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1 | AN ACT concerning insurance.
| |||||||||||||||||||||||||||||||
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 | (Text of Section before amendment by P.A. 95-958 ) | |||||||||||||||||||||||||||||||
8 | Sec. 6.11. Required health benefits; Illinois Insurance | |||||||||||||||||||||||||||||||
9 | Code
requirements. The program of health
benefits shall provide | |||||||||||||||||||||||||||||||
10 | the post-mastectomy care benefits required to be covered
by a | |||||||||||||||||||||||||||||||
11 | policy of accident and health insurance under Section 356t of | |||||||||||||||||||||||||||||||
12 | the Illinois
Insurance Code. The program of health benefits | |||||||||||||||||||||||||||||||
13 | shall provide the coverage
required under Sections 356g.5,
| |||||||||||||||||||||||||||||||
14 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.7, 356z.9, | |||||||||||||||||||||||||||||||
15 | 356z.10, 356z.13
356z.11 , and 356z.14
of the
Illinois Insurance | |||||||||||||||||||||||||||||||
16 | Code.
The program of health benefits must comply with Section | |||||||||||||||||||||||||||||||
17 | 155.37 of the
Illinois Insurance Code.
| |||||||||||||||||||||||||||||||
18 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | |||||||||||||||||||||||||||||||
19 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | |||||||||||||||||||||||||||||||
20 | 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| |||||||||||||||||||||||||||||||
21 | (Text of Section after amendment by P.A. 95-958 )
| |||||||||||||||||||||||||||||||
22 | Sec. 6.11. Required health benefits; Illinois Insurance |
| |||||||
| |||||||
1 | Code
requirements. The program of health
benefits shall provide | ||||||
2 | the post-mastectomy care benefits required to be covered
by a | ||||||
3 | policy of accident and health insurance under Section 356t of | ||||||
4 | the Illinois
Insurance Code. The program of health benefits | ||||||
5 | shall provide the coverage
required under Sections 356g.5,
| ||||||
6 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.7, 356z.9, | ||||||
7 | 356z.10, 356z.11, and 356z.12 , 356z.13
356z.11 , and 356z.14 of | ||||||
8 | the
Illinois Insurance Code.
The program of health benefits | ||||||
9 | must comply with Section 155.37 of the
Illinois Insurance Code.
| ||||||
10 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
11 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
12 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
13 | 12-15-08.)
| ||||||
14 | Section 10. The Counties Code is amended by changing | ||||||
15 | Section 5-1069.3 as follows: | ||||||
16 | (55 ILCS 5/5-1069.3)
| ||||||
17 | (Text of Section before amendment by P.A. 95-958 )
| ||||||
18 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
19 | including a home
rule
county, is a self-insurer for purposes of | ||||||
20 | providing health insurance coverage
for its employees, the | ||||||
21 | coverage shall include coverage for the post-mastectomy
care | ||||||
22 | benefits required to be covered by a policy of accident and | ||||||
23 | health
insurance under Section 356t and the coverage required | ||||||
24 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.7, |
| |||||||
| |||||||
1 | 356z.9, 356z.10, 356z.13
356z.11 , and 356z.14 of
the Illinois | ||||||
2 | Insurance Code. The requirement that health benefits be covered
| ||||||
3 | as provided in this Section is an
exclusive power and function | ||||||
4 | of the State and is a denial and limitation under
Article VII, | ||||||
5 | Section 6, subsection (h) of the Illinois Constitution. A home
| ||||||
6 | rule county to which this Section applies must comply with | ||||||
7 | every provision of
this Section.
| ||||||
8 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
9 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||||||
10 | 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| ||||||
11 | (Text of Section after amendment by P.A. 95-958 ) | ||||||
12 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
13 | including a home
rule
county, is a self-insurer for purposes of | ||||||
14 | providing health insurance coverage
for its employees, the | ||||||
15 | coverage shall include coverage for the post-mastectomy
care | ||||||
16 | benefits required to be covered by a policy of accident and | ||||||
17 | health
insurance under Section 356t and the coverage required | ||||||
18 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.7, | ||||||
19 | 356z.9, 356z.10, 356z.11, and 356z.12 , 356z.13
356z.11 , and | ||||||
20 | 356z.14 of
the Illinois Insurance Code. The requirement that | ||||||
21 | health benefits be covered
as provided in this Section is an
| ||||||
22 | exclusive power and function of the State and is a denial and | ||||||
23 | limitation under
Article VII, Section 6, subsection (h) of the | ||||||
24 | Illinois Constitution. A home
rule county to which this Section | ||||||
25 | applies must comply with every provision of
this Section.
