2022, a company shall
12expressly identify the policy as HSA-eligible in all policy
13forms and in all sales and marketing materials. Any name or
14title of a product that is an HSA-eligible HDHP shall include
15the term "HSA-eligible".
16 (d) For all policies issued, delivered, amended, or
17renewed on or after January 1, 2022, unless the policy is an
18HSA-eligible HDHP, no company shall use the terms
19"HSA-eligible", "HSA", "for HSAs", "high deductible health
20plan", "HDHP", or any substantially similar term or phrase, to
21describe a policy of individual or group accident and health
22insurance coverage in any policy form or related sales or
23marketing materials. For all policies in effect on or after
24the effective date of this amendatory Act of the 102nd General
25Assembly, a company or producer shall not in any way represent
26that a policy not satisfying the definition in subsection (a)

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1is an HSA-eligible HDHP.
2 (e) For high deductible non-HSA policies issued,
3delivered, amended, or renewed on or after January 1, 2022,
4the company shall use the term "non-HSA" in any name or title
5of the product found in its policy form, as well as in all
6sales and marketing materials. Any policy, certificate,
7evidence of coverage, or outline of coverage for a high
8deductible non-HSA policy shall include a statement
9substantially the same as the following within the first 2
10pages of substantive text: "Pursuant to Section 355.5 of the
11Illinois Insurance Code, we are required to disclose that the
12coverage provided under this policy may not qualify as a
13"high-deductible health plan" under 26 U.S.C. 223. As a
14result, your enrollment under this policy may not qualify you
15as an "eligible individual" to contribute to a health savings
16account.".
17 (f) Beginning January 1, 2022, if a company offers any
18HSA-eligible HDHP in the large group market, then it shall
19also offer in the same market at least one high-deductible
20non-HSA policy. If a company offers any HSA-eligible HDHP in
21the individual or small group market, then it shall also offer
22in the same market at least one high-deductible non-HSA policy
23at each level of coverage defined in 45 CFR 156.140 for which
24the company offers an HSA-eligible HDHP. A company is not
25required to offer a high-deductible non-HSA policy version of
26every HSA-eligible HDHP that it offers in a market unless the

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1company only offers one HSA-eligible HDHP in the large group
2market or one HSA-eligible HDHP in each applicable level of
3coverage in the individual or small group market. No company
4is required to offer an HSA-eligible HDHP merely because it
5offers a high deductible non-HSA policy.
6 (g) If an applicant or policyholder obtains an
7HSA-eligible HDHP, any successive policy shall not be deemed a
8renewal policy unless it is issued as an HSA-eligible HDHP.
9Nothing in this subsection shall prevent a company from
10offering a policyholder a high deductible non-HSA policy as an
11alternative to renewing their HSA-eligible HDHP, nor from
12discontinuing to offer any HSA-eligible HDHP altogether in the
13Illinois individual, small group, or large group market.
14 (h) This Section does not apply to short-term,
15limited-duration health insurance coverage as defined in
16Section 5 of the Short-Term, Limited-Duration Health Insurance
17Coverage 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
21individual policy, contract, or certificate of insurance
22issued or renewed for persons who are residents of this State,
23coverage for screening by low-dose mammography for all women
2435 years of age or older for the presence of occult breast
25cancer within the provisions of the policy, contract, or

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1certificate. 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
6deductible, coinsurance, copayment, or any other cost-sharing
7requirement on the coverage provided; except that this
8sentence does not apply to coverage of diagnostic mammograms
9to the extent such coverage would disqualify a high-deductible
10health plan from eligibility for a health savings account
11pursuant to Section 223 of the Internal Revenue Code (26
12U.S.C. 223).
13 For purposes of this Section:
14 "Diagnostic mammogram" means a mammogram obtained using
15diagnostic mammography.
16 "Diagnostic mammography" means a method of screening that
17is designed to evaluate an abnormality in a breast, including
18an abnormality seen or suspected on a screening mammogram or a
19subjective or objective abnormality otherwise detected in the
20breast.
21 "Low-dose mammography" means the x-ray examination of the
22breast using equipment dedicated specifically for mammography,
23including the x-ray tube, filter, compression device, and
24image receptor, with radiation exposure delivery of less than
251 rad per breast for 2 views of an average size breast. The
26term also includes digital mammography and includes breast

