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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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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, | ||||||
13 | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | ||||||
14 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | ||||||
15 | 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17 356z.15 , | ||||||
16 | 356z.19, and 364.01 of the
Illinois Insurance Code.
The program | ||||||
17 | of health benefits must comply with Section 155.37 of the
| ||||||
18 | Illinois Insurance Code.
| ||||||
19 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
20 | amendatory Act of the 95th General Assembly , if any, is | ||||||
21 | conditioned on the rules being adopted in accordance with all | ||||||
22 | provisions of the Illinois Administrative Procedure Act and all | ||||||
23 | rules and procedures of the Joint Committee on Administrative |
| |||||||
| |||||||
1 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
2 | is unauthorized. | ||||||
3 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
4 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
5 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, | ||||||
6 | eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
7 | 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | ||||||
8 | revised 10-22-09.) | ||||||
9 | Section 10. The Counties Code is amended by changing | ||||||
10 | Section 5-1069.3 as follows: | ||||||
11 | (55 ILCS 5/5-1069.3)
| ||||||
12 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
13 | including a home
rule
county, is a self-insurer for purposes of | ||||||
14 | providing health insurance coverage
for its employees, the | ||||||
15 | coverage shall include coverage for the post-mastectomy
care | ||||||
16 | benefits required to be covered by a policy of accident and | ||||||
17 | health
insurance under Section 356t and the coverage required | ||||||
18 | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | ||||||
19 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | ||||||
20 | 356z.13, and 356z.14, and 356z.15 356z.14 , 356z.19, and 364.01 | ||||||
21 | of
the Illinois Insurance Code. The requirement that health | ||||||
22 | benefits be covered
as provided in this Section is an
exclusive | ||||||
23 | power and function of the State and is a denial and limitation | ||||||
24 | under
Article VII, Section 6, subsection (h) of the Illinois |
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| |||||||
1 | Constitution. A home
rule county to which this Section applies | ||||||
2 | must comply with every provision of
this Section.
| ||||||
3 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
4 | amendatory Act of the 95th General Assembly , if any, is | ||||||
5 | conditioned on the rules being adopted in accordance with all | ||||||
6 | provisions of the Illinois Administrative Procedure Act and all | ||||||
7 | rules and procedures of the Joint Committee on Administrative | ||||||
8 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
9 | is unauthorized. | ||||||
10 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
11 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
12 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | ||||||
13 | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | ||||||
14 | 96-328, eff. 8-11-09; revised 10-22-09.) | ||||||
15 | Section 15. The Illinois Municipal Code is amended by | ||||||
16 | changing Section 10-4-2.3 as follows: | ||||||
17 | (65 ILCS 5/10-4-2.3)
| ||||||
18 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
19 | municipality, including a
home rule municipality, is a | ||||||
20 | self-insurer for purposes of providing health
insurance | ||||||
21 | coverage for its employees, the coverage shall include coverage | ||||||
22 | for
the post-mastectomy care benefits required to be covered by | ||||||
23 | a policy of
accident and health insurance under Section 356t | ||||||
24 | and the coverage required
under Sections 356g, 356g.5, |
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| |||||||
1 | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
2 | 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15 | ||||||
3 | 356z.14 , 356z.19, and 364.01 of the Illinois
Insurance
Code. | ||||||
4 | The requirement that health
benefits be covered as provided in | ||||||
5 | this is an exclusive power and function of
the State and is a | ||||||
6 | denial and limitation under Article VII, Section 6,
subsection | ||||||
7 | (h) of the Illinois Constitution. A home rule municipality to | ||||||
8 | which
this Section applies must comply with every provision of | ||||||
9 | this Section.
| ||||||
10 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
11 | amendatory Act of the 95th General Assembly , if any, is | ||||||
12 | conditioned on the rules being adopted in accordance with all | ||||||
13 | provisions of the Illinois Administrative Procedure Act and all | ||||||
14 | rules and procedures of the Joint Committee on Administrative | ||||||
15 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
16 | is unauthorized. | ||||||
17 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
18 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
19 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | ||||||
20 | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | ||||||
21 | 96-328, eff. 8-11-09; revised 10-23-09.) | ||||||
22 | Section 20. The School Code is amended by changing Section | ||||||
23 | 10-22.3f as follows: | ||||||
24 | (105 ILCS 5/10-22.3f)
|
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| |||||||
1 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
2 | protection and
benefits
for employees shall provide the | ||||||
3 | post-mastectomy care benefits required to be
covered by a | ||||||
4 | policy of accident and health insurance under Section 356t and | ||||||
5 | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | ||||||
6 | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | ||||||
7 | 356z.13, and 356z.14, and 356z.15 356z.14 , 356z.19, and 364.01 | ||||||
8 | of
the
Illinois Insurance Code.
