State of Illinois
92nd General Assembly
Legislation

   [ Search ]   [ PDF text ]   [ Legislation ]   
[ Home ]   [ Back ]   [ Bottom ]


[ Introduced ][ Engrossed ][ Senate Amendment 001 ]
[ Senate Amendment 002 ][ Senate Amendment 004 ]


92_HB1889enr

 
HB1889 Enrolled                               LRB9200925JSpcB

 1        AN ACT concerning insurance coverage.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 5.  The State Employees Group  Insurance  Act  of
 5    1971 is amended by changing Section 6.11 as follows:

 6        (5 ILCS 375/6.11)
 7        Sec.  6.11.  Required health benefits; Illinois Insurance
 8    Code requirements.  The  program  of  health  benefits  shall
 9    provide  the  post-mastectomy  care  benefits  required to be
10    covered by a policy of accident and  health  insurance  under
11    Section  356t of the Illinois Insurance Code.  The program of
12    health benefits shall provide  the  coverage  required  under
13    Sections  356u,  356w,  and  356x, and 356z.2 of the Illinois
14    Insurance Code. The program of health  benefits  must  comply
15    with Section 155.37 of the Illinois Insurance Code.
16    (Source: P.A. 92-440, eff. 8-17-01.)

17        Section  10.  The  Illinois  Insurance Code is amended by
18    adding Section 356z.2 as follows:

19        (215 ILCS 5/356z.2 new)
20        Sec. 356z.2.  Coverage for adjunctive services in  dental
21    care.
22        (a)  An individual or group policy of accident and health
23    insurance  amended,  delivered,  issued, or renewed after the
24    effective date of this amendatory Act  of  the  92nd  General
25    Assembly   shall  cover  charges  incurred,  and  anesthetics
26    provided, in conjunction with dental care that is provided to
27    a covered individual in a hospital or an ambulatory  surgical
28    treatment center if any of the following applies:
29             (1)  the individual is a child age 6 or under;
 
HB1889 Enrolled            -2-                LRB9200925JSpcB
 1             (2)  the  individual  has  a  medical condition that
 2        requires hospitalization or general anesthesia for dental
 3        care; or
 4             (3)  the individual is disabled.
 5        (b)  For purposes of this Section,  "ambulatory  surgical
 6    treatment  center"  has  the  meaning  given  to that term in
 7    Section 3 of the Ambulatory Surgical Treatment Center Act.
 8        For purposes of this Section, "disabled" means a  person,
 9    regardless  of  age, with a chronic disability if the chronic
10    disability meets all of the following conditions:
11             (1)  It is attributable  to  a  mental  or  physical
12        impairment   or    combination  of  mental  and  physical
13        impairments.
14             (2)  It is likely to continue.
15             (3) It results in substantial functional limitations
16        in one or more of  the  following  areas  of  major  life
17        activity:
18                  (A)  self-care;
19                  (B)  receptive and expressive language;
20                  (C)  learning;
21                  (D)  mobility;
22                  (E)  capacity for independent living; or
23                  (F)  economic self-sufficiency.
24        (c)  The  coverage  required  under  this  Section may be
25    subject  to  any  limitations,  exclusions,  or  cost-sharing
26    provisions that apply generally under the insurance policy.
27        (d)  This Section does not apply to a policy that  covers
28    only dental care.
29        (e)  Nothing  in  this  Section  requires that the dental
30    services be covered.
31        (f)  The provisions of  this  Section  do  not  apply  to
32    short-term   travel,  accident-only,  limited,  or  specified
33    disease policies, nor to policies or contracts  designed  for
34    issuance  to  persons eligible for coverage under Title XVIII
 
HB1889 Enrolled            -3-                LRB9200925JSpcB
 1    of the Social Security Act, known as Medicare, or  any  other
 2    similar coverage under State or federal governmental plans.

