Full Text of SB0673 97th General Assembly
SB0673eng 97TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 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 | | changing Section 356z.16 and adding Section 356z.19 as follows: | 6 | | (215 ILCS 5/356z.16) | 7 | | Sec. 356z.16. Applicability of mandated benefits to | 8 | | supplemental policies. Unless specified otherwise, the | 9 | | following Sections of the Illinois Insurance Code do not apply | 10 | | to short-term travel, disability income, long-term care, | 11 | | accident only, or limited or specified disease policies: 356b, | 12 | | 356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t, | 13 | | 356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | 14 | | 356z.8, 356z.12, 356z.19, 367.2-5, and 367e.
| 15 | | (Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10; | 16 | | 96-1034, eff. 1-1-11.) | 17 | | (215 ILCS 5/356z.19 new) | 18 | | Sec. 356z.19. Tobacco use cessation programs; coverage | 19 | | offer. | 20 | | (a) Tobacco use is the number one cause of preventable | 21 | | disease and death in Illinois, costing $4.1 billion annually in | 22 | | direct health care costs and an additional $4.35 billion in |
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| 1 | | lost productivity. In Illinois, the smoking rates are highest | 2 | | among African Americans (25.8%). Smoking rates among lesbian, | 3 | | gay, and bisexual adults range from 25% to 44%. The U.S. Public | 4 | | Health Service Clinical Practice Guideline 2008 Update found | 5 | | that tobacco dependence treatments are both clinically | 6 | | effective and highly cost effective. A study in the Journal of | 7 | | Preventive Medicine concluded that comprehensive smoking | 8 | | cessation treatment is one of the 3 most important and cost | 9 | | effective preventive services that can be provided in medical | 10 | | practice. Greater efforts are needed to achieve more of this | 11 | | potential value by increasing current low
levels of | 12 | | performance. | 13 | | (b) In this Section, "tobacco use cessation program" means | 14 | | a program recommended by a physician that follows | 15 | | evidence-based treatment, such as is outlined in the United | 16 | | States Public Health Service guidelines for tobacco use | 17 | | cessation. "Tobacco use cessation program" includes education | 18 | | and medical treatment components designed to assist a person in | 19 | | ceasing the use of tobacco products. "Tobacco use cessation | 20 | | program" includes education and counseling by physicians or | 21 | | associated medical personnel and all FDA approved medications | 22 | | for the treatment of tobacco dependence irrespective of whether | 23 | | they are available only over the counter, only by prescription, | 24 | | or both over the counter and by prescription. | 25 | | (c) On or after the effective date of this amendatory Act | 26 | | of the 97th General Assembly, every
insurer that amends, |
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| 1 | | delivers, issues, or renews group accident and health policies | 2 | | providing coverage for hospital or medical treatment or | 3 | | services on an expense-incurred basis shall offer, for an | 4 | | additional premium and subject to the insurer's standard of | 5 | | insurability, optional coverage or optional reimbursement of | 6 | | up to $500 annually for a tobacco use cessation program for a | 7 | | person enrolled in the plan who is 18 years of age or older. | 8 | | (d) The coverage required by this Section shall be subject
| 9 | | to other general exclusions and limitations of the policy,
| 10 | | including coordination of benefits, participating provider
| 11 | | requirements, restrictions on services provided by family or | 12 | | household members, utilization review of health care services, | 13 | | including review of medical necessity, case management, | 14 | | experimental and investigational treatments, and other managed | 15 | | care provisions. | 16 | | (e) For the coverage provided under this Section, an | 17 | | insurer may not penalize or reduce or limit the reimbursement | 18 | | of an attending provider or provide incentives, monetary or | 19 | | otherwise, to an attending provider to induce the provider to | 20 | | provide care to an insured in a manner inconsistent with the | 21 | | coverage under this Section.
| 22 | | Section 10. 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 | | Sec. 5-3. Insurance Code provisions.
