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90_HB0188
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 to provide that
individual and group policies and managed care plans that
require the designation of a primary care provider shall
allow an insured to designate an endocrinology care provider
to which the insured shall have access without the
requirement of a referral. Amends the Health Maintenance
Organization Act, the Limited Health Service Organization
Act, and the Voluntary Health Services Plans Act to require
endocrinology provider access under those Acts.
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1 AN ACT concerning the availability of endocrinology
2 services, amending named Acts.
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. Endocrinologist provider.
9 (a) An individual or group policy of accident and health
10 insurance or a managed care plan amended, delivered, issued,
11 or renewed in this State after the effective date of this
12 amendatory Act of 1997 that requires an insured or enrollee
13 to designate an individual to coordinate care or to control
14 access to health care services shall also permit an insured
15 or enrollee to designate a participating endocrinologist
16 provider.
17 (b) If an insured or enrollee has designated an
18 endocrinologist provider, then the insured or enrollee must
19 be given direct access to the endocrinologist provider for
20 services covered by the policy or plan without the need for a
21 referral or prior approval. Nothing shall prohibit the
22 insurer or managed care plan from requiring prior
23 authorization or approval from either a primary care provider
24 or the endocrinologist provider for referrals for additional
25 care or services.
26 (c) For the purposes of this Section the following terms
27 are defined:
28 (1) "Endocrinologist provider" means a physician
29 licensed to practice medicine in all of its branches
30 specializing in endocrinology.
31 (2) "Managed care entity" means a licensed
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1 insurance company, hospital or medical service plan,
2 health maintenance organization, limited health service
3 organization, preferred provider organization, third
4 party administrator, an employer or employee
5 organization, or any person or entity that establishes,
6 operates, or maintains a network of participating
7 providers.
8 (3) "Managed care plan" means a plan operated by a
9 managed care entity that provides for the financing of
10 health care services to persons enrolled in the plan
11 through:
12 (A) organizational arrangements for ongoing
13 quality assurance, utilization review programs, or
14 dispute resolution; or
15 (B) financial incentives for persons enrolled
16 in the plan to use the participating providers and
17 procedures covered by the plan.
18 (4) "Participating provider" means a physician who
19 has contracted with an insurer or managed care plan to
20 provide services to insureds or enrollees as defined by
21 the contract.
22 Section 10. The Health Maintenance Organization Act is
23 amended by changing Section 5-3 as follows:
24 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
25 Sec. 5-3. Insurance Code provisions.
26 (a) Health Maintenance Organizations shall be subject to
27 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
28 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
29 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356t, 367i, 401,
30 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
31 subsection (2) of Section 367, and Articles VIII 1/2, XII,
32 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
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1 Code.
2 (b) For purposes of the Illinois Insurance Code, except
3 for Articles XIII and XIII 1/2, Health Maintenance
4 Organizations in the following categories are deemed to be
5 "domestic companies":
6 (1) a corporation authorized under the Medical
7 Service Plan Act, the Dental Service Plan Act, the Vision
8 Service Plan Act, the Pharmaceutical Service Plan Act,
9 the Voluntary Health Services Plan Act, or the Nonprofit
10 Health Care Service Plan Act;
11 (2) a corporation organized under the laws of this
12 State; or
13 (3) a corporation organized under the laws of
14 another state, 30% or more of the enrollees of which are
15 residents of this State, except a corporation subject to
16 substantially the same requirements in its state of
17 organization as is a "domestic company" under Article
18 VIII 1/2 of the Illinois Insurance Code.
19 (c) In considering the merger, consolidation, or other
20 acquisition of control of a Health Maintenance Organization
21 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22 (1) the Director shall give primary consideration
23 to the continuation of benefits to enrollees and the
24 financial conditions of the acquired Health Maintenance
25 Organization after the merger, consolidation, or other
26 acquisition of control takes effect;
27 (2)(i) the criteria specified in subsection (1)(b)
28 of Section 131.8 of the Illinois Insurance Code shall not
29 apply and (ii) the Director, in making his determination
30 with respect to the merger, consolidation, or other
31 acquisition of control, need not take into account the
32 effect on competition of the merger, consolidation, or
33 other acquisition of control;
34 (3) the Director shall have the power to require
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1 the following information:
2 (A) certification by an independent actuary of
3 the adequacy of the reserves of the Health
4 Maintenance Organization sought to be acquired;
5 (B) pro forma financial statements reflecting
6 the combined balance sheets of the acquiring company
7 and the Health Maintenance Organization sought to be
8 acquired as of the end of the preceding year and as
9 of a date 90 days prior to the acquisition, as well
10 as pro forma financial statements reflecting
11 projected combined operation for a period of 2
12 years;
13 (C) a pro forma business plan detailing an
14 acquiring party's plans with respect to the
15 operation of the Health Maintenance Organization
16 sought to be acquired for a period of not less than
17 3 years; and
18 (D) such other information as the Director
19 shall require.
