Rep. Mary E. Flowers
Filed: 3/11/2009
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| 1 | AMENDMENT TO HOUSE BILL 626
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| 2 | AMENDMENT NO. ______. Amend House Bill 626 by replacing | ||||||
| 3 | everything after the enacting clause with the following:
| ||||||
| 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.9, 356z.10, | ||||||
| 15 | 356z.13
356z.11, and 356z.14, 356z.15, and 356z.16
of the
| ||||||
| 16 | Illinois Insurance Code.
The program of health benefits must | ||||||
| |||||||
| |||||||
| 1 | comply with Section 155.37 of the
Illinois Insurance Code.
| ||||||
| 2 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
| 3 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||||||
| 4 | 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| ||||||
| 5 | (Text of Section after amendment by P.A. 95-958)
| ||||||
| 6 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
| 7 | Code
requirements. The program of health
benefits shall provide | ||||||
| 8 | the post-mastectomy care benefits required to be covered
by a | ||||||
| 9 | policy of accident and health insurance under Section 356t of | ||||||
| 10 | the Illinois
Insurance Code. The program of health benefits | ||||||
| 11 | shall provide the coverage
required under Sections 356g.5,
| ||||||
| 12 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10, | ||||||
| 13 | 356z.11, and 356z.12, 356z.13
356z.11, and 356z.14, 356z.15, | ||||||
| 14 | and 356z.16 of the
Illinois Insurance Code.
The program of | ||||||
| 15 | health benefits must comply with Section 155.37 of the
Illinois | ||||||
| 16 | Insurance Code.
| ||||||
| 17 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
| 18 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
| 19 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
| 20 | 12-15-08.)
| ||||||
| 21 | Section 10. The Counties Code is amended by changing | ||||||
| 22 | Section 5-1069.3 as
follows:
| ||||||
| 23 | (55 ILCS 5/5-1069.3)
| ||||||
| |||||||
| |||||||
| 1 | (Text of Section before amendment by P.A. 95-958)
| ||||||
| 2 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
| 3 | including a home
rule
county, is a self-insurer for purposes of | ||||||
| 4 | providing health insurance coverage
for its employees, the | ||||||
| 5 | coverage shall include coverage for the post-mastectomy
care | ||||||
| 6 | benefits required to be covered by a policy of accident and | ||||||
| 7 | health
insurance under Section 356t and the coverage required | ||||||
| 8 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.9, | ||||||
| 9 | 356z.10, 356z.13
356z.11, and 356z.14, 356z.15, and 356z.16 of
| ||||||
| 10 | the Illinois Insurance Code. The requirement that health | ||||||
| 11 | benefits be covered
as provided in this Section is an
exclusive | ||||||
| 12 | power and function of the State and is a denial and limitation | ||||||
| 13 | under
Article VII, Section 6, subsection (h) of the Illinois | ||||||
| 14 | Constitution. A home
rule county to which this Section applies | ||||||
| 15 | must comply with every provision of
this Section.
| ||||||
| 16 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
| 17 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||||||
| 18 | 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| ||||||
| 19 | (Text of Section after amendment by P.A. 95-958) | ||||||
| 20 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
| 21 | including a home
rule
county, is a self-insurer for purposes of | ||||||
| 22 | providing health insurance coverage
for its employees, the | ||||||
| 23 | coverage shall include coverage for the post-mastectomy
care | ||||||
| 24 | benefits required to be covered by a policy of accident and | ||||||
| 25 | health
insurance under Section 356t and the coverage required | ||||||
| |||||||
| |||||||
| 1 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.9, | ||||||
| 2 | 356z.10, 356z.11, and 356z.12, 356z.13
356z.11, and 356z.14, | ||||||
| 3 | 356z.15, and 356z.16 of
the Illinois Insurance Code. The | ||||||
| 4 | requirement that health benefits be covered
as provided in this | ||||||
| 5 | Section is an
exclusive power and function of the State and is | ||||||
| 6 | a denial and limitation under
Article VII, Section 6, | ||||||
| 7 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
| 8 | to which this Section applies must comply with every provision | ||||||
| 9 | of
this Section.
