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1 | AN ACT concerning regulation. | |||||||||||||||||||||||||||||
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 | |||||||||||||||||||||||||||||
9 | provide the post-mastectomy care benefits required to be | |||||||||||||||||||||||||||||
10 | covered by a policy of accident and health insurance under | |||||||||||||||||||||||||||||
11 | Section 356t of the Illinois Insurance Code. The program of | |||||||||||||||||||||||||||||
12 | health benefits shall provide the coverage required under | |||||||||||||||||||||||||||||
13 | Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, | |||||||||||||||||||||||||||||
14 | 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, | |||||||||||||||||||||||||||||
15 | 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, | |||||||||||||||||||||||||||||
16 | 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, | |||||||||||||||||||||||||||||
17 | 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, | |||||||||||||||||||||||||||||
18 | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, | |||||||||||||||||||||||||||||
19 | 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and | |||||||||||||||||||||||||||||
20 | 356z.70, and 356z.71 , 356z.74, 356z.76, 356z.77, and 356z.80 | |||||||||||||||||||||||||||||
21 | of the Illinois Insurance Code. The program of health benefits | |||||||||||||||||||||||||||||
22 | must comply with Sections 155.22a, 155.37, 355b, 356z.19, | |||||||||||||||||||||||||||||
23 | 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance |
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1 | Code. The program of health benefits shall provide the | ||||||
2 | coverage required under Section 356m of the Illinois Insurance | ||||||
3 | Code and, for the employees of the State Employee Group | ||||||
4 | Insurance Program only, the coverage as also provided in | ||||||
5 | Section 6.11B of this Act. The Department of Insurance shall | ||||||
6 | enforce the requirements of this Section with respect to | ||||||
7 | Sections 370c and 370c.1 of the Illinois Insurance Code; all | ||||||
8 | other requirements of this Section shall be enforced by the | ||||||
9 | Department of Central Management Services. | ||||||
10 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
11 | any, is conditioned on the rules being adopted in accordance | ||||||
12 | with all provisions of the Illinois Administrative Procedure | ||||||
13 | Act and all rules and procedures of the Joint Committee on | ||||||
14 | Administrative Rules; any purported rule not so adopted, for | ||||||
15 | whatever reason, is unauthorized. | ||||||
16 | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||||||
17 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. | ||||||
18 | 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, | ||||||
19 | eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||||||
20 | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||||||
21 | 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, | ||||||
22 | eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; | ||||||
23 | 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. | ||||||
24 | 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751, | ||||||
25 | eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25; | ||||||
26 | 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff. |
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1 | 1-1-25; revised 11-26-24.) | ||||||
2 | Section 10. The Counties Code is amended by changing | ||||||
3 | Section 5-1069.3 as follows: | ||||||
4 | (55 ILCS 5/5-1069.3) | ||||||
5 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
6 | including a home rule county, is a self-insurer for purposes | ||||||
7 | of providing health insurance coverage for its employees, the | ||||||
8 | coverage shall include coverage for the post-mastectomy care | ||||||
9 | benefits required to be covered by a policy of accident and | ||||||
10 | health insurance under Section 356t and the coverage required | ||||||
11 | under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, | ||||||
12 | 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, | ||||||
13 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, | ||||||
14 | 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, | ||||||
15 | 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, | ||||||
16 | 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, | ||||||
17 | 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71 , | ||||||
18 | 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code. | ||||||
19 | The coverage shall comply with Sections 155.22a, 355b, | ||||||
20 | 356z.19, and 370c of the Illinois Insurance Code. The | ||||||
21 | Department of Insurance shall enforce the requirements of this | ||||||
22 | Section. The requirement that health benefits be covered as | ||||||
23 | provided in this Section is an exclusive power and function of | ||||||
24 | the State and is a denial and limitation under Article VII, |
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1 | Section 6, subsection (h) of the Illinois Constitution. A home | ||||||
2 | rule county to which this Section applies must comply with | ||||||
3 | every provision of this Section. | ||||||
4 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
5 | any, is conditioned on the rules being adopted in accordance | ||||||
6 | with all provisions of the Illinois Administrative Procedure | ||||||
7 | Act and all rules and procedures of the Joint Committee on | ||||||
8 | Administrative Rules; any purported rule not so adopted, for | ||||||
