|
|
|
96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010 SB3188
Introduced 2/9/2010, by Sen. Mike Jacobs SYNOPSIS AS INTRODUCED: |
|
5 ILCS 375/6.11 |
|
55 ILCS 5/5-1069.3 |
|
65 ILCS 5/10-4-2.3 |
|
105 ILCS 5/10-22.3f |
|
215 ILCS 5/356z.3 |
|
215 ILCS 5/356z.3a new |
|
215 ILCS 125/5-3 |
from Ch. 111 1/2, par. 1411.2 |
215 ILCS 165/10 |
from Ch. 32, par. 604 |
|
Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Illinois Insurance Code, Health Maintenance Organization Act, and Voluntary Health Services Plans Act. Provides that when a beneficiary utilizes a participating network hospital or a participating network ambulatory surgery center and services at the network hospital or network ambulatory surgery center are provided by a nonparticipating facility-based physician or provider, the insurer shall ensure that the beneficiary shall incur no greater out-of-pocket liability than had the beneficiary received services from a participating physician or provider for covered services. Sets forth conditions under which an insurer may initiate binding arbitration regarding the reasonableness of the charges of the nonparticipating physician or provider. Provides that the Department of Insurance shall publish a list of approved arbitrators or entities that shall provide binding arbitration. Provides that the nonprevailing party shall pay the arbitrator's fees. Makes other changes. Contains a nonacceleration clause. Effective January 1, 2011.
|
| |
|
|
A BILL FOR
|
|
|
|
|
SB3188 |
|
LRB096 20286 RPM 35897 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 State Employees Group Insurance Act of 1971 |
5 |
| is amended by changing Section 6.11 as follows:
|
6 |
| (5 ILCS 375/6.11)
|
7 |
| Sec. 6.11. Required health benefits; Illinois Insurance |
8 |
| Code
requirements. The program of health
benefits shall provide |
9 |
| the post-mastectomy care benefits required to be covered
by a |
10 |
| policy of accident and health insurance under Section 356t of |
11 |
| the Illinois
Insurance Code. The program of health benefits |
12 |
| shall provide the coverage
required under Sections 356g, |
13 |
| 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
14 |
| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
15 |
| 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17 356z.15 |
16 |
| of the
Illinois Insurance Code and shall be subject to the |
17 |
| provisions set forth in Section 356z.3a of
the
Illinois |
18 |
| Insurance Code .
The program of health benefits must comply with |
19 |
| Section 155.37 of the
Illinois Insurance Code.
|
20 |
| Rulemaking authority to implement Public Act 95-1045 this |
21 |
| amendatory Act of the 95th General Assembly , if any, is |
22 |
| conditioned on the rules being adopted in accordance with all |
23 |
| provisions of the Illinois Administrative Procedure Act and all |
|
|
|
SB3188 |
- 2 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| rules and procedures of the Joint Committee on Administrative |
2 |
| Rules; any purported rule not so adopted, for whatever reason, |
3 |
| is unauthorized. |
4 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
5 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
6 |
| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, |
7 |
| eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
8 |
| 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
9 |
| revised 10-22-09.) |
10 |
| Section 10. The Counties Code is amended by changing |
11 |
| Section 5-1069.3 as follows: |
12 |
| (55 ILCS 5/5-1069.3)
|
13 |
| Sec. 5-1069.3. Required health benefits. If a county, |
14 |
| including a home
rule
county, is a self-insurer for purposes of |
15 |
| providing health insurance coverage
for its employees, the |
16 |
| coverage shall include coverage for the post-mastectomy
care |
17 |
| benefits required to be covered by a policy of accident and |
18 |
| health
insurance under Section 356t and the coverage required |
19 |
| under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
20 |
| 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and |
21 |
| 356z.13, and 356z.14, and 356z.15 356z.14 of
the Illinois |
22 |
| Insurance Code and shall be subject to the provisions set forth |
23 |
| in Section 356z.3a of
the
Illinois Insurance Code . The |
24 |
| requirement that health benefits be covered
as provided in this |
|
|
|
SB3188 |
- 3 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| Section is an
exclusive power and function of the State and is |
2 |
| a denial and limitation under
Article VII, Section 6, |
3 |
| subsection (h) of the Illinois Constitution. A home
rule county |
4 |
| to which this Section applies must comply with every provision |
5 |
| of
this Section.
