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| Public Act 100-1057
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| HB4821 Enrolled | LRB100 18480 SMS 33695 b |
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The State Employees Group Insurance Act of 1971 |
is amended by changing Section 6.11 as follows:
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(5 ILCS 375/6.11)
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Sec. 6.11. Required health benefits; Illinois Insurance |
Code
requirements. The program of health
benefits shall provide |
the post-mastectomy care benefits required to be covered
by a |
policy of accident and health insurance under Section 356t of |
the Illinois
Insurance Code. The program of health benefits |
shall provide the coverage
required under Sections 356g, |
356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
356z.14, 356z.15, 356z.17, 356z.22, and 356z.25, 356z.26, and |
356z.29 of the
Illinois Insurance Code.
The program of health |
benefits must comply with Sections 155.22a, 155.37, 355b, |
356z.19, 370c, and 370c.1 of the
Illinois Insurance Code.
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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 |
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whatever reason, is unauthorized. |
(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; |
100-138, eff. 8-18-17; revised 10-3-17.)
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Section 10. The Counties Code is amended by changing |
Section 5-1069.3 as follows:
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(55 ILCS 5/5-1069.3)
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Sec. 5-1069.3. Required health benefits. If a county, |
including a home
rule
county, is a self-insurer for purposes of |
providing health insurance coverage
for its employees, the |
coverage shall include coverage for the post-mastectomy
care |
benefits required to be covered by a policy of accident and |
health
insurance under Section 356t and the coverage required |
under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and 356z.29 of
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the Illinois Insurance Code. The coverage shall comply with |
Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois |
Insurance Code. The requirement that health benefits be covered
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as provided in this Section is an
exclusive power and function |
of the State and is a denial and limitation under
Article VII, |
Section 6, subsection (h) of the Illinois Constitution. A home
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rule county to which this Section applies must comply with |
every provision of
this Section.
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Rulemaking authority to implement Public Act 95-1045, if |
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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. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; |
100-138, eff. 8-18-17; revised 10-5-17.)
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Section 15. The Illinois Municipal Code is amended by |
changing Section 10-4-2.3 as follows:
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(65 ILCS 5/10-4-2.3)
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Sec. 10-4-2.3. Required health benefits. If a |
municipality, including a
home rule municipality, is a |
self-insurer for purposes of providing health
insurance |
coverage for its employees, the coverage shall include coverage |
for
the post-mastectomy care benefits required to be covered by |
a policy of
accident and health insurance under Section 356t |
and the coverage required
under Sections 356g, 356g.5, |
356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and |
356z.25, 356z.26, and 356z.29 of the Illinois
Insurance
Code. |
The coverage shall comply with Sections 155.22a, 355b, 356z.19, |
and 370c of
the Illinois Insurance Code. The requirement that |
health
benefits be covered as provided in this is an exclusive |
power and function of
the State and is a denial and limitation |
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under Article VII, Section 6,
subsection (h) of the Illinois |
Constitution. A home rule municipality to which
this Section |
applies must comply with every provision of this Section.
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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. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; |
100-138, eff. 8-18-17; revised 10-5-17.)
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Section 20. The School Code is amended by changing Section |
10-22.3f as follows:
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(105 ILCS 5/10-22.3f)
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Sec. 10-22.3f. Required health benefits. Insurance |
protection and
benefits
for employees shall provide the |
post-mastectomy care benefits required to be
covered by a |
policy of accident and health insurance under Section 356t and |
the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
356z.13, 356z.14, 356z.15, 356z.22, and 356z.25, 356z.26, and |
356z.29 of
the
Illinois Insurance Code.
Insurance policies |
shall comply with Section 356z.19 of the Illinois Insurance |
Code. The coverage shall comply with Sections 155.22a and 355b |
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of
the Illinois Insurance Code.
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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. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
revised 9-25-17.)
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Section 25. The Illinois Insurance Code is amended by |
adding Section 356z.29 as follows:
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(215 ILCS 5/356z.29 new) |
Sec. 356z.29. Stage 4 advanced, metastatic cancer. |
(a) As used in this Section, "stage 4 advanced, metastatic |
cancer" means cancer that has spread from the primary or |
original site of the cancer to nearby tissues, lymph nodes, or |
other areas or parts of the body. |
(b) No individual or group policy of accident and health |
insurance amended, issued, delivered, or renewed in this State |
after the effective date of this amendatory Act of the 100th |
General Assembly that, as a provision of hospital, medical, or |
surgical services, directly or indirectly covers the treatment |
of stage 4 advanced, metastatic cancer shall limit or exclude |
coverage for a drug approved by the United States Food and Drug |
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Administration by mandating that the insured shall first be |
required to fail to successfully respond to a different drug or |
prove a history of failure of the drug as long as the use of the |
drug is consistent with best practices for the treatment of |
stage 4 advanced, metastatic cancer and is supported by |
peer-reviewed medical literature. |
(c) If, at any time before or after the effective date of |
this amendatory Act of the 100th General Assembly, the |
Secretary of the United States Department of Health and Human |
Services, or its successor agency, promulgates rules or |
regulations to be published in the Federal Register, publishes |
a comment in the Federal Register, or issues an opinion, |
guidance, or other action that would require the State, |
pursuant to any provision of the Patient Protection and |
Affordable Care Act (Pub. L. 111–148), including, but not |
limited to, 42 U.S.C. 18031(d)(3)(B) or any successor |
provision, to defray the cost of the prohibition of coverage |
restrictions or exclusions contained in subsection (b) of this |
Section for the treatment of stage 4 advanced, metastatic |
cancer, then this Section is inoperative with respect to all |
such coverage other than that authorized under Section 1902 of |
the Social Security Act, 42 U.S.C. 1396a, and the State shall |
not assume any obligation for the cost of the prohibition of |
coverage restrictions or exclusions contained in subsection |
(b) of this Section for the treatment of stage 4 advanced, |
metastatic cancer.
