Full Text of SB2486 95th General Assembly
SB2486eng 95TH GENERAL ASSEMBLY
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| AN ACT concerning regulation.
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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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| Sec. 6.11. Required health benefits; Illinois Insurance | 8 |
| Code
requirements. The program of health
benefits shall provide | 9 |
| the post-mastectomy care benefits required to be covered
by a | 10 |
| policy of accident and health insurance under Section 356t of | 11 |
| the Illinois
Insurance Code. The program of health benefits | 12 |
| shall provide the coverage
required under Sections 356g.5,
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| 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, | 14 |
| and 356z.11 and
356z.9 of the
Illinois Insurance Code.
The | 15 |
| program of health benefits must comply with Section 155.37 of | 16 |
| the
Illinois Insurance Code.
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| (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | 18 |
| 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 10. The Illinois Insurance Code is amended by | 20 |
| adding Section 356z.11 as follows: | 21 |
| (215 ILCS 5/356z.11 new) |
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| Sec. 356z.11. Wellness coverage. | 2 |
| (a) A group or individual policy of accident and health | 3 |
| insurance or managed care plan amended, delivered, issued, or | 4 |
| renewed after the effective date of this amendatory Act of the | 5 |
| 95th General Assembly that provides coverage for hospital or | 6 |
| medical treatment on an expense incurred basis may offer a | 7 |
| reasonably designed program for wellness coverage that allows | 8 |
| for a reward, a health spending account contribution, a | 9 |
| reduction in premiums or reduced medical, prescription drug, or | 10 |
| equipment copayments, coinsurance, or deductibles, or a | 11 |
| combination of these incentives, for participation in any | 12 |
| health behavior wellness, maintenance, or improvement program | 13 |
| approved or offered by the insurer or managed care plan. The | 14 |
| insured or enrollee may be required to provide evidence of | 15 |
| participation in a program, demonstrative compliance with | 16 |
| treatment recommendations, or improvement of the individual's | 17 |
| or dependent's health behaviors as determined by the health | 18 |
| insurer or managed care plan. | 19 |
| (b) For purposes of this Section, "wellness coverage" means | 20 |
| health care coverage with the primary purpose to engage and | 21 |
| motivate the insured or enrollee through: incentives; | 22 |
| provision of health education, counseling, and self-management | 23 |
| skills; identification of modifiable health risks; and other | 24 |
| activities to influence health behavior changes. | 25 |
| (c) Incentives as outlined in this Section are specific and | 26 |
| unique to the offering of wellness coverage and have no |
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| application to any other required or optional health care | 2 |
| benefit. | 3 |
| (d) Such wellness coverage shall satisfy the requirements | 4 |
| for an exception from the general prohibition against | 5 |
| discrimination based on a health factor under the federal | 6 |
| Health Insurance Portability and Accountability Act of 1996 | 7 |
| (P.L. 104-191; 110 Stat. 1936), including any federal | 8 |
| regulations that are adopted pursuant to that Act. | 9 |
| (e) A reward, health spending account contribution, or | 10 |
| reduction established under this Section does not violate | 11 |
| Section 151 of this Code. | 12 |
| Section 15. The Health Maintenance Organization Act is | 13 |
| 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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| Sec. 5-3. Insurance Code provisions.
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| (a) Health Maintenance Organizations
shall be subject to | 17 |
| the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | 18 |
| 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 19 |
| 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | 20 |
| 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | 21 |
| 356z.11
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | 22 |
| 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | 23 |
| 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | 24 |
| 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, |
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| XXV, and XXVI of the Illinois Insurance Code.
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| (b) For purposes of the Illinois Insurance Code, except for | 3 |
| Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 4 |
| Maintenance Organizations in
the following categories are | 5 |
| deemed to be "domestic companies":
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| (1) a corporation authorized under the
Dental Service | 7 |
| Plan Act or the Voluntary Health Services Plans Act;
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| (2) a corporation organized under the laws of this | 9 |
| State; or
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| (3) a corporation organized under the laws of another | 11 |
| state, 30% or more
of the enrollees of which are residents | 12 |
| of this State, except a
corporation subject to | 13 |
| substantially the same requirements in its state of
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| organization as is a "domestic company" under Article VIII | 15 |
| 1/2 of the
Illinois Insurance Code.
