HB5285 Re-Enrolled

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 
5
is amended  by changing Section 6.11 as follows:
 


6
    (5 ILCS 375/6.11)


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

13
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, 
14
356z.11, and 356z.12 and
356z.9 of the
Illinois Insurance Code.

15
The program of health benefits must comply with Section 155.37 
16
of 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, 356z.11, and 356z.12 and
356z.9 of
the Illinois 
9
Insurance Code.  The requirement that health benefits be covered

10
as provided in this Section is an
exclusive power and function 
11
of the State and is a denial and limitation under
Article VII, 
12
Section 6, subsection (h) of the Illinois Constitution.  A home

13
rule county to which this Section applies must comply with 
14
every provision 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:
 
19
    (65 ILCS 5/10-4-2.3)

20
    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, 356z.11, and 356z.12 and

4
356z.9 of the Illinois
Insurance
Code.  The requirement that 
5
health
benefits be covered as provided in this is an exclusive 
6
power and function of
the State and is a denial and limitation 
7
under 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:
 
14
    (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, 356z.11, and 356z.12 of
the
Illinois 
21
Insurance Code.


22
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; 
23
revised 12-4-07.)

 
 


 






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    Section 25. The Illinois Insurance Code is amended  by 
2
adding Section 356z.11 and Section 356z.12 as follows:
 
3
    (215 ILCS 5/356z.11  new)
4
    Sec. 356z.11. Dependent students; medical leave of 
5
absence.  A group or individual policy of accident and health 
6
insurance or managed care plan amended, delivered, issued, or 
7
renewed after the effective date of this amendatory Act of the 
8
95th General Assembly must continue to provide coverage for a 
9
dependent college student who takes a medical leave of absence 
10
or reduces his or her course load to part-time status because 
11
of a catastrophic illness or injury.
12
    Continuation of coverage under this Section is subject to 
13
all of the policy's terms and
conditions applicable to those 
14
forms of insurance. Continuation of insurance under the policy 
15
shall terminate  12 months after notice of the illness or injury 
16
or until the coverage would have otherwise lapsed pursuant to 
17
the terms and conditions of the policy, whichever comes first, 
18
provided the need for part-time status or medical leave of 
19
absence is supported by a clinical certification of need from a 
20
physician licensed to practice medicine in all its branches.
21
    The provisions of this Section do not apply to short-term 
22
travel, accident-only, limited, or specified disease policies 
23
or to policies or contracts designed for issuance to persons 
24
eligible for coverage under Title XVIII of the Social Security 
25
Act, known as Medicare, or any other similar coverage under 
 


 






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State or federal governmental plans.
 
2
    (215 ILCS 5/356z.12  new)
3
    Sec. 356z.12. Dependent coverage. 
4
    (a) A group or individual policy of accident and health 
5
insurance or managed care plan that provides coverage for 
6
dependents and that is amended, delivered, issued, or renewed 
7
after the effective date of this amendatory Act of the 95th 
8
General Assembly shall not terminate coverage or deny the 
9
election of coverage for an unmarried dependent by reason of 
10
the dependent's age before the dependent's 26th birthday.
11
    (b)  A policy or plan subject to this Section shall, upon 
12
amendment, delivery, issuance, or renewal, establish an 
13
initial enrollment period of not less than 90 days during which 
14
an insured may make a written election for coverage of an 
15
unmarried person as a dependent under this Section.  After the 
16
initial enrollment period, enrollment by a dependent pursuant 
17
to this Section shall be consistent with the enrollment terms 
18
of the plan or policy.
19
    (c)  A policy or plan subject to this Section shall allow 
20
for dependent coverage during the annual open enrollment date 
21
or the annual renewal date if the dependent, as of the date on 
22
which the insured elects dependent coverage under this 
23
subsection, has:
24
        (1) a period of continuous creditable coverage of 90 
25
    days or more; and
 


 






