INS CD-LIMIT COST SHARING

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB3607

Introduced 2/18/2025, by Rep. Camille Y. Lilly

SYNOPSIS AS INTRODUCED:

5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.80 new
215 ILCS 125/5-3

from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003

from Ch. 73, par. 1504-3
215 ILCS 165/10

from Ch. 32, par. 604
305 ILCS 5/5-16.8

Amends the Illinois Insurance Code. Provides that a group or
individual policy of accident or health insurance that is issued, amended,
delivered, or renewed on or after January 1, 2027 shall not charge insured
persons a copayment as a method of cost-sharing or include a deductible
greater than $1,000. Provides that yearly out-of-pocket expenses for
insured persons must be less than or equal to $1,500. Amends the State
Employees Group Insurance Act of 1971, the Counties Code, the Illinois
Municipal Code, the School Code, the Health Maintenance Organization Act,
the Limited Health Service Organization Act, the Voluntary Health Services
Plans Act, and the Illinois Public Aid Code to require coverage under those
provisions.
LRB104 11275 BAB 21360 b

A BILL FOR

HB3607
LRB104 11275 BAB 21360 b
1

AN ACT concerning regulation.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 5.
The State Employees Group Insurance Act of 1971
5
is amended by changing Section 6.11 as follows:

6

(5 ILCS 375/6.11)
7

Sec. 6.11.
Required health benefits; Illinois Insurance
8
Code requirements.
The program of health benefits shall
9
provide the post-mastectomy care benefits required to be
10
covered by a policy of accident and health insurance under
11
Section 356t of the Illinois Insurance Code. The program of
12
health benefits shall provide the coverage required under
13
Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10,
14
356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
15
356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
16
356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
17
356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
18
356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
19
356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68,
and

20
356z.70,
and
356z.71
, 356z.74, 356z.76, 356z.77, and 356z.80

21
of the Illinois Insurance Code. The program of health benefits
22
must comply with Sections 155.22a, 155.37, 355b, 356z.19,
23
370c, and 370c.1 and Article XXXIIB of the Illinois Insurance

HB3607
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LRB104 11275 BAB 21360 b
1
Code. The program of health benefits shall provide the
2
coverage required under Section 356m of the Illinois Insurance
3
Code and, for the employees of the State Employee Group
4
Insurance Program only, the coverage as also provided in
5
Section 6.11B of this Act. The Department of Insurance shall
6
enforce the requirements of this Section with respect to
7
Sections 370c and 370c.1 of the Illinois Insurance Code; all
8
other requirements of this Section shall be enforced by the
9
Department of Central Management Services.
10

Rulemaking authority to implement Public Act 95-1045, if
11
any, is conditioned on the rules being adopted in accordance
12
with all provisions of the Illinois Administrative Procedure
13
Act and all rules and procedures of the Joint Committee on
14
Administrative Rules; any purported rule not so adopted, for
15
whatever reason, is unauthorized.
16
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
17
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
18
1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
19
eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
20
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
21
1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
22
eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
23
103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
24
8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751,
25
eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25;
26
103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff.

HB3607
- 3 -
LRB104 11275 BAB 21360 b
1
1-1-25; revised 11-26-24.)

2

Section 10.
The Counties Code is amended by changing
3
Section 5-1069.3 as follows:

4

(55 ILCS 5/5-1069.3)
5

Sec. 5-1069.3.
Required health benefits.
If a county,
6
including a home rule county, is a self-insurer for purposes
7
of providing health insurance coverage for its employees, the
8
coverage shall include coverage for the post-mastectomy care
9
benefits required to be covered by a policy of accident and
10
health insurance under Section 356t and the coverage required
11
under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u,
12
356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9,
13
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
14
356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36,
15
356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
16
356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
17
356z.62, 356z.64, 356z.67, 356z.68,
and
356z.70,
and
356z.71
,
18
356z.74, 356z.77, and 356z.80
of the Illinois Insurance Code.
19
The coverage shall comply with Sections 155.22a, 355b,
20
356z.19, and 370c of the Illinois Insurance Code. The
21
Department of Insurance shall enforce the requirements of this
22
Section. The requirement that health benefits be covered as
23
provided in this Section is an exclusive power and function of
24
the State and is a denial and limitation under Article VII,

