Full Text of HB2499 103rd General Assembly
HB2499enr 103RD GENERAL ASSEMBLY | | | HB2499 Enrolled | | LRB103 30875 AMQ 57395 b |
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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 Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and | 6 | | by adding Section 352c as follows: | 7 | | (215 ILCS 5/121-2.05) (from Ch. 73, par. 733-2.05) | 8 | | Sec. 121-2.05. Group insurance policies issued and | 9 | | delivered in other State-Transactions in this State. With the | 10 | | exception of insurance transactions authorized under Sections | 11 | | 230.2 or 367.3 of this Code or transactions described under | 12 | | Section 352c , transactions in this State involving group | 13 | | legal, group life and group accident and health or blanket | 14 | | accident and health insurance or group annuities where the | 15 | | master policy of such groups was lawfully issued and delivered | 16 | | in, and under the laws of, a State in which the insurer was | 17 | | authorized to do an insurance business, to a group properly | 18 | | established pursuant to law or regulation, and where the | 19 | | policyholder is domiciled or otherwise has a bona fide situs. | 20 | | (Source: P.A. 86-753.) | 21 | | (215 ILCS 5/352c new) | 22 | | Sec. 352c. Short-term, limited-duration insurance |
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| 1 | | prohibited. | 2 | | (a) In this Section: | 3 | | "Excepted benefits" has the meaning given to that term in | 4 | | 42 U.S.C. 300gg-91 and implementing regulations. "Excepted | 5 | | benefits" includes individual, group, or blanket coverage. | 6 | | "Short-term, limited-duration insurance" means any type of | 7 | | accident and health insurance offered or provided within this | 8 | | State pursuant to a group or individual policy or individual | 9 | | certificate by a company, regardless of the situs state of the | 10 | | delivery of the policy, that has an expiration date specified | 11 | | in the contract that is fewer than 365 days after the original | 12 | | effective date. Regardless of the duration of coverage, | 13 | | "short-term, limited-duration insurance" does not include | 14 | | excepted benefits or any student health insurance coverage. | 15 | | (b) On and after January 1, 2025, no company shall issue, | 16 | | deliver, amend, or renew short-term, limited-duration | 17 | | insurance to any natural or legal person that is a resident or | 18 | | domiciled in this State. | 19 | | (215 ILCS 5/356z.18) | 20 | | (Text of Section before amendment by P.A. 103-512 ) | 21 | | Sec. 356z.18. Prosthetic and customized orthotic devices. | 22 | | (a) For the purposes of this Section: | 23 | | "Customized orthotic device" means a supportive device for | 24 | | the body or a part of the body, the head, neck, or extremities, | 25 | | and includes the replacement or repair of the device based on |
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| 1 | | the patient's physical condition as medically necessary, | 2 | | excluding foot orthotics defined as an in-shoe device designed | 3 | | to support the structural components of the foot during | 4 | | weight-bearing activities. | 5 | | "Licensed provider" means a prosthetist, orthotist, or | 6 | | pedorthist licensed to practice in this State. | 7 | | "Prosthetic device" means an artificial device to replace, | 8 | | in whole or in part, an arm or leg and includes accessories | 9 | | essential to the effective use of the device and the | 10 | | replacement or repair of the device based on the patient's | 11 | | physical condition as medically necessary. | 12 | | (b) This amendatory Act of the 96th General Assembly shall | 13 | | provide benefits to any person covered thereunder for expenses | 14 | | incurred in obtaining a prosthetic or custom orthotic device | 15 | | from any Illinois licensed prosthetist, licensed orthotist, or | 16 | | licensed pedorthist as required under the Orthotics, | 17 | | Prosthetics, and Pedorthics Practice Act. | 18 | | (c) A group or individual major medical policy of accident | 19 | | or health insurance or managed care plan or medical, health, | 20 | | or hospital service corporation contract that provides | 21 | | coverage for prosthetic or custom orthotic care and is | 22 | | amended, delivered, issued, or renewed 6 months after the | 23 | | effective date of this amendatory Act of the 96th General | 24 | | Assembly must provide coverage for prosthetic and orthotic | 25 | | devices in accordance with this subsection (c). The coverage | 26 | | required under this Section shall be subject to the other |