|
6 |
| Rulemaking authority to implement Public Act 95-1045 this |
7 |
| amendatory Act of the 95th General Assembly , if any, is |
8 |
| conditioned on the rules being adopted in accordance with all |
9 |
| provisions of the Illinois Administrative Procedure Act and all |
10 |
| rules and procedures of the Joint Committee on Administrative |
11 |
| Rules; any purported rule not so adopted, for whatever reason, |
12 |
| is unauthorized. |
13 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
14 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
15 |
| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
16 |
| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
17 |
| 96-328, eff. 8-11-09; revised 10-22-09.) |
18 |
| Section 15. The Illinois Municipal Code is amended by |
19 |
| changing Section 10-4-2.3 as follows: |
20 |
| (65 ILCS 5/10-4-2.3)
|
21 |
| Sec. 10-4-2.3. Required health benefits. If a |
22 |
| municipality, including a
home rule municipality, is a |
23 |
| self-insurer for purposes of providing health
insurance |
24 |
| coverage for its employees, the coverage shall include coverage |
|
|
|
SB3188 |
- 4 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| for
the post-mastectomy care benefits required to be covered by |
2 |
| a policy of
accident and health insurance under Section 356t |
3 |
| and the coverage required
under Sections 356g, 356g.5, |
4 |
| 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
5 |
| 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15 356z.14 |
6 |
| of the Illinois
Insurance
Code and shall be subject to the |
7 |
| provisions set forth in Section 356z.3a of
the
Illinois |
8 |
| Insurance Code . The requirement that health
benefits be covered |
9 |
| as provided in this is an exclusive power and function of
the |
10 |
| State and is a denial and limitation under Article VII, Section |
11 |
| 6,
subsection (h) of the Illinois Constitution. A home rule |
12 |
| municipality to which
this Section applies must comply with |
13 |
| every provision of this Section.
|
14 |
| Rulemaking authority to implement Public Act 95-1045 this |
15 |
| amendatory Act of the 95th General Assembly , if any, is |
16 |
| conditioned on the rules being adopted in accordance with all |
17 |
| provisions of the Illinois Administrative Procedure Act and all |
18 |
| rules and procedures of the Joint Committee on Administrative |
19 |
| Rules; any purported rule not so adopted, for whatever reason, |
20 |
| is unauthorized. |
21 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
22 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. |
23 |
| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
24 |
| eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; |
25 |
| 96-328, eff. 8-11-09; revised 10-23-09.) |
|
|
|
SB3188 |
- 5 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| Section 20. The School Code is amended by changing Section |
2 |
| 10-22.3f as follows: |
3 |
| (105 ILCS 5/10-22.3f)
|
4 |
| Sec. 10-22.3f. Required health benefits. Insurance |
5 |
| protection and
benefits
for employees shall provide the |
6 |
| post-mastectomy care benefits required to be
covered by a |
7 |
| policy of accident and health insurance under Section 356t and |
8 |
| the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
9 |
| 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
10 |
| 356z.13, and 356z.14, and 356z.15 356z.14 of
the
Illinois |
11 |
| Insurance Code and shall be subject to the provisions set forth |
12 |
| in Section 356z.3a of
the
Illinois Insurance Code .
