HB5285 Engrossed

LRB095 17860 KBJ 43940 b






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    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 
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is amended  by changing Section 6.11 as follows:
 


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    (5 ILCS 375/6.11)


7
    Sec. 6.11. Required health benefits; Illinois Insurance 
8
Code
requirements.  The program of health
benefits shall provide 
9
the post-mastectomy care benefits required to be covered
by a 
10
policy of accident and health insurance under Section 356t of 
11
the Illinois
Insurance Code.  The program of health benefits 
12
shall provide the coverage
required under Sections 356g.5,

13
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, 
14
and 356z.11 and
356z.9 of the
Illinois Insurance Code.
The 
15
program of health benefits must comply with Section 155.37 of 
16
the
Illinois Insurance Code.

17
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
18
95-520, eff. 8-28-07; revised 12-4-07.)

 
19
    Section 10. The Counties Code is amended  by changing 
20
Section 5-1069.3 as follows:
 
21
    (55 ILCS 5/5-1069.3)

 


 






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    Sec. 5-1069.3. Required health benefits.   If a county, 
2
including a home
rule
county, is a self-insurer for purposes of 
3
providing health insurance coverage
for its employees, the 
4
coverage shall include coverage for the post-mastectomy
care 
5
benefits required to be covered by a policy of accident and 
6
health
insurance under Section 356t and the coverage required 
7
under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, 
8
356z.10, and 356z.11 and
356z.9 of
the Illinois Insurance Code.  
9
The requirement that health benefits be covered
as provided in 
10
this Section is an
exclusive power and function of the State 
11
and is a denial and limitation under
Article VII, Section 6, 
12
subsection (h) of the Illinois Constitution.  A home
rule county 
13
to which this Section applies must comply with every provision 
14
of
this Section.


15
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
16
95-520, eff. 8-28-07; revised 12-4-07.)

 
17
    Section 15. The Illinois Municipal Code is amended  by 
18
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 
21
municipality, including a
home rule municipality, is a 
22
self-insurer for purposes of providing health
insurance 
23
coverage for its employees, the coverage shall include coverage 
24
for
the post-mastectomy care benefits required to be covered by 
 


 






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a policy of
accident and health insurance under Section 356t 
2
and the coverage required
under Sections 356g.5, 356u, 356w, 
3
356x, 356z.6, and 356z.9, 356z.10, and 356z.11 and
356z.9 of 
4
the Illinois
Insurance
Code.  The requirement that health

5
benefits be covered as provided in this is an exclusive power 
6
and function of
the State and is a denial and limitation under 
7
Article VII, Section 6,
subsection (h) of the Illinois 
8
Constitution.  A home rule municipality to which
this Section 
9
applies must comply with every provision of this Section.


10
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
11
95-520, eff. 8-28-07; revised 12-4-07.)

 
12
    Section 20. The School Code is amended  by changing Section 
13
10-22.3f as follows:
 
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    (105 ILCS 5/10-22.3f)

15
    Sec. 10-22.3f. Required health benefits.   Insurance 
16
protection and
benefits
for employees shall provide the 
17
post-mastectomy care benefits required to be
covered by a 
18
policy of accident and health insurance under Section 356t and 
19
the
coverage required under Sections 356g.5, 356u, 356w, 356x,


20
356z.6, and 356z.9, and 356z.11 of
the
Illinois Insurance Code.


21
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
22
revised 12-4-07.)

 
23
    Section 25. The Illinois Insurance Code is amended  by 
 


 






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adding Section 356z.11 as follows:
 
2
    (215 ILCS 5/356z.11  new)
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    Sec. 356z.11. Dependent students; medical leave of 
4
absence.  A group or individual policy of accident and health 
5
insurance or managed care plan amended, delivered, issued, or 
6
renewed after the effective date of this amendatory Act of the 
7
95th General Assembly must continue to provide coverage for a 
8
dependent college student who takes a medical leave of absence 
9
or reduces his or her course load to part-time status because 
10
of a catastrophic illness or injury.
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    Continuation of coverage under this Section is subject to 
12
all of the policy's terms and
conditions applicable to those 
13
forms of insurance. Continuation of insurance under the policy 
14
shall terminate  12 months after notice of the illness or injury 
15
or until the coverage would have otherwise lapsed pursuant to 
16
the terms and conditions of the policy, whichever comes first, 
17
provided the need for part-time status or medical leave of 
18
absence is supported by a clinical certification of need from a 
19
physician licensed to practice medicine in all its branches.
20
    The provisions of this Section do not apply to short-term 
21
travel, accident-only, limited, or specified disease policies 
22
or to policies or contracts designed for issuance to persons 
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eligible for coverage under Title XVIII of the Social Security 
24
Act, known as Medicare, or any other similar coverage under 
25
State or federal governmental plans.
 
 


 






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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. 

5
    (a) Health Maintenance Organizations
shall be subject to 
6
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
7
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
8
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
9
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 
10
356z.11
356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 
11
368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 
12
412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section 
13
367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, 
14
XXV, and XXVI of the Illinois Insurance Code.

