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1 | | prohibited. |
2 | | (a) In this Section: |
3 | | "Excepted benefits" has the meaning given to that term in |
4 | | 42 U.S.C. 300gg-91 and implementing regulations. "Excepted |
5 | | benefits" includes individual, group, or blanket coverage. |
6 | | "Short-term, limited-duration insurance" means any type of |
7 | | accident and health insurance offered or provided within this |
8 | | State pursuant to a group or individual policy or individual |
9 | | certificate by a company, regardless of the situs state of the |
10 | | delivery of the policy, that has an expiration date specified |
11 | | in the contract that is fewer than 365 days after the original |
12 | | effective date. Regardless of the duration of coverage, |
13 | | "short-term, limited-duration insurance" does not include |
14 | | excepted benefits or any student health insurance coverage. |
15 | | (b) On and after January 1, 2025, no company shall issue, |
16 | | deliver, amend, or renew short-term, limited-duration |
17 | | insurance to any natural or legal person that is a resident or |
18 | | domiciled in this State. |
19 | | (215 ILCS 5/356z.18) |
20 | | (Text of Section before amendment by P.A. 103-512 ) |
21 | | Sec. 356z.18. Prosthetic and customized orthotic devices. |
22 | | (a) For the purposes of this Section: |
23 | | "Customized orthotic device" means a supportive device for |
24 | | the body or a part of the body, the head, neck, or extremities, |
25 | | and includes the replacement or repair of the device based on |
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1 | | the patient's physical condition as medically necessary, |
2 | | excluding foot orthotics defined as an in-shoe device designed |
3 | | to support the structural components of the foot during |
4 | | weight-bearing activities. |
5 | | "Licensed provider" means a prosthetist, orthotist, or |
6 | | pedorthist licensed to practice in this State. |
7 | | "Prosthetic device" means an artificial device to replace, |
8 | | in whole or in part, an arm or leg and includes accessories |
9 | | essential to the effective use of the device and the |
10 | | replacement or repair of the device based on the patient's |
11 | | physical condition as medically necessary. |
12 | | (b) This amendatory Act of the 96th General Assembly shall |
13 | | provide benefits to any person covered thereunder for expenses |
14 | | incurred in obtaining a prosthetic or custom orthotic device |
15 | | from any Illinois licensed prosthetist, licensed orthotist, or |
16 | | licensed pedorthist as required under the Orthotics, |
17 | | Prosthetics, and Pedorthics Practice Act. |
18 | | (c) A group or individual major medical policy of accident |
19 | | or health insurance or managed care plan or medical, health, |
20 | | or hospital service corporation contract that provides |
21 | | coverage for prosthetic or custom orthotic care and is |
22 | | amended, delivered, issued, or renewed 6 months after the |
23 | | effective date of this amendatory Act of the 96th General |
24 | | Assembly must provide coverage for prosthetic and orthotic |
25 | | devices in accordance with this subsection (c). The coverage |
26 | | required under this Section shall be subject to the other |
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1 | | general exclusions, limitations, and financial requirements of |
2 | | the policy, including coordination of benefits, participating |
3 | | provider requirements, utilization review of health care |
4 | | services, including review of medical necessity, case |
5 | | management, and experimental and investigational treatments, |
6 | | and other managed care provisions under terms and conditions |
7 | | that are no less favorable than the terms and conditions that |
8 | | apply to substantially all medical and surgical benefits |
9 | | provided under the plan or coverage. |
10 | | (d) The policy or plan or contract may require prior |
11 | | authorization for the prosthetic or orthotic devices in the |
12 | | same manner that prior authorization is required for any other |
13 | | covered benefit. |
14 | | (e) Repairs and replacements of prosthetic and orthotic |
15 | | devices are also covered, subject to the co-payments and |
16 | | deductibles, unless necessitated by misuse or loss. |
17 | | (f) A policy or plan or contract may require that, if |
18 | | coverage is provided through a managed care plan, the benefits |
19 | | mandated pursuant to this Section shall be covered benefits |
20 | | only if the prosthetic or orthotic devices are provided by a |
21 | | licensed provider employed by a provider service who contracts |
22 | | with or is designated by the carrier, to the extent that the |
23 | | carrier provides in-network and out-of-network service, the |
24 | | coverage for the prosthetic or orthotic device shall be |
25 | | offered no less extensively. |
26 | | (g) The policy or plan or contract shall also meet |
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1 | | adequacy requirements as established by the Health Care |
2 | | Reimbursement Reform Act of 1985 of the Illinois Insurance |