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| (c) In considering the merger, consolidation, or other | 17 |
| acquisition of
control of a Health Maintenance Organization | 18 |
| pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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| (1) the Director shall give primary consideration to | 20 |
| the continuation of
benefits to enrollees and the financial | 21 |
| conditions of the acquired Health
Maintenance Organization | 22 |
| after the merger, consolidation, or other
acquisition of | 23 |
| control takes effect;
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| (2)(i) the criteria specified in subsection (1)(b) of | 25 |
| Section 131.8 of
the Illinois Insurance Code shall not | 26 |
| apply and (ii) the Director, in making
his determination |
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| with respect to the merger, consolidation, or other
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| acquisition of control, need not take into account the | 3 |
| effect on
competition of the merger, consolidation, or | 4 |
| other acquisition of control;
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| (3) the Director shall have the power to require the | 6 |
| following
information:
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| (A) certification by an independent actuary of the | 8 |
| adequacy
of the reserves of the Health Maintenance | 9 |
| Organization sought to be acquired;
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| (B) pro forma financial statements reflecting the | 11 |
| combined balance
sheets of the acquiring company and | 12 |
| the Health Maintenance Organization sought
to be | 13 |
| acquired as of the end of the preceding year and as of | 14 |
| a date 90 days
prior to the acquisition, as well as pro | 15 |
| forma financial statements
reflecting projected | 16 |
| combined operation for a period of 2 years;
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| (C) a pro forma business plan detailing an | 18 |
| acquiring party's plans with
respect to the operation | 19 |
| of the Health Maintenance Organization sought to
be | 20 |
| acquired for a period of not less than 3 years; and
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| (D) such other information as the Director shall | 22 |
| require.
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| (d) The provisions of Article VIII 1/2 of the Illinois | 24 |
| Insurance Code
and this Section 5-3 shall apply to the sale by | 25 |
| any health maintenance
organization of greater than 10% of its
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| enrollee population (including without limitation the health |
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| maintenance
organization's right, title, and interest in and to | 2 |
| its health care
certificates).
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| (e) In considering any management contract or service | 4 |
| agreement subject
to Section 141.1 of the Illinois Insurance | 5 |
| Code, the Director (i) shall, in
addition to the criteria | 6 |
| specified in Section 141.2 of the Illinois
Insurance Code, take | 7 |
| into account the effect of the management contract or
service | 8 |
| agreement on the continuation of benefits to enrollees and the
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| financial condition of the health maintenance organization to | 10 |
| be managed or
serviced, and (ii) need not take into account the | 11 |
| effect of the management
contract or service agreement on | 12 |
| competition.
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| (f) Except for small employer groups as defined in the | 14 |
| Small Employer
Rating, Renewability and Portability Health | 15 |
| Insurance Act and except for
medicare supplement policies as | 16 |
| defined in Section 363 of the Illinois
Insurance Code, a Health | 17 |
| Maintenance Organization may by contract agree with a
group or | 18 |
| other enrollment unit to effect refunds or charge additional | 19 |
| premiums
under the following terms and conditions:
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| (i) the amount of, and other terms and conditions with | 21 |
| respect to, the
refund or additional premium are set forth | 22 |
| in the group or enrollment unit
contract agreed in advance | 23 |
| 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 | 25 |
| be less than one
year); and
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| (ii) the amount of the refund or additional premium |
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| shall not exceed 20%
of the Health Maintenance | 2 |
| Organization's profitable or unprofitable experience
with | 3 |
| respect to the group or other enrollment unit for the | 4 |
| period (and, for
purposes of a refund or additional | 5 |
| premium, the profitable or unprofitable
experience shall | 6 |
| be calculated taking into account a pro rata share of the
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| Health Maintenance Organization's administrative and | 8 |
| marketing expenses, but
shall not include any refund to be | 9 |
| made or additional premium to be paid
pursuant to this | 10 |
| subsection (f)). The Health Maintenance Organization and | 11 |
| the
group or enrollment unit may agree that the profitable | 12 |
| or unprofitable
experience may be calculated taking into | 13 |
| account the refund period and the
immediately preceding 2 | 14 |
| plan years.
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| The Health Maintenance Organization shall include a | 16 |
| statement in the
evidence of coverage issued to each enrollee | 17 |
| describing the possibility of a
refund or additional premium, | 18 |
| and upon request of any group or enrollment unit,
provide to | 19 |
| the group or enrollment unit a description of the method used | 20 |
| to
calculate (1) the Health Maintenance Organization's | 21 |
| profitable experience with
respect to the group or enrollment | 22 |
| unit and the resulting refund to the group
or enrollment unit | 23 |
| or (2) the Health Maintenance Organization's unprofitable
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| experience with respect to the group or enrollment unit and the | 25 |
| resulting
additional premium to be paid by the group or | 26 |
| enrollment unit.
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| In no event shall the Illinois Health Maintenance | 2 |
| Organization
Guaranty Association be liable to pay any | 3 |
| contractual obligation of an
insolvent organization to pay any | 4 |
| refund authorized under this Section.
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| (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | 6 |
| 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
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| Section 99. Effective date. This Act takes effect January | 8 |
| 1, 2009.
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