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Senate Amendment 001

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Introduced

Senate Amendment 001

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
SB1259

Introduced 1/28/2025, by Sen. Graciela Guzmán

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.32a new
215 ILCS 125/5-3

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

from Ch. 73, par. 1504-3
305 ILCS 5/5-16.8

Amends the Illinois Insurance Code. Requires an individual or group
policy of accident and health insurance amended, delivered, issued, or
renewed in the State after June 1, 2026 to provide coverage for expenses
for standard fertility preservation services and follow-up services
related to that coverage. Defines "standard fertility preservation
services" as procedures based upon current evidence-based standards of
care established by the American Society for Reproductive Medicine, the
American Society of Clinical Oncology, or other national medical
associations that follow current evidence-based standards of care. Makes
conforming changes in 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,
and the Illinois Public Aid Code. Effective immediately.
LRB104 08129 BAB 18175 b

A BILL FOR

SB1259
LRB104 08129 BAB 18175 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.32a,
356z.33, 356z.36, 356z.40, 356z.41, 356z.45,
18
356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56,
19
356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67,
20
356z.68,
and
356z.70,
and
356z.71
, 356z.74, 356z.76, and
21
356z.77
of the Illinois Insurance Code. The program of health
22
benefits must comply with Sections 155.22a, 155.37, 355b,
23
356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois

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LRB104 08129 BAB 18175 b
1
Insurance Code. The program of health benefits shall provide
2
the coverage required under Section 356m of the Illinois
3
Insurance Code and, for the employees of the State Employee
4
Group 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.

SB1259
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LRB104 08129 BAB 18175 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.32a,

15
356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
16
356z.48, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59,
17
356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68,
and

18
356z.70,
and
356z.71
, 356z.74, and 356z.77
of the Illinois
19
Insurance Code. The coverage shall comply with Sections
20
155.22a, 355b, 356z.19, and 370c of the Illinois Insurance
21
Code. The Department of Insurance shall enforce the
22
requirements of this Section. The requirement that health
23
benefits be covered as provided in this Section is an
24
exclusive power and function of the State and is a denial and

SB1259
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LRB104 08129 BAB 18175 b
1
limitation under Article VII, Section 6, subsection (h) of the
2
Illinois Constitution. A home rule county to which this
3
Section applies must comply with every provision of this
4
Section.
5

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

22

Section 15.
The Illinois Municipal Code is amended by
23
changing Section 10-4-2.3 as follows:

24

(65 ILCS 5/10-4-2.3)

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LRB104 08129 BAB 18175 b
1

Sec. 10-4-2.3.
Required health benefits.
If a
2
municipality, including a home rule municipality, is a
3
self-insurer for purposes of providing health insurance
4
coverage for its employees, the coverage shall include
5
coverage for the post-mastectomy care benefits required to be
6
covered by a policy of accident and health insurance under
7
Section 356t and the coverage required under Sections 356g,
8
356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
9
356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
10
356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
11
356z.29, 356z.30, 356z.32,
356z.32a,
356z.33, 356z.36,
12
356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
13
356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
14
356z.62, 356z.64, 356z.67, 356z.68,
and
356z.70,
and
356z.71
,
15
356z.74, and 356z.77
of the Illinois Insurance Code. The
16
coverage shall comply with Sections 155.22a, 355b, 356z.19,
17
and 370c of the Illinois Insurance Code. The Department of
18
Insurance shall enforce the requirements of this Section. The
19
requirement that health benefits be covered as provided in
20
this is an exclusive power and function of the State and is a
21
denial and limitation under Article VII, Section 6, subsection
22
(h) of the Illinois Constitution. A home rule municipality to
23
which this Section applies must comply with every provision of
24
this Section.
25

Rulemaking authority to implement Public Act 95-1045, if
26
any, is conditioned on the rules being adopted in accordance

SB1259
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LRB104 08129 BAB 18175 b
1
with all provisions of the Illinois Administrative Procedure
2
Act and all rules and procedures of the Joint Committee on
3
Administrative Rules; any purported rule not so adopted, for
4
whatever reason, is unauthorized.
5
(Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
6
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
7
1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
8
eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
9
102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
10
1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
11
eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
12
103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
13
7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
14
eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
15
revised 11-26-24.)

