Sen. Laura Fine
Filed: 5/20/2024
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1 | AMENDMENT TO HOUSE BILL 2499 | ||||||
2 | AMENDMENT NO. ______. Amend House Bill 2499, AS AMENDED, | ||||||
3 | by replacing everything after the enacting clause with the | ||||||
4 | following: | ||||||
5 | "Section 5. The Illinois Insurance Code is amended by | ||||||
6 | changing Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and | ||||||
7 | by adding Section 352c as follows: | ||||||
8 | (215 ILCS 5/121-2.05) (from Ch. 73, par. 733-2.05) | ||||||
9 | Sec. 121-2.05. Group insurance policies issued and | ||||||
10 | delivered in other State-Transactions in this State. With the | ||||||
11 | exception of insurance transactions authorized under Sections | ||||||
12 | 230.2 or 367.3 of this Code or transactions described under | ||||||
13 | Section 352c , transactions in this State involving group | ||||||
14 | legal, group life and group accident and health or blanket | ||||||
15 | accident and health insurance or group annuities where the | ||||||
16 | master policy of such groups was lawfully issued and delivered |
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1 | in, and under the laws of, a State in which the insurer was | ||||||
2 | authorized to do an insurance business, to a group properly | ||||||
3 | established pursuant to law or regulation, and where the | ||||||
4 | policyholder is domiciled or otherwise has a bona fide situs. | ||||||
5 | (Source: P.A. 86-753.) | ||||||
6 | (215 ILCS 5/352c new) | ||||||
7 | Sec. 352c. Short-term, limited-duration insurance | ||||||
8 | prohibited. | ||||||
9 | (a) In this Section: | ||||||
10 | "Excepted benefits" has the meaning given to that term in | ||||||
11 | 42 U.S.C. 300gg-91 and implementing regulations. "Excepted | ||||||
12 | benefits" includes individual, group, or blanket coverage. | ||||||
13 | "Short-term, limited-duration insurance" means any type of | ||||||
14 | accident and health insurance offered or provided within this | ||||||
15 | State pursuant to a group or individual policy or individual | ||||||
16 | certificate by a company, regardless of the situs state of the | ||||||
17 | delivery of the policy, that has an expiration date specified | ||||||
18 | in the contract that is fewer than 365 days after the original | ||||||
19 | effective date. Regardless of the duration of coverage, | ||||||
20 | "short-term, limited-duration insurance" does not include | ||||||
21 | excepted benefits or any student health insurance coverage. | ||||||
22 | (b) On and after January 1, 2025, no company shall issue, | ||||||
23 | deliver, amend, or renew short-term, limited-duration | ||||||
24 | insurance to any natural or legal person that is a resident or | ||||||
25 | domiciled in this State. |
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1 | (215 ILCS 5/356z.18) | ||||||
2 | (Text of Section before amendment by P.A. 103-512 ) | ||||||
3 | Sec. 356z.18. Prosthetic and customized orthotic devices. | ||||||
4 | (a) For the purposes of this Section: | ||||||
5 | "Customized orthotic device" means a supportive device for | ||||||
6 | the body or a part of the body, the head, neck, or extremities, | ||||||
7 | and includes the replacement or repair of the device based on | ||||||
8 | the patient's physical condition as medically necessary, | ||||||
9 | excluding foot orthotics defined as an in-shoe device designed | ||||||
10 | to support the structural components of the foot during | ||||||
11 | weight-bearing activities. | ||||||
12 | "Licensed provider" means a prosthetist, orthotist, or | ||||||
13 | pedorthist licensed to practice in this State. | ||||||
14 | "Prosthetic device" means an artificial device to replace, | ||||||
15 | in whole or in part, an arm or leg and includes accessories | ||||||
16 | essential to the effective use of the device and the | ||||||
17 | replacement or repair of the device based on the patient's | ||||||
18 | physical condition as medically necessary. | ||||||
19 | (b) This amendatory Act of the 96th General Assembly shall | ||||||
20 | provide benefits to any person covered thereunder for expenses | ||||||
21 | incurred in obtaining a prosthetic or custom orthotic device | ||||||
22 | from any Illinois licensed prosthetist, licensed orthotist, or | ||||||
23 | licensed pedorthist as required under the Orthotics, | ||||||
24 | Prosthetics, and Pedorthics Practice Act. | ||||||
25 | (c) A group or individual major medical policy of accident |
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1 | or health insurance or managed care plan or medical, health, | ||||||
2 | or hospital service corporation contract that provides | ||||||
3 | coverage for prosthetic or custom orthotic care and is | ||||||
4 | amended, delivered, issued, or renewed 6 months after the | ||||||
5 | effective date of this amendatory Act of the 96th General | ||||||
6 | Assembly must provide coverage for prosthetic and orthotic | ||||||
7 | devices in accordance with this subsection (c). The coverage | ||||||
