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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| AN ACT concerning regulation.
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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 1. Short title. This Act may be cited as the |
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| Premium and Loss Data Reporting Act. |
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| Section 5. Application. This Act shall apply to: (i) all |
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| insurers authorized to transact the class of business set forth |
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| in subsection (b) of Class 1 and subsection (a) of Class 2 of |
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| Section 4 of the Illinois Insurance Code; and (ii) all health |
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| plans authorized under the Health Maintenance Organization |
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| Act. |
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| Section 10. Definitions. In this Act: |
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| "Accident only" means an insurance contract that provides |
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| coverage, alone or in combination, for death, dismemberment, |
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| disability, or hospital and medical care caused by or |
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| necessitated as a result of accident or specified kinds of |
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| accidents.
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| "Accidental death and dismemberment" means an insurance |
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| contract that pays a stated benefit in the event of death or |
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| dismemberment caused by accident or specified kinds of |
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| accidents.
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| "Administrative services only" means a contractual |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| arrangement utilized by a self-funded employer, whereby a |
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| separate company processes claims and provides other |
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| administrative services pertinent to the employer's health |
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| care plans. The fees associated with these services are |
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| included in this Act.
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| "Annual statement" means that statement required by |
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| Section 136 of the Illinois Insurance Code to be filed annually |
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| by the company with the Director. |
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| "Blanket accident/sickness" means a health insurance |
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| contract that covers all of a class of persons not individually |
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| identified in the contract. |
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| "Champus/Tricare supplement" means Civilian Health and |
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| Medical Program of the Uniformed Services (Champus). |
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| "Champus/Tricare supplement" also includes a private health |
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| plan that provides beneficiaries eligible for Champus with |
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| supplemental health care coverage. |
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| "Code" means the Illinois Insurance Code. |
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| "Covered dependents at end of reporting quarter" means the |
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| total number of individuals covered by the primary insured's |
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| plan who receive coverage due to his or her dependent |
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| relationship to the primary insured, as of the final day of the |
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| reporting quarter. |
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| "Dental" means insurance that provides benefits for |
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| routine dental examinations, preventive dental work, and |
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| dental procedures needed to treat tooth decay and diseases of |
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| the teeth and jaw. |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| "Direct premiums earned for new and renewal business" means |
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| the insurers direct premium earned from the first through the |
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| final day of the reporting quarter, and includes only premium |
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| specific to covered Illinois residents. |
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| "Director" means the Director of the Division of Insurance |
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| of the Illinois Department of Financial and Professional |
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| Regulation.
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| "Direct losses incurred" means direct losses incurred from |
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| the first through the final day of the reporting quarter and |
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| includes only premium specific to covered Illinois residents.
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| "Direct premiums earned for new business only" means the |
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| direct premium earned for new business only from the first |
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| through the final day of the reporting and includes only |
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| premium specific to covered Illinois residents.
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| "Disability income" means a policy designed to compensate |
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| insureds for a portion of the income they lose because of a |
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| disabling injury or illness. "Disability income" includes |
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| business overhead expense, short-term, long-term, and combined |
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| short-term and long-term coverage.
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| "Employers, if group coverage, at end of reporting quarter" |
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| means for all group categories, the number of employers who |
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| covered Illinois resident employees, as of the final day of the |
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| reporting quarter.
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| "Excess/stop loss" means the type of insurance may be |
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| extended to either a health plan or self-insured employer plan. |
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| Its purpose is to insure against the risk that any one claim |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| will exceed a specific dollar amount or that an entire plan's |
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| losses will exceed a specific amount. "Excess/stop loss" |
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| includes accident and sickness, managed care, provider, and |
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| self-funded health plan coverage.
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| "FEHBP" means health, vision, and dental coverage provided |
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| pursuant to the Federal Employees Health Benefits Program. |
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| "Hospital indemnity" means an insurance contract that pays |
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| a fixed dollar amount without regard to the actual expense |
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| incurred for each day the covered person is confined to the |
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| hospital as a result of injury, sickness, or medical condition. |
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| "Hospital surgical" means an insurance contract that |
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| provides coverage to or reimburses the covered person for |
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| hospital, surgical, or medical expense incurred as a result of |
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| injury, sickness, or medical condition. |
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| "In-state" groups means Illinois groups with group master |
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| contracts issued to a trust sitused in Illinois.
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| "Insurer" means an insurance company authorized to |
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| transact the class of business as set forth in subsection (b) |
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| of Class 1 and subsection (a) of Class 2 of Section 4 of the |
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| Insurance Code, as well as health care plans authorized under |
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| the Health Maintenance Organization Act.