|
13 |
| Rulemaking authority to implement Public Act 95-1045 this |
14 |
| amendatory Act of the 95th General Assembly , if any, is |
15 |
| conditioned on the rules being adopted in accordance with all |
16 |
| provisions of the Illinois Administrative Procedure Act and all |
17 |
| rules and procedures of the Joint Committee on Administrative |
18 |
| Rules; any purported rule not so adopted, for whatever reason, |
19 |
| is unauthorized. |
20 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
21 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
22 |
| 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
23 |
| 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised |
24 |
| 10-23-09.) |
|
|
|
SB3188 |
- 6 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| Section 25. The Illinois Insurance Code is amended by |
2 |
| changing Section 356z.3 and by adding Section 356z.3a as |
3 |
| follows:
|
4 |
| (215 ILCS 5/356z.3)
|
5 |
| Sec. 356z.3. Disclosure of limited benefit. An insurer that
|
6 |
| issues,
delivers,
amends, or
renews an individual or group |
7 |
| policy of accident and health insurance in this
State after the
|
8 |
| effective date of this amendatory Act of the 92nd General |
9 |
| Assembly and
arranges, contracts
with, or administers |
10 |
| contracts with a provider whereby beneficiaries are
provided an |
11 |
| incentive to
use the services of such provider must include the |
12 |
| following disclosure on its
contracts and
evidences of |
13 |
| coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
|
14 |
| NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that |
15 |
| when you elect
to
utilize the services of a non-participating |
16 |
| provider for a covered service in non-emergency
situations, |
17 |
| benefit payments to such non-participating provider are not |
18 |
| based upon the amount
billed. The basis of your benefit payment |
19 |
| will be determined according to your policy's fee
schedule, |
20 |
| usual and customary charge (which is determined by comparing |
21 |
| charges for similar
services adjusted to the geographical area |
22 |
| where the services are performed), or other method as
defined |
23 |
| by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE
|
24 |
| AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS |
25 |
| REQUIRED
PORTION. Non-participating providers may bill members |
|
|
|
SB3188 |
- 7 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| for any amount up to the
billed
charge after the plan has paid |
2 |
| its portion of the bill , except for emergency services and as |
3 |
| provided in Section 356z.3a of this Code . Participating |
4 |
| providers
have agreed to accept
discounted payments for |
5 |
| services with no additional billing to the member other
than |
6 |
| co-insurance and deductible amounts. You may obtain further |
7 |
| information
about the
participating
status of professional |
8 |
| providers and information on out-of-pocket expenses by
calling |
9 |
| the toll
free telephone number on your identification card.".
|
10 |
| (Source: P.A. 95-331, eff. 8-21-07.)
|
11 |
| (215 ILCS 5/356z.3a new) |
12 |
| Sec. 356z.3a. Nonparticipating physicians and providers. |
13 |
| (a) When a beneficiary utilizes a participating network |
14 |
| hospital or a participating network ambulatory surgery center |
15 |
| and services at the network hospital or network ambulatory |
16 |
| surgery center are provided by a nonparticipating |
17 |
| facility-based physician or provider, the insurer shall ensure |
18 |
| that the beneficiary shall incur no greater out-of-pocket |
19 |
| liability than had the beneficiary received services from a |
20 |
| participating physician or provider for covered services. This |
21 |
| Section does not apply to a beneficiary who willfully chooses |
22 |
| to access a nonparticipating facility-based physician or |
23 |
| provider for health care services available through the |
24 |
| insurer's network of participating physicians and providers. |
25 |
| (b) An insurer may initiate binding arbitration with the |
|
|
|
SB3188 |
- 8 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| nonparticipating physician or provider regarding the |
2 |
| reasonableness of the charges of the nonparticipating |
3 |
| physician or provider submitted to the insurer by filing a |
4 |
| request with the Department of Insurance. In order for an |
5 |
| insurer to initiate binding arbitration, the physician's or |
6 |
| provider's charge must be greater than either (1) what the |
7 |
| insurer would have paid to a participating network physician or |
8 |
| provider in the same specialty and same geographical area where |
9 |
| the services were performed or (2) 125% of Medicare coverage |
10 |
| for the same services. |
11 |
| (c) The Department of Insurance shall publish a list of |
12 |
| approved arbitrators or entities that shall provide binding |
13 |
| arbitration. Binding arbitration shall provide for resolution |
14 |
| within 30 days after the insurer has filed the request with the |
15 |
| Department of Insurance. The nonprevailing party shall pay the |
16 |
| arbitrator's fees. |
17 |
| (d) The nonparticipating facility-based physician or |
18 |
| provider shall not bill the beneficiary except for applicable |
19 |
| deductible, copayment, or coinsurance amounts that would apply |
20 |
| if the beneficiary utilized a participating physician or |
21 |
| provider for covered services. If the physician or other |
22 |
| provider bills the member in violation of this Section, then |
23 |
| the Department of Insurance shall refer the matter to the |
24 |
| Office of the Attorney General for civil action and injunctive |
25 |
| relief against the physician or other provider. |
|
|
|
SB3188 |
- 9 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| Section 30. The Health Maintenance Organization Act is |
2 |
| amended by changing Section 5-3 as follows:
|
3 |
| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
|
4 |
| (Text of Section before amendment by P.A. 96-833 ) |
5 |
| Sec. 5-3. Insurance Code provisions.
