98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB0038

 

Introduced 1/10/2013, by Sen. Ira I. Silverstein

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.22 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the Illinois Insurance Code, the Voluntary Health Services Plans Act, and the Voluntary Health Services Plans Act to require coverage for hearing instruments and related services for all individuals when a hearing care professional prescribes a hearing instrument. Provides that an insurer shall provide coverage for up to $2,500 per hearing aid per insured's hearing impaired ear subject to certain restrictions. Provides that an insurer shall not be required to pay a claim if the insured filed such a claim 36 months prior to the date of filing the claim with the insurer and the claim was paid by any insurer. Effective immediately.


LRB098 02909 RPM 32921 b

 

 

A BILL FOR

 

SB0038LRB098 02909 RPM 32921 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 356z.22 as follows:
 
6    (215 ILCS 5/356z.22 new)
7    Sec. 356z.22. Coverage for hearing aids for all
8individuals.
9    (a) As used in this Section:
10    "Hearing care professional" means a person who is a
11licensed audiologist or a licensed physician.
12    "Hearing instrument" or "hearing aid" means any wearable
13non-disposable instrument or device designed to aid or
14compensate for impaired human hearing in cases where functional
15ability cannot be restored either medically or surgically and
16any parts, attachments, or accessories for the instrument or
17device, including an ear mold but excluding batteries and
18cords.
19    "Related services" means those services necessary to
20assess, select, and adjust or fit the hearing instrument to
21ensure optimal performance including but not limited to:
22audiological exams, replacement ear molds, and repairs to the
23hearing instrument.

 

 

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1    (b) An individual or group policy of accident and health
2insurance or managed care plan that is amended, delivered,
3issued, or renewed after the effective date of this amendatory
4Act of the 98th General Assembly must provide coverage for
5hearing instruments and related services for all individuals
6when a hearing care professional prescribes a hearing
7instrument to augment communication.
8    (c) An insurer shall provide coverage, subject to all
9applicable co-payments, co-insurance, deductibles, and
10out-of-pocket limits, for up to $2,500 per hearing aid per
11insured's hearing impaired ear subject to the following
12restrictions:
13        (1) for all insured individuals, hearing aids may be
14    replaced up to once every 36 months as prescribed and
15    dispensed by a hearing care professional;
16        (2) for all insured individuals, any hearing aid may be
17    replaced at any time regardless of the above restrictions
18    if there is a significant change in the insured
19    individual's hearing status; such significant change is
20    defined as a change of 10 decibels HL on the
21    three-frequency pure-tone average (500 Hz, 1000 Hz and 2000
22    Hz) on a valid audiogram provided by a hearing care
23    professional; and
24        (3) for all insured individuals, related services,
25    such as audiological exams, ear molds, and hearing aid
26    repairs, shall be covered at all times when prescribed by a

 

 

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1    hearing care professional.
2    (d) An insurer shall not be required to pay a claim filed
3by its insured for the payment of the cost of a hearing aid
4covered by this Section if less than 36 months prior to the
5date of the claim its insured filed a claim for payment of the
6cost of the hearing aid and the claim was paid by any insurer.
 
7    Section 10. The Health Maintenance Organization Act is
8amended 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. Insurance Code provisions.
11    (a) Health Maintenance Organizations shall be subject to
12the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
13141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
14154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
15356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4, 356z.5,
16356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
17356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22,
18364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
19370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
20444, and 444.1, paragraph (c) of subsection (2) of Section 367,
21and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
22and XXVI of the Illinois Insurance Code.
23    (b) For purposes of the Illinois Insurance Code, except for
24Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health

 

 

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1Maintenance Organizations in the following categories are
2deemed to be "domestic companies":
3        (1) a corporation authorized under the Dental Service
4    Plan Act or the Voluntary Health Services Plans Act;
5        (2) a corporation organized under the laws of this
6    State; or
7        (3) a corporation organized under the laws of another
8    state, 30% or more of the enrollees of which are residents
9    of this State, except a corporation subject to
10    substantially the same requirements in its state of
11    organization as is a "domestic company" under Article VIII
12    1/2 of the Illinois Insurance Code.
13    (c) In considering the merger, consolidation, or other
14acquisition of control of a Health Maintenance Organization
15pursuant to Article VIII 1/2 of the Illinois Insurance Code,
16        (1) the Director shall give primary consideration to
17    the continuation of benefits to enrollees and the financial
18    conditions of the acquired Health Maintenance Organization
19    after the merger, consolidation, or other acquisition of
20    control takes effect;
21        (2)(i) the criteria specified in subsection (1)(b) of
22    Section 131.8 of the Illinois Insurance Code shall not
23    apply and (ii) the Director, in making his determination
24    with respect to the merger, consolidation, or other
25    acquisition of control, need not take into account the
26    effect on competition of the merger, consolidation, or

