Full Text of SB2366 98th General Assembly
SB2366sam003 98TH GENERAL ASSEMBLY | Sen. Don Harmon Filed: 4/15/2013
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| 1 | | AMENDMENT TO SENATE BILL 2366
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 2366 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 | | 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, 356z.13, | 15 | | 356z.14, 356z.15, and 356z.17 , and 356z.22 and 356z.19 of the
| 16 | | Illinois Insurance Code.
The program of health benefits must |
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| 1 | | comply with Sections 155.22a, 155.37, and 356z.19 of the
| 2 | | Illinois Insurance Code.
| 3 | | Rulemaking authority to implement Public Act 95-1045, if | 4 | | any, is conditioned on the rules being adopted in accordance | 5 | | with all provisions of the Illinois Administrative Procedure | 6 | | Act and all rules and procedures of the Joint Committee on | 7 | | Administrative Rules; any purported rule not so adopted, for | 8 | | whatever reason, is unauthorized. | 9 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; | 10 | | 96-639, eff. 1-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; | 11 | | 97-343, eff. 1-1-12; 97-813, eff. 7-13-12.) | 12 | | Section 10. The Counties Code is amended by changing | 13 | | Section 5-1069.3 as follows: | 14 | | (55 ILCS 5/5-1069.3)
| 15 | | Sec. 5-1069.3. Required health benefits. If a county, | 16 | | including a home
rule
county, is a self-insurer for purposes of | 17 | | providing health insurance coverage
for its employees, the | 18 | | coverage shall include coverage for the post-mastectomy
care | 19 | | benefits required to be covered by a policy of accident and | 20 | | health
insurance under Section 356t and the coverage required | 21 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 22 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 23 | | 356z.14, and 356z.15 , and 356z.22 of
the Illinois Insurance | 24 | | Code. The coverage shall comply with Sections 155.22a and |
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| 1 | | 356z.19 of
the Illinois Insurance Code. The requirement that | 2 | | health benefits be covered
as provided in this Section is an
| 3 | | exclusive power and function of the State and is a denial and | 4 | | limitation under
Article VII, Section 6, subsection (h) of the | 5 | | Illinois Constitution. A home
rule county to which this Section | 6 | | applies must comply with every provision of
this Section.
| 7 | | Rulemaking authority to implement Public Act 95-1045, if | 8 | | any, is conditioned on the rules being adopted in accordance | 9 | | with all provisions of the Illinois Administrative Procedure | 10 | | Act and all rules and procedures of the Joint Committee on | 11 | | Administrative Rules; any purported rule not so adopted, for | 12 | | whatever reason, is unauthorized. | 13 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; | 14 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; | 15 | | 97-813, eff. 7-13-12.) | 16 | | Section 15. The Illinois Municipal Code is amended by | 17 | | changing Section 10-4-2.3 as follows: | 18 | | (65 ILCS 5/10-4-2.3)
| 19 | | Sec. 10-4-2.3. Required health benefits. If a | 20 | | municipality, including a
home rule municipality, is a | 21 | | self-insurer for purposes of providing health
insurance | 22 | | coverage for its employees, the coverage shall include coverage | 23 | | for
the post-mastectomy care benefits required to be covered by | 24 | | a policy of
accident and health insurance under Section 356t |
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| 1 | | and the coverage required
under Sections 356g, 356g.5, | 2 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 3 | | 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15 , and 356z.22 of | 4 | | the Illinois
Insurance
Code. The coverage shall comply with | 5 | | Sections 155.22a and 356z.19 of
the Illinois Insurance Code. | 6 | | The requirement that health
benefits be covered as provided in | 7 | | this is an exclusive power and function of
the State and is a | 8 | | denial and limitation under Article VII, Section 6,
subsection | 9 | | (h) of the Illinois Constitution. A home rule municipality to | 10 | | which
this Section applies must comply with every provision of | 11 | | this Section.
| 12 | | Rulemaking authority to implement Public Act 95-1045, if | 13 | | any, is conditioned on the rules being adopted in accordance | 14 | | with all provisions of the Illinois Administrative Procedure | 15 | | Act and all rules and procedures of the Joint Committee on | 16 | | Administrative Rules; any purported rule not so adopted, for | 17 | | whatever reason, is unauthorized. | 18 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; | 19 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; | 20 | | 97-813, eff. 7-13-12.) | 21 | | Section 20. The School Code is amended by changing Section | 22 | | 10-22.3f as follows: | 23 | | (105 ILCS 5/10-22.3f)
| 24 | | Sec. 10-22.3f. Required health benefits. Insurance |
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| 1 | | protection and
benefits
for employees shall provide the | 2 | | post-mastectomy care benefits required to be
covered by a | 3 | | policy of accident and health insurance under Section 356t and | 4 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 5 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 6 | | 356z.13, 356z.14, and 356z.15 , and 356z.22 of
the
Illinois | 7 | | Insurance Code.
