Full Text of SB1877 96th General Assembly
SB1877enr 96TH GENERAL ASSEMBLY
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 5. The State Employees Group Insurance Act of 1971 | 5 |
| is amended by changing Section 6.11 as follows:
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| (5 ILCS 375/6.11)
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| (Text of Section before amendment by P.A. 95-958 ) | 8 |
| Sec. 6.11. Required health benefits; Illinois Insurance | 9 |
| Code
requirements. The program of health
benefits shall provide | 10 |
| the post-mastectomy care benefits required to be covered
by a | 11 |
| policy of accident and health insurance under Section 356t of | 12 |
| the Illinois
Insurance Code. The program of health benefits | 13 |
| shall provide the coverage
required under Sections 356g.5,
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| 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10, | 15 |
| 356z.13 356z.11 , and 356z.14 , and 356z.15
of the
Illinois | 16 |
| Insurance Code.
The program of health benefits must comply with | 17 |
| Section 155.37 of the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 19 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | 20 |
| 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
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| (Text of Section after amendment by P.A. 95-958 )
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| Sec. 6.11. Required health benefits; Illinois Insurance |
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| Code
requirements. The program of health
benefits shall provide | 2 |
| the post-mastectomy care benefits required to be covered
by a | 3 |
| policy of accident and health insurance under Section 356t of | 4 |
| the Illinois
Insurance Code. The program of health benefits | 5 |
| shall provide the coverage
required under Sections 356g.5,
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| 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10, | 7 |
| 356z.11, and 356z.12 , 356z.13
356z.11 , and 356z.14 , and 356z.15 | 8 |
| of the
Illinois Insurance Code.
The program of health benefits | 9 |
| must comply with Section 155.37 of the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 11 |
| 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | 12 |
| 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | 13 |
| 12-15-08.) | 14 |
| Section 10. The Illinois Insurance Code is amended by | 15 |
| adding Section 356z.15 as follows: | 16 |
| (215 ILCS 5/356z.15 new)
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| Sec. 356z.15. Wellness coverage. | 18 |
| (a) A group or individual policy of accident and health | 19 |
| insurance or managed care plan amended, delivered, issued, or | 20 |
| renewed after the effective date of this amendatory Act of the | 21 |
| 96th General Assembly that provides coverage for hospital or | 22 |
| medical treatment on an expense incurred basis may offer a | 23 |
| reasonably designed program for wellness coverage that allows | 24 |
| for a reward, a contribution, a reduction in premiums or |
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| reduced medical, prescription drug, or equipment copayments, | 2 |
| coinsurance, or deductibles, or a combination of these | 3 |
| incentives, for participation in any health behavior wellness, | 4 |
| maintenance, or improvement program approved or offered by the | 5 |
| insurer or managed care plan. The insured or enrollee may be | 6 |
| required to provide evidence of participation in a program. | 7 |
| Individuals unable to participate in these incentives due to an | 8 |
| adverse health factor shall not be penalized based upon an | 9 |
| adverse health status. | 10 |
| (b) For purposes of this Section, "wellness coverage" means | 11 |
| health care coverage with the primary purpose to engage and | 12 |
| motivate the insured or enrollee through: incentives; | 13 |
| provision of health education, counseling, and self-management | 14 |
| skills; identification of modifiable health risks; and other | 15 |
| activities to influence health behavior changes. | 16 |
| For the purposes of this Section, "reasonably designed | 17 |
| program" means a program of wellness coverage that has a | 18 |
| reasonable chance of improving health or preventing disease; is | 19 |
| not overly burdensome; does not discriminate based upon factors | 20 |
| of health; and is not otherwise contrary to law. | 21 |
| (c) Incentives as outlined in this Section are specific and | 22 |
| unique to the offering of wellness coverage and have no | 23 |
| application to any other required or optional health care | 24 |
| benefit. | 25 |
| (d) Such wellness coverage must satisfy the requirements | 26 |
| for an exception from the general prohibition against |
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| discrimination based on a health factor under the federal | 2 |
| Health Insurance Portability and Accountability Act of 1996 | 3 |
| (P.L. 104-191; 110 Stat. 1936), including any federal | 4 |
| regulations that are adopted pursuant to that Act. | 5 |
| (e) A plan offering wellness coverage must do the | 6 |
| following: | 7 |
| (i) give participants the opportunity to qualify for | 8 |
| offered incentives at least once a year; | 9 |
| (ii) allow a reasonable alternative to any individual | 10 |
| for whom it is unreasonably difficult, due to a medical | 11 |
| condition, to satisfy otherwise applicable wellness | 12 |
| program standards. Plans may seek physician verification | 13 |
| that health factors make it unreasonably difficult or | 14 |
| medically inadvisable for the participant to satisfy the | 15 |
| standards; and | 16 |
| (iii) not provide a total incentive that exceeds 20% of | 17 |
| the cost of employee-only coverage. The cost of | 18 |
| employee-only coverage includes both employer and employee | 19 |
| contributions. For plans offering family coverage, the 20% | 20 |
| limitation applies to cost of family coverage and applies | 21 |
| to the entire family. | 22 |
| (f) A reward, contribution, or reduction established under | 23 |
| this Section and included in the policy or certificate does not | 24 |
| violate Section 151 of this Code. | 25 |
| Section 15. The Health Maintenance Organization Act is |
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| amended by changing Section 5-3 as follows:
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| (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| (Text of Section before amendment by P.A. 95-958 )
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| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to | 6 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 7 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 8 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | 9 |
| 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | 10 |
| 356z.13
356z.11 , 356z.14, 356z.15,
364.01, 367.2, 367.2-5, | 11 |
| 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, | 12 |
| 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of | 13 |
| subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
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| XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | 15 |
| Insurance Code.
