093_SB0467enr

 
SB467 Enrolled                       LRB093 10601 JLS 10855 b

 1        AN ACT concerning insurance coverage.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

 4        Section  5.  The  Illinois  Insurance  Code is amended by
 5    adding Section 356z.4 as follows:

 6        (215 ILCS 5/356z.4 new)
 7        Sec.  356z.4.  Prescription   inhalants.   A   group   or
 8    individual policy of accident and health insurance or managed
 9    care  plan  amended,  delivered, issued, or renewed after the
10    effective date of this amendatory Act  of  the  93rd  General
11    Assembly  that  provides  coverage for prescription drugs may
12    not deny or limit  coverage  for  prescription  inhalants  to
13    enable persons to breathe when suffering from asthma or other
14    life-threatening    bronchial   ailments   based   upon   any
15    restriction on the number of days before  an  inhaler  refill
16    may  be  obtained  if,  contrary  to  those restrictions, the
17    inhalants have been ordered or  prescribed  by  the  treating
18    physician and are medically appropriate.

19        Section  10.  The  Health Maintenance Organization Act is
20    amended by changing Section 5-3 as follows:

21        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
22        Sec. 5-3.  Insurance Code provisions.
23        (a)  Health Maintenance Organizations shall be subject to
24    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
25    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
26    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
27    356y, 356z.2, 356z.4, 367i, 368a, 401, 401.1, 402, 403, 403A,
28    408,  408.2,  409,  412,  444,  and  444.1,  paragraph (c) of
29    subsection (2) of Section 367, and Articles  IIA,  VIII  1/2,

 
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 1    XII,  XII  1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
 2    Insurance Code.
 3        (b)  For purposes of the Illinois Insurance Code,  except
 4    for  Sections  444  and 444.1 and Articles XIII and XIII 1/2,
 5    Health Maintenance Organizations in the following  categories
 6    are deemed to be "domestic companies":
 7             (1)  a   corporation  authorized  under  the  Dental
 8        Service Plan Act or the Voluntary Health  Services  Plans
 9        Act;
10             (2)  a  corporation organized under the laws of this
11        State; or
12             (3)  a  corporation  organized  under  the  laws  of
13        another state, 30% or more of the enrollees of which  are
14        residents  of this State, except a corporation subject to
15        substantially the  same  requirements  in  its  state  of
16        organization  as  is  a  "domestic company" under Article
17        VIII 1/2 of the Illinois Insurance Code.
18        (c)  In considering the merger, consolidation,  or  other
19    acquisition  of  control of a Health Maintenance Organization
20    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
21             (1)  the Director shall give  primary  consideration
22        to  the  continuation  of  benefits  to enrollees and the
23        financial conditions of the acquired  Health  Maintenance
24        Organization  after  the  merger, consolidation, or other
25        acquisition of control takes effect;
26             (2)(i)  the criteria specified in subsection  (1)(b)
27        of Section 131.8 of the Illinois Insurance Code shall not
28        apply  and (ii) the Director, in making his determination
29        with respect  to  the  merger,  consolidation,  or  other
30        acquisition  of  control,  need not take into account the
31        effect on competition of the  merger,  consolidation,  or
32        other acquisition of control;
33             (3)  the  Director  shall  have the power to require
34        the following information:
 
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 1                  (A)  certification by an independent actuary of
 2             the  adequacy  of  the  reserves   of   the   Health
 3             Maintenance Organization sought to be acquired;
 4                  (B)  pro  forma financial statements reflecting
 5             the combined balance sheets of the acquiring company
 6             and the Health Maintenance Organization sought to be
 7             acquired as of the end of the preceding year and  as
 8             of  a date 90 days prior to the acquisition, as well
 9             as  pro  forma   financial   statements   reflecting
10             projected  combined  operation  for  a  period  of 2
11             years;
12                  (C)  a pro forma  business  plan  detailing  an
13             acquiring   party's   plans   with  respect  to  the
14             operation of  the  Health  Maintenance  Organization
15             sought  to be acquired for a period of not less than
16             3 years; and
17                  (D)  such other  information  as  the  Director
18             shall require.
19        (d)  The  provisions  of Article VIII 1/2 of the Illinois
20    Insurance Code and this Section 5-3 shall apply to  the  sale
21    by any health maintenance organization of greater than 10% of
22    its  enrollee  population  (including  without limitation the
23    health maintenance organization's right, title, and  interest
24    in and to its health care certificates).
25        (e)  In  considering  any  management contract or service
26    agreement subject to Section 141.1 of the Illinois  Insurance
27    Code,  the  Director  (i)  shall, in addition to the criteria
28    specified in Section 141.2 of the  Illinois  Insurance  Code,
29    take  into  account  the effect of the management contract or
30    service  agreement  on  the  continuation  of   benefits   to
31    enrollees   and   the   financial  condition  of  the  health
32    maintenance organization to be managed or serviced, and  (ii)
33    need  not  take  into  account  the  effect of the management
34    contract or service agreement on competition.
 