9 | whatever reason, is unauthorized. | ||||||
10 | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||||||
11 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
12 | 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | ||||||
13 | eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||||||
14 | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||||||
15 | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||||||
16 | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||||||
17 | 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. | ||||||
18 | 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, | ||||||
19 | eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; | ||||||
20 | revised 11-26-24.) | ||||||
21 | Section 15. The Illinois Municipal Code is amended by | ||||||
22 | changing Section 10-4-2.3 as follows: | ||||||
23 | (65 ILCS 5/10-4-2.3) | ||||||
24 | Sec. 10-4-2.3. Required health benefits. If a |
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1 | municipality, including a home rule municipality, is a | ||||||
2 | self-insurer for purposes of providing health insurance | ||||||
3 | coverage for its employees, the coverage shall include | ||||||
4 | coverage for the post-mastectomy care benefits required to be | ||||||
5 | covered by a policy of accident and health insurance under | ||||||
6 | Section 356t and the coverage required under Sections 356g, | ||||||
7 | 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, | ||||||
8 | 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | ||||||
9 | 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, | ||||||
10 | 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, | ||||||
11 | 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, | ||||||
12 | 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, | ||||||
13 | 356z.67, 356z.68, and 356z.70, and 356z.71 , 356z.74, 356z.77, | ||||||
14 | and 356z.80 of the Illinois Insurance Code. The coverage shall | ||||||
15 | comply with Sections 155.22a, 355b, 356z.19, and 370c of the | ||||||
16 | Illinois Insurance Code. The Department of Insurance shall | ||||||
17 | enforce the requirements of this Section. The requirement that | ||||||
18 | health benefits be covered as provided in this is an exclusive | ||||||
19 | power and function of the State and is a denial and limitation | ||||||
20 | under Article VII, Section 6, subsection (h) of the Illinois | ||||||
21 | Constitution. A home rule municipality to which this Section | ||||||
22 | applies must comply with every provision of this Section. | ||||||
23 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
24 | any, is conditioned on the rules being adopted in accordance | ||||||
25 | with all provisions of the Illinois Administrative Procedure | ||||||
26 | Act and all rules and procedures of the Joint Committee on |
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1 | Administrative Rules; any purported rule not so adopted, for | ||||||
2 | whatever reason, is unauthorized. | ||||||
3 | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||||||
4 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
5 | 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, | ||||||
6 | eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; | ||||||
7 | 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. | ||||||
8 | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | ||||||
9 | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | ||||||
10 | 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. | ||||||
11 | 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, | ||||||
12 | eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; | ||||||
13 | revised 11-26-24.) | ||||||
14 | Section 20. The School Code is amended by changing Section | ||||||
15 | 10-22.3f as follows: | ||||||
16 | (105 ILCS 5/10-22.3f) | ||||||
17 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
18 | protection and benefits for employees shall provide the | ||||||
19 | post-mastectomy care benefits required to be covered by a | ||||||
20 | policy of accident and health insurance under Section 356t and | ||||||
21 | the coverage required under Sections 356g, 356g.5, 356g.5-1, | ||||||
22 | 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a, | ||||||
23 | 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, | ||||||
24 | 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, |
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1 | 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, | ||||||
2 | 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, | ||||||
3 | 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and | ||||||
4 | 356z.71 , 356z.74, 356z.77, and 356z.80 of the Illinois | ||||||
5 | Insurance Code. Insurance policies shall comply with Section | ||||||
6 | 356z.19 of the Illinois Insurance Code. The coverage shall | ||||||
7 | comply with Sections 155.22a, 355b, and 370c of the Illinois | ||||||
8 | Insurance Code. The Department of Insurance shall enforce the | ||||||
9 | requirements of this Section. | ||||||
10 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
11 | any, is conditioned on the rules being adopted in accordance | ||||||
12 | with all provisions of the Illinois Administrative Procedure | ||||||
13 | Act and all rules and procedures of the Joint Committee on | ||||||
14 | Administrative Rules; any purported rule not so adopted, for | ||||||
15 | whatever reason, is unauthorized. | ||||||
16 | (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; | ||||||
17 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. | ||||||
18 | 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, | ||||||
