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1 | AN ACT concerning insurance, which may be referred to as | |||||||||||||||||||||||||
2 | the Women's Health Insurance Justice Law.
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3 | Be it enacted by the People of the State of Illinois,
| |||||||||||||||||||||||||
4 | represented in the General Assembly:
| |||||||||||||||||||||||||
5 | Section 5. The Illinois Insurance Code is amended by adding | |||||||||||||||||||||||||
6 | Sections 356z.19 and 364a as follows: | |||||||||||||||||||||||||
7 | (215 ILCS 5/356z.19 new) | |||||||||||||||||||||||||
8 | Sec. 356z.19. Maternity coverage. | |||||||||||||||||||||||||
9 | (a) As used in this Section: | |||||||||||||||||||||||||
10 | "Maternity care" shall include diagnoses of pregnancy, | |||||||||||||||||||||||||
11 | prenatal care, delivery, care for complications of pregnancy, | |||||||||||||||||||||||||
12 | and other maternity services including physician services, | |||||||||||||||||||||||||
13 | hospital services, operating or other special procedure rooms, | |||||||||||||||||||||||||
14 | radiology and laboratory services, appropriate medications, | |||||||||||||||||||||||||
15 | and anesthesia. | |||||||||||||||||||||||||
16 | "Financial requirement" means deductibles, copayments, | |||||||||||||||||||||||||
17 | coinsurance, out-of-pocket expenses, aggregate lifetime | |||||||||||||||||||||||||
18 | limits, and annual limits. | |||||||||||||||||||||||||
19 | "Treatment limitation" means limits on the frequency of | |||||||||||||||||||||||||
20 | treatment, number of visits, days of coverage, or other similar | |||||||||||||||||||||||||
21 | limits on the scope or duration of treatment. | |||||||||||||||||||||||||
22 | (b) A group or individual policy of accident and health | |||||||||||||||||||||||||
23 | insurance that is amended, delivered, issued, or renewed after |
| |||||||
| |||||||
1 | the effective date of this amendatory Act of the 96th General | ||||||
2 | Assembly shall provide coverage for maternity care. | ||||||
3 | (c) An insurer providing coverage under this Section shall | ||||||
4 | ensure that: | ||||||
5 | (1) the financial requirements applicable to such | ||||||
6 | maternity benefits are no more restrictive than the | ||||||
7 | predominant financial requirements applied to | ||||||
8 | substantially all hospital and medical benefits covered by | ||||||
9 | the policy, and that there are no separate cost-sharing | ||||||
10 | requirements that are applicable only with respect to | ||||||
11 | maternity benefits; and | ||||||
12 | (2) the treatment limitations applicable to such | ||||||
13 | maternity benefits are no more restrictive than the | ||||||
14 | predominant treatment limitations applied to substantially | ||||||
15 | all hospital and medical benefits covered by the policy and | ||||||
16 | that there are no separate treatment limitations that are | ||||||
17 | applicable only with respect to maternity benefits. | ||||||
18 | (d) Notwithstanding any other provision of law, an insurer | ||||||
19 | shall not impose any preexisting condition exclusion relating | ||||||
20 | to pregnancy as a preexisting condition. | ||||||
21 | (e) An insurer shall not refuse to insure, refuse to | ||||||
22 | continue to insure, limit the amount or extent or kind of | ||||||
23 | coverage available to an individual, or charge an individual a | ||||||
24 | different rate for the same coverage solely on the basis that | ||||||
25 | the individual is pregnant or had a previous cesarean delivery. | ||||||
26 | (f) This Section shall not be construed as limiting |
| |||||||
| |||||||
1 | benefits that are otherwise available to an individual under a | ||||||
2 | policy of accident and health insurance. | ||||||
3 | (215 ILCS 5/364a new) | ||||||
4 | Sec. 364a. Gender rating prohibited. No company, in any | ||||||
5 | policy of accident or health insurance issued in this State, | ||||||
6 | may determine the premium rate or any other underwriting | ||||||
7 | decision, including initial issuance, through a method that is | ||||||
8 | in any way based upon the gender of any person covered or to be | ||||||
9 | covered under the policy. | ||||||
10 | Section 10. The Health Maintenance Organization Act is | ||||||
11 | amended by changing Section 5-3 and by adding Section 4-6.1a as | ||||||
12 | follows: | ||||||
13 | (215 ILCS 125/4-6.1a new) | ||||||
14 | Sec. 4-6.1a. Maternity care and coverage for pregnant | ||||||
15 | women. | ||||||
16 | (a) As used in this Section: | ||||||
17 | "Maternity care" shall include diagnoses of pregnancy, | ||||||
18 | prenatal care, delivery, care for complications of pregnancy, | ||||||
