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95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008 HB4223
Introduced , by Rep. Mary E. Flowers - LaShawn K. Ford - Karen May SYNOPSIS AS INTRODUCED: |
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Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, and the Voluntary Health Services Plans Act. Provides that a policy of accident or health insurance or managed care plan shall establish and maintain an appeals procedure related to the denial of health care benefits. Sets forth guidelines for maintaining an appeals procedure, including an expedited process for an enrollee with an ongoing course of treatment ordered
by a health care provider,
the denial of which could significantly
increase the risk to an
enrollee's health,
or a treatment referral, service,
procedure, or other health care service,
the denial of which could significantly
increase the risk to an
enrollee's health. Provides that if an initial appeal is denied by the policy or plan, an enrollee is entitled to seek external independent review of the decision made by the policy or plan. Sets forth guidelines and requirements for the external independent review process. Provides that nothing in the provision shall be construed to require a policy or
plan to pay for a health care service not covered under the enrollee's
certificate of coverage or policy. Provides that the Office of Consumer Health Insurance of the Division of Insurance of the Department of Financial and Professional Regulation shall adopt rules for the enforcement of the provision. Makes other changes.
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FISCAL NOTE ACT MAY APPLY | |
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT |
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A BILL FOR
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 5. The State Employees Group Insurance Act of 1971 |
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| is amended by changing Section 6.11 as follows:
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| (5 ILCS 375/6.11)
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| Sec. 6.11. Required health benefits; Illinois Insurance |
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| Code
requirements. The program of health
benefits shall provide |
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| the post-mastectomy care benefits required to be covered
by a |
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| policy of accident and health insurance under Section 356t of |
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| the Illinois
Insurance Code. The program of health benefits |
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| shall provide the coverage
required under Sections 356f.1, |
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| 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, |
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| and 356z.10
356z.9 of the
Illinois Insurance Code.
The program |
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| of health benefits must comply with Section 155.37 of the
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| Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 10. The Counties Code is amended by changing |
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| Section 5-1069.3 as follows: |
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| (55 ILCS 5/5-1069.3)
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| Sec. 5-1069.3. Required health benefits. If a county, |
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| including a home
rule
county, is a self-insurer for purposes of |
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| providing health insurance coverage
for its employees, the |
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| coverage shall include coverage for the post-mastectomy
care |
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| benefits required to be covered by a policy of accident and |
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| health
insurance under Section 356t and the coverage required |
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| under Sections 356f.1, 356g.5, 356u,
356w, 356x, 356z.6, and |
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| 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The |
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| requirement that health benefits be covered
as provided in this |
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| Section is an
exclusive power and function of the State and is |
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| a denial and limitation under
Article VII, Section 6, |
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| subsection (h) of the Illinois Constitution. A home
rule county |
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| to which this Section applies must comply with every provision |
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| of
this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 15. The Illinois Municipal Code is amended by |
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| changing Section 10-4-2.3 as follows: |
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| (65 ILCS 5/10-4-2.3)
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| Sec. 10-4-2.3. Required health benefits. If a |
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| municipality, including a
home rule municipality, is a |
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| self-insurer for purposes of providing health
insurance |
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| coverage for its employees, the coverage shall include coverage |
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| for
the post-mastectomy care benefits required to be covered by |
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| a policy of
accident and health insurance under Section 356t |
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| and the coverage required
under Sections 356f.1, 356g.5, 356u, |
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| 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the |
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| Illinois
Insurance
Code. The requirement that health
benefits |
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| be covered as provided in this is an exclusive power and |
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| function of
the State and is a denial and limitation under |
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| Article VII, Section 6,
subsection (h) of the Illinois |
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| Constitution. A home rule municipality to which
this Section |
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| applies must comply with every provision of this Section.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 20. The School Code is amended by changing Section |
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| 10-22.3f as follows: |
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| (105 ILCS 5/10-22.3f)
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| Sec. 10-22.3f. Required health benefits. Insurance |
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| protection and
benefits
for employees shall provide the |
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| post-mastectomy care benefits required to be
covered by a |
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| policy of accident and health insurance under Section 356t and |
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| the
coverage required under Sections 356f.1, 356g.5, 356u, |
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| 356w, 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
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| revised 12-4-07.)
