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| [ Engrossed ] | [ House Amendment 001 ] |
90_HB0143
215 ILCS 5/356t new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003 from Ch. 73, par. 1504-3
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code, the Health
Maintenance Organization Act, the Limited Health Service
Organization Act, and the Voluntary Health Services Plans
Act. Requires individual and group accident and health
insurance policies and coverage by a health maintenance
organization or under a health service plan to include
coverage for nonprescription enteral formulas and
reduced-protein foods that are necessary for the treatment or
management of certain gastrointestinal conditions or
inherited diseases involving amino acids. Effective
immediately.
LRB9000461JSgc
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1 AN ACT concerning insurance coverage for certain
2 conditions.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 adding Section 356t as follows:
7 (215 ILCS 5/356t new)
8 Sec. 356t. Treatment of certain gastrointestinal and
9 other conditions.
10 (a) An individual or group policy of accident and health
11 insurance that is issued, delivered, amended, or renewed in
12 this State on or after January 1, 1998 shall include the
13 following:
14 (1) Coverage for nonprescription enteral and oral
15 formulas for home use, for which a physician has issued a
16 written order and which are medically necessary for the
17 treatment or management of malabsorption caused by
18 Crohn's disease, ulcerative colitis, gastroesophageal
19 reflux, gastrointestinal motility, chronic intestinal
20 pseudo-obstruction, or inherited diseases involving amino
21 acids or other organic acids (including, but not limited
22 to, phenylketonuria).
23 (2) Coverage for up to $2,500 per year worth of
24 food products modified to be low in protein, for which a
25 physician has issued a written order and which are
26 medically necessary for the management of phenylketonuria
27 or other inherited diseases involving amino acids or
28 other organic acids.
29 (b) The coverage required under subsection (a) shall
30 also be provided by health maintenance organizations, limited
31 health service organizations, and voluntary health services
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1 plans.
2 Section 10. The Health Maintenance Organization Act is
3 amended by changing Section 5-3 as follows:
4 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
5 Sec. 5-3. Insurance Code provisions.
6 (a) Health Maintenance Organizations shall be subject to
7 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
8 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
9 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356t, 367i, 401,
10 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
11 subsection (2) of Section 367, and Articles VIII 1/2, XII,
12 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
13 Code.
14 (b) For purposes of the Illinois Insurance Code, except
15 for Articles XIII and XIII 1/2, Health Maintenance
16 Organizations in the following categories are deemed to be
17 "domestic companies":
18 (1) a corporation authorized under the Medical
19 Service Plan Act, the Dental Service Plan Act, the Vision
20 Service Plan Act, the Pharmaceutical Service Plan Act,
21 the Voluntary Health Services Plan Act, or the Nonprofit
22 Health Care Service Plan Act;
23 (2) a corporation organized under the laws of this
24 State; or
25 (3) a corporation organized under the laws of
26 another state, 30% or more of the enrollees of which are
27 residents of this State, except a corporation subject to
28 substantially the same requirements in its state of
29 organization as is a "domestic company" under Article
30 VIII 1/2 of the Illinois Insurance Code.
31 (c) In considering the merger, consolidation, or other
32 acquisition of control of a Health Maintenance Organization
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1 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
2 (1) the Director shall give primary consideration
3 to the continuation of benefits to enrollees and the
4 financial conditions of the acquired Health Maintenance
5 Organization after the merger, consolidation, or other
6 acquisition of control takes effect;
7 (2)(i) the criteria specified in subsection (1)(b)
8 of Section 131.8 of the Illinois Insurance Code shall not
9 apply and (ii) the Director, in making his determination
10 with respect to the merger, consolidation, or other
11 acquisition of control, need not take into account the
12 effect on competition of the merger, consolidation, or
13 other acquisition of control;
14 (3) the Director shall have the power to require
15 the following information:
16 (A) certification by an independent actuary of
17 the adequacy of the reserves of the Health
18 Maintenance Organization sought to be acquired;
19 (B) pro forma financial statements reflecting
20 the combined balance sheets of the acquiring company
21 and the Health Maintenance Organization sought to be
22 acquired as of the end of the preceding year and as
23 of a date 90 days prior to the acquisition, as well
24 as pro forma financial statements reflecting
25 projected combined operation for a period of 2
26 years;
27 (C) a pro forma business plan detailing an
28 acquiring party's plans with respect to the
29 operation of the Health Maintenance Organization
30 sought to be acquired for a period of not less than
31 3 years; and
32 (D) such other information as the Director
33 shall require.