|
| |||||||
| |||||||
1 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
2 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
3 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
4 | 12-15-08.)
| ||||||
5 | Section 15. The Illinois Municipal Code is amended by | ||||||
6 | changing Section 10-4-2.3 as follows: | ||||||
7 | (65 ILCS 5/10-4-2.3)
| ||||||
8 | (Text of Section before amendment by P.A. 95-958 )
| ||||||
9 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
10 | municipality, including a
home rule municipality, is a | ||||||
11 | self-insurer for purposes of providing health
insurance | ||||||
12 | coverage for its employees, the coverage shall include coverage | ||||||
13 | for
the post-mastectomy care benefits required to be covered by | ||||||
14 | a policy of
accident and health insurance under Section 356t | ||||||
15 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
16 | 356x, 356z.6, 356z.7, 356z.9, 356z.10, 356z.13
356z.11 , and | ||||||
17 | 356z.14 of the Illinois
Insurance
Code. 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 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
24 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. |
| |||||||
| |||||||
1 | 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| ||||||
2 | (Text of Section after amendment by P.A. 95-958 ) | ||||||
3 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
4 | municipality, including a
home rule municipality, is a | ||||||
5 | self-insurer for purposes of providing health
insurance | ||||||
6 | coverage for its employees, the coverage shall include coverage | ||||||
7 | for
the post-mastectomy care benefits required to be covered by | ||||||
8 | a policy of
accident and health insurance under Section 356t | ||||||
9 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
10 | 356x, 356z.6, 356z.7, 356z.9, 356z.10, 356z.11, and 356z.12 , | ||||||
11 | 356z.13
356z.11 , and 356z.14 of the Illinois
Insurance
Code. | ||||||
12 | The requirement that health
benefits be covered as provided in | ||||||
13 | this is an exclusive power and function of
the State and is a | ||||||
14 | denial and limitation under Article VII, Section 6,
subsection | ||||||
15 | (h) of the Illinois Constitution. A home rule municipality to | ||||||
16 | which
this Section applies must comply with every provision of | ||||||
17 | this Section.
| ||||||
18 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
19 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
20 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
21 | 12-15-08.) | ||||||
22 | Section 20. The School Code is amended by changing Section | ||||||
23 | 10-22.3f as follows: |
| |||||||
| |||||||
1 | (105 ILCS 5/10-22.3f)
| ||||||
2 | (Text of Section before amendment by P.A. 95-958 )
| ||||||
3 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
4 | protection and
benefits
for employees shall provide the | ||||||
5 | post-mastectomy care benefits required to be
covered by a | ||||||
6 | policy of accident and health insurance under Section 356t and | ||||||
7 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
| ||||||
8 | 356z.6, 356z.7, 356z.9, 356z.13
and 356z.11 , and 356z.14 of
the
| ||||||
9 | Illinois Insurance Code.
| ||||||
10 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
11 | 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. | ||||||
12 | 12-12-08; revised 12-15-08.)
| ||||||
13 | (Text of Section after amendment by P.A. 95-958 ) | ||||||
14 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
15 | protection and
benefits
for employees shall provide the | ||||||
16 | post-mastectomy care benefits required to be
covered by a | ||||||
17 | policy of accident and health insurance under Section 356t and | ||||||
18 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
| ||||||
19 | 356z.6, 356z.7, 356z.9, 356z.11, and 356z.12, 356z.13
and | ||||||
20 | 356z.11 , and 356z.14 of
the
Illinois Insurance Code.
| ||||||
21 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
22 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
23 | 95-1005, 12-12-08; revised 12-15-08.)