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        (2) not been without creditable coverage for more than 
2
    63 days.
3
An insured may elect coverage for a dependent who does not meet 
4
the continuous creditable coverage requirements of this 
5
subsection (c) and that dependent shall not be denied coverage 
6
due to age. 
7
    For purposes of this subsection (c), "creditable coverage" 
8
shall have the meaning provided under subsection (C)(1) of 
9
Section 20 of the Illinois Health Insurance Portability and 
10
Accountability Act. 
11
    (d) Military personnel. A group or individual policy of 
12
accident and health insurance or managed care plan that 
13
provides coverage for dependents and that is amended, 
14
delivered, issued, or renewed after the effective date of this 
15
amendatory Act of the 95th General Assembly shall not terminate 
16
coverage or deny the election of coverage for an unmarried 
17
dependent by reason of the dependent's age before the 
18
dependent's 30th birthday if the dependent (i) is an Illinois 
19
resident, (ii) served as a member of the active or reserve 
20
components of any of the branches of the Armed Forces of the 
21
United States, and (iii) has received a release or discharge 
22
other than a dishonorable discharge. To be eligible for 
23
coverage under this subsection (d), the eligible dependent 
24
shall submit to the insurer a form approved by the Illinois 
25
Department of Veterans' Affairs stating the date on which the 
26
dependent was released from service.
 


 






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    (e) Calculation of the cost of coverage provided to an 
2
unmarried dependent under this Section shall be identical.
3
    (f) Nothing in this Section shall prohibit an employer from 
4
requiring an employee to pay all or part of the cost of 
5
coverage provided under this Section.
6
    (g) No exclusions or limitations may be applied to coverage 
7
elected pursuant to this Section that do not apply to all 
8
dependents covered under the policy.
9
    (h) A policy or plan subject to this Section shall not 
10
condition eligibility for dependent coverage provided pursuant 
11
to this Section on enrollment in any educational institution.
12
    (i) Notice regarding coverage for a dependent as provided 
13
pursuant to this Section shall be provided to an insured by the 
14
insurer: 
15
        (1) upon application or enrollment;
16
        (2) in the certificate of coverage or equivalent 
17
    document prepared for an insured and delivered on or about 
18
    the date on which the coverage commences; and
19
        (3) in a notice delivered to an insured on a 
20
    semi-annual basis. 
 
21
    Section 30. The Health Maintenance Organization Act is 
22
amended  by changing Section 5-3 as follows:
 


23
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)



24
    Sec. 5-3. Insurance Code provisions. 

 


 






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    (a) Health Maintenance Organizations
shall be subject to 
2
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
3
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
4
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
5
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 
6
356z.11, 356z.12
356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 
7
368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 
8
408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection 
9
(2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, 
10
XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

11
    (b) For purposes of the Illinois Insurance Code, except for 
12
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
13
Maintenance Organizations in
the following categories are 
14
deemed to be "domestic companies":


15
        (1) a corporation authorized under the
Dental Service 
16
    Plan Act or the Voluntary Health Services Plans Act;


17
        (2) a corporation organized under the laws of this 
18
    State; or


19
        (3) a corporation organized under the laws of another 
20
    state, 30% or more
of the enrollees of which are residents 
21
    of this State, except a
corporation subject to 
22
    substantially the same requirements in its state of

23
    organization as is a "domestic company" under Article VIII 
24
    1/2 of the
Illinois Insurance Code.

25
    (c) In considering the merger, consolidation, or other 
26
acquisition of
control of a Health Maintenance Organization 
 


 






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pursuant to Article VIII 1/2
of the Illinois Insurance Code,


2
        (1) the Director shall give primary consideration to 
3
    the continuation of
benefits to enrollees and the financial 
4
    conditions of the acquired Health
Maintenance Organization 
5
    after the merger, consolidation, or other
acquisition of 
6
    control takes effect;


7
        (2)(i) the criteria specified in subsection (1)(b) of 
8
    Section 131.8 of
the Illinois Insurance Code shall not 
9
    apply and (ii) the Director, in making
his determination 
10
    with respect to the merger, consolidation, or other

11
    acquisition of control, need not take into account the 
12
    effect on
competition of the merger, consolidation, or 
13
    other acquisition of control;


14
        (3) the Director shall have the power to require the 
15
    following
information:


16
            (A) certification by an independent actuary of the 
17
        adequacy
of the reserves of the Health Maintenance 
18
        Organization sought to be acquired;


19
            (B) pro forma financial statements reflecting the 
20
        combined balance
sheets of the acquiring company and 
21
        the Health Maintenance Organization sought
to be 
22
        acquired as of the end of the preceding year and as of 
23
        a date 90 days
prior to the acquisition, as well as pro 
24
        forma financial statements
reflecting projected 
25
        combined operation for a period of 2 years;


26
            (C) a pro forma business plan detailing an 
 


 






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        acquiring party's plans with
respect to the operation 
2
        of the Health Maintenance Organization sought to
be 
3
        acquired for a period of not less than 3 years; and


4
            (D) such other information as the Director shall 
5
        require.