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1tomosynthesis. As used in this Section, the term "breast
2tomosynthesis" means a radiologic procedure that involves the
3acquisition of projection images over the stationary breast to
4produce cross-sectional digital three-dimensional images of
5the breast.
6 If, at any time, the Secretary of the United States
7Department of Health and Human Services, or its successor
8agency, promulgates rules or regulations to be published in
9the Federal Register or publishes a comment in the Federal
10Register or issues an opinion, guidance, or other action that
11would require the State, pursuant to any provision of the
12Patient Protection and Affordable Care Act (Public Law
13111-148), including, but not limited to, 42 U.S.C.
1418031(d)(3)(B) or any successor provision, to defray the cost
15of any coverage for breast tomosynthesis outlined in this
16subsection, then the requirement that an insurer cover breast
17tomosynthesis is inoperative other than any such coverage
18authorized under Section 1902 of the Social Security Act, 42
19U.S.C. 1396a, and the State shall not assume any obligation
20for the cost of coverage for breast tomosynthesis set forth in
21this subsection.
22 (a-5) Coverage as described by subsection (a) shall be
23provided at no cost to the insured and shall not be applied to
24an annual or lifetime maximum benefit.
25 (a-10) When health care services are available through
26contracted providers and a person does not comply with plan

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1provisions specific to the use of contracted providers, the
2requirements of subsection (a-5) are not applicable. When a
3person does not comply with plan provisions specific to the
4use of contracted providers, plan provisions specific to the
5use of non-contracted providers must be applied without
6distinction for coverage required by this Section and shall be
7at least as favorable as for other radiological examinations
8covered by the policy or contract.
9 (b) No policy of accident or health insurance that
10provides for the surgical procedure known as a mastectomy
11shall be issued, amended, delivered, or renewed in this State
12unless that coverage also provides for prosthetic devices or
13reconstructive surgery incident to the mastectomy. Coverage
14for breast reconstruction in connection with a mastectomy
15shall 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.
23Care shall be determined in consultation with the attending
24physician and the patient. The offered coverage for prosthetic
25devices and reconstructive surgery shall be subject to the
26deductible and coinsurance conditions applied to the

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1mastectomy, and all other terms and conditions applicable to
2other benefits. When a mastectomy is performed and there is no
3evidence of malignancy then the offered coverage may be
4limited to the provision of prosthetic devices and
5reconstructive surgery to within 2 years after the date of the
6mastectomy. As used in this Section, "mastectomy" means the
7removal of all or part of the breast for medically necessary
8reasons, as determined by a licensed physician.
9 Written notice of the availability of coverage under this
10Section shall be delivered to the insured upon enrollment and
11annually thereafter. An insurer may not deny to an insured
12eligibility, or continued eligibility, to enroll or to renew
13coverage under the terms of the plan solely for the purpose of
14avoiding the requirements of this Section. An insurer may not
15penalize or reduce or limit the reimbursement of an attending
16provider or provide incentives (monetary or otherwise) to an
17attending provider to induce the provider to provide care to
18an insured in a manner inconsistent with this Section.
19 (c) Rulemaking authority to implement Public Act 95-1045,
20if any, is conditioned on the rules being adopted in
21accordance with all provisions of the Illinois Administrative
22Procedure Act and all rules and procedures of the Joint
23Committee on Administrative Rules; any purported rule not so
24adopted, 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
4of 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,
25examinations, procedures, and medical services related to the
26use of contraceptive methods (including natural family