16

Section 20.
The School Code is amended by changing Section
17
10-22.3f as follows:

18

(105 ILCS 5/10-22.3f)
19

Sec. 10-22.3f.
Required health benefits.
Insurance
20
protection and benefits for employees shall provide the
21
post-mastectomy care benefits required to be covered by a
22
policy of accident and health insurance under Section 356t and
23
the coverage required under Sections 356g, 356g.5, 356g.5-1,
24
356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,

SB1259
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LRB104 08129 BAB 18175 b
1
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
2
356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
3
356z.32a,
356z.33, 356z.36, 356z.40, 356z.41, 356z.45,
4
356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.56, 356z.57,
5
356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68,
6
and
356z.70,
and
356z.71
, 356z.74, and 356z.77
of the Illinois
7
Insurance Code. Insurance policies shall comply with Section
8
356z.19 of the Illinois Insurance Code. The coverage shall
9
comply with Sections 155.22a, 355b, and 370c of the Illinois
10
Insurance Code. The Department of Insurance shall enforce the
11
requirements of this Section.
12

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

SB1259
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LRB104 08129 BAB 18175 b
1
eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)

2

Section 25.
The Illinois Insurance Code is amended by
3
adding Section 356z.32a as follows:

4

(215 ILCS 5/356z.32a new)
5

Sec. 356z.32a.
Coverage for standard fertility
6
preservation services.
7

(a) As used in this Section, "standard fertility
8
preservation services" means procedures based upon current
9
evidence-based standards of care established by the American
10
Society for Reproductive Medicine, the American Society of
11
Clinical Oncology, or other national medical associations that
12
follow current evidence-based standards of care, including,
13
but not limited to, cryopreservation.
14

(b) An individual or group policy of accident and health
15
insurance amended, delivered, issued, or renewed in this State
16
after June 1, 2026 must provide coverage for expenses for
17
standard fertility preservation services and follow-up
18
services related to that coverage, including storage.
19

(c) In determining coverage under this Section, an insurer
20
shall not discriminate based on an individual's:
21

(1) expected length of life, present or predicted
22
disability, degree of medical dependency, quality of life, or
23
other health conditions; or
24

(2) personal characteristics, including age, sex,

SB1259
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LRB104 08129 BAB 18175 b
1
sexual orientation, or marital status.
2

(d) An individual or group policy of accident and health
3
insurance may not:
4

(1) impose any exclusions, limitations, or other
5

restrictions on coverage of standard fertility
6

preservation services that are different from those
7

imposed on any other prescription medications;
8

(2) impose any exclusions, limitations, or other
9

restrictions on coverage of any standard fertility
10

preservation services based on a covered individual's
11

participation in fertility services provided by or to a
12

third party; or
13

(2) impose deductibles, copayments, coinsurance,
14

benefit maximums, waiting periods, or any other
15

limitations on coverage for standard fertility
16

preservation services that are different from those
17

imposed upon benefits for services not related to
18

fertility.

19

Section 30.
The Health Maintenance Organization Act is
20
amended by changing Section 5-3 as follows:

21

(215 ILCS 125/5-3)

(from Ch. 111 1/2, par. 1411.2)
22

(Text of Section before amendment by P.A. 103-808
)
23

Sec. 5-3.
Insurance Code provisions.
24

(a) Health Maintenance Organizations shall be subject to

SB1259
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LRB104 08129 BAB 18175 b
1
the provisions of Sections 133, 134, 136, 137, 139, 140,
2
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
3
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
4
155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
5
356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
6
356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
7
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
8
356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
9
356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
10
356z.32a,
356z.33, 356z.34, 356z.35, 356z.36, 356z.37,
11
356z.38, 356z.39, 356z.40, 356z.40a, 356z.41, 356z.44,
12
356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51,
13
356z.53

