HB4924 Engrossed

LRB096 16233 RPM 31489 b






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 Illinois Insurance Code is amended  by adding 
5
Section 356z.19 as follows:
 
6
    (215 ILCS 5/356z.19 new)

7
    Sec. 356z.19. Cochlear implants; audiological services.
8
    (a) A group or individual policy of accident and health 
9
insurance or managed care plan amended, delivered, issued, or 
10
renewed after the effective date of this amendatory Act of the 
11
96th General Assembly must provide coverage for an operation, 
12
either monaurally or binaurally, to implant cochlear implants 
13
and cochlear devices, including all internal and external 
14
components, and provide post-treatment services, including, 
15
but not limited to, programming, troubleshooting, repairs, 
16
replacement components, such as external speech processors, 
17
microphones, coils, headsets, cables, and batteries, FM 
18
systems, auditory training, aural rehabilitation, and speech 
19
therapy for children identified by 18 years of age as having 
20
hearing impairment to the degree that they would benefit from 
21
implantation. These services must be provided by a 
22
speech-language pathologist, audiologist, or physician 
23
licensed to practice in this State.
 


 






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1
    (b) A group or individual
policy of accident and health 
2
insurance or managed care plan
amended, delivered, issued, or 
3
renewed after the effective date
of this amendatory Act of the 
4
96th General Assembly must
provide coverage for audiological 
5
services and hearing aids for
children up to 18 years of age. 
6
This coverage shall only apply
to hearing aids that are 
7
prescribed, filled, and dispensed by a
licensed audiologist. A 
8
policy or plan may limit the hearing
aid benefit payable for 
9
each hearing-impaired ear to every 38
months. A policy or plan 
10
may provide for up to 4 additional ear
molds per year for 
11
children up to 2 years of age. 
 
12
    Section 10. The Health Maintenance Organization Act is 
13
amended  by changing Section 5-3 as follows:
 


14
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


15
    (Text of Section before amendment by P.A. 96-833)
16
    Sec. 5-3. Insurance Code provisions. 

17
    (a) Health Maintenance Organizations
shall be subject to 
18
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
19
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
20
154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, 
21
356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 
22
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14, 
23
356z.17 356z.15, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 
24
368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 
 


 






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1
408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection 
2
(2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, 
3
XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

4
    (b) For purposes of the Illinois Insurance Code, except for 
5
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
6
Maintenance Organizations in
the following categories are 
7
deemed to be "domestic companies":


8
        (1) a corporation authorized under the
Dental Service 
9
    Plan Act or the Voluntary Health Services Plans Act;


10
        (2) a corporation organized under the laws of this 
11
    State; or


12
        (3) a corporation organized under the laws of another 
13
    state, 30% or more
of the enrollees of which are residents 
14
    of this State, except a
corporation subject to 
15
    substantially the same requirements in its state of

16
    organization as is a "domestic company" under Article VIII 
17
    1/2 of the
Illinois Insurance Code.

18
    (c) In considering the merger, consolidation, or other 
19
acquisition of
control of a Health Maintenance Organization 
20
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


21
        (1) the Director shall give primary consideration to 
22
    the continuation of
benefits to enrollees and the financial 
23
    conditions of the acquired Health
Maintenance Organization 
24
    after the merger, consolidation, or other
acquisition of 
25
    control takes effect;


26
        (2)(i) the criteria specified in subsection (1)(b) of 
 


 






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1
    Section 131.8 of
the Illinois Insurance Code shall not 
2
    apply and (ii) the Director, in making
his determination 
3
    with respect to the merger, consolidation, or other

4
    acquisition of control, need not take into account the 
5
    effect on
competition of the merger, consolidation, or 
6
    other acquisition of control;


7
        (3) the Director shall have the power to require the 
8
    following
information:


9
            (A) certification by an independent actuary of the 
10
        adequacy
of the reserves of the Health Maintenance 
11
        Organization sought to be acquired;


12
            (B) pro forma financial statements reflecting the 
13
        combined balance
sheets of the acquiring company and 
14
        the Health Maintenance Organization sought
to be 
15
        acquired as of the end of the preceding year and as of 
16
        a date 90 days
prior to the acquisition, as well as pro 
17
        forma financial statements
reflecting projected 
18
        combined operation for a period of 2 years;


19
            (C) a pro forma business plan detailing an 
20
        acquiring party's plans with
respect to the operation 
21
        of the Health Maintenance Organization sought to
be 
22
        acquired for a period of not less than 3 years; and


23
            (D) such other information as the Director shall 
24
        require.

