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HB5766 Engrossed |
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LRB096 19907 RPM 35370 b |
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
|
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| Section 5. The State Employees Group Insurance Act of 1971 |
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| is amended by changing Section 6.11 as follows:
|
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| (5 ILCS 375/6.11)
|
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| Sec. 6.11. Required health benefits; Illinois Insurance |
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| Code
requirements. The program of health
benefits shall provide |
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| the post-mastectomy care benefits required to be covered
by a |
10 |
| policy of accident and health insurance under Section 356t of |
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| the Illinois
Insurance Code. The program of health benefits |
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| shall provide the coverage
required under Sections 356g, |
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| 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
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| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
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| 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17 356z.15 , |
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| and 356z.19 of the
Illinois Insurance Code.
The program of |
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| health benefits must comply with Section 155.37 of the
Illinois |
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| Insurance Code.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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HB5766 Engrossed |
- 2 - |
LRB096 19907 RPM 35370 b |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, |
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| eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
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| 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
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| revised 10-22-09.) |
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| Section 10. The Counties Code is amended by changing |
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| Section 5-1069.3 as follows: |
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| (55 ILCS 5/5-1069.3)
|
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| Sec. 5-1069.3. Required health benefits. If a county, |
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| including a home
rule
county, is a self-insurer for purposes of |
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| providing health insurance coverage
for its employees, the |
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| coverage shall include coverage for the post-mastectomy
care |
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| benefits required to be covered by a policy of accident and |
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| health
insurance under Section 356t and the coverage required |
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| under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
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| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
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| 356z.13, and 356z.14, and 356z.15 356z.14 , and 356z.19 of
the |
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| Illinois Insurance Code. The requirement that health benefits |
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| be covered
as provided in this Section is an
exclusive power |
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| and function of the State and is a denial and limitation under
|
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| Article VII, Section 6, subsection (h) of the Illinois |
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HB5766 Engrossed |
- 3 - |
LRB096 19907 RPM 35370 b |
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| Constitution. A home
rule county to which this Section applies |
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| must comply with every provision of
this Section.
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
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| provisions of the Illinois Administrative Procedure Act and all |
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| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
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| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
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| 96-328, eff. 8-11-09; revised 10-22-09.) |
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| Section 15. The Illinois Municipal Code is amended by |
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| changing Section 10-4-2.3 as follows: |
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| (65 ILCS 5/10-4-2.3)
|
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| Sec. 10-4-2.3. Required health benefits. If a |
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| municipality, including a
home rule municipality, is a |
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| self-insurer for purposes of providing health
insurance |
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| coverage for its employees, the coverage shall include coverage |
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| for
the post-mastectomy care benefits required to be covered by |
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| a policy of
accident and health insurance under Section 356t |
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| and the coverage required
under Sections 356g, 356g.5, |
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HB5766 Engrossed |
- 4 - |
LRB096 19907 RPM 35370 b |
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| 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
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| 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15 |
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| 356z.14 , and 356z.19 of the Illinois
Insurance
Code. The |
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| requirement that health
benefits be covered as provided in this |
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| is an exclusive power and function of
the State and is a denial |
6 |
| and limitation under Article VII, Section 6,
subsection (h) of |
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| the Illinois Constitution. A home rule municipality to which
|
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| this Section applies must comply with every provision of this |
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| Section.
|
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| Rulemaking authority to implement Public Act 95-1045 this |
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| amendatory Act of the 95th General Assembly , if any, is |
12 |
| conditioned on the rules being adopted in accordance with all |
13 |
| provisions of the Illinois Administrative Procedure Act and all |
14 |
| rules and procedures of the Joint Committee on Administrative |
15 |
| Rules; any purported rule not so adopted, for whatever reason, |
16 |
| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
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| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
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| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
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| 96-328, eff. 8-11-09; revised 10-23-09.) |
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| Section 20. The School Code is amended by changing Section |
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| 10-22.3f as follows: |
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| (105 ILCS 5/10-22.3f)
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HB5766 Engrossed |
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LRB096 19907 RPM 35370 b |
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| Sec. 10-22.3f. Required health benefits. Insurance |
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| protection and
benefits
for employees shall provide the |
3 |
| post-mastectomy care benefits required to be
covered by a |
4 |
| policy of accident and health insurance under Section 356t and |
5 |
| the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
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| 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
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| 356z.13, and 356z.14, and 356z.15 356z.14 , and 356z.19 of
the
|
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| Illinois Insurance Code.