| ||||||
24 | Section 25. The Illinois Insurance Code is amended by |
| |||||||
| |||||||
1 | changing Section 356z.7 and by renumbering Section 356z.11 (as | ||||||
2 | added by Public Act 95-978) as follows:
| ||||||
3 | (215 ILCS 5/356z.7) (was 215 ILCS 5/370r)
| ||||||
4 | Sec. 356z.7. Prescription drugs; cancer treatment. | ||||||
5 | (a) No group policy of
accident or health insurance that | ||||||
6 | provides coverage for prescribed
drugs approved by the federal | ||||||
7 | Food and Drug Administration for the
treatment of certain types | ||||||
8 | of cancer shall exclude coverage of any drug on
the basis that | ||||||
9 | the drug has been prescribed for the treatment of a type of
| ||||||
10 | cancer for which the drug has not been approved by the federal | ||||||
11 | Food and
Drug Administration. The drug, however, must be | ||||||
12 | approved by the federal
Food and Drug Administration and must | ||||||
13 | be recognized for the treatment of the
specific type of cancer | ||||||
14 | for which the drug has been prescribed in any
one of the | ||||||
15 | following established reference compendia:
| ||||||
16 | (1) (a) the American Medical Association Drug | ||||||
17 | Evaluations;
| ||||||
18 | (2) (b) the American Hospital Formulary Service Drug | ||||||
19 | Information; or
| ||||||
20 | (3) (c) the United States Pharmacopeia Drug | ||||||
21 | Information;
| ||||||
22 | or if not in the compendia, recommended for that particular | ||||||
23 | type of cancer
in formal clinical studies, the results of which | ||||||
24 | have been published in at
least two peer reviewed professional | ||||||
25 | medical journals published in the
United States or Great |
| |||||||
| |||||||
1 | Britain.
| ||||||
2 | Any coverage required by this Section shall also include | ||||||
3 | those medically
necessary services associated with the | ||||||
4 | administration of a drug.
| ||||||
5 | Despite the provisions of this Section, coverage shall
not | ||||||
6 | be required for any experimental or investigational drugs or | ||||||
7 | any drug
that the federal Food and Drug Administration has | ||||||
8 | determined to be
contraindicated for treatment of the specific | ||||||
9 | type of cancer for which the
drug has been prescribed. This | ||||||
10 | Section shall apply only to cancer drugs.
Nothing in this | ||||||
11 | Section shall be construed, expressly or by implication, to
| ||||||
12 | create, impair, alter, limit, notify, enlarge, abrogate or | ||||||
13 | prohibit
reimbursement for drugs used in the treatment of any | ||||||
14 | other disease or
condition.
| ||||||
15 | (b) If a policy of accident and health or managed care plan | ||||||
16 | amended, delivered, issued, or renewed in this State has an | ||||||
17 | annual dollar limit for prescription drug coverage, that policy | ||||||
18 | or plan may not discontinue or deny coverage for prescription | ||||||
19 | drugs for the
treatment of cancer, including leukemia, when an | ||||||
20 | insured reaches the annual dollar limit for prescription drugs | ||||||
21 | if the insured has started treatment for cancer. In such case, | ||||||
22 | the policy shall continue to cover the prescription drugs for | ||||||
23 | the
treatment of cancer for that year of coverage. | ||||||
24 | (Source: P.A. 95-331, eff. 8-21-07.)
| ||||||
25 | (215 ILCS 5/356z.13) |
| |||||||
| |||||||
1 | Sec. 356z.13
356z.11 . Shingles vaccine. A group or | ||||||
2 | individual policy of accident and health insurance or managed | ||||||
3 | care plan amended, delivered, issued, or renewed after the | ||||||
4 | effective date of the amendatory Act of this 95th General | ||||||
5 | Assembly must provide coverage for a vaccine for shingles that | ||||||
6 | is approved for marketing by the federal Food and Drug | ||||||
7 | Administration if the vaccine is ordered by a physician | ||||||
8 | licensed to practice medicine in all its branches and the | ||||||
9 | enrollee is 60 years of age or older.
| ||||||
10 | (Source: P.A. 95-978, eff. 1-1-09; revised 10-14-08.)
| ||||||
11 | Section 30. The Health Maintenance Organization Act is | ||||||
12 | amended by changing Section 5-3 as follows:
| ||||||
13 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
14 | (Text of Section before amendment by P.A. 95-958 )
| ||||||
15 | Sec. 5-3. Insurance Code provisions.
| ||||||
16 | (a) Health Maintenance Organizations
shall be subject to | ||||||
17 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
18 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
19 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
20 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 356z.8, 356z.9, | ||||||
21 | 356z.10, 356z.13
356z.11 , 356z.14,
364.01, 367.2, 367.2-5, | ||||||
22 | 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, | ||||||
23 | 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | ||||||
24 | subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
|
| |||||||
| |||||||
1 | XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | ||||||
2 | Insurance Code.
