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1 | AN ACT concerning regulation.
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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.9, 356z.10, | ||||||
15 | 356z.13 356z.11 , and 356z.14 , and 356z.15
of the
Illinois | ||||||
16 | Insurance Code.
The program of health benefits must comply with | ||||||
17 | Section 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.9, 356z.10, | ||||||
7 | 356z.11, and 356z.12 , 356z.13
356z.11 , and 356z.14 , and 356z.15 | ||||||
8 | of 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 Illinois Insurance Code is amended by | ||||||
15 | adding Section 356z.15 as follows: | ||||||
16 | (215 ILCS 5/356z.15 new)
| ||||||
17 | Sec. 356z.15. Wellness coverage. | ||||||
18 | (a) A group or individual policy of accident and health | ||||||
19 | insurance or managed care plan amended, delivered, issued, or | ||||||
20 | renewed after the effective date of this amendatory Act of the | ||||||
21 | 96th General Assembly that provides coverage for hospital or | ||||||
22 | medical treatment on an expense incurred basis may offer a | ||||||
23 | reasonably designed program for wellness coverage that allows | ||||||
24 | for a reward, a contribution, a reduction in premiums or |
| |||||||
| |||||||
1 | reduced medical, prescription drug, or equipment copayments, | ||||||
2 | coinsurance, or deductibles, or a combination of these | ||||||
3 | incentives, for participation in any health behavior wellness, | ||||||
4 | maintenance, or improvement program approved or offered by the | ||||||
5 | insurer or managed care plan. The insured or enrollee may be | ||||||
6 | required to provide evidence of participation in a program. | ||||||
7 | Individuals unable to participate in these incentives due to an | ||||||
8 | adverse health factor shall not be penalized based upon an | ||||||
9 | adverse health status. | ||||||
10 | (b) For purposes of this Section, "wellness coverage" means | ||||||
11 | health care coverage with the primary purpose to engage and | ||||||
12 | motivate the insured or enrollee through: incentives; | ||||||
13 | provision of health education, counseling, and self-management | ||||||
14 | skills; identification of modifiable health risks; and other | ||||||
15 | activities to influence health behavior changes. | ||||||
16 | For the purposes of this Section, "reasonably designed | ||||||
17 | program" means a program of wellness coverage that has a | ||||||
18 | reasonable chance of improving health or preventing disease; is | ||||||
19 | not overly burdensome; does not discriminate based upon factors | ||||||
20 | of health; and is not otherwise contrary to law. | ||||||
21 | (c) Incentives as outlined in this Section are specific and | ||||||
22 | unique to the offering of wellness coverage and have no | ||||||
23 | application to any other required or optional health care | ||||||
24 | benefit. | ||||||
25 | (d) Such wellness coverage must satisfy the requirements | ||||||
26 | for an exception from the general prohibition against |
| |||||||
| |||||||
1 | discrimination based on a health factor under the federal | ||||||
2 | Health Insurance Portability and Accountability Act of 1996 | ||||||
3 | (P.L. 104-191; 110 Stat. 1936), including any federal | ||||||
4 | regulations that are adopted pursuant to that Act. | ||||||
5 | (e) A plan offering wellness coverage must do the | ||||||
6 | following: | ||||||
7 | (i) give participants the opportunity to qualify for | ||||||
8 | offered incentives at least once a year; | ||||||
9 | (ii) allow a reasonable alternative to any individual | ||||||
10 | for whom it is unreasonably difficult, due to a medical | ||||||
11 | condition, to satisfy otherwise applicable wellness | ||||||
12 | program standards. Plans may seek physician verification | ||||||
13 | that health factors make it unreasonably difficult or | ||||||
14 | medically inadvisable for the participant to satisfy the | ||||||
15 | standards; and | ||||||
16 | (iii) not provide a total incentive that exceeds 20% of | ||||||
17 | the cost of employee-only coverage. The cost of | ||||||
18 | employee-only coverage includes both employer and employee | ||||||
19 | contributions. For plans offering family coverage, the 20% | ||||||
20 | limitation applies to cost of family coverage and applies | ||||||
21 | to the entire family. | ||||||
22 | (f) A reward, contribution, or reduction established under | ||||||
23 | this Section and included in the policy or certificate does not | ||||||
24 | violate Section 151 of this Code. | ||||||
25 | Section 15. The Health Maintenance Organization Act is |
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| |||||||
1 | amended by changing Section 5-3 as follows:
| ||||||
2 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
3 | (Text of Section before amendment by P.A. 95-958 )
| ||||||
4 | Sec. 5-3. Insurance Code provisions.