|
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| Rulemaking authority to implement Public Act 95-1045 this |
10 |
| amendatory Act of the 95th General Assembly , if any, is |
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| conditioned on the rules being adopted in accordance with all |
12 |
| provisions of the Illinois Administrative Procedure Act and all |
13 |
| rules and procedures of the Joint Committee on Administrative |
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| Rules; any purported rule not so adopted, for whatever reason, |
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| is unauthorized. |
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
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| 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
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| 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised |
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| 10-23-09.) |
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| Section 25. The Illinois Insurance Code is amended by |
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| adding Section 356z.19 as follows: |
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| (215 ILCS 5/356z.19 new) |
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| Sec. 356z.19. Tobacco use cessation programs. |
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HB5766 Engrossed |
- 6 - |
LRB096 19907 RPM 35370 b |
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| (a) This Section may be referred to as the Tobacco |
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| Dependence Coverage Law. |
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| (b) Tobacco use is the number one cause of preventable |
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| disease and death in Illinois, costing $4.1 billion annually in |
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| direct health care costs and an additional $4.35 billion in |
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| lost productivity. In Illinois, the smoking rates are highest |
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| among African Americans (25.8%). Smoking rates among lesbian, |
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| gay, and bisexual adults range from 25% to 44%. The U.S. Public |
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| Health Service Clinical Practice Guideline 2008 Update found |
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| that tobacco dependence treatments are both clinically |
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| effective and highly cost effective. A study in the Journal of |
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| Preventive Medicine concluded that comprehensive smoking |
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| cessation treatment is one of the 3 most important and cost |
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| effective preventive services that can be provided in medical |
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| practice. Greater efforts are needed to achieve more of this |
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| potential value by increasing current low
levels of |
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| performance. |
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| (c) In this Section, "tobacco use cessation program" means |
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| a program recommended by a physician that follows |
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| evidence-based treatment, such as is outlined in the United |
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| States Public Health Service guidelines for tobacco use |
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| cessation. "Tobacco use cessation program" includes education |
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| and medical treatment components designed to assist a person in |
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| ceasing the use of tobacco products. "Tobacco use cessation |
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| program" includes education and counseling by physicians or |
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| associated medical personnel and all FDA approved medications |
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HB5766 Engrossed |
- 7 - |
LRB096 19907 RPM 35370 b |
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| for the treatment of tobacco dependence irrespective of whether |
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| they are available only over the counter, only by prescription, |
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| or both over the counter and by prescription. |
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| (d) A group or individual policy of accident and health |
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| insurance or managed care plan amended, delivered, issued, or |
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| renewed after the effective date of this amendatory Act of the |
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| 96th General Assembly to a resident of this State must provide |
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| coverage or reimbursement of up to $500 annually for a tobacco |
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| use cessation program for a person enrolled in the plan who is |
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| 18 years of age or older. |
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| (e) Written notice of the availability of coverage under |
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| this Section shall be delivered to the insured upon enrollment |
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| and annually thereafter. An insurer may not deny to an insured |
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| eligibility or continued eligibility to enroll or to renew |
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| coverage under the terms of the plan solely for the purpose of |
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| avoiding the requirements of this Section. An insurer may not |
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| penalize or reduce or limit the reimbursement of an attending |
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| provider or provide incentives, monetary or otherwise, to an |
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| attending provider to induce the provider to provide care to an |
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| insured in a manner inconsistent with this Section.
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| Section 30. The Health Maintenance Organization Act is |
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| amended by changing Section 5-3 as follows:
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| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| (Text of Section before amendment by P.A. 96-833 ) |
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HB5766 Engrossed |
- 8 - |
LRB096 19907 RPM 35370 b |
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|
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| Sec. 5-3. Insurance Code provisions.
|
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| (a) Health Maintenance Organizations
shall be subject to |
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| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
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| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
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| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
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| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
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| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , |
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| 356z.17 356z.15 , 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, |
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| 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, |
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| 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection |
11 |
| (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, |
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| XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
|
13 |
| (b) For purposes of the Illinois Insurance Code, except for |
14 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
15 |
| Maintenance Organizations in
the following categories are |
16 |
| deemed to be "domestic companies":
|
17 |
| (1) a corporation authorized under the
Dental Service |
18 |
| Plan Act or the Voluntary Health Services Plans Act;
|
19 |
| (2) a corporation organized under the laws of this |
20 |
| State; or
|
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| (3) a corporation organized under the laws of another |
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| state, 30% or more
of the enrollees of which are residents |
23 |
| of this State, except a
corporation subject to |
24 |
| substantially the same requirements in its state of
|
25 |
| organization as is a "domestic company" under Article VIII |
26 |
| 1/2 of the
Illinois Insurance Code.
