Sen. Dan Kotowski

Filed: 3/25/2009

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 1877

2     AMENDMENT NO. ______. Amend Senate Bill 1877 by replacing
3 everything after the enacting clause with the following:
 
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     (Text of Section before amendment by P.A. 95-958)
8     Sec. 6.11. Required health benefits; Illinois Insurance
9 Code requirements. The program of health benefits shall provide
10 the post-mastectomy care benefits required to be covered by a
11 policy of accident and health insurance under Section 356t of
12 the Illinois Insurance Code. The program of health benefits
13 shall provide the coverage required under Sections 356g.5,
14 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10,
15 356z.13 356z.11, and 356z.14, and 356z.15 of the Illinois
16 Insurance Code. The program of health benefits must comply with

 

 

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1 Section 155.37 of the Illinois Insurance Code.
2 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
3 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff.
4 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
 
5     (Text of Section after amendment by P.A. 95-958)
6     Sec. 6.11. Required health benefits; Illinois Insurance
7 Code requirements. The program of health benefits shall provide
8 the post-mastectomy care benefits required to be covered by a
9 policy of accident and health insurance under Section 356t of
10 the Illinois Insurance Code. The program of health benefits
11 shall provide the coverage required under Sections 356g.5,
12 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10,
13 356z.11, and 356z.12, 356z.13 356z.11, and 356z.14, and 356z.15
14 of the Illinois Insurance Code. The program of health benefits
15 must comply with Section 155.37 of the Illinois Insurance Code.
16 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
17 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
18 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised
19 12-15-08.)
 
20     Section 10. The Illinois Insurance Code is amended by
21 adding Section 356z.15 as follows:
 
22     (215 ILCS 5/356z.15 new)
23     Sec. 356z.15. Wellness coverage.

 

 

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1     (a) A group or individual policy of accident and health
2 insurance or managed care plan amended, delivered, issued, or
3 renewed after the effective date of this amendatory Act of the
4 96th General Assembly that provides coverage for hospital or
5 medical treatment on an expense incurred basis may offer a
6 reasonably designed program for wellness coverage that allows
7 for a reward, a health spending account contribution, a
8 reduction in premiums or reduced medical, prescription drug, or
9 equipment copayments, coinsurance, or deductibles, or a
10 combination of these incentives, for participation in any
11 health behavior wellness, maintenance, or improvement program
12 approved or offered by the insurer or managed care plan. The
13 insured or enrollee may be required to provide evidence of
14 participation in a program, or demonstrative compliance with
15 treatment recommendations as determined by the health insurer
16 or managed care plan.
17     (b) For purposes of this Section, "wellness coverage" means
18 health care coverage with the primary purpose to engage and
19 motivate the insured or enrollee through: incentives;
20 provision of health education, counseling, and self-management
21 skills; identification of modifiable health risks; and other
22 activities to influence health behavior changes.
23     (c) Incentives as outlined in this Section are specific and
24 unique to the offering of wellness coverage and have no
25 application to any other required or optional health care
26 benefit.

 

 

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1     (d) Such wellness coverage must satisfy the requirements
2 for an exception from the general prohibition against
3 discrimination based on a health factor under the federal
4 Health Insurance Portability and Accountability Act of 1996
5 (P.L. 104-191; 110 Stat. 1936), including any federal
6 regulations that are adopted pursuant to that Act.
7     (e) A plan offering wellness coverage must do the
8 following:
9         (i) give participants the opportunity to qualify for
10     offered incentives at least once a year;
11         (ii) allow a reasonable alternative to any individual
12     for whom it is unreasonably difficult, due to a medical
13     condition, to satisfy otherwise applicable wellness
14     program standards. Plans may seek physician verification
15     that health factors make it unreasonably difficult or
16     medically inadvisable for the participant to satisfy the
17     standards; and
18         (iii) not provide a total incentive that exceeds 20% of
19     the cost of employee-only coverage. The cost of
20     employee-only coverage includes both employer and employee
21     contributions. For plans offering family coverage, the 20%
22     limitation applies to cost of family coverage and applies
23     to the entire family.
24     (f) A reward, health spending account contribution, or
25 reduction established under this Section does not violate
26 Section 151 of this Code.