19 | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | ||||||
20 | 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. | ||||||
21 | 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, | ||||||
22 | eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; | ||||||
23 | 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. | ||||||
24 | 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, | ||||||
25 | eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.) |
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1 | Section 25. The Illinois Insurance Code is amended by | ||||||
2 | adding Section 356z.80 as follows: | ||||||
3 | (215 ILCS 5/356z.80 new) | ||||||
4 | Sec. 356z.80. Coverage for hippotherapy and therapeutic | ||||||
5 | riding. | ||||||
6 | (a) As used in this Section: | ||||||
7 | "Disability" means a determinable physical or mental | ||||||
8 | characteristic of a person, including, but not limited to, a | ||||||
9 | determinable physical characteristic that necessitates the | ||||||
10 | person's use of a guide, hearing, or support dog, that may | ||||||
11 | result from a disease, injury, or congenital condition of | ||||||
12 | birth or a functional disorder. | ||||||
13 | "Hippotherapy" means physical, occupational, or speech | ||||||
14 | therapy, prescribed by a physician and delivered by a licensed | ||||||
15 | occupational therapist, physical therapist, or speech-language | ||||||
16 | pathologist, in conjunction with a professional horse handler | ||||||
17 | and a therapy horse. | ||||||
18 | "Therapeutic riding" means horseback riding lessons | ||||||
19 | adapted to an individual with a disability, delivered by a | ||||||
20 | professional horse handler and a therapy horse. | ||||||
21 | (b) A group or individual policy of accident and health | ||||||
22 | insurance or managed care plan that is amended, delivered, | ||||||
23 | issued, or renewed after the effective date of this amendatory | ||||||
24 | Act of the 104th General Assembly shall provide coverage for | ||||||
25 | hippotherapy and other forms of therapeutic riding. |
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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. 103-808 ) | ||||||
5 | Sec. 5-3. Insurance Code provisions. | ||||||
6 | (a) Health Maintenance Organizations shall be subject to | ||||||
7 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
8 | 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, | ||||||
9 | 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, | ||||||
10 | 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1, | ||||||
11 | 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a, | ||||||
12 | 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
13 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, | ||||||
14 | 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25, | ||||||
15 | 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33, | ||||||
16 | 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, | ||||||
17 | 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47, | ||||||
18 | 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55, | ||||||
19 | 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62, | ||||||
20 | 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69, | ||||||
21 | 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77, | ||||||
22 | 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
23 | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||||||
24 | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of |
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1 | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||||||
2 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
3 | Illinois Insurance Code. | ||||||
4 | (b) For purposes of the Illinois Insurance Code, except | ||||||
5 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
6 | Health Maintenance Organizations in the following categories | ||||||
7 | are deemed to be "domestic companies": | ||||||
8 | (1) a corporation authorized under the Dental Service | ||||||
9 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
10 | (2) a corporation organized under the laws of this | ||||||
11 | State; or | ||||||
12 | (3) a corporation organized under the laws of another | ||||||
13 | state, 30% or more of the enrollees of which are residents | ||||||
14 | of this State, except a corporation subject to | ||||||
15 | substantially the same requirements in its state of | ||||||
16 | organization as is a "domestic company" under Article VIII | ||||||
17 | 1/2 of the Illinois Insurance Code. | ||||||
18 | (c) In considering the merger, consolidation, or other | ||||||
19 | acquisition of control of a Health Maintenance Organization | ||||||
20 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||||||
21 | (1) the Director shall give primary consideration to | ||||||
22 | the continuation of benefits to enrollees and the | ||||||
23 | financial conditions of the acquired Health Maintenance | ||||||
24 | Organization after the merger, consolidation, or other | ||||||
25 | acquisition of control takes effect; | ||||||
26 | (2)(i) the criteria specified in subsection (1)(b) of |
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1 | Section 131.8 of the Illinois Insurance Code shall not | ||||||
2 | apply and (ii) the Director, in making his determination | ||||||
3 | with respect to the merger, consolidation, or other | ||||||
4 | acquisition of control, need not take into account the | ||||||
5 | effect on competition of the merger, consolidation, or | ||||||
6 | other acquisition of control; | ||||||
