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Public Act 095-1049 |
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AN ACT regarding disabled persons.
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Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly:
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Section 5. The State Employees Group Insurance Act of 1971 | ||||
is amended by changing Section 6.11 as follows:
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(5 ILCS 375/6.11)
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Sec. 6.11. Required health benefits; Illinois Insurance | ||||
Code
requirements. The program of health
benefits shall provide | ||||
the post-mastectomy care benefits required to be covered
by a | ||||
policy of accident and health insurance under Section 356t of | ||||
the Illinois
Insurance Code. The program of health benefits | ||||
shall provide the coverage
required under Sections 356g.5,
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356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, and 356z.10 , | ||||
and 356z.14
of the
Illinois Insurance Code.
The program of | ||||
health benefits must comply with Section 155.37 of the
Illinois | ||||
Insurance Code.
| ||||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
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Section 10. The Counties Code is amended by changing | ||||
Section 5-1069.3 as follows: | ||||
(55 ILCS 5/5-1069.3)
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Sec. 5-1069.3. Required health benefits. If a county, | ||
including a home
rule
county, is a self-insurer for purposes of | ||
providing health insurance coverage
for its employees, the | ||
coverage shall include coverage for the post-mastectomy
care | ||
benefits required to be covered by a policy of accident and | ||
health
insurance under Section 356t and the coverage required | ||
under Sections 356g.5, 356u,
356w, 356x, 356z.6, 356z.9, and | ||
356z.10 , and 356z.14
of
the Illinois Insurance Code. The | ||
requirement that health benefits be covered
as provided in this | ||
Section is an
exclusive power and function of the State and is | ||
a denial and limitation under
Article VII, Section 6, | ||
subsection (h) of the Illinois Constitution. A home
rule county | ||
to which this Section applies must comply with every provision | ||
of
this Section.
| ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
| ||
Section 15. The Illinois Municipal Code is amended by | ||
changing Section 10-4-2.3 as follows: | ||
(65 ILCS 5/10-4-2.3)
| ||
Sec. 10-4-2.3. Required health benefits. If a | ||
municipality, including a
home rule municipality, is a | ||
self-insurer for purposes of providing health
insurance | ||
coverage for its employees, the coverage shall include coverage | ||
for
the post-mastectomy care benefits required to be covered by |
a policy of
accident and health insurance under Section 356t | ||
and the coverage required
under Sections 356g.5, 356u, 356w, | ||
356x, 356z.6, 356z.9, and 356z.10 , and 356z.14
of the Illinois
| ||
Insurance
Code. The requirement that health
benefits be covered | ||
as provided in this is an exclusive power and function of
the | ||
State and is a denial and limitation under Article VII, Section | ||
6,
subsection (h) of the Illinois Constitution. A home rule | ||
municipality to which
this Section applies must comply with | ||
every provision of this Section.
| ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
| ||
Section 20. The School Code is amended by changing Section | ||
10-22.3f as follows: | ||
(105 ILCS 5/10-22.3f)
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Sec. 10-22.3f. Required health benefits. Insurance | ||
protection and
benefits
for employees shall provide the | ||
post-mastectomy care benefits required to be
covered by a | ||
policy of accident and health insurance under Section 356t and | ||
the
coverage required under Sections 356g.5, 356u, 356w, 356x,
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356z.6, and 356z.9 , and 356z.14 of
the
Illinois Insurance Code.
| ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-876, eff. 8-21-08.)