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1planning) 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
4severity of side effects, differences in permanence and
5reversibility of contraceptive, and ability to adhere to the
6appropriate use of the item or service, as determined by the
7attending provider.
8 "Therapeutic equivalent version" means drugs, devices, or
9products that can be expected to have the same clinical effect
10and safety profile when administered to patients under the
11conditions specified in the labeling and satisfy the following
12general 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
2insurance amended, delivered, issued, or renewed in this State
3after the effective date of this amendatory Act of the 99th
4General Assembly shall provide coverage for all of the
5following 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
19policy subject to this subsection (a) shall not impose a
20deductible, coinsurance, copayment, or any other cost-sharing
21requirement on the coverage provided. The provisions of this
22paragraph do not apply to coverage of voluntary male
23sterilization procedures to the extent such coverage would
24disqualify a high-deductible health plan from eligibility for
25a health savings account pursuant to the federal Internal
26Revenue 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
3the coverage required under this subsection (a).
4 (6) If, at any time, the Secretary of the United States
5Department of Health and Human Services, or its successor
6agency, promulgates rules or regulations to be published in
7the Federal Register or publishes a comment in the Federal
8Register or issues an opinion, guidance, or other action that
9would require the State, pursuant to any provision of the
10Patient Protection and Affordable Care Act (Public Law
11111-148), including, but not limited to, 42 U.S.C.
1218031(d)(3)(B) or any successor provision, to defray the cost
13of any coverage outlined in this subsection (a), then this
14subsection (a) is inoperative with respect to all coverage
15outlined in this subsection (a) other than that authorized
16under Section 1902 of the Social Security Act, 42 U.S.C.
171396a, and the State shall not assume any obligation for the
18cost of the coverage set forth in this subsection (a).
19 (b) This subsection (b) shall become operative if and only
20if subsection (a) becomes inoperative.
21 An individual or group policy of accident and health
22insurance amended, delivered, issued, or renewed in this State
23after the date this subsection (b) becomes operative that
24provides coverage for outpatient services and outpatient
25prescription drugs or devices must provide coverage for the
26insured and any dependent of the insured covered by the policy

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1for all outpatient contraceptive services and all outpatient
2contraceptive drugs and devices approved by the Food and Drug
3Administration. Coverage required under this Section may not
4impose any deductible, coinsurance, waiting period, or other
5cost-sharing or limitation that is greater than that required
6for any outpatient service or outpatient prescription drug or
7device otherwise covered by the policy.
8 Nothing in this subsection (b) shall be construed to
9require an insurance company to cover services related to
10permanent sterilization that requires a surgical procedure.
11 As used in this subsection (b), "outpatient contraceptive
12service" means consultations, examinations, procedures, and
13medical services, provided on an outpatient basis and related
14to the use of contraceptive methods (including natural family
15planning) to prevent an unintended pregnancy.
16 (c) (Blank).
17 (d) If a plan or issuer utilizes a network of providers,
18nothing in this Section shall be construed to require coverage
19or to prohibit the plan or issuer from imposing cost-sharing
20for items or services described in this Section that are
21provided or delivered by an out-of-network provider, unless
22the plan or issuer does not have in its network a provider who
23is able to or is willing to provide the applicable items or
24services.
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
3individual or group policy of accident and health insurance
4shall cover, without imposing a deductible, coinsurance,
5copayment, or any other cost-sharing requirement upon the
6insured patient, one annual office visit, using appropriate
7routine evaluation and management Current Procedural
8Terminology codes or any successor codes, for a whole body
9skin examination for lesions suspicious for skin cancer. The
10whole body skin examination shall be indicated using an
11appropriate International Statistical Classification of
12Diseases and Related Health Problems code or any successor
13codes. The provisions of this Section do not apply to the
14extent such coverage would disqualify a high-deductible health
15plan from eligibility for a health savings account pursuant to
1626 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
19amended 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
23Health Maintenance Organization for persons who are residents
24of this State shall contain coverage for screening by low-dose