34 (d) The provisions of Article VIII 1/2 of the Illinois
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1 Insurance Code and this Section 5-3 shall apply to the sale
2 by any health maintenance organization of greater than 10% of
3 its enrollee population (including without limitation the
4 health maintenance organization's right, title, and interest
5 in and to its health care certificates).
6 (e) In considering any management contract or service
7 agreement subject to Section 141.1 of the Illinois Insurance
8 Code, the Director (i) shall, in addition to the criteria
9 specified in Section 141.2 of the Illinois Insurance Code,
10 take into account the effect of the management contract or
11 service agreement on the continuation of benefits to
12 enrollees and the financial condition of the health
13 maintenance organization to be managed or serviced, and (ii)
14 need not take into account the effect of the management
15 contract or service agreement on competition.
16 (f) Except for small employer groups as defined in the
17 Small Employer Rating, Renewability and Portability Health
18 Insurance Act and except for medicare supplement policies as
19 defined in Section 363 of the Illinois Insurance Code, a
20 Health Maintenance Organization may by contract agree with a
21 group or other enrollment unit to effect refunds or charge
22 additional premiums under the following terms and conditions:
23 (i) the amount of, and other terms and conditions
24 with respect to, the refund or additional premium are set
25 forth in the group or enrollment unit contract agreed in
26 advance of the period for which a refund is to be paid or
27 additional premium is to be charged (which period shall
28 not be less than one year); and
29 (ii) the amount of the refund or additional premium
30 shall not exceed 20% of the Health Maintenance
31 Organization's profitable or unprofitable experience with
32 respect to the group or other enrollment unit for the
33 period (and, for purposes of a refund or additional
34 premium, the profitable or unprofitable experience shall
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1 be calculated taking into account a pro rata share of the
2 Health Maintenance Organization's administrative and
3 marketing expenses, but shall not include any refund to
4 be made or additional premium to be paid pursuant to this
5 subsection (f)). The Health Maintenance Organization and
6 the group or enrollment unit may agree that the
7 profitable or unprofitable experience may be calculated
8 taking into account the refund period and the immediately
9 preceding 2 plan years.
10 The Health Maintenance Organization shall include a
11 statement in the evidence of coverage issued to each enrollee
12 describing the possibility of a refund or additional premium,
13 and upon request of any group or enrollment unit, provide to
14 the group or enrollment unit a description of the method used
15 to calculate (1) the Health Maintenance Organization's
16 profitable experience with respect to the group or enrollment
17 unit and the resulting refund to the group or enrollment unit
18 or (2) the Health Maintenance Organization's unprofitable
19 experience with respect to the group or enrollment unit and
20 the resulting additional premium to be paid by the group or
21 enrollment unit.
22 In no event shall the Illinois Health Maintenance
23 Organization Guaranty Association be liable to pay any
24 contractual obligation of an insolvent organization to pay
25 any refund authorized under this Section.
26 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
27 Section 15. The Limited Health Service Organization Act
28 is amended by changing Section 4003 as follows:
29 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
30 Sec. 4003. Illinois Insurance Code provisions. Limited
31 health service organizations shall be subject to the
32 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
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1 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
2 154.6, 154.7, 154.8, 155.04, 355.2, 356t, 401, 401.1, 402,
3 403, 403A, 408, 408.2, and 412, and Articles VIII 1/2, XII,
4 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
5 Code. For purposes of the Illinois Insurance Code, except
6 for Articles XIII and XIII 1/2, limited health service
7 organizations in the following categories are deemed to be
8 domestic companies:
9 (1) a corporation under the laws of this State; or
10 (2) a corporation organized under the laws of
11 another state, 30% of more of the enrollees of which are
12 residents of this State, except a corporation subject to
13 substantially the same requirements in its state of
14 organization as is a domestic company under Article VIII
15 1/2 of the Illinois Insurance Code.
16 (Source: P.A. 86-600; 87-587; 87-1090.)
17 Section 20. The Voluntary Health Services Plans Act is
18 amended by changing Section 10 as follows:
19 (215 ILCS 165/10) (from Ch. 32, par. 604)
20 Sec. 10. Application of Insurance Code provisions.
21 Health services plan corporations and all persons interested
22 therein or dealing therewith shall be subject to the
23 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
24 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
25 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
26 (15) of Section 367 of the Illinois Insurance Code.
27 (Source: P.A. 89-514, eff. 7-17-96.)
28 Section 99. Effective date. This Act takes effect upon
29 becoming law.