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| "Limited benefit" means the plan:
(1) pays benefits for the |
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| diagnosis and treatment of a specifically named disease or
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| diseases. Benefits can be paid as expense incurred, per diem, |
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| or a principle sum;
(2) provides a daily benefit for |
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| confinement in a qualified intensive care unit of a
certified |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| hospital. Benefits are specific to services delivered by the |
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| staff of a
hospital intensive care unit. Benefits are not to |
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| exceed a stated dollar amount per
day; and
(3) provides |
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| benefits for services incurred as a result of human or |
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| non-human
organ transplant. Benefits are specific to the |
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| delivery of care associated with the
covered organ or tissue |
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| transplant. Benefits are not to exceed a stated dollar
amount |
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| per day.
"Limited benefit" includes coverage for specified |
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| disease, critical illness, dread disease, dread disease-cancer |
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| only, HIV indemnity, intensive care, and organ and tissue |
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| transplant. |
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| "Long-term care" means coverage that includes long-term |
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| care, nursing home, and home care contracts that provide |
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| reimbursement for these services. |
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| "Loss-ratio" means the insurer's ratio of direct losses |
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| incurred to direct premiums earned for new and renewal business |
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| from the first through the final day of the reporting quarter |
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| and includes only premium specific to covered Illinois |
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| residents. |
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| "Major medical" means a hospital, surgical, or medical |
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| expense contract that is designed to cover expenses of serious |
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| illness, chronic care, or hospitalization. "Major medical" |
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| does not include hospital indemnity, accidental death and |
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| dismemberment, workers' compensation, credit accident and |
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| health, short-term accident and health, accident only, |
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| long-term care, Medicare supplement, pre-paid products, |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| student blanket, stand-alone policies, dental-only, |
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| vision-only, prescription drug benefits, disability income, |
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| specified disease, or similar supplementary benefits; coverage |
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| issued as a supplement to liability insurance; workers' |
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| compensation or similar insurance; or automobile |
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| medical-payment insurance. |
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| "Medicare supplement" means a group or individual policy of |
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| accident or health insurance or a subscriber contract of |
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| hospital and medical service associations, other than a policy |
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| issued pursuant to a contract under Section 1876 of the federal |
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| Social Security Act or a policy issued pursuant to a |
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| demonstration project specified in Section 1395ss(g)(1) of the |
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| federal Social Security Act, which is advertised, marketed, or |
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| designed primarily as a supplement to reimbursements under |
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| Medicare for the hospital, medical, or surgical expenses of |
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| persons eligible for Medicare.
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| "Member months at end of reporting quarter" means the total |
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| number of months that each member or policyholder is provided |
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| coverage from the first day through the final day of the |
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| reporting quarter.
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| "Out-of-state" groups means groups that have master |
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| contracts issued to a trust sitused outside of Illinois.
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| "Primary insureds at end of reporting quarter" means the |
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| total number of resident individual policyholders or resident |
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| group employee or member certificate holders, as of the final |
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| day of the reporting quarter.
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| "Quarter" means the following quarter years:
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| (1) October 1 through December 31; |
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| (2) January 1 through March 31;
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| (3) April 1 through June 30; and |
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| (4) July 1 through September 30. |
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"Short-term care" means coverage that includes medical and |
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| other services to insureds who need constant care in their own |
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| home or in a nursing facility for periods of less than one |
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| year. "Short-term care" includes home health care, nursing |
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| home, and adult day care. |
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| "Student" means a health insurance contract that covers a |
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| class of students not individually identified in the contract. |
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| "Travel" means limited benefit expense policies and |
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| benefits for loss incurred while traveling generally outside a |
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| 100-mile radius of the US borders, subject to State |
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| limitations. |
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| "Vision" means limited benefit expense policies that |
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| provide benefits for eye care and eye care accessories and may |
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| include surgical benefits for injury or sickness associated |
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| with the eye. |
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| "Wellness program participation premium discounts" means |
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| the dollar value of plan-administered premium discounts, |
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| rebates of premium or contribution, or waivers of all or part |
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| of a surcharge or cost-sharing mechanism, such as deductibles, |
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| co-pays, or coinsurance, provided to individual insureds for |
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| their participation in a bona fide wellness program, from the |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| first day through the final day of the reporting quarter. To |
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| qualify as a bona fide wellness program, the program must:
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| (1) offer a limited reward or discount;
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| (2) be reasonably designed to promote good health and
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| disease prevention; |
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| (3) allow policyholders to qualify for the program's |
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| reward at least once per
year; and |
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| (4) be available to all similarly situated employees, |
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| with reasonable alternative
standards for those for which |
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| the general standard is unreasonably difficult or |
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| medically
inadvisable.