356z.53
, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
14
356z.59, 356z.60, 356z.61, 356z.62, 356z.63, 356z.64, 356z.65,
15
356z.66, 356z.67, 356z.68, 356z.69, 356z.70, 356z.71,
356z.72,
16
356z.73, 356z.74, 356z.75, 356z.77,
364, 364.01, 364.3, 367.2,
17
367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1,
18
401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and
19
444.1, paragraph (c) of subsection (2) of Section 367, and
20
Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
21
XXVI, and XXXIIB of the Illinois Insurance Code.
22

(b) For purposes of the Illinois Insurance Code, except
23
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
24
Health Maintenance Organizations in the following categories
25
are deemed to be "domestic companies":
26

(1) a corporation authorized under the Dental Service

SB1259
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LRB104 08129 BAB 18175 b
1

Plan Act or the Voluntary Health Services Plans Act;
2

(2) a corporation organized under the laws of this
3

State; or
4

(3) a corporation organized under the laws of another
5

state, 30% or more of the enrollees of which are residents
6

of this State, except a corporation subject to
7

substantially the same requirements in its state of
8

organization as is a "domestic company" under Article VIII
9

1/2 of the Illinois Insurance Code.
10

(c) In considering the merger, consolidation, or other
11
acquisition of control of a Health Maintenance Organization
12
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
13

(1) the Director shall give primary consideration to
14

the continuation of benefits to enrollees and the
15

financial conditions of the acquired Health Maintenance
16

Organization after the merger, consolidation, or other
17

acquisition of control takes effect;
18

(2)(i) the criteria specified in subsection (1)(b) of
19

Section 131.8 of the Illinois Insurance Code shall not
20

apply and (ii) the Director, in making his determination
21

with respect to the merger, consolidation, or other
22

acquisition of control, need not take into account the
23

effect on competition of the merger, consolidation, or
24

other acquisition of control;
25

(3) the Director shall have the power to require the
26

following information:

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LRB104 08129 BAB 18175 b
1

(A) certification by an independent actuary of the
2

adequacy of the reserves of the Health Maintenance
3

Organization sought to be acquired;
4

(B) pro forma financial statements reflecting the
5

combined balance sheets of the acquiring company and
6

the Health Maintenance Organization sought to be
7

acquired as of the end of the preceding year and as of
8

a date 90 days prior to the acquisition, as well as pro
9

forma financial statements reflecting projected
10

combined operation for a period of 2 years;
11

(C) a pro forma business plan detailing an
12

acquiring party's plans with respect to the operation
13

of the Health Maintenance Organization sought to be
14

acquired for a period of not less than 3 years; and
15

(D) such other information as the Director shall
16

require.
17

(d) The provisions of Article VIII 1/2 of the Illinois
18
Insurance Code and this Section 5-3 shall apply to the sale by
19
any health maintenance organization of greater than 10% of its
20
enrollee population (including, without limitation, the health
21
maintenance organization's right, title, and interest in and
22
to its health care certificates).
23

(e) In considering any management contract or service
24
agreement subject to Section 141.1 of the Illinois Insurance
25
Code, the Director (i) shall, in addition to the criteria
26
specified in Section 141.2 of the Illinois Insurance Code,

SB1259
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LRB104 08129 BAB 18175 b
1
take into account the effect of the management contract or
2
service agreement on the continuation of benefits to enrollees
3
and the financial condition of the health maintenance
4
organization to be managed or serviced, and (ii) need not take
5
into account the effect of the management contract or service
6
agreement on competition.
7

(f) Except for small employer groups as defined in the
8
Small Employer Rating, Renewability and Portability Health
9
Insurance Act and except for medicare supplement policies as
10
defined in Section 363 of the Illinois Insurance Code, a
11
Health Maintenance Organization may by contract agree with a
12
group or other enrollment unit to effect refunds or charge
13
additional premiums under the following terms and conditions:
14

(i) the amount of, and other terms and conditions with
15

respect to, the refund or additional premium are set forth
16

in the group or enrollment unit contract agreed in advance
17

of the period for which a refund is to be paid or
18

additional premium is to be charged (which period shall
19

not be less than one year); and
20

(ii) the amount of the refund or additional premium
21

shall not exceed 20% of the Health Maintenance
22

Organization's profitable or unprofitable experience with
23

respect to the group or other enrollment unit for the
24

period (and, for purposes of a refund or additional
25

premium, the profitable or unprofitable experience shall
26

be calculated taking into account a pro rata share of the

SB1259
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LRB104 08129 BAB 18175 b
1