3 | | Code. |
4 | | (h) This Section shall not apply to accident only, |
5 | | specified disease, short-term travel hospital or medical , |
6 | | hospital confinement indemnity or other fixed indemnity , |
7 | | credit, dental, vision, Medicare supplement, long-term care, |
8 | | basic hospital and medical-surgical expense coverage, |
9 | | disability income insurance coverage, coverage issued as a |
10 | | supplement to liability insurance, workers' compensation |
11 | | insurance, or automobile medical payment insurance. |
12 | | (Source: P.A. 96-833, eff. 6-1-10 .) |
13 | | (Text of Section after amendment by P.A. 103-512 ) |
14 | | Sec. 356z.18. Prosthetic and customized orthotic devices. |
15 | | (a) For the purposes of this Section: |
16 | | "Customized orthotic device" means a supportive device for |
17 | | the body or a part of the body, the head, neck, or extremities, |
18 | | and includes the replacement or repair of the device based on |
19 | | the patient's physical condition as medically necessary, |
20 | | excluding foot orthotics defined as an in-shoe device designed |
21 | | to support the structural components of the foot during |
22 | | weight-bearing activities. |
23 | | "Licensed provider" means a prosthetist, orthotist, or |
24 | | pedorthist licensed to practice in this State. |
25 | | "Prosthetic device" means an artificial device to replace, |
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1 | | in whole or in part, an arm or leg and includes accessories |
2 | | essential to the effective use of the device and the |
3 | | replacement or repair of the device based on the patient's |
4 | | physical condition as medically necessary. |
5 | | (b) This amendatory Act of the 96th General Assembly shall |
6 | | provide benefits to any person covered thereunder for expenses |
7 | | incurred in obtaining a prosthetic or custom orthotic device |
8 | | from any Illinois licensed prosthetist, licensed orthotist, or |
9 | | licensed pedorthist as required under the Orthotics, |
10 | | Prosthetics, and Pedorthics Practice Act. |
11 | | (c) A group or individual major medical policy of accident |
12 | | or health insurance or managed care plan or medical, health, |
13 | | or hospital service corporation contract that provides |
14 | | coverage for prosthetic or custom orthotic care and is |
15 | | amended, delivered, issued, or renewed 6 months after the |
16 | | effective date of this amendatory Act of the 96th General |
17 | | Assembly must provide coverage for prosthetic and orthotic |
18 | | devices in accordance with this subsection (c). The coverage |
19 | | required under this Section shall be subject to the other |
20 | | general exclusions, limitations, and financial requirements of |
21 | | the policy, including coordination of benefits, participating |
22 | | provider requirements, utilization review of health care |
23 | | services, including review of medical necessity, case |
24 | | management, and experimental and investigational treatments, |
25 | | and other managed care provisions under terms and conditions |
26 | | that are no less favorable than the terms and conditions that |
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1 | | apply to substantially all medical and surgical benefits |
2 | | provided under the plan or coverage. |
3 | | (d) With respect to an enrollee at any age, in addition to |
4 | | coverage of a prosthetic or custom orthotic device required by |
5 | | this Section, benefits shall be provided for a prosthetic or |
6 | | custom orthotic device determined by the enrollee's provider |
7 | | to be the most appropriate model that is medically necessary |
8 | | for the enrollee to perform physical activities, as |
9 | | applicable, such as running, biking, swimming, and lifting |
10 | | weights, and to maximize the enrollee's whole body health and |
11 | | strengthen the lower and upper limb function. |
12 | | (e) The requirements of this Section do not constitute an |
13 | | addition to this State's essential health benefits that |
14 | | requires defrayal of costs by this State pursuant to 42 U.S.C. |
15 | | 18031(d)(3)(B). |
16 | | (f) The policy or plan or contract may require prior |
17 | | authorization for the prosthetic or orthotic devices in the |
18 | | same manner that prior authorization is required for any other |
19 | | covered benefit. |
20 | | (g) Repairs and replacements of prosthetic and orthotic |
21 | | devices are also covered, subject to the co-payments and |
22 | | deductibles, unless necessitated by misuse or loss. |
23 | | (h) A policy or plan or contract may require that, if |
24 | | coverage is provided through a managed care plan, the benefits |
25 | | mandated pursuant to this Section shall be covered benefits |
26 | | only if the prosthetic or orthotic devices are provided by a |
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1 | | licensed provider employed by a provider service who contracts |
2 | | with or is designated by the carrier, to the extent that the |
3 | | carrier provides in-network and out-of-network service, the |