8 | required under this Section shall be subject to the other | ||||||
9 | general exclusions, limitations, and financial requirements of | ||||||
10 | the policy, including coordination of benefits, participating | ||||||
11 | provider requirements, utilization review of health care | ||||||
12 | services, including review of medical necessity, case | ||||||
13 | management, and experimental and investigational treatments, | ||||||
14 | and other managed care provisions under terms and conditions | ||||||
15 | that are no less favorable than the terms and conditions that | ||||||
16 | apply to substantially all medical and surgical benefits | ||||||
17 | provided under the plan or coverage. | ||||||
18 | (d) The policy or plan or contract may require prior | ||||||
19 | authorization for the prosthetic or orthotic devices in the | ||||||
20 | same manner that prior authorization is required for any other | ||||||
21 | covered benefit. | ||||||
22 | (e) Repairs and replacements of prosthetic and orthotic | ||||||
23 | devices are also covered, subject to the co-payments and | ||||||
24 | deductibles, unless necessitated by misuse or loss. | ||||||
25 | (f) A policy or plan or contract may require that, if | ||||||
26 | coverage is provided through a managed care plan, the benefits |
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1 | mandated pursuant to this Section shall be covered benefits | ||||||
2 | only if the prosthetic or orthotic devices are provided by a | ||||||
3 | licensed provider employed by a provider service who contracts | ||||||
4 | with or is designated by the carrier, to the extent that the | ||||||
5 | carrier provides in-network and out-of-network service, the | ||||||
6 | coverage for the prosthetic or orthotic device shall be | ||||||
7 | offered no less extensively. | ||||||
8 | (g) The policy or plan or contract shall also meet | ||||||
9 | adequacy requirements as established by the Health Care | ||||||
10 | Reimbursement Reform Act of 1985 of the Illinois Insurance | ||||||
11 | Code. | ||||||
12 | (h) This Section shall not apply to accident only, | ||||||
13 | specified disease, short-term travel hospital or medical , | ||||||
14 | hospital confinement indemnity or other fixed indemnity , | ||||||
15 | credit, dental, vision, Medicare supplement, long-term care, | ||||||
16 | basic hospital and medical-surgical expense coverage, | ||||||
17 | disability income insurance coverage, coverage issued as a | ||||||
18 | supplement to liability insurance, workers' compensation | ||||||
19 | insurance, or automobile medical payment insurance. | ||||||
20 | (Source: P.A. 96-833, eff. 6-1-10 .) | ||||||
21 | (Text of Section after amendment by P.A. 103-512 ) | ||||||
22 | Sec. 356z.18. Prosthetic and customized orthotic devices. | ||||||
23 | (a) For the purposes of this Section: | ||||||
24 | "Customized orthotic device" means a supportive device for | ||||||
25 | the body or a part of the body, the head, neck, or extremities, |
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1 | and includes the replacement or repair of the device based on | ||||||
2 | the patient's physical condition as medically necessary, | ||||||
3 | excluding foot orthotics defined as an in-shoe device designed | ||||||
4 | to support the structural components of the foot during | ||||||
5 | weight-bearing activities. | ||||||
6 | "Licensed provider" means a prosthetist, orthotist, or | ||||||
7 | pedorthist licensed to practice in this State. | ||||||
8 | "Prosthetic device" means an artificial device to replace, | ||||||
9 | in whole or in part, an arm or leg and includes accessories | ||||||
10 | essential to the effective use of the device and the | ||||||
11 | replacement or repair of the device based on the patient's | ||||||
12 | physical condition as medically necessary. | ||||||
13 | (b) This amendatory Act of the 96th General Assembly shall | ||||||
14 | provide benefits to any person covered thereunder for expenses | ||||||
15 | incurred in obtaining a prosthetic or custom orthotic device | ||||||
16 | from any Illinois licensed prosthetist, licensed orthotist, or | ||||||
17 | licensed pedorthist as required under the Orthotics, | ||||||
18 | Prosthetics, and Pedorthics Practice Act. | ||||||
19 | (c) A group or individual major medical policy of accident | ||||||
20 | or health insurance or managed care plan or medical, health, | ||||||
21 | or hospital service corporation contract that provides | ||||||
22 | coverage for prosthetic or custom orthotic care and is | ||||||
23 | amended, delivered, issued, or renewed 6 months after the | ||||||
24 | effective date of this amendatory Act of the 96th General | ||||||
25 | Assembly must provide coverage for prosthetic and orthotic | ||||||
26 | devices in accordance with this subsection (c). The coverage |
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1 | required under this Section shall be subject to the other | ||||||
2 | general exclusions, limitations, and financial requirements of | ||||||
3 | the policy, including coordination of benefits, participating | ||||||