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 1        (f)  Except for small employer groups as defined  in  the
 2    Small  Employer  Rating,  Renewability and Portability Health
 3    Insurance Act and except for medicare supplement policies  as
 4    defined  in  Section  363  of  the Illinois Insurance Code, a
 5    Health Maintenance Organization may by contract agree with  a
 6    group  or  other  enrollment unit to effect refunds or charge
 7    additional premiums under the following terms and conditions:
 8             (i)  the amount of, and other terms  and  conditions
 9        with respect to, the refund or additional premium are set
10        forth  in the group or enrollment unit contract agreed in
11        advance of the period for which a refund is to be paid or
12        additional premium is to be charged (which  period  shall
13        not be less than one year); and
14             (ii)  the amount of the refund or additional premium
15        shall   not   exceed   20%   of  the  Health  Maintenance
16        Organization's profitable or unprofitable experience with
17        respect to the group or other  enrollment  unit  for  the
18        period  (and,  for  purposes  of  a  refund or additional
19        premium, the profitable or unprofitable experience  shall
20        be calculated taking into account a pro rata share of the
21        Health   Maintenance  Organization's  administrative  and
22        marketing expenses, but shall not include any  refund  to
23        be made or additional premium to be paid pursuant to this
24        subsection (f)).  The Health Maintenance Organization and
25        the   group   or  enrollment  unit  may  agree  that  the
26        profitable or unprofitable experience may  be  calculated
27        taking into account the refund period and the immediately
28        preceding 2 plan years.
29        The  Health  Maintenance  Organization  shall  include  a
30    statement in the evidence of coverage issued to each enrollee
31    describing the possibility of a refund or additional premium,
32    and  upon request of any group or enrollment unit, provide to
33    the group or enrollment unit a description of the method used
34    to  calculate  (1)  the  Health  Maintenance   Organization's
 
SB467 Enrolled              -5-      LRB093 10601 JLS 10855 b
 1    profitable experience with respect to the group or enrollment
 2    unit and the resulting refund to the group or enrollment unit
 3    or  (2)  the  Health  Maintenance Organization's unprofitable
 4    experience with respect to the group or enrollment  unit  and
 5    the  resulting  additional premium to be paid by the group or
 6    enrollment unit.
 7        In  no  event  shall  the  Illinois  Health   Maintenance
 8    Organization  Guaranty  Association  be  liable  to  pay  any
 9    contractual  obligation  of  an insolvent organization to pay
10    any refund authorized under this Section.
11    (Source: P.A. 91-357,  eff.  7-29-99;  91-406,  eff.  1-1-00;
12    91-549,  eff.  8-14-99;  91-605,  eff. 12-14-99; 91-788, eff.
13    6-9-00; 92-764, eff. 1-1-03.)

14        Section 15.  The Voluntary Health Services Plans  Act  is
15    amended by changing Section 10 as follows:

16        (215 ILCS 165/10) (from Ch. 32, par. 604)
17        Sec.   10.  Application  of  Insurance  Code  provisions.
18    Health services plan corporations and all persons  interested
19    therein   or  dealing  therewith  shall  be  subject  to  the
20    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
21    140, 143, 143c, 149, 155.37, 354, 355.2,  356r,  356t,  356u,
22    356v,  356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 367.2, 368a,
23    401,  401.1,  402,  403,  403A,  408,  408.2,  and  412,  and
24    paragraphs (7) and  (15)  of  Section  367  of  the  Illinois
25    Insurance Code.
26    (Source: P.A.  91-406,  eff.  1-1-00;  91-549,  eff. 8-14-99;
27    91-605, eff. 12-14-99;  91-788,  eff.  6-9-00;  92-130,  eff.
28    7-20-01;  92-440, eff. 8-17-01; 92-651, eff. 7-11-02; 92-764,
29    eff. 1-1-03.)

30        Section 99.  Effective date.  This Act takes effect  upon
31    becoming law.