Insurance policies shall comply with Section | 8 | | 356z.19 of the Illinois Insurance Code. The coverage shall | 9 | | comply with Section 155.22a of
the Illinois Insurance Code.
| 10 | | Rulemaking authority to implement Public Act 95-1045, if | 11 | | any, is conditioned on the rules being adopted in accordance | 12 | | with all provisions of the Illinois Administrative Procedure | 13 | | Act and all rules and procedures of the Joint Committee on | 14 | | Administrative Rules; any purported rule not so adopted, for | 15 | | whatever reason, is unauthorized. | 16 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; | 17 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; | 18 | | 97-813, eff. 7-13-12.) | 19 | | Section 25. The Illinois Insurance Code is amended by | 20 | | adding Section 356z.22 as follows: | 21 | | (215 ILCS 5/356z.22 new) | 22 | | Sec. 356z.22. Telehealth. | 23 | | (a) The General Assembly finds and declares the following: | 24 | | (1) Lack of primary care providers, specialty |
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| 1 | | providers, and transportation continue to be significant | 2 | | barriers to access to health services in medically | 3 | | underserved rural and urban areas. | 4 | | (2) Parts of Illinois have difficulty attracting and | 5 | | retaining health professionals, as well as supporting | 6 | | local health facilities to provide a continuum of health | 7 | | care. | 8 | | (3) Individuals in rural areas are much less likely to | 9 | | have access to the specialty health services they need, due | 10 | | to major distance and time barriers, transportation | 11 | | limitations, or mobility limitations, all of which lead to | 12 | | disparities in access to care. | 13 | | (4) Hospital emergency rooms have become the default | 14 | | provider of health care to patients with acute crises and | 15 | | for whom no appropriate alternatives are available, and the | 16 | | majority of emergency rooms do not have reliable, ready | 17 | | consultative access to psychiatrists or other medical | 18 | | specialties. | 19 | | (5) Telehealth has been shown to be an effective medium | 20 | | through which to deliver physical health and mental health | 21 | | care. | 22 | | (6) Key findings from the Illinois Rural Health | 23 | | Association's Mental Health Access Forum Report recommend | 24 | | the increased use of telehealth and technology to improve | 25 | | access to care, increase training opportunities, and | 26 | | evaluate quality of care. |
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| 1 | | (7) The State of Illinois has already recognized, and | 2 | | currently reimburses providers for, telepsychiatry | 3 | | services to patients receiving State public aid. | 4 | | (8) Telehealth is a mode of delivering health care | 5 | | services of a personal, family, and public health nature | 6 | | through utilizing information and communication | 7 | | technologies to enable the examination, diagnosis, | 8 | | consultation, treatment, education, care management, and | 9 | | self-management of patients at a distance from health
care | 10 | | providers. | 11 | | (9) The use of information and telecommunication | 12 | | technologies to deliver health services has the potential | 13 | | to reduce costs, improve quality, change the conditions of | 14 | | practice, and improve access to health care, particularly | 15 | | in rural and other medically underserved areas, as well as | 16 | | in emergency rooms in large urban areas where the wait for | 17 | | specialty care can be lengthy. | 18 | | (10) Telehealth will assist in maintaining or | 19 | | improving the physical and economic health of medically | 20 | | underserved communities by keeping the source of medical | 21 | | care in the local area by assisting primary care | 22 | | physicians, strengthening the health infrastructure, and | 23 | | preserving health care-related jobs. | 24 | | (11) Consumers of health care will benefit from | 25 | | telehealth in many ways, including expanded access to | 26 | | providers, faster and more convenient treatment, better |
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| 1 | | continuity of care, reduction of lost work time and travel | 2 | | costs, and the ability to remain with support networks. | 3 | | (12) It is the intent of the General Assembly that the | 4 | | fundamental health care provider-patient relationship not | 5 | | only be preserved, but also be augmented and enhanced, | 6 | | through the use of telehealth as a tool to be integrated | 7 | | into practices. | 8 | | (13)