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HB5766 Engrossed |
- 9 - |
LRB096 19907 RPM 35370 b |
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|
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| (c) In considering the merger, consolidation, or other |
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| acquisition of
control of a Health Maintenance Organization |
3 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
4 |
| (1) the Director shall give primary consideration to |
5 |
| the continuation of
benefits to enrollees and the financial |
6 |
| conditions of the acquired Health
Maintenance Organization |
7 |
| after the merger, consolidation, or other
acquisition of |
8 |
| control takes effect;
|
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| (2)(i) the criteria specified in subsection (1)(b) of |
10 |
| Section 131.8 of
the Illinois Insurance Code shall not |
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| apply and (ii) the Director, in making
his determination |
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| with respect to the merger, consolidation, or other
|
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| acquisition of control, need not take into account the |
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| effect on
competition of the merger, consolidation, or |
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| other acquisition of control;
|
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| (3) the Director shall have the power to require the |
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| following
information:
|
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| (A) certification by an independent actuary of the |
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| adequacy
of the reserves of the Health Maintenance |
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| Organization sought to be acquired;
|
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| (B) pro forma financial statements reflecting the |
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| combined balance
sheets of the acquiring company and |
23 |
| the Health Maintenance Organization sought
to be |
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| acquired as of the end of the preceding year and as of |
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| a date 90 days
prior to the acquisition, as well as pro |
26 |
| forma financial statements
reflecting projected |
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HB5766 Engrossed |
- 10 - |
LRB096 19907 RPM 35370 b |
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|
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| combined operation for a period of 2 years;
|
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| (C) a pro forma business plan detailing an |
3 |
| acquiring party's plans with
respect to the operation |
4 |
| of the Health Maintenance Organization sought to
be |
5 |
| acquired for a period of not less than 3 years; and
|
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| (D) such other information as the Director shall |
7 |
| require.
|
8 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
9 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
10 |
| any health maintenance
organization of greater than 10% of its
|
11 |
| enrollee population (including without limitation the health |
12 |
| maintenance
organization's right, title, and interest in and to |
13 |
| its health care
certificates).
|
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| (e) In considering any management contract or service |
15 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
16 |
| Code, the Director (i) shall, in
addition to the criteria |
17 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
18 |
| into account the effect of the management contract or
service |
19 |
| agreement on the continuation of benefits to enrollees and the
|
20 |
| financial condition of the health maintenance organization to |
21 |
| be managed or
serviced, and (ii) need not take into account the |
22 |
| effect of the management
contract or service agreement on |
23 |
| competition.
|
24 |
| (f) Except for small employer groups as defined in the |
25 |
| Small Employer
Rating, Renewability and Portability Health |
26 |
| Insurance Act and except for
medicare supplement policies as |
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HB5766 Engrossed |
- 11 - |
LRB096 19907 RPM 35370 b |
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|
1 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
2 |
| Maintenance Organization may by contract agree with a
group or |
3 |
| other enrollment unit to effect refunds or charge additional |
4 |
| premiums
under the following terms and conditions:
|
5 |
| (i) the amount of, and other terms and conditions with |
6 |
| respect to, the
refund or additional premium are set forth |
7 |
| in the group or enrollment unit
contract agreed in advance |
8 |
| of the period for which a refund is to be paid or
|
9 |
| additional premium is to be charged (which period shall not |
10 |
| be less than one
year); and
|
11 |
| (ii) the amount of the refund or additional premium |
12 |
| shall not exceed 20%
of the Health Maintenance |
13 |
| Organization's profitable or unprofitable experience
with |
14 |
| respect to the group or other enrollment unit for the |
15 |
| period (and, for
purposes of a refund or additional |
16 |
| premium, the profitable or unprofitable
experience shall |
17 |
| be calculated taking into account a pro rata share of the
|
18 |
| Health Maintenance Organization's administrative and |
19 |
| marketing expenses, but
shall not include any refund to be |
20 |
| made or additional premium to be paid
pursuant to this |
21 |
| subsection (f)). The Health Maintenance Organization and |
22 |
| the
group or enrollment unit may agree that the profitable |
23 |
| or unprofitable
experience may be calculated taking into |
24 |
| account the refund period and the
immediately preceding 2 |
25 |
| plan years.