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| Section 25. The Illinois Insurance Code is amended by |
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LRB095 15305 KBJ 41293 b |
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| adding Section 356f.1 as follows: |
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| (215 ILCS 5/356f.1 new) |
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| Sec. 356f.1. Health care services appeals,
complaints, and
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| external independent reviews. |
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| (a) A policy of accident or health insurance or managed |
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| care plan shall establish and maintain an appeals procedure as
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| outlined in this Section. Compliance with this Section's |
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| appeals procedures shall
satisfy a policy or plan's obligation |
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| to provide appeal procedures under any
other State law or |
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| rules. |
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| (b) When an appeal concerns a decision or action by a |
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| policy of accident or health insurance or managed care plan,
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| its
employees, or its subcontractors that relates to (i) health |
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| care services,
including, but not limited to, procedures or
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| treatments
for an enrollee with an ongoing course of treatment |
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| ordered
by a health care provider,
the denial of which could |
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| significantly
increase the risk to an
enrollee's health,
or |
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| (ii) a treatment referral, service,
procedure, or other health |
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| care service,
the denial of which could significantly
increase |
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| the risk to an
enrollee's health,
the policy or plan must allow |
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| for the filing of an appeal
either orally or in writing. Upon |
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| submission of the appeal, a policy or plan
must notify the |
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| party filing the appeal, as soon as possible, but in no event
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| more than 24 hours after the submission of the appeal, of all |
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| information
that the plan requires to evaluate the appeal.
The |
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LRB095 15305 KBJ 41293 b |
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| policy or plan shall render a decision on the appeal within
24 |
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| hours after receipt of the required information. The policy or |
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| plan shall
notify the party filing the
appeal and the enrollee, |
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| enrollee's primary care physician, and any health care
provider |
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| who recommended the health care service involved in the appeal |
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| of its
decision orally
followed-up by a written notice of the |
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| determination. |
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| (c) For all appeals related to health care services |
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| including, but not
limited to, procedures or treatments for an |
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| enrollee and not covered by
subsection (b) above, the policy or |
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| plan shall establish a procedure for the filing of such |
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| appeals. Upon
submission of an appeal under this subsection, a |
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| policy or plan must notify
the party filing an appeal, within 3 |
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| business days, of all information that the
policy or plan |
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| requires to evaluate the appeal.
The policy or plan shall |
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| render a decision on the appeal within 15 business
days after |
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| receipt of the required information. The policy or plan shall
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| notify the party filing the appeal,
the enrollee, the |
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| enrollee's primary care physician, and any health care
provider
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| who recommended the health care service involved in the appeal |
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| orally of its
decision followed-up by a written notice of the |
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| determination. |
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| (d) An appeal under subsection (b) or (c) may be filed by |
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| the
enrollee, the enrollee's designee or guardian, the |
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| enrollee's primary care
physician, or the enrollee's health |
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| care provider. A policy or plan shall
designate a clinical peer |
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LRB095 15305 KBJ 41293 b |
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| to review
appeals, because these appeals pertain to medical or |
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| clinical matters
and such an appeal must be reviewed by an |
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| appropriate
health care professional. No one reviewing an |
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| appeal may have had any
involvement
in the initial |
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| determination that is the subject of the appeal. The written
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| notice of determination required under subsections (b) and (c) |
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| shall
include (i) clear and detailed reasons for the |
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| determination, (ii)
the medical or
clinical criteria for the |
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| determination, which shall be based upon sound
clinical |
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| evidence and reviewed on a periodic basis, and (iii) in the |
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| case of an
adverse determination, the
procedures for requesting |
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| an external independent review under subsection (f). |
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| (e) If an appeal filed under subsection (b) or (c) is |
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| denied for a reason
including, but not limited to, the
service, |
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| procedure, or treatment is not viewed as medically necessary,
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| denial of specific tests or procedures, denial of referral
to |
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| specialist physicians or denial of hospitalization requests or |
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| length of
stay requests, any involved party may request an |
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| external independent review
under subsection (f) of the adverse |
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| determination. |
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| (f) The party seeking an external independent review shall |
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| so notify the
policy or plan.