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1mammography for all women 35 years of age or older for the
2presence of occult breast cancer. The coverage shall be as
3follows:
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
5deductible, coinsurance, copayment, or any other cost-sharing
6requirement on the coverage provided; except that this
7sentence does not apply to coverage of diagnostic mammograms
8to the extent such coverage would disqualify a high-deductible
9health plan from eligibility for a health savings account
10pursuant to Section 223 of the Internal Revenue Code (26
11U.S.C. 223).
12 For purposes of this Section:
13 "Diagnostic mammogram" means a mammogram obtained using
14diagnostic mammography.
15 "Diagnostic mammography" means a method of screening that
16is designed to evaluate an abnormality in a breast, including
17an abnormality seen or suspected on a screening mammogram or a
18subjective or objective abnormality otherwise detected in the
19breast.
20 "Low-dose mammography" means the x-ray examination of the
21breast using equipment dedicated specifically for mammography,
22including the x-ray tube, filter, compression device, and
23image receptor, with radiation exposure delivery of less than
241 rad per breast for 2 views of an average size breast. The
25term also includes digital mammography and includes breast
26tomosynthesis.

HB2948- 21 -LRB102 11004 BMS 16336 b
1 "Breast tomosynthesis" means a radiologic procedure that
2involves the acquisition of projection images over the
3stationary breast to produce cross-sectional digital
4three-dimensional images of the breast.
5 If, at any time, the Secretary of the United States
6Department of Health and Human Services, or its successor
7agency, promulgates rules or regulations to be published in
8the Federal Register or publishes a comment in the Federal
9Register or issues an opinion, guidance, or other action that
10would require the State, pursuant to any provision of the
11Patient Protection and Affordable Care Act (Public Law
12111-148), including, but not limited to, 42 U.S.C.
1318031(d)(3)(B) or any successor provision, to defray the cost
14of any coverage for breast tomosynthesis outlined in this
15subsection, then the requirement that an insurer cover breast
16tomosynthesis is inoperative other than any such coverage
17authorized under Section 1902 of the Social Security Act, 42
18U.S.C. 1396a, and the State shall not assume any obligation
19for the cost of coverage for breast tomosynthesis set forth in
20this subsection.
21 (a-5) Coverage as described in subsection (a) shall be
22provided at no cost to the enrollee and shall not be applied to
23an annual or lifetime maximum benefit.
24 (b) No contract or evidence of coverage issued by a health
25maintenance organization that provides for the surgical
26procedure known as a mastectomy shall be issued, amended,

HB2948- 22 -LRB102 11004 BMS 16336 b
1delivered, or renewed in this State on or after the effective
2date of this amendatory Act of the 92nd General Assembly
3unless that coverage also provides for prosthetic devices or
4reconstructive surgery incident to the mastectomy, providing
5that the mastectomy is performed after the effective date of
6this amendatory Act. Coverage for breast reconstruction in
7connection 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.
15Care shall be determined in consultation with the attending
16physician and the patient. The offered coverage for prosthetic
17devices and reconstructive surgery shall be subject to the
18deductible and coinsurance conditions applied to the
19mastectomy and all other terms and conditions applicable to
20other benefits. When a mastectomy is performed and there is no
21evidence of malignancy, then the offered coverage may be
22limited to the provision of prosthetic devices and
23reconstructive surgery to within 2 years after the date of the
24mastectomy. As used in this Section, "mastectomy" means the
25removal of all or part of the breast for medically necessary
26reasons, as determined by a licensed physician.

HB2948- 23 -LRB102 11004 BMS 16336 b
1 Written notice of the availability of coverage under this
2Section shall be delivered to the enrollee upon enrollment and
3annually thereafter. A health maintenance organization may not
4deny to an enrollee eligibility, or continued eligibility, to
5enroll or to renew coverage under the terms of the plan solely
6for the purpose of avoiding the requirements of this Section.
7A health maintenance organization may not penalize or reduce
8or limit the reimbursement of an attending provider or provide
9incentives (monetary or otherwise) to an attending provider to
10induce the provider to provide care to an insured in a manner
11inconsistent with this Section.
12 (c) Rulemaking authority to implement this amendatory Act
13of the 95th General Assembly, if any, is conditioned on the
14rules being adopted in accordance with all provisions of the
15Illinois Administrative Procedure Act and all rules and
16procedures of the Joint Committee on Administrative Rules; any
17purported rule not so adopted, for whatever reason, is
18unauthorized.
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
23the provisions of Sections 133, 134, 136, 137, 139, 140,
24141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
25154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,