|
26 |
| The Health Maintenance Organization shall include a |
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HB5766 Engrossed |
- 12 - |
LRB096 19907 RPM 35370 b |
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|
1 |
| statement in the
evidence of coverage issued to each enrollee |
2 |
| describing the possibility of a
refund or additional premium, |
3 |
| and upon request of any group or enrollment unit,
provide to |
4 |
| the group or enrollment unit a description of the method used |
5 |
| to
calculate (1) the Health Maintenance Organization's |
6 |
| profitable experience with
respect to the group or enrollment |
7 |
| unit and the resulting refund to the group
or enrollment unit |
8 |
| or (2) the Health Maintenance Organization's unprofitable
|
9 |
| experience with respect to the group or enrollment unit and the |
10 |
| resulting
additional premium to be paid by the group or |
11 |
| enrollment unit.
|
12 |
| In no event shall the Illinois Health Maintenance |
13 |
| Organization
Guaranty Association be liable to pay any |
14 |
| contractual obligation of an
insolvent organization to pay any |
15 |
| refund authorized under this Section.
|
16 |
| (g) Rulemaking authority to implement Public Act 95-1045 |
17 |
| this amendatory Act of the 95th General Assembly , if any, is |
18 |
| conditioned on the rules being adopted in accordance with all |
19 |
| provisions of the Illinois Administrative Procedure Act and all |
20 |
| rules and procedures of the Joint Committee on Administrative |
21 |
| Rules; any purported rule not so adopted, for whatever reason, |
22 |
| is unauthorized. |
23 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
24 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
25 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
26 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised |
|
|
|
HB5766 Engrossed |
- 13 - |
LRB096 19907 RPM 35370 b |
|
|
1 |
| 10-23-09.) |
2 |
| (Text of Section after amendment by P.A. 96-833 ) |
3 |
| Sec. 5-3. Insurance Code provisions.
|
4 |
| (a) Health Maintenance Organizations
shall be subject to |
5 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
6 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
7 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
8 |
| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
9 |
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, |
10 |
| 356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, |
11 |
| 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, |
12 |
| 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of |
13 |
| Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, |
14 |
| XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
|
15 |
| (b) For purposes of the Illinois Insurance Code, except for |
16 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
17 |
| Maintenance Organizations in
the following categories are |
18 |
| deemed to be "domestic companies":
|
19 |
| (1) a corporation authorized under the
Dental Service |
20 |
| Plan Act or the Voluntary Health Services Plans Act;
|
21 |
| (2) a corporation organized under the laws of this |
22 |
| State; or
|
23 |
| (3) a corporation organized under the laws of another |
24 |
| state, 30% or more
of the enrollees of which are residents |
25 |
| of this State, except a
corporation subject to |
|
|
|
HB5766 Engrossed |
- 14 - |
LRB096 19907 RPM 35370 b |
|
|
1 |
| substantially the same requirements in its state of
|
2 |
| organization as is a "domestic company" under Article VIII |
3 |
| 1/2 of the
Illinois Insurance Code.