 

 

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1     (g) Rulemaking authority to implement this amendatory Act
2 of the 96th General Assembly, if any, is conditioned on the
3 rules being adopted in accordance with all provisions of the
4 Illinois Administrative Procedure Act and all rules and
5 procedures of the Joint Committee on Administrative Rules; any
6 purported rule not so adopted, for whatever reason, is
7 unauthorized.
 
8     Section 15. The Health Maintenance Organization Act is
9 amended by changing Section 5-3 as follows:
 
10     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
11     (Text of Section before amendment by P.A. 95-958)
12     Sec. 5-3. Insurance Code provisions.
13     (a) Health Maintenance Organizations shall be subject to
14 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
15 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
16 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
17 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
18 356z.13 356z.11, 356z.14, 356z.15, 364.01, 367.2, 367.2-5,
19 367i, 368a, 368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403,
20 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
21 subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,
22 XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
23 Insurance Code.
24     (b) For purposes of the Illinois Insurance Code, except for

 

 

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1 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
2 Maintenance Organizations in the following categories are
3 deemed to be "domestic companies":
4         (1) a corporation authorized under the Dental Service
5     Plan Act or the Voluntary Health Services Plans Act;
6         (2) a corporation organized under the laws of this
7     State; or
8         (3) a corporation organized under the laws of another
9     state, 30% or more of the enrollees of which are residents
10     of this State, except a corporation subject to
11     substantially the same requirements in its state of
12     organization as is a "domestic company" under Article VIII
13     1/2 of the Illinois Insurance Code.
14     (c) In considering the merger, consolidation, or other
15 acquisition of control of a Health Maintenance Organization
16 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
17         (1) the Director shall give primary consideration to
18     the continuation of benefits to enrollees and the financial
19     conditions of the acquired Health Maintenance Organization
20     after the merger, consolidation, or other acquisition of
21     control takes effect;
22         (2)(i) the criteria specified in subsection (1)(b) of
23     Section 131.8 of the Illinois Insurance Code shall not
24     apply and (ii) the Director, in making his determination
25     with respect to the merger, consolidation, or other
26     acquisition of control, need not take into account the

 

 

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1     effect on competition of the merger, consolidation, or
2     other acquisition of control;
3         (3) the Director shall have the power to require the
4     following information:
5             (A) certification by an independent actuary of the
6         adequacy of the reserves of the Health Maintenance
7         Organization sought to be acquired;
8             (B) pro forma financial statements reflecting the
9         combined balance sheets of the acquiring company and
10         the Health Maintenance Organization sought to be
11         acquired as of the end of the preceding year and as of
12         a date 90 days prior to the acquisition, as well as pro
13         forma financial statements reflecting projected
14         combined operation for a period of 2 years;
15             (C) a pro forma business plan detailing an
16         acquiring party's plans with respect to the operation
17         of the Health Maintenance Organization sought to be
18         acquired for a period of not less than 3 years; and
19             (D) such other information as the Director shall
20         require.
21     (d) The provisions of Article VIII 1/2 of the Illinois
22 Insurance Code and this Section 5-3 shall apply to the sale by
23 any health maintenance organization of greater than 10% of its
24 enrollee population (including without limitation the health
25 maintenance organization's right, title, and interest in and to
26 its health care certificates).

