INS-HEALTH/CORONARY SCAN

Illinois General Assembly - Full Text of HB4207

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Full Text of HB4207

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HB4207 - 104th General Assembly

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HB4207 Engrossed
LRB104 15812 BAB 29011 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 Illinois Insurance Code is amended by
5
adding Section 356z.88 as follows:

6

(215 ILCS 5/356z.88 new)
7

Sec. 356z.88.
Coronary calcium scan and scoring.
8

(a) An individual or group policy of accident and health
9
insurance that is amended, delivered, issued, or renewed on or
10
after January 1, 2028 and is subject to this Code shall provide
11
coverage for a medically necessary coronary calcium scan and
12
scoring if:
13

(1) the individual is between 40 and 75 years of age;
14

(2) the scan is ordered by a licensed health care
15

provider; and
16

(3) the provider has conducted and documented a
17

cardiovascular risk assessment demonstrating clinical
18

appropriateness consistent with evidence-based
19

guidelines.
20

(b) Coverage shall be provided at intervals consistent
21
with evidence-based clinical guidelines and shall not be
22
subject to more restrictive limitations than other diagnostic
23
imaging services covered under the policy.

HB4207 Engrossed
- 2 -
LRB104 15812 BAB 29011 b
1

(c) For policies subject to cost-sharing requirements, the
2
cost sharing for a coronary calcium scan and scoring shall not
3
exceed the cost sharing applied to comparable diagnostic
4
imaging services.
5

(d) Nothing in this Section shall be construed to require
6
coverage in a manner inconsistent with federal law.

7

Section 10.
The Health Maintenance Organization Act is
8
amended by changing Section 5-3 as follows:

9

(215 ILCS 125/5-3)

(from Ch. 111 1/2, par. 1411.2)
10

Sec. 5-3.
Illinois Insurance Code provisions.
11

(a) Health Maintenance Organizations shall be subject to
12
the provisions of Sections 133, 134, 136, 137, 139, 140,
13
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
14
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
15
155.49, 352c, 355.2, 355.3, 355.6, 355.7, 355b, 355c, 356f,
16
356g, 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
17
356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
18
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
19
356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
20
356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
21
356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
22
356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
23
356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
24
356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,

HB4207 Engrossed
- 3 -
LRB104 15812 BAB 29011 b
1
356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
2
356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
3
356z.76, 356z.77, 356z.78,
356z.79,
356z.80,
356z.81, 356z.82,
4
356z.83, 356z.84, 356z.85, 356z.88,
364, 364.01, 364.3, 367.2,
5
367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370a, 370c,
6
370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444,
7
and 444.1, paragraph (c) of subsection (2) of Section 367, and
8
Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
9
XXVI, and XXXIIB of the Illinois Insurance Code.
10

(b) For purposes of the Illinois Insurance Code, except
11
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
12
Health Maintenance Organizations in the following categories
13
are deemed to be "domestic companies":
14

(1) a corporation authorized under the Dental Service
15

Plan Act or the Voluntary Health Services Plans Act;
16

(2) a corporation organized under the laws of this
17

State; or
18

(3) a corporation organized under the laws of another
19

state, 30% or more of the enrollees of which are residents
20

of this State, except a corporation subject to
21

substantially the same requirements in its state of
22

organization as is a "domestic company" under Article VIII
23

1/2 of the Illinois Insurance Code.
24

(c) In considering the merger, consolidation, or other
25
acquisition of control of a Health Maintenance Organization
26
pursuant to Article VIII 1/2 of the Illinois Insurance Code,