| ||||||
| 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 15. The Illinois Municipal Code is amended by | ||||||
| 15 | changing Section
10-4-2.3 as follows:
| ||||||
| 16 | (65 ILCS 5/10-4-2.3)
| ||||||
| 17 | (Text of Section before amendment by P.A. 95-958)
| ||||||
| 18 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
| 19 | municipality, including a
home rule municipality, is a | ||||||
| 20 | self-insurer for purposes of providing health
insurance | ||||||
| 21 | coverage for its employees, the coverage shall include coverage | ||||||
| 22 | for
the post-mastectomy care benefits required to be covered by | ||||||
| 23 | a policy of
accident and health insurance under Section 356t | ||||||
| 24 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
| |||||||
| |||||||
| 1 | 356x, 356z.6, 356z.9, 356z.10, 356z.13
356z.11, and 356z.14, | ||||||
| 2 | 356z.15, and 356z.16 of the Illinois
Insurance
Code. The | ||||||
| 3 | requirement that health
benefits be covered as provided in this | ||||||
| 4 | is an exclusive power and function of
the State and is a denial | ||||||
| 5 | and limitation under Article VII, Section 6,
subsection (h) of | ||||||
| 6 | the Illinois Constitution. A home rule municipality to which
| ||||||
| 7 | this Section applies must comply with every provision of this | ||||||
| 8 | Section.
| ||||||
| 9 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
| 10 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||||||
| 11 | 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| ||||||
| 12 | (Text of Section after amendment by P.A. 95-958) | ||||||
| 13 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
| 14 | municipality, including a
home rule municipality, is a | ||||||
| 15 | self-insurer for purposes of providing health
insurance | ||||||
| 16 | coverage for its employees, the coverage shall include coverage | ||||||
| 17 | for
the post-mastectomy care benefits required to be covered by | ||||||
| 18 | a policy of
accident and health insurance under Section 356t | ||||||
| 19 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
| 20 | 356x, 356z.6, 356z.9, 356z.10, 356z.11, and 356z.12, 356z.13
| ||||||
| 21 | 356z.11, and 356z.14, 356z.15, and 356z.16 of the Illinois
| ||||||
| 22 | Insurance
Code. The requirement that health
benefits be covered | ||||||
| 23 | as provided in this is an exclusive power and function of
the | ||||||
| 24 | State and is a denial and limitation under Article VII, Section | ||||||
| 25 | 6,
subsection (h) of the Illinois Constitution. A home rule | ||||||
| |||||||
| |||||||
| 1 | municipality to which
this Section applies must comply with | ||||||
| 2 | every provision of this Section.
| ||||||
| 3 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
| 4 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
| 5 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
| 6 | 12-15-08.)
| ||||||
| 7 | Section 20. The School Code is amended by changing Section | ||||||
| 8 | 10-22.3f as
follows:
| ||||||
| 9 | (105 ILCS 5/10-22.3f)
| ||||||
| 10 | (Text of Section before amendment by P.A. 95-958)
| ||||||
| 11 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
| 12 | protection and
benefits
for employees shall provide the | ||||||
| 13 | post-mastectomy care benefits required to be
covered by a | ||||||
| 14 | policy of accident and health insurance under Section 356t and | ||||||
| 15 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
| ||||||
| 16 | 356z.6, 356z.9, 356z.13
and 356z.11, and 356z.14, 356z.15, and | ||||||
| 17 | 356z.16 of
the
Illinois Insurance Code.
| ||||||
| 18 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
| 19 | 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. | ||||||
| 20 | 12-12-08; revised 12-15-08.)
| ||||||
| 21 | (Text of Section after amendment by P.A. 95-958) | ||||||
| 22 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
| 23 | protection and
benefits
for employees shall provide the | ||||||
| |||||||
| |||||||
| 1 | post-mastectomy care benefits required to be
covered by a | ||||||
| 2 | policy of accident and health insurance under Section 356t and | ||||||
| 3 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
| ||||||
| 4 | 356z.6, 356z.9, 356z.11, and 356z.12, 356z.13
and 356z.11, and | ||||||
| 5 | 356z.14, 356z.15, and 356z.16 of
the
Illinois Insurance Code.