7 | (3) the Director shall have the power to require the | ||||||
8 | following information: | ||||||
9 | (A) certification by an independent actuary of the | ||||||
10 | adequacy of the reserves of the Health Maintenance | ||||||
11 | Organization sought to be acquired; | ||||||
12 | (B) pro forma financial statements reflecting the | ||||||
13 | combined balance sheets of the acquiring company and | ||||||
14 | the Health Maintenance Organization sought to be | ||||||
15 | acquired as of the end of the preceding year and as of | ||||||
16 | a date 90 days prior to the acquisition, as well as pro | ||||||
17 | forma financial statements reflecting projected | ||||||
18 | combined operation for a period of 2 years; | ||||||
19 | (C) a pro forma business plan detailing an | ||||||
20 | acquiring party's plans with respect to the operation | ||||||
21 | of the Health Maintenance Organization sought to be | ||||||
22 | acquired for a period of not less than 3 years; and | ||||||
23 | (D) such other information as the Director shall | ||||||
24 | require. | ||||||
25 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
26 | Insurance Code and this Section 5-3 shall apply to the sale by |
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1 | any health maintenance organization of greater than 10% of its | ||||||
2 | enrollee population (including, without limitation, the health | ||||||
3 | maintenance organization's right, title, and interest in and | ||||||
4 | to its health care certificates). | ||||||
5 | (e) In considering any management contract or service | ||||||
6 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
7 | Code, the Director (i) shall, in addition to the criteria | ||||||
8 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
9 | take into account the effect of the management contract or | ||||||
10 | service agreement on the continuation of benefits to enrollees | ||||||
11 | and the financial condition of the health maintenance | ||||||
12 | organization to be managed or serviced, and (ii) need not take | ||||||
13 | into account the effect of the management contract or service | ||||||
14 | agreement on competition. | ||||||
15 | (f) Except for small employer groups as defined in the | ||||||
16 | Small Employer Rating, Renewability and Portability Health | ||||||
17 | Insurance Act and except for medicare supplement policies as | ||||||
18 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
19 | Health Maintenance Organization may by contract agree with a | ||||||
20 | group or other enrollment unit to effect refunds or charge | ||||||
21 | additional premiums under the following terms and conditions: | ||||||
22 | (i) the amount of, and other terms and conditions with | ||||||
23 | respect to, the refund or additional premium are set forth | ||||||
24 | in the group or enrollment unit contract agreed in advance | ||||||
25 | of the period for which a refund is to be paid or | ||||||
26 | additional premium is to be charged (which period shall |
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1 | not be less than one year); and | ||||||
2 | (ii) the amount of the refund or additional premium | ||||||
3 | shall not exceed 20% of the Health Maintenance | ||||||
4 | Organization's profitable or unprofitable experience with | ||||||
5 | respect to the group or other enrollment unit for the | ||||||
6 | period (and, for purposes of a refund or additional | ||||||
7 | premium, the profitable or unprofitable experience shall | ||||||
8 | be calculated taking into account a pro rata share of the | ||||||
9 | Health Maintenance Organization's administrative and | ||||||
10 | marketing expenses, but shall not include any refund to be | ||||||
11 | made or additional premium to be paid pursuant to this | ||||||
12 | subsection (f)). The Health Maintenance Organization and | ||||||
13 | the group or enrollment unit may agree that the profitable | ||||||
14 | or unprofitable experience may be calculated taking into | ||||||
15 | account the refund period and the immediately preceding 2 | ||||||
16 | plan years. | ||||||
17 | The Health Maintenance Organization shall include a | ||||||
18 | statement in the evidence of coverage issued to each enrollee | ||||||
19 | describing the possibility of a refund or additional premium, | ||||||
20 | and upon request of any group or enrollment unit, provide to | ||||||
21 | the group or enrollment unit a description of the method used | ||||||
22 | to calculate (1) the Health Maintenance Organization's | ||||||
23 | profitable experience with respect to the group or enrollment | ||||||
24 | unit and the resulting refund to the group or enrollment unit | ||||||
25 | or (2) the Health Maintenance Organization's unprofitable | ||||||
26 | experience with respect to the group or enrollment unit and |
| |||||||
| |||||||
1 | the resulting additional premium to be paid by the group or | ||||||
2 | enrollment unit. | ||||||
3 | In no event shall the Illinois Health Maintenance | ||||||
4 | Organization Guaranty Association be liable to pay any | ||||||
5 | contractual obligation of an insolvent organization to pay any | ||||||
6 | refund authorized under this Section. | ||||||
7 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
8 | if any, is conditioned on the rules being adopted in | ||||||
9 | accordance with all provisions of the Illinois Administrative | ||||||
10 | Procedure Act and all rules and procedures of the Joint | ||||||
11 | Committee on Administrative Rules; any purported rule not so | ||||||
12 | adopted, for whatever reason, is unauthorized. | ||||||
