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91_HB0140
LRB9100795JSpc
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 356y as follows:
7 (215 ILCS 5/356y new)
8 Sec. 356y. Treatment of certain metabolic diseases.
9 (a) An individual or group policy of accident and health
10 insurance that is issued, delivered, amended, or renewed in
11 this State on or after January 1, 2000 shall include the
12 following:
13 (1) Coverage for prescription enteral and oral
14 formulas for home use, for which a physician has issued a
15 written order and which are medically necessary for the
16 treatment or management of inherited diseases involving
17 amino acids or organic acids (including, but not limited
18 to, phenylketonuria).
19 (2) Coverage for up to $2,500 per year worth of
20 food products modified to be low in protein, for which a
21 physician has issued a written order and which are
22 medically necessary for the management of phenylketonuria
23 or other inherited diseases involving amino acids or
24 other organic acids.
25 (b) The coverage required under subsection (a) shall
26 also be provided by health maintenance organizations, limited
27 health service organizations, and voluntary health services
28 plans.
29 Section 10. The Health Maintenance Organization Act is
30 amended by changing Section 5-3 as follows:
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1 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
2 Sec. 5-3. Insurance Code provisions.
3 (a) Health Maintenance Organizations shall be subject to
4 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
5 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
6 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356t, 356w, 356x,
7 356y, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
8 444, and 444.1, paragraph (c) of subsection (2) of Section
9 367, and Articles VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
10 XXV, and XXVI of the Illinois Insurance Code.
11 (b) For purposes of the Illinois Insurance Code, except
12 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
13 Health Maintenance Organizations in the following categories
14 are deemed to be "domestic companies":
15 (1) a corporation authorized under the Dental
16 Service Plan Act or the Voluntary Health Services Plans
17 Act;
18 (2) a corporation organized under the laws of this
19 State; or
20 (3) a corporation organized under the laws of
21 another state, 30% or more of the enrollees of which are
22 residents of this State, except a corporation subject to
23 substantially the same requirements in its state of
24 organization as is a "domestic company" under Article
25 VIII 1/2 of the Illinois Insurance Code.
26 (c) In considering the merger, consolidation, or other
27 acquisition of control of a Health Maintenance Organization
28 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
29 (1) the Director shall give primary consideration
30 to the continuation of benefits to enrollees and the
31 financial conditions of the acquired Health Maintenance
32 Organization after the merger, consolidation, or other
33 acquisition of control takes effect;
34 (2)(i) the criteria specified in subsection (1)(b)
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1 of Section 131.8 of the Illinois Insurance Code shall not
2 apply and (ii) the Director, in making his determination
3 with respect to the merger, consolidation, or other
4 acquisition of control, need not take into account the
5 effect on competition of the merger, consolidation, or
6 other acquisition of control;
7 (3) the Director shall have the power to require
8 the following information:
9 (A) certification by an independent actuary of
10 the adequacy of the reserves of the Health
11 Maintenance Organization sought to be acquired;
12 (B) pro forma financial statements reflecting
13 the combined balance sheets of the acquiring company
14 and the Health Maintenance Organization sought to be
15 acquired as of the end of the preceding year and as
16 of a date 90 days prior to the acquisition, as well
17 as pro forma financial statements reflecting
18 projected combined operation for a period of 2
19 years;
20 (C) a pro forma business plan detailing an
21 acquiring party's plans with respect to the
22 operation of the Health Maintenance Organization
23 sought to be acquired for a period of not less than
24 3 years; and
25 (D) such other information as the Director
26 shall require.
27 (d) The provisions of Article VIII 1/2 of the Illinois
28 Insurance Code and this Section 5-3 shall apply to the sale
29 by any health maintenance organization of greater than 10% of
30 its enrollee population (including without limitation the
31 health maintenance organization's right, title, and interest
32 in and to its health care certificates).
33 (e) In considering any management contract or service
34 agreement subject to Section 141.1 of the Illinois Insurance
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1 Code, the Director (i) shall, in addition to the criteria
2 specified in Section 141.2 of the Illinois Insurance Code,
3 take into account the effect of the management contract or
4 service agreement on the continuation of benefits to
5 enrollees and the financial condition of the health
6 maintenance organization to be managed or serviced, and (ii)
7 need not take into account the effect of the management
8 contract or service agreement on competition.
9 (f) Except for small employer groups as defined in the
10 Small Employer Rating, Renewability and Portability Health
11 Insurance Act and except for medicare supplement policies as
12 defined in Section 363 of the Illinois Insurance Code, a
13 Health Maintenance Organization may by contract agree with a
14 group or other enrollment unit to effect refunds or charge
15 additional premiums under the following terms and conditions:
16 (i) the amount of, and other terms and conditions
17 with respect to, the refund or additional premium are set
18 forth in the group or enrollment unit contract agreed in
19 advance of the period for which a refund is to be paid or
20 additional premium is to be charged (which period shall
21 not be less than one year); and
22 (ii) the amount of the refund or additional premium
23 shall not exceed 20% of the Health Maintenance
24 Organization's profitable or unprofitable experience with
25 respect to the group or other enrollment unit for the
26 period (and, for purposes of a refund or additional
27 premium, the profitable or unprofitable experience shall
28 be calculated taking into account a pro rata share of the
29 Health Maintenance Organization's administrative and
30 marketing expenses, but shall not include any refund to
31 be made or additional premium to be paid pursuant to this
32 subsection (f)). The Health Maintenance Organization and
33 the group or enrollment unit may agree that the
34 profitable or unprofitable experience may be calculated
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1 taking into account the refund period and the immediately
2 preceding 2 plan years.
3 The Health Maintenance Organization shall include a
4 statement in the evidence of coverage issued to each enrollee
5 describing the possibility of a refund or additional premium,
6 and upon request of any group or enrollment unit, provide to
7 the group or enrollment unit a description of the method used
8 to calculate (1) the Health Maintenance Organization's
9 profitable experience with respect to the group or enrollment
10 unit and the resulting refund to the group or enrollment unit
11 or (2) the Health Maintenance Organization's unprofitable
12 experience with respect to the group or enrollment unit and
13 the resulting additional premium to be paid by the group or
14 enrollment unit.
15 In no event shall the Illinois Health Maintenance
16 Organization Guaranty Association be liable to pay any
17 contractual obligation of an insolvent organization to pay
18 any refund authorized under this Section.
19 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
20 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; 90-583, eff.
21 5-29-98; 90-655, eff. 7-30-98; 90-741, eff. 1-1-99; revised
22 9-8-98.)
23 Section 15. The Voluntary Health Services Plans Act is
24 amended by changing Section 10 as follows:
25 (215 ILCS 165/10) (from Ch. 32, par. 604)
26 Sec. 10. Application of Insurance Code provisions.
27 Health services plan corporations and all persons interested
28 therein or dealing therewith shall be subject to the
29 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
30 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
31 356x, 356y, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2,
32 and 412, and paragraphs (7) and (15) of Section 367 of the
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1 Illinois Insurance Code.
2 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
3 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 90-741, eff.
4 1-1-99.)
5 Section 99. Effective date. This Act takes effect upon
6 becoming law.