Health Maintenance Organization's administrative and
2

marketing expenses, but shall not include any refund to be
3

made or additional premium to be paid pursuant to this
4

subsection (f)). The Health Maintenance Organization and
5

the group or enrollment unit may agree that the profitable
6

or unprofitable experience may be calculated taking into
7

account the refund period and the immediately preceding 2
8

plan years.
9

The Health Maintenance Organization shall include a
10
statement in the evidence of coverage issued to each enrollee
11
describing the possibility of a refund or additional premium,
12
and upon request of any group or enrollment unit, provide to
13
the group or enrollment unit a description of the method used
14
to calculate (1) the Health Maintenance Organization's
15
profitable experience with respect to the group or enrollment
16
unit and the resulting refund to the group or enrollment unit
17
or (2) the Health Maintenance Organization's unprofitable
18
experience with respect to the group or enrollment unit and
19
the resulting additional premium to be paid by the group or
20
enrollment unit.
21

In no event shall the Illinois Health Maintenance
22
Organization Guaranty Association be liable to pay any
23
contractual obligation of an insolvent organization to pay any
24
refund authorized under this Section.
25

(g) Rulemaking authority to implement Public Act 95-1045,
26
if any, is conditioned on the rules being adopted in

SB1259
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LRB104 08129 BAB 18175 b
1
accordance with all provisions of the Illinois Administrative
2
Procedure Act and all rules and procedures of the Joint
3
Committee on Administrative Rules; any purported rule not so
4
adopted, for whatever reason, is unauthorized.
5
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
6
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
7
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
8
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
9
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
10
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
11
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
12
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
13
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
14
eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
15
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
16
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
17
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
18
103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
19
1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)

20

(Text of Section after amendment by P.A. 103-808
)
21

Sec. 5-3.
Insurance Code provisions.
22

(a) Health Maintenance Organizations shall be subject to
23
the provisions of Sections 133, 134, 136, 137, 139, 140,
24
141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
25
152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,

SB1259
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1
155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
2
356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
3
356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
4
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
5
356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
6
356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
7
356z.32a,
356z.33, 356z.34, 356z.35, 356z.36, 356z.37,
8
356z.38, 356z.39, 356z.40, 356z.40a, 356z.41, 356z.44,
9
356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51,
10
356z.53

356z.53
, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
11
356z.59, 356z.60, 356z.61, 356z.62, 356z.63, 356z.64, 356z.65,
12
356z.66, 356z.67, 356z.68, 356z.69, 356z.70, 356z.71,
356z.72,
13
356z.73, 356z.74, 356z.75, 356z.77,
364, 364.01, 364.3, 367.2,
14
367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1,
15
401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and
16
444.1, paragraph (c) of subsection (2) of Section 367, and
17
Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
18
XXVI, and XXXIIB of the Illinois Insurance Code.
19

(b) For purposes of the Illinois Insurance Code, except
20
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
21
Health Maintenance Organizations in the following categories
22
are deemed to be "domestic companies":
23

(1) a corporation authorized under the Dental Service
24

Plan Act or the Voluntary Health Services Plans Act;
25

(2) a corporation organized under the laws of this
26

State; or

SB1259
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LRB104 08129 BAB 18175 b
1

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

state, 30% or more of the enrollees of which are residents
3

of this State, except a corporation subject to
4

substantially the same requirements in its state of
5

organization as is a "domestic company" under Article VIII
6

1/2 of the Illinois Insurance Code.
7

(c) In considering the merger, consolidation, or other
8
acquisition of control of a Health Maintenance Organization
9
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
10

(1) the Director shall give primary consideration to
11

the continuation of benefits to enrollees and the
12

financial conditions of the acquired Health Maintenance
13

Organization after the merger, consolidation, or other
14

acquisition of control takes effect;
15

(2)(i) the criteria specified in subsection (1)(b) of
16

Section 131.8 of the Illinois Insurance Code shall not
17

apply and (ii) the Director, in making his determination
18

with respect to the merger, consolidation, or other
19

acquisition of control, need not take into account the
20

effect on competition of the merger, consolidation, or
21

other acquisition of control;
22

(3) the Director shall have the power to require the
23

following information:
24

(A) certification by an independent actuary of the
25

adequacy of the reserves of the Health Maintenance
26

Organization sought to be acquired;