Without the assurance of payment and the | 9 | | resolution of legal and policy barriers, the full potential | 10 | | of telehealth will not be realized. | 11 | | The purpose of this Section is to require certain insurers, | 12 | | nonprofit health service plans, managed care organizations, | 13 | | and health maintenance organizations to provide coverage for | 14 | | health care services delivered through telehealth in a certain | 15 | | manner; prohibit certain insurers, nonprofit health service | 16 | | plans, health maintenance organizations and managed care | 17 | | organizations from excluding a health care service from | 18 | | coverage solely because it is delivered by telehealth and not | 19 | | in another manner; require certain insurers, nonprofit health | 20 | | service plans, and health maintenance organizations to | 21 | | reimburse health care providers for certain services under | 22 | | certain circumstances; authorize the imposition of a | 23 | | deductible, copayment, coinsurance amount, or annual dollar | 24 | | maximum for certain services in compliance with Illinois and | 25 | | federal parity laws; prohibit the imposition of a lifetime | 26 | | dollar maximum for certain services; prohibit a health |
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| 1 | | insurance policy or contract from distinguishing between | 2 | | patients in rural or urban locations in providing certain | 3 | | coverage; and provide for the application of this Code. | 4 | | (b) For the purposes of this Section: | 5 | | "Asynchronous store and forward" means the transmission of | 6 | | a patient's medical information from an originating site to the | 7 | | health care provider at a distant site without the presence of | 8 | | the patient. | 9 | | "Distant site" means the location at which the provider | 10 | | rendering the service is located. | 11 | | "Facility fee" means the reimbursement made to the | 12 | | following originating sites for the telehealth service: | 13 | | physician's office, local health departments, community mental | 14 | | health centers, rural health clinics, hospitals, and substance | 15 | | use disorder facilities licensed by the Department of Human | 16 | | Services or the Department of Public Health. | 17 | | "Health care provider" means a licensed or certified health | 18 | | care professional, including, but not limited to, advanced | 19 | | practice nurses, psychologists, social workers, physicians, | 20 | | licensed clinical professional counselors, and mental health | 21 | | professionals as defined in 59 Ill. Adm. Code 132.25 and | 22 | | substance use disorder professionals as defined in 77 Ill. Adm. | 23 | | Code 2060.309. | 24 | | "Interactive telecommunications system" means multimedia | 25 | | communications equipment that includes, at a minimum, audio and | 26 | | video equipment permitting 2-way, real-time interactive |
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| 1 | | communication between the patient and the distant site | 2 | | provider. Telephones, facsimile machines, and electronic mail | 3 | | systems do not meet the definition of "interactive | 4 | | telecommunications system". | 5 | | "Originating site" means the location at which the | 6 | | participant receiving the service is located, including, but | 7 | | not limited to, hospitals, rural health clinics, Federally | 8 | | Qualified Health Centers, and other health care providers. | 9 | | "Physician" means a physician licensed to practice | 10 | | medicine in all its branches. | 11 | | "Synchronous interaction" means a real-time interaction | 12 | | between a patient at an originating site and a health care | 13 | | provider located at a distant site. | 14 | | "Telecommunication system" means an asynchronous store and | 15 | | forward technology or an interactive telecommunications | 16 | | system, or both, that is used to transmit data between the | 17 | | originating and distant sites. | 18 | | "Telehealth" means (1) the provision of services and the | 19 | | mode of delivering health care services and public health via | 20 | | information and communication technologies to facilitate the | 21 | | examination, assessment, diagnosis, consultation, treatment, | 22 | | education, care management, and self-management of a patient's | 23 | | health care while the patient is at the originating site and | 24 | | the health care provider is at a distant site; telehealth | 25 | | facilitates patient self-management and caregiver support for | 26 | | patients and includes synchronous interactions
and |
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| 1 | | asynchronous store and forward transfers and (2) as it relates | 2 | | to the delivery of health care, mental health care, substance | 3 | | use disorder treatment, and public health services, the use of | 4 | | interactive audio, video, or other telecommunications or | 5 | | electronic technology by a health care provider to deliver a | 6 | | health care service within the scope of practice of the health | 7 | | care provider from the distant site to the originating site at | 8 | | which the patient is located; telehealth is the provision of | 9 | | services via information and communication technologies to | 10 | | facilitate the assessment, diagnosis, consultation, treatment, | 11 | | education, care management, and self-management of a patient's | 12 | | health care while the patient is at the originating site and | 13 | | the health care provider is at a distant site; telehealth | 14 | | facilitates patient self-management and caregiver support for | 15 | | patients and includes synchronous interactions and | 16 | | asynchronous store and forward transfers.