4 | provider requirements, utilization review of health care | ||||||
5 | services, including review of medical necessity, case | ||||||
6 | management, and experimental and investigational treatments, | ||||||
7 | and other managed care provisions under terms and conditions | ||||||
8 | that are no less favorable than the terms and conditions that | ||||||
9 | apply to substantially all medical and surgical benefits | ||||||
10 | provided under the plan or coverage. | ||||||
11 | (d) With respect to an enrollee at any age, in addition to | ||||||
12 | coverage of a prosthetic or custom orthotic device required by | ||||||
13 | this Section, benefits shall be provided for a prosthetic or | ||||||
14 | custom orthotic device determined by the enrollee's provider | ||||||
15 | to be the most appropriate model that is medically necessary | ||||||
16 | for the enrollee to perform physical activities, as | ||||||
17 | applicable, such as running, biking, swimming, and lifting | ||||||
18 | weights, and to maximize the enrollee's whole body health and | ||||||
19 | strengthen the lower and upper limb function. | ||||||
20 | (e) The requirements of this Section do not constitute an | ||||||
21 | addition to this State's essential health benefits that | ||||||
22 | requires defrayal of costs by this State pursuant to 42 U.S.C. | ||||||
23 | 18031(d)(3)(B). | ||||||
24 | (f) The policy or plan or contract may require prior | ||||||
25 | authorization for the prosthetic or orthotic devices in the | ||||||
26 | same manner that prior authorization is required for any other |
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1 | covered benefit. | ||||||
2 | (g) Repairs and replacements of prosthetic and orthotic | ||||||
3 | devices are also covered, subject to the co-payments and | ||||||
4 | deductibles, unless necessitated by misuse or loss. | ||||||
5 | (h) A policy or plan or contract may require that, if | ||||||
6 | coverage is provided through a managed care plan, the benefits | ||||||
7 | mandated pursuant to this Section shall be covered benefits | ||||||
8 | only if the prosthetic or orthotic devices are provided by a | ||||||
9 | licensed provider employed by a provider service who contracts | ||||||
10 | with or is designated by the carrier, to the extent that the | ||||||
11 | carrier provides in-network and out-of-network service, the | ||||||
12 | coverage for the prosthetic or orthotic device shall be | ||||||
13 | offered no less extensively. | ||||||
14 | (i) The policy or plan or contract shall also meet | ||||||
15 | adequacy requirements as established by the Health Care | ||||||
16 | Reimbursement Reform Act of 1985 of the Illinois Insurance | ||||||
17 | Code. | ||||||
18 | (j) This Section shall not apply to accident only, | ||||||
19 | specified disease, short-term travel hospital or medical , | ||||||
20 | hospital confinement indemnity or other fixed indemnity , | ||||||
21 | credit, dental, vision, Medicare supplement, long-term care, | ||||||
22 | basic hospital and medical-surgical expense coverage, | ||||||
23 | disability income insurance coverage, coverage issued as a | ||||||
24 | supplement to liability insurance, workers' compensation | ||||||
25 | insurance, or automobile medical payment insurance. | ||||||
26 | (Source: P.A. 103-512, eff. 1-1-25.) |
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1 | (215 ILCS 5/367.3) (from Ch. 73, par. 979.3) | ||||||
2 | Sec. 367.3. Group accident and health insurance; | ||||||
3 | discretionary groups. | ||||||
4 | (a) No group health insurance offered to a resident of | ||||||
5 | this State under a policy issued to a group, other than one | ||||||
6 | specifically described in Section 367(1), shall be delivered | ||||||
7 | or issued for delivery in this State unless the Director | ||||||
8 | determines that: | ||||||
9 | (1) the issuance of the policy is not contrary to the | ||||||
10 | public interest; | ||||||
11 | (2) the issuance of the policy will result in | ||||||
12 | economies of acquisition and administration; and | ||||||
13 | (3) the benefits under the policy are reasonable in | ||||||
14 | relation to the premium charged. | ||||||
15 | (b) No such group health insurance may be offered in this | ||||||
16 | State under a policy issued in another state unless this State | ||||||
17 | or the state in which the group policy is issued has made a | ||||||
18 | determination that the requirements of subsection (a) have | ||||||
19 | been met. | ||||||
20 | Where insurance is to be offered in this State under a | ||||||
21 | policy described in this subsection, the insurer shall file | ||||||
22 | for informational review purposes: | ||||||
23 | (1) a copy of the group master contract; | ||||||
24 | (2) a copy of the statute authorizing the issuance of | ||||||
25 | the group policy in the state of situs, which statute has |
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1 | the same or similar requirements as this State, or in the | ||||||
2 | absence of such statute, a certification by an officer of | ||||||