13 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
14 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
15 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
16 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
17 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
18 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
19 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
20 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||||||
21 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
22 | eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; | ||||||
23 | 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. | ||||||
24 | 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, | ||||||
25 | eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; | ||||||
26 | 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff. |
| |||||||
| |||||||
1 | 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.) | ||||||
2 | (Text of Section after amendment by P.A. 103-808 ) | ||||||
3 | Sec. 5-3. Insurance Code provisions. | ||||||
4 | (a) Health Maintenance Organizations shall be subject to | ||||||
5 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
6 | 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, | ||||||
7 | 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, | ||||||
8 | 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g, | ||||||
9 | 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, | ||||||
10 | 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
11 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | ||||||
12 | 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, | ||||||
13 | 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, | ||||||
14 | 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, | ||||||
15 | 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, | ||||||
16 | 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, | ||||||
17 | 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, | ||||||
18 | 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, | ||||||
19 | 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, | ||||||
20 | 356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, | ||||||
21 | 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, | ||||||
22 | 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) | ||||||
23 | of subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||||||
24 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
25 | Illinois Insurance Code. |
| |||||||
| |||||||
1 | (b) For purposes of the Illinois Insurance Code, except | ||||||
2 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
3 | Health Maintenance Organizations in the following categories | ||||||
4 | are deemed to be "domestic companies": | ||||||
5 | (1) a corporation authorized under the Dental Service | ||||||
6 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
7 | (2) a corporation organized under the laws of this | ||||||
8 | State; or | ||||||
9 | (3) a corporation organized under the laws of another | ||||||
10 | state, 30% or more of the enrollees of which are residents | ||||||
11 | of this State, except a corporation subject to | ||||||
12 | substantially the same requirements in its state of | ||||||
13 | organization as is a "domestic company" under Article VIII | ||||||
14 | 1/2 of the Illinois Insurance Code. | ||||||
15 | (c) In considering the merger, consolidation, or other | ||||||
16 | acquisition of control of a Health Maintenance Organization | ||||||
17 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||||||
18 | (1) the Director shall give primary consideration to | ||||||
19 | the continuation of benefits to enrollees and the | ||||||
20 | financial conditions of the acquired Health Maintenance | ||||||
21 | Organization after the merger, consolidation, or other | ||||||
22 | acquisition of control takes effect; | ||||||
23 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
24 | Section 131.8 of the Illinois Insurance Code shall not | ||||||
25 | apply and (ii) the Director, in making his determination | ||||||
26 | with respect to the merger, consolidation, or other |
| |||||||
| |||||||
1 | acquisition of control, need not take into account the | ||||||
2 | effect on competition of the merger, consolidation, or | ||||||
3 | other acquisition of control; | ||||||
4 | (3) the Director shall have the power to require the | ||||||
5 | following information: | ||||||
6 | (A) certification by an independent actuary of the | ||||||
7 | adequacy of the reserves of the Health Maintenance | ||||||
8 | Organization sought to be acquired; | ||||||
9 | (B) pro forma financial statements reflecting the | ||||||
10 | combined balance sheets of the acquiring company and | ||||||
11 | the Health Maintenance Organization sought to be | ||||||
12 | acquired as of the end of the preceding year and as of | ||||||
13 | a date 90 days prior to the acquisition, as well as pro | ||||||
14 | forma financial statements reflecting projected | ||||||
15 | combined operation for a period of 2 years; | ||||||
16 | (C) a pro forma business plan detailing an | ||||||
17 | acquiring party's plans with respect to the operation | ||||||
18 | of the Health Maintenance Organization sought to be | ||||||
19 | acquired for a period of not less than 3 years; and | ||||||
20 | (D) such other information as the Director shall | ||||||
21 | require. | ||||||
22 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
23 | Insurance Code and this Section 5-3 shall apply to the sale by | ||||||
24 | any health maintenance organization of greater than 10% of its | ||||||
25 | enrollee population (including, without limitation, the health | ||||||