25
    (d) The provisions of Article VIII 1/2 of the Illinois 
26
Insurance Code
and this Section 5-3 shall apply to the sale by 
 


 






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1
any health maintenance
organization of greater than 10% of its

2
enrollee population (including without limitation the health 
3
maintenance
organization's right, title, and interest in and to 
4
its health care
certificates).

5
    (e) In considering any management contract or service 
6
agreement subject
to Section 141.1 of the Illinois Insurance 
7
Code, the Director (i) shall, in
addition to the criteria 
8
specified in Section 141.2 of the Illinois
Insurance Code, take 
9
into account the effect of the management contract or
service 
10
agreement on the continuation of benefits to enrollees and the

11
financial condition of the health maintenance organization to 
12
be managed or
serviced, and (ii) need not take into account the 
13
effect of the management
contract or service agreement on 
14
competition.

15
    (f) Except for small employer groups as defined in the 
16
Small Employer
Rating, Renewability and Portability Health 
17
Insurance Act and except for
medicare supplement policies as 
18
defined in Section 363 of the Illinois
Insurance Code, a Health 
19
Maintenance Organization may by contract agree with a
group or 
20
other enrollment unit to effect refunds or charge additional 
21
premiums
under the following terms and conditions:


22
        (i) the amount of, and other terms and conditions with 
23
    respect to, the
refund or additional premium are set forth 
24
    in the group or enrollment unit
contract agreed in advance 
25
    of the period for which a refund is to be paid or

26
    additional premium is to be charged (which period shall not 
 


 






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1
    be less than one
year); and


2
        (ii) the amount of the refund or additional premium 
3
    shall not exceed 20%
of the Health Maintenance 
4
    Organization's profitable or unprofitable experience
with 
5
    respect to the group or other enrollment unit for the 
6
    period (and, for
purposes of a refund or additional 
7
    premium, the profitable or unprofitable
experience shall 
8
    be calculated taking into account a pro rata share of the

9
    Health Maintenance Organization's administrative and 
10
    marketing expenses, but
shall not include any refund to be 
11
    made or additional premium to be paid
pursuant to this 
12
    subsection (f)).  The Health Maintenance Organization and 
13
    the
group or enrollment unit may agree that the profitable 
14
    or unprofitable
experience may be calculated taking into 
15
    account the refund period and the
immediately preceding 2 
16
    plan years.

17
    The Health Maintenance Organization shall include a 
18
statement in the
evidence of coverage issued to each enrollee 
19
describing the possibility of a
refund or additional premium, 
20
and upon request of any group or enrollment unit,
provide to 
21
the group or enrollment unit a description of the method used 
22
to
calculate (1) the Health Maintenance Organization's 
23
profitable experience with
respect to the group or enrollment 
24
unit and the resulting refund to the group
or enrollment unit 
25
or (2) the Health Maintenance Organization's unprofitable

26
experience with respect to the group or enrollment unit and the 
 


 






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1
resulting
additional premium to be paid by the group or 
2
enrollment unit.

3
    In no event shall the Illinois Health Maintenance 
4
Organization
Guaranty Association be liable to pay any 
5
contractual obligation of an
insolvent organization to pay any 
6
refund authorized under this Section.

7
    (g) Rulemaking authority to implement Public Act 95-1045 
8
this amendatory Act of the 95th General Assembly, if any, is 
9
conditioned on the rules being adopted in accordance with all 
10
provisions of the Illinois Administrative Procedure Act and all 
11
rules and procedures of the Joint Committee on Administrative 
12
Rules; any purported rule not so adopted, for whatever reason, 
13
is unauthorized. 
14
(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 
15
95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 
16
95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 
17
1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised 
18
10-23-09.)
 
19
    (Text of Section after amendment by P.A. 96-833)
20
    Sec. 5-3. Insurance Code provisions. 