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| 1 | | general exclusions, limitations, and financial requirements of | 2 | | the policy, including coordination of benefits, participating | 3 | | provider requirements, utilization review of health care | 4 | | services, including review of medical necessity, case | 5 | | management, and experimental and investigational treatments, | 6 | | and other managed care provisions under terms and conditions | 7 | | that are no less favorable than the terms and conditions that | 8 | | apply to substantially all medical and surgical benefits | 9 | | provided under the plan or coverage. | 10 | | (d) The policy or plan or contract may require prior | 11 | | authorization for the prosthetic or orthotic devices in the | 12 | | same manner that prior authorization is required for any other | 13 | | covered benefit. | 14 | | (e) Repairs and replacements of prosthetic and orthotic | 15 | | devices are also covered, subject to the co-payments and | 16 | | deductibles, unless necessitated by misuse or loss. | 17 | | (f) A policy or plan or contract may require that, if | 18 | | coverage is provided through a managed care plan, the benefits | 19 | | mandated pursuant to this Section shall be covered benefits | 20 | | only if the prosthetic or orthotic devices are provided by a | 21 | | licensed provider employed by a provider service who contracts | 22 | | with or is designated by the carrier, to the extent that the | 23 | | carrier provides in-network and out-of-network service, the | 24 | | coverage for the prosthetic or orthotic device shall be | 25 | | offered no less extensively. | 26 | | (g) The policy or plan or contract shall also meet |
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| 1 | | adequacy requirements as established by the Health Care | 2 | | Reimbursement Reform Act of 1985 of the Illinois Insurance | 3 | | Code. | 4 | | (h) This Section shall not apply to accident only, | 5 | | specified disease, short-term travel hospital or medical , | 6 | | hospital confinement indemnity or other fixed indemnity , | 7 | | credit, dental, vision, Medicare supplement, long-term care, | 8 | | basic hospital and medical-surgical expense coverage, | 9 | | disability income insurance coverage, coverage issued as a | 10 | | supplement to liability insurance, workers' compensation | 11 | | insurance, or automobile medical payment insurance. | 12 | | (Source: P.A. 96-833, eff. 6-1-10 .) | 13 | | (Text of Section after amendment by P.A. 103-512 ) | 14 | | Sec. 356z.18. Prosthetic and customized orthotic devices. | 15 | | (a) For the purposes of this Section: | 16 | | "Customized orthotic device" means a supportive device for | 17 | | the body or a part of the body, the head, neck, or extremities, | 18 | | and includes the replacement or repair of the device based on | 19 | | the patient's physical condition as medically necessary, | 20 | | excluding foot orthotics defined as an in-shoe device designed | 21 | | to support the structural components of the foot during | 22 | | weight-bearing activities. | 23 | | "Licensed provider" means a prosthetist, orthotist, or | 24 | | pedorthist licensed to practice in this State. | 25 | | "Prosthetic device" means an artificial device to replace, |
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| 1 | | in whole or in part, an arm or leg and includes accessories | 2 | | essential to the effective use of the device and the | 3 | | replacement or repair of the device based on the patient's | 4 | | physical condition as medically necessary. | 5 | | (b) This amendatory Act of the 96th General Assembly shall | 6 | | provide benefits to any person covered thereunder for expenses | 7 | | incurred in obtaining a prosthetic or custom orthotic device | 8 | | from any Illinois licensed prosthetist, licensed orthotist, or | 9 | | licensed pedorthist as required under the Orthotics, | 10 | | Prosthetics, and Pedorthics Practice Act. | 11 | | (c) A group or individual major medical policy of accident | 12 | | or health insurance or managed care plan or medical, health, | 13 | | or hospital service corporation contract that provides | 14 | | coverage for prosthetic or custom orthotic care and is | 15 | | amended, delivered, issued, or renewed 6 months after the | 16 | | effective date of this amendatory Act of the 96th General | 17 | | Assembly must provide coverage for prosthetic and orthotic | 18 | | devices in accordance with this subsection (c). The coverage | 19 | | required under this Section shall be subject to the other | 20 | | general exclusions, limitations, and financial requirements of | 21 | | the policy, including coordination of benefits, participating | 22 | | provider requirements, utilization review of health care | 23 | | services, including review of medical necessity, case | 24 | | management, and experimental and investigational treatments, | 25 | | and other managed care provisions under terms and conditions | 26 | | that are no less favorable than the terms and conditions that |
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| 1 | | apply to substantially all medical and surgical benefits | 2 | | provided under the plan or coverage. | 3 | | (d) With respect to an enrollee at any age, in addition to | 4 | | coverage of a prosthetic or custom orthotic device required by | 5 | | this Section, benefits shall be provided for a prosthetic or | 6 | | custom orthotic device determined by the enrollee's provider | 7 | | to be the most appropriate model that is medically necessary | 8 | | for the enrollee to perform physical activities, as | 9 | | applicable, such as running, biking, swimming, and lifting | 10 | | weights, and to maximize the enrollee's whole body health and | 11 | | strengthen the lower and upper limb function. | 12 | | (e) The requirements of this Section do not constitute an | 13 | | addition to this State's essential health benefits that | 14 | | requires defrayal of costs by this State pursuant to 42 U.S.C. | 15 | | 18031(d)(3)(B). | 16 | | (f) The policy or plan or contract may require prior | 17 | | authorization for the prosthetic or orthotic devices in the | 18 | | same manner that prior authorization is required for any other | 19 | | covered benefit. | 20 | | (g) Repairs and replacements of prosthetic and orthotic | 21 | | devices are also covered, subject to the co-payments and | 22 | | deductibles, unless necessitated by misuse or loss. | 23 | | (h) A policy or plan or contract may require that, if | 24 | | coverage is provided through a managed care plan, the benefits | 25 | | mandated pursuant to this Section shall be covered benefits | 26 | | only if the prosthetic or orthotic devices are provided by a |