| ||
Section 25. The Illinois Insurance Code is amended by |
changing Section 370c and adding Section 356z.14 as follows: | ||
(215 ILCS 5/356z.14 new) | ||
Sec. 356z.14. Habilitative services for children. | ||
(a) As used in this Section, "habilitative services" means | ||
occupational therapy, physical therapy, speech therapy, and | ||
other services prescribed by the insured's treating physician | ||
pursuant to a treatment plan to enhance the ability of a child | ||
to function with a congenital, genetic, or early acquired | ||
disorder. A congenital or genetic disorder includes, but is not | ||
limited to, hereditary disorders. An early acquired disorder | ||
refers to a disorder resulting from illness, trauma, injury, or | ||
some other event or condition suffered by a child prior to that | ||
child developing functional life skills such as, but not | ||
limited to, walking, talking, or self-help skills. Congenital, | ||
genetic, and early acquired disorders may include, but are not | ||
limited to, autism or an autism spectrum disorder, cerebral | ||
palsy, and other disorders resulting from early childhood | ||
illness, trauma, or injury. | ||
(b) A group or individual policy of accident and health | ||
insurance or managed care plan amended, delivered, issued, or | ||
renewed after the effective date of this amendatory Act of the | ||
95th General Assembly must provide coverage for habilitative | ||
services for children under 19 years of age with a congenital, | ||
genetic, or early acquired disorder so long as all of the | ||
following conditions are met: |
(1) A physician licensed to practice medicine in all | ||
its branches has diagnosed the child's congenital, | ||
genetic, or early acquired disorder. | ||
(2) The treatment is administered by a licensed | ||
speech-language pathologist, licensed audiologist, | ||
licensed occupational therapist, licensed physical | ||
therapist, licensed physician, licensed nurse, licensed | ||
optometrist, licensed nutritionist, licensed social | ||
worker, or licensed psychologist upon the referral of a | ||
physician licensed to practice medicine in all its | ||
branches. | ||
(3) The initial or continued treatment must be | ||
medically necessary and therapeutic and not experimental | ||
or investigational. | ||
(c) The coverage required by this Section shall be subject | ||
to other general exclusions and limitations of the policy, | ||
including coordination of benefits, participating provider | ||
requirements, restrictions on services provided by family or | ||
household members, utilization review of health care services, | ||
including review of medical necessity, case management, | ||
experimental, and investigational treatments, and other | ||
managed care provisions. | ||
(d) Coverage under this Section does not apply to those | ||
services that are solely educational in nature or otherwise | ||
paid under State or federal law for purely educational | ||
services. Nothing in this subsection (d) relieves an insurer or |
similar third party from an otherwise valid obligation to | ||
provide or to pay for services provided to a child with a | ||
disability. | ||
(e) Coverage under this Section for children under age 19 | ||
shall not apply to treatment of mental or emotional disorders | ||
or illnesses as covered under Section 370 of this Code as well | ||
as any other benefit based upon a specific diagnosis that may | ||
be otherwise required by law. | ||
(f) The provisions of this Section do not apply to | ||
short-term travel, accident-only, limited, or specific disease | ||
policies. | ||
(g) Any denial of care for habilitative services shall be | ||
subject to appeal and external independent review procedures as | ||
provided by Section 45 of the Managed Care Reform and Patient | ||
Rights Act. | ||
(h) Upon request of the reimbursing insurer, the provider | ||
under whose supervision the habilitative services are being | ||
provided shall furnish medical records, clinical notes, or | ||
other necessary data to allow the insurer to substantiate that | ||
initial or continued medical treatment is medically necessary | ||
and that the patient's condition is clinically improving. When | ||
the treating provider anticipates that continued treatment is | ||
or will be required to permit the patient to achieve | ||
demonstrable progress, the insurer may request that the | ||
provider furnish a treatment plan consisting of diagnosis, | ||
proposed treatment by type, frequency, anticipated duration of |
treatment, the anticipated goals of treatment, and how | ||
frequently the treatment plan will be updated. | ||
(i) Rulemaking authority to implement this amendatory Act | ||
of the 95th General Assembly, if any, is conditioned on the | ||
rules being adopted in accordance with all provisions of the | ||
Illinois Administrative Procedure Act and all rules and | ||
procedures of the Joint Committee on Administrative Rules; any | ||
purported rule not so adopted, for whatever reason, is | ||
unauthorized.
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(215 ILCS 5/370c) (from Ch. 73, par. 982c)
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Sec. 370c. Mental and emotional disorders.
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(a) (1) On and after the effective date of this Section,
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every insurer which delivers, issues for delivery or renews or | ||
modifies
group A&H policies providing coverage for hospital or | ||
medical treatment or
services for illness on an | ||
expense-incurred basis shall offer to the
applicant or group | ||
policyholder subject to the insurers standards of
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insurability, coverage for reasonable and necessary treatment | ||
and services
for mental, emotional or nervous disorders or | ||
conditions, other than serious
mental illnesses as defined in | ||
item (2) of subsection (b), up to the limits
provided in the | ||
policy for other disorders or conditions, except (i) the
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insured may be required to pay up to 50% of expenses incurred | ||
as a result
of the treatment or services, and (ii) the annual | ||
benefit limit may be
limited to the lesser of $10,000 or 25% of |
the lifetime policy limit.