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| (b) For purposes of the Illinois Insurance Code, except for | 17 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 18 |
| Maintenance Organizations in
the following categories are | 19 |
| deemed to be "domestic companies":
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| (1) a corporation authorized under the
Dental Service | 21 |
| Plan Act or the Voluntary Health Services Plans Act;
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| (2) a corporation organized under the laws of this | 23 |
| State; or
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| (3) a corporation organized under the laws of another | 25 |
| state, 30% or more
of the enrollees of which are residents |
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| of this State, except a
corporation subject to | 2 |
| substantially the same requirements in its state of
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| organization as is a "domestic company" under Article VIII | 4 |
| 1/2 of the
Illinois Insurance Code.
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| (c) In considering the merger, consolidation, or other | 6 |
| acquisition of
control of a Health Maintenance Organization | 7 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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| (1) the Director shall give primary consideration to | 9 |
| the continuation of
benefits to enrollees and the financial | 10 |
| conditions of the acquired Health
Maintenance Organization | 11 |
| after the merger, consolidation, or other
acquisition of | 12 |
| control takes effect;
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| (2)(i) the criteria specified in subsection (1)(b) of | 14 |
| Section 131.8 of
the Illinois Insurance Code shall not | 15 |
| apply and (ii) the Director, in making
his determination | 16 |
| with respect to the merger, consolidation, or other
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| acquisition of control, need not take into account the | 18 |
| effect on
competition of the merger, consolidation, or | 19 |
| other acquisition of control;
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| (3) the Director shall have the power to require the | 21 |
| following
information:
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| (A) certification by an independent actuary of the | 23 |
| adequacy
of the reserves of the Health Maintenance | 24 |
| Organization sought to be acquired;
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| (B) pro forma financial statements reflecting the | 26 |
| combined balance
sheets of the acquiring company and |
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| the Health Maintenance Organization sought
to be | 2 |
| acquired as of the end of the preceding year and as of | 3 |
| a date 90 days
prior to the acquisition, as well as pro | 4 |
| forma financial statements
reflecting projected | 5 |
| combined operation for a period of 2 years;
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| (C) a pro forma business plan detailing an | 7 |
| acquiring party's plans with
respect to the operation | 8 |
| of the Health Maintenance Organization sought to
be | 9 |
| acquired for a period of not less than 3 years; and
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| (D) such other information as the Director shall | 11 |
| require.
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| (d) The provisions of Article VIII 1/2 of the Illinois | 13 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 14 |
| any health maintenance
organization of greater than 10% of its
| 15 |
| enrollee population (including without limitation the health | 16 |
| maintenance
organization's right, title, and interest in and to | 17 |
| its health care
certificates).
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| (e) In considering any management contract or service | 19 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 20 |
| Code, the Director (i) shall, in
addition to the criteria | 21 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 22 |
| into account the effect of the management contract or
service | 23 |
| agreement on the continuation of benefits to enrollees and the
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| financial condition of the health maintenance organization to | 25 |
| be managed or
serviced, and (ii) need not take into account the | 26 |
| effect of the management
contract or service agreement on |
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| competition.