"Telehealth" does | 17 | | not include: | 18 | | (A) an audio-only telephone conversation between a | 19 | | health care provider and a patient; | 20 | | (B) an electronic mail message between a health care | 21 | | provider and a patient; or | 22 | | (C) a facsimile transmission between a health care | 23 | | provider and a patient. | 24 | | "Teleophthalmology and teledermatology by store and | 25 | | forward" means an asynchronous transmission of medical | 26 | | information to be reviewed at a later time by a physician at a |
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| 1 | | distant site who is trained in ophthalmology or dermatology or, | 2 | | for teleophthalmology, by an optometrist who is licensed | 3 | | pursuant to the Illinois Optometric Practice Act of 1987 where | 4 | | the physician or optometrist at the distant site reviews the | 5 | | medical information without the patient being present in real | 6 | | time. | 7 | | (c) This Section applies to: | 8 | | (1) insurers and nonprofit health service plans that | 9 | | provide hospital, medical, mental health, substance use | 10 | | disorder, or surgical benefits to individuals or groups on | 11 | | an expense-incurred basis under health insurance policies | 12 | | or contracts that are issued or delivered in this State; | 13 | | and | 14 | | (2) health maintenance organizations that provide | 15 | | hospital, medical, mental health, substance use disorder, | 16 | | or surgical benefits to individuals or groups under | 17 | | contracts that are issued or delivered in this State. | 18 | | This Section shall not be construed to alter the scope of | 19 | | practice of any health care provider or authorize the delivery | 20 | | of health care services in a setting or in a manner not | 21 | | otherwise authorized by law.
All laws regarding the | 22 | | confidentiality of health care information and a patient's | 23 | | rights to his or her medical information shall apply to | 24 | | telehealth interactions. This Section applies to a group or | 25 | | individual policy of accident and health insurance or managed | 26 | | care plan amended, delivered, issued, or renewed after the |
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| 1 | | effective date of this amendatory Act of the 98th General | 2 | | Assembly. | 3 | | (d) An entity subject to this Section: | 4 | | (1) shall provide coverage under a health insurance | 5 | | policy or contract for health care services appropriately | 6 | | delivered through telehealth; | 7 | | (2) may not exclude from coverage a health care service | 8 | | solely because it is provided through telehealth and is not | 9 | | provided through an in-person consultation or contact | 10 | | between a health care provider and a patient; and | 11 | | (3) shall not require that in-person contact occur | 12 | | between a health care provider and a patient before payment | 13 | | is made for the covered services appropriately provided | 14 | | through telehealth. | 15 | | No health care service plan shall require the health care | 16 | | provider to document a barrier to an in-person visit for | 17 | | coverage of services to be provided via telehealth. No health | 18 | | care service plan shall limit the type of setting where | 19 | | services are provided for the patient or by the health care | 20 | | provider before payment is made for the covered services | 21 | | appropriately provided through telehealth, subject to the | 22 | | terms and conditions of the contract entered into between the | 23 | | enrollee or subscriber and the health care service plan and its | 24 | | participating providers or provider groups. | 25 | | Notwithstanding any other provision, this Section shall | 26 | | not be interpreted to authorize a health care service plan to |
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| 1 | | require the use of telehealth when the health care provider has | 2 | | determined that it is not appropriate. | 3 | | (e) With regard to reimbursement, an entity subject to this | 4 | | Section: | 5 | | (1) shall reimburse a health care provider for the | 6 | | examination, assessment, diagnosis, consultation, and | 7 | | treatment of an insured patient for a health care service | 8 | | covered under a health insurance policy or contract that | 9 | | can appropriately be provided through telehealth; | 10 | | (2) is not required to: | 11 | | (A) reimburse a health care provider for a health | 12 | | care service delivered in person or through telehealth | 13 | | that is not a covered benefit under the health | 14 | | insurance policy or contract; or | 15 | | (B) reimburse a health care provider who is not a | 16 | | covered provider under the health insurance policy or | 17 | | contract; | 18 | | (3) may impose the same deductible, copayment, or | 19 | | coinsurance amount on benefits for health care services | 20 | | that are delivered through an in-person consultation or | 21 | | through telehealth in compliance with Illinois and federal | 22 | | parity laws; and | 23 | | (4) may not impose a lifetime dollar maximum or limit | 24 | | the provision of mental health or substance use disorder | 25 | | services in a manner that violates Illinois or federal | 26 | | parity laws. |