3 | the company that the policy meets the Illinois minimum | ||||||
4 | standards required for individual accident and health | ||||||
5 | policies under authority of Section 401 of this Code, as | ||||||
6 | now or hereafter amended, as promulgated by rule at 50 | ||||||
7 | Illinois Administrative Code, Ch. I, Sec. 2007, et seq., | ||||||
8 | as now or hereafter amended, or by a successor rule; | ||||||
9 | (3) evidence of approval by the state of situs of the | ||||||
10 | group master policy; and | ||||||
11 | (4) copies of all supportive material furnished to the | ||||||
12 | state of situs to satisfy the criteria for approval. | ||||||
13 | (c) The Director may, at any time after receipt of the | ||||||
14 | information required under subsection (b) and after finding | ||||||
15 | that the standards of subsection (a) have not been met, order | ||||||
16 | the insurer to cease the issuance or marketing of that | ||||||
17 | coverage in this State. | ||||||
18 | (d) Notwithstanding subsections (a) and (b), group Group | ||||||
19 | accident and health insurance subject to the provisions of | ||||||
20 | this Section is also subject to the provisions of Sections | ||||||
21 | 352c and Section 367i of this Code and rules thereunder . | ||||||
22 | (Source: P.A. 90-655, eff. 7-30-98.) | ||||||
23 | (215 ILCS 5/367a) (from Ch. 73, par. 979a) | ||||||
24 | Sec. 367a. Blanket accident and health insurance. | ||||||
25 | (1) Blanket accident and health insurance is the that form |
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1 | of accident and health insurance providing excepted benefits, | ||||||
2 | as defined in Section 352c, that covers covering special | ||||||
3 | groups of persons as enumerated in one of the following | ||||||
4 | paragraphs (a) to (g), inclusive: | ||||||
5 | (a) Under a policy or contract issued to any carrier for | ||||||
6 | hire, which shall be deemed the policyholder, covering a group | ||||||
7 | defined as all persons who may become passengers on such | ||||||
8 | carrier. | ||||||
9 | (b) Under a policy or contract issued to an employer, who | ||||||
10 | shall be deemed the policyholder, covering all employees or | ||||||
11 | any group of employees defined by reference to exceptional | ||||||
12 | hazards incident to such employment. | ||||||
13 | (c) Under a policy or contract issued to a college, | ||||||
14 | school, or other institution of learning or to the head or | ||||||
15 | principal thereof, who or which shall be deemed the | ||||||
16 | policyholder, covering students or teachers. However, student | ||||||
17 | health insurance coverage, as defined in 45 CFR 147.145, shall | ||||||
18 | remain subject to the standards and requirements for | ||||||
19 | individual health insurance coverage except where inconsistent | ||||||
20 | with that regulation. An issuer providing student health | ||||||
21 | insurance coverage or a policy or contract covering students | ||||||
22 | for limited-scope dental or vision under 45 CFR 148.220 shall | ||||||
23 | require an individual application or enrollment form and shall | ||||||
24 | furnish each insured individual a certificate, which shall | ||||||
25 | have been approved by the Director under Section 355. | ||||||
26 | (d) Under a policy or contract issued in the name of any |
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1 | volunteer fire department, first aid, or other such volunteer | ||||||
2 | group, which shall be deemed the policyholder, covering all of | ||||||
3 | the members of such department or group. | ||||||
4 | (e) Under a policy or contract issued to a creditor, who | ||||||
5 | shall be deemed the policyholder, to insure debtors of the | ||||||
6 | creditors; Provided, however, that in the case of a loan which | ||||||
7 | is subject to the Small Loans Act, no insurance premium or | ||||||
8 | other cost shall be directly or indirectly charged or assessed | ||||||
9 | against, or collected or received from the borrower. | ||||||
10 | (f) Under a policy or contract issued to a sports team or | ||||||
11 | to a camp, which team or camp sponsor shall be deemed the | ||||||
12 | policyholder, covering members or campers. | ||||||
13 | (g) Under a policy or contract issued to any other | ||||||
14 | substantially similar group which, in the discretion of the | ||||||
15 | Director, may be subject to the issuance of a blanket accident | ||||||
16 | and health policy or contract. | ||||||
17 | (2) Any insurance company authorized to write accident and | ||||||
18 | health insurance in this state shall have the power to issue | ||||||
19 | blanket accident and health insurance. No such blanket policy | ||||||
20 | may be issued or delivered in this State unless a copy of the | ||||||
21 | form thereof shall have been filed in accordance with Section | ||||||
22 | 355, and it contains in substance such of those provisions | ||||||
23 | contained in Sections 357.1 through 357.30 as may be | ||||||
24 | applicable to blanket accident and health insurance and the | ||||||