21
    (a) Health Maintenance Organizations
shall be subject to 
22
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
23
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
24
154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, 
25
356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 
 


 






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1
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 
2
356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 
3
368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 
4
409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of 
5
Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, 
6
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

7
    (b) For purposes of the Illinois Insurance Code, except for 
8
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
9
Maintenance Organizations in
the following categories are 
10
deemed to be "domestic companies":


11
        (1) a corporation authorized under the
Dental Service 
12
    Plan Act or the Voluntary Health Services Plans Act;


13
        (2) a corporation organized under the laws of this 
14
    State; or


15
        (3) a corporation organized under the laws of another 
16
    state, 30% or more
of the enrollees of which are residents 
17
    of this State, except a
corporation subject to 
18
    substantially the same requirements in its state of

19
    organization as is a "domestic company" under Article VIII 
20
    1/2 of the
Illinois Insurance Code.

21
    (c) In considering the merger, consolidation, or other 
22
acquisition of
control of a Health Maintenance Organization 
23
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


24
        (1) the Director shall give primary consideration to 
25
    the continuation of
benefits to enrollees and the financial 
26
    conditions of the acquired Health
Maintenance Organization 
 


 






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1
    after the merger, consolidation, or other
acquisition of 
2
    control takes effect;


3
        (2)(i) the criteria specified in subsection (1)(b) of 
4
    Section 131.8 of
the Illinois Insurance Code shall not 
5
    apply and (ii) the Director, in making
his determination 
6
    with respect to the merger, consolidation, or other

7
    acquisition of control, need not take into account the 
8
    effect on
competition of the merger, consolidation, or 
9
    other acquisition of control;


10
        (3) the Director shall have the power to require the 
11
    following
information:


12
            (A) certification by an independent actuary of the 
13
        adequacy
of the reserves of the Health Maintenance 
14
        Organization sought to be acquired;


15
            (B) pro forma financial statements reflecting the 
16
        combined balance
sheets of the acquiring company and 
17
        the Health Maintenance Organization sought
to be 
18
        acquired as of the end of the preceding year and as of 
19
        a date 90 days
prior to the acquisition, as well as pro 
20
        forma financial statements
reflecting projected 
21
        combined operation for a period of 2 years;


22
            (C) a pro forma business plan detailing an 
23
        acquiring party's plans with
respect to the operation 
24
        of the Health Maintenance Organization sought to
be 
25
        acquired for a period of not less than 3 years; and


26
            (D) such other information as the Director shall 
 


 






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1
        require.

2
    (d) The provisions of Article VIII 1/2 of the Illinois 
3
Insurance Code
and this Section 5-3 shall apply to the sale by 
4
any health maintenance
organization of greater than 10% of its

5
enrollee population (including without limitation the health 
6
maintenance
organization's right, title, and interest in and to 
7
its health care
certificates).

8
    (e) In considering any management contract or service 
9
agreement subject
to Section 141.1 of the Illinois Insurance 
10
Code, the Director (i) shall, in
addition to the criteria 
11
specified in Section 141.2 of the Illinois
Insurance Code, take 
12
into account the effect of the management contract or
service 
13
agreement on the continuation of benefits to enrollees and the

14
financial condition of the health maintenance organization to 
15
be managed or
serviced, and (ii) need not take into account the 
16
effect of the management
contract or service agreement on 
17
competition.

18
    (f) Except for small employer groups as defined in the 
19
Small Employer
Rating, Renewability and Portability Health 
20
Insurance Act and except for
medicare supplement policies as 
21
defined in Section 363 of the Illinois
Insurance Code, a Health 
22
Maintenance Organization may by contract agree with a
group or 
23
other enrollment unit to effect refunds or charge additional 
24
premiums
under the following terms and conditions:


25
        (i) the amount of, and other terms and conditions with 
26
    respect to, the
refund or additional premium are set forth 
 


 






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1
    in the group or enrollment unit
contract agreed in advance 
2
    of the period for which a refund is to be paid or

3
    additional premium is to be charged (which period shall not 
4
    be less than one
year); and


5
        (ii) the amount of the refund or additional premium 
6
    shall not exceed 20%
of the Health Maintenance 
7
    Organization's profitable or unprofitable experience
with 
8
    respect to the group or other enrollment unit for the 
9
    period (and, for
purposes of a refund or additional 
10
    premium, the profitable or unprofitable
experience shall 
11
    be calculated taking into account a pro rata share of the

12
    Health Maintenance Organization's administrative and 
13
    marketing expenses, but
shall not include any refund to be 
14
    made or additional premium to be paid
pursuant to this 
15
    subsection (f)).  The Health Maintenance Organization and 
16
    the
group or enrollment unit may agree that the profitable 
17
    or unprofitable
experience may be calculated taking into 
18
    account the refund period and the
immediately preceding 2 
19
    plan years.