 

 

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1    other acquisition of control;
2        (3) the Director shall have the power to require the
3    following information:
4            (A) certification by an independent actuary of the
5        adequacy of the reserves of the Health Maintenance
6        Organization sought to be acquired;
7            (B) pro forma financial statements reflecting the
8        combined balance sheets of the acquiring company and
9        the Health Maintenance Organization sought to be
10        acquired as of the end of the preceding year and as of
11        a date 90 days prior to the acquisition, as well as pro
12        forma financial statements reflecting projected
13        combined operation for a period of 2 years;
14            (C) a pro forma business plan detailing an
15        acquiring party's plans with respect to the operation
16        of the Health Maintenance Organization sought to be
17        acquired for a period of not less than 3 years; and
18            (D) such other information as the Director shall
19        require.
20    (d) The provisions of Article VIII 1/2 of the Illinois
21Insurance Code and this Section 5-3 shall apply to the sale by
22any health maintenance organization of greater than 10% of its
23enrollee population (including without limitation the health
24maintenance organization's right, title, and interest in and to
25its health care certificates).
26    (e) In considering any management contract or service

 

 

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1agreement subject to Section 141.1 of the Illinois Insurance
2Code, the Director (i) shall, in addition to the criteria
3specified in Section 141.2 of the Illinois Insurance Code, take
4into account the effect of the management contract or service
5agreement on the continuation of benefits to enrollees and the
6financial condition of the health maintenance organization to
7be managed or serviced, and (ii) need not take into account the
8effect of the management contract or service agreement on
9competition.
10    (f) Except for small employer groups as defined in the
11Small Employer Rating, Renewability and Portability Health
12Insurance Act and except for medicare supplement policies as
13defined in Section 363 of the Illinois Insurance Code, a Health
14Maintenance Organization may by contract agree with a group or
15other enrollment unit to effect refunds or charge additional
16premiums under the following terms and conditions:
17        (i) the amount of, and other terms and conditions with
18    respect to, the refund or additional premium are set forth
19    in the group or enrollment unit contract agreed in advance
20    of the period for which a refund is to be paid or
21    additional premium is to be charged (which period shall not
22    be less than one year); and
23        (ii) the amount of the refund or additional premium
24    shall not exceed 20% of the Health Maintenance
25    Organization's profitable or unprofitable experience with
26    respect to the group or other enrollment unit for the

 

 

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1    period (and, for purposes of a refund or additional
2    premium, the profitable or unprofitable experience shall
3    be calculated taking into account a pro rata share of the
4    Health Maintenance Organization's administrative and
5    marketing expenses, but shall not include any refund to be
6    made or additional premium to be paid pursuant to this
7    subsection (f)). The Health Maintenance Organization and
8    the group or enrollment unit may agree that the profitable
9    or unprofitable experience may be calculated taking into
10    account the refund period and the immediately preceding 2
11    plan years.
12    The Health Maintenance Organization shall include a
13statement in the evidence of coverage issued to each enrollee
14describing the possibility of a refund or additional premium,
15and upon request of any group or enrollment unit, provide to
16the group or enrollment unit a description of the method used
17to calculate (1) the Health Maintenance Organization's
18profitable experience with respect to the group or enrollment
19unit and the resulting refund to the group or enrollment unit
20or (2) the Health Maintenance Organization's unprofitable
21experience with respect to the group or enrollment unit and the
22resulting additional premium to be paid by the group or
23enrollment unit.
24    In no event shall the Illinois Health Maintenance
25Organization Guaranty Association be liable to pay any
26contractual obligation of an insolvent organization to pay any

 

 

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1refund authorized under this Section.
2    (g) Rulemaking authority to implement Public Act 95-1045,
3if any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
996-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11;
1097-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12;
1197-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff.
127-13-12.)
 
13    Section 15. The Voluntary Health Services Plans Act is
14amended by changing Section 10 as follows:
 
15    (215 ILCS 165/10)  (from Ch. 32, par. 604)
16    Sec. 10. Application of Insurance Code provisions. Health
17services plan corporations and all persons interested therein
18or dealing therewith shall be subject to the provisions of
19Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
20143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 356g,
21356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
22356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
23356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
24356z.19, 356z.21, 356z.22, 364.01, 367.2, 368a, 401, 401.1,

 

 

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1402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
2(15) of Section 367 of the Illinois Insurance Code.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10;
1096-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
1197-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13;
1297-813, eff. 7-13-12.)
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.