| ||||||
| 6 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
| 7 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
| 8 | 95-1005, 12-12-08; revised 12-15-08.)
| ||||||
| 9 | Section 25. The Illinois Insurance Code is amended by | ||||||
| 10 | adding Sections
356z.15 and
356z.16
as
follows:
| ||||||
| 11 | (215 ILCS 5/356z.15 new)
| ||||||
| 12 | Sec. 356z.15. Intravenous feeding. A group or individual | ||||||
| 13 | policy of
accident and health insurance or managed care plan | ||||||
| 14 | amended, delivered, issued,
or renewed after the effective date | ||||||
| 15 | of this amendatory Act of the 96th General
Assembly must | ||||||
| 16 | provide coverage for intravenous feeding. The benefits under
| ||||||
| 17 | this Section shall be at least as favorable as for other | ||||||
| 18 | coverages under the
policy and may be subject to the same | ||||||
| 19 | dollar amount limits, deductibles, and
co-insurance | ||||||
| 20 | requirements applicable generally to other coverages under the
| ||||||
| 21 | policy. | ||||||
| 22 | (215 ILCS 5/356z.16 new)
| ||||||
| 23 | Sec. 356z.16. Prescription nutritional supplements. A | ||||||
| |||||||
| |||||||
| 1 | group or individual
policy of
accident and health insurance or | ||||||
| 2 | managed care plan amended, delivered, issued,
or renewed
after | ||||||
| 3 | the effective date of this amendatory Act of the 96th General | ||||||
| 4 | Assembly
that provides
coverage for prescription drugs must | ||||||
| 5 | provide coverage for reimbursement for
medically
appropriate | ||||||
| 6 | prescription nutritional supplements when ordered by a | ||||||
| 7 | physician
licensed to
practice medicine in all its branches and | ||||||
| 8 | the insured suffers from a condition
that prevents
him or her | ||||||
| 9 | from taking sufficient oral nourishment to sustain life.
| ||||||
| 10 | Section 30. The Health Maintenance Organization Act is | ||||||
| 11 | amended by changing
Section 5-3 as follows:
| ||||||
| 12 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
| 13 | (Text of Section before amendment by P.A. 95-958)
| ||||||
| 14 | Sec. 5-3. Insurance Code provisions.
| ||||||
| 15 | (a) Health Maintenance Organizations
shall be subject to | ||||||
| 16 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
| 17 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
| 18 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
| 19 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
| 20 | 356z.13
356z.11, 356z.14, 356z.15, 356z.16,
364.01, 367.2, | ||||||
| 21 | 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, | ||||||
| 22 | 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph | ||||||
| 23 | (c) of subsection (2) of Section 367, and Articles IIA, VIII | ||||||
| 24 | 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the | ||||||
| |||||||
| |||||||
| 1 | Illinois Insurance Code.
| ||||||
| 2 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
| 3 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
| 4 | Maintenance Organizations in
the following categories are | ||||||
| 5 | deemed to be "domestic companies":
| ||||||
| 6 | (1) a corporation authorized under the
Dental Service | ||||||
| 7 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
| 8 | (2) a corporation organized under the laws of this | ||||||
| 9 | State; or
| ||||||
| 10 | (3) a corporation organized under the laws of another | ||||||
| 11 | state, 30% or more
of the enrollees of which are residents | ||||||
| 12 | of this State, except a
corporation subject to | ||||||
| 13 | substantially the same requirements in its state of
| ||||||
| 14 | organization as is a "domestic company" under Article VIII | ||||||
| 15 | 1/2 of the
Illinois Insurance Code.