20
    The Health Maintenance Organization shall include a 
21
statement in the
evidence of coverage issued to each enrollee 
22
describing the possibility of a
refund or additional premium, 
23
and upon request of any group or enrollment unit,
provide to 
24
the group or enrollment unit a description of the method used 
25
to
calculate (1) the Health Maintenance Organization's 
26
profitable experience with
respect to the group or enrollment 
 


 






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1
unit and the resulting refund to the group
or enrollment unit 
2
or (2) the Health Maintenance Organization's unprofitable

3
experience with respect to the group or enrollment unit and the 
4
resulting
additional premium to be paid by the group or 
5
enrollment unit.

6
    In no event shall the Illinois Health Maintenance 
7
Organization
Guaranty Association be liable to pay any 
8
contractual obligation of an
insolvent organization to pay any 
9
refund authorized under this Section.

10
    (g) Rulemaking authority to implement Public Act 95-1045, 
11
if any, is conditioned on the rules being adopted in accordance 
12
with all provisions of the Illinois Administrative Procedure 
13
Act and all rules and procedures of the Joint Committee on 
14
Administrative Rules; any purported rule not so adopted, for 
15
whatever reason, is unauthorized. 
16
(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 
17
95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 
18
95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 
19
1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. 
20
6-1-10.)
 
21
    Section 15. The Voluntary Health Services Plans Act is 
22
amended  by changing Section 10 as follows:
 


23
    (215 ILCS 165/10)  (from Ch. 32, par. 604)

24
    (Text of Section before amendment by P.A. 96-833)
 


 






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1
    Sec. 10. Application of Insurance Code provisions. Health 
2
services
plan corporations and all persons interested therein 
3
or dealing therewith
shall be subject to the provisions of 
4
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
5
149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, 
6
356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 
7
356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 
8
356z.14, 356z.15
356z.14, 356z.19, 364.01, 367.2, 368a, 401, 
9
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
10
and (15) of Section 367 of the Illinois
Insurance Code.

11
    Rulemaking authority to implement Public Act 95-1045
this 
12
amendatory Act of the 95th General Assembly, if any, is 
13
conditioned on the rules being adopted in accordance with all 
14
provisions of the Illinois Administrative Procedure Act and all 
15
rules and procedures of the Joint Committee on Administrative 
16
Rules; any purported rule not so adopted, for whatever reason, 
17
is unauthorized. 
18
(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; 
19
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. 
20
8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, 
21
eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; 
22
96-328, eff. 8-11-09; revised 9-25-09.)
 
23
    (Text of Section after amendment by P.A. 96-833)
24
    Sec. 10. Application of Insurance Code provisions. Health 
25
services
plan corporations and all persons interested therein 
 


 






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1
or dealing therewith
shall be subject to the provisions of 
2
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
3
149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, 
4
356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 
5
356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 
6
356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401, 
7
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
8
and (15) of Section 367 of the Illinois
Insurance Code.

9
    Rulemaking authority to implement Public Act 95-1045, if 
10
any, is conditioned on the rules being adopted in accordance 
11
with all provisions of the Illinois Administrative Procedure 
12
Act and all rules and procedures of the Joint Committee on 
13
Administrative Rules; any purported rule not so adopted, for 
14
whatever reason, is unauthorized. 
15
(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; 
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; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; 
19
96-328, eff. 8-11-09; 96-833, eff. 6-1-10.)

 
20
    Section 95. No acceleration or delay. Where this Act makes 
21
changes in a statute that is represented in this Act by text 
22
that is not yet or no longer in effect (for example, a Section 
23
represented by multiple versions), the use of that text does 
24
not accelerate or delay the taking effect of (i) the changes 
25
made by this Act or (ii) provisions derived from any other 
 


 






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1
Public Act.