|
4 |
| (c) In considering the merger, consolidation, or other |
5 |
| acquisition of
control of a Health Maintenance Organization |
6 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
7 |
| (1) the Director shall give primary consideration to |
8 |
| the continuation of
benefits to enrollees and the financial |
9 |
| conditions of the acquired Health
Maintenance Organization |
10 |
| after the merger, consolidation, or other
acquisition of |
11 |
| control takes effect;
|
12 |
| (2)(i) the criteria specified in subsection (1)(b) of |
13 |
| Section 131.8 of
the Illinois Insurance Code shall not |
14 |
| apply and (ii) the Director, in making
his determination |
15 |
| with respect to the merger, consolidation, or other
|
16 |
| acquisition of control, need not take into account the |
17 |
| effect on
competition of the merger, consolidation, or |
18 |
| other acquisition of control;
|
19 |
| (3) the Director shall have the power to require the |
20 |
| following
information:
|
21 |
| (A) certification by an independent actuary of the |
22 |
| adequacy
of the reserves of the Health Maintenance |
23 |
| Organization sought to be acquired;
|
24 |
| (B) pro forma financial statements reflecting the |
25 |
| combined balance
sheets of the acquiring company and |
26 |
| the Health Maintenance Organization sought
to be |
|
|
|
HB5766 Engrossed |
- 15 - |
LRB096 19907 RPM 35370 b |
|
|
1 |
| acquired as of the end of the preceding year and as of |
2 |
| a date 90 days
prior to the acquisition, as well as pro |
3 |
| forma financial statements
reflecting projected |
4 |
| combined operation for a period of 2 years;
|
5 |
| (C) a pro forma business plan detailing an |
6 |
| acquiring party's plans with
respect to the operation |
7 |
| of the Health Maintenance Organization sought to
be |
8 |
| acquired for a period of not less than 3 years; and
|
9 |
| (D) such other information as the Director shall |
10 |
| require.
|
11 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
12 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
13 |
| any health maintenance
organization of greater than 10% of its
|
14 |
| enrollee population (including without limitation the health |
15 |
| maintenance
organization's right, title, and interest in and to |
16 |
| its health care
certificates).
|
17 |
| (e) In considering any management contract or service |
18 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
19 |
| Code, the Director (i) shall, in
addition to the criteria |
20 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
21 |
| into account the effect of the management contract or
service |
22 |
| agreement on the continuation of benefits to enrollees and the
|
23 |
| financial condition of the health maintenance organization to |
24 |
| be managed or
serviced, and (ii) need not take into account the |
25 |
| effect of the management
contract or service agreement on |
26 |
| competition.
|
|
|
|
HB5766 Engrossed |
- 16 - |
LRB096 19907 RPM 35370 b |
|
|
1 |
| (f) Except for small employer groups as defined in the |
2 |
| Small Employer
Rating, Renewability and Portability Health |
3 |
| Insurance Act and except for
medicare supplement policies as |
4 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
5 |
| Maintenance Organization may by contract agree with a
group or |
6 |
| other enrollment unit to effect refunds or charge additional |
7 |
| premiums
under the following terms and conditions:
|
8 |
| (i) the amount of, and other terms and conditions with |
9 |
| respect to, the
refund or additional premium are set forth |
10 |
| in the group or enrollment unit
contract agreed in advance |
11 |
| of the period for which a refund is to be paid or
|
12 |
| additional premium is to be charged (which period shall not |
13 |
| be less than one
year); and
|
14 |
| (ii) the amount of the refund or additional premium |
15 |
| shall not exceed 20%
of the Health Maintenance |
16 |
| Organization's profitable or unprofitable experience
with |
17 |
| respect to the group or other enrollment unit for the |
18 |
| period (and, for
purposes of a refund or additional |
19 |
| premium, the profitable or unprofitable
experience shall |
20 |
| be calculated taking into account a pro rata share of the
|
21 |
| Health Maintenance Organization's administrative and |
22 |
| marketing expenses, but
shall not include any refund to be |
23 |
| made or additional premium to be paid
pursuant to this |
24 |
| subsection (f)). The Health Maintenance Organization and |
25 |
| the
group or enrollment unit may agree that the profitable |
26 |
| or unprofitable
experience may be calculated taking into |
|
|
|
HB5766 Engrossed |
- 17 - |
LRB096 19907 RPM 35370 b |
|
|
1 |
| account the refund period and the
immediately preceding 2 |
2 |
| plan years.
|
3 |
| The Health Maintenance Organization shall include a |
4 |
| statement in the
evidence of coverage issued to each enrollee |
5 |
| describing the possibility of a
refund or additional premium, |
6 |
| and upon request of any group or enrollment unit,
provide to |
7 |
| the group or enrollment unit a description of the method used |
8 |
| to
calculate (1) the Health Maintenance Organization's |
9 |
| profitable experience with
respect to the group or enrollment |
10 |
| unit and the resulting refund to the group
or enrollment unit |
11 |
| or (2) the Health Maintenance Organization's unprofitable
|
12 |
| experience with respect to the group or enrollment unit and the |
13 |
| resulting
additional premium to be paid by the group or |
14 |
| enrollment unit.