| ||||||
9 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
10 | amendatory Act of the 95th General Assembly , if any, is | ||||||
11 | conditioned on the rules being adopted in accordance with all | ||||||
12 | provisions of the Illinois Administrative Procedure Act and all | ||||||
13 | rules and procedures of the Joint Committee on Administrative | ||||||
14 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
15 | is unauthorized. | ||||||
16 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
17 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
18 | 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
19 | 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised | ||||||
20 | 10-23-09.) | ||||||
21 | Section 25. The Illinois Insurance Code is amended by | ||||||
22 | adding Section 356z.19 and by changing Section 364.01 as | ||||||
23 | follows: | ||||||
24 | (215 ILCS 5/356z.19 new) |
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| |||||||
1 | Sec. 356z.19. Cancer drug parity. | ||||||
2 | (a) As used in this Section: | ||||||
3 | "Financial requirement" means deductibles, copayments, | ||||||
4 | coinsurance, out-of-pocket expenses, aggregate lifetime | ||||||
5 | limits, and annual limits. | ||||||
6 | "Treatment limitation" means limits on the frequency of | ||||||
7 | treatment, days of coverage, or other similar limits on the | ||||||
8 | scope or duration of treatment. | ||||||
9 | (b) An individual or group policy of accident and health | ||||||
10 | insurance amended, delivered, issued, or renewed on or after | ||||||
11 | the effective date of this amendatory Act of the 96th General | ||||||
12 | Assembly that provides coverage for prescription drugs or | ||||||
13 | cancer chemotherapy treatment must provide coverage for | ||||||
14 | prescribed orally-administered cancer medication used to kill | ||||||
15 | or slow the growth of cancerous cells. An insurer providing | ||||||
16 | coverage under this Section shall ensure that: | ||||||
17 | (1) the financial requirements applicable to such | ||||||
18 | prescribed orally-administered cancer medications are no | ||||||
19 | more restrictive than the financial requirements applied | ||||||
20 | to intravenously administered or injected cancer | ||||||
21 | medications that are covered by the policy and that there | ||||||
22 | are no separate cost-sharing requirements that are | ||||||
23 | applicable only with respect to such prescribed | ||||||
24 | orally-administered cancer medications; and | ||||||
25 | (2) the treatment limitations applicable to such | ||||||
26 | prescribed orally-administered cancer medications are no |
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| |||||||
1 | more restrictive than the treatment limitations applied to | ||||||
2 | intravenously administered or injected cancer medications | ||||||
3 | that are covered by the policy and that there are no | ||||||
4 | separate treatment limitations that are applicable only | ||||||
5 | with respect to such prescribed orally-administered cancer | ||||||
6 | medications. | ||||||
7 | (215 ILCS 5/364.01) | ||||||
8 | Sec. 364.01. Qualified clinical cancer trials. | ||||||
9 | (a) No individual or group policy of accident and health | ||||||
10 | insurance issued or renewed in this State may be cancelled or | ||||||
11 | non-renewed for any individual based on that individual's | ||||||
12 | participation in a qualified clinical cancer trial. | ||||||
13 | (b) Qualified clinical cancer trials must meet the | ||||||
14 | following criteria: | ||||||
15 | (1) the effectiveness of the treatment has not been | ||||||
16 | determined relative to established therapies; | ||||||
17 | (2) the trial is under clinical investigation as part | ||||||
18 | of an approved cancer research trial in Phase II, Phase | ||||||
19 | III, or Phase IV of investigation; | ||||||
20 | (3) the trial is: | ||||||
21 | (A) approved by the Food and Drug Administration; | ||||||
22 | or | ||||||
23 | (B) approved and funded by the National Institutes | ||||||
24 | of Health, the Centers for Disease Control and | ||||||
25 | Prevention, the Agency for Healthcare Research and |
| |||||||
| |||||||
1 | Quality, the United States Department of Defense, the | ||||||
2 | United States Department of Veterans Affairs, or the | ||||||
3 | United States Department of Energy in the form of an | ||||||
4 | investigational new drug application, or a cooperative | ||||||
5 | group or center of any entity described in this | ||||||
6 | subdivision (B); and
| ||||||
7 | (4) the patient's primary care physician, if any, is | ||||||
8 | involved in the coordination of care.