| ||||||
5 | (a) Health Maintenance Organizations
shall be subject to | ||||||
6 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
7 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
8 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
9 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
10 | 356z.13
356z.11 , 356z.14, 356z.15,
364.01, 367.2, 367.2-5, | ||||||
11 | 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, | ||||||
12 | 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | ||||||
13 | subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
| ||||||
14 | XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | ||||||
15 | Insurance Code.
| ||||||
16 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
17 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
18 | Maintenance Organizations in
the following categories are | ||||||
19 | deemed to be "domestic companies":
| ||||||
20 | (1) a corporation authorized under the
Dental Service | ||||||
21 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
22 | (2) a corporation organized under the laws of this | ||||||
23 | State; or
| ||||||
24 | (3) a corporation organized under the laws of another | ||||||
25 | state, 30% or more
of the enrollees of which are residents |
| |||||||
| |||||||
1 | of this State, except a
corporation subject to | ||||||
2 | substantially the same requirements in its state of
| ||||||
3 | organization as is a "domestic company" under Article VIII | ||||||
4 | 1/2 of the
Illinois Insurance Code.
| ||||||
5 | (c) In considering the merger, consolidation, or other | ||||||
6 | acquisition of
control of a Health Maintenance Organization | ||||||
7 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
8 | (1) the Director shall give primary consideration to | ||||||
9 | the continuation of
benefits to enrollees and the financial | ||||||
10 | conditions of the acquired Health
Maintenance Organization | ||||||
11 | after the merger, consolidation, or other
acquisition of | ||||||
12 | control takes effect;
| ||||||
13 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
14 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
15 | apply and (ii) the Director, in making
his determination | ||||||
16 | with respect to the merger, consolidation, or other
| ||||||
17 | acquisition of control, need not take into account the | ||||||
18 | effect on
competition of the merger, consolidation, or | ||||||
19 | other acquisition of control;
| ||||||
20 | (3) the Director shall have the power to require the | ||||||
21 | following
information:
| ||||||
22 | (A) certification by an independent actuary of the | ||||||
23 | adequacy
of the reserves of the Health Maintenance | ||||||
24 | Organization sought to be acquired;
| ||||||
25 | (B) pro forma financial statements reflecting the | ||||||
26 | combined balance
sheets of the acquiring company and |
| |||||||
| |||||||
1 | the Health Maintenance Organization sought
to be | ||||||
2 | acquired as of the end of the preceding year and as of | ||||||
3 | a date 90 days
prior to the acquisition, as well as pro | ||||||
4 | forma financial statements
reflecting projected | ||||||
5 | combined operation for a period of 2 years;
| ||||||
6 | (C) a pro forma business plan detailing an | ||||||
7 | acquiring party's plans with
respect to the operation | ||||||
8 | of the Health Maintenance Organization sought to
be | ||||||
9 | acquired for a period of not less than 3 years; and
| ||||||
10 | (D) such other information as the Director shall | ||||||
11 | require.
| ||||||
12 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
13 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
14 | any health maintenance
organization of greater than 10% of its
| ||||||
15 | enrollee population (including without limitation the health | ||||||
16 | maintenance
organization's right, title, and interest in and to | ||||||
17 | its health care
certificates).
| ||||||
18 | (e) In considering any management contract or service | ||||||
19 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
20 | Code, the Director (i) shall, in
addition to the criteria | ||||||
21 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
22 | into account the effect of the management contract or
service | ||||||
23 | agreement on the continuation of benefits to enrollees and the
| ||||||
24 | financial condition of the health maintenance organization to | ||||||
25 | be managed or
serviced, and (ii) need not take into account the | ||||||
26 | effect of the management
contract or service agreement on |
| |||||||
| |||||||
1 | competition.
| ||||||
2 | (f) Except for small employer groups as defined in the | ||||||
3 | Small Employer
Rating, Renewability and Portability Health | ||||||
4 | Insurance Act and except for
medicare supplement policies as | ||||||
5 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
6 | Maintenance Organization may by contract agree with a
group or | ||||||
7 | other enrollment unit to effect refunds or charge additional | ||||||
8 | premiums
under the following terms and conditions:
| ||||||
9 | (i) the amount of, and other terms and conditions with | ||||||
10 | respect to, the
refund or additional premium are set forth | ||||||
11 | in the group or enrollment unit
contract agreed in advance | ||||||
12 | of the period for which a refund is to be paid or
| ||||||
13 | additional premium is to be charged (which period shall not | ||||||
14 | be less than one
year); and
| ||||||
15 | (ii) the amount of the refund or additional premium | ||||||
16 | shall not exceed 20%
of the Health Maintenance | ||||||
17 | Organization's profitable or unprofitable experience
with | ||||||
18 | respect to the group or other enrollment unit for the | ||||||
19 | period (and, for
purposes of a refund or additional | ||||||
20 | premium, the profitable or unprofitable
experience shall | ||||||
21 | be calculated taking into account a pro rata share of the
| ||||||
22 | Health Maintenance Organization's administrative and | ||||||
23 | marketing expenses, but
shall not include any refund to be | ||||||
24 | made or additional premium to be paid
pursuant to this | ||||||
25 | subsection (f)). The Health Maintenance Organization and | ||||||
26 | the
group or enrollment unit may agree that the profitable |
| |||||||
| |||||||
1 | or unprofitable
experience may be calculated taking into | ||||||
2 | account the refund period and the
immediately preceding 2 | ||||||
3 | plan years.