25 | following provisions: | ||||||
26 | (a) A provision that the policy and the application shall |
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1 | constitute the entire contract between the parties, and that | ||||||
2 | all statements made by the policyholder shall, in absence of | ||||||
3 | fraud, be deemed representations and not warranties, and that | ||||||
4 | no such statements shall be used in defense to a claim under | ||||||
5 | the policy, unless it is contained in a written application. | ||||||
6 | (b) A provision that to the group or class thereof | ||||||
7 | originally insured shall be added from time to time all new | ||||||
8 | persons or individuals eligible for coverage. | ||||||
9 | (3) An individual application shall not be required from a | ||||||
10 | person covered under a blanket accident or health policy or | ||||||
11 | contract, nor shall it be necessary for the insurer to furnish | ||||||
12 | each person a certificate. | ||||||
13 | (4) All benefits under any blanket accident and health | ||||||
14 | policy shall be payable to the person insured, or to his | ||||||
15 | designated beneficiary or beneficiaries, or to his or her | ||||||
16 | estate, except that if the person insured be a minor or person | ||||||
17 | under legal disability, such benefits may be made payable to | ||||||
18 | his or her parent, guardian, or other person actually | ||||||
19 | supporting him or her. Provided further, however, that the | ||||||
20 | policy may provide that all or any portion of any indemnities | ||||||
21 | provided by any such policy on account of hospital, nursing, | ||||||
22 | medical or surgical services may, at the insurer's option, be | ||||||
23 | paid directly to the hospital or person rendering such | ||||||
24 | services; but the policy may not require that the service be | ||||||
25 | rendered by a particular hospital or person. Payment so made | ||||||
26 | shall discharge the insurer's obligation with respect to the |
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1 | amount of insurance so paid. | ||||||
2 | (5) Nothing contained in this section shall be deemed to | ||||||
3 | affect the legal liability of policyholders for the death of | ||||||
4 | or injury to, any such member of such group. | ||||||
5 | (Source: P.A. 83-1362.) | ||||||
6 | (215 ILCS 5/368f) | ||||||
7 | Sec. 368f. Military service member insurance | ||||||
8 | reinstatement. | ||||||
9 | (a) No Illinois resident activated for military service | ||||||
10 | and no spouse or dependent of the resident who becomes | ||||||
11 | eligible for a federal government-sponsored health insurance | ||||||
12 | program, including the TriCare program providing coverage for | ||||||
13 | civilian dependents of military personnel, as a result of the | ||||||
14 | activation shall be denied reinstatement into the same | ||||||
15 | individual health insurance coverage with the health insurer | ||||||
16 | that the resident lapsed as a result of activation or becoming | ||||||
17 | covered by the federal government-sponsored health insurance | ||||||
18 | program. The resident shall have the right to reinstatement in | ||||||
19 | the same individual health insurance coverage without medical | ||||||
20 | underwriting, subject to payment of the current premium | ||||||
21 | charged to other persons of the same age and gender that are | ||||||
22 | covered under the same individual health coverage. Except in | ||||||
23 | the case of birth or adoption that occurs during the period of | ||||||
24 | activation, reinstatement must be into the same coverage type | ||||||
25 | as the resident held prior to lapsing the individual health |
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1 | insurance coverage and at the same or, at the option of the | ||||||
2 | resident, higher deductible level. The reinstatement rights | ||||||
3 | provided under this subsection (a) are not available to a | ||||||
4 | resident or dependents if the activated person is discharged | ||||||
5 | from the military under other than honorable conditions. | ||||||
6 | (b) The health insurer with which the reinstatement is | ||||||
7 | being requested must receive a request for reinstatement no | ||||||
8 | later than 63 days following the later of (i) deactivation or | ||||||
9 | (ii) loss of coverage under the federal government-sponsored | ||||||
10 | health insurance program. The health insurer may request proof | ||||||
11 | of loss of coverage and the timing of the loss of coverage of | ||||||
12 | the government-sponsored coverage in order to determine | ||||||
13 | eligibility for reinstatement into the individual coverage. | ||||||
14 | The effective date of the reinstatement of individual health | ||||||
15 | coverage shall be the first of the month following receipt of | ||||||
16 | the notice requesting reinstatement. | ||||||
17 | (c) All insurers must provide written notice to the | ||||||
18 | policyholder of individual health coverage of the rights | ||||||
19 | described in subsection (a) of this Section. In lieu of the | ||||||