19 | and other maternity services including physician services, | ||||||
20 | hospital services, operating or other special procedure rooms, | ||||||
21 | radiology and laboratory services, appropriate medications, | ||||||
22 | and anesthesia. | ||||||
23 | (b) Every contract or evidence of coverage issued by a |
| |||||||
| |||||||
1 | health maintenance organization after the effective date of | ||||||
2 | this amendatory Act of the 96th General Assembly for persons | ||||||
3 | who are residents of this State shall provide coverage for | ||||||
4 | maternity care. | ||||||
5 | (c) No health maintenance organization shall refuse to | ||||||
6 | insure, refuse to continue to insure, limit the amount or | ||||||
7 | extent or kind of coverage available to an individual, or | ||||||
8 | charge an individual a different rate for the same coverage | ||||||
9 | solely on the basis that the individual is pregnant or had a | ||||||
10 | previous cesarean delivery.
| ||||||
11 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
12 | (Text of Section before amendment by P.A. 96-833 ) | ||||||
13 | Sec. 5-3. Insurance Code provisions.
| ||||||
14 | (a) Health Maintenance Organizations
shall be subject to | ||||||
15 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
16 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
17 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
18 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
19 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , | ||||||
20 | 356z.17 356z.15 , 364a, 364.01, 367.2, 367.2-5, 367i, 368a, | ||||||
21 | 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, | ||||||
22 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||||||
23 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
24 | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
25 | (b) For purposes of the Illinois Insurance Code, except for |
| |||||||
| |||||||
1 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
2 | Maintenance Organizations in
the following categories are | ||||||
3 | deemed to be "domestic companies":
| ||||||
4 | (1) a corporation authorized under the
Dental Service | ||||||
5 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
6 | (2) a corporation organized under the laws of this | ||||||
7 | State; or
| ||||||
8 | (3) a corporation organized under the laws of another | ||||||
9 | state, 30% or more
of the enrollees of which are residents | ||||||
10 | of this State, except a
corporation subject to | ||||||
11 | substantially the same requirements in its state of
| ||||||
12 | organization as is a "domestic company" under Article VIII | ||||||
13 | 1/2 of the
Illinois Insurance Code.
| ||||||
14 | (c) In considering the merger, consolidation, or other | ||||||
15 | acquisition of
control of a Health Maintenance Organization | ||||||
16 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
17 | (1) the Director shall give primary consideration to | ||||||
18 | the continuation of
benefits to enrollees and the financial | ||||||
19 | conditions of the acquired Health
Maintenance Organization | ||||||
20 | after the merger, consolidation, or other
acquisition of | ||||||
21 | control takes effect;
| ||||||
22 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
23 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
24 | apply and (ii) the Director, in making
his determination | ||||||
25 | with respect to the merger, consolidation, or other
| ||||||
26 | acquisition of control, need not take into account the |
| |||||||
| |||||||
1 | effect on
competition of the merger, consolidation, or | ||||||
2 | other acquisition of control;
| ||||||
3 | (3) the Director shall have the power to require the | ||||||
4 | following
information:
| ||||||
5 | (A) certification by an independent actuary of the | ||||||
6 | adequacy
of the reserves of the Health Maintenance | ||||||
7 | Organization sought to be acquired;
| ||||||
8 | (B) pro forma financial statements reflecting the | ||||||
9 | combined balance
sheets of the acquiring company and | ||||||
10 | the Health Maintenance Organization sought
to be | ||||||
11 | acquired as of the end of the preceding year and as of | ||||||
12 | a date 90 days
prior to the acquisition, as well as pro | ||||||
13 | forma financial statements
reflecting projected | ||||||
14 | combined operation for a period of 2 years;
| ||||||
15 | (C) a pro forma business plan detailing an | ||||||
16 | acquiring party's plans with
respect to the operation | ||||||
17 | of the Health Maintenance Organization sought to
be | ||||||
18 | acquired for a period of not less than 3 years; and
| ||||||
19 | (D) such other information as the Director shall | ||||||
20 | require.