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(2) Each insured that is covered for mental, emotional or | ||
nervous
disorders or conditions shall be free to select the | ||
physician licensed to
practice medicine in all its branches, | ||
licensed clinical psychologist,
licensed clinical social | ||
worker, or licensed clinical professional counselor of
his | ||
choice to treat such disorders, and
the insurer shall pay the | ||
covered charges of such physician licensed to
practice medicine | ||
in all its branches, licensed clinical psychologist,
licensed | ||
clinical social worker, or licensed clinical professional | ||
counselor up
to the limits of coverage, provided (i)
the | ||
disorder or condition treated is covered by the policy, and | ||
(ii) the
physician, licensed psychologist, licensed clinical | ||
social worker, or licensed
clinical professional counselor is
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authorized to provide said services under the statutes of this | ||
State and in
accordance with accepted principles of his | ||
profession.
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(3) Insofar as this Section applies solely to licensed | ||
clinical social
workers and licensed clinical professional | ||
counselors, those persons who may
provide services to | ||
individuals shall do so
after the licensed clinical social | ||
worker or licensed clinical professional
counselor has | ||
informed the patient of the
desirability of the patient | ||
conferring with the patient's primary care
physician and the | ||
licensed clinical social worker or licensed clinical
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professional counselor has
provided written
notification to |
the patient's primary care physician, if any, that services
are | ||
being provided to the patient. That notification may, however, | ||
be
waived by the patient on a written form. Those forms shall | ||
be retained by
the licensed clinical social worker or licensed | ||
clinical professional counselor
for a period of not less than 5 | ||
years.
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(b) (1) An insurer that provides coverage for hospital or | ||
medical
expenses under a group policy of accident and health | ||
insurance or
health care plan amended, delivered, issued, or | ||
renewed after the effective
date of this amendatory Act of the | ||
92nd General Assembly shall provide coverage
under the policy | ||
for treatment of serious mental illness under the same terms
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and conditions as coverage for hospital or medical expenses | ||
related to other
illnesses and diseases. The coverage required | ||
under this Section must provide
for same durational limits, | ||
amount limits, deductibles, and co-insurance
requirements for | ||
serious mental illness as are provided for other illnesses
and | ||
diseases. This subsection does not apply to coverage provided | ||
to
employees by employers who have 50 or fewer employees.
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(2) "Serious mental illness" means the following | ||
psychiatric illnesses as
defined in the most current edition of | ||
the Diagnostic and Statistical Manual
(DSM) published by the | ||
American Psychiatric Association:
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(A) schizophrenia;
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(B) paranoid and other psychotic disorders;
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(C) bipolar disorders (hypomanic, manic, depressive, |
and mixed);
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(D) major depressive disorders (single episode or | ||
recurrent);
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(E) schizoaffective disorders (bipolar or depressive);
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(F) pervasive developmental disorders;
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(G) obsessive-compulsive disorders;
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(H) depression in childhood and adolescence;
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(I) panic disorder; and | ||
(J) post-traumatic stress disorders (acute, chronic, | ||
or with delayed onset).
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(3) Upon request of the reimbursing insurer, a provider of | ||
treatment of
serious mental illness shall furnish medical | ||
records or other necessary data
that substantiate that initial | ||
or continued treatment is at all times medically
necessary. An | ||
insurer shall provide a mechanism for the timely review by a
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provider holding the same license and practicing in the same | ||
specialty as the
patient's provider, who is unaffiliated with | ||
the insurer, jointly selected by
the patient (or the patient's | ||
next of kin or legal representative if the
patient is unable to | ||
act for himself or herself), the patient's provider, and
the | ||
insurer in the event of a dispute between the insurer and | ||
patient's
provider regarding the medical necessity of a | ||
treatment proposed by a patient's
provider. If the reviewing | ||
provider determines the treatment to be medically
necessary, | ||
the insurer shall provide reimbursement for the treatment. | ||
Future
contractual or employment actions by the insurer |
regarding the patient's
provider may not be based on the | ||
provider's participation in this procedure.