20 | inclusion of the notice in the individual health insurance | ||||||
21 | policy, an insurance company may satisfy the notification | ||||||
22 | requirement by providing a single written notice: | ||||||
23 | (1) in conjunction with the enrollment process for a | ||||||
24 | policyholder initially enrolling in the individual | ||||||
25 | coverage on or after the effective date of this amendatory | ||||||
26 | Act of the 94th General Assembly; or |
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1 | (2) by mailing written notice to policyholders whose | ||||||
2 | coverage was effective prior to the effective date of this | ||||||
3 | amendatory Act of the 94th General Assembly no later than | ||||||
4 | 90 days following the effective date of this amendatory | ||||||
5 | Act of the 94th General Assembly. | ||||||
6 | (d) The provisions of subsection (a) of this Section do | ||||||
7 | not apply to any policy or certificate providing coverage for | ||||||
8 | any specified disease, specified accident or accident-only | ||||||
9 | coverage, credit, dental, disability income, hospital | ||||||
10 | indemnity or other fixed indemnity , long-term care, Medicare | ||||||
11 | supplement, vision care, or short-term travel nonrenewable | ||||||
12 | health policy or other limited-benefit supplemental insurance, | ||||||
13 | or any coverage issued as a supplement to any liability | ||||||
14 | insurance, workers' compensation or similar insurance, or any | ||||||
15 | insurance under which benefits are payable with or without | ||||||
16 | regard to fault, whether written on a group, blanket, or | ||||||
17 | individual basis. | ||||||
18 | (e) Nothing in this Section shall require an insurer to | ||||||
19 | reinstate the resident if the insurer requires residency in an | ||||||
20 | enrollment area and those residency requirements are not met | ||||||
21 | after deactivation or loss of coverage under the | ||||||
22 | government-sponsored health insurance program. | ||||||
23 | (f) All terms, conditions, and limitations of the | ||||||
24 | individual coverage into which reinstatement is made apply | ||||||
25 | equally to all insureds enrolled in the coverage. | ||||||
26 | (g) The Secretary may adopt rules as may be necessary to |
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1 | carry out the provisions of this Section. | ||||||
2 | (Source: P.A. 94-1037, eff. 7-20-06.) | ||||||
3 | Section 10. The Health Maintenance Organization Act is | ||||||
4 | amended by changing Section 5-3 as follows: | ||||||
5 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||||||
6 | Sec. 5-3. Insurance Code provisions. | ||||||
7 | (a) Health Maintenance Organizations shall be subject to | ||||||
8 | the provisions of Sections 133, 134, 136, 137, 139, 140, | ||||||
9 | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | ||||||
10 | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | ||||||
11 | 352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | ||||||
12 | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | ||||||
13 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
14 | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | ||||||
15 | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | ||||||
16 | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | ||||||
17 | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | ||||||
18 | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | ||||||
19 | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | ||||||
20 | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | ||||||
21 | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
22 | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||||||
23 | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||||||
24 | subsection (2) of Section 367, and Articles IIA, VIII 1/2, |
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1 | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||||||
2 | Illinois Insurance Code. | ||||||
3 | (b) For purposes of the Illinois Insurance Code, except | ||||||
4 | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||||||
5 | Health Maintenance Organizations in the following categories | ||||||
6 | are deemed to be "domestic companies": | ||||||
7 | (1) a corporation authorized under the Dental Service | ||||||
8 | Plan Act or the Voluntary Health Services Plans Act; | ||||||
9 | (2) a corporation organized under the laws of this | ||||||
10 | State; or | ||||||
11 | (3) a corporation organized under the laws of another | ||||||
12 | state, 30% or more of the enrollees of which are residents | ||||||
13 | of this State, except a corporation subject to | ||||||
14 | substantially the same requirements in its state of | ||||||
15 | organization as is a "domestic company" under Article VIII | ||||||
16 | 1/2 of the Illinois Insurance Code. | ||||||
17 | (c) In considering the merger, consolidation, or other | ||||||
18 | acquisition of control of a Health Maintenance Organization | ||||||
19 | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||||||
