Bill Text: IL HB4207 | 2025-2026 | 104th General Assembly | Engrossed

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Bill Title: Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2028 and is subject to the Code shall provide coverage for a medically necessary coronary calcium scan and scoring if: (1) the individual is between 40 and 75 years of age; (2) the scan is ordered by a licensed health care provider; and (3) the provider has conducted and documented a cardiovascular risk assessment demonstrating clinical appropriateness consistent with evidence-based guidelines. Provides that coverage shall be provided at intervals consistent with evidence-based clinical guidelines and shall not be subject to more restrictive limitations than other diagnostic imaging services covered under the policy. Sets forth provisions concerning cost-sharing. Amends the Health Maintenance Organization Act to require the same coverage under the provisions of that Act. Amends the Illinois Public Aid Code to require coverage for a medically necessary coronary calcium scan and scoring for an eligible individual who: (A) is between 40 and 75 years of age; (B) is assessed by a licensed health care provider as having moderate or greater risk of atherosclerotic cardiovascular disease based on a documented cardiovascular risk assessment consistent with nationally recognized evidence-based clinical guidelines; (C) does not have a prior diagnosis of coronary artery disease; and (D) has not received a covered coronary artery calcium scan within the previous 5 years, unless medically necessary as determined by the Department of Healthcare and Family Services. Requires coverage without cost sharing and provides that the Department may adopt reasonable utilization controls consistent with other diagnostic imaging services covered under the medical assistance program. Provides that implementation of the coverage shall occur only to the extent that federal financial participation is available and approved by the federal Centers for Medicare and Medicaid Services.

Sponsorship: Strong Partisan Bill (Democrat 15-1)

Status: (Engrossed - Dead) 2026-05-19 - Added as Alternate Co-Sponsor Sen. Laura M. Murphy [HB4207 Detail]

Download: Illinois-2025-HB4207-Engrossed.html

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HB4207 Engrossed LRB104 15812 BAB 29011 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
adding Section 356z.88 as follows:
(215 ILCS 5/356z.88 new)
Sec. 356z.88. Coronary calcium scan and scoring.
(a) An individual or group policy of accident and health
insurance that is amended, delivered, issued, or renewed on or
after January 1, 2028 and is subject to this Code shall provide
coverage for a medically necessary coronary calcium scan and
scoring if:
(1) the individual is between 40 and 75 years of age;
(2) the scan is ordered by a licensed health care
provider; and
(3) the provider has conducted and documented a
cardiovascular risk assessment demonstrating clinical
appropriateness consistent with evidence-based
guidelines.
(b) Coverage shall be provided at intervals consistent
with evidence-based clinical guidelines and shall not be
subject to more restrictive limitations than other diagnostic
imaging services covered under the policy.

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(c) For policies subject to cost-sharing requirements, the
cost sharing for a coronary calcium scan and scoring shall not
exceed the cost sharing applied to comparable diagnostic
imaging services.
(d) Nothing in this Section shall be construed to require
coverage in a manner inconsistent with federal law.
Section 10. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
Sec. 5-3. Illinois Insurance Code provisions.
(a) Health Maintenance Organizations shall be subject to
the provisions of Sections 133, 134, 136, 137, 139, 140,
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
155.49, 352c, 355.2, 355.3, 355.6, 355.7, 355b, 355c, 356f,
356g, 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,

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356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
356z.76, 356z.77, 356z.78, 356z.79, 356z.80, 356z.81, 356z.82,
356z.83, 356z.84, 356z.85, 356z.88, 364, 364.01, 364.3, 367.2,
367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370a, 370c,
370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444,
and 444.1, paragraph (c) of subsection (2) of Section 367, and
Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
XXVI, and XXXIIB of the Illinois Insurance Code.
(b) For purposes of the Illinois Insurance Code, except
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
Health Maintenance Organizations in the following categories
are deemed to be "domestic companies":
(1) a corporation authorized under the Dental Service
Plan Act or the Voluntary Health Services Plans Act;
(2) a corporation organized under the laws of this
State; or
(3) a corporation organized under the laws of another
state, 30% or more of the enrollees of which are residents
of this State, except a corporation subject to
substantially the same requirements in its state of
organization as is a "domestic company" under Article VIII
1/2 of the Illinois Insurance Code.
(c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,

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(1) the Director shall give primary consideration to
the continuation of benefits to enrollees and the
financial conditions of the acquired Health Maintenance
Organization after the merger, consolidation, or other
acquisition of control takes effect;
(2)(i) the criteria specified in subsection (1)(b) of
Section 131.8 of the Illinois Insurance Code shall not
apply and (ii) the Director, in making his determination
with respect to the merger, consolidation, or other
acquisition of control, need not take into account the
effect on competition of the merger, consolidation, or
other acquisition of control;
(3) the Director shall have the power to require the
following information:
(A) certification by an independent actuary of the
adequacy of the reserves of the Health Maintenance
Organization sought to be acquired;
(B) pro forma financial statements reflecting the
combined balance sheets of the acquiring company and
the Health Maintenance Organization sought to be
acquired as of the end of the preceding year and as of
a date 90 days prior to the acquisition, as well as pro
forma financial statements reflecting projected
combined operation for a period of 2 years;
(C) a pro forma business plan detailing an
acquiring party's plans with respect to the operation