HB3607
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LRB104 11275 BAB 21360 b
1
Section 6, subsection (h) of the Illinois Constitution. A home
2
rule county to which this Section applies must comply with
3
every provision of this Section.
4

Rulemaking authority to implement Public Act 95-1045, if
5
any, is conditioned on the rules being adopted in accordance
6
with all provisions of the Illinois Administrative Procedure
7
Act and all rules and procedures of the Joint Committee on
8
Administrative Rules; any purported rule not so adopted, for
9
whatever reason, is unauthorized.
10
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
11
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
12
1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
13
eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
14
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
15
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
16
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
17
103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
18
7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
19
eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
20
revised 11-26-24.)

21

Section 15.
The Illinois Municipal Code is amended by
22
changing Section 10-4-2.3 as follows:

23

(65 ILCS 5/10-4-2.3)
24

Sec. 10-4-2.3.
Required health benefits.
If a

HB3607
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LRB104 11275 BAB 21360 b
1
municipality, including a home rule municipality, is a
2
self-insurer for purposes of providing health insurance
3
coverage for its employees, the coverage shall include
4
coverage for the post-mastectomy care benefits required to be
5
covered by a policy of accident and health insurance under
6
Section 356t and the coverage required under Sections 356g,
7
356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
8
356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
9
356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
10
356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
11
356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54,
12
356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
13
356z.67, 356z.68,
and
356z.70,
and
356z.71
, 356z.74, 356z.77,
14
and 356z.80
of the Illinois Insurance Code. The coverage shall
15
comply with Sections 155.22a, 355b, 356z.19, and 370c of the
16
Illinois Insurance Code. The Department of Insurance shall
17
enforce the requirements of this Section. The requirement that
18
health benefits be covered as provided in this is an exclusive
19
power and function of the State and is a denial and limitation
20
under Article VII, Section 6, subsection (h) of the Illinois
21
Constitution. A home rule municipality to which this Section
22
applies must comply with every provision of this Section.
23

Rulemaking authority to implement Public Act 95-1045, if
24
any, is conditioned on the rules being adopted in accordance
25
with all provisions of the Illinois Administrative Procedure
26
Act and all rules and procedures of the Joint Committee on

HB3607
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LRB104 11275 BAB 21360 b
1
Administrative Rules; any purported rule not so adopted, for
2
whatever reason, is unauthorized.
3
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
4
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
5
1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
6
eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
7
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
8
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
9
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
10
103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
11
7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
12
eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
13
revised 11-26-24.)

14

Section 20.
The School Code is amended by changing Section
15
10-22.3f as follows:

16

(105 ILCS 5/10-22.3f)
17

Sec. 10-22.3f.
Required health benefits.
Insurance
18
protection and benefits for employees shall provide the
19
post-mastectomy care benefits required to be covered by a
20
policy of accident and health insurance under Section 356t and
21
the coverage required under Sections 356g, 356g.5, 356g.5-1,
22
356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,
23
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
24
356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,

HB3607
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LRB104 11275 BAB 21360 b
1
356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
2
356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
3
356z.61, 356z.62, 356z.64, 356z.67, 356z.68,
and
356z.70,
and

4
356z.71
, 356z.74, 356z.77, and 356z.80
of the Illinois
5
Insurance Code. Insurance policies shall comply with Section
6
356z.19 of the Illinois Insurance Code. The coverage shall
7
comply with Sections 155.22a, 355b, and 370c of the Illinois
8
Insurance Code. The Department of Insurance shall enforce the
9
requirements of this Section.
10