4 | | coverage for the prosthetic or orthotic device shall be |
5 | | offered no less extensively. |
6 | | (i) The policy or plan or contract shall also meet |
7 | | adequacy requirements as established by the Health Care |
8 | | Reimbursement Reform Act of 1985 of the Illinois Insurance |
9 | | Code. |
10 | | (j) This Section shall not apply to accident only, |
11 | | specified disease, short-term travel hospital or medical , |
12 | | hospital confinement indemnity or other fixed indemnity , |
13 | | credit, dental, vision, Medicare supplement, long-term care, |
14 | | basic hospital and medical-surgical expense coverage, |
15 | | disability income insurance coverage, coverage issued as a |
16 | | supplement to liability insurance, workers' compensation |
17 | | insurance, or automobile medical payment insurance. |
18 | | (Source: P.A. 103-512, eff. 1-1-25.) |
19 | | (215 ILCS 5/367.3) (from Ch. 73, par. 979.3) |
20 | | Sec. 367.3. Group accident and health insurance; |
21 | | discretionary groups. |
22 | | (a) No group health insurance offered to a resident of |
23 | | this State under a policy issued to a group, other than one |
24 | | specifically described in Section 367(1), shall be delivered |
25 | | or issued for delivery in this State unless the Director |
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1 | | determines that: |
2 | | (1) the issuance of the policy is not contrary to the |
3 | | public interest; |
4 | | (2) the issuance of the policy will result in |
5 | | economies of acquisition and administration; and |
6 | | (3) the benefits under the policy are reasonable in |
7 | | relation to the premium charged. |
8 | | (b) No such group health insurance may be offered in this |
9 | | State under a policy issued in another state unless this State |
10 | | or the state in which the group policy is issued has made a |
11 | | determination that the requirements of subsection (a) have |
12 | | been met. |
13 | | Where insurance is to be offered in this State under a |
14 | | policy described in this subsection, the insurer shall file |
15 | | for informational review purposes: |
16 | | (1) a copy of the group master contract; |
17 | | (2) a copy of the statute authorizing the issuance of |
18 | | the group policy in the state of situs, which statute has |
19 | | the same or similar requirements as this State, or in the |
20 | | absence of such statute, a certification by an officer of |
21 | | the company that the policy meets the Illinois minimum |
22 | | standards required for individual accident and health |
23 | | policies under authority of Section 401 of this Code, as |
24 | | now or hereafter amended, as promulgated by rule at 50 |
25 | | Illinois Administrative Code, Ch. I, Sec. 2007, et seq., |
26 | | as now or hereafter amended, or by a successor rule; |
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1 | | (3) evidence of approval by the state of situs of the |
2 | | group master policy; and |
3 | | (4) copies of all supportive material furnished to the |
4 | | state of situs to satisfy the criteria for approval. |
5 | | (c) The Director may, at any time after receipt of the |
6 | | information required under subsection (b) and after finding |
7 | | that the standards of subsection (a) have not been met, order |
8 | | the insurer to cease the issuance or marketing of that |
9 | | coverage in this State. |
10 | | (d) Notwithstanding subsections (a) and (b), group Group |
11 | | accident and health insurance subject to the provisions of |
12 | | this Section is also subject to the provisions of Sections |
13 | | 352c and Section 367i of this Code and rules thereunder . |
14 | | (Source: P.A. 90-655, eff. 7-30-98.) |
15 | | (215 ILCS 5/367a) (from Ch. 73, par. 979a) |
16 | | Sec. 367a. Blanket accident and health insurance. |
17 | | (1) Blanket accident and health insurance is the that form |
18 | | of accident and health insurance providing excepted benefits, |
19 | | as defined in Section 352c, that covers covering special |
20 | | groups of persons as enumerated in one of the following |
21 | | paragraphs (a) to (g), inclusive: |
22 | | (a) Under a policy or contract issued to any carrier for |
23 | | hire, which shall be deemed the policyholder, covering a group |
24 | | defined as all persons who may become passengers on such |
25 | | carrier. |
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1 | | (b) Under a policy or contract issued to an employer, who |
2 | | shall be deemed the policyholder, covering all employees or |
3 | | any group of employees defined by reference to exceptional |
4 | | hazards incident to such employment. |
5 | | (c) Under a policy or contract issued to a college, |
6 | | school, or other institution of learning or to the head or |
7 | | principal thereof, who or which shall be deemed the |
8 | | policyholder, covering students or teachers. However, student |
9 | | health insurance coverage, as defined in 45 CFR 147.145, shall |
10 | | remain subject to the standards and requirements for |
11 | | individual health insurance coverage except where inconsistent |
12 | | with that regulation. An issuer providing student health |