| ||||||
| 16 | (c) In considering the merger, consolidation, or other | ||||||
| 17 | acquisition of
control of a Health Maintenance Organization | ||||||
| 18 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
| 19 | (1) the Director shall give primary consideration to | ||||||
| 20 | the continuation of
benefits to enrollees and the financial | ||||||
| 21 | conditions of the acquired Health
Maintenance Organization | ||||||
| 22 | after the merger, consolidation, or other
acquisition of | ||||||
| 23 | control takes effect;
| ||||||
| 24 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
| 25 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
| 26 | apply and (ii) the Director, in making
his determination | ||||||
| |||||||
| |||||||
| 1 | with respect to the merger, consolidation, or other
| ||||||
| 2 | acquisition of control, need not take into account the | ||||||
| 3 | effect on
competition of the merger, consolidation, or | ||||||
| 4 | other acquisition of control;
| ||||||
| 5 | (3) the Director shall have the power to require the | ||||||
| 6 | following
information:
| ||||||
| 7 | (A) certification by an independent actuary of the | ||||||
| 8 | adequacy
of the reserves of the Health Maintenance | ||||||
| 9 | Organization sought to be acquired;
| ||||||
| 10 | (B) pro forma financial statements reflecting the | ||||||
| 11 | combined balance
sheets of the acquiring company and | ||||||
| 12 | the Health Maintenance Organization sought
to be | ||||||
| 13 | acquired as of the end of the preceding year and as of | ||||||
| 14 | a date 90 days
prior to the acquisition, as well as pro | ||||||
| 15 | forma financial statements
reflecting projected | ||||||
| 16 | combined operation for a period of 2 years;
| ||||||
| 17 | (C) a pro forma business plan detailing an | ||||||
| 18 | acquiring party's plans with
respect to the operation | ||||||
| 19 | of the Health Maintenance Organization sought to
be | ||||||
| 20 | acquired for a period of not less than 3 years; and
| ||||||
| 21 | (D) such other information as the Director shall | ||||||
| 22 | require.
| ||||||
| 23 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
| 24 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
| 25 | any health maintenance
organization of greater than 10% of its
| ||||||
| 26 | enrollee population (including without limitation the health | ||||||
| |||||||
| |||||||
| 1 | maintenance
organization's right, title, and interest in and to | ||||||
| 2 | its health care
certificates).
| ||||||
| 3 | (e) In considering any management contract or service | ||||||
| 4 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
| 5 | Code, the Director (i) shall, in
addition to the criteria | ||||||
| 6 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
| 7 | into account the effect of the management contract or
service | ||||||
| 8 | agreement on the continuation of benefits to enrollees and the
| ||||||
| 9 | financial condition of the health maintenance organization to | ||||||
| 10 | be managed or
serviced, and (ii) need not take into account the | ||||||
| 11 | effect of the management
contract or service agreement on | ||||||
| 12 | competition.
| ||||||
| 13 | (f) Except for small employer groups as defined in the | ||||||
| 14 | Small Employer
Rating, Renewability and Portability Health | ||||||
| 15 | Insurance Act and except for
medicare supplement policies as | ||||||
| 16 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
| 17 | Maintenance Organization may by contract agree with a
group or | ||||||
| 18 | other enrollment unit to effect refunds or charge additional | ||||||
| 19 | premiums
under the following terms and conditions:
| ||||||
| 20 | (i) the amount of, and other terms and conditions with | ||||||
| 21 | respect to, the
refund or additional premium are set forth | ||||||
| 22 | in the group or enrollment unit
contract agreed in advance | ||||||
| 23 | of the period for which a refund is to be paid or
| ||||||
| 24 | additional premium is to be charged (which period shall not | ||||||
| 25 | be less than one
year); and
| ||||||
| 26 | (ii) the amount of the refund or additional premium | ||||||
| |||||||
| |||||||
| 1 | shall not exceed 20%
of the Health Maintenance | ||||||
| 2 | Organization's profitable or unprofitable experience
with | ||||||
| 3 | respect to the group or other enrollment unit for the | ||||||
| 4 | period (and, for
purposes of a refund or additional | ||||||
| 5 | premium, the profitable or unprofitable
experience shall | ||||||
| 6 | be calculated taking into account a pro rata share of the
| ||||||
| 7 | Health Maintenance Organization's administrative and | ||||||
| 8 | marketing expenses, but
shall not include any refund to be | ||||||
| 9 | made or additional premium to be paid
pursuant to this | ||||||
| 10 | subsection (f)). The Health Maintenance Organization and | ||||||
| 11 | the
group or enrollment unit may agree that the profitable | ||||||
| 12 | or unprofitable
experience may be calculated taking into | ||||||
| 13 | account the refund period and the
immediately preceding 2 | ||||||
| 14 | plan years.