HB2948- 24 -LRB102 11004 BMS 16336 b
1355.3, 355.5, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
2356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
3356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
4356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,
5356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, 356z.35,
6356z.36, 356z.41, 364, 364.01, 367.2, 367.2-5, 367i, 368a,
7368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403,
8403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
9subsection (2) of Section 367, and Articles IIA, VIII 1/2,
10XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
11Illinois Insurance Code.
12 (b) For purposes of the Illinois Insurance Code, except
13for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
14Health Maintenance Organizations in the following categories
15are 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

HB2948- 25 -LRB102 11004 BMS 16336 b
1acquisition of control of a Health Maintenance Organization
2pursuant 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;

HB2948- 26 -LRB102 11004 BMS 16336 b
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
8Insurance Code and this Section 5-3 shall apply to the sale by
9any health maintenance organization of greater than 10% of its
10enrollee population (including without limitation the health
11maintenance organization's right, title, and interest in and
12to its health care certificates).
13 (e) In considering any management contract or service
14agreement subject to Section 141.1 of the Illinois Insurance
15Code, the Director (i) shall, in addition to the criteria
16specified in Section 141.2 of the Illinois Insurance Code,
17take into account the effect of the management contract or
18service agreement on the continuation of benefits to enrollees
19and the financial condition of the health maintenance
20organization to be managed or serviced, and (ii) need not take
21into account the effect of the management contract or service
22agreement on competition.
23 (f) Except for small employer groups as defined in the
24Small Employer Rating, Renewability and Portability Health
25Insurance Act and except for medicare supplement policies as
26defined in Section 363 of the Illinois Insurance Code, a

HB2948- 27 -LRB102 11004 BMS 16336 b
1Health Maintenance Organization may by contract agree with a
2group or other enrollment unit to effect refunds or charge
3additional 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
26statement in the evidence of coverage issued to each enrollee

HB2948- 28 -LRB102 11004 BMS 16336 b
1describing the possibility of a refund or additional premium,
2and upon request of any group or enrollment unit, provide to
3the group or enrollment unit a description of the method used
4to calculate (1) the Health Maintenance Organization's
5profitable experience with respect to the group or enrollment
6unit and the resulting refund to the group or enrollment unit
7or (2) the Health Maintenance Organization's unprofitable
8experience with respect to the group or enrollment unit and
9the resulting additional premium to be paid by the group or
10enrollment unit.
11 In no event shall the Illinois Health Maintenance
12Organization Guaranty Association be liable to pay any
13contractual obligation of an insolvent organization to pay any
14refund authorized under this Section.
15 (g) Rulemaking authority to implement Public Act 95-1045,
16if any, is conditioned on the rules being adopted in
17accordance with all provisions of the Illinois Administrative
18Procedure Act and all rules and procedures of the Joint
19Committee on Administrative Rules; any purported rule not so
20adopted, for whatever reason, is unauthorized.
21(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
22100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
231-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
24eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20;
25101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
261-1-20; 101-625, eff. 1-1-21.)

HB2948- 29 -LRB102 11004 BMS 16336 b
1 Section 15. The Voluntary Health Services Plans Act is
2amended 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
5services plan corporations and all persons interested therein
6or dealing therewith shall be subject to the provisions of
7Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
8143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355.5,
9355b, 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w,
10356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
11356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
12356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
13356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
14356z.41, 364.01, 367.2, 368a, 401, 401.1, 402, 403, 403A, 408,
15408.2, and 412, and paragraphs (7) and (15) of Section 367 of
16the Illinois Insurance Code.
17 Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
24100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.

HB2948- 30 -LRB102 11004 BMS 16336 b
11-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81,
2eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20;
3101-625, eff. 1-1-21.)
4 Section 99. Effective date. This Act takes effect January
51, 2022.

HB2948- 31 -LRB102 11004 BMS 16336 b
1 INDEX
2 Statutes amended in order of appearance