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| (f) Except for small employer groups as defined in the | 3 |
| Small Employer
Rating, Renewability and Portability Health | 4 |
| Insurance Act and except for
medicare supplement policies as | 5 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 6 |
| Maintenance Organization may by contract agree with a
group or | 7 |
| other enrollment unit to effect refunds or charge additional | 8 |
| premiums
under the following terms and conditions:
| 9 |
| (i) the amount of, and other terms and conditions with | 10 |
| respect to, the
refund or additional premium are set forth | 11 |
| in the group or enrollment unit
contract agreed in advance | 12 |
| of the period for which a refund is to be paid or
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| additional premium is to be charged (which period shall not | 14 |
| be less than one
year); and
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| (ii) the amount of the refund or additional premium | 16 |
| shall not exceed 20%
of the Health Maintenance | 17 |
| Organization's profitable or unprofitable experience
with | 18 |
| respect to the group or other enrollment unit for the | 19 |
| period (and, for
purposes of a refund or additional | 20 |
| premium, the profitable or unprofitable
experience shall | 21 |
| be calculated taking into account a pro rata share of the
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| Health Maintenance Organization's administrative and | 23 |
| marketing expenses, but
shall not include any refund to be | 24 |
| made or additional premium to be paid
pursuant to this | 25 |
| subsection (f)). The Health Maintenance Organization and | 26 |
| the
group or enrollment unit may agree that the profitable |
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| or unprofitable
experience may be calculated taking into | 2 |
| account the refund period and the
immediately preceding 2 | 3 |
| plan years.
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| The Health Maintenance Organization shall include a | 5 |
| statement in the
evidence of coverage issued to each enrollee | 6 |
| describing the possibility of a
refund or additional premium, | 7 |
| and upon request of any group or enrollment unit,
provide to | 8 |
| the group or enrollment unit a description of the method used | 9 |
| to
calculate (1) the Health Maintenance Organization's | 10 |
| profitable experience with
respect to the group or enrollment | 11 |
| unit and the resulting refund to the group
or enrollment unit | 12 |
| or (2) the Health Maintenance Organization's unprofitable
| 13 |
| experience with respect to the group or enrollment unit and the | 14 |
| resulting
additional premium to be paid by the group or | 15 |
| enrollment unit.
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| In no event shall the Illinois Health Maintenance | 17 |
| Organization
Guaranty Association be liable to pay any | 18 |
| contractual obligation of an
insolvent organization to pay any | 19 |
| refund authorized under this Section.
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| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 21 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 22 |
| 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | 23 |
| 12-15-08.)
| 24 |
| (Text of Section after amendment by P.A. 95-958 ) | 25 |
| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to | 2 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 3 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 4 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | 5 |
| 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | 6 |
| 356z.11, 356z.12 , 356z.13
356z.11 , 356z.14, 356z.15, 364.01, | 7 |
| 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | 8 |
| 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
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| paragraph (c) of subsection (2) of Section 367, and Articles | 10 |
| IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | 11 |
| the Illinois Insurance Code.
| 12 |
| (b) For purposes of the Illinois Insurance Code, except for | 13 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 14 |
| Maintenance Organizations in
the following categories are | 15 |
| deemed to be "domestic companies":
| 16 |
| (1) a corporation authorized under the
Dental Service | 17 |
| Plan Act or the Voluntary Health Services Plans Act;
| 18 |
| (2) a corporation organized under the laws of this | 19 |
| State; or
| 20 |
| (3) 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 |
| (c) In considering the merger, consolidation, or other |
|
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SB1877 Enrolled |
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LRB096 11290 RPM 21719 b |
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| acquisition of
control of a Health Maintenance Organization | 2 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 3 |
| (1) the Director shall give primary consideration to | 4 |
| the continuation of
benefits to enrollees and the financial | 5 |
| conditions of the acquired Health
Maintenance Organization | 6 |
| after the merger, consolidation, or other
acquisition of | 7 |
| control takes effect;
| 8 |
| (2)(i) the criteria specified in subsection (1)(b) of | 9 |
| Section 131.8 of
the Illinois Insurance Code shall not | 10 |
| apply and (ii) the Director, in making
his determination | 11 |
| with respect to the merger, consolidation, or other
| 12 |
| acquisition of control, need not take into account the | 13 |
| effect on
competition of the merger, consolidation, or | 14 |
| other acquisition of control;
| 15 |
| (3) the Director shall have the power to require the | 16 |
| following
information:
| 17 |
| (A) certification by an independent actuary of the | 18 |
| adequacy
of the reserves of the Health Maintenance | 19 |
| Organization sought to be acquired;
| 20 |
| (B) pro forma financial statements reflecting the | 21 |
| combined balance
sheets of the acquiring company and | 22 |
| the Health Maintenance Organization sought
to be | 23 |
| acquired as of the end of the preceding year and as of | 24 |
| a date 90 days
prior to the acquisition, as well as pro | 25 |
| forma financial statements
reflecting projected | 26 |
| combined operation for a period of 2 years;
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| (C) a pro forma business plan detailing an | 2 |
| acquiring party's plans with
respect to the operation | 3 |
| of the Health Maintenance Organization sought to
be | 4 |
| acquired for a period of not less than 3 years; and
| 5 |
| (D) such other information as the Director shall | 6 |
| require.