| ||||||
4 | The Health Maintenance Organization shall include a | ||||||
5 | statement in the
evidence of coverage issued to each enrollee | ||||||
6 | describing the possibility of a
refund or additional premium, | ||||||
7 | and upon request of any group or enrollment unit,
provide to | ||||||
8 | the group or enrollment unit a description of the method used | ||||||
9 | to
calculate (1) the Health Maintenance Organization's | ||||||
10 | profitable experience with
respect to the group or enrollment | ||||||
11 | unit and the resulting refund to the group
or enrollment unit | ||||||
12 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
13 | experience with respect to the group or enrollment unit and the | ||||||
14 | resulting
additional premium to be paid by the group or | ||||||
15 | enrollment unit.
| ||||||
16 | In no event shall the Illinois Health Maintenance | ||||||
17 | Organization
Guaranty Association be liable to pay any | ||||||
18 | contractual obligation of an
insolvent organization to pay any | ||||||
19 | refund authorized under this Section.
| ||||||
20 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
21 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
22 | 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||||||
23 | 12-15-08.)
| ||||||
24 | (Text of Section after amendment by P.A. 95-958 ) | ||||||
25 | Sec. 5-3. Insurance Code provisions.
|
| |||||||
| |||||||
1 | (a) Health Maintenance Organizations
shall be subject to | ||||||
2 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
3 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
4 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
5 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
6 | 356z.11, 356z.12 , 356z.13
356z.11 , 356z.14, 356z.15, 364.01, | ||||||
7 | 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | ||||||
8 | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
| ||||||
9 | paragraph (c) of subsection (2) of Section 367, and Articles | ||||||
10 | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | ||||||
11 | the Illinois Insurance Code.
| ||||||
12 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
13 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
14 | Maintenance Organizations in
the following categories are | ||||||
15 | deemed to be "domestic companies":
| ||||||
16 | (1) a corporation authorized under the
Dental Service | ||||||
17 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
18 | (2) a corporation organized under the laws of this | ||||||
19 | State; or
| ||||||
20 | (3) a corporation organized under the laws of another | ||||||
21 | state, 30% or more
of the enrollees of which are residents | ||||||
22 | of this State, except a
corporation subject to | ||||||
23 | substantially the same requirements in its state of
| ||||||
24 | organization as is a "domestic company" under Article VIII | ||||||
25 | 1/2 of the
Illinois Insurance Code.
| ||||||
26 | (c) In considering the merger, consolidation, or other |
| |||||||
| |||||||
1 | acquisition of
control of a Health Maintenance Organization | ||||||
2 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
3 | (1) the Director shall give primary consideration to | ||||||
4 | the continuation of
benefits to enrollees and the financial | ||||||
5 | conditions of the acquired Health
Maintenance Organization | ||||||
6 | after the merger, consolidation, or other
acquisition of | ||||||
7 | control takes effect;
| ||||||
8 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
9 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
10 | apply and (ii) the Director, in making
his determination | ||||||
11 | with respect to the merger, consolidation, or other
| ||||||
12 | acquisition of control, need not take into account the | ||||||
13 | effect on
competition of the merger, consolidation, or | ||||||
14 | other acquisition of control;
| ||||||
15 | (3) the Director shall have the power to require the | ||||||
16 | following
information:
| ||||||
17 | (A) certification by an independent actuary of the | ||||||
18 | adequacy
of the reserves of the Health Maintenance | ||||||
19 | Organization sought to be acquired;
| ||||||
20 | (B) pro forma financial statements reflecting the | ||||||
21 | combined balance
sheets of the acquiring company and | ||||||
22 | the Health Maintenance Organization sought
to be | ||||||
23 | acquired as of the end of the preceding year and as of | ||||||
24 | a date 90 days
prior to the acquisition, as well as pro | ||||||
25 | forma financial statements
reflecting projected | ||||||
26 | combined operation for a period of 2 years;
|
| |||||||
| |||||||
1 | (C) a pro forma business plan detailing an | ||||||
2 | acquiring party's plans with
respect to the operation | ||||||
3 | of the Health Maintenance Organization sought to
be | ||||||
4 | acquired for a period of not less than 3 years; and
| ||||||
5 | (D) such other information as the Director shall | ||||||
6 | require.