26 | maintenance organization's right, title, and interest in and |
| |||||||
| |||||||
1 | to its health care certificates). | ||||||
2 | (e) In considering any management contract or service | ||||||
3 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
4 | Code, the Director (i) shall, in addition to the criteria | ||||||
5 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
6 | take into account the effect of the management contract or | ||||||
7 | service agreement on the continuation of benefits to enrollees | ||||||
8 | and the financial condition of the health maintenance | ||||||
9 | organization to be managed or serviced, and (ii) need not take | ||||||
10 | into account the effect of the management contract or service | ||||||
11 | agreement on competition. | ||||||
12 | (f) Except for small employer groups as defined in the | ||||||
13 | Small Employer Rating, Renewability and Portability Health | ||||||
14 | Insurance Act and except for medicare supplement policies as | ||||||
15 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
16 | Health Maintenance Organization may by contract agree with a | ||||||
17 | group or other enrollment unit to effect refunds or charge | ||||||
18 | additional premiums under the following terms and conditions: | ||||||
19 | (i) the amount of, and other terms and conditions with | ||||||
20 | respect to, the refund or additional premium are set forth | ||||||
21 | in the group or enrollment unit contract agreed in advance | ||||||
22 | of the period for which a refund is to be paid or | ||||||
23 | additional premium is to be charged (which period shall | ||||||
24 | not be less than one year); and | ||||||
25 | (ii) the amount of the refund or additional premium | ||||||
26 | shall not exceed 20% of the Health Maintenance |
| |||||||
| |||||||
1 | Organization's profitable or unprofitable experience with | ||||||
2 | respect to the group or other enrollment unit for the | ||||||
3 | period (and, for purposes of a refund or additional | ||||||
4 | premium, the profitable or unprofitable experience shall | ||||||
5 | be calculated taking into account a pro rata share of the | ||||||
6 | Health Maintenance Organization's administrative and | ||||||
7 | marketing expenses, but shall not include any refund to be | ||||||
8 | made or additional premium to be paid pursuant to this | ||||||
9 | subsection (f)). The Health Maintenance Organization and | ||||||
10 | the group or enrollment unit may agree that the profitable | ||||||
11 | or unprofitable experience may be calculated taking into | ||||||
12 | account the refund period and the immediately preceding 2 | ||||||
13 | plan years. | ||||||
14 | The Health Maintenance Organization shall include a | ||||||
15 | statement in the evidence of coverage issued to each enrollee | ||||||
16 | describing the possibility of a refund or additional premium, | ||||||
17 | and upon request of any group or enrollment unit, provide to | ||||||
18 | the group or enrollment unit a description of the method used | ||||||
19 | to calculate (1) the Health Maintenance Organization's | ||||||
20 | profitable experience with respect to the group or enrollment | ||||||
21 | unit and the resulting refund to the group or enrollment unit | ||||||
22 | or (2) the Health Maintenance Organization's unprofitable | ||||||
23 | experience with respect to the group or enrollment unit and | ||||||
24 | the resulting additional premium to be paid by the group or | ||||||
25 | enrollment unit. | ||||||
26 | In no event shall the Illinois Health Maintenance |
| |||||||
| |||||||
1 | Organization Guaranty Association be liable to pay any | ||||||
2 | contractual obligation of an insolvent organization to pay any | ||||||
3 | refund authorized under this Section. | ||||||
4 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
5 | if any, is conditioned on the rules being adopted in | ||||||
6 | accordance with all provisions of the Illinois Administrative | ||||||
7 | Procedure Act and all rules and procedures of the Joint | ||||||
8 | Committee on Administrative Rules; any purported rule not so | ||||||
9 | adopted, for whatever reason, is unauthorized. | ||||||
10 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
11 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
12 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
13 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
14 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
15 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
16 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
17 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||||||
18 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
19 | eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; | ||||||
20 | 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. | ||||||
21 | 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, | ||||||
22 | eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; | ||||||
23 | 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff. | ||||||
24 | 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised | ||||||
25 | 11-26-24.) |
| |||||||
| |||||||
1 | Section 95. No acceleration or delay. Where this Act makes | ||||||
2 | changes in a statute that is represented in this Act by text | ||||||
3 | that is not yet or no longer in effect (for example, a Section | ||||||
4 | represented by multiple versions), the use of that text does | ||||||
5 | not accelerate or delay the taking effect of (i) the changes | ||||||
6 | made by this Act or (ii) provisions derived from any other | ||||||
7 | Public Act. |