| ||||||
21 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
22 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
23 | any health maintenance
organization of greater than 10% of its
| ||||||
24 | enrollee population (including without limitation the health | ||||||
25 | maintenance
organization's right, title, and interest in and to | ||||||
26 | its health care
certificates).
|
| |||||||
| |||||||
1 | (e) In considering any management contract or service | ||||||
2 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
3 | Code, the Director (i) shall, in
addition to the criteria | ||||||
4 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
5 | into account the effect of the management contract or
service | ||||||
6 | agreement on the continuation of benefits to enrollees and the
| ||||||
7 | financial condition of the health maintenance organization to | ||||||
8 | be managed or
serviced, and (ii) need not take into account the | ||||||
9 | effect of the management
contract or service agreement on | ||||||
10 | competition.
| ||||||
11 | (f) Except for small employer groups as defined in the | ||||||
12 | Small Employer
Rating, Renewability and Portability Health | ||||||
13 | Insurance Act and except for
medicare supplement policies as | ||||||
14 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
15 | Maintenance Organization may by contract agree with a
group or | ||||||
16 | other enrollment unit to effect refunds or charge additional | ||||||
17 | premiums
under the following terms and conditions:
| ||||||
18 | (i) the amount of, and other terms and conditions with | ||||||
19 | respect to, the
refund or additional premium are set forth | ||||||
20 | in the group or enrollment unit
contract agreed in advance | ||||||
21 | of the period for which a refund is to be paid or
| ||||||
22 | additional premium is to be charged (which period shall not | ||||||
23 | be less than one
year); and
| ||||||
24 | (ii) the amount of the refund or additional premium | ||||||
25 | shall not exceed 20%
of the Health Maintenance | ||||||
26 | Organization's profitable or unprofitable experience
with |
| |||||||
| |||||||
1 | respect to the group or other enrollment unit for the | ||||||
2 | period (and, for
purposes of a refund or additional | ||||||
3 | premium, the profitable or unprofitable
experience shall | ||||||
4 | be calculated taking into account a pro rata share of the
| ||||||
5 | Health Maintenance Organization's administrative and | ||||||
6 | marketing expenses, but
shall not include any refund to be | ||||||
7 | made or additional premium to be paid
pursuant to this | ||||||
8 | subsection (f)). The Health Maintenance Organization and | ||||||
9 | the
group or enrollment unit may agree that the profitable | ||||||
10 | or unprofitable
experience may be calculated taking into | ||||||
11 | account the refund period and the
immediately preceding 2 | ||||||
12 | plan years.
| ||||||
13 | The Health Maintenance Organization shall include a | ||||||
14 | statement in the
evidence of coverage issued to each enrollee | ||||||
15 | describing the possibility of a
refund or additional premium, | ||||||
16 | and upon request of any group or enrollment unit,
provide to | ||||||
17 | the group or enrollment unit a description of the method used | ||||||
18 | to
calculate (1) the Health Maintenance Organization's | ||||||
19 | profitable experience with
respect to the group or enrollment | ||||||
20 | unit and the resulting refund to the group
or enrollment unit | ||||||
21 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
22 | experience with respect to the group or enrollment unit and the | ||||||
23 | resulting
additional premium to be paid by the group or | ||||||
24 | enrollment unit.