20 | (1) the Director shall give primary consideration to | ||||||
21 | the continuation of benefits to enrollees and the | ||||||
22 | financial conditions of the acquired Health Maintenance | ||||||
23 | Organization after the merger, consolidation, or other | ||||||
24 | acquisition of control takes effect; | ||||||
25 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
26 | Section 131.8 of the Illinois Insurance Code shall not |
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1 | apply and (ii) the Director, in making his determination | ||||||
2 | with respect to the merger, consolidation, or other | ||||||
3 | acquisition of control, need not take into account the | ||||||
4 | effect on competition of the merger, consolidation, or | ||||||
5 | other acquisition of control; | ||||||
6 | (3) the Director shall have the power to require the | ||||||
7 | following information: | ||||||
8 | (A) certification by an independent actuary of the | ||||||
9 | adequacy of the reserves of the Health Maintenance | ||||||
10 | Organization sought to be acquired; | ||||||
11 | (B) pro forma financial statements reflecting the | ||||||
12 | combined balance sheets of the acquiring company and | ||||||
13 | the Health Maintenance Organization sought to be | ||||||
14 | acquired as of the end of the preceding year and as of | ||||||
15 | a date 90 days prior to the acquisition, as well as pro | ||||||
16 | forma financial statements reflecting projected | ||||||
17 | combined operation for a period of 2 years; | ||||||
18 | (C) a pro forma business plan detailing an | ||||||
19 | acquiring party's plans with respect to the operation | ||||||
20 | of the Health Maintenance Organization sought to be | ||||||
21 | acquired for a period of not less than 3 years; and | ||||||
22 | (D) such other information as the Director shall | ||||||
23 | require. | ||||||
24 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
25 | Insurance Code and this Section 5-3 shall apply to the sale by | ||||||
26 | any health maintenance organization of greater than 10% of its |
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1 | enrollee population (including , without limitation , the health | ||||||
2 | maintenance organization's right, title, and interest in and | ||||||
3 | to its health care certificates). | ||||||
4 | (e) In considering any management contract or service | ||||||
5 | agreement subject to Section 141.1 of the Illinois Insurance | ||||||
6 | Code, the Director (i) shall, in addition to the criteria | ||||||
7 | specified in Section 141.2 of the Illinois Insurance Code, | ||||||
8 | take into account the effect of the management contract or | ||||||
9 | service agreement on the continuation of benefits to enrollees | ||||||
10 | and the financial condition of the health maintenance | ||||||
11 | organization to be managed or serviced, and (ii) need not take | ||||||
12 | into account the effect of the management contract or service | ||||||
13 | agreement on competition. | ||||||
14 | (f) Except for small employer groups as defined in the | ||||||
15 | Small Employer Rating, Renewability and Portability Health | ||||||
16 | Insurance Act and except for medicare supplement policies as | ||||||
17 | defined in Section 363 of the Illinois Insurance Code, a | ||||||
18 | Health Maintenance Organization may by contract agree with a | ||||||
19 | group or other enrollment unit to effect refunds or charge | ||||||
20 | additional premiums under the following terms and conditions: | ||||||
21 | (i) the amount of, and other terms and conditions with | ||||||
22 | respect to, the refund or additional premium are set forth | ||||||
23 | in the group or enrollment unit contract agreed in advance | ||||||
24 | of the period for which a refund is to be paid or | ||||||
25 | additional premium is to be charged (which period shall | ||||||
26 | not be less than one year); and |
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1 | (ii) the amount of the refund or additional premium | ||||||
2 | shall not exceed 20% of the Health Maintenance | ||||||
3 | Organization's profitable or unprofitable experience with | ||||||
4 | respect to the group or other enrollment unit for the | ||||||
5 | period (and, for purposes of a refund or additional | ||||||
6 | premium, the profitable or unprofitable experience shall | ||||||
7 | be calculated taking into account a pro rata share of the | ||||||
8 | Health Maintenance Organization's administrative and | ||||||
9 | marketing expenses, but shall not include any refund to be | ||||||
10 | made or additional premium to be paid pursuant to this | ||||||
11 | subsection (f)). The Health Maintenance Organization and | ||||||
12 | the group or enrollment unit may agree that the profitable | ||||||
13 | or unprofitable experience may be calculated taking into | ||||||
14 | account the refund period and the immediately preceding 2 | ||||||
15 | plan years. | ||||||
16 | The Health Maintenance Organization shall include a | ||||||
17 | statement in the evidence of coverage issued to each enrollee | ||||||