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| 1 | | A facility fee shall be paid to providers. Participating | 2 | | providers shall be reimbursed for the appropriate current | 3 | | procedural terminology (CPT) code for the telehealth service | 4 | | rendered. | 5 | | (f) A patient receiving services by store and forward shall | 6 | | be notified of the right to receive interactive communication | 7 | | with the distant specialist physician or optometrist, and shall | 8 | | receive an interactive communication with the distant | 9 | | specialist physician or optometrist upon request. If | 10 | | requested, communication with the distant specialist physician | 11 | | or optometrist may occur either at the time of the consultation | 12 | | or within 30 days after the patient's notification of the | 13 | | results of the consultation. If the reviewing optometrist | 14 | | identifies a disease or condition requiring consultation or | 15 | | referral, then that consultation or referral shall be with an | 16 | | ophthalmologist or other appropriate physician and surgeon as | 17 | | required. | 18 | | (g) The requirements for telehealth services are as | 19 | | follows: | 20 | | (1) A physician or other health care provider must be | 21 | | onsite and available to the patient at the originating | 22 | | site, except: | 23 | | (A) where the patient requests that the health care | 24 | | provider not be present in the same room with the | 25 | | patient, but such health care provider is otherwise | 26 | | available to the patient onsite; or |
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| 1 | | (B) where the patient and his or her treating | 2 | | health care provider consent to the provision of level | 3 | | one substance use disorder treatment services in | 4 | | accordance with 77 Ill. Adm. Code 2060.401 without a | 5 | | health care provider present onsite with the patient. | 6 | | (2) The distant site provider must be a physician or | 7 | | health care provider. | 8 | | (3) Medical data may be exchanged through a | 9 | | telecommunication system. | 10 | | (4) The interactive telecommunications system must, at | 11 | | a minimum, have the capability of allowing the consulting | 12 | | physician to examine the patient sufficiently to allow | 13 | | proper diagnosis. The system must also be capable of | 14 | | transmitting clearly audible sounds as well as clear video | 15 | | images. | 16 | | (h) The requirements for telepsychiatry services are as | 17 | | follows: | 18 | | (1) A physician or other health care provider as | 19 | | defined in 59 Ill. Adm. Code 132.25 must be onsite and | 20 | | available to the patient at the originating site, but at | 21 | | the patient's request does not need to be present in the | 22 | | room with the patient. | 23 | | (2) The distant site provider must be a physician or | 24 | | health care provider licensed by the State of Illinois or | 25 | | by the state where the patient is located and must have | 26 | | completed or be registered in and supervised by a physician |
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| 1 | | who has completed an approved general psychiatry residency | 2 | | program. When treating patients age 16 and younger, the | 3 | | physician must have also completed an approved child and | 4 | | adolescent residency program or be registered in an | 5 | | approved general psychiatry residency program or a child | 6 | | and adolescent psychiatry fellowship program and | 7 | | supervised by a physician who has completed an approved | 8 | | child and adolescent psychiatry fellowship program. The | 9 | | distant site provider must personally render the | 10 | | telepsychiatry service. Telepsychiatry services must be | 11 | | rendered using an interactive video telecommunications | 12 | | system. | 13 | | Group psychotherapy is a covered telepsychiatry service. | 14 | | (i) The originating site must maintain records to document | 15 | | the services provided to patients and the health care providers | 16 | | involved in the services at all originating and distant site | 17 | | locations.
| 18 | | Section 30. The Health Maintenance Organization Act is | 19 | | amended by changing Section 5-3 as follows:
| 20 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 21 | | Sec. 5-3. Insurance Code provisions.
| 22 | | (a) Health Maintenance Organizations
shall be subject to | 23 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 24 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
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| 1 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 2 | | 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, 356z.5, | 3 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 4 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, | 5 | | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | 6 | | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | 7 | | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | 8 | | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | 9 | | and XXVI of the Illinois Insurance Code.