The policy or plan shall seek to |
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| resolve all
external independent
reviews in the most |
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| expeditious manner and shall make a determination and
provide |
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| notice of the determination no more
than 24 hours after the |
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| receipt of all necessary information when a delay would
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| significantly increase
the risk to an enrollee's health or when |
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| extended health care services for an
enrollee undergoing a
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| course of treatment prescribed by a health care provider are at |
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| issue. |
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| (1) Within 30 days after the enrollee receives written |
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| notice of an
adverse
determination,
if the enrollee decides |
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| to initiate an external independent review, the
enrollee |
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| shall send to the policy or plan a written request for an |
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| external independent review, including any
information or
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| documentation to support the enrollee's request for the |
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| covered service or
claim for a covered
service. |
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| (2) Within 30 days after the policy or plan receives a |
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| request for an
external
independent review from an enrollee |
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| or, within 24 hours after the receipt of a request if a |
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| delay would significantly increase the risk to the |
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| enrollee's health, the policy or plan shall: |
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| (a) provide a mechanism for joint selection of an |
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| external independent
reviewer by the enrollee, the |
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| enrollee's physician or other health care
provider,
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| and the policy or plan; and |
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| (b) forward to the independent reviewer all |
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| medical records and
supporting
documentation |
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| pertaining to the case, a summary description of the |
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| applicable
issues including a
statement of the |
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| decision made by, the criteria used, and the
medical |
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| and clinical reasons
for that decision. |
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| (3) Within 5 days after receipt of all necessary |
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| information or within 24 hours when a delay would
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| significantly increase
the risk to an enrollee's health, |
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| the
independent
reviewer
shall evaluate and analyze the |
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| case and render a decision that is based on
whether or not |
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| the health
care service or claim for the health care |
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| service is medically appropriate. The
decision by the
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| independent reviewer is final. If the external independent |
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| reviewer determines
the health care
service to be medically
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| appropriate, the policy or plan shall pay for the health |
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| care service. |
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| (4) The policy or plan shall be solely responsible for |
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| paying the fees
of the external
independent reviewer who is |
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| selected to perform the review. |
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| (5) An external independent reviewer who acts in good |
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| faith shall have
immunity
from any civil or criminal |
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| liability or professional discipline as a result of
acts or |
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| omissions with
respect to any external independent review, |
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| unless the acts or omissions
constitute wilful and wanton
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| misconduct. For purposes of any proceeding, the good faith |
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| of the person
participating shall be
presumed. |
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| (6) Future contractual or employment action by the |
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| policy or plan
regarding the
patient's physician or other |
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| health care provider shall not be based solely on
the |
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| physician's or other
health care provider's participation |
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| in this procedure. |
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| (7) For the purposes of this Section, an external |
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| independent reviewer
shall: |
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| (a) be a clinical peer; |
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| (b) have no direct financial interest in |
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| connection with the case; and |
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| (c) have not been informed of the specific identity |
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| of the enrollee. |
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| (g) Nothing in this Section shall be construed to require a |
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| policy or
plan to pay for a health care service not covered |
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| under the enrollee's
certificate of coverage or policy. |
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| (h) The Office of Consumer Health Insurance of the Division |
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| of Insurance of the Department of Financial and Professional |
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| Regulation shall adopt rules for the enforcement of this |
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| Section.
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| Section 30. The Health Maintenance Organization Act is |
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| amended by changing Section 5-3 as follows:
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| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to |
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| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
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| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
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| 154.6,
154.7, 154.8, 155.04, 355.2, 356f.1, 356m, 356v, 356w, |
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| 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, |
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| 356z.10
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, |
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, |
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| 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section |
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| 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, |
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| XXV, and XXVI of the Illinois Insurance Code.