| ||||||
25 | In no event shall the Illinois Health Maintenance | ||||||
26 | Organization
Guaranty Association be liable to pay any |
| |||||||
| |||||||
1 | contractual obligation of an
insolvent organization to pay any | ||||||
2 | refund authorized under this Section.
| ||||||
3 | (g) Rulemaking authority to implement Public Act 95-1045 | ||||||
4 | this amendatory Act of the 95th General Assembly , if any, is | ||||||
5 | conditioned on the rules being adopted in accordance with all | ||||||
6 | provisions of the Illinois Administrative Procedure Act and all | ||||||
7 | rules and procedures of the Joint Committee on Administrative | ||||||
8 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
9 | is unauthorized. | ||||||
10 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
11 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
12 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
13 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised | ||||||
14 | 10-23-09.) | ||||||
15 | (Text of Section after 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.17, | ||||||
23 | 356z.18, 364a, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
24 | 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | ||||||
25 | 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section |
| |||||||
| |||||||
1 | 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | ||||||
2 | XXV, and XXVI of the Illinois Insurance Code.
| ||||||
3 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
4 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
5 | Maintenance Organizations in
the following categories are | ||||||
6 | deemed to be "domestic companies":
| ||||||
7 | (1) a corporation authorized under the
Dental Service | ||||||
8 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
9 | (2) a corporation organized under the laws of this | ||||||
10 | State; or
| ||||||
11 | (3) a corporation organized under the laws of another | ||||||
12 | state, 30% or more
of the enrollees of which are residents | ||||||
13 | of this State, except a
corporation subject to | ||||||
14 | substantially the same requirements in its state of
| ||||||
15 | organization as is a "domestic company" under Article VIII | ||||||
16 | 1/2 of the
Illinois Insurance Code.
| ||||||
17 | (c) In considering the merger, consolidation, or other | ||||||
18 | acquisition of
control of a Health Maintenance Organization | ||||||
19 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
20 | (1) the Director shall give primary consideration to | ||||||
21 | the continuation of
benefits to enrollees and the financial | ||||||
22 | conditions of the acquired Health
Maintenance Organization | ||||||
23 | after the merger, consolidation, or other
acquisition of | ||||||
24 | control takes effect;
| ||||||
25 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
26 | Section 131.8 of
the Illinois Insurance Code shall not |
| |||||||
| |||||||
1 | apply and (ii) the Director, in making
his determination | ||||||
2 | with respect to the merger, consolidation, or other
| ||||||
3 | acquisition of control, need not take into account the | ||||||
4 | effect on
competition of the merger, consolidation, or | ||||||
5 | other acquisition of control;
| ||||||
6 | (3) the Director shall have the power to require the | ||||||
7 | following
information:
| ||||||
8 | (A) certification by an independent actuary of the | ||||||
9 | adequacy
of the reserves of the Health Maintenance | ||||||
10 | Organization sought to be acquired;
| ||||||
11 | (B) pro forma financial statements reflecting the | ||||||
12 | combined balance
sheets of the acquiring company and | ||||||
13 | the Health Maintenance Organization sought
to be | ||||||
14 | acquired as of the end of the preceding year and as of | ||||||
15 | a date 90 days
prior to the acquisition, as well as pro | ||||||
16 | forma financial statements
reflecting projected | ||||||
17 | combined operation for a period of 2 years;
| ||||||
18 | (C) a pro forma business plan detailing an | ||||||
19 | acquiring party's plans with
respect to the operation | ||||||
20 | of the Health Maintenance Organization sought to
be | ||||||
21 | acquired for a period of not less than 3 years; and
| ||||||
22 | (D) such other information as the Director shall | ||||||
23 | require.
| ||||||
24 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
25 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
26 | any health maintenance
organization of greater than 10% of its
|
| |||||||
| |||||||
1 | enrollee population (including without limitation the health | ||||||
2 | maintenance
organization's right, title, and interest in and to | ||||||
3 | its health care
certificates).