| ||||||
| 15 | The Health Maintenance Organization shall include a | ||||||
| 16 | statement in the
evidence of coverage issued to each enrollee | ||||||
| 17 | describing the possibility of a
refund or additional premium, | ||||||
| 18 | and upon request of any group or enrollment unit,
provide to | ||||||
| 19 | the group or enrollment unit a description of the method used | ||||||
| 20 | to
calculate (1) the Health Maintenance Organization's | ||||||
| 21 | profitable experience with
respect to the group or enrollment | ||||||
| 22 | unit and the resulting refund to the group
or enrollment unit | ||||||
| 23 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
| 24 | experience with respect to the group or enrollment unit and the | ||||||
| 25 | resulting
additional premium to be paid by the group or | ||||||
| 26 | enrollment unit.
| ||||||
| |||||||
| |||||||
| 1 | In no event shall the Illinois Health Maintenance | ||||||
| 2 | Organization
Guaranty Association be liable to pay any | ||||||
| 3 | contractual obligation of an
insolvent organization to pay any | ||||||
| 4 | refund authorized under this Section.
| ||||||
| 5 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
| 6 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
| 7 | 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
| 8 | 12-15-08.)
| ||||||
| 9 | (Text of Section after amendment by P.A. 95-958) | ||||||
| 10 | Sec. 5-3. Insurance Code provisions.
| ||||||
| 11 | (a) Health Maintenance Organizations
shall be subject to | ||||||
| 12 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
| 13 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
| 14 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
| 15 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
| 16 | 356z.11, 356z.12, 356z.13
356z.11, 356z.14, 356z.15, 356z.16, | ||||||
| 17 | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | ||||||
| 18 | 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
| ||||||
| 19 | and
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, and | ||||||
| 21 | XXVI of the Illinois Insurance Code.
| ||||||
| 22 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
| 23 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
| 24 | Maintenance Organizations in
the following categories are | ||||||
| 25 | deemed to be "domestic companies":
| ||||||
| |||||||
| |||||||
| 1 | (1) a corporation authorized under the
Dental Service | ||||||
| 2 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
| 3 | (2) a corporation organized under the laws of this | ||||||
| 4 | State; or
| ||||||
| 5 | (3) a corporation organized under the laws of another | ||||||
| 6 | state, 30% or more
of the enrollees of which are residents | ||||||
| 7 | of this State, except a
corporation subject to | ||||||
| 8 | substantially the same requirements in its state of
| ||||||
| 9 | organization as is a "domestic company" under Article VIII | ||||||
| 10 | 1/2 of the
Illinois Insurance Code.