Nothing prevents
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the insured from agreeing in writing to continue treatment at | ||
his or her
expense. When making a determination of the medical | ||
necessity for a treatment
modality for serous mental illness, | ||
an insurer must make the determination in a
manner that is | ||
consistent with the manner used to make that determination with
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respect to other diseases or illnesses covered under the | ||
policy, including an
appeals process.
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(4) A group health benefit plan:
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(A) shall provide coverage based upon medical | ||
necessity for the following
treatment of mental illness in | ||
each calendar year:
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(i) 45 days of inpatient treatment; and
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(ii) beginning on June 26, 2006 (the effective date | ||
of Public Act 94-921), 60 visits for outpatient | ||
treatment including group and individual
outpatient | ||
treatment; and | ||
(iii) for plans or policies delivered, issued for | ||
delivery, renewed, or modified after January 1, 2007 | ||
(the effective date of Public Act 94-906),
20 | ||
additional outpatient visits for speech therapy for | ||
treatment of pervasive developmental disorders that | ||
will be in addition to speech therapy provided pursuant | ||
to item (ii) of this subparagraph (A);
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(B) may not include a lifetime limit on the number of |
days of inpatient
treatment or the number of outpatient | ||
visits covered under the plan; and
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(C) shall include the same amount limits, deductibles, | ||
copayments, and
coinsurance factors for serious mental | ||
illness as for physical illness.
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(5) An issuer of a group health benefit plan may not count | ||
toward the number
of outpatient visits required to be covered | ||
under this Section an outpatient
visit for the purpose of | ||
medication management and shall cover the outpatient
visits | ||
under the same terms and conditions as it covers outpatient | ||
visits for
the treatment of physical illness.
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(6) An issuer of a group health benefit
plan may provide or | ||
offer coverage required under this Section through a
managed | ||
care plan.
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(7) This Section shall not be interpreted to require a | ||
group health benefit
plan to provide coverage for treatment of:
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(A) an addiction to a controlled substance or cannabis | ||
that is used in
violation of law; or
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(B) mental illness resulting from the use of a | ||
controlled substance or
cannabis in violation of law.
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(8)
(Blank).
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(c) This Section shall not be interpreted to require | ||
coverage for speech therapy or other habilitative services for | ||
those individuals covered under Section 356z.14 of this Code. | ||
(Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | ||
94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. |
8-21-07.)
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Section 30. The Health Maintenance Organization Act is | ||
amended by changing Section 5-3 as follows:
| ||
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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Sec. 5-3. Insurance Code provisions.
| ||
(a) Health Maintenance Organizations
shall be subject to | ||
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||
356z.14, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | ||
368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | ||
444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | ||
and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | ||
and XXVI of the Illinois Insurance Code.
| ||
(b) For purposes of the Illinois Insurance Code, except for | ||
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||
Maintenance Organizations in
the following categories are | ||
deemed to be "domestic companies":
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(1) a corporation authorized under the
Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act;
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(2) a corporation organized under the laws of this | ||
State; or
| ||
(3) a corporation organized under the laws of another |
state, 30% or more
of the enrollees of which are residents | ||
of this State, except a
corporation subject to | ||
substantially the same requirements in its state of
| ||
organization as is a "domestic company" under Article VIII | ||
1/2 of the
Illinois Insurance Code.
| ||
(c) In considering the merger, consolidation, or other | ||
acquisition of
control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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(1) the Director shall give primary consideration to | ||
the continuation of
benefits to enrollees and the financial | ||
conditions of the acquired Health
Maintenance Organization | ||
after the merger, consolidation, or other
acquisition of | ||
control takes effect;
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(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of
the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making
his determination | ||
with respect to the merger, consolidation, or other
| ||
acquisition of control, need not take into account the | ||
effect on
competition of the merger, consolidation, or | ||
other acquisition of control;
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(3) the Director shall have the power to require the | ||
following
information:
| ||
(A) certification by an independent actuary of the | ||
adequacy
of the reserves of the Health Maintenance | ||
Organization sought to be acquired;
| ||
(B) pro forma financial statements reflecting the |
combined balance
sheets of the acquiring company and | ||
the Health Maintenance Organization sought
to be | ||
acquired as of the end of the preceding year and as of | ||
a date 90 days
prior to the acquisition, as well as pro | ||
forma financial statements
reflecting projected | ||
combined operation for a period of 2 years;
| ||
(C) a pro forma business plan detailing an | ||
acquiring party's plans with
respect to the operation | ||
of the Health Maintenance Organization sought to
be | ||
acquired for a period of not less than 3 years; and
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(D) such other information as the Director shall | ||
require.
| ||
(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code
and this Section 5-3 shall apply to the sale by | ||
any health maintenance
organization of greater than 10% of its
| ||
enrollee population (including without limitation the health | ||
maintenance
organization's right, title, and interest in and to | ||
its health care
certificates).