18 | describing the possibility of a refund or additional premium, | ||||||
19 | and upon request of any group or enrollment unit, provide to | ||||||
20 | the group or enrollment unit a description of the method used | ||||||
21 | to calculate (1) the Health Maintenance Organization's | ||||||
22 | profitable experience with respect to the group or enrollment | ||||||
23 | unit and the resulting refund to the group or enrollment unit | ||||||
24 | or (2) the Health Maintenance Organization's unprofitable | ||||||
25 | experience with respect to the group or enrollment unit and | ||||||
26 | the resulting additional premium to be paid by the group or |
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1 | enrollment unit. | ||||||
2 | In no event shall the Illinois Health Maintenance | ||||||
3 | Organization Guaranty Association be liable to pay any | ||||||
4 | contractual obligation of an insolvent organization to pay any | ||||||
5 | refund authorized under this Section. | ||||||
6 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
7 | if any, is conditioned on the rules being adopted in | ||||||
8 | accordance with all provisions of the Illinois Administrative | ||||||
9 | Procedure Act and all rules and procedures of the Joint | ||||||
10 | Committee on Administrative Rules; any purported rule not so | ||||||
11 | adopted, for whatever reason, is unauthorized. | ||||||
12 | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||||||
13 | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||||||
14 | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||||||
15 | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||||||
16 | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||||||
17 | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||||||
18 | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||||||
19 | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||||||
20 | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
21 | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | ||||||
22 | Section 15. The Limited Health Service Organization Act is | ||||||
23 | amended by changing Section 4003 as follows: | ||||||
24 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) |
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1 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
2 | health service organizations shall be subject to the | ||||||
3 | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||||||
4 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | ||||||
5 | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, | ||||||
6 | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | ||||||
7 | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | ||||||
8 | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | ||||||
9 | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | ||||||
10 | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | ||||||
11 | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | ||||||
12 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | ||||||
13 | Nothing in this Section shall require a limited health care | ||||||
14 | plan to cover any service that is not a limited health service. | ||||||
15 | For purposes of the Illinois Insurance Code, except for | ||||||
16 | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | ||||||
17 | health service organizations in the following categories are | ||||||
18 | deemed to be domestic companies: | ||||||
19 | (1) a corporation under the laws of this State; or | ||||||
20 | (2) a corporation organized under the laws of another | ||||||
21 | state, 30% or more of the enrollees of which are residents | ||||||
22 | of this State, except a corporation subject to | ||||||
23 | substantially the same requirements in its state of | ||||||
24 | organization as is a domestic company under Article VIII | ||||||
25 | 1/2 of the Illinois Insurance Code. | ||||||
26 | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; |
| |||||||
| |||||||
1 | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||||||
2 | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||||||
3 | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||||||
4 | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||||||
5 | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||||||
6 | eff. 1-1-24; revised 8-29-23.) | ||||||
7 | (215 ILCS 190/Act rep.) | ||||||
8 | Section 20. The Short-Term, Limited-Duration Health | ||||||
9 | Insurance Coverage Act is repealed. | ||||||
10 | Section 95. No acceleration or delay. Where this Act makes | ||||||
11 | changes in a statute that is represented in this Act by text | ||||||
12 | that is not yet or no longer in effect (for example, a Section | ||||||
13 | represented by multiple versions), the use of that text does | ||||||
14 | not accelerate or delay the taking effect of (i) the changes | ||||||
15 | made by this Act or (ii) provisions derived from any other | ||||||
16 | Public Act. | ||||||
17 | Section 99. Effective date. This Act takes effect January | ||||||
18 | 1, 2025.". |