 

 

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1     (e) In considering any management contract or service
2 agreement subject to Section 141.1 of the Illinois Insurance
3 Code, the Director (i) shall, in addition to the criteria
4 specified in Section 141.2 of the Illinois Insurance Code, take
5 into account the effect of the management contract or service
6 agreement on the continuation of benefits to enrollees and the
7 financial condition of the health maintenance organization to
8 be managed or serviced, and (ii) need not take into account the
9 effect of the management contract or service agreement on
10 competition.
11     (f) Except for small employer groups as defined in the
12 Small Employer Rating, Renewability and Portability Health
13 Insurance Act and except for medicare supplement policies as
14 defined in Section 363 of the Illinois Insurance Code, a Health
15 Maintenance Organization may by contract agree with a group or
16 other enrollment unit to effect refunds or charge additional
17 premiums under the following terms and conditions:
18         (i) the amount of, and other terms and conditions with
19     respect to, the refund or additional premium are set forth
20     in the group or enrollment unit contract agreed in advance
21     of the period for which a refund is to be paid or
22     additional premium is to be charged (which period shall not
23     be less than one year); and
24         (ii) the amount of the refund or additional premium
25     shall not exceed 20% of the Health Maintenance
26     Organization's profitable or unprofitable experience with

 

 

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1     respect to the group or other enrollment unit for the
2     period (and, for purposes of a refund or additional
3     premium, the profitable or unprofitable experience shall
4     be calculated taking into account a pro rata share of the
5     Health Maintenance Organization's administrative and
6     marketing expenses, but shall not include any refund to be
7     made or additional premium to be paid pursuant to this
8     subsection (f)). The Health Maintenance Organization and
9     the group or enrollment unit may agree that the profitable
10     or unprofitable experience may be calculated taking into
11     account the refund period and the immediately preceding 2
12     plan years.
13     The Health Maintenance Organization shall include a
14 statement in the evidence of coverage issued to each enrollee
15 describing the possibility of a refund or additional premium,
16 and upon request of any group or enrollment unit, provide to
17 the group or enrollment unit a description of the method used
18 to calculate (1) the Health Maintenance Organization's
19 profitable experience with respect to the group or enrollment
20 unit and the resulting refund to the group or enrollment unit
21 or (2) the Health Maintenance Organization's unprofitable
22 experience with respect to the group or enrollment unit and the
23 resulting additional premium to be paid by the group or
24 enrollment unit.
25     In no event shall the Illinois Health Maintenance
26 Organization Guaranty Association be liable to pay any

 

 

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1 contractual obligation of an insolvent organization to pay any
2 refund authorized under this Section.
3 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
4 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
5 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised
6 12-15-08.)
 
7     (Text of Section after amendment by P.A. 95-958)
8     Sec. 5-3. Insurance Code provisions.
9     (a) Health Maintenance Organizations shall be subject to
10 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
11 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
12 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
13 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
14 356z.11, 356z.12, 356z.13 356z.11, 356z.14, 356z.15, 364.01,
15 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 401,
16 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
17 paragraph (c) of subsection (2) of Section 367, and Articles
18 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
19 the Illinois Insurance Code.
20     (b) For purposes of the Illinois Insurance Code, except for
21 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
22 Maintenance Organizations in the following categories are
23 deemed to be "domestic companies":
24         (1) a corporation authorized under the Dental Service
25     Plan Act or the Voluntary Health Services Plans Act;

 

 

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1         (2) a corporation organized under the laws of this
2     State; or
3         (3) a corporation organized under the laws of another
4     state, 30% or more of the enrollees of which are residents
5     of this State, except a corporation subject to
6     substantially the same requirements in its state of
7     organization as is a "domestic company" under Article VIII
8     1/2 of the Illinois Insurance Code.
9     (c) In considering the merger, consolidation, or other
10 acquisition of control of a Health Maintenance Organization
11 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
12         (1) the Director shall give primary consideration to
13     the continuation of benefits to enrollees and the financial
14     conditions of the acquired Health Maintenance Organization
15     after the merger, consolidation, or other acquisition of
16     control takes effect;
17         (2)(i) the criteria specified in subsection (1)(b) of
18     Section 131.8 of the Illinois Insurance Code shall not
19     apply and (ii) the Director, in making his determination
20     with respect to the merger, consolidation, or other
21     acquisition of control, need not take into account the
22     effect on competition of the merger, consolidation, or
23     other acquisition of control;
24         (3) the Director shall have the power to require the
25     following information:
26             (A) certification by an independent actuary of the

 

 