13 | | insurance coverage or a policy or contract covering students |
14 | | for limited-scope dental or vision under 45 CFR 148.220 shall |
15 | | require an individual application or enrollment form and shall |
16 | | furnish each insured individual a certificate, which shall |
17 | | have been approved by the Director under Section 355. |
18 | | (d) Under a policy or contract issued in the name of any |
19 | | volunteer fire department, first aid, or other such volunteer |
20 | | group, which shall be deemed the policyholder, covering all of |
21 | | the members of such department or group. |
22 | | (e) Under a policy or contract issued to a creditor, who |
23 | | shall be deemed the policyholder, to insure debtors of the |
24 | | creditors; Provided, however, that in the case of a loan which |
25 | | is subject to the Small Loans Act, no insurance premium or |
26 | | other cost shall be directly or indirectly charged or assessed |
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1 | | against, or collected or received from the borrower. |
2 | | (f) Under a policy or contract issued to a sports team or |
3 | | to a camp, which team or camp sponsor shall be deemed the |
4 | | policyholder, covering members or campers. |
5 | | (g) Under a policy or contract issued to any other |
6 | | substantially similar group which, in the discretion of the |
7 | | Director, may be subject to the issuance of a blanket accident |
8 | | and health policy or contract. |
9 | | (2) Any insurance company authorized to write accident and |
10 | | health insurance in this state shall have the power to issue |
11 | | blanket accident and health insurance. No such blanket policy |
12 | | may be issued or delivered in this State unless a copy of the |
13 | | form thereof shall have been filed in accordance with Section |
14 | | 355, and it contains in substance such of those provisions |
15 | | contained in Sections 357.1 through 357.30 as may be |
16 | | applicable to blanket accident and health insurance and the |
17 | | following provisions: |
18 | | (a) A provision that the policy and the application shall |
19 | | constitute the entire contract between the parties, and that |
20 | | all statements made by the policyholder shall, in absence of |
21 | | fraud, be deemed representations and not warranties, and that |
22 | | no such statements shall be used in defense to a claim under |
23 | | the policy, unless it is contained in a written application. |
24 | | (b) A provision that to the group or class thereof |
25 | | originally insured shall be added from time to time all new |
26 | | persons or individuals eligible for coverage. |
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1 | | (3) An individual application shall not be required from a |
2 | | person covered under a blanket accident or health policy or |
3 | | contract, nor shall it be necessary for the insurer to furnish |
4 | | each person a certificate. |
5 | | (4) All benefits under any blanket accident and health |
6 | | policy shall be payable to the person insured, or to his |
7 | | designated beneficiary or beneficiaries, or to his or her |
8 | | estate, except that if the person insured be a minor or person |
9 | | under legal disability, such benefits may be made payable to |
10 | | his or her parent, guardian, or other person actually |
11 | | supporting him or her. Provided further, however, that the |
12 | | policy may provide that all or any portion of any indemnities |
13 | | provided by any such policy on account of hospital, nursing, |
14 | | medical or surgical services may, at the insurer's option, be |
15 | | paid directly to the hospital or person rendering such |
16 | | services; but the policy may not require that the service be |
17 | | rendered by a particular hospital or person. Payment so made |
18 | | shall discharge the insurer's obligation with respect to the |
19 | | amount of insurance so paid. |
20 | | (5) Nothing contained in this section shall be deemed to |
21 | | affect the legal liability of policyholders for the death of |
22 | | or injury to, any such member of such group. |
23 | | (Source: P.A. 83-1362.) |
24 | | (215 ILCS 5/368f) |
25 | | Sec. 368f. Military service member insurance |
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1 | | reinstatement. |
2 | | (a) No Illinois resident activated for military service |
3 | | and no spouse or dependent of the resident who becomes |
4 | | eligible for a federal government-sponsored health insurance |
5 | | program, including the TriCare program providing coverage for |
6 | | civilian dependents of military personnel, as a result of the |
7 | | activation shall be denied reinstatement into the same |
8 | | individual health insurance coverage with the health insurer |
9 | | that the resident lapsed as a result of activation or becoming |
10 | | covered by the federal government-sponsored health insurance |
11 | | program. The resident shall have the right to reinstatement in |
12 | | the same individual health insurance coverage without medical |
13 | | underwriting, subject to payment of the current premium |