| ||||||
3 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
4 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
5 | Maintenance Organizations in
the following categories are | ||||||
6 | deemed to be "domestic companies":
| ||||||
7 | (1) a corporation authorized under the
Dental Service | ||||||
8 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
9 | (2) a corporation organized under the laws of this | ||||||
10 | State; or
| ||||||
11 | (3) 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 | (c) In considering the merger, consolidation, or other | ||||||
18 | acquisition of
control of a Health Maintenance Organization | ||||||
19 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
20 | (1) the Director shall give primary consideration to | ||||||
21 | the continuation of
benefits to enrollees and the financial | ||||||
22 | conditions of the acquired Health
Maintenance Organization | ||||||
23 | after the merger, consolidation, or other
acquisition of | ||||||
24 | control takes effect;
| ||||||
25 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
26 | Section 131.8 of
the Illinois Insurance Code shall not |
| |||||||
| |||||||
1 | apply and (ii) the Director, in making
his determination | ||||||
2 | with respect to the merger, consolidation, or other
| ||||||
3 | acquisition of control, need not take into account the | ||||||
4 | effect on
competition of the merger, consolidation, or | ||||||
5 | other acquisition of control;
| ||||||
6 | (3) the Director shall have the power to require the | ||||||
7 | following
information:
| ||||||
8 | (A) certification by an independent actuary of the | ||||||
9 | adequacy
of the reserves of the Health Maintenance | ||||||
10 | Organization sought to be acquired;
| ||||||
11 | (B) pro forma financial statements reflecting the | ||||||
12 | combined balance
sheets of the acquiring company and | ||||||
13 | the Health Maintenance Organization sought
to be | ||||||
14 | acquired as of the end of the preceding year and as of | ||||||
15 | a date 90 days
prior to the acquisition, as well as pro | ||||||
16 | forma financial statements
reflecting projected | ||||||
17 | combined operation for a period of 2 years;
| ||||||
18 | (C) a pro forma business plan detailing an | ||||||
19 | acquiring party's plans with
respect to the operation | ||||||
20 | of the Health Maintenance Organization sought to
be | ||||||
21 | acquired for a period of not less than 3 years; and
| ||||||
22 | (D) such other information as the Director shall | ||||||
23 | require.
| ||||||
24 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
25 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
26 | any health maintenance
organization of greater than 10% of its
|
| |||||||
| |||||||
1 | enrollee population (including without limitation the health | ||||||
2 | maintenance
organization's right, title, and interest in and to | ||||||
3 | its health care
certificates).
| ||||||
4 | (e) In considering any management contract or service | ||||||
5 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
6 | Code, the Director (i) shall, in
addition to the criteria | ||||||
7 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
8 | into account the effect of the management contract or
service | ||||||
9 | agreement on the continuation of benefits to enrollees and the
| ||||||
10 | financial condition of the health maintenance organization to | ||||||
11 | be managed or
serviced, and (ii) need not take into account the | ||||||
12 | effect of the management
contract or service agreement on | ||||||
13 | competition.
| ||||||
14 | (f) Except for small employer groups as defined in the | ||||||
15 | Small Employer
Rating, Renewability and Portability Health | ||||||
16 | Insurance Act and except for
medicare supplement policies as | ||||||
17 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
18 | Maintenance Organization may by contract agree with a
group or | ||||||
19 | other enrollment unit to effect refunds or charge additional | ||||||
20 | premiums
under the following terms and conditions:
| ||||||
21 | (i) the amount of, and other terms and conditions with | ||||||
22 | respect to, the
refund or additional premium are set forth | ||||||
23 | in the group or enrollment unit
contract agreed in advance | ||||||
24 | of the period for which a refund is to be paid or
| ||||||
25 | additional premium is to be charged (which period shall not | ||||||
26 | be less than one
year); and
|
| |||||||
| |||||||
1 | (ii) the amount of the refund or additional premium | ||||||
2 | shall not exceed 20%
of the Health Maintenance | ||||||
3 | Organization's profitable or unprofitable experience
with | ||||||
4 | respect to the group or other enrollment unit for the | ||||||
5 | period (and, for
purposes of a refund or additional | ||||||
6 | premium, the profitable or unprofitable
experience shall | ||||||
7 | be calculated taking into account a pro rata share of the
| ||||||
8 | Health Maintenance Organization's administrative and | ||||||
9 | marketing expenses, but
shall not include any refund to be | ||||||
10 | made or additional premium to be paid
pursuant to this | ||||||
11 | subsection (f)). The Health Maintenance Organization and | ||||||
12 | the
group or enrollment unit may agree that the profitable | ||||||
13 | or unprofitable
experience may be calculated taking into | ||||||
14 | account the refund period and the
immediately preceding 2 | ||||||
15 | plan years.