Rulemaking authority to implement Public Act 95-1045, if
11
any, is conditioned on the rules being adopted in accordance
12
with all provisions of the Illinois Administrative Procedure
13
Act and all rules and procedures of the Joint Committee on
14
Administrative Rules; any purported rule not so adopted, for
15
whatever reason, is unauthorized.
16
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
17
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
18
1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
19
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
20
102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
21
1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
22
eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
23
103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
24
7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,
25
eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)

HB3607
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LRB104 11275 BAB 21360 b
1

Section 22.
The Illinois Insurance Code is amended by
2
adding Section 356z.80 as follows:

3

(215 ILCS 5/356z.80 new)
4

Sec. 356z.80.
Prohibition of copayment and other
5
out-of-pocket limitations.
A group or individual policy of
6
accident or health insurance that is issued, amended,
7
delivered, or renewed on or after January 1, 2027 shall not
8
charge insured persons a copayment as a method of cost-sharing
9
or include a deductible greater than $1,000. Yearly
10
out-of-pocket expenses for insured persons must be less than
11
or equal to $1,500.

12

Section 25.
The Health Maintenance Organization Act is
13
amended by changing Section 5-3 as follows:

14

(215 ILCS 125/5-3)

(from Ch. 111 1/2, par. 1411.2)
15

(Text of Section before amendment by P.A. 103-808
)
16

Sec. 5-3.
Insurance Code provisions.
17

(a) Health Maintenance Organizations shall be subject to
18
the provisions of Sections 133, 134, 136, 137, 139, 140,
19
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
20
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
21
155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
22
356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
23
356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,

HB3607
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LRB104 11275 BAB 21360 b
1
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
2
356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
3
356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
4
356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
5
356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
6
356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
7
356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
8
356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
9
356z.70, 356z.71,
356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
10
356z.80,
364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
11
368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
12
408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
13
subsection (2) of Section 367, and Articles IIA, VIII 1/2,
14
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
15
Illinois Insurance Code.
16

(b) For purposes of the Illinois Insurance Code, except
17
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
18
Health Maintenance Organizations in the following categories
19
are deemed to be "domestic companies":
20

(1) a corporation authorized under the Dental Service
21

Plan Act or the Voluntary Health Services Plans Act;
22

(2) a corporation organized under the laws of this
23

State; or
24

(3) a corporation organized under the laws of another
25

state, 30% or more of the enrollees of which are residents
26

of this State, except a corporation subject to

HB3607
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LRB104 11275 BAB 21360 b
1

substantially the same requirements in its state of
2

organization as is a "domestic company" under Article VIII
3

1/2 of the Illinois Insurance Code.
4

(c) In considering the merger, consolidation, or other
5
acquisition of control of a Health Maintenance Organization
6
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
7

(1) the Director shall give primary consideration to
8

the continuation of benefits to enrollees and the
9

financial conditions of the acquired Health Maintenance
10

Organization after the merger, consolidation, or other
11

acquisition of control takes effect;
12

(2)(i) the criteria specified in subsection (1)(b) of
13

Section 131.8 of the Illinois Insurance Code shall not
14

apply and (ii) the Director, in making his determination
15

with respect to the merger, consolidation, or other
16

acquisition of control, need not take into account the
17

effect on competition of the merger, consolidation, or
18

other acquisition of control;
19

(3) the Director shall have the power to require the
20

following information:
21

(A) certification by an independent actuary of the
22

adequacy of the reserves of the Health Maintenance
23

Organization sought to be acquired;
24

(B) pro forma financial statements reflecting the
25

combined balance sheets of the acquiring company and
26

the Health Maintenance Organization sought to be

HB3607
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LRB104 11275 BAB 21360 b
1

acquired as of the end of the preceding year and as of
2

a date 90 days prior to the acquisition, as well as pro
3

forma financial statements reflecting projected
4

combined operation for a period of 2 years;
5

(C) a pro forma business plan detailing an
6

acquiring party's plans with respect to the operation
7

of the Health Maintenance Organization sought to be
8

acquired for a period of not less than 3 years; and
9

(D) such other information as the Director shall
10

require.
11

(d) The provisions of Article VIII 1/2 of the Illinois
12
Insurance Code and this Section 5-3 shall apply to the sale by
13
any health maintenance organization of greater than 10% of its
14
enrollee population (including, without limitation, the health
15
maintenance organization's right, title, and interest in and
16
to its health care certificates).
17