HB4207 Engrossed
- 4 -
LRB104 15812 BAB 29011 b
1

(1) the Director shall give primary consideration to
2

the continuation of benefits to enrollees and the
3

financial conditions of the acquired Health Maintenance
4

Organization after the merger, consolidation, or other
5

acquisition of control takes effect;
6

(2)(i) the criteria specified in subsection (1)(b) of
7

Section 131.8 of the Illinois Insurance Code shall not
8

apply and (ii) the Director, in making his determination
9

with respect to the merger, consolidation, or other
10

acquisition of control, need not take into account the
11

effect on competition of the merger, consolidation, or
12

other acquisition of control;
13

(3) the Director shall have the power to require the
14

following information:
15

(A) certification by an independent actuary of the
16

adequacy of the reserves of the Health Maintenance
17

Organization sought to be acquired;
18

(B) pro forma financial statements reflecting the
19

combined balance sheets of the acquiring company and
20

the Health Maintenance Organization sought to be
21

acquired as of the end of the preceding year and as of
22

a date 90 days prior to the acquisition, as well as pro
23

forma financial statements reflecting projected
24

combined operation for a period of 2 years;
25

(C) a pro forma business plan detailing an
26

acquiring party's plans with respect to the operation

HB4207 Engrossed
- 5 -
LRB104 15812 BAB 29011 b
1

of the Health Maintenance Organization sought to be
2

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

(D) such other information as the Director shall
4

require.
5

(d) The provisions of Article VIII 1/2 of the Illinois
6
Insurance Code and this Section 5-3 shall apply to the sale by
7
any health maintenance organization of greater than 10% of its
8
enrollee population (including, without limitation, the health
9
maintenance organization's right, title, and interest in and
10
to its health care certificates).
11

(e) In considering any management contract or service
12
agreement subject to Section 141.1 of the Illinois Insurance
13
Code, the Director (i) shall, in addition to the criteria
14
specified in Section 141.2 of the Illinois Insurance Code,
15
take into account the effect of the management contract or
16
service agreement on the continuation of benefits to enrollees
17
and the financial condition of the health maintenance
18
organization to be managed or serviced, and (ii) need not take
19
into account the effect of the management contract or service
20
agreement on competition.
21

(f) Except for small employer groups as defined in the
22
Small Employer Rating, Renewability and Portability Health
23
Insurance Act and except for medicare supplement policies as
24
defined in Section 363 of the Illinois Insurance Code, a
25
Health Maintenance Organization may by contract agree with a
26
group or other enrollment unit to effect refunds or charge

HB4207 Engrossed
- 6 -
LRB104 15812 BAB 29011 b
1
additional premiums under the following terms and conditions:
2

(i) the amount of, and other terms and conditions with
3

respect to, the refund or additional premium are set forth
4

in the group or enrollment unit contract agreed in advance
5

of the period for which a refund is to be paid or
6

additional premium is to be charged (which period shall
7

not be less than one year); and
8

(ii) the amount of the refund or additional premium
9

shall not exceed 20% of the Health Maintenance
10

Organization's profitable or unprofitable experience with
11

respect to the group or other enrollment unit for the
12

period (and, for purposes of a refund or additional
13

premium, the profitable or unprofitable experience shall
14

be calculated taking into account a pro rata share of the
15

Health Maintenance Organization's administrative and
16

marketing expenses, but shall not include any refund to be
17

made or additional premium to be paid pursuant to this
18

subsection (f)). The Health Maintenance Organization and
19

the group or enrollment unit may agree that the profitable
20

or unprofitable experience may be calculated taking into
21

account the refund period and the immediately preceding 2
22

plan years.
23

The Health Maintenance Organization shall include a
24
statement in the evidence of coverage issued to each enrollee
25
describing the possibility of a refund or additional premium,
26
and upon request of any group or enrollment unit, provide to

HB4207 Engrossed
- 7 -
LRB104 15812 BAB 29011 b
1
the group or enrollment unit a description of the method used
2
to calculate (1) the Health Maintenance Organization's
3
profitable experience with respect to the group or enrollment
4
unit and the resulting refund to the group or enrollment unit
5
or (2) the Health Maintenance Organization's unprofitable
6
experience with respect to the group or enrollment unit and
7
the resulting additional premium to be paid by the group or
8
enrollment unit.
9

In no event shall the Illinois Health Maintenance
10
Organization Guaranty Association be liable to pay any
11
contractual obligation of an insolvent organization to pay any
12
refund authorized under this Section.
13

(g) Rulemaking authority to implement Public Act 95-1045,
14
if any, is conditioned on the rules being adopted in
15
accordance with all provisions of the Illinois Administrative
16
Procedure Act and all rules and procedures of the Joint
17
Committee on Administrative Rules; any purported rule not so
18
adopted, for whatever reason, is unauthorized.
19
(Source: P.A. 103-84, eff. 1-1-24; 103-91, eff. 1-1-24;
20
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-420, eff.
21
1-1-24; 103-426, eff. 8-4-23; 103-445, eff. 1-1-24; 103-551,
22
eff. 8-11-23; 103-605, eff. 7-1-24; 103-618, eff. 1-1-25;
23
103-649, eff. 1-1-25; 103-656, eff. 1-1-25; 103-700, eff.
24
1-1-25; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-753,
25
eff. 8-2-24; 103-758, eff. 1-1-25; 103-777, eff. 8-2-24;
26
103-808, eff. 1-1-26; 103-914, eff. 1-1-25; 103-918, eff.