 3        Section  15.  The  Health Maintenance Organization Act is
 4    amended by changing Section 5-3 as follows:

 5        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
 6        Sec. 5-3.  Insurance Code provisions.
 7        (a)  Health Maintenance Organizations shall be subject to
 8    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
 9    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
10    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
11    356y,  356z.2,  367i,  368a, 401, 401.1, 402, 403, 403A, 408,
12    408.2, 409, 412, 444, and 444.1, paragraph (c) of  subsection
13    (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
14    XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
15        (b)  For  purposes of the Illinois Insurance Code, except
16    for Sections 444 and 444.1 and Articles XIII  and  XIII  1/2,
17    Health  Maintenance Organizations in the following categories
18    are deemed to be "domestic companies":
19             (1)  a  corporation  authorized  under  the   Dental
20        Service  Plan  Act or the Voluntary Health Services Plans
21        Act;
22             (2)  a corporation organized under the laws of  this
23        State; or
24             (3)  a  corporation  organized  under  the  laws  of
25        another  state, 30% or more of the enrollees of which are
26        residents of this State, except a corporation subject  to
27        substantially  the  same  requirements  in  its  state of
28        organization as is a  "domestic  company"  under  Article
29        VIII 1/2 of the Illinois Insurance Code.
30        (c)  In  considering  the merger, consolidation, or other
31    acquisition of control of a Health  Maintenance  Organization
32    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
 
HB1889 Enrolled            -4-                LRB9200925JSpcB
 1             (1)  the  Director  shall give primary consideration
 2        to the continuation of  benefits  to  enrollees  and  the
 3        financial  conditions  of the acquired Health Maintenance
 4        Organization after the merger,  consolidation,  or  other
 5        acquisition of control takes effect;
 6             (2)(i)  the  criteria specified in subsection (1)(b)
 7        of Section 131.8 of the Illinois Insurance Code shall not
 8        apply and (ii) the Director, in making his  determination
 9        with  respect  to  the  merger,  consolidation,  or other
10        acquisition of control, need not take  into  account  the
11        effect  on  competition  of the merger, consolidation, or
12        other acquisition of control;
13             (3)  the Director shall have the  power  to  require
14        the following information:
15                  (A)  certification by an independent actuary of
16             the   adequacy   of   the  reserves  of  the  Health
17             Maintenance Organization sought to be acquired;
18                  (B)  pro forma financial statements  reflecting
19             the combined balance sheets of the acquiring company
20             and the Health Maintenance Organization sought to be
21             acquired  as of the end of the preceding year and as
22             of a date 90 days prior to the acquisition, as  well
23             as   pro   forma   financial  statements  reflecting
24             projected combined  operation  for  a  period  of  2
25             years;
26                  (C)  a  pro  forma  business  plan detailing an
27             acquiring  party's  plans  with   respect   to   the
28             operation  of  the  Health  Maintenance Organization
29             sought to be acquired for a period of not less  than
30             3 years; and
31                  (D)  such  other  information  as  the Director
32             shall require.
33        (d)  The provisions of Article VIII 1/2 of  the  Illinois
34    Insurance  Code  and this Section 5-3 shall apply to the sale
 