| 2 | | (a) Health Maintenance Organizations
shall be subject to | 3 | | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 4 | | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 5 | | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | 6 | | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 7 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | 8 | | 356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | 9 | | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | 10 | | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | 11 | | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | 12 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| 13 | | (b) For purposes of the Illinois Insurance Code, except for | 14 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 15 | | Maintenance Organizations in
the following categories are | 16 | | deemed to be "domestic companies":
| 17 | | (1) a corporation authorized under the
Dental Service | 18 | | Plan Act or the Voluntary Health Services Plans Act;
| 19 | | (2) a corporation organized under the laws of this | 20 | | State; or
| 21 | | (3) a corporation organized under the laws of another | 22 | | state, 30% or more
of the enrollees of which are residents | 23 | | of this State, except a
corporation subject to | 24 | | substantially the same requirements in its state of
| 25 | | organization as is a "domestic company" under Article VIII | 26 | | 1/2 of the
Illinois Insurance Code.
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| 1 | | (c) In considering the merger, consolidation, or other | 2 | | acquisition of
control of a Health Maintenance Organization | 3 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 4 | | (1) the Director shall give primary consideration to | 5 | | the continuation of
benefits to enrollees and the financial | 6 | | conditions of the acquired Health
Maintenance Organization | 7 | | after the merger, consolidation, or other
acquisition of | 8 | | control takes effect;
| 9 | | (2)(i) the criteria specified in subsection (1)(b) of | 10 | | Section 131.8 of
the Illinois Insurance Code shall not | 11 | | apply and (ii) the Director, in making
his determination | 12 | | with respect to the merger, consolidation, or other
| 13 | | acquisition of control, need not take into account the | 14 | | effect on
competition of the merger, consolidation, or | 15 | | other acquisition of control;
| 16 | | (3) the Director shall have the power to require the | 17 | | following
information:
| 18 | | (A) certification by an independent actuary of the | 19 | | adequacy
of the reserves of the Health Maintenance | 20 | | Organization sought to be acquired;
| 21 | | (B) pro forma financial statements reflecting the | 22 | | combined balance
sheets of the acquiring company and | 23 | | the Health Maintenance Organization sought
to be | 24 | | acquired as of the end of the preceding year and as of | 25 | | a date 90 days
prior to the acquisition, as well as pro | 26 | | forma financial statements
reflecting projected |
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| 1 | | combined operation for a period of 2 years;
| 2 | | (C) a pro forma business plan detailing an | 3 | | acquiring party's plans with
respect to the operation | 4 | | of the Health Maintenance Organization sought to
be | 5 | | acquired for a period of not less than 3 years; and
| 6 | | (D) such other information as the Director shall | 7 | | require.
| 8 | | (d) The provisions of Article VIII 1/2 of the Illinois | 9 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 10 | | any health maintenance
organization of greater than 10% of its
| 11 | | enrollee population (including without limitation the health | 12 | | maintenance
organization's right, title, and interest in and to | 13 | | its health care
certificates).
| 14 | | (e) In considering any management contract or service | 15 | | agreement subject
to Section 141.1 of the Illinois Insurance | 16 | | Code, the Director (i) shall, in
addition to the criteria | 17 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 18 | | into account the effect of the management contract or
service | 19 | | agreement on the continuation of benefits to enrollees and the
| 20 | | financial condition of the health maintenance organization to | 21 | | be managed or
serviced, and (ii) need not take into account the | 22 | | effect of the management
contract or service agreement on | 23 | | competition.
| 24 | | (f) Except for small employer groups as defined in the | 25 | | Small Employer
Rating, Renewability and Portability Health | 26 | | Insurance Act and except for
medicare supplement policies as |
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| 1 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 2 | | Maintenance Organization may by contract agree with a
group or | 3 | | other enrollment unit to effect refunds or charge additional | 4 | | premiums
under the following terms and conditions:
| 5 | | (i) the amount of, and other terms and conditions with | 6 | | respect to, the
refund or additional premium are set forth | 7 | | in the group or enrollment unit
contract agreed in advance | 8 | | of the period for which a refund is to be paid or
| 9 | | additional premium is to be charged (which period shall not | 10 | | be less than one
year); and
| 11 | | (ii) the amount of the refund or additional premium | 12 | | shall not exceed 20%
of the Health Maintenance | 13 | | Organization's profitable or unprofitable experience
with | 14 | | respect to the group or other enrollment unit for the | 15 | | period (and, for
purposes of a refund or additional | 16 | | premium, the profitable or unprofitable
experience shall | 17 | | be calculated taking into account a pro rata share of the
| 18 | | Health Maintenance Organization's administrative and | 19 | | marketing expenses, but
shall not include any refund to be | 20 | | made or additional premium to be paid
pursuant to this | 21 | | subsection (f)). The Health Maintenance Organization and | 22 | | the
group or enrollment unit may agree that the profitable | 23 | | or unprofitable
experience may be calculated taking into | 24 | | account the refund period and the
immediately preceding 2 | 25 | | plan years.