6
    (d) The provisions of Article VIII 1/2 of the Illinois 
7
Insurance Code
and this Section 5-3 shall apply to the sale by 
8
any health maintenance
organization of greater than 10% of its

9
enrollee population (including without limitation the health 
10
maintenance
organization's right, title, and interest in and to 
11
its health care
certificates).

12
    (e) In considering any management contract or service 
13
agreement subject
to Section 141.1 of the Illinois Insurance 
14
Code, the Director (i) shall, in
addition to the criteria 
15
specified in Section 141.2 of the Illinois
Insurance Code, take 
16
into account the effect of the management contract or
service 
17
agreement on the continuation of benefits to enrollees and the

18
financial condition of the health maintenance organization to 
19
be managed or
serviced, and (ii) need not take into account the 
20
effect of the management
contract or service agreement on 
21
competition.

22
    (f) Except for small employer groups as defined in the 
23
Small Employer
Rating, Renewability and Portability Health 
24
Insurance Act and except for
medicare supplement policies as 
25
defined in Section 363 of the Illinois
Insurance Code, a Health 
26
Maintenance Organization may by contract agree with a
group or 
 


 






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1
other enrollment unit to effect refunds or charge additional 
2
premiums
under the following terms and conditions:


3
        (i) the amount of, and other terms and conditions with 
4
    respect to, the
refund or additional premium are set forth 
5
    in the group or enrollment unit
contract agreed in advance 
6
    of the period for which a refund is to be paid or

7
    additional premium is to be charged (which period shall not 
8
    be less than one
year); and


9
        (ii) the amount of the refund or additional premium 
10
    shall not exceed 20%
of the Health Maintenance 
11
    Organization's profitable or unprofitable experience
with 
12
    respect to the group or other enrollment unit for the 
13
    period (and, for
purposes of a refund or additional 
14
    premium, the profitable or unprofitable
experience shall 
15
    be calculated taking into account a pro rata share of the

16
    Health Maintenance Organization's administrative and 
17
    marketing expenses, but
shall not include any refund to be 
18
    made or additional premium to be paid
pursuant to this 
19
    subsection (f)).  The Health Maintenance Organization and 
20
    the
group or enrollment unit may agree that the profitable 
21
    or unprofitable
experience may be calculated taking into 
22
    account the refund period and the
immediately preceding 2 
23
    plan years.

24
    The Health Maintenance Organization shall include a 
25
statement in the
evidence of coverage issued to each enrollee 
26
describing the possibility of a
refund or additional premium, 
 


 






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and upon request of any group or enrollment unit,
provide to 
2
the group or enrollment unit a description of the method used 
3
to
calculate (1) the Health Maintenance Organization's 
4
profitable experience with
respect to the group or enrollment 
5
unit and the resulting refund to the group
or enrollment unit 
6
or (2) the Health Maintenance Organization's unprofitable

7
experience with respect to the group or enrollment unit and the 
8
resulting
additional premium to be paid by the group or 
9
enrollment unit.

10
    In no event shall the Illinois Health Maintenance 
11
Organization
Guaranty Association be liable to pay any 
12
contractual obligation of an
insolvent organization to pay any 
13
refund authorized under this Section.

14
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
15
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)

 
16
    Section 35. The Voluntary Health Services Plans Act is 
17
amended  by changing Section 10 as follows:
 



18
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


19
    Sec. 10. Application of Insurance Code provisions. Health 
20
services
plan corporations and all persons interested therein 
21
or dealing therewith
shall be subject to the provisions of 
22
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
23
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
24
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
 


 






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356z.9,
356z.10, 356z.11, 356z.12
356z.9, 364.01, 367.2, 368a, 
2
401, 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs 
3
(7) and (15) of Section 367 of the Illinois
Insurance Code.

4
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
5
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
6
8-28-07; revised 12-5-07.)