[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
|[ Introduced ]|
90_HB0579eng 215 ILCS 5/356t new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 215 ILCS 130/3009 from Ch. 73, par. 1503-9 215 ILCS 165/10 from Ch. 32, par. 604 Amends the Illinois Insurance Code, Health Maintenance Organization Act, Limited Health Service Organization Act, and Voluntary Health Services Plans Act. Provides that health benefit coverage under those Acts must include coverage for hospital and medical expenses when dental services for insureds who are disabled are required to be delivered in a hospital or medical outpatient facility because of the insured's medical condition. Defines terms. Effective January 1, 1998. LRB9000565JSgc HB0579 Engrossed LRB9000565JSgc 1 AN ACT concerning insurance coverage for certain dental 2 expenses, 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. Coverage of medical services ancillary to 9 dental services for the disabled. An individual or group 10 policy of accident and health insurance amended, delivered, 11 issued, or renewed after the effective date of this 12 amendatory Act of 1997 that covers hospital and medical 13 expenses may not deny coverage for hospital and medical 14 expenses incurred by an insured person who has a disability, 15 as defined by the federal Americans with Disabilities Act of 16 1990, when those hospital and medical expenses are incurred 17 in conjunction with dental services that are required, due to 18 the nature of the disability, to be delivered in a hospital 19 or medical outpatient facility. Nothing in this Section 20 requires that the actual dental services be covered. 21 Section 10. The Health Maintenance Organization Act is 22 amended by changing Section 5-3 as follows: 23 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) 24 Sec. 5-3. Insurance Code provisions. 25 (a) Health Maintenance Organizations shall be subject to 26 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2, 27 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 28 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356t, 367i, 401, 29 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of HB0579 Engrossed -2- LRB9000565JSgc 1 subsection (2) of Section 367, and Articles VIII 1/2, XII, 2 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance 3 Code. 4 (b) For purposes of the Illinois Insurance Code, except 5 for Articles XIII and XIII 1/2, Health Maintenance 6 Organizations in the following categories are deemed to be 7 "domestic companies": 8 (1) a corporation authorized under the Medical 9 Service Plan Act, the Dental Service Plan Act, the Vision 10 Service Plan Act, the Pharmaceutical Service Plan Act, 11 the Voluntary Health Services Plan Act, or the Nonprofit 12 Health Care Service Plan Act; 13 (2) a corporation organized under the laws of this 14 State; or 15 (3) a corporation organized under the laws of 16 another state, 30% or more of the enrollees of which are 17 residents of this State, except a corporation subject to 18 substantially the same requirements in its state of 19 organization as is a "domestic company" under Article 20 VIII 1/2 of the Illinois Insurance Code. 21 (c) In considering the merger, consolidation, or other 22 acquisition of control of a Health Maintenance Organization 23 pursuant to Article VIII 1/2 of the Illinois Insurance Code, 24 (1) the Director shall give primary consideration 25 to the continuation of benefits to enrollees and the 26 financial conditions of the acquired Health Maintenance 27 Organization after the merger, consolidation, or other 28 acquisition of control takes effect; 29 (2)(i) the criteria specified in subsection (1)(b) 30 of Section 131.8 of the Illinois Insurance Code shall not 31 apply and (ii) the Director, in making his determination 32 with respect to the merger, consolidation, or other 33 acquisition of control, need not take into account the 34 effect on competition of the merger, consolidation, or HB0579 Engrossed -3- LRB9000565JSgc 1 other acquisition of control; 2 (3) the Director shall have the power to require 3 the following information: 4 (A) certification by an independent actuary of 5 the adequacy of the reserves of the Health 6 Maintenance Organization sought to be acquired; 7 (B) pro forma financial statements reflecting 8 the combined balance sheets of the acquiring company 9 and the Health Maintenance Organization sought to be 10 acquired as of the end of the preceding year and as 11 of a date 90 days prior to the acquisition, as well 12 as pro forma financial statements reflecting 13 projected combined operation for a period of 2 14 years; 15 (C) a pro forma business plan detailing an 16 acquiring party's plans with respect to the 17 operation of the Health Maintenance Organization 18 sought to be acquired for a period of not less than 19 3 years; and 20 (D) such other information as the Director 21 shall require. 