(e) In considering any management contract or service
18
agreement subject to Section 141.1 of the Illinois Insurance
19
Code, the Director (i) shall, in addition to the criteria
20
specified in Section 141.2 of the Illinois Insurance Code,
21
take into account the effect of the management contract or
22
service agreement on the continuation of benefits to enrollees
23
and the financial condition of the health maintenance
24
organization to be managed or serviced, and (ii) need not take
25
into account the effect of the management contract or service
26
agreement on competition.

HB3607
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LRB104 11275 BAB 21360 b
1

(f) Except for small employer groups as defined in the
2
Small Employer Rating, Renewability and Portability Health
3
Insurance Act and except for medicare supplement policies as
4
defined in Section 363 of the Illinois Insurance Code, a
5
Health Maintenance Organization may by contract agree with a
6
group or other enrollment unit to effect refunds or charge
7
additional premiums under the following terms and conditions:
8

(i) the amount of, and other terms and conditions with
9

respect to, the refund or additional premium are set forth
10

in the group or enrollment unit contract agreed in advance
11

of the period for which a refund is to be paid or
12

additional premium is to be charged (which period shall
13

not be less than one year); and
14

(ii) the amount of the refund or additional premium
15

shall not exceed 20% of the Health Maintenance
16

Organization's profitable or unprofitable experience with
17

respect to the group or other enrollment unit for the
18

period (and, for purposes of a refund or additional
19

premium, the profitable or unprofitable experience shall
20

be calculated taking into account a pro rata share of the
21

Health Maintenance Organization's administrative and
22

marketing expenses, but shall not include any refund to be
23

made or additional premium to be paid pursuant to this
24

subsection (f)). The Health Maintenance Organization and
25

the group or enrollment unit may agree that the profitable
26

or unprofitable experience may be calculated taking into

HB3607
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LRB104 11275 BAB 21360 b
1

account the refund period and the immediately preceding 2
2

plan years.
3

The Health Maintenance Organization shall include a
4
statement in the evidence of coverage issued to each enrollee
5
describing the possibility of a refund or additional premium,
6
and upon request of any group or enrollment unit, provide to
7
the group or enrollment unit a description of the method used
8
to calculate (1) the Health Maintenance Organization's
9
profitable experience with respect to the group or enrollment
10
unit and the resulting refund to the group or enrollment unit
11
or (2) the Health Maintenance Organization's unprofitable
12
experience with respect to the group or enrollment unit and
13
the resulting additional premium to be paid by the group or
14
enrollment unit.
15

In no event shall the Illinois Health Maintenance
16
Organization Guaranty Association be liable to pay any
17
contractual obligation of an insolvent organization to pay any
18
refund authorized under this Section.
19

(g) Rulemaking authority to implement Public Act 95-1045,
20
if any, is conditioned on the rules being adopted in
21
accordance with all provisions of the Illinois Administrative
22
Procedure Act and all rules and procedures of the Joint
23
Committee on Administrative Rules; any purported rule not so
24
adopted, for whatever reason, is unauthorized.
25
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
26
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.