| ||||||
9 | (c) An individual or group policy of accident and health | ||||||
10 | insurance amended, delivered, issued, or renewed on or after | ||||||
11 | the effective date of this amendatory Act of the 96th General | ||||||
12 | Assembly shall provide coverage to a qualified individual for | ||||||
13 | participation in a qualified clinical cancer trial. | ||||||
14 | (d) An insurer providing coverage under this Section shall | ||||||
15 | not: | ||||||
16 | (1) deny the qualified individual participation in the | ||||||
17 | qualified clinical cancer trial; | ||||||
18 | (2) subject to subsection (f) of this Section, deny, | ||||||
19 | limit, or impose additional conditions on the coverage of | ||||||
20 | routine patient costs for items and services furnished in | ||||||
21 | connection with participation in the qualified clinical | ||||||
22 | cancer trial; or | ||||||
23 | (3) discriminate against the qualified individual on | ||||||
24 | the basis of the individual's participation in the | ||||||
25 | qualified clinical cancer trial. | ||||||
26 | (e) If one or more participating providers is participating |
| |||||||
| |||||||
1 | in a qualified clinical cancer trial, nothing in subsections | ||||||
2 | (c) or (d) of this Section shall be construed as preventing an | ||||||
3 | insurer from requiring that a qualified individual participate | ||||||
4 | in the trial through such a participating provider if the | ||||||
5 | provider will accept the individual as a participant in the | ||||||
6 | trial. | ||||||
7 | (f) An insurer shall provide for payment for routine | ||||||
8 | patient costs but is not required to pay for the costs of items | ||||||
9 | and services that are customarily provided by the research | ||||||
10 | sponsors free of charge for individuals participating in the | ||||||
11 | qualified clinical cancer trial. In the case of covered items | ||||||
12 | and services provided by a participating provider, the payment | ||||||
13 | rate shall be at the agreed upon rate. In the case of covered | ||||||
14 | items and services provided by a nonparticipating provider, the | ||||||
15 | payment rate shall be at the usual and customary rate for | ||||||
16 | comparable items and services provided by the participating | ||||||
17 | provider. | ||||||
18 | (g) As used in this Section: | ||||||
19 | "Qualified individual" means an individual who is a | ||||||
20 | participant or beneficiary in a group or individual policy of | ||||||
21 | accident and health insurance and who meets the following | ||||||
22 | conditions: | ||||||
23 | (1) the individual has been diagnosed with cancer; | ||||||
24 | (2) the individual is eligible to participate in a | ||||||
25 | qualified clinical cancer trial according to the trial | ||||||
26 | protocol with respect to treatment of such illness; and |
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| |||||||
1 | (3) one of the following circumstances exists: (A) the | ||||||
2 | referring physician is a participating provider and has | ||||||
3 | concluded that the individual's participation in the trial | ||||||
4 | would be appropriate based upon the individual meeting the | ||||||
5 | conditions described in items (1) and (2) of this | ||||||
6 | definition or (B) the individual provides medical and | ||||||
7 | scientific information establishing that the individual's | ||||||
8 | participation in the trial would be appropriate based upon | ||||||
9 | the individual meeting the conditions described in items | ||||||
10 | (1) and (2) of this definition. | ||||||
11 | "Routine patient costs" mean all items and services | ||||||
12 | provided in the qualified cancer trial that are otherwise | ||||||
13 | generally available to the qualified individual, except: | ||||||
14 | (1) in the cases of items and services, the | ||||||
15 | investigational item or service itself; or | ||||||
16 | (2) items and services that are provided solely to | ||||||
17 | satisfy data collection and analysis needs and that are not | ||||||
18 | used in the direct clinical management of the patient. | ||||||
19 | (h) Nothing in this Section shall be construed to limit an | ||||||
20 | insurer's coverage with respect to clinical trials. | ||||||
21 | (Source: P.A. 93-1000, eff. 1-1-05.) | ||||||
22 | Section 30. The Health Maintenance Organization Act is | ||||||
23 | amended by changing Section 5-3 as follows:
| ||||||
24 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
|
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| |||||||
1 | (Text of Section before amendment by P.A. 96-833 ) | ||||||
2 | Sec. 5-3. Insurance Code provisions.