| ||||||
| 11 | (c) In considering the merger, consolidation, or other | ||||||
| 12 | acquisition of
control of a Health Maintenance Organization | ||||||
| 13 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
| 14 | (1) the Director shall give primary consideration to | ||||||
| 15 | the continuation of
benefits to enrollees and the financial | ||||||
| 16 | conditions of the acquired Health
Maintenance Organization | ||||||
| 17 | after the merger, consolidation, or other
acquisition of | ||||||
| 18 | control takes effect;
| ||||||
| 19 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
| 20 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
| 21 | apply and (ii) the Director, in making
his determination | ||||||
| 22 | with respect to the merger, consolidation, or other
| ||||||
| 23 | acquisition of control, need not take into account the | ||||||
| 24 | effect on
competition of the merger, consolidation, or | ||||||
| 25 | other acquisition of control;
| ||||||
| 26 | (3) the Director shall have the power to require the | ||||||
| |||||||
| |||||||
| 1 | following
information:
| ||||||
| 2 | (A) certification by an independent actuary of the | ||||||
| 3 | adequacy
of the reserves of the Health Maintenance | ||||||
| 4 | Organization sought to be acquired;
| ||||||
| 5 | (B) pro forma financial statements reflecting the | ||||||
| 6 | combined balance
sheets of the acquiring company and | ||||||
| 7 | the Health Maintenance Organization sought
to be | ||||||
| 8 | acquired as of the end of the preceding year and as of | ||||||
| 9 | a date 90 days
prior to the acquisition, as well as pro | ||||||
| 10 | forma financial statements
reflecting projected | ||||||
| 11 | combined operation for a period of 2 years;
| ||||||
| 12 | (C) a pro forma business plan detailing an | ||||||
| 13 | acquiring party's plans with
respect to the operation | ||||||
| 14 | of the Health Maintenance Organization sought to
be | ||||||
| 15 | acquired for a period of not less than 3 years; and
| ||||||
| 16 | (D) such other information as the Director shall | ||||||
| 17 | require.
| ||||||
| 18 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
| 19 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
| 20 | any health maintenance
organization of greater than 10% of its
| ||||||
| 21 | enrollee population (including without limitation the health | ||||||
| 22 | maintenance
organization's right, title, and interest in and to | ||||||
| 23 | its health care
certificates).
| ||||||
| 24 | (e) In considering any management contract or service | ||||||
| 25 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
| 26 | Code, the Director (i) shall, in
addition to the criteria | ||||||
| |||||||
| |||||||
| 1 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
| 2 | into account the effect of the management contract or
service | ||||||
| 3 | agreement on the continuation of benefits to enrollees and the
| ||||||
| 4 | financial condition of the health maintenance organization to | ||||||
| 5 | be managed or
serviced, and (ii) need not take into account the | ||||||
| 6 | effect of the management
contract or service agreement on | ||||||
| 7 | competition.
| ||||||
| 8 | (f) Except for small employer groups as defined in the | ||||||
| 9 | Small Employer
Rating, Renewability and Portability Health | ||||||
| 10 | Insurance Act and except for
medicare supplement policies as | ||||||
| 11 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
| 12 | Maintenance Organization may by contract agree with a
group or | ||||||
| 13 | other enrollment unit to effect refunds or charge additional | ||||||
| 14 | premiums
under the following terms and conditions:
| ||||||
| 15 | (i) the amount of, and other terms and conditions with | ||||||
| 16 | respect to, the
refund or additional premium are set forth | ||||||
| 17 | in the group or enrollment unit
contract agreed in advance | ||||||
| 18 | of the period for which a refund is to be paid or
| ||||||
| 19 | additional premium is to be charged (which period shall not | ||||||
| 20 | be less than one
year); and
| ||||||
| 21 | (ii) the amount of the refund or additional premium | ||||||
| 22 | shall not exceed 20%
of the Health Maintenance | ||||||
| 23 | Organization's profitable or unprofitable experience
with | ||||||
| 24 | respect to the group or other enrollment unit for the | ||||||
| 25 | period (and, for
purposes of a refund or additional | ||||||
| 26 | premium, the profitable or unprofitable
experience shall | ||||||
| |||||||
| |||||||
| 1 | be calculated taking into account a pro rata share of the
| ||||||
| 2 | Health Maintenance Organization's administrative and | ||||||
| 3 | marketing expenses, but
shall not include any refund to be | ||||||
| 4 | made or additional premium to be paid
pursuant to this | ||||||
| 5 | subsection (f)). The Health Maintenance Organization and | ||||||
| 6 | the
group or enrollment unit may agree that the profitable | ||||||
| 7 | or unprofitable
experience may be calculated taking into | ||||||
| 8 | account the refund period and the
immediately preceding 2 | ||||||
| 9 | plan years.