| 10 | | (b) For purposes of the Illinois Insurance Code, except for | 11 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 12 | | Maintenance Organizations in
the following categories are | 13 | | deemed to be "domestic companies":
| 14 | | (1) a corporation authorized under the
Dental Service | 15 | | Plan Act or the Voluntary Health Services Plans Act;
| 16 | | (2) a corporation organized under the laws of this | 17 | | State; or
| 18 | | (3) a corporation organized under the laws of another | 19 | | state, 30% or more
of the enrollees of which are residents | 20 | | of this State, except a
corporation subject to | 21 | | substantially the same requirements in its state of
| 22 | | organization as is a "domestic company" under Article VIII | 23 | | 1/2 of the
Illinois Insurance Code.
| 24 | | (c) In considering the merger, consolidation, or other | 25 | | acquisition of
control of a Health Maintenance Organization | 26 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
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| 1 | | (1) the Director shall give primary consideration to | 2 | | the continuation of
benefits to enrollees and the financial | 3 | | conditions of the acquired Health
Maintenance Organization | 4 | | after the merger, consolidation, or other
acquisition of | 5 | | control takes effect;
| 6 | | (2)(i) the criteria specified in subsection (1)(b) of | 7 | | Section 131.8 of
the Illinois Insurance Code shall not | 8 | | apply and (ii) the Director, in making
his determination | 9 | | with respect to the merger, consolidation, or other
| 10 | | acquisition of control, need not take into account the | 11 | | effect on
competition of the merger, consolidation, or | 12 | | other acquisition of control;
| 13 | | (3) the Director shall have the power to require the | 14 | | following
information:
| 15 | | (A) certification by an independent actuary of the | 16 | | adequacy
of the reserves of the Health Maintenance | 17 | | Organization sought to be acquired;
| 18 | | (B) pro forma financial statements reflecting the | 19 | | combined balance
sheets of the acquiring company and | 20 | | the Health Maintenance Organization sought
to be | 21 | | acquired as of the end of the preceding year and as of | 22 | | a date 90 days
prior to the acquisition, as well as pro | 23 | | forma financial statements
reflecting projected | 24 | | combined operation for a period of 2 years;
| 25 | | (C) a pro forma business plan detailing an | 26 | | acquiring party's plans with
respect to the operation |
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| 1 | | of the Health Maintenance Organization sought to
be | 2 | | acquired for a period of not less than 3 years; and
| 3 | | (D) such other information as the Director shall | 4 | | require.
| 5 | | (d) The provisions of Article VIII 1/2 of the Illinois | 6 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 7 | | any health maintenance
organization of greater than 10% of its
| 8 | | enrollee population (including without limitation the health | 9 | | maintenance
organization's right, title, and interest in and to | 10 | | its health care
certificates).
| 11 | | (e) In considering any management contract or service | 12 | | agreement subject
to Section 141.1 of the Illinois Insurance | 13 | | Code, the Director (i) shall, in
addition to the criteria | 14 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 15 | | into account the effect of the management contract or
service | 16 | | agreement on the continuation of benefits to enrollees and the
| 17 | | financial condition of the health maintenance organization to | 18 | | be managed or
serviced, and (ii) need not take into account the | 19 | | effect of the management
contract or service agreement on | 20 | | competition.
| 21 | | (f) Except for small employer groups as defined in the | 22 | | Small Employer
Rating, Renewability and Portability Health | 23 | | Insurance Act and except for
medicare supplement policies as | 24 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 25 | | Maintenance Organization may by contract agree with a
group or | 26 | | other enrollment unit to effect refunds or charge additional |
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| 1 | | premiums
under the following terms and conditions:
| 2 | | (i) the amount of, and other terms and conditions with | 3 | | respect to, the
refund or additional premium are set forth | 4 | | in the group or enrollment unit
contract agreed in advance | 5 | | of the period for which a refund is to be paid or
| 6 | | additional premium is to be charged (which period shall not | 7 | | be less than one
year); and
| 8 | | (ii) the amount of the refund or additional premium | 9 | | shall not exceed 20%
of the Health Maintenance | 10 | | Organization's profitable or unprofitable experience
with | 11 | | respect to the group or other enrollment unit for the | 12 | | period (and, for
purposes of a refund or additional | 13 | | premium, the profitable or unprofitable
experience shall | 14 | | be calculated taking into account a pro rata share of the
| 15 | | Health Maintenance Organization's administrative and | 16 | | marketing expenses, but
shall not include any refund to be | 17 | | made or additional premium to be paid
pursuant to this | 18 | | subsection (f)). The Health Maintenance Organization and | 19 | | the
group or enrollment unit may agree that the profitable | 20 | | or unprofitable
experience may be calculated taking into | 21 | | account the refund period and the
immediately preceding 2 | 22 | | plan years.