HB3607
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LRB104 11275 BAB 21360 b
1
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
2
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
3
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
4
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
5
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
6
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
7
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
8
eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
9
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
10
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
11
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
12
103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
13
1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)

14

(Text of Section after amendment by P.A. 103-808
)
15

Sec. 5-3.
Insurance Code provisions.
16

(a) Health Maintenance Organizations shall be subject to
17
the provisions of Sections 133, 134, 136, 137, 139, 140,
18
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
19
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
20
155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
21
356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
22
356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
23
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
24
356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
25
356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,

HB3607
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LRB104 11275 BAB 21360 b
1
356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
2
356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
3
356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
4
356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
5
356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
6
356z.69, 356z.70, 356z.71,
356z.72, 356z.73, 356z.74, 356z.75,
7
356z.77, 356z.80,
364, 364.01, 364.3, 367.2, 367.2-5, 367i,
8
368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402,
9
403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
10
of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
11
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
12
Illinois Insurance Code.
13

(b) For purposes of the Illinois Insurance Code, except
14
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
15
Health Maintenance Organizations in the following categories
16
are deemed to be "domestic companies":
17

(1) a corporation authorized under the Dental Service
18

Plan Act or the Voluntary Health Services Plans Act;
19

(2) a corporation organized under the laws of this
20

State; or
21

(3) a corporation organized under the laws of another
22

state, 30% or more of the enrollees of which are residents
23

of this State, except a corporation subject to
24

substantially the same requirements in its state of
25

organization as is a "domestic company" under Article VIII
26

1/2 of the Illinois Insurance Code.

HB3607
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LRB104 11275 BAB 21360 b
1

(c) In considering the merger, consolidation, or other
2
acquisition of control of a Health Maintenance Organization
3
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
4

(1) the Director shall give primary consideration to
5

the continuation of benefits to enrollees and the
6

financial conditions of the acquired Health Maintenance
7

Organization after the merger, consolidation, or other
8

acquisition of control takes effect;
9

(2)(i) the criteria specified in subsection (1)(b) of
10

Section 131.8 of the Illinois Insurance Code shall not
11

apply and (ii) the Director, in making his determination
12

with respect to the merger, consolidation, or other
13

acquisition of control, need not take into account the
14

effect on competition of the merger, consolidation, or
15

other acquisition of control;
16

(3) the Director shall have the power to require the
17

following information:
18

(A) certification by an independent actuary of the
19

adequacy of the reserves of the Health Maintenance
20

Organization sought to be acquired;
21

(B) pro forma financial statements reflecting the
22

combined balance sheets of the acquiring company and
23

the Health Maintenance Organization sought to be
24

acquired as of the end of the preceding year and as of
25

a date 90 days prior to the acquisition, as well as pro
26

forma financial statements reflecting projected

HB3607
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LRB104 11275 BAB 21360 b
1

combined operation for a period of 2 years;
2

(C) a pro forma business plan detailing an
3

acquiring party's plans with respect to the operation
4

of the Health Maintenance Organization sought to be
5

acquired for a period of not less than 3 years; and
6

(D) such other information as the Director shall
7

require.
8

(d) The provisions of Article VIII 1/2 of the Illinois
9
Insurance Code and this Section 5-3 shall apply to the sale by
10
any health maintenance organization of greater than 10% of its
11
enrollee population (including, without limitation, the health
12
maintenance organization's right, title, and interest in and
13
to its health care certificates).
14

(e) In considering any management contract or service
15
agreement subject to Section 141.1 of the Illinois Insurance
16
Code, the Director (i) shall, in addition to the criteria
17
specified in Section 141.2 of the Illinois Insurance Code,
18
take into account the effect of the management contract or
19
service agreement on the continuation of benefits to enrollees
20
and the financial condition of the health maintenance
21
organization to be managed or serviced, and (ii) need not take
22
into account the effect of the management contract or service
23
agreement on competition.
24

(f) Except for small employer groups as defined in the
25
Small Employer Rating, Renewability and Portability Health
26
Insurance Act and except for medicare supplement policies as

HB3607
- 18 -
LRB104 11275 BAB 21360 b
1
defined in Section 363 of the Illinois Insurance Code, a
2
Health Maintenance Organization may by contract agree with a
3
group or other enrollment unit to effect refunds or charge
4
additional premiums under the following terms and conditions:
5