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1         adequacy of the reserves of the Health Maintenance
2         Organization sought to be acquired;
3             (B) pro forma financial statements reflecting the
4         combined balance sheets of the acquiring company and
5         the Health Maintenance Organization sought to be
6         acquired as of the end of the preceding year and as of
7         a date 90 days prior to the acquisition, as well as pro
8         forma financial statements reflecting projected
9         combined operation for a period of 2 years;
10             (C) a pro forma business plan detailing an
11         acquiring party's plans with respect to the operation
12         of the Health Maintenance Organization sought to be
13         acquired for a period of not less than 3 years; and
14             (D) such other information as the Director shall
15         require.
16     (d) The provisions of Article VIII 1/2 of the Illinois
17 Insurance Code and this Section 5-3 shall apply to the sale by
18 any health maintenance organization of greater than 10% of its
19 enrollee population (including without limitation the health
20 maintenance organization's right, title, and interest in and to
21 its health care certificates).
22     (e) In considering any management contract or service
23 agreement subject to Section 141.1 of the Illinois Insurance
24 Code, the Director (i) shall, in addition to the criteria
25 specified in Section 141.2 of the Illinois Insurance Code, take
26 into account the effect of the management contract or service

 

 

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1 agreement on the continuation of benefits to enrollees and the
2 financial condition of the health maintenance organization to
3 be managed or serviced, and (ii) need not take into account the
4 effect of the management contract or service agreement on
5 competition.
6     (f) Except for small employer groups as defined in the
7 Small Employer Rating, Renewability and Portability Health
8 Insurance Act and except for medicare supplement policies as
9 defined in Section 363 of the Illinois Insurance Code, a Health
10 Maintenance Organization may by contract agree with a group or
11 other enrollment unit to effect refunds or charge additional
12 premiums under the following terms and conditions:
13         (i) the amount of, and other terms and conditions with
14     respect to, the refund or additional premium are set forth
15     in the group or enrollment unit contract agreed in advance
16     of the period for which a refund is to be paid or
17     additional premium is to be charged (which period shall not
18     be less than one year); and
19         (ii) the amount of the refund or additional premium
20     shall not exceed 20% of the Health Maintenance
21     Organization's profitable or unprofitable experience with
22     respect to the group or other enrollment unit for the
23     period (and, for purposes of a refund or additional
24     premium, the profitable or unprofitable experience shall
25     be calculated taking into account a pro rata share of the
26     Health Maintenance Organization's administrative and

 

 

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1     marketing expenses, but shall not include any refund to be
2     made or additional premium to be paid pursuant to this
3     subsection (f)). The Health Maintenance Organization and
4     the group or enrollment unit may agree that the profitable
5     or unprofitable experience may be calculated taking into
6     account the refund period and the immediately preceding 2
7     plan years.
8     The Health Maintenance Organization shall include a
9 statement in the evidence of coverage issued to each enrollee
10 describing the possibility of a refund or additional premium,
11 and upon request of any group or enrollment unit, provide to
12 the group or enrollment unit a description of the method used
13 to calculate (1) the Health Maintenance Organization's
14 profitable experience with respect to the group or enrollment
15 unit and the resulting refund to the group or enrollment unit
16 or (2) the Health Maintenance Organization's unprofitable
17 experience with respect to the group or enrollment unit and the
18 resulting additional premium to be paid by the group or
19 enrollment unit.
20     In no event shall the Illinois Health Maintenance
21 Organization Guaranty Association be liable to pay any
22 contractual obligation of an insolvent organization to pay any
23 refund authorized under this Section.
24 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
25 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
26 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,

 

 

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1 eff. 12-12-08; revised 12-15-08.)
 
2     Section 95. No acceleration or delay. Where this Act makes
3 changes in a statute that is represented in this Act by text
4 that is not yet or no longer in effect (for example, a Section
5 represented by multiple versions), the use of that text does
6 not accelerate or delay the taking effect of (i) the changes
7 made by this Act or (ii) provisions derived from any other
8 Public Act.
 
9     Section 99. Effective date. This Act takes effect January
10 1, 2010.".