|
6 |
| (a) Health Maintenance Organizations
shall be subject to |
7 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
8 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
9 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
10 |
| 356x, 356y,
356z.2, 356z.3a, 356z.4, 356z.5, 356z.6, 356z.8, |
11 |
| 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 |
12 |
| 356z.14 , 356z.17 356z.15 , 364.01, 367.2, 367.2-5, 367i, 368a, |
13 |
| 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, |
14 |
| 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection |
15 |
| (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, |
16 |
| XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
|
17 |
| (b) For purposes of the Illinois Insurance Code, except for |
18 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
19 |
| Maintenance Organizations in
the following categories are |
20 |
| deemed to be "domestic companies":
|
21 |
| (1) a corporation authorized under the
Dental Service |
22 |
| Plan Act or the Voluntary Health Services Plans Act;
|
23 |
| (2) a corporation organized under the laws of this |
24 |
| State; or
|
25 |
| (3) a corporation organized under the laws of another |
|
|
|
SB3188 |
- 10 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| state, 30% or more
of the enrollees of which are residents |
2 |
| of this State, except a
corporation subject to |
3 |
| substantially the same requirements in its state of
|
4 |
| organization as is a "domestic company" under Article VIII |
5 |
| 1/2 of the
Illinois Insurance Code.
|
6 |
| (c) In considering the merger, consolidation, or other |
7 |
| acquisition of
control of a Health Maintenance Organization |
8 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
9 |
| (1) the Director shall give primary consideration to |
10 |
| the continuation of
benefits to enrollees and the financial |
11 |
| conditions of the acquired Health
Maintenance Organization |
12 |
| after the merger, consolidation, or other
acquisition of |
13 |
| control takes effect;
|
14 |
| (2)(i) the criteria specified in subsection (1)(b) of |
15 |
| Section 131.8 of
the Illinois Insurance Code shall not |
16 |
| apply and (ii) the Director, in making
his determination |
17 |
| with respect to the merger, consolidation, or other
|
18 |
| acquisition of control, need not take into account the |
19 |
| effect on
competition of the merger, consolidation, or |
20 |
| other acquisition of control;
|
21 |
| (3) the Director shall have the power to require the |
22 |
| following
information:
|
23 |
| (A) certification by an independent actuary of the |
24 |
| adequacy
of the reserves of the Health Maintenance |
25 |
| Organization sought to be acquired;
|
26 |
| (B) pro forma financial statements reflecting the |
|
|
|
SB3188 |
- 11 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| combined balance
sheets of the acquiring company and |
2 |
| the Health Maintenance Organization sought
to be |
3 |
| acquired as of the end of the preceding year and as of |
4 |
| a date 90 days
prior to the acquisition, as well as pro |
5 |
| forma financial statements
reflecting projected |
6 |
| combined operation for a period of 2 years;
|
7 |
| (C) a pro forma business plan detailing an |
8 |
| acquiring party's plans with
respect to the operation |
9 |
| of the Health Maintenance Organization sought to
be |
10 |
| acquired for a period of not less than 3 years; and
|
11 |
| (D) such other information as the Director shall |
12 |
| require.
|
13 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
14 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
15 |
| any health maintenance
organization of greater than 10% of its
|
16 |
| enrollee population (including without limitation the health |
17 |
| maintenance
organization's right, title, and interest in and to |
18 |
| its health care
certificates).
|
19 |
| (e) In considering any management contract or service |
20 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
21 |
| Code, the Director (i) shall, in
addition to the criteria |
22 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
23 |
| into account the effect of the management contract or
service |
24 |
| agreement on the continuation of benefits to enrollees and the
|
25 |
| financial condition of the health maintenance organization to |
26 |
| be managed or
serviced, and (ii) need not take into account the |
|
|
|
SB3188 |
- 12 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| effect of the management
contract or service agreement on |
2 |
| competition.