| ||||||
| 10 | The Health Maintenance Organization shall include a | ||||||
| 11 | statement in the
evidence of coverage issued to each enrollee | ||||||
| 12 | describing the possibility of a
refund or additional premium, | ||||||
| 13 | and upon request of any group or enrollment unit,
provide to | ||||||
| 14 | the group or enrollment unit a description of the method used | ||||||
| 15 | to
calculate (1) the Health Maintenance Organization's | ||||||
| 16 | profitable experience with
respect to the group or enrollment | ||||||
| 17 | unit and the resulting refund to the group
or enrollment unit | ||||||
| 18 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
| 19 | experience with respect to the group or enrollment unit and the | ||||||
| 20 | resulting
additional premium to be paid by the group or | ||||||
| 21 | enrollment unit.
| ||||||
| 22 | In no event shall the Illinois Health Maintenance | ||||||
| 23 | Organization
Guaranty Association be liable to pay any | ||||||
| 24 | contractual obligation of an
insolvent organization to pay any | ||||||
| 25 | refund authorized under this Section.
| ||||||
| 26 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
| |||||||
| |||||||
| 1 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
| 2 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
| 3 | eff. 12-12-08; revised 12-15-08.)
| ||||||
| 4 | Section 35. The Voluntary Health Services Plans Act is | ||||||
| 5 | amended by changing
Section 10 as follows:
| ||||||
| 6 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
| 7 | (Text of Section before amendment by P.A. 95-958)
| ||||||
| 8 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
| 9 | services
plan corporations and all persons interested therein | ||||||
| 10 | or dealing therewith
shall be subject to the provisions of | ||||||
| 11 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
| 12 | 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | ||||||
| 13 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||||||
| 14 | 356z.9,
356z.10, 356z.13
356z.11, 356z.14, 356z.15, 356z.16,
| ||||||
| 15 | 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | ||||||
| 16 | and 412, and paragraphs (7) and (15) of Section 367 of the | ||||||
| 17 | Illinois
Insurance Code.
| ||||||
| 18 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
| 19 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
| 20 | 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; 95-1005, | ||||||
| 21 | eff. 12-12-08; revised 12-15-08.)
| ||||||
| 22 | (Text of Section after amendment by P.A. 95-958) | ||||||
| 23 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
| |||||||
| |||||||
| 1 | services
plan corporations and all persons interested therein | ||||||
| 2 | or dealing therewith
shall be subject to the provisions of | ||||||
| 3 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
| 4 | 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | ||||||
| 5 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||||||
| 6 | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13
356z.11, 356z.14, | ||||||
| 7 | 356z.15, 356z.16, 364.01, 367.2, 368a, 401, 401.1,
402,
403, | ||||||
| 8 | 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | ||||||
| 9 | Section 367 of the Illinois
Insurance Code.
| ||||||
| 10 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
| 11 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
| 12 | 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, | ||||||
| 13 | eff. 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| ||||||
| 14 | Section 90. The State Mandates Act is amended by adding | ||||||
| 15 | Section 8.33 as follows: | ||||||
| 16 | (30 ILCS 805/8.33 new) | ||||||
| 17 | Sec. 8.33. Exempt mandate. Notwithstanding Sections 6 and 8 | ||||||
| 18 | of this Act, no reimbursement by the State is required for the | ||||||
| 19 | implementation of any mandate created by this amendatory Act of | ||||||
| 20 | the 96th General Assembly. | ||||||
| 21 | Section 95. No acceleration or delay. Where this Act makes | ||||||
| 22 | changes in a statute that is represented in this Act by text | ||||||
| 23 | that is not yet or no longer in effect (for example, a Section | ||||||
| |||||||
| |||||||
| 1 | represented by multiple versions), the use of that text does | ||||||
| 2 | not accelerate or delay the taking effect of (i) the changes | ||||||
| 3 | made by this Act or (ii) provisions derived from any other | ||||||
| 4 | Public Act.".
| ||||||