(i) the amount of, and other terms and conditions with
6

respect to, the refund or additional premium are set forth
7

in the group or enrollment unit contract agreed in advance
8

of the period for which a refund is to be paid or
9

additional premium is to be charged (which period shall
10

not be less than one year); and
11

(ii) the amount of the refund or additional premium
12

shall not exceed 20% of the Health Maintenance
13

Organization's profitable or unprofitable experience with
14

respect to the group or other enrollment unit for the
15

period (and, for purposes of a refund or additional
16

premium, the profitable or unprofitable experience shall
17

be calculated taking into account a pro rata share of the
18

Health Maintenance Organization's administrative and
19

marketing expenses, but shall not include any refund to be
20

made or additional premium to be paid pursuant to this
21

subsection (f)). The Health Maintenance Organization and
22

the group or enrollment unit may agree that the profitable
23

or unprofitable experience may be calculated taking into
24

account the refund period and the immediately preceding 2
25

plan years.
26

The Health Maintenance Organization shall include a

HB3607
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LRB104 11275 BAB 21360 b
1
statement in the evidence of coverage issued to each enrollee
2
describing the possibility of a refund or additional premium,
3
and upon request of any group or enrollment unit, provide to
4
the group or enrollment unit a description of the method used
5
to calculate (1) the Health Maintenance Organization's
6
profitable experience with respect to the group or enrollment
7
unit and the resulting refund to the group or enrollment unit
8
or (2) the Health Maintenance Organization's unprofitable
9
experience with respect to the group or enrollment unit and
10
the resulting additional premium to be paid by the group or
11
enrollment unit.
12

In no event shall the Illinois Health Maintenance
13
Organization Guaranty Association be liable to pay any
14
contractual obligation of an insolvent organization to pay any
15
refund authorized under this Section.
16

(g) Rulemaking authority to implement Public Act 95-1045,
17
if any, is conditioned on the rules being adopted in
18
accordance with all provisions of the Illinois Administrative
19
Procedure Act and all rules and procedures of the Joint
20
Committee on Administrative Rules; any purported rule not so
21
adopted, for whatever reason, is unauthorized.
22
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
23
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
24
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
25
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
26
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.

HB3607
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LRB104 11275 BAB 21360 b
1
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
2
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
3
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
4
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
5
eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
6
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
7
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
8
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
9
103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
10
1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
11
11-26-24.)

12

Section 30.
The Limited Health Service Organization Act is
13
amended by changing Section 4003 as follows:

14

(215 ILCS 130/4003)

(from Ch. 73, par. 1504-3)
15

Sec. 4003.
Illinois Insurance Code provisions.
Limited
16
health service organizations shall be subject to the
17
provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
18
141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153,
19
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c,
20
355.2, 355.3, 355b, 355d, 356m, 356q, 356v, 356z.4, 356z.4a,
21
356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.32,
22
356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54,
23
356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, 356z.71,
24
356z.73, 356z.74, 356z.75, 356z.80,
364.3, 368a, 401, 401.1,

HB3607
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LRB104 11275 BAB 21360 b
1
402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and
2
Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and
3
XXVI of the Illinois Insurance Code. Nothing in this Section
4
shall require a limited health care plan to cover any service
5
that is not a limited health service. For purposes of the
6
Illinois Insurance Code, except for Sections 444 and 444.1 and
7
Articles XIII and XIII 1/2, limited health service
8
organizations in the following categories are deemed to be
9
domestic companies:
10

(1) a corporation under the laws of this State; or
11

(2) a corporation organized under the laws of another
12

state, 30% or more of the enrollees of which are residents
13

of this State, except a corporation subject to
14

substantially the same requirements in its state of
15

organization as is a domestic company under Article VIII
16

1/2 of the Illinois Insurance Code.
17
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
18
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
19
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
20
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
21
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
22
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
23
eff. 1-1-24; 103-605, eff. 7-1-24; 103-649, eff. 1-1-25;
24
103-656, eff. 1-1-25; 103-700, eff. 1-1-25; 103-718, eff.
25
7-19-24; 103-751, eff. 8-2-24; 103-758, eff. 1-1-25; 103-832,
26
eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)