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| Section 15. Reports. |
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| (a) All insurers subject to this Act shall, beginning at |
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| the current quarter and year, and continuing through all |
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| subsequent quarters and years, report accurate and complete |
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| information for each accident and health coverage type |
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| requested to the Director. The following reports are requested: |
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| (1) on the final day of each quarter, file a quarterly |
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| report for the prior quarter (not for the quarter on which |
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| the due date falls) regarding information on health benefit |
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| plans currently in force in this State; and |
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| (2) on or before April 1 for the preceding year ending |
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| December 31,
file an annual report for the prior year (not |
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| for the year on which the due date falls) regarding |
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| information on health benefit plans currently at force in |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| this State. |
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| In addition, insurers with comprehensive major medical |
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| business
currently in force in this State that covers more than |
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| 500
unduplicated persons (primary insureds plus dependents)
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| shall, on or before April 1 for the preceding year ending
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| December 31, file a completed annual supplemental report
with |
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| premium and loss data on health benefit plans currently in |
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| force in this State. |
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| Information reported under this Section must be reported in |
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| an aggregate format. This Section does not allow for the |
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| collection of any information that allows for the |
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| identification of an individual provider. |
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| (b) The following comprehensive major medical, major |
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| medical, and other hospital-surgical coverage types are |
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| requested in this Act: |
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| (1) major medical; |
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| (2) hospital surgical; |
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| (3) in-state groups; |
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| (4) out-of-state groups; |
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| (5) administrative services only;
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| (6) accident only; |
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| (7) accidental death and dismemberment; |
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| (8) blanket accident/sickness; |
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| (9) dental; |
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| (10) disability income (includes business overhead |
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| expense, short-term, and long-term); |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| (11) combined short-term and long-term;
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| (12) excess/stop loss (includes accident and sickness, |
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| managed care, provider, and self-funded health plan); |
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| (13) FEHBP coverage provided pursuant to the federal |
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| employees health benefits program. |
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| (14) limited benefit (includes specified disease, |
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| critical illness, dread disease, dread disease-cancer |
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| only, HIV indemnity, intensive care, and organ and tissue |
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| transplant); |
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| (15) short-term care (includes home health care, |
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| nursing home, and adult day care) Medicare supplement; |
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| (16) Champus/Tricare supplement; |
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| (17) travel; |
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| (18) vision; and |
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| (19) other accident and health care coverage not |
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| specifically described. |
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| (c) The following information is requested for each |
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| accident and coverage type requested:
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| (1) direct premiums earned for new and renewal |
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| business; |
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| (2) direct losses incurred; |
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| (3) direct premiums earned for new business; |
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| (4) loss-ratio; |
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| (5) employers, if group coverage, at end of reporting |
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| quarter; |
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| (6) primary insureds at end of reporting quarter; |
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HB5865 Engrossed |
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LRB095 19773 KBJ 46147 b |
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| (7) covered dependents at end of reporting quarter; |
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| (8) member months at end of reporting quarter; and
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| (9) wellness program participation premium discounts.
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| Section 20. No authority to make or promulgate rules. |
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| Notwithstanding any other rulemaking authority that may exist, |
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| neither the Governor nor any agency or agency head under the |
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| jurisdiction of the Governor has any authority to make or |
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| promulgate rules to implement or enforce the provisions of this |
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| Act. If, however, the Governor believes that rules are |
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| necessary to implement or enforce the provisions of this Act, |
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| the Governor may suggest rules to the General Assembly by |
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| filing them with the Clerk of the House and Secretary of the |
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| Senate and by requesting that the General Assembly authorize |
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| such rulemaking by law, enact those suggested rules into law, |
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| or take any other appropriate action in the General Assembly's |
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| discretion. Nothing contained in this Act shall be interpreted |
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| to grant rulemaking authority under any other Illinois statute |
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| where such authority is not otherwise explicitly given. For the |
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| purposes of this Act, "rules" is given the meaning contained in |
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| Section 1-70 of the Illinois Administrative Procedure Act, and |
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| "agency" and "agency head" are given the meanings contained in |
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| Sections 1-20 and 1-25 of the Illinois Administrative Procedure |
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| Act to the extent that such definitions apply to agencies or |
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| agency heads under the jurisdiction of the Governor.
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