Illinois General Assembly - Illinois Compiled Statutes

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215 ILCS 125/4-12

(215 ILCS 125/4-12) (from Ch. 111 1/2, par. 1409.5)
(Text of Section before amendment by P.A. 103-650)

Sec. 4-12.

Changes in rate methodology and benefits, material
modifications.

A health maintenance organization shall file with the
Director, prior to use, a notice of any change in rate methodology, or
benefits and of any material modification of any matter or document
furnished pursuant to Section 2-1, together with such supporting documents
as are necessary to fully explain the change or modification.

(a) Contract modifications described in subsections (c)(5), (c)(6) and
(c)(7) of Section 2-1 shall include all form agreements between the
organization and enrollees, providers, administrators of services and
insurers of health maintenance organizations.

(b) Material transactions or series of transactions other than those
described in subsection (a) of this Section, the total annual value of
which exceeds the greater of $100,000 or 5% of net earned subscription
revenue for the most current 12-month period as determined from filed
financial statements.

(c) Any agreement between the organization and an insurer shall be
subject to the provisions of the laws of this State regarding reinsurance
as provided in Article XI of the Illinois Insurance Code.  All reinsurance
agreements must be filed.  Approval of the Director is required for all
agreements except the following:  individual stop loss, aggregate excess,
hospitalization benefits or out-of-area of the participating providers
unless 20% or more of the organization's total risk is reinsured, in which
case all reinsurance agreements require approval.

(d)   In addition to any applicable provisions of this Act, premium rate filings shall be subject to subsections (a) and (c) through (i) of Section 355 of the Illinois Insurance Code.

(Source: P.A. 103-106, eff. 1-1-24.)

(Text of Section after amendment by P.A. 103-650)
Sec. 4-12. Changes in rate methodology and benefits, material modifications.

A health maintenance organization shall file with the Director, prior to use, a notice of any change in rate methodology, or benefits and of any material modification of any matter or document furnished pursuant to Section 2-1, together with such supporting documents as are necessary to fully explain the change or modification.

(a) Contract modifications described in subsections (c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all form agreements between the organization and enrollees, providers, administrators of services and insurers of health maintenance organizations.

(b) Material transactions or series of transactions other than those described in subsection (a) of this Section, the total annual value of which exceeds the greater of $100,000 or 5% of net earned subscription revenue for the most current 12-month period as determined from filed financial statements.

(c) Any agreement between the organization and an insurer shall be subject to the provisions of the laws of this State regarding reinsurance as provided in Article XI of the Illinois Insurance Code. All reinsurance agreements must be filed. Approval of the Director is required for all agreements except the following: individual stop loss, aggregate excess, hospitalization benefits or out-of-area of the participating providers unless 20% or more of the organization's total risk is reinsured, in which case all reinsurance agreements require approval.

(d) In addition to any applicable provisions of this Act, premium rate filings shall be subject to subsections (a) and (c) through (j) of Section 355 of the Illinois Insurance Code.

(Source: P.A. 103-106, eff. 1-1-24; 103-650, eff. 1-1-25.)