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| 1 | | licensed provider employed by a provider service who contracts | 2 | | with or is designated by the carrier, to the extent that the | 3 | | carrier provides in-network and out-of-network service, the | 4 | | coverage for the prosthetic or orthotic device shall be | 5 | | offered no less extensively. | 6 | | (i) The policy or plan or contract shall also meet | 7 | | adequacy requirements as established by the Health Care | 8 | | Reimbursement Reform Act of 1985 of the Illinois Insurance | 9 | | Code. | 10 | | (j) This Section shall not apply to accident only, | 11 | | specified disease, short-term travel hospital or medical , | 12 | | hospital confinement indemnity or other fixed indemnity , | 13 | | credit, dental, vision, Medicare supplement, long-term care, | 14 | | basic hospital and medical-surgical expense coverage, | 15 | | disability income insurance coverage, coverage issued as a | 16 | | supplement to liability insurance, workers' compensation | 17 | | insurance, or automobile medical payment insurance. | 18 | | (Source: P.A. 103-512, eff. 1-1-25.) | 19 | | (215 ILCS 5/367.3) (from Ch. 73, par. 979.3) | 20 | | Sec. 367.3. Group accident and health insurance; | 21 | | discretionary groups. | 22 | | (a) No group health insurance offered to a resident of | 23 | | this State under a policy issued to a group, other than one | 24 | | specifically described in Section 367(1), shall be delivered | 25 | | or issued for delivery in this State unless the Director |
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| 1 | | determines that: | 2 | | (1) the issuance of the policy is not contrary to the | 3 | | public interest; | 4 | | (2) the issuance of the policy will result in | 5 | | economies of acquisition and administration; and | 6 | | (3) the benefits under the policy are reasonable in | 7 | | relation to the premium charged. | 8 | | (b) No such group health insurance may be offered in this | 9 | | State under a policy issued in another state unless this State | 10 | | or the state in which the group policy is issued has made a | 11 | | determination that the requirements of subsection (a) have | 12 | | been met. | 13 | | Where insurance is to be offered in this State under a | 14 | | policy described in this subsection, the insurer shall file | 15 | | for informational review purposes: | 16 | | (1) a copy of the group master contract; | 17 | | (2) a copy of the statute authorizing the issuance of | 18 | | the group policy in the state of situs, which statute has | 19 | | the same or similar requirements as this State, or in the | 20 | | absence of such statute, a certification by an officer of | 21 | | the company that the policy meets the Illinois minimum | 22 | | standards required for individual accident and health | 23 | | policies under authority of Section 401 of this Code, as | 24 | | now or hereafter amended, as promulgated by rule at 50 | 25 | | Illinois Administrative Code, Ch. I, Sec. 2007, et seq., | 26 | | as now or hereafter amended, or by a successor rule; |
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| 1 | | (3) evidence of approval by the state of situs of the | 2 | | group master policy; and | 3 | | (4) copies of all supportive material furnished to the | 4 | | state of situs to satisfy the criteria for approval. | 5 | | (c) The Director may, at any time after receipt of the | 6 | | information required under subsection (b) and after finding | 7 | | that the standards of subsection (a) have not been met, order | 8 | | the insurer to cease the issuance or marketing of that | 9 | | coverage in this State. | 10 | | (d) Notwithstanding subsections (a) and (b), group Group | 11 | | accident and health insurance subject to the provisions of | 12 | | this Section is also subject to the provisions of Sections | 13 | | 352c and Section 367i of this Code and rules thereunder . | 14 | | (Source: P.A. 90-655, eff. 7-30-98.) | 15 | | (215 ILCS 5/367a) (from Ch. 73, par. 979a) | 16 | | Sec. 367a. Blanket accident and health insurance. | 17 | | (1) Blanket accident and health insurance is the that form | 18 | | of accident and health insurance providing excepted benefits, | 19 | | as defined in Section 352c, that covers covering special | 20 | | groups of persons as enumerated in one of the following | 21 | | paragraphs (a) to (g), inclusive: | 22 | | (a) Under a policy or contract issued to any carrier for | 23 | | hire, which shall be deemed the policyholder, covering a group | 24 | | defined as all persons who may become passengers on such | 25 | | carrier. |