HB1889 Enrolled            -5-                LRB9200925JSpcB
 1    by any health maintenance organization of greater than 10% of
 2    its enrollee population  (including  without  limitation  the
 3    health  maintenance organization's right, title, and interest
 4    in and to its health care certificates).
 5        (e)  In considering any management  contract  or  service
 6    agreement  subject to Section 141.1 of the Illinois Insurance
 7    Code, the Director (i) shall, in  addition  to  the  criteria
 8    specified  in  Section  141.2 of the Illinois Insurance Code,
 9    take into account the effect of the  management  contract  or
10    service   agreement   on  the  continuation  of  benefits  to
11    enrollees  and  the  financial  condition   of   the   health
12    maintenance  organization to be managed or serviced, and (ii)
13    need not take into  account  the  effect  of  the  management
14    contract or service agreement on competition.
15        (f)  Except  for  small employer groups as defined in the
16    Small Employer Rating, Renewability  and  Portability  Health
17    Insurance  Act and except for medicare supplement policies as
18    defined in Section 363 of  the  Illinois  Insurance  Code,  a
19    Health  Maintenance Organization may by contract agree with a
20    group or other enrollment unit to effect  refunds  or  charge
21    additional premiums under the following terms and conditions:
22             (i)  the  amount  of, and other terms and conditions
23        with respect to, the refund or additional premium are set
24        forth in the group or enrollment unit contract agreed  in
25        advance of the period for which a refund is to be paid or
26        additional  premium  is to be charged (which period shall
27        not be less than one year); and
28             (ii)  the amount of the refund or additional premium
29        shall  not  exceed  20%   of   the   Health   Maintenance
30        Organization's profitable or unprofitable experience with
31        respect  to  the  group  or other enrollment unit for the
32        period (and, for  purposes  of  a  refund  or  additional
33        premium,  the profitable or unprofitable experience shall
34        be calculated taking into account a pro rata share of the
 
HB1889 Enrolled            -6-                LRB9200925JSpcB
 1        Health  Maintenance  Organization's  administrative   and
 2        marketing  expenses,  but shall not include any refund to
 3        be made or additional premium to be paid pursuant to this
 4        subsection (f)).  The Health Maintenance Organization and
 5        the  group  or  enrollment  unit  may  agree   that   the
 6        profitable  or  unprofitable experience may be calculated
 7        taking into account the refund period and the immediately
 8        preceding 2 plan years.
 9        The  Health  Maintenance  Organization  shall  include  a
10    statement in the evidence of coverage issued to each enrollee
11    describing the possibility of a refund or additional premium,
12    and upon request of any group or enrollment unit, provide  to
13    the group or enrollment unit a description of the method used
14    to   calculate  (1)  the  Health  Maintenance  Organization's
15    profitable experience with respect to the group or enrollment
16    unit and the resulting refund to the group or enrollment unit
17    or (2) the  Health  Maintenance  Organization's  unprofitable
18    experience  with  respect to the group or enrollment unit and
19    the resulting additional premium to be paid by the  group  or
20    enrollment unit.
21        In   no  event  shall  the  Illinois  Health  Maintenance
22    Organization  Guaranty  Association  be  liable  to  pay  any
23    contractual obligation of an insolvent  organization  to  pay
24    any refund authorized under this Section.
25    (Source: P.A.  90-25,  eff.  1-1-98;  90-177,  eff.  7-23-97;
26    90-372,  eff.  7-1-98;  90-583,  eff.  5-29-98;  90-655, eff.
27    7-30-98; 90-741, eff. 1-1-99; 91-357, eff.  7-29-99;  91-406,
28    eff.  1-1-00;  91-549,  eff.  8-14-99; 91-605, eff. 12-14-99;
29    91-788, eff. 6-9-00.)

30        Section 20.  The Voluntary Health Services Plans  Act  is
31    amended by changing Section 10 as follows:

32        (215 ILCS 165/10) (from Ch. 32, par. 604)
 
HB1889 Enrolled            -7-                LRB9200925JSpcB
 1        Sec.   10.  Application  of  Insurance  Code  provisions.
 2    Health services plan corporations and all persons  interested
 3    therein   or  dealing  therewith  shall  be  subject  to  the
 4    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
 5    140, 143, 143c, 149, 155.37, 354, 355.2,  356r,  356t,  356u,
 6    356v,  356w,  356x,  356y,  356z.1, 356z.2, 367.2, 368a, 401,
 7    401.1, 402, 403, 403A, 408, 408.2, and  412,  and  paragraphs
 8    (7) and (15) of Section 367 of the Illinois Insurance Code.
 9    (Source: P.A.  91-406,  eff.  1-1-00;  91-549,  eff. 8-14-99;
10    91-605, eff. 12-14-99;  91-788,  eff.  6-9-00;  92-130,  eff.
11    7-20-01; 92-440, eff. 8-17-01; revised 9-12-01.)

[ Top ]