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(e) In considering any management contract or service | ||
agreement subject
to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in
addition to the criteria | ||
specified in Section 141.2 of the Illinois
Insurance Code, take | ||
into account the effect of the management contract or
service | ||
agreement on the continuation of benefits to enrollees and the
| ||
financial condition of the health maintenance organization to | ||
be managed or
serviced, and (ii) need not take into account the |
effect of the management
contract or service agreement on | ||
competition.
| ||
(f) Except for small employer groups as defined in the | ||
Small Employer
Rating, Renewability and Portability Health | ||
Insurance Act and except for
medicare supplement policies as | ||
defined in Section 363 of the Illinois
Insurance Code, a Health | ||
Maintenance Organization may by contract agree with a
group or | ||
other enrollment unit to effect refunds or charge additional | ||
premiums
under the following terms and conditions:
| ||
(i) the amount of, and other terms and conditions with | ||
respect to, the
refund or additional premium are set forth | ||
in the group or enrollment unit
contract agreed in advance | ||
of the period for which a refund is to be paid or
| ||
additional premium is to be charged (which period shall not | ||
be less than one
year); and
| ||
(ii) the amount of the refund or additional premium | ||
shall not exceed 20%
of the Health Maintenance | ||
Organization's profitable or unprofitable experience
with | ||
respect to the group or other enrollment unit for the | ||
period (and, for
purposes of a refund or additional | ||
premium, the profitable or unprofitable
experience shall | ||
be calculated taking into account a pro rata share of the
| ||
Health Maintenance Organization's administrative and | ||
marketing expenses, but
shall not include any refund to be | ||
made or additional premium to be paid
pursuant to this | ||
subsection (f)). The Health Maintenance Organization and |
the
group or enrollment unit may agree that the profitable | ||
or unprofitable
experience may be calculated taking into | ||
account the refund period and the
immediately preceding 2 | ||
plan years.
| ||
The Health Maintenance Organization shall include a | ||
statement in the
evidence of coverage issued to each enrollee | ||
describing the possibility of a
refund or additional premium, | ||
and upon request of any group or enrollment unit,
provide to | ||
the group or enrollment unit a description of the method used | ||
to
calculate (1) the Health Maintenance Organization's | ||
profitable experience with
respect to the group or enrollment | ||
unit and the resulting refund to the group
or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable
| ||
experience with respect to the group or enrollment unit and the | ||
resulting
additional premium to be paid by the group or | ||
enrollment unit.
| ||
In no event shall the Illinois Health Maintenance | ||
Organization
Guaranty Association be liable to pay any | ||
contractual obligation of an
insolvent organization to pay any | ||
refund authorized under this Section.
| ||
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||
8-21-08.)
| ||
Section 35. The Voluntary Health Services Plans Act is | ||
amended by changing Section 10 as follows:
|
(215 ILCS 165/10) (from Ch. 32, par. 604)
| ||
Sec. 10. Application of Insurance Code provisions. Health | ||
services
plan corporations and all persons interested therein | ||
or dealing therewith
shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | ||
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||
356z.9,
356z.10, 356z.14, 364.01, 367.2, 368a, 401, 401.1,
402,
| ||
403, 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | ||
Section 367 of the Illinois
Insurance Code.
| ||
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||
8-28-07; 95-876, eff. 8-21-08.)
| ||
Section 90. The State Mandates Act is amended by adding | ||
Section 8.32 as follows: | ||
(30 ILCS 805/8.32 new) | ||
Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8 | ||
of this Act, no reimbursement by the State is required for the | ||
implementation of any mandate created by this amendatory Act of | ||
the 95th General Assembly. |