| 7 |
| (d) The provisions of Article VIII 1/2 of the Illinois | 8 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 9 |
| any health maintenance
organization of greater than 10% of its
| 10 |
| enrollee population (including without limitation the health | 11 |
| maintenance
organization's right, title, and interest in and to | 12 |
| its health care
certificates).
| 13 |
| (e) In considering any management contract or service | 14 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 15 |
| Code, the Director (i) shall, in
addition to the criteria | 16 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 17 |
| into account the effect of the management contract or
service | 18 |
| agreement on the continuation of benefits to enrollees and the
| 19 |
| financial condition of the health maintenance organization to | 20 |
| be managed or
serviced, and (ii) need not take into account the | 21 |
| effect of the management
contract or service agreement on | 22 |
| competition.
| 23 |
| (f) Except for small employer groups as defined in the | 24 |
| Small Employer
Rating, Renewability and Portability Health | 25 |
| Insurance Act and except for
medicare supplement policies as | 26 |
| defined in Section 363 of the Illinois
Insurance Code, a Health |
|
|
|
SB1877 Enrolled |
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LRB096 11290 RPM 21719 b |
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| Maintenance Organization may by contract agree with a
group or | 2 |
| other enrollment unit to effect refunds or charge additional | 3 |
| premiums
under the following terms and conditions:
| 4 |
| (i) the amount of, and other terms and conditions with | 5 |
| respect to, the
refund or additional premium are set forth | 6 |
| in the group or enrollment unit
contract agreed in advance | 7 |
| of the period for which a refund is to be paid or
| 8 |
| additional premium is to be charged (which period shall not | 9 |
| be less than one
year); and
| 10 |
| (ii) the amount of the refund or additional premium | 11 |
| shall not exceed 20%
of the Health Maintenance | 12 |
| Organization's profitable or unprofitable experience
with | 13 |
| respect to the group or other enrollment unit for the | 14 |
| period (and, for
purposes of a refund or additional | 15 |
| premium, the profitable or unprofitable
experience shall | 16 |
| be calculated taking into account a pro rata share of the
| 17 |
| Health Maintenance Organization's administrative and | 18 |
| marketing expenses, but
shall not include any refund to be | 19 |
| made or additional premium to be paid
pursuant to this | 20 |
| subsection (f)). The Health Maintenance Organization and | 21 |
| the
group or enrollment unit may agree that the profitable | 22 |
| or unprofitable
experience may be calculated taking into | 23 |
| account the refund period and the
immediately preceding 2 | 24 |
| plan years.
| 25 |
| The Health Maintenance Organization shall include a | 26 |
| statement in the
evidence of coverage issued to each enrollee |
|
|
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| 1 |
| describing the possibility of a
refund or additional premium, | 2 |
| and upon request of any group or enrollment unit,
provide to | 3 |
| the group or enrollment unit a description of the method used | 4 |
| to
calculate (1) the Health Maintenance Organization's | 5 |
| profitable experience with
respect to the group or enrollment | 6 |
| unit and the resulting refund to the group
or enrollment unit | 7 |
| or (2) the Health Maintenance Organization's unprofitable
| 8 |
| experience with respect to the group or enrollment unit and the | 9 |
| resulting
additional premium to be paid by the group or | 10 |
| enrollment unit.
| 11 |
| In no event shall the Illinois Health Maintenance | 12 |
| Organization
Guaranty Association be liable to pay any | 13 |
| contractual obligation of an
insolvent organization to pay any | 14 |
| refund authorized under this Section.
| 15 |
| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 16 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | 17 |
| 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | 18 |
| eff. 12-12-08; revised 12-15-08.) | 19 |
| Section 95. No acceleration or delay. Where this Act makes | 20 |
| changes in a statute that is represented in this Act by text | 21 |
| that is not yet or no longer in effect (for example, a Section | 22 |
| represented by multiple versions), the use of that text does | 23 |
| not accelerate or delay the taking effect of (i) the changes | 24 |
| made by this Act or (ii) provisions derived from any other | 25 |
| Public Act.
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| Section 99. Effective date. This Act takes effect January | 2 |
| 1, 2010.
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