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Public Act 096-0639
Public Act 0639 96TH GENERAL ASSEMBLY
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Public Act 096-0639
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| SB1877 Enrolled |
LRB096 11290 RPM 21719 b |
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| AN ACT concerning insurance.
| Be it enacted by the People of the State of Illinois,
| represented in the General Assembly:
| Section 5. The State Employees Group Insurance Act of 1971 | is amended by changing Section 6.11 as follows:
| (5 ILCS 375/6.11)
| (Text of Section before amendment by P.A. 95-958) | 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,
| 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10, | 356z.13 356z.11, and 356z.14, and 356z.15
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; 95-978, eff. | 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
| (Text of Section after amendment by P.A. 95-958)
| 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,
| 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10, | 356z.11, and 356z.12, 356z.13
356z.11, and 356z.14, and 356z.15 | 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; 95-958, eff. | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | 12-15-08.)
| Section 10. The Illinois Insurance Code is amended by | adding Section 356z.15 as follows:
| (215 ILCS 5/356z.15 new)
| Sec. 356z.15. Wellness coverage. | (a) 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 | 96th General Assembly that provides coverage for hospital or | medical treatment on an expense incurred basis may offer a | reasonably designed program for wellness coverage that allows | for a reward, a contribution, a reduction in premiums or |
| reduced medical, prescription drug, or equipment copayments, | coinsurance, or deductibles, or a combination of these | incentives, for participation in any health behavior wellness, | maintenance, or improvement program approved or offered by the | insurer or managed care plan. The insured or enrollee may be | required to provide evidence of participation in a program. | Individuals unable to participate in these incentives due to an | adverse health factor shall not be penalized based upon an | adverse health status. | (b) For purposes of this Section, "wellness coverage" means | health care coverage with the primary purpose to engage and | motivate the insured or enrollee through: incentives; | provision of health education, counseling, and self-management | skills; identification of modifiable health risks; and other | activities to influence health behavior changes. | For the purposes of this Section, "reasonably designed | program" means a program of wellness coverage that has a | reasonable chance of improving health or preventing disease; is | not overly burdensome; does not discriminate based upon factors | of health; and is not otherwise contrary to law. | (c) Incentives as outlined in this Section are specific and | unique to the offering of wellness coverage and have no | application to any other required or optional health care | benefit. | (d) Such wellness coverage must satisfy the requirements | for an exception from the general prohibition against |
| discrimination based on a health factor under the federal | Health Insurance Portability and Accountability Act of 1996 | (P.L. 104-191; 110 Stat. 1936), including any federal | regulations that are adopted pursuant to that Act. | (e) A plan offering wellness coverage must do the | following: | (i) give participants the opportunity to qualify for | offered incentives at least once a year; | (ii) allow a reasonable alternative to any individual | for whom it is unreasonably difficult, due to a medical | condition, to satisfy otherwise applicable wellness | program standards. Plans may seek physician verification | that health factors make it unreasonably difficult or | medically inadvisable for the participant to satisfy the | standards; and | (iii) not provide a total incentive that exceeds 20% of | the cost of employee-only coverage. The cost of | employee-only coverage includes both employer and employee | contributions. For plans offering family coverage, the 20% | limitation applies to cost of family coverage and applies | to the entire family. | (f) A reward, contribution, or reduction established under | this Section and included in the policy or certificate does not | violate Section 151 of this Code.
| Section 15. 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)
| (Text of Section before amendment by P.A. 95-958)
| 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.13
356z.11, 356z.14, 356z.15,
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":
| (1) a corporation authorized under the
Dental Service | Plan Act or the Voluntary Health Services Plans Act;
| (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,
| (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;
| (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;
| (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
| (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).
| (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; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | 12-15-08.)
| (Text of Section after amendment by P.A. 95-958) | 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.11, 356z.12, 356z.13
356z.11, 356z.14, 356z.15, 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":
| (1) a corporation authorized under the
Dental Service | Plan Act or the Voluntary Health Services Plans Act;
| (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,
| (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;
| (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;
| (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
| (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).
| (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; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | eff. 12-12-08; revised 12-15-08.)
| Section 95. No acceleration or delay. Where this Act makes | changes in a statute that is represented in this Act by text | that is not yet or no longer in effect (for example, a Section | represented by multiple versions), the use of that text does | not accelerate or delay the taking effect of (i) the changes | made by this Act or (ii) provisions derived from any other | Public Act.
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| Section 99. Effective date. This Act takes effect January | 1, 2010.
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Effective Date: 1/1/2010
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