22 (d) The provisions of Article VIII 1/2 of the Illinois 23 Insurance Code and this Section 5-3 shall apply to the sale 24 by any health maintenance organization of greater than 10% of 25 its enrollee population (including without limitation the 26 health maintenance organization's right, title, and interest 27 in and to its health care certificates). 28 (e) In considering any management contract or service 29 agreement subject to Section 141.1 of the Illinois Insurance 30 Code, the Director (i) shall, in addition to the criteria 31 specified in Section 141.2 of the Illinois Insurance Code, 32 take into account the effect of the management contract or 33 service agreement on the continuation of benefits to 34 enrollees and the financial condition of the health HB0579 Engrossed -4- LRB9000565JSgc 1 maintenance organization to be managed or serviced, and (ii) 2 need not take into account the effect of the management 3 contract or service agreement on competition. 4 (f) Except for small employer groups as defined in the 5 Small Employer Rating, Renewability and Portability Health 6 Insurance Act and except for medicare supplement policies as 7 defined in Section 363 of the Illinois Insurance Code, a 8 Health Maintenance Organization may by contract agree with a 9 group or other enrollment unit to effect refunds or charge 10 additional premiums under the following terms and conditions: 11 (i) the amount of, and other terms and conditions 12 with respect to, the refund or additional premium are set 13 forth in the group or enrollment unit contract agreed in 14 advance of the period for which a refund is to be paid or 15 additional premium is to be charged (which period shall 16 not be less than one year); and 17 (ii) the amount of the refund or additional premium 18 shall not exceed 20% of the Health Maintenance 19 Organization's profitable or unprofitable experience with 20 respect to the group or other enrollment unit for the 21 period (and, for purposes of a refund or additional 22 premium, the profitable or unprofitable experience shall 23 be calculated taking into account a pro rata share of the 24 Health Maintenance Organization's administrative and 25 marketing expenses, but shall not include any refund to 26 be made or additional premium to be paid pursuant to this 27 subsection (f)). The Health Maintenance Organization and 28 the group or enrollment unit may agree that the 29 profitable or unprofitable experience may be calculated 30 taking into account the refund period and the immediately 31 preceding 2 plan years. 32 The Health Maintenance Organization shall include a 33 statement in the evidence of coverage issued to each enrollee 34 describing the possibility of a refund or additional premium, HB0579 Engrossed -5- LRB9000565JSgc 1 and upon request of any group or enrollment unit, provide to 2 the group or enrollment unit a description of the method used 3 to calculate (1) the Health Maintenance Organization's 4 profitable experience with respect to the group or enrollment 5 unit and the resulting refund to the group or enrollment unit 6 or (2) the Health Maintenance Organization's unprofitable 7 experience with respect to the group or enrollment unit and 8 the resulting additional premium to be paid by the group or 9 enrollment unit. 10 In no event shall the Illinois Health Maintenance 11 Organization Guaranty Association be liable to pay any 12 contractual obligation of an insolvent organization to pay 13 any refund authorized under this Section. 14 (Source: P.A. 88-313; 89-90, eff. 6-30-95.) 15 Section 15. The Limited Health Service Organization Act 16 is amended by changing Section 3009 as follows: 17 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9) 18 Sec. 3009. Point-of-service limited health service 19 contracts. 20 (a) An LHSO that offers a POS contract: 21 (1) shall include as in-plan covered services all 22 services required by law to be provided by an LHSO; 23 (2) shall provide incentives, which shall include 24 financial incentives, for enrollees to use in-plan 25 covered services; 26 (3) shall not offer services out-of-plan without 27 providing those services on an in-plan basis; 28 (4) may limit or exclude specific types of services 29 from coverage when obtained out-of-plan; 30 (5) may include annual out-of-pocket limits and 31 lifetime maximum benefits allowances for out-of-plan 32 services that are separate from any limits or allowances HB0579 Engrossed -6- LRB9000565JSgc 1 applied to in-plan services; 2 (6) shall include an annual maximum benefit 3 allowance not to exceed $2,500 per year that is separate 4 from