| ||||||
3 | (a) Health Maintenance Organizations
shall be subject to | ||||||
4 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
5 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
6 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
7 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
8 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , | ||||||
9 | 356z.17 356z.15 , 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, | ||||||
10 | 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, | ||||||
11 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||||||
12 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
13 | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
14 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
15 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
16 | Maintenance Organizations in
the following categories are | ||||||
17 | deemed to be "domestic companies":
| ||||||
18 | (1) a corporation authorized under the
Dental Service | ||||||
19 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
20 | (2) a corporation organized under the laws of this | ||||||
21 | State; or
| ||||||
22 | (3) a corporation organized under the laws of another | ||||||
23 | state, 30% or more
of the enrollees of which are residents | ||||||
24 | of this State, except a
corporation subject to | ||||||
25 | substantially the same requirements in its state of
| ||||||
26 | organization as is a "domestic company" under Article VIII |
| |||||||
| |||||||
1 | 1/2 of the
Illinois Insurance Code.
| ||||||
2 | (c) In considering the merger, consolidation, or other | ||||||
3 | acquisition of
control of a Health Maintenance Organization | ||||||
4 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
5 | (1) the Director shall give primary consideration to | ||||||
6 | the continuation of
benefits to enrollees and the financial | ||||||
7 | conditions of the acquired Health
Maintenance Organization | ||||||
8 | after the merger, consolidation, or other
acquisition of | ||||||
9 | control takes effect;
| ||||||
10 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
11 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
12 | apply and (ii) the Director, in making
his determination | ||||||
13 | with respect to the merger, consolidation, or other
| ||||||
14 | acquisition of control, need not take into account the | ||||||
15 | effect on
competition of the merger, consolidation, or | ||||||
16 | other acquisition of control;
| ||||||
17 | (3) the Director shall have the power to require the | ||||||
18 | following
information:
| ||||||
19 | (A) certification by an independent actuary of the | ||||||
20 | adequacy
of the reserves of the Health Maintenance | ||||||
21 | Organization sought to be acquired;
| ||||||
22 | (B) pro forma financial statements reflecting the | ||||||
23 | combined balance
sheets of the acquiring company and | ||||||
24 | the Health Maintenance Organization sought
to be | ||||||
25 | acquired as of the end of the preceding year and as of | ||||||
26 | a date 90 days
prior to the acquisition, as well as pro |
| |||||||
| |||||||
1 | forma financial statements
reflecting projected | ||||||
2 | combined operation for a period of 2 years;
| ||||||
3 | (C) a pro forma business plan detailing an | ||||||
4 | acquiring party's plans with
respect to the operation | ||||||
5 | of the Health Maintenance Organization sought to
be | ||||||
6 | acquired for a period of not less than 3 years; and
| ||||||
7 | (D) such other information as the Director shall | ||||||
8 | require.
| ||||||
9 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
10 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
11 | any health maintenance
organization of greater than 10% of its
| ||||||
12 | enrollee population (including without limitation the health | ||||||
13 | maintenance
organization's right, title, and interest in and to | ||||||
14 | its health care
certificates).
| ||||||
15 | (e) In considering any management contract or service | ||||||
16 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
17 | Code, the Director (i) shall, in
addition to the criteria | ||||||
18 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
19 | into account the effect of the management contract or
service | ||||||
20 | agreement on the continuation of benefits to enrollees and the
| ||||||
21 | financial condition of the health maintenance organization to | ||||||
22 | be managed or
serviced, and (ii) need not take into account the | ||||||
23 | effect of the management
contract or service agreement on | ||||||
24 | competition.