|
3 |
| (f) Except for small employer groups as defined in the |
4 |
| Small Employer
Rating, Renewability and Portability Health |
5 |
| Insurance Act and except for
medicare supplement policies as |
6 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
7 |
| Maintenance Organization may by contract agree with a
group or |
8 |
| other enrollment unit to effect refunds or charge additional |
9 |
| premiums
under the following terms and conditions:
|
10 |
| (i) the amount of, and other terms and conditions with |
11 |
| respect to, the
refund or additional premium are set forth |
12 |
| in the group or enrollment unit
contract agreed in advance |
13 |
| of the period for which a refund is to be paid or
|
14 |
| additional premium is to be charged (which period shall not |
15 |
| be less than one
year); and
|
16 |
| (ii) the amount of the refund or additional premium |
17 |
| shall not exceed 20%
of the Health Maintenance |
18 |
| Organization's profitable or unprofitable experience
with |
19 |
| respect to the group or other enrollment unit for the |
20 |
| period (and, for
purposes of a refund or additional |
21 |
| premium, the profitable or unprofitable
experience shall |
22 |
| be calculated taking into account a pro rata share of the
|
23 |
| Health Maintenance Organization's administrative and |
24 |
| marketing expenses, but
shall not include any refund to be |
25 |
| made or additional premium to be paid
pursuant to this |
26 |
| subsection (f)). The Health Maintenance Organization and |
|
|
|
SB3188 |
- 13 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| the
group or enrollment unit may agree that the profitable |
2 |
| or unprofitable
experience may be calculated taking into |
3 |
| account the refund period and the
immediately preceding 2 |
4 |
| plan years.
|
5 |
| The Health Maintenance Organization shall include a |
6 |
| statement in the
evidence of coverage issued to each enrollee |
7 |
| describing the possibility of a
refund or additional premium, |
8 |
| and upon request of any group or enrollment unit,
provide to |
9 |
| the group or enrollment unit a description of the method used |
10 |
| to
calculate (1) the Health Maintenance Organization's |
11 |
| profitable experience with
respect to the group or enrollment |
12 |
| unit and the resulting refund to the group
or enrollment unit |
13 |
| or (2) the Health Maintenance Organization's unprofitable
|
14 |
| experience with respect to the group or enrollment unit and the |
15 |
| resulting
additional premium to be paid by the group or |
16 |
| enrollment unit.
|
17 |
| In no event shall the Illinois Health Maintenance |
18 |
| Organization
Guaranty Association be liable to pay any |
19 |
| contractual obligation of an
insolvent organization to pay any |
20 |
| refund authorized under this Section.
|
21 |
| (g) Rulemaking authority to implement Public Act 95-1045 |
22 |
| this amendatory Act of the 95th General Assembly , if any, is |
23 |
| conditioned on the rules being adopted in accordance with all |
24 |
| provisions of the Illinois Administrative Procedure Act and all |
25 |
| rules and procedures of the Joint Committee on Administrative |
26 |
| Rules; any purported rule not so adopted, for whatever reason, |
|
|
|
SB3188 |
- 14 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| is unauthorized. |
2 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
3 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
4 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
5 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised |
6 |
| 10-23-09.) |
7 |
| (Text of Section after amendment by P.A. 96-833 ) |
8 |
| Sec. 5-3. Insurance Code provisions.
|
9 |
| (a) Health Maintenance Organizations
shall be subject to |
10 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
11 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
12 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, |
13 |
| 356x, 356y,
356z.2, 356z.3a, 356z.4, 356z.5, 356z.6, 356z.8, |
14 |
| 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, |
15 |
| 356z.17, 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, |
16 |
| 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, |
17 |
| 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of |
18 |
| Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, |
19 |
| XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
|
20 |
| (b) For purposes of the Illinois Insurance Code, except for |
21 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
22 |
| Maintenance Organizations in
the following categories are |
23 |
| deemed to be "domestic companies":
|
24 |
| (1) a corporation authorized under the
Dental Service |
25 |
| Plan Act or the Voluntary Health Services Plans Act;
|
|
|
|
SB3188 |
- 15 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| (2) a corporation organized under the laws of this |
2 |
| State; or
|
3 |
| (3) a corporation organized under the laws of another |
4 |
| state, 30% or more
of the enrollees of which are residents |
5 |
| of this State, except a
corporation subject to |
6 |
| substantially the same requirements in its state of
|
7 |
| organization as is a "domestic company" under Article VIII |
8 |
| 1/2 of the
Illinois Insurance Code.