15
    (b) For purposes of the Illinois Insurance Code, except for 
16
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
17
Maintenance Organizations in
the following categories are 
18
deemed to be "domestic companies":


19
        (1) a corporation authorized under the
Dental Service 
20
    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 
2
    substantially the same requirements in its state of

3
    organization as is a "domestic company" under Article VIII 
4
    1/2 of the
Illinois Insurance Code.

5
    (c) In considering the merger, consolidation, or other 
6
acquisition of
control of a Health Maintenance Organization 
7
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


8
        (1) the Director shall give primary consideration to 
9
    the continuation of
benefits to enrollees and the financial 
10
    conditions of the acquired Health
Maintenance Organization 
11
    after the merger, consolidation, or other
acquisition of 
12
    control takes effect;


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        (2)(i) the criteria specified in subsection (1)(b) of 
14
    Section 131.8 of
the Illinois Insurance Code shall not 
15
    apply and (ii) the Director, in making
his determination 
16
    with respect to the merger, consolidation, or other

17
    acquisition of control, need not take into account the 
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    effect on
competition of the merger, consolidation, or 
19
    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 
2
        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 
4
        forma financial statements
reflecting projected 
5
        combined operation for a period of 2 years;


6
            (C) a pro forma business plan detailing an 
7
        acquiring party's plans with
respect to the operation 
8
        of the Health Maintenance Organization sought to
be 
9
        acquired for a period of not less than 3 years; and


10
            (D) such other information as the Director shall 
11
        require.

12
    (d) The provisions of Article VIII 1/2 of the Illinois 
13
Insurance Code
and this Section 5-3 shall apply to the sale by 
14
any health maintenance
organization of greater than 10% of its

15
enrollee population (including without limitation the health 
16
maintenance
organization's right, title, and interest in and to 
17
its health care
certificates).

18
    (e) In considering any management contract or service 
19
agreement subject
to Section 141.1 of the Illinois Insurance 
20
Code, the Director (i) shall, in
addition to the criteria 
21
specified in Section 141.2 of the Illinois
Insurance Code, take 
22
into account the effect of the management contract or
service 
23
agreement on the continuation of benefits to enrollees and the

24
financial condition of the health maintenance organization to 
25
be managed or
serviced, and (ii) need not take into account the 
26
effect of the management
contract or service agreement on 
 


 






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competition.

2
    (f) Except for small employer groups as defined in the 
3
Small Employer
Rating, Renewability and Portability Health 
4
Insurance Act and except for
medicare supplement policies as 
5
defined in Section 363 of the Illinois
Insurance Code, a Health 
6
Maintenance Organization may by contract agree with a
group or 
7
other enrollment unit to effect refunds or charge additional 
8
premiums
under the following terms and conditions:


9
        (i) the amount of, and other terms and conditions with 
10
    respect to, the
refund or additional premium are set forth 
11
    in the group or enrollment unit
contract agreed in advance 
12
    of the period for which a refund is to be paid or

13
    additional premium is to be charged (which period shall not 
14
    be less than one
year); and


15
        (ii) the amount of the refund or additional premium 
16
    shall not exceed 20%
of the Health Maintenance 
17
    Organization's profitable or unprofitable experience
with 
18
    respect to the group or other enrollment unit for the 
19
    period (and, for
purposes of a refund or additional 
20
    premium, the profitable or unprofitable
experience shall 
21
    be calculated taking into account a pro rata share of the

22
    Health Maintenance Organization's administrative and 
23
    marketing expenses, but
shall not include any refund to be 
24
    made or additional premium to be paid
pursuant to this 
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    subsection (f)).  The Health Maintenance Organization and 
26
    the
group or enrollment unit may agree that the profitable 
 


 






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    or unprofitable
experience may be calculated taking into 
2
    account the refund period and the
immediately preceding 2 
3
    plan years.

4
    The Health Maintenance Organization shall include a 
5
statement in the
evidence of coverage issued to each enrollee 
6
describing the possibility of a
refund or additional premium, 
7
and upon request of any group or enrollment unit,
provide to 
8
the group or enrollment unit a description of the method used 
9
to
calculate (1) the Health Maintenance Organization's 
10
profitable experience with
respect to the group or enrollment 
11
unit and the resulting refund to the group
or enrollment unit 
12
or (2) the Health Maintenance Organization's unprofitable

13
experience with respect to the group or enrollment unit and the 
14
resulting
additional premium to be paid by the group or 
15
enrollment unit.

16
    In no event shall the Illinois Health Maintenance 
17
Organization
Guaranty Association be liable to pay any 
18
contractual obligation of an
insolvent organization to pay any 
19
refund authorized under this Section.

20
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
21
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)

 
22
    Section 35. The Voluntary Health Services Plans Act is 
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amended  by changing Section 10 as follows:
 



24
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


 


 






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    Sec. 10. Application of Insurance Code provisions. Health 
2
services
plan corporations and all persons interested therein 
3
or dealing therewith
shall be subject to the provisions of 
4
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
5
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
6
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
7
356z.9,
356z.10, 356z.11
356z.9, 364.01, 367.2, 368a, 401, 
8
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) 
9
and (15) of Section 367 of the Illinois
Insurance Code.

10
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
11
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
12
8-28-07; revised 12-5-07.)