| ||||||
4 | (e) In considering any management contract or service | ||||||
5 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
6 | Code, the Director (i) shall, in
addition to the criteria | ||||||
7 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
8 | into account the effect of the management contract or
service | ||||||
9 | agreement on the continuation of benefits to enrollees and the
| ||||||
10 | financial condition of the health maintenance organization to | ||||||
11 | be managed or
serviced, and (ii) need not take into account the | ||||||
12 | effect of the management
contract or service agreement on | ||||||
13 | competition.
| ||||||
14 | (f) Except for small employer groups as defined in the | ||||||
15 | Small Employer
Rating, Renewability and Portability Health | ||||||
16 | Insurance Act and except for
medicare supplement policies as | ||||||
17 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
18 | Maintenance Organization may by contract agree with a
group or | ||||||
19 | other enrollment unit to effect refunds or charge additional | ||||||
20 | premiums
under the following terms and conditions:
| ||||||
21 | (i) the amount of, and other terms and conditions with | ||||||
22 | respect to, the
refund or additional premium are set forth | ||||||
23 | in the group or enrollment unit
contract agreed in advance | ||||||
24 | of the period for which a refund is to be paid or
| ||||||
25 | additional premium is to be charged (which period shall not | ||||||
26 | be less than one
year); and
|
| |||||||
| |||||||
1 | (ii) the amount of the refund or additional premium | ||||||
2 | shall not exceed 20%
of the Health Maintenance | ||||||
3 | Organization's profitable or unprofitable experience
with | ||||||
4 | respect to the group or other enrollment unit for the | ||||||
5 | period (and, for
purposes of a refund or additional | ||||||
6 | premium, the profitable or unprofitable
experience shall | ||||||
7 | be calculated taking into account a pro rata share of the
| ||||||
8 | Health Maintenance Organization's administrative and | ||||||
9 | marketing expenses, but
shall not include any refund to be | ||||||
10 | made or additional premium to be paid
pursuant to this | ||||||
11 | subsection (f)). The Health Maintenance Organization and | ||||||
12 | the
group or enrollment unit may agree that the profitable | ||||||
13 | or unprofitable
experience may be calculated taking into | ||||||
14 | account the refund period and the
immediately preceding 2 | ||||||
15 | plan years.
| ||||||
16 | The Health Maintenance Organization shall include a | ||||||
17 | statement in the
evidence of coverage issued to each enrollee | ||||||
18 | describing the possibility of a
refund or additional premium, | ||||||
19 | and upon request of any group or enrollment unit,
provide to | ||||||
20 | the group or enrollment unit a description of the method used | ||||||
21 | to
calculate (1) the Health Maintenance Organization's | ||||||
22 | profitable experience with
respect to the group or enrollment | ||||||
23 | unit and the resulting refund to the group
or enrollment unit | ||||||
24 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
25 | experience with respect to the group or enrollment unit and the | ||||||
26 | resulting
additional premium to be paid by the group or |
| |||||||
| |||||||
1 | enrollment unit.
| ||||||
2 | In no event shall the Illinois Health Maintenance | ||||||
3 | Organization
Guaranty Association be liable to pay any | ||||||
4 | contractual obligation of an
insolvent organization to pay any | ||||||
5 | refund authorized under this Section.
| ||||||
6 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
7 | if any, is conditioned on the rules being adopted in accordance | ||||||
8 | with all provisions of the Illinois Administrative Procedure | ||||||
9 | Act and all rules and procedures of the Joint Committee on | ||||||
10 | Administrative Rules; any purported rule not so adopted, for | ||||||
11 | whatever reason, is unauthorized. | ||||||
12 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
13 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
14 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
15 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | ||||||
16 | 6-1-10.)
| ||||||
17 | Section 95. No acceleration or delay. Where this Act makes | ||||||
18 | changes in a statute that is represented in this Act by text | ||||||
19 | that is not yet or no longer in effect (for example, a Section | ||||||
20 | represented by multiple versions), the use of that text does | ||||||
21 | not accelerate or delay the taking effect of (i) the changes | ||||||
22 | made by this Act or (ii) provisions derived from any other | ||||||
23 | Public Act. | ||||||
24 | Section 99. Effective date. This Act takes effect July 1, | ||||||
25 | 2010.
|