|
9 |
| (c) In considering the merger, consolidation, or other |
10 |
| acquisition of
control of a Health Maintenance Organization |
11 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
12 |
| (1) the Director shall give primary consideration to |
13 |
| the continuation of
benefits to enrollees and the financial |
14 |
| conditions of the acquired Health
Maintenance Organization |
15 |
| after the merger, consolidation, or other
acquisition of |
16 |
| control takes effect;
|
17 |
| (2)(i) the criteria specified in subsection (1)(b) of |
18 |
| Section 131.8 of
the Illinois Insurance Code shall not |
19 |
| apply and (ii) the Director, in making
his determination |
20 |
| with respect to the merger, consolidation, or other
|
21 |
| acquisition of control, need not take into account the |
22 |
| effect on
competition of the merger, consolidation, or |
23 |
| other acquisition of control;
|
24 |
| (3) the Director shall have the power to require the |
25 |
| following
information:
|
26 |
| (A) certification by an independent actuary of the |
|
|
|
SB3188 |
- 16 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| adequacy
of the reserves of the Health Maintenance |
2 |
| Organization sought to be acquired;
|
3 |
| (B) pro forma financial statements reflecting the |
4 |
| combined balance
sheets of the acquiring company and |
5 |
| the Health Maintenance Organization sought
to be |
6 |
| acquired as of the end of the preceding year and as of |
7 |
| a date 90 days
prior to the acquisition, as well as pro |
8 |
| forma financial statements
reflecting projected |
9 |
| combined operation for a period of 2 years;
|
10 |
| (C) a pro forma business plan detailing an |
11 |
| acquiring party's plans with
respect to the operation |
12 |
| of the Health Maintenance Organization sought to
be |
13 |
| acquired for a period of not less than 3 years; and
|
14 |
| (D) such other information as the Director shall |
15 |
| require.
|
16 |
| (d) The provisions of Article VIII 1/2 of the Illinois |
17 |
| Insurance Code
and this Section 5-3 shall apply to the sale by |
18 |
| any health maintenance
organization of greater than 10% of its
|
19 |
| enrollee population (including without limitation the health |
20 |
| maintenance
organization's right, title, and interest in and to |
21 |
| its health care
certificates).
|
22 |
| (e) In considering any management contract or service |
23 |
| agreement subject
to Section 141.1 of the Illinois Insurance |
24 |
| Code, the Director (i) shall, in
addition to the criteria |
25 |
| specified in Section 141.2 of the Illinois
Insurance Code, take |
26 |
| into account the effect of the management contract or
service |
|
|
|
SB3188 |
- 17 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| agreement on the continuation of benefits to enrollees and the
|
2 |
| financial condition of the health maintenance organization to |
3 |
| be managed or
serviced, and (ii) need not take into account the |
4 |
| effect of the management
contract or service agreement on |
5 |
| competition.
|
6 |
| (f) Except for small employer groups as defined in the |
7 |
| Small Employer
Rating, Renewability and Portability Health |
8 |
| Insurance Act and except for
medicare supplement policies as |
9 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
10 |
| Maintenance Organization may by contract agree with a
group or |
11 |
| other enrollment unit to effect refunds or charge additional |
12 |
| premiums
under the following terms and conditions:
|
13 |
| (i) the amount of, and other terms and conditions with |
14 |
| respect to, the
refund or additional premium are set forth |
15 |
| in the group or enrollment unit
contract agreed in advance |
16 |
| of the period for which a refund is to be paid or
|
17 |
| additional premium is to be charged (which period shall not |
18 |
| be less than one
year); and
|
19 |
| (ii) the amount of the refund or additional premium |
20 |
| shall not exceed 20%
of the Health Maintenance |
21 |
| Organization's profitable or unprofitable experience
with |
22 |
| respect to the group or other enrollment unit for the |
23 |
| period (and, for
purposes of a refund or additional |
24 |
| premium, the profitable or unprofitable
experience shall |
25 |
| be calculated taking into account a pro rata share of the
|
26 |
| Health Maintenance Organization's administrative and |
|
|
|
SB3188 |
- 18 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| marketing expenses, but
shall not include any refund to be |
2 |
| made or additional premium to be paid
pursuant to this |
3 |
| subsection (f)). The Health Maintenance Organization and |
4 |
| the
group or enrollment unit may agree that the profitable |
5 |
| or unprofitable
experience may be calculated taking into |
6 |
| account the refund period and the
immediately preceding 2 |
7 |
| plan years.