SB1259
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LRB104 08129 BAB 18175 b
1

(B) pro forma financial statements reflecting the
2

combined balance sheets of the acquiring company and
3

the Health Maintenance Organization sought to be
4

acquired as of the end of the preceding year and as of
5

a date 90 days prior to the acquisition, as well as pro
6

forma financial statements reflecting projected
7

combined operation for a period of 2 years;
8

(C) a pro forma business plan detailing an
9

acquiring party's plans with respect to the operation
10

of the Health Maintenance Organization sought to be
11

acquired for a period of not less than 3 years; and
12

(D) such other information as the Director shall
13

require.
14

(d) The provisions of Article VIII 1/2 of the Illinois
15
Insurance Code and this Section 5-3 shall apply to the sale by
16
any health maintenance organization of greater than 10% of its
17
enrollee population (including, without limitation, the health
18
maintenance organization's right, title, and interest in and
19
to its health care certificates).
20

(e) In considering any management contract or service
21
agreement subject to Section 141.1 of the Illinois Insurance
22
Code, the Director (i) shall, in addition to the criteria
23
specified in Section 141.2 of the Illinois Insurance Code,
24
take into account the effect of the management contract or
25
service agreement on the continuation of benefits to enrollees
26
and the financial condition of the health maintenance

SB1259
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LRB104 08129 BAB 18175 b
1
organization to be managed or serviced, and (ii) need not take
2
into account the effect of the management contract or service
3
agreement on competition.
4

(f) Except for small employer groups as defined in the
5
Small Employer Rating, Renewability and Portability Health
6
Insurance Act and except for medicare supplement policies as
7
defined in Section 363 of the Illinois Insurance Code, a
8
Health Maintenance Organization may by contract agree with a
9
group or other enrollment unit to effect refunds or charge
10
additional premiums under the following terms and conditions:
11

(i) the amount of, and other terms and conditions with
12

respect to, the refund or additional premium are set forth
13

in the group or enrollment unit contract agreed in advance
14

of the period for which a refund is to be paid or
15

additional premium is to be charged (which period shall
16

not be less than one year); and
17

(ii) the amount of the refund or additional premium
18

shall not exceed 20% of the Health Maintenance
19

Organization's profitable or unprofitable experience with
20

respect to the group or other enrollment unit for the
21

period (and, for purposes of a refund or additional
22

premium, the profitable or unprofitable experience shall
23

be calculated taking into account a pro rata share of the
24

Health Maintenance Organization's administrative and
25

marketing expenses, but shall not include any refund to be
26

made or additional premium to be paid pursuant to this

SB1259
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LRB104 08129 BAB 18175 b
1

subsection (f)). The Health Maintenance Organization and
2

the group or enrollment unit may agree that the profitable
3

or unprofitable experience may be calculated taking into
4

account the refund period and the immediately preceding 2
5

plan years.
6

The Health Maintenance Organization shall include a
7
statement in the evidence of coverage issued to each enrollee
8
describing the possibility of a refund or additional premium,
9
and upon request of any group or enrollment unit, provide to
10
the group or enrollment unit a description of the method used
11
to calculate (1) the Health Maintenance Organization's
12
profitable experience with respect to the group or enrollment
13
unit and the resulting refund to the group or enrollment unit
14
or (2) the Health Maintenance Organization's unprofitable
15
experience with respect to the group or enrollment unit and
16
the resulting additional premium to be paid by the group or
17
enrollment unit.
18

In no event shall the Illinois Health Maintenance
19
Organization Guaranty Association be liable to pay any
20
contractual obligation of an insolvent organization to pay any
21
refund authorized under this Section.
22

(g) Rulemaking authority to implement Public Act 95-1045,
23
if any, is conditioned on the rules being adopted in
24
accordance with all provisions of the Illinois Administrative
25
Procedure Act and all rules and procedures of the Joint
26
Committee on Administrative Rules; any purported rule not so

SB1259
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LRB104 08129 BAB 18175 b
1
adopted, for whatever reason, is unauthorized.
2
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
3
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
4
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
5
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
6
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
7
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
8
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
9
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
10
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
11
eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
12
103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
13
1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
14
eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
15
103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
16
1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised
17
11-26-24.)