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| (b) For purposes of the Illinois Insurance Code, except for |
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| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
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| Maintenance Organizations in
the following categories are |
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| deemed to be "domestic companies":
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| (1) a corporation authorized under the
Dental Service |
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| Plan Act or the Voluntary Health Services Plans Act;
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| (2) a corporation organized under the laws of this |
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| State; or
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| (3) a corporation organized under the laws of another |
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| state, 30% or more
of the enrollees of which are residents |
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| of this State, except a
corporation subject to |
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| substantially the same requirements in its state of
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| organization as is a "domestic company" under Article VIII |
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| 1/2 of the
Illinois Insurance Code.
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| (c) In considering the merger, consolidation, or other |
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| acquisition of
control of a Health Maintenance Organization |
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| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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| (1) the Director shall give primary consideration to |
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| the continuation of
benefits to enrollees and the financial |
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| conditions of the acquired Health
Maintenance Organization |
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| after the merger, consolidation, or other
acquisition of |
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| control takes effect;
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LRB095 15305 KBJ 41293 b |
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| (2)(i) the criteria specified in subsection (1)(b) of |
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| Section 131.8 of
the Illinois Insurance Code shall not |
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| apply and (ii) the Director, in making
his determination |
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| with respect to the merger, consolidation, or other
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| acquisition of control, need not take into account the |
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| effect on
competition of the merger, consolidation, or |
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| other acquisition of control;
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| (3) the Director shall have the power to require the |
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| following
information:
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| (A) certification by an independent actuary of the |
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| adequacy
of the reserves of the Health Maintenance |
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| Organization sought to be acquired;
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| (B) pro forma financial statements reflecting the |
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| combined balance
sheets of the acquiring company and |
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| the Health Maintenance Organization sought
to be |
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| acquired as of the end of the preceding year and as of |
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| a date 90 days
prior to the acquisition, as well as pro |
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| forma financial statements
reflecting projected |
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| combined operation for a period of 2 years;
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| (C) a pro forma business plan detailing an |
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| acquiring party's plans with
respect to the operation |
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| of the Health Maintenance Organization sought to
be |
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| acquired for a period of not less than 3 years; and
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| (D) such other information as the Director shall |
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| require.
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| (d) The provisions of Article VIII 1/2 of the Illinois |
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LRB095 15305 KBJ 41293 b |
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| Insurance Code
and this Section 5-3 shall apply to the sale by |
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| any health maintenance
organization of greater than 10% of its
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| enrollee population (including without limitation the health |
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| maintenance
organization's right, title, and interest in and to |
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| its health care
certificates).
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| (e) In considering any management contract or service |
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| agreement subject
to Section 141.1 of the Illinois Insurance |
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| Code, the Director (i) shall, in
addition to the criteria |
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| specified in Section 141.2 of the Illinois
Insurance Code, take |
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| into account the effect of the management contract or
service |
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| agreement on the continuation of benefits to enrollees and the
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| financial condition of the health maintenance organization to |
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| be managed or
serviced, and (ii) need not take into account the |
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| effect of the management
contract or service agreement on |
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| competition.
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| (f) Except for small employer groups as defined in the |
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| Small Employer
Rating, Renewability and Portability Health |
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| Insurance Act and except for
medicare supplement policies as |
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| defined in Section 363 of the Illinois
Insurance Code, a Health |
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| Maintenance Organization may by contract agree with a
group or |
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| other enrollment unit to effect refunds or charge additional |
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| premiums
under the following terms and conditions:
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| (i) the amount of, and other terms and conditions with |
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| respect to, the
refund or additional premium are set forth |
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| in the group or enrollment unit
contract agreed in advance |
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| of the period for which a refund is to be paid or
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| additional premium is to be charged (which period shall not |
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| be less than one
year); and
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| (ii) the amount of the refund or additional premium |
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| shall not exceed 20%
of the Health Maintenance |
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| Organization's profitable or unprofitable experience
with |
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| respect to the group or other enrollment unit for the |
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| period (and, for
purposes of a refund or additional |
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| premium, the profitable or unprofitable
experience shall |
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| be calculated taking into account a pro rata share of the
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| Health Maintenance Organization's administrative and |
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| marketing expenses, but
shall not include any refund to be |
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| made or additional premium to be paid
pursuant to this |
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| subsection (f)). The Health Maintenance Organization and |
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| the
group or enrollment unit may agree that the profitable |
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| or unprofitable
experience may be calculated taking into |
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| account the refund period and the
immediately preceding 2 |
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| plan years.