any limits or allowances applied to in-plan 5 services; 6 (7) may limit the groups to which a POS product is 7 offered, however, if a POS product is offered to a group, 8 then it must be offered to all eligible members of that 9 group, when an LHSO provider is available; 10 (8) shall not consider emergency services, 11 authorized referral services, or non-routine services 12 obtained out of the service area to be POS services; and 13 (9) may treat as out-of-plan services those 14 services that an enrollee obtains from a participating 15 provider, but for which the proper authorization was not 16 given by the LHSO. 17 (b) An LHSO offering a POS contract shall be subject to 18 the following limitations: 19 (1) The LHSO shall not expend in any calendar 20 quarter more than 20% of its total limited health 21 services expenditures for all its members for out-of-plan 22 covered services. 23 (2) If the amount specified in paragraph (1) is 24 exceeded by 2% in a quarter, the LHSO shall effect 25 compliance with paragraph (1) by the end of the following 26 quarter. 27 (3) If compliance with the amount specified in 28 paragraph (1) is not demonstrated in the LHSO's next 29 quarterly report, the LHSO may not offer the POS contract 30 to new groups or include the POS option in the renewal of 31 an existing group until compliance with the amount 32 specified in paragraph (1) is demonstrated or otherwise 33 allowed by the Director. 34 (4) Any LHSO failing, without just cause, to comply HB0579 Engrossed -7- LRB9000565JSgc 1 with the provisions of this subsection shall be required, 2 after notice and hearing, to pay a penalty of $250 for 3 each day out of compliance, to be recovered by the 4 Director of Insurance. Any penalty recovered shall be 5 paid into the General Revenue Fund. The Director may 6 reduce the penalty if the LHSO demonstrates to the 7 Director that the imposition of the penalty would 8 constitute a financial hardship to the LHSO. 9 (c) Any LHSO that offers a POS product shall: 10 (1) File a quarterly financial statement detailing 11 compliance with the requirements of subsection (b). 12 (2) Track out-of-plan POS utilization separately 13 from in-plan or non-POS out-of-plan emergency care, 14 referral care, and urgent care out of the service area 15 utilization. 16 (3) Record out-of-plan utilization in a manner that 17 will permit such utilization and cost reporting as the 18 Director may, by regulation, require. 19 (4) Demonstrate to the Director's satisfaction that 20 the LHSO has the fiscal, administrative, and marketing 21 capacity to control its POS enrollment, utilization, and 22 costs so as not to jeopardize the financial security of 23 the LHSO. 24 (5) Maintain the deposit required by subsection (b) 25 of Section 2006 in addition to any other deposit required 26 under this Act. 27 (d) An LHSO shall not issue a POS contract until it has 28 filed and had approved by the Director a plan to comply with 29 the provisions of this Section. The compliance plan shall at 30 a minimum include provisions demonstrating that the LHSO will 31 do all of the following: 32 (1) Design the benefit levels and conditions of 33 coverage for in-plan covered services and out-of-plan 34 covered services as required by this Article. HB0579 Engrossed -8- LRB9000565JSgc 1 (2) Provide or arrange for the provision of 2 adequate systems to: 3 (A) process and pay claims for all out-of-plan 4 covered services; 5 (B) meet the requirements for a POS contract 6 set forth in this Section and any additional 7 requirements that may be set forth by the Director; 8 and 9 (C) generate accurate data and financial and 10 regulatory reports on a timely basis so that the 11 Department can evaluate the LHSO's experience with 12 the POS contract and monitor compliance with POS 13 contract provisions. 14 (3) Comply initially and on an ongoing basis with 15 the requirements of subsections (b) and (c). 16 (e) A POS contract must comply with the requirements of 17 Section 356t of the Illinois Insurance Code. 18 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.) 19 Section 20. The Voluntary Health Services Plans Act is 20 amended by changing Section 10 as follows: 21 (215 ILCS 165/10) (from Ch. 32, par. 604) 22 Sec. 10. Application of Insurance Code provisions. 23 Health services plan corporations and all persons interested 24 therein or dealing therewith shall be subject to the 25 provisions of Article XII 1/2 and Sections 3.1, 133, 140, 26 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1, 27 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and 28 (15) of Section 367 of the Illinois Insurance Code. 29 (Source: P.A. 89-514, eff. 7-17-96.) 30 Section 99. Effective date. This Act takes effect 31 January 1, 1998.
[ Top ]