20 (d) The provisions of Article VIII 1/2 of the Illinois
21 Insurance Code and this Section 5-3 shall apply to the sale
22 by any health maintenance organization of greater than 10% of
23 its enrollee population (including without limitation the
24 health maintenance organization's right, title, and interest
25 in and to its health care certificates).
26 (e) In considering any management contract or service
27 agreement subject to Section 141.1 of the Illinois Insurance
28 Code, the Director (i) shall, in addition to the criteria
29 specified in Section 141.2 of the Illinois Insurance Code,
30 take into account the effect of the management contract or
31 service agreement on the continuation of benefits to
32 enrollees and the financial condition of the health
33 maintenance organization to be managed or serviced, and (ii)
34 need not take into account the effect of the management
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1 contract or service agreement on competition.
2 (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
6 Health Maintenance Organization may by contract agree with a
7 group or other enrollment unit to effect refunds or charge
8 additional premiums under the following terms and conditions:
9 (i) the amount of, and other terms and conditions
10 with respect to, the refund or additional premium are set
11 forth in the group or enrollment unit contract agreed in
12 advance of the period for which a refund is to be paid or
13 additional premium is to be charged (which period shall
14 not be less than one year); and
15 (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
22 Health Maintenance Organization's administrative and
23 marketing expenses, but shall not include any refund to
24 be 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
27 profitable or unprofitable experience may be calculated
28 taking into account the refund period and the immediately
29 preceding 2 plan years.
30 The Health Maintenance Organization shall include a
31 statement in the evidence of coverage issued to each enrollee
32 describing the possibility of a refund or additional premium,
33 and upon request of any group or enrollment unit, provide to
34 the group or enrollment unit a description of the method used
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1 to calculate (1) the Health Maintenance Organization's
2 profitable experience with respect to the group or enrollment
3 unit and the resulting refund to the group or enrollment unit
4 or (2) the Health Maintenance Organization's unprofitable
5 experience with respect to the group or enrollment unit and
6 the resulting additional premium to be paid by the group or
7 enrollment unit.
8 In no event shall the Illinois Health Maintenance
9 Organization Guaranty Association be liable to pay any
10 contractual obligation of an insolvent organization to pay
11 any refund authorized under this Section.
12 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
13 Section 15. The Limited Health Service Organization Act
14 is amended by changing Section 4003 as follows:
15 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
16 Sec. 4003. Illinois Insurance Code provisions. Limited
17 health service organizations shall be subject to the
18 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
19 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
20 154.6, 154.7, 154.8, 155.04, 355.2, 356t, 401, 401.1, 402,
21 403, 403A, 408, 408.2, and 412, and Articles VIII 1/2, XII,
22 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
23 Code. For purposes of the Illinois Insurance Code, except
24 for Articles XIII and XIII 1/2, limited health service
25 organizations in the following categories are deemed to be
26 domestic companies:
27 (1) a corporation under the laws of this State; or
28 (2) a corporation organized under the laws of
29 another state, 30% of more of the enrollees of which are
30 residents of this State, except a corporation subject to
31 substantially the same requirements in its state of
32 organization as is a domestic company under Article VIII
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1 1/2 of the Illinois Insurance Code.
2 (Source: P.A. 86-600; 87-587; 87-1090.)
3 Section 20. The Voluntary Health Services Plans Act is
4 amended by changing Section 10 as follows:
5 (215 ILCS 165/10) (from Ch. 32, par. 604)
6 Sec. 10. Application of Insurance Code provisions.
7 Health services plan corporations and all persons interested
8 therein or dealing therewith shall be subject to the
9 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
10 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
11 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
12 (15) of Section 367 of the Illinois Insurance Code.
13 (Source: P.A. 89-514, eff. 7-17-96.)