| ||||||
16 | The Health Maintenance Organization shall include a | ||||||
17 | statement in the
evidence of coverage issued to each enrollee | ||||||
18 | describing the possibility of a
refund or additional premium, | ||||||
19 | and upon request of any group or enrollment unit,
provide to | ||||||
20 | the group or enrollment unit a description of the method used | ||||||
21 | to
calculate (1) the Health Maintenance Organization's | ||||||
22 | profitable experience with
respect to the group or enrollment | ||||||
23 | unit and the resulting refund to the group
or enrollment unit | ||||||
24 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
25 | experience with respect to the group or enrollment unit and the | ||||||
26 | resulting
additional premium to be paid by the group or |
| |||||||
| |||||||
1 | enrollment unit.
| ||||||
2 | In no event shall the Illinois Health Maintenance | ||||||
3 | Organization
Guaranty Association be liable to pay any | ||||||
4 | contractual obligation of an
insolvent organization to pay any | ||||||
5 | refund authorized under this Section.
| ||||||
6 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
7 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
8 | 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
9 | 12-15-08.)
| ||||||
10 | (Text of Section after amendment by P.A. 95-958 ) | ||||||
11 | Sec. 5-3. Insurance Code provisions.
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12 | (a) Health Maintenance Organizations
shall be subject to | ||||||
13 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
14 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
15 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
16 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 356z.8, 356z.9, | ||||||
17 | 356z.10, 356z.11, 356z.12 , 356z.13
356z.11 , 356z.14, 364.01, | ||||||
18 | 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | ||||||
19 | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
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20 | paragraph (c) of subsection (2) of Section 367, and Articles | ||||||
21 | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | ||||||
22 | the Illinois Insurance Code.
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23 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
24 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
25 | Maintenance Organizations in
the following categories are |
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1 | deemed to be "domestic companies":
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2 | (1) a corporation authorized under the
Dental Service | ||||||
3 | Plan Act or the Voluntary Health Services Plans Act;
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4 | (2) a corporation organized under the laws of this | ||||||
5 | State; or
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6 | (3) a corporation organized under the laws of another | ||||||
7 | state, 30% or more
of the enrollees of which are residents | ||||||
8 | of this State, except a
corporation subject to | ||||||
9 | substantially the same requirements in its state of
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10 | organization as is a "domestic company" under Article VIII | ||||||
11 | 1/2 of the
Illinois Insurance Code.
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12 | (c) In considering the merger, consolidation, or other | ||||||
13 | acquisition of
control of a Health Maintenance Organization | ||||||
14 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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15 | (1) the Director shall give primary consideration to | ||||||
16 | the continuation of
benefits to enrollees and the financial | ||||||
17 | conditions of the acquired Health
Maintenance Organization | ||||||
18 | after the merger, consolidation, or other
acquisition of | ||||||
19 | control takes effect;
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20 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
21 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
22 | apply and (ii) the Director, in making
his determination | ||||||
23 | with respect to the merger, consolidation, or other
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24 | acquisition of control, need not take into account the | ||||||
25 | effect on
competition of the merger, consolidation, or | ||||||
26 | other acquisition of control;
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1 | (3) the Director shall have the power to require the | ||||||
2 | following
information:
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3 | (A) certification by an independent actuary of the | ||||||
4 | adequacy
of the reserves of the Health Maintenance | ||||||
5 | Organization sought to be acquired;
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6 | (B) pro forma financial statements reflecting the | ||||||
7 | combined balance
sheets of the acquiring company and | ||||||
8 | the Health Maintenance Organization sought
to be | ||||||
9 | acquired as of the end of the preceding year and as of | ||||||
10 | a date 90 days
prior to the acquisition, as well as pro | ||||||
11 | forma financial statements
reflecting projected | ||||||
12 | combined operation for a period of 2 years;
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13 | (C) a pro forma business plan detailing an | ||||||
14 | acquiring party's plans with
respect to the operation | ||||||
15 | of the Health Maintenance Organization sought to
be | ||||||
16 | acquired for a period of not less than 3 years; and
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17 | (D) such other information as the Director shall | ||||||
18 | require.