HB3607
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LRB104 11275 BAB 21360 b
1

Section 35.
The Voluntary Health Services Plans Act is
2
amended by changing Section 10 as follows:

3

(215 ILCS 165/10)

(from Ch. 32, par. 604)
4

Sec. 10.
Application of Insurance Code provisions.
Health
5
services plan corporations and all persons interested therein
6
or dealing therewith shall be subject to the provisions of
7
Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
8
143, 143.31, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3,
9
355b, 355d, 356g, 356g.5, 356g.5-1, 356m, 356q, 356r, 356t,
10
356u, 356u.10, 356v, 356w, 356x, 356y, 356z.1, 356z.2,
11
356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
12
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
13
356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
14
356z.32, 356z.32a, 356z.33, 356z.40, 356z.41, 356z.46,
15
356z.47, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59,
16
356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.71,
17
356z.72, 356z.74, 356z.75, 356z.77, 356z.80,
364.01, 364.3,
18
367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
19
and paragraphs (7) and (15) of Section 367 of the Illinois
20
Insurance Code.
21

Rulemaking authority to implement Public Act 95-1045, if
22
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

HB3607
- 23 -
LRB104 11275 BAB 21360 b
1
Administrative Rules; any purported rule not so adopted, for
2
whatever reason, is unauthorized.
3
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
4
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
5
10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
6
eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
7
102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
8
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
9
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
10
103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-656, eff.
11
1-1-25; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-753,
12
eff. 8-2-24; 103-758, eff. 1-1-25; 103-832, eff. 1-1-25;
13
103-914, eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff.
14
1-1-25; revised 11-26-24.)

15

Section 40.
The Illinois Public Aid Code is amended by
16
changing Section 5-16.8 as follows:

17

(305 ILCS 5/5-16.8)
18

Sec. 5-16.8.
Required health benefits.
The medical
19
assistance program shall (i) provide the post-mastectomy care
20
benefits required to be covered by a policy of accident and
21
health insurance under Section 356t and the coverage required
22
under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6,
23
356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46,
24
356z.47, 356z.51, 356z.53, 356z.59, 356z.60, 356z.61, 356z.64,

HB3607
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LRB104 11275 BAB 21360 b
1
and
356z.67,
and
356z.71
, 356z.75, and 356z.80
of the Illinois
2
Insurance Code, (ii) be subject to the provisions of Sections
3
356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the
4
Illinois Insurance Code, and (iii) be subject to the
5
provisions of subsection (d-5) of Section 10 of the Network
6
Adequacy and Transparency Act.
7

The Department, by rule, shall adopt a model similar to
8
the requirements of Section 356z.39 of the Illinois Insurance
9
Code.
10

On and after July 1, 2012, the Department shall reduce any
11
rate of reimbursement for services or other payments or alter
12
any methodologies authorized by this Code to reduce any rate
13
of reimbursement for services or other payments in accordance
14
with Section 5-5e.
15

To ensure full access to the benefits set forth in this
16
Section, on and after January 1, 2016, the Department shall
17
ensure that provider and hospital reimbursement for
18
post-mastectomy care benefits required under this Section are
19
no lower than the Medicare reimbursement rate.
20
(Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22;
21
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff.
22
1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813,
23
eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23;
24
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
25
1-1-24; 103-420, eff. 1-1-24; 103-605, eff. 7-1-24; 103-703,
26
eff. 1-1-25; 103-758, eff. 1-1-25; 103-1024, eff. 1-1-25;

HB3607
- 25 -
LRB104 11275 BAB 21360 b
1
revised 11-26-24.)

2

Section 95.
No acceleration or delay.
Where this Act makes
3
changes in a statute that is represented in this Act by text
4
that is not yet or no longer in effect (for example, a Section
5
represented by multiple versions), the use of that text does
6
not accelerate or delay the taking effect of (i) the changes
7
made by this Act or (ii) provisions derived from any other
8
Public Act.

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