| 26 | | The Health Maintenance Organization shall include a |
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| 1 | | statement in the
evidence of coverage issued to each enrollee | 2 | | describing the possibility of a
refund or additional premium, | 3 | | and upon request of any group or enrollment unit,
provide to | 4 | | the group or enrollment unit a description of the method used | 5 | | to
calculate (1) the Health Maintenance Organization's | 6 | | profitable experience with
respect to the group or enrollment | 7 | | unit and the resulting refund to the group
or enrollment unit | 8 | | or (2) the Health Maintenance Organization's unprofitable
| 9 | | experience with respect to the group or enrollment unit and the | 10 | | resulting
additional premium to be paid by the group or | 11 | | enrollment unit.
| 12 | | In no event shall the Illinois Health Maintenance | 13 | | Organization
Guaranty Association be liable to pay any | 14 | | contractual obligation of an
insolvent organization to pay any | 15 | | refund authorized under this Section.
| 16 | | (g) Rulemaking authority to implement Public Act 95-1045, | 17 | | if any, is conditioned on the rules being adopted in accordance | 18 | | with all provisions of the Illinois Administrative Procedure | 19 | | Act and all rules and procedures of the Joint Committee on | 20 | | Administrative Rules; any purported rule not so adopted, for | 21 | | whatever reason, is unauthorized. | 22 | | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | 23 | | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | 24 | | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | 25 | | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | 26 | | 6-1-10; 96-1000, eff. 7-2-10.) |
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| 1 | | Section 15. The Limited Health Service Organization Act is | 2 | | amended by changing Section 4003 as follows:
| 3 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| 4 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 5 | | health service
organizations shall be subject to the provisions | 6 | | of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | 7 | | 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | 8 | | 155.04, 155.37, 355.2, 356v, 356z.10, 356z.19, 368a, 401, | 9 | | 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and | 10 | | Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and | 11 | | XXVI of the Illinois Insurance Code. For purposes of the
| 12 | | Illinois Insurance Code, except for Sections 444 and 444.1 and | 13 | | Articles XIII
and XIII 1/2, limited health service | 14 | | organizations in the following categories
are deemed to be | 15 | | domestic companies:
| 16 | | (1) a corporation under the laws of this State; or
| 17 | | (2) a corporation organized under the laws of another | 18 | | state, 30% of more
of the enrollees of which are residents | 19 | | of this State, except a corporation
subject to | 20 | | substantially the same requirements in its state of | 21 | | organization as
is a domestic company under Article VIII | 22 | | 1/2 of the Illinois Insurance Code.
| 23 | | (Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
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| 1 | | Section 20. The Voluntary Health Services Plans Act is | 2 | | amended by changing Section 10 as follows:
| 3 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
| 4 | | Sec. 10. Application of Insurance Code provisions. Health | 5 | | services
plan corporations and all persons interested therein | 6 | | or dealing therewith
shall be subject to the provisions of | 7 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | 8 | | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | 9 | | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | 10 | | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | 11 | | 356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401, | 12 | | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | 13 | | and (15) of Section 367 of the Illinois
Insurance Code.
| 14 | | Rulemaking authority to implement Public Act 95-1045, if | 15 | | any, is conditioned on the rules being adopted in accordance | 16 | | with all provisions of the Illinois Administrative Procedure | 17 | | Act and all rules and procedures of the Joint Committee on | 18 | | Administrative Rules; any purported rule not so adopted, for | 19 | | whatever reason, is unauthorized. | 20 | | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | 21 | | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 22 | | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | 23 | | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | 24 | | 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff. | 25 | | 7-2-10.)
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