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of the Health Maintenance Organization sought to be
acquired for a period of not less than 3 years; and
(D) such other information as the Director shall
require.
(d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the sale by
any health maintenance organization of greater than 10% of its
enrollee population (including, without limitation, the health
maintenance organization's right, title, and interest in and
to its health care certificates).
(e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois Insurance
Code, the Director (i) shall, in addition to the criteria
specified in Section 141.2 of the Illinois Insurance Code,
take into account the effect of the management contract or
service agreement on the continuation of benefits to enrollees
and the financial condition of the health maintenance
organization to be managed or serviced, and (ii) need not take
into account the effect of the management contract or service
agreement on competition.
(f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health
Insurance Act and except for medicare supplement policies as
defined in Section 363 of the Illinois Insurance Code, a
Health Maintenance Organization may by contract agree with a
group or other enrollment unit to effect refunds or charge

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additional premiums under the following terms and conditions:
(i) the amount of, and other terms and conditions with
respect to, the refund or additional premium are set forth
in the group or enrollment unit contract agreed in advance
of the period for which a refund is to be paid or
additional premium is to be charged (which period shall
not be less than one year); and
(ii) the amount of the refund or additional premium
shall not exceed 20% of the Health Maintenance
Organization's profitable or unprofitable experience with
respect to the group or other enrollment unit for the
period (and, for purposes of a refund or additional
premium, the profitable or unprofitable experience shall
be calculated taking into account a pro rata share of the
Health Maintenance Organization's administrative and
marketing expenses, but shall not include any refund to be
made or additional premium to be paid pursuant to this
subsection (f)). The Health Maintenance Organization and
the group or enrollment unit may agree that the profitable
or unprofitable experience may be calculated taking into
account the refund period and the immediately preceding 2
plan years.
The Health Maintenance Organization shall include a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and upon request of any group or enrollment unit, provide to

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the group or enrollment unit a description of the method used
to calculate (1) the Health Maintenance Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or (2) the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit and
the resulting additional premium to be paid by the group or
enrollment unit.
In no event shall the Illinois Health Maintenance
Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to pay any
refund authorized under this Section.
(g) Rulemaking authority to implement Public Act 95-1045,
if any, is conditioned on the rules being adopted in
accordance with all provisions of the Illinois Administrative
Procedure Act and all rules and procedures of the Joint
Committee on Administrative Rules; any purported rule not so
adopted, for whatever reason, is unauthorized.
(Source: P.A. 103-84, eff. 1-1-24; 103-91, eff. 1-1-24;
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-420, eff.
1-1-24; 103-426, eff. 8-4-23; 103-445, eff. 1-1-24; 103-551,
eff. 8-11-23; 103-605, eff. 7-1-24; 103-618, eff. 1-1-25;
103-649, eff. 1-1-25; 103-656, eff. 1-1-25; 103-700, eff.
1-1-25; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-753,
eff. 8-2-24; 103-758, eff. 1-1-25; 103-777, eff. 8-2-24;
103-808, eff. 1-1-26; 103-914, eff. 1-1-25; 103-918, eff.

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1-1-25; 103-1024, eff. 1-1-25; 104-1, eff. 6-9-25; 104-28,
eff. 1-1-26; 104-42, eff. 8-1-25; 104-68, eff. 1-1-26; 104-73,
eff. 1-1-26; 104-98, eff. 1-1-26; 104-289, eff. 1-1-26;
104-324, eff. 1-1-26; 104-334, eff. 8-15-25; 104-379, eff.
1-1-26; 104-417, eff. 8-15-25; revised 11-21-25.)
Section 15. The Illinois Public Aid Code is amended by
changing Section 5-16.8 as follows:
(305 ILCS 5/5-16.8)
Sec. 5-16.8. Required health benefits.
(a) The medical assistance program shall (i) provide the
post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t and
the coverage required under Sections 356g.5, 356q, 356u, 356w,
356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34,
356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.59, 356z.60,
356z.61, 356z.64, 356z.67, 356z.71, and 356z.75, and 356z.80,
356z.84, and 356z.85 of the Illinois Insurance Code, (ii) be
subject to the provisions of Sections 356z.19, 356z.44,
356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance
Code, and (iii) be subject to the provisions of subsection
(d-5) of Section 10 of the Network Adequacy and Transparency
Act.
The Department, by rule, shall adopt a model similar to
the requirements of Section 356z.39 of the Illinois Insurance

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Code.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
To ensure full access to the benefits set forth in this
Section, on and after January 1, 2016, the Department shall
ensure that provider and hospital reimbursement for
post-mastectomy care benefits required under this Section are
no lower than the Medicare reimbursement rate.
(b)(1) Subject to appropriation and federal approval, the
Department shall provide coverage under the medical assistance
program for a medically necessary coronary artery calcium scan
and scoring for an eligible individual who:
(A) is between 40 and 75 years of age;
(B) is assessed by a licensed health care provider as
having moderate or greater risk of atherosclerotic
cardiovascular disease based on a documented
cardiovascular risk assessment consistent with nationally
recognized evidence-based clinical guidelines;
(C) does not have a prior diagnosis of coronary artery
disease; and
(D) has not received a covered coronary artery calcium
scan within the previous 5 years, unless medically
necessary as determined by the Department.

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(2) Coverage under this subsection shall be provided
without cost sharing to the beneficiary.
(3) The Department may adopt reasonable utilization
controls consistent with other diagnostic imaging services
covered under the medical assistance program.
(4) Implementation of coverage under this subsection shall
occur only to the extent that federal financial participation
is available and approved by the federal Centers for Medicare
and Medicaid Services.
(Source: P.A. 103-84, eff. 1-1-24; 103-91, eff. 1-1-24;
103-420, eff. 1-1-24; 103-605, eff. 7-1-24; 103-703, eff.
1-1-25; 103-758, eff. 1-1-25; 103-1024, eff. 1-1-25; 104-73,
eff. 1-1-26; 104-324, eff. 1-1-26; 104-379, eff. 1-1-26;
104-417, eff. 8-15-25; revised 11-21-25.)