| ||||||
7 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
8 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
9 | any health maintenance
organization of greater than 10% of its
| ||||||
10 | enrollee population (including without limitation the health | ||||||
11 | maintenance
organization's right, title, and interest in and to | ||||||
12 | its health care
certificates).
| ||||||
13 | (e) In considering any management contract or service | ||||||
14 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
15 | Code, the Director (i) shall, in
addition to the criteria | ||||||
16 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
17 | into account the effect of the management contract or
service | ||||||
18 | agreement on the continuation of benefits to enrollees and the
| ||||||
19 | financial condition of the health maintenance organization to | ||||||
20 | be managed or
serviced, and (ii) need not take into account the | ||||||
21 | effect of the management
contract or service agreement on | ||||||
22 | competition.
| ||||||
23 | (f) Except for small employer groups as defined in the | ||||||
24 | Small Employer
Rating, Renewability and Portability Health | ||||||
25 | Insurance Act and except for
medicare supplement policies as | ||||||
26 | defined in Section 363 of the Illinois
Insurance Code, a Health |
| |||||||
| |||||||
1 | Maintenance Organization may by contract agree with a
group or | ||||||
2 | other enrollment unit to effect refunds or charge additional | ||||||
3 | premiums
under the following terms and conditions:
| ||||||
4 | (i) the amount of, and other terms and conditions with | ||||||
5 | respect to, the
refund or additional premium are set forth | ||||||
6 | in the group or enrollment unit
contract agreed in advance | ||||||
7 | of the period for which a refund is to be paid or
| ||||||
8 | additional premium is to be charged (which period shall not | ||||||
9 | be less than one
year); and
| ||||||
10 | (ii) the amount of the refund or additional premium | ||||||
11 | shall not exceed 20%
of the Health Maintenance | ||||||
12 | Organization's profitable or unprofitable experience
with | ||||||
13 | respect to the group or other enrollment unit for the | ||||||
14 | period (and, for
purposes of a refund or additional | ||||||
15 | premium, the profitable or unprofitable
experience shall | ||||||
16 | be calculated taking into account a pro rata share of the
| ||||||
17 | Health Maintenance Organization's administrative and | ||||||
18 | marketing expenses, but
shall not include any refund to be | ||||||
19 | made or additional premium to be paid
pursuant to this | ||||||
20 | subsection (f)). The Health Maintenance Organization and | ||||||
21 | the
group or enrollment unit may agree that the profitable | ||||||
22 | or unprofitable
experience may be calculated taking into | ||||||
23 | account the refund period and the
immediately preceding 2 | ||||||
24 | plan years.
| ||||||
25 | The Health Maintenance Organization shall include a | ||||||
26 | statement in the
evidence of coverage issued to each enrollee |
| |||||||
| |||||||
1 | describing the possibility of a
refund or additional premium, | ||||||
2 | and upon request of any group or enrollment unit,
provide to | ||||||
3 | the group or enrollment unit a description of the method used | ||||||
4 | to
calculate (1) the Health Maintenance Organization's | ||||||
5 | profitable experience with
respect to the group or enrollment | ||||||
6 | unit and the resulting refund to the group
or enrollment unit | ||||||
7 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
8 | experience with respect to the group or enrollment unit and the | ||||||
9 | resulting
additional premium to be paid by the group or | ||||||
10 | enrollment unit.
| ||||||
11 | In no event shall the Illinois Health Maintenance | ||||||
12 | Organization
Guaranty Association be liable to pay any | ||||||
13 | contractual obligation of an
insolvent organization to pay any | ||||||
14 | refund authorized under this Section.
| ||||||
15 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
16 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
17 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
18 | eff. 12-12-08; revised 12-15-08.) | ||||||
19 | Section 95. No acceleration or delay. Where this Act makes | ||||||
20 | changes in a statute that is represented in this Act by text | ||||||
21 | that is not yet or no longer in effect (for example, a Section | ||||||
22 | represented by multiple versions), the use of that text does | ||||||
23 | not accelerate or delay the taking effect of (i) the changes | ||||||
24 | made by this Act or (ii) provisions derived from any other | ||||||
25 | Public Act.
|
| |||||||
| |||||||
1 | Section 99. Effective date. This Act takes effect January | ||||||
2 | 1, 2010.
|