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Section 30. The Health Maintenance Organization Act is |
amended by changing Section 5-3 as follows:
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(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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Sec. 5-3. Insurance Code provisions.
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(a) Health Maintenance Organizations
shall be subject to |
the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
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141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, |
355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, |
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.21, |
356z.22, 356z.25, 356z.26, 356z.29, 364, 364.01, 367.2, |
367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
370c.1, 401, |
401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
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paragraph (c) of subsection (2) of Section 367, and Articles |
IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of |
the Illinois Insurance Code.
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(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":
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(1) a corporation authorized under the
Dental Service |
Plan Act or the Voluntary Health Services Plans Act;
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(2) a corporation organized under the laws of this |
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State; or
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(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
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organization as is a "domestic company" under Article VIII |
1/2 of the
Illinois Insurance Code.
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(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;
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(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
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acquisition of control, need not take into account the |
effect on
competition of the merger, consolidation, or |
other acquisition of control;
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(3) the Director shall have the power to require the |
following
information:
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(A) certification by an independent actuary of the |
adequacy
of the reserves of the Health Maintenance |
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Organization sought to be acquired;
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(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;
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(C) a pro forma business plan detailing an |
acquiring party's plans with
respect to the operation |
of the Health Maintenance Organization sought to
be |
acquired for a period of not less than 3 years; and
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(D) such other information as the Director shall |
require.
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(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
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enrollee population (including without limitation the health |
maintenance
organization's right, title, and interest in and to |
its health care
certificates).
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(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
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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.
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(f) Except for small employer groups as defined in the |
Small Employer
Rating, Renewability and Portability Health |
Insurance Act and except for
medicare supplement policies as |
defined in Section 363 of the Illinois
Insurance Code, a Health |
Maintenance Organization may by contract agree with a
group or |
other enrollment unit to effect refunds or charge additional |
premiums
under the following terms and conditions:
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(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
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additional premium is to be charged (which period shall not |
be less than one
year); and
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(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
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Health Maintenance Organization's administrative and |
marketing expenses, but
shall not include any refund to be |
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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.
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The Health Maintenance Organization shall include a |
statement in the
evidence of coverage issued to each enrollee |
describing the possibility of a
refund or additional premium, |
and upon request of any group or enrollment unit,
provide to |
the group or enrollment unit a description of the method used |
to
calculate (1) the Health Maintenance Organization's |
profitable experience with
respect to the group or enrollment |
unit and the resulting refund to the group
or enrollment unit |
or (2) the Health Maintenance Organization's unprofitable
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experience with respect to the group or enrollment unit and the |
resulting
additional premium to be paid by the group or |
enrollment unit.
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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.
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(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 |
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Administrative Rules; any purported rule not so adopted, for |
whatever reason, is unauthorized. |
(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; |
100-138, eff. 8-18-17; revised 10-5-17.)
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Section 35. The Limited Health Service Organization Act is |
amended by changing Section 4003 as follows:
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(215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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Sec. 4003. Illinois Insurance Code provisions. Limited |
health service
organizations shall be subject to the provisions |
of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, |
143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, |
154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355b, 356v, |
356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 368a, |
401, 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and |
444.1 and Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, |
XXV, and XXVI of the Illinois Insurance Code. For purposes of |
the
Illinois Insurance Code, except for Sections 444 and 444.1 |
and Articles XIII
and XIII 1/2, limited health service |
organizations in the following categories
are deemed to be |
domestic companies:
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(1) a corporation under the laws of this State; or
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(2) a corporation organized under the laws of another |
state, 30% or more
of the enrollees of which are residents |
of this State, except a corporation
subject to |
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substantially the same requirements in its state of |
organization as
is a domestic company under Article VIII |
1/2 of the Illinois Insurance Code.
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(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
100-201, eff. 8-18-17; revised 10-5-17.)
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Section 40. The Voluntary Health Services Plans Act is |
amended by changing Section 10 as follows:
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(215 ILCS 165/10) (from Ch. 32, par. 604)
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Sec. 10. Application of Insurance Code provisions. Health |
services
plan corporations and all persons interested therein |
or dealing therewith
shall be subject to the provisions of |
Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, |
143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, |
356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, |
356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
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356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, |
356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 364.01, |
367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, |
and paragraphs (7) and (15) of Section 367 of the Illinois
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Insurance Code.
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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. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
revised 10-5-17.)
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Section 45. The Illinois Public Aid Code is amended by |
changing Section 5-16.8 as follows:
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(305 ILCS 5/5-16.8)
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Sec. 5-16.8. Required health benefits. 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
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under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, and |
356z.29 and 356z.25 of the Illinois
Insurance Code and (ii) be |
subject to the provisions of Sections 356z.19, 364.01, 370c, |
and 370c.1 of the Illinois
Insurance Code.
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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 |