18

Section 35.
The Limited Health Service Organization Act is
19
amended by changing Section 4003 as follows:

20

(215 ILCS 130/4003)

(from Ch. 73, par. 1504-3)
21

Sec. 4003.
Illinois Insurance Code provisions.
Limited
22
health service organizations shall be subject to the
23
provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
24
141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 152, 153,

SB1259
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LRB104 08129 BAB 18175 b
1
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c,
2
355.2, 355.3, 355b, 355d, 356m, 356q, 356v, 356z.4, 356z.4a,
3
356z.10, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.32,
4
356z.32a,
356z.33, 356z.41, 356z.46, 356z.47, 356z.51,
5
356z.53, 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67,
6
356z.68, 356z.71,
356z.73, 356z.74, 356z.75,
364.3, 368a, 401,
7
401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and
8
Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and
9
XXVI of the Illinois Insurance Code. Nothing in this Section
10
shall require a limited health care plan to cover any service
11
that is not a limited health service. For purposes of the
12
Illinois Insurance Code, except for Sections 444 and 444.1 and
13
Articles XIII and XIII 1/2, limited health service
14
organizations in the following categories are deemed to be
15
domestic companies:
16

(1) a corporation under the laws of this State; or
17

(2) a corporation organized under the laws of another
18

state, 30% or more of the enrollees of which are residents
19

of this State, except a corporation subject to
20

substantially the same requirements in its state of
21

organization as is a domestic company under Article VIII
22

1/2 of the Illinois Insurance Code.
23
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
24
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
25
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
26
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;

SB1259
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LRB104 08129 BAB 18175 b
1
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
2
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
3
eff. 1-1-24; 103-605, eff. 7-1-24; 103-649, eff. 1-1-25;
4
103-656, eff. 1-1-25; 103-700, eff. 1-1-25; 103-718, eff.
5
7-19-24; 103-751, eff. 8-2-24; 103-758, eff. 1-1-25; 103-832,
6
eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)

7

Section 40.
The Illinois Public Aid Code is amended by
8
changing Section 5-16.8 as follows:

9

(305 ILCS 5/5-16.8)
10

Sec. 5-16.8.
Required health benefits.
The medical
11
assistance program shall (i) provide the post-mastectomy care
12
benefits required to be covered by a policy of accident and
13
health insurance under Section 356t and the coverage required
14
under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6,
15
356z.26, 356z.29, 356z.32,
356z.32a,
356z.33, 356z.34,
16
356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.59, 356z.60,
17
356z.61, 356z.64,
and
356z.67,
and
356z.71
, and 356z.75
of the
18
Illinois Insurance Code, (ii) be subject to the provisions of
19
Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1
20
of the Illinois Insurance Code, and (iii) be subject to the
21
provisions of subsection (d-5) of Section 10 of the Network
22
Adequacy and Transparency Act.
23

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

SB1259
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LRB104 08129 BAB 18175 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
(Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22;
13
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff.
14
1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813,
15
eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23;
16
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
17
1-1-24; 103-420, eff. 1-1-24; 103-605, eff. 7-1-24; 103-703,
18
eff. 1-1-25; 103-758, eff. 1-1-25; 103-1024, eff. 1-1-25;
19
revised 11-26-24.)

20

Section 95.
No acceleration or delay.
Where this Act makes
21
changes in a statute that is represented in this Act by text
22
that is not yet or no longer in effect (for example, a Section
23
represented by multiple versions), the use of that text does
24
not accelerate or delay the taking effect of (i) the changes
25
made by this Act or (ii) provisions derived from any other

SB1259
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LRB104 08129 BAB 18175 b
1
Public Act.

2

Section 99.
Effective date.
This Act takes effect upon
3
becoming law.

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