14 | | charged to other persons of the same age and gender that are |
15 | | covered under the same individual health coverage. Except in |
16 | | the case of birth or adoption that occurs during the period of |
17 | | activation, reinstatement must be into the same coverage type |
18 | | as the resident held prior to lapsing the individual health |
19 | | insurance coverage and at the same or, at the option of the |
20 | | resident, higher deductible level. The reinstatement rights |
21 | | provided under this subsection (a) are not available to a |
22 | | resident or dependents if the activated person is discharged |
23 | | from the military under other than honorable conditions. |
24 | | (b) The health insurer with which the reinstatement is |
25 | | being requested must receive a request for reinstatement no |
26 | | later than 63 days following the later of (i) deactivation or |
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1 | | (ii) loss of coverage under the federal government-sponsored |
2 | | health insurance program. The health insurer may request proof |
3 | | of loss of coverage and the timing of the loss of coverage of |
4 | | the government-sponsored coverage in order to determine |
5 | | eligibility for reinstatement into the individual coverage. |
6 | | The effective date of the reinstatement of individual health |
7 | | coverage shall be the first of the month following receipt of |
8 | | the notice requesting reinstatement. |
9 | | (c) All insurers must provide written notice to the |
10 | | policyholder of individual health coverage of the rights |
11 | | described in subsection (a) of this Section. In lieu of the |
12 | | inclusion of the notice in the individual health insurance |
13 | | policy, an insurance company may satisfy the notification |
14 | | requirement by providing a single written notice: |
15 | | (1) in conjunction with the enrollment process for a |
16 | | policyholder initially enrolling in the individual |
17 | | coverage on or after the effective date of this amendatory |
18 | | Act of the 94th General Assembly; or |
19 | | (2) by mailing written notice to policyholders whose |
20 | | coverage was effective prior to the effective date of this |
21 | | amendatory Act of the 94th General Assembly no later than |
22 | | 90 days following the effective date of this amendatory |
23 | | Act of the 94th General Assembly. |
24 | | (d) The provisions of subsection (a) of this Section do |
25 | | not apply to any policy or certificate providing coverage for |
26 | | any specified disease, specified accident or accident-only |
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1 | | coverage, credit, dental, disability income, hospital |
2 | | indemnity or other fixed indemnity , long-term care, Medicare |
3 | | supplement, vision care, or short-term travel nonrenewable |
4 | | health policy or other limited-benefit supplemental insurance, |
5 | | or any coverage issued as a supplement to any liability |
6 | | insurance, workers' compensation or similar insurance, or any |
7 | | insurance under which benefits are payable with or without |
8 | | regard to fault, whether written on a group, blanket, or |
9 | | individual basis. |
10 | | (e) Nothing in this Section shall require an insurer to |
11 | | reinstate the resident if the insurer requires residency in an |
12 | | enrollment area and those residency requirements are not met |
13 | | after deactivation or loss of coverage under the |
14 | | government-sponsored health insurance program. |
15 | | (f) All terms, conditions, and limitations of the |
16 | | individual coverage into which reinstatement is made apply |
17 | | equally to all insureds enrolled in the coverage. |
18 | | (g) The Secretary may adopt rules as may be necessary to |
19 | | carry out the provisions of this Section. |
20 | | (Source: P.A. 94-1037, eff. 7-20-06.) |
21 | | Section 10. The Health Maintenance Organization Act is |
22 | | amended by changing Section 5-3 as follows: |
23 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) |
24 | | Sec. 5-3. Insurance Code provisions. |
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1 | | (a) Health Maintenance Organizations shall be subject to |
2 | | the provisions of Sections 133, 134, 136, 137, 139, 140, |
3 | | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, |
4 | | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, |
5 | | 352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, |
6 | | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, |
7 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
8 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, |
9 | | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, |
10 | | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, |
11 | | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, |
12 | | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, |
13 | | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, |
14 | | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, |
15 | | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, |
16 | | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, |