| ||||||
25 | (f) Except for small employer groups as defined in the | ||||||
26 | Small Employer
Rating, Renewability and Portability Health |
| |||||||
| |||||||
1 | Insurance Act and except for
medicare supplement policies as | ||||||
2 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
3 | Maintenance Organization may by contract agree with a
group or | ||||||
4 | other enrollment unit to effect refunds or charge additional | ||||||
5 | premiums
under the following terms and conditions:
| ||||||
6 | (i) the amount of, and other terms and conditions with | ||||||
7 | respect to, the
refund or additional premium are set forth | ||||||
8 | in the group or enrollment unit
contract agreed in advance | ||||||
9 | of the period for which a refund is to be paid or
| ||||||
10 | additional premium is to be charged (which period shall not | ||||||
11 | be less than one
year); and
| ||||||
12 | (ii) the amount of the refund or additional premium | ||||||
13 | shall not exceed 20%
of the Health Maintenance | ||||||
14 | Organization's profitable or unprofitable experience
with | ||||||
15 | respect to the group or other enrollment unit for the | ||||||
16 | period (and, for
purposes of a refund or additional | ||||||
17 | premium, the profitable or unprofitable
experience shall | ||||||
18 | be calculated taking into account a pro rata share of the
| ||||||
19 | Health Maintenance Organization's administrative and | ||||||
20 | marketing expenses, but
shall not include any refund to be | ||||||
21 | made or additional premium to be paid
pursuant to this | ||||||
22 | subsection (f)). The Health Maintenance Organization and | ||||||
23 | the
group or enrollment unit may agree that the profitable | ||||||
24 | or unprofitable
experience may be calculated taking into | ||||||
25 | account the refund period and the
immediately preceding 2 | ||||||
26 | plan years.
|
| |||||||
| |||||||
1 | The Health Maintenance Organization shall include a | ||||||
2 | statement in the
evidence of coverage issued to each enrollee | ||||||
3 | describing the possibility of a
refund or additional premium, | ||||||
4 | and upon request of any group or enrollment unit,
provide to | ||||||
5 | the group or enrollment unit a description of the method used | ||||||
6 | to
calculate (1) the Health Maintenance Organization's | ||||||
7 | profitable experience with
respect to the group or enrollment | ||||||
8 | unit and the resulting refund to the group
or enrollment unit | ||||||
9 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
10 | experience with respect to the group or enrollment unit and the | ||||||
11 | resulting
additional premium to be paid by the group or | ||||||
12 | enrollment unit.
| ||||||
13 | In no event shall the Illinois Health Maintenance | ||||||
14 | Organization
Guaranty Association be liable to pay any | ||||||
15 | contractual obligation of an
insolvent organization to pay any | ||||||
16 | refund authorized under this Section.
| ||||||
17 | (g) Rulemaking authority to implement Public Act 95-1045 | ||||||
18 | this amendatory Act of the 95th General Assembly , if any, is | ||||||
19 | conditioned on the rules being adopted in accordance with all | ||||||
20 | provisions of the Illinois Administrative Procedure Act and all | ||||||
21 | rules and procedures of the Joint Committee on Administrative | ||||||
22 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
23 | is unauthorized. | ||||||
24 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
25 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
26 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. |
| |||||||
| |||||||
1 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised | ||||||
2 | 10-23-09.) | ||||||
3 | (Text of Section after amendment by P.A. 96-833 ) | ||||||
4 | Sec. 5-3. Insurance Code provisions.
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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, 356g.5-1, 356m, 356v, 356w, | ||||||
9 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
10 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | ||||||
11 | 356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
12 | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
13 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
14 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
15 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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16 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
17 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
18 | Maintenance Organizations in
the following categories are | ||||||
19 | deemed to be "domestic companies":
| ||||||
20 | (1) a corporation authorized under the
Dental Service | ||||||
21 | Plan Act or the Voluntary Health Services Plans Act;
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22 | (2) a corporation organized under the laws of this | ||||||
23 | State; or
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24 | (3) a corporation organized under the laws of another | ||||||
25 | state, 30% or more
of the enrollees of which are residents |
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1 | of this State, except a
corporation subject to | ||||||
2 | substantially the same requirements in its state of
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3 | organization as is a "domestic company" under Article VIII | ||||||
4 | 1/2 of the
Illinois Insurance Code.