HB4207 Engrossed
- 8 -
LRB104 15812 BAB 29011 b
1
1-1-25; 103-1024, eff. 1-1-25; 104-1, eff. 6-9-25; 104-28,
2
eff. 1-1-26; 104-42, eff. 8-1-25; 104-68, eff. 1-1-26; 104-73,
3
eff. 1-1-26; 104-98, eff. 1-1-26; 104-289, eff. 1-1-26;
4
104-324, eff. 1-1-26; 104-334, eff. 8-15-25; 104-379, eff.
5
1-1-26; 104-417, eff. 8-15-25; revised 11-21-25.)

6

Section 15.
The Illinois Public Aid Code is amended by
7
changing Section 5-16.8 as follows:

8

(305 ILCS 5/5-16.8)
9

Sec. 5-16.8.
Required health benefits.

10

(a)
The medical assistance program shall (i) provide the
11
post-mastectomy care benefits required to be covered by a
12
policy of accident and health insurance under Section 356t and
13
the coverage required under Sections 356g.5, 356q, 356u, 356w,
14
356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34,
15
356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.59, 356z.60,
16
356z.61, 356z.64, 356z.67, 356z.71,
and
356z.75,
and
356z.80
,
17
356z.84, and 356z.85
of the Illinois Insurance Code, (ii) be
18
subject to the provisions of Sections 356z.19, 356z.44,
19
356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance
20
Code, and (iii) be subject to the provisions of subsection
21
(d-5) of Section 10 of the Network Adequacy and Transparency
22
Act.
23

The Department, by rule, shall adopt a model similar to
24
the requirements of Section 356z.39 of the Illinois Insurance

HB4207 Engrossed
- 9 -
LRB104 15812 BAB 29011 b
1
Code.
2

On and after July 1, 2012, the Department shall reduce any
3
rate of reimbursement for services or other payments or alter
4
any methodologies authorized by this Code to reduce any rate
5
of reimbursement for services or other payments in accordance
6
with Section 5-5e.
7

To ensure full access to the benefits set forth in this
8
Section, on and after January 1, 2016, the Department shall
9
ensure that provider and hospital reimbursement for
10
post-mastectomy care benefits required under this Section are
11
no lower than the Medicare reimbursement rate.
12

(b)(1) Subject to appropriation and federal approval, the
13
Department shall provide coverage under the medical assistance
14
program for a medically necessary coronary artery calcium scan
15
and scoring for an eligible individual who:

16

(A) is between 40 and 75 years of age;
17

(B) is assessed by a licensed health care provider as
18

having moderate or greater risk of atherosclerotic
19

cardiovascular disease based on a documented
20

cardiovascular risk assessment consistent with nationally
21

recognized evidence-based clinical guidelines;
22

(C) does not have a prior diagnosis of coronary artery
23

disease; and

24

(D) has not received a covered coronary artery calcium
25

scan within the previous 5 years, unless medically
26

necessary as determined by the Department.

HB4207 Engrossed
- 10 -
LRB104 15812 BAB 29011 b
1

(2) Coverage under this subsection shall be provided
2
without cost sharing to the beneficiary.

3

(3) The Department may adopt reasonable utilization
4
controls consistent with other diagnostic imaging services
5
covered under the medical assistance program.

6

(4) Implementation of coverage under this subsection shall
7
occur only to the extent that federal financial participation
8
is available and approved by the federal Centers for Medicare
9
and Medicaid Services.

10
(Source: P.A. 103-84, eff. 1-1-24; 103-91, eff. 1-1-24;
11
103-420, eff. 1-1-24; 103-605, eff. 7-1-24; 103-703, eff.
12
1-1-25; 103-758, eff. 1-1-25; 103-1024, eff. 1-1-25; 104-73,
13
eff. 1-1-26; 104-324, eff. 1-1-26; 104-379, eff. 1-1-26;
14
104-417, eff. 8-15-25; revised 11-21-25.)

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