|
8 |
| The Health Maintenance Organization shall include a |
9 |
| statement in the
evidence of coverage issued to each enrollee |
10 |
| describing the possibility of a
refund or additional premium, |
11 |
| and upon request of any group or enrollment unit,
provide to |
12 |
| the group or enrollment unit a description of the method used |
13 |
| to
calculate (1) the Health Maintenance Organization's |
14 |
| profitable experience with
respect to the group or enrollment |
15 |
| unit and the resulting refund to the group
or enrollment unit |
16 |
| or (2) the Health Maintenance Organization's unprofitable
|
17 |
| experience with respect to the group or enrollment unit and the |
18 |
| resulting
additional premium to be paid by the group or |
19 |
| enrollment unit.
|
20 |
| In no event shall the Illinois Health Maintenance |
21 |
| Organization
Guaranty Association be liable to pay any |
22 |
| contractual obligation of an
insolvent organization to pay any |
23 |
| refund authorized under this Section.
|
24 |
| (g) Rulemaking authority to implement Public Act 95-1045, |
25 |
| if any, is conditioned on the rules being adopted in accordance |
26 |
| with all provisions of the Illinois Administrative Procedure |
|
|
|
SB3188 |
- 19 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| Act and all rules and procedures of the Joint Committee on |
2 |
| Administrative Rules; any purported rule not so adopted, for |
3 |
| whatever reason, is unauthorized. |
4 |
| (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
5 |
| 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
6 |
| 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
7 |
| 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. |
8 |
| 6-1-10.) |
9 |
| Section 35. The Voluntary Health Services Plans Act is |
10 |
| amended by changing Section 10 as follows:
|
11 |
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
12 |
| (Text of Section before amendment by P.A. 96-833 ) |
13 |
| Sec. 10. Application of Insurance Code provisions. Health |
14 |
| services
plan corporations and all persons interested therein |
15 |
| or dealing therewith
shall be subject to the provisions of |
16 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
17 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
18 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, |
19 |
| 356z.5, 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, |
20 |
| 356z.13, 356z.14, 356z.15
356z.14 , 364.01, 367.2, 368a, 401, |
21 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
22 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
23 |
| Rulemaking authority to implement Public Act 95-1045
this |
24 |
| amendatory Act of the 95th General Assembly , if any, is |
|
|
|
SB3188 |
- 20 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| conditioned on the rules being adopted in accordance with all |
2 |
| provisions of the Illinois Administrative Procedure Act and all |
3 |
| rules and procedures of the Joint Committee on Administrative |
4 |
| Rules; any purported rule not so adopted, for whatever reason, |
5 |
| is unauthorized. |
6 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
7 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
8 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
9 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
10 |
| 96-328, eff. 8-11-09; revised 9-25-09.) |
11 |
| (Text of Section after amendment by P.A. 96-833 ) |
12 |
| Sec. 10. Application of Insurance Code provisions. Health |
13 |
| services
plan corporations and all persons interested therein |
14 |
| or dealing therewith
shall be subject to the provisions of |
15 |
| Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
16 |
| 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, |
17 |
| 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, |
18 |
| 356z.5, 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, |
19 |
| 356z.13, 356z.14, 356z.15, 356z.18, 364.01, 367.2, 368a, 401, |
20 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
21 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
22 |
| Rulemaking authority to implement Public Act 95-1045, if |
23 |
| any, is conditioned on the rules being adopted in accordance |
24 |
| with all provisions of the Illinois Administrative Procedure |
25 |
| Act and all rules and procedures of the Joint Committee on |
|
|
|
SB3188 |
- 21 - |
LRB096 20286 RPM 35897 b |
|
|
1 |
| Administrative Rules; any purported rule not so adopted, for |
2 |
| whatever reason, is unauthorized. |
3 |
| (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
4 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
5 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, |
6 |
| eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; |
7 |
| 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.) |
8 |
| Section 95. No acceleration or delay. Where this Act makes |
9 |
| changes in a statute that is represented in this Act by text |
10 |
| that is not yet or no longer in effect (for example, a Section |
11 |
| represented by multiple versions), the use of that text does |
12 |
| not accelerate or delay the taking effect of (i) the changes |
13 |
| made by this Act or (ii) provisions derived from any other |
14 |
| Public Act.
|
15 |
| Section 99. Effective date. This Act takes effect January |
16 |
| 1, 2011.
|