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| 1 | | (b) Under a policy or contract issued to an employer, who | 2 | | shall be deemed the policyholder, covering all employees or | 3 | | any group of employees defined by reference to exceptional | 4 | | hazards incident to such employment. | 5 | | (c) Under a policy or contract issued to a college, | 6 | | school, or other institution of learning or to the head or | 7 | | principal thereof, who or which shall be deemed the | 8 | | policyholder, covering students or teachers. However, student | 9 | | health insurance coverage, as defined in 45 CFR 147.145, shall | 10 | | remain subject to the standards and requirements for | 11 | | individual health insurance coverage except where inconsistent | 12 | | with that regulation. An issuer providing student health | 13 | | insurance coverage or a policy or contract covering students | 14 | | for limited-scope dental or vision under 45 CFR 148.220 shall | 15 | | require an individual application or enrollment form and shall | 16 | | furnish each insured individual a certificate, which shall | 17 | | have been approved by the Director under Section 355. | 18 | | (d) Under a policy or contract issued in the name of any | 19 | | volunteer fire department, first aid, or other such volunteer | 20 | | group, which shall be deemed the policyholder, covering all of | 21 | | the members of such department or group. | 22 | | (e) Under a policy or contract issued to a creditor, who | 23 | | shall be deemed the policyholder, to insure debtors of the | 24 | | creditors; Provided, however, that in the case of a loan which | 25 | | is subject to the Small Loans Act, no insurance premium or | 26 | | other cost shall be directly or indirectly charged or assessed |
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| 1 | | against, or collected or received from the borrower. | 2 | | (f) Under a policy or contract issued to a sports team or | 3 | | to a camp, which team or camp sponsor shall be deemed the | 4 | | policyholder, covering members or campers. | 5 | | (g) Under a policy or contract issued to any other | 6 | | substantially similar group which, in the discretion of the | 7 | | Director, may be subject to the issuance of a blanket accident | 8 | | and health policy or contract. | 9 | | (2) Any insurance company authorized to write accident and | 10 | | health insurance in this state shall have the power to issue | 11 | | blanket accident and health insurance. No such blanket policy | 12 | | may be issued or delivered in this State unless a copy of the | 13 | | form thereof shall have been filed in accordance with Section | 14 | | 355, and it contains in substance such of those provisions | 15 | | contained in Sections 357.1 through 357.30 as may be | 16 | | applicable to blanket accident and health insurance and the | 17 | | following provisions: | 18 | | (a) A provision that the policy and the application shall | 19 | | constitute the entire contract between the parties, and that | 20 | | all statements made by the policyholder shall, in absence of | 21 | | fraud, be deemed representations and not warranties, and that | 22 | | no such statements shall be used in defense to a claim under | 23 | | the policy, unless it is contained in a written application. | 24 | | (b) A provision that to the group or class thereof | 25 | | originally insured shall be added from time to time all new | 26 | | persons or individuals eligible for coverage. |
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| 1 | | (3) An individual application shall not be required from a | 2 | | person covered under a blanket accident or health policy or | 3 | | contract, nor shall it be necessary for the insurer to furnish | 4 | | each person a certificate. | 5 | | (4) All benefits under any blanket accident and health | 6 | | policy shall be payable to the person insured, or to his | 7 | | designated beneficiary or beneficiaries, or to his or her | 8 | | estate, except that if the person insured be a minor or person | 9 | | under legal disability, such benefits may be made payable to | 10 | | his or her parent, guardian, or other person actually | 11 | | supporting him or her. Provided further, however, that the | 12 | | policy may provide that all or any portion of any indemnities | 13 | | provided by any such policy on account of hospital, nursing, | 14 | | medical or surgical services may, at the insurer's option, be | 15 | | paid directly to the hospital or person rendering such | 16 | | services; but the policy may not require that the service be | 17 | | rendered by a particular hospital or person. Payment so made | 18 | | shall discharge the insurer's obligation with respect to the | 19 | | amount of insurance so paid. | 20 | | (5) Nothing contained in this section shall be deemed to | 21 | | affect the legal liability of policyholders for the death of | 22 | | or injury to, any such member of such group. | 23 | | (Source: P.A. 83-1362.) | 24 | | (215 ILCS 5/368f) | 25 | | Sec. 368f. Military service member insurance |