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| The Health Maintenance Organization shall include a |
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| statement in the
evidence of coverage issued to each enrollee |
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| describing the possibility of a
refund or additional premium, |
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| and upon request of any group or enrollment unit,
provide to |
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| the group or enrollment unit a description of the method used |
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| to
calculate (1) the Health Maintenance Organization's |
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| profitable experience with
respect to the group or enrollment |
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| unit and the resulting refund to the group
or enrollment unit |
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| or (2) the Health Maintenance Organization's unprofitable
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HB4223 |
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LRB095 15305 KBJ 41293 b |
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| experience with respect to the group or enrollment unit and the |
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| resulting
additional premium to be paid by the group or |
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| enrollment unit.
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| In no event shall the Illinois Health Maintenance |
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| Organization
Guaranty Association be liable to pay any |
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| contractual obligation of an
insolvent organization to pay any |
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| refund authorized under this Section.
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| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; |
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| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 35. The Limited Health Service Organization Act is |
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| amended by changing Section 4003 as follows:
|
12 |
| (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
|
13 |
| Sec. 4003. Illinois Insurance Code provisions. Limited |
14 |
| health service
organizations shall be subject to the provisions |
15 |
| of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, |
16 |
| 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, |
17 |
| 155.04, 155.37, 355.2, 356f.1, 356v, 356z.10
356z.9 , 368a, 401, |
18 |
| 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and |
19 |
| Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and |
20 |
| XXVI of the Illinois Insurance Code. For purposes of the
|
21 |
| Illinois Insurance Code, except for Sections 444 and 444.1 and |
22 |
| Articles XIII
and XIII 1/2, limited health service |
23 |
| organizations in the following categories
are deemed to be |
24 |
| domestic companies:
|
|
|
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1 |
| (1) a corporation under the laws of this State; or
|
2 |
| (2) a corporation organized under the laws of another |
3 |
| state, 30% of more
of the enrollees of which are residents |
4 |
| of this State, except a corporation
subject to |
5 |
| substantially the same requirements in its state of |
6 |
| organization as
is a domestic company under Article VIII |
7 |
| 1/2 of the Illinois Insurance Code.
|
8 |
| (Source: P.A. 95-520, eff. 8-28-07; revised 12-5-07.)
|
9 |
| Section 40. 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 |
| 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, 356f.1, 356g.5, 356r, 356t, 356u, |
17 |
| 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, |
18 |
| 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, |
19 |
| 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
20 |
| and (15) of Section 367 of the Illinois
Insurance Code.
|
21 |
| (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; |
22 |
| 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. |
23 |
| 8-28-07; revised 12-5-07.)
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| 1 |
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INDEX
| 2 |
|
Statutes amended in order of appearance
|
| 3 |
| 5 ILCS 375/6.11 |
|
| 4 |
| 55 ILCS 5/5-1069.3 |
|
| 5 |
| 65 ILCS 5/10-4-2.3 |
|
| 6 |
| 105 ILCS 5/10-22.3f |
|
| 7 |
| 215 ILCS 5/356f.1 new |
|
| 8 |
| 215 ILCS 125/5-3 |
from Ch. 111 1/2, par. 1411.2 |
| 9 |
| 215 ILCS 130/4003 |
from Ch. 73, par. 1504-3 |
| 10 |
| 215 ILCS 165/10 |
from Ch. 32, par. 604 |
|
|