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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,
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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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13 | (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 | ||||||
18 | effect on
competition of the merger, consolidation, or | ||||||
19 | other acquisition of control;
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20 | (3) the Director shall have the power to require the | ||||||
21 | following
information:
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22 | (A) certification by an independent actuary of the | ||||||
23 | adequacy
of the reserves of the Health Maintenance | ||||||
24 | Organization sought to be acquired;
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25 | (B) pro forma financial statements reflecting the | ||||||
26 | combined balance
sheets of the acquiring company and |
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1 | the Health Maintenance Organization sought
to be | ||||||
2 | acquired as of the end of the preceding year and as of | ||||||
3 | 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;
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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
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10 | (D) such other information as the Director shall | ||||||
11 | require.
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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).
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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
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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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1 | competition.
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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:
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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
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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 | ||||||
25 | subsection (f)). The Health Maintenance Organization and | ||||||
26 | the
group or enrollment unit may agree that the profitable |
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1 | or unprofitable
experience may be calculated taking into | ||||||
2 | account the refund period and the
immediately preceding 2 | ||||||
3 | plan years.
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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.
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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.
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20 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
21 | if any, is conditioned on the rules being adopted in accordance | ||||||
22 | with all provisions of the Illinois Administrative Procedure | ||||||
23 | Act and all rules and procedures of the Joint Committee on | ||||||
24 | Administrative Rules; any purported rule not so adopted, for | ||||||
25 | whatever reason, is unauthorized. | ||||||
26 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; |
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1 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
2 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
3 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | ||||||
4 | 6-1-10.) | ||||||
5 | Section 35. The Voluntary Health Services Plans Act is | ||||||
6 | amended by changing Section 10 as follows:
| ||||||
7 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
8 | (Text of Section before amendment by P.A. 96-833 ) | ||||||
9 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
10 | services
plan corporations and all persons interested therein | ||||||
11 | or dealing therewith
shall be subject to the provisions of | ||||||
12 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
13 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | ||||||
14 | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | ||||||
15 | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | ||||||
16 | 356z.14, 356z.15
356z.14 , 356z.19, 364.01, 367.2, 368a, 401, | ||||||
17 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
18 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
19 | Rulemaking authority to implement Public Act 95-1045
this | ||||||
20 | amendatory Act of the 95th General Assembly , if any, is | ||||||
21 | conditioned on the rules being adopted in accordance with all | ||||||
22 | provisions of the Illinois Administrative Procedure Act and all | ||||||
23 | rules and procedures of the Joint Committee on Administrative | ||||||
24 | Rules; any purported rule not so adopted, for whatever reason, |
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| |||||||
1 | is unauthorized. | ||||||
2 | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | ||||||
3 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
4 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
5 | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
6 | 96-328, eff. 8-11-09; revised 9-25-09.) | ||||||
7 | (Text of Section after amendment by P.A. 96-833 ) | ||||||
8 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
9 | services
plan corporations and all persons interested therein | ||||||
10 | or dealing therewith
shall be subject to the provisions of | ||||||
11 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
12 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | ||||||
13 | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | ||||||
14 | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | ||||||
15 | 356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401, | ||||||
16 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
17 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
18 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
19 | any, is conditioned on the rules being adopted in accordance | ||||||
20 | with all provisions of the Illinois Administrative Procedure | ||||||
21 | Act and all rules and procedures of the Joint Committee on | ||||||
22 | Administrative Rules; any purported rule not so adopted, for | ||||||
23 | whatever reason, is unauthorized. | ||||||
24 | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | ||||||
25 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. |
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| |||||||
1 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
2 | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
3 | 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.) | ||||||
4 | Section 97. No acceleration or delay. Where this Act makes | ||||||
5 | changes in a statute that is represented in this Act by text | ||||||
6 | that is not yet or no longer in effect (for example, a Section | ||||||
7 | represented by multiple versions), the use of that text does | ||||||
8 | not accelerate or delay the taking effect of (i) the changes | ||||||
9 | made by this Act or (ii) provisions derived from any other | ||||||
10 | Public Act.
| ||||||
11 | Section 99. Effective date. This Act takes effect upon | ||||||
12 | becoming law.
|