97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB0071

 

Introduced 1/27/2011, by Sen. Ira I. Silverstein

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.19 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the Illinois Insurance Code, the Voluntary Health Services Plans Act, and the Voluntary Health Services Plans Act to require coverage for hearing instruments and related services for all individuals when a hearing care professional prescribes a hearing instrument. Provides that an insurer shall provide coverage for up to $2,500 per hearing aid per insured's hearing impaired ear subject to certain restrictions. Provides that an insurer shall not be required to pay a claim if the insured filed such a claim 36 months prior to the date of filing the claim with the insurer and the claim was paid by any insurer. Effective immediately.


LRB097 02743 RPM 42765 b

 

 

A BILL FOR

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 356z.19 as follows:
 
6    (215 ILCS 5/356z.19 new)
7    Sec. 356z.19. Coverage for hearing aids for all
8individuals.
9    (a) As used in this Section:
10    "Hearing care professional" means a person who is a
11licensed audiologist or a licensed physician.
12    "Hearing instrument" or "hearing aid" means any wearable
13non-disposable instrument or device designed to aid or
14compensate for impaired human hearing in cases where functional
15ability cannot be restored either medically or surgically and
16any parts, attachments, or accessories for the instrument or
17device, including an ear mold but excluding batteries and
18cords.
19    "Related services" means those services necessary to
20assess, select, and adjust or fit the hearing instrument to
21ensure optimal performance including but not limited to:
22audiological exams, replacement ear molds, and repairs to the
23hearing instrument.

 

 

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1    (b) An individual or group policy of accident and health
2insurance or managed care plan that is amended, delivered,
3issued, or renewed after the effective date of this amendatory
4Act of the 97th General Assembly must provide coverage for
5hearing instruments and related services for all individuals
6when a hearing care professional prescribes a hearing
7instrument to augment communication.
8    (c) An insurer shall provide coverage, subject to all
9applicable copayments, coinsurance, deductibles, and
10out-of-pocket limits, for up to $2,500 per hearing aid per
11insured's hearing impaired ear subject to the following
12restrictions:
13        (1) for all insured individuals, hearing aids may be
14    replaced up to once every 36 months as prescribed and
15    dispensed by a hearing care professional;
16        (2) for all insured individuals, any hearing aid may be
17    replaced at any time regardless of the above restrictions
18    if there is a significant change in the insured
19    individual's hearing status; such significant change is
20    defined as a change of 10 decibels HL on the
21    three-frequency pure-tone average (500 Hz, 1000 Hz and 2000
22    Hz) on a valid audiogram provided by a hearing care
23    professional; and
24        (3) for all insured individuals, related services,
25    such as audiological exams, ear molds, and hearing aid
26    repairs, shall be covered at all times when prescribed by a

 

 

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1    hearing care professional.
2    (d) An insurer shall not be required to pay a claim filed
3by its insured for the payment of the cost of a hearing aid
4covered by this Section if less than 36 months prior to the
5date of the claim its insured filed a claim for payment of the
6cost of the hearing aid and the claim was paid by any insurer.
 
7    Section 10. The Health Maintenance Organization Act is
8amended by changing Section 5-3 as follows:
 
9    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
10    Sec. 5-3. Insurance Code provisions.
11    (a) Health Maintenance Organizations shall be subject to
12the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
13141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
14154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
15356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
16356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
17356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
18368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
19409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
20Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
21XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
22    (b) For purposes of the Illinois Insurance Code, except for
23Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
24Maintenance Organizations in the following categories are

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1    (g) Rulemaking authority to implement Public Act 95-1045,
2if any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
895-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
995-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
101-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
116-1-10; 96-1000, eff. 7-2-10.)
 
12    Section 15. The Voluntary Health Services Plans Act is
13amended by changing Section 10 as follows:
 
14    (215 ILCS 165/10)  (from Ch. 32, par. 604)
15    Sec. 10. Application of Insurance Code provisions. Health
16services plan corporations and all persons interested therein
17or dealing therewith shall be subject to the provisions of
18Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
19149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
20356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
21356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
22356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401,
23401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
24and (15) of Section 367 of the Illinois Insurance Code.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
895-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
98-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
10eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
1196-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff.
127-2-10.)
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.