| 23 | | The Health Maintenance Organization shall include a | 24 | | statement in the
evidence of coverage issued to each enrollee | 25 | | describing the possibility of a
refund or additional premium, | 26 | | and upon request of any group or enrollment unit,
provide to |
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| 1 | | the group or enrollment unit a description of the method used | 2 | | to
calculate (1) the Health Maintenance Organization's | 3 | | profitable experience with
respect to the group or enrollment | 4 | | unit and the resulting refund to the group
or enrollment unit | 5 | | or (2) the Health Maintenance Organization's unprofitable
| 6 | | experience with respect to the group or enrollment unit and the | 7 | | resulting
additional premium to be paid by the group or | 8 | | enrollment unit.
| 9 | | In no event shall the Illinois Health Maintenance | 10 | | Organization
Guaranty Association be liable to pay any | 11 | | contractual obligation of an
insolvent organization to pay any | 12 | | refund authorized under this Section.
| 13 | | (g) Rulemaking authority to implement Public Act 95-1045, | 14 | | if any, is conditioned on the rules being adopted in accordance | 15 | | with all provisions of the Illinois Administrative Procedure | 16 | | Act and all rules and procedures of the Joint Committee on | 17 | | Administrative Rules; any purported rule not so adopted, for | 18 | | whatever reason, is unauthorized. | 19 | | (Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | 20 | | 96-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; | 21 | | 97-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12; | 22 | | 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff. | 23 | | 7-13-12.) | 24 | | Section 35. The Limited Health Service Organization Act is | 25 | | amended by changing Section 4003 as follows:
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| 1 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| 2 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 3 | | health service
organizations shall be subject to the provisions | 4 | | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | 5 | | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | 6 | | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 356v, 356z.10, | 7 | | 356z.21, 356z.22, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | 8 | | 409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII | 9 | | 1/2,
XIII,
XIII 1/2, XXV, and XXVI of the Illinois Insurance | 10 | | Code. For purposes of the
Illinois Insurance Code, except for | 11 | | Sections 444 and 444.1 and Articles XIII
and XIII 1/2, limited | 12 | | health service organizations in the following categories
are | 13 | | deemed to be domestic companies:
| 14 | | (1) a corporation under the laws of this State; or
| 15 | | (2) a corporation organized under the laws of another | 16 | | state, 30% of more
of the enrollees of which are residents | 17 | | of this State, except a corporation
subject to | 18 | | substantially the same requirements in its state of | 19 | | organization as
is a domestic company under Article VIII | 20 | | 1/2 of the Illinois Insurance Code.
| 21 | | (Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff. | 22 | | 1-1-13; 97-813, eff. 7-13-12.)
| 23 | | Section 40. The Voluntary Health Services Plans Act is | 24 | | amended by changing Section 10 as follows:
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| 1 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
| 2 | | Sec. 10. Application of Insurance Code provisions. Health | 3 | | services
plan corporations and all persons interested therein | 4 | | or dealing therewith
shall be subject to the provisions of | 5 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 6 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 356g, | 7 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | 8 | | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| 9 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | 10 | | 356z.19, 356z.21, 356z.22, 364.01, 367.2, 368a, 401, 401.1,
| 11 | | 402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) and | 12 | | (15) of Section 367 of the Illinois
Insurance Code.
| 13 | | Rulemaking authority to implement Public Act 95-1045, if | 14 | | any, is conditioned on the rules being adopted in accordance | 15 | | with all provisions of the Illinois Administrative Procedure | 16 | | Act and all rules and procedures of the Joint Committee on | 17 | | Administrative Rules; any purported rule not so adopted, for | 18 | | whatever reason, is unauthorized. | 19 | | (Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; | 20 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; | 21 | | 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; | 22 | | 97-813, eff. 7-13-12.)".
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