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| 1 | | reinstatement. | 2 | | (a) No Illinois resident activated for military service | 3 | | and no spouse or dependent of the resident who becomes | 4 | | eligible for a federal government-sponsored health insurance | 5 | | program, including the TriCare program providing coverage for | 6 | | civilian dependents of military personnel, as a result of the | 7 | | activation shall be denied reinstatement into the same | 8 | | individual health insurance coverage with the health insurer | 9 | | that the resident lapsed as a result of activation or becoming | 10 | | covered by the federal government-sponsored health insurance | 11 | | program. The resident shall have the right to reinstatement in | 12 | | the same individual health insurance coverage without medical | 13 | | underwriting, subject to payment of the current premium | 14 | | charged to other persons of the same age and gender that are | 15 | | covered under the same individual health coverage. Except in | 16 | | the case of birth or adoption that occurs during the period of | 17 | | activation, reinstatement must be into the same coverage type | 18 | | as the resident held prior to lapsing the individual health | 19 | | insurance coverage and at the same or, at the option of the | 20 | | resident, higher deductible level. The reinstatement rights | 21 | | provided under this subsection (a) are not available to a | 22 | | resident or dependents if the activated person is discharged | 23 | | from the military under other than honorable conditions. | 24 | | (b) The health insurer with which the reinstatement is | 25 | | being requested must receive a request for reinstatement no | 26 | | later than 63 days following the later of (i) deactivation or |
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| 1 | | (ii) loss of coverage under the federal government-sponsored | 2 | | health insurance program. The health insurer may request proof | 3 | | of loss of coverage and the timing of the loss of coverage of | 4 | | the government-sponsored coverage in order to determine | 5 | | eligibility for reinstatement into the individual coverage. | 6 | | The effective date of the reinstatement of individual health | 7 | | coverage shall be the first of the month following receipt of | 8 | | the notice requesting reinstatement. | 9 | | (c) All insurers must provide written notice to the | 10 | | policyholder of individual health coverage of the rights | 11 | | described in subsection (a) of this Section. In lieu of the | 12 | | inclusion of the notice in the individual health insurance | 13 | | policy, an insurance company may satisfy the notification | 14 | | requirement by providing a single written notice: | 15 | | (1) in conjunction with the enrollment process for a | 16 | | policyholder initially enrolling in the individual | 17 | | coverage on or after the effective date of this amendatory | 18 | | Act of the 94th General Assembly; or | 19 | | (2) by mailing written notice to policyholders whose | 20 | | coverage was effective prior to the effective date of this | 21 | | amendatory Act of the 94th General Assembly no later than | 22 | | 90 days following the effective date of this amendatory | 23 | | Act of the 94th General Assembly. | 24 | | (d) The provisions of subsection (a) of this Section do | 25 | | not apply to any policy or certificate providing coverage for | 26 | | any specified disease, specified accident or accident-only |
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| 1 | | coverage, credit, dental, disability income, hospital | 2 | | indemnity or other fixed indemnity , long-term care, Medicare | 3 | | supplement, vision care, or short-term travel nonrenewable | 4 | | health policy or other limited-benefit supplemental insurance, | 5 | | or any coverage issued as a supplement to any liability | 6 | | insurance, workers' compensation or similar insurance, or any | 7 | | insurance under which benefits are payable with or without | 8 | | regard to fault, whether written on a group, blanket, or | 9 | | individual basis. | 10 | | (e) Nothing in this Section shall require an insurer to | 11 | | reinstate the resident if the insurer requires residency in an | 12 | | enrollment area and those residency requirements are not met | 13 | | after deactivation or loss of coverage under the | 14 | | government-sponsored health insurance program. | 15 | | (f) All terms, conditions, and limitations of the | 16 | | individual coverage into which reinstatement is made apply | 17 | | equally to all insureds enrolled in the coverage. | 18 | | (g) The Secretary may adopt rules as may be necessary to | 19 | | carry out the provisions of this Section. | 20 | | (Source: P.A. 94-1037, eff. 7-20-06.) | 21 | | Section 10. The Health Maintenance Organization Act is | 22 | | amended by changing Section 5-3 as follows: | 23 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | 24 | | Sec. 5-3. Insurance Code provisions. |
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| 1 | | (a) Health Maintenance Organizations shall be subject to | 2 | | the provisions of Sections 133, 134, 136, 137, 139, 140, | 3 | | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | 4 | | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | 5 | | 352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | 6 | | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | 7 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 8 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | 9 | | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | 10 | | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | 11 | | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | 12 | | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | 13 | | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | 14 | | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | 15 | | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | 16 | | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | 17 | | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | 18 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2, | 19 | | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | 20 | | Illinois Insurance Code. | 21 | | (b) For purposes of the Illinois Insurance Code, except | 22 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | 23 | | Health Maintenance Organizations in the following categories | 24 | | are deemed to be "domestic companies": | 25 | | (1) a corporation authorized under the Dental Service | 26 | | 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 | 14 | | financial conditions of the acquired Health Maintenance | 15 | | Organization after the merger, consolidation, or other | 16 | | acquisition of 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 | 21 | | to 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, | 26 | | take into account the effect of the management contract or |
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| 1 | | service agreement on the continuation of benefits to enrollees | 2 | | and the financial condition of the health maintenance | 3 | | organization to be managed or serviced, and (ii) need not take | 4 | | into account the effect of the management contract or service | 5 | | agreement on 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 | 10 | | Health Maintenance Organization may by contract agree with a | 11 | | group or other enrollment unit to effect refunds or charge | 12 | | additional 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 | 18 | | not 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 | 18 | | the 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 | | (g) Rulemaking authority to implement Public Act 95-1045, | 25 | | if any, is conditioned on the rules being adopted in | 26 | | accordance with all provisions of the Illinois Administrative |
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| 1 | | Procedure Act and all rules and procedures of the Joint | 2 | | Committee on Administrative Rules; any purported rule not so | 3 | | adopted, for whatever reason, is unauthorized. | 4 | | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | 5 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 6 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | 7 | | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | 8 | | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | 9 | | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | 10 | | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | 11 | | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | 12 | | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 13 | | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | 14 | | Section 15. The Limited Health Service Organization Act is | 15 | | amended by changing Section 4003 as follows: | 16 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | 17 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 18 | | health service organizations shall be subject to the | 19 | | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | 20 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | 21 | | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, | 22 | | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | 23 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | 24 | | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, |
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| 1 | | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | 2 | | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | 3 | | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | 4 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | 5 | | Nothing in this Section shall require a limited health care | 6 | | plan to cover any service that is not a limited health service. | 7 | | For purposes of the Illinois Insurance Code, except for | 8 | | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | 9 | | health service organizations in the following categories are | 10 | | deemed to be domestic companies: | 11 | | (1) a corporation under the laws of this State; or | 12 | | (2) a corporation organized under the laws of another | 13 | | state, 30% or more of the enrollees of which are residents | 14 | | 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 VIII | 17 | | 1/2 of the Illinois Insurance Code. | 18 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | 19 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | 20 | | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | 21 | | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | 22 | | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | 23 | | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 24 | | eff. 1-1-24; revised 8-29-23.) | 25 | | (215 ILCS 190/Act rep.) |
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| 1 | | Section 20. The Short-Term, Limited-Duration Health | 2 | | Insurance Coverage Act is repealed. | 3 | | Section 95. No acceleration or delay. Where this Act makes | 4 | | changes in a statute that is represented in this Act by text | 5 | | that is not yet or no longer in effect (for example, a Section | 6 | | represented by multiple versions), the use of that text does | 7 | | not accelerate or delay the taking effect of (i) the changes | 8 | | made by this Act or (ii) provisions derived from any other | 9 | | Public Act. | 10 | | Section 99. Effective date. This Act takes effect January | 11 | | 1, 2025. |
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