17 | | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of |
18 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2, |
19 | | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the |
20 | | Illinois Insurance Code. |
21 | | (b) For purposes of the Illinois Insurance Code, except |
22 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, |
23 | | Health Maintenance Organizations in the following categories |
24 | | are deemed to be "domestic companies": |
25 | | (1) a corporation authorized under the Dental Service |
26 | | Plan Act or the Voluntary Health Services Plans Act; |
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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 |
14 | | financial conditions of the acquired Health Maintenance |
15 | | Organization after the merger, consolidation, or other |
16 | | acquisition of 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 |
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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 |
21 | | to 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, |
26 | | take into account the effect of the management contract or |
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1 | | service agreement on the continuation of benefits to enrollees |
2 | | and the financial condition of the health maintenance |
3 | | organization to be managed or serviced, and (ii) need not take |
4 | | into account the effect of the management contract or service |
5 | | agreement on 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 |
10 | | Health Maintenance Organization may by contract agree with a |
11 | | group or other enrollment unit to effect refunds or charge |
12 | | additional 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 |
18 | | not 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 |
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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 |
18 | | the 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 |
26 | | accordance with all provisions of the Illinois Administrative |
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1 | | Procedure Act and all rules and procedures of the Joint |
2 | | Committee on Administrative Rules; any purported rule not so |
3 | | adopted, for whatever reason, is unauthorized. |
4 | | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; |
5 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. |
6 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, |
7 | | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; |
8 | | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. |
9 | | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, |
10 | | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; |
11 | | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. |
12 | | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
13 | | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) |
14 | | Section 15. The Limited Health Service Organization Act is |
15 | | amended by changing Section 4003 as follows: |
16 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) |
17 | | Sec. 4003. Illinois Insurance Code provisions. Limited |
18 | | health service organizations shall be subject to the |
19 | | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, |
20 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, |
21 | | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, |
22 | | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, |
23 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, |
24 | | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, |
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1 | | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, |
2 | | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, |
3 | | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, |
4 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. |
5 | | Nothing in this Section shall require a limited health care |
6 | | plan to cover any service that is not a limited health service. |
7 | | For purposes of the Illinois Insurance Code, except for |
8 | | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited |
9 | | health service organizations in the following categories are |
10 | | deemed to be domestic companies: |
11 | | (1) a corporation under the laws of this State; or |
12 | | (2) a corporation organized under the laws of another |
13 | | state, 30% or more of the enrollees of which are residents |
14 | | of this State, except a corporation subject to |
15 | | substantially the same requirements in its state of |
16 | | organization as is a domestic company under Article VIII |
17 | | 1/2 of the Illinois Insurance Code. |
18 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; |
19 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. |
20 | | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, |
21 | | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; |
22 | | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. |
23 | | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
24 | | eff. 1-1-24; revised 8-29-23.) |
25 | | (215 ILCS 190/Act rep.) |