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19 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
20 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
21 | any health maintenance
organization of greater than 10% of its
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22 | enrollee population (including without limitation the health | ||||||
23 | maintenance
organization's right, title, and interest in and to | ||||||
24 | its health care
certificates).
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25 | (e) In considering any management contract or service | ||||||
26 | agreement subject
to Section 141.1 of the Illinois Insurance |
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1 | Code, the Director (i) shall, in
addition to the criteria | ||||||
2 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
3 | into account the effect of the management contract or
service | ||||||
4 | agreement on the continuation of benefits to enrollees and the
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5 | financial condition of the health maintenance organization to | ||||||
6 | be managed or
serviced, and (ii) need not take into account the | ||||||
7 | effect of the management
contract or service agreement on | ||||||
8 | competition.
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9 | (f) Except for small employer groups as defined in the | ||||||
10 | Small Employer
Rating, Renewability and Portability Health | ||||||
11 | Insurance Act and except for
medicare supplement policies as | ||||||
12 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
13 | Maintenance Organization may by contract agree with a
group or | ||||||
14 | other enrollment unit to effect refunds or charge additional | ||||||
15 | premiums
under the following terms and conditions:
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16 | (i) the amount of, and other terms and conditions with | ||||||
17 | respect to, the
refund or additional premium are set forth | ||||||
18 | in the group or enrollment unit
contract agreed in advance | ||||||
19 | of the period for which a refund is to be paid or
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20 | additional premium is to be charged (which period shall not | ||||||
21 | be less than one
year); and
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22 | (ii) the amount of the refund or additional premium | ||||||
23 | shall not exceed 20%
of the Health Maintenance | ||||||
24 | Organization's profitable or unprofitable experience
with | ||||||
25 | respect to the group or other enrollment unit for the | ||||||
26 | period (and, for
purposes of a refund or additional |
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1 | premium, the profitable or unprofitable
experience shall | ||||||
2 | be calculated taking into account a pro rata share of the
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3 | Health Maintenance Organization's administrative and | ||||||
4 | marketing expenses, but
shall not include any refund to be | ||||||
5 | made or additional premium to be paid
pursuant to this | ||||||
6 | subsection (f)). The Health Maintenance Organization and | ||||||
7 | the
group or enrollment unit may agree that the profitable | ||||||
8 | or unprofitable
experience may be calculated taking into | ||||||
9 | account the refund period and the
immediately preceding 2 | ||||||
10 | plan years.
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11 | The Health Maintenance Organization shall include a | ||||||
12 | statement in the
evidence of coverage issued to each enrollee | ||||||
13 | describing the possibility of a
refund or additional premium, | ||||||
14 | and upon request of any group or enrollment unit,
provide to | ||||||
15 | the group or enrollment unit a description of the method used | ||||||
16 | to
calculate (1) the Health Maintenance Organization's | ||||||
17 | profitable experience with
respect to the group or enrollment | ||||||
18 | unit and the resulting refund to the group
or enrollment unit | ||||||
19 | or (2) the Health Maintenance Organization's unprofitable
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20 | experience with respect to the group or enrollment unit and the | ||||||
21 | resulting
additional premium to be paid by the group or | ||||||
22 | enrollment unit.
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23 | In no event shall the Illinois Health Maintenance | ||||||
24 | Organization
Guaranty Association be liable to pay any | ||||||
25 | contractual obligation of an
insolvent organization to pay any | ||||||
26 | refund authorized under this Section.
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1 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
2 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
3 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
4 | eff. 12-12-08; revised 12-15-08.)
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5 | Section 95. No acceleration or delay. Where this Act makes | ||||||
6 | changes in a statute that is represented in this Act by text | ||||||
7 | that is not yet or no longer in effect (for example, a Section | ||||||
8 | represented by multiple versions), the use of that text does | ||||||
9 | not accelerate or delay the taking effect of (i) the changes | ||||||
10 | made by this Act or (ii) provisions derived from any other | ||||||
11 | Public Act.
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