|
15 |
| In no event shall the Illinois Health Maintenance |
16 |
| Organization
Guaranty Association be liable to pay any |
17 |
| contractual obligation of an
insolvent organization to pay any |
18 |
| refund authorized under this Section.
|
19 |
| (g) Rulemaking authority to implement Public Act 95-1045, |
20 |
| if any, is conditioned on the rules being adopted in accordance |
21 |
| with all provisions of the Illinois Administrative Procedure |
22 |
| Act and all rules and procedures of the Joint Committee on |
23 |
| Administrative Rules; any purported rule not so adopted, for |
24 |
| whatever reason, is unauthorized. |
25 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
26 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
|
|
|
HB5766 Engrossed |
- 18 - |
LRB096 19907 RPM 35370 b |
|
|
1 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
2 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. |
3 |
| 6-1-10.) |
4 |
| Section 35. The Limited Health Service Organization Act is |
5 |
| amended by changing Section 4003 as follows:
|
6 |
| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
|
7 |
| Sec. 4003. Illinois Insurance Code provisions. Limited |
8 |
| health service
organizations shall be subject to the provisions |
9 |
| of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, |
10 |
| 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, |
11 |
| 155.04, 155.37, 355.2, 356v, 356z.10, 356z.19, 368a, 401, |
12 |
| 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and |
13 |
| Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and |
14 |
| XXVI of the Illinois Insurance Code. For purposes of the
|
15 |
| Illinois Insurance Code, except for Sections 444 and 444.1 and |
16 |
| Articles XIII
and XIII 1/2, limited health service |
17 |
| organizations in the following categories
are deemed to be |
18 |
| domestic companies:
|
19 |
| (1) a corporation under the laws of this State; or
|
20 |
| (2) a corporation organized under the laws of another |
21 |
| state, 30% of 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 |
|
|
|
HB5766 Engrossed |
- 19 - |
LRB096 19907 RPM 35370 b |
|
|
1 |
| 1/2 of the Illinois Insurance Code.
|
2 |
| (Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
|
3 |
| Section 40. The Voluntary Health Services Plans Act is |
4 |
| amended by changing Section 10 as follows:
|
5 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
6 |
| (Text of Section before amendment by P.A. 96-833 ) |
7 |
| Sec. 10. Application of Insurance Code provisions. Health |
8 |
| services
plan corporations and all persons interested therein |
9 |
| or dealing therewith
shall be subject to the provisions of |
10 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
11 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
12 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
13 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
14 |
| 356z.14, 356z.15
356z.14 , 356z.19, 364.01, 367.2, 368a, 401, |
15 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
16 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
17 |
| Rulemaking authority to implement Public Act 95-1045
this |
18 |
| amendatory Act of the 95th General Assembly , if any, is |
19 |
| conditioned on the rules being adopted in accordance with all |
20 |
| provisions of the Illinois Administrative Procedure Act and all |
21 |
| rules and procedures of the Joint Committee on Administrative |
22 |
| Rules; any purported rule not so adopted, for whatever reason, |
23 |
| is unauthorized. |
24 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
|
|
|
HB5766 Engrossed |
- 20 - |
LRB096 19907 RPM 35370 b |
|
|
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; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
4 |
| 96-328, eff. 8-11-09; revised 9-25-09.) |
5 |
| (Text of Section after amendment by P.A. 96-833 ) |
6 |
| Sec. 10. Application of Insurance Code provisions. Health |
7 |
| services
plan corporations and all persons interested therein |
8 |
| or dealing therewith
shall be subject to the provisions of |
9 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
10 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
11 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, |
12 |
| 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, |
13 |
| 356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401, |
14 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
15 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
16 |
| Rulemaking authority to implement Public Act 95-1045, if |
17 |
| any, is conditioned on the rules being adopted in accordance |
18 |
| with all provisions of the Illinois Administrative Procedure |
19 |
| Act and all rules and procedures of the Joint Committee on |
20 |
| Administrative Rules; any purported rule not so adopted, for |
21 |
| whatever reason, is unauthorized. |
22 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
23 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
24 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
25 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |