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| | 102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022 HB3794 Introduced 2/22/2021, by Rep. Bradley Stephens SYNOPSIS AS INTRODUCED: |
| 5 ILCS 375/6.11 | | 55 ILCS 5/5-1069.3 | | 65 ILCS 5/10-4-2.3 | | 105 ILCS 5/10-22.3f | | 215 ILCS 5/356w | | 215 ILCS 5/356z.43 new | | 215 ILCS 125/5-3 | from Ch. 111 1/2, par. 1411.2 | 215 ILCS 130/4003 | from Ch. 73, par. 1504-3 | 215 ILCS 165/10 | from Ch. 32, par. 604 |
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Amends the Illinois Insurance Code. Provides that insurers that provide coverage for diabetic self-management supplies must limit the total amount an insured is required to pay for diabetic self-management supplies to $100 per 30-day supply of diabetic self-management supplies required by an insured with diabetes for diabetic self-management. Provides that the limitation on diabetic self-management supplies costs also applies to provisions requiring coverage of certain diabetes items to be subject to the same coverage, deductible, co-payment, and co-insurance provisions under a policy. Defines "diabetic self-management supplies". Makes conforming changes in the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, and the Voluntary Health Services Plans Act. Effective January 1, 2022.
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| | FISCAL NOTE ACT MAY APPLY | | STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT |
| | A BILL FOR |
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1 | | AN ACT concerning regulation.
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2 | | Be it enacted by the People of the State of Illinois,
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3 | | represented in the General Assembly:
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4 | | Section 5. The State Employees Group Insurance Act of 1971 |
5 | | is amended by changing Section 6.11 as follows:
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6 | | (5 ILCS 375/6.11)
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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 356g, 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, |
14 | | 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, |
15 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, |
16 | | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, |
17 | | 356z.36, and 356z.41 , and 356z.43 of the
Illinois Insurance |
18 | | Code.
The program of health benefits must comply with Sections |
19 | | 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article |
20 | | XXXIIB of the
Illinois Insurance Code. The Department of |
21 | | Insurance shall enforce the requirements of this Section with |
22 | | respect to Sections 370c and 370c.1 of the Illinois Insurance |
23 | | Code; all other requirements of this Section shall be enforced |
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1 | | by the Department of Central Management Services.
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2 | | Rulemaking authority to implement Public Act 95-1045, if |
3 | | any, is conditioned on the rules being adopted in accordance |
4 | | with all provisions of the Illinois Administrative Procedure |
5 | | Act and all rules and procedures of the Joint Committee on |
6 | | Administrative Rules; any purported rule not so adopted, for |
7 | | whatever reason, is unauthorized. |
8 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
9 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
10 | | 1-1-19; 100-1102, eff. 1-1-19; 100-1170, eff. 6-1-19; 101-13, |
11 | | eff. 6-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; |
12 | | 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff. |
13 | | 1-1-21 .) |
14 | | Section 10. The Counties Code is amended by changing |
15 | | Section 5-1069.3 as follows: |
16 | | (55 ILCS 5/5-1069.3)
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17 | | Sec. 5-1069.3. Required health benefits. If a county, |
18 | | including a home
rule
county, is a self-insurer for purposes |
19 | | of providing health insurance coverage
for its employees, the |
20 | | coverage shall include coverage for the post-mastectomy
care |
21 | | benefits required to be covered by a policy of accident and |
22 | | health
insurance under Section 356t and the coverage required |
23 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
24 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
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1 | | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, |
2 | | 356z.30a, 356z.32, 356z.33, 356z.36, and 356z.41 , and 356z.43 |
3 | | of
the Illinois Insurance Code. The coverage shall comply with |
4 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois |
5 | | Insurance Code. The Department of Insurance shall enforce the |
6 | | requirements of this Section. The requirement that health |
7 | | benefits be covered
as provided in this Section is an
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8 | | exclusive power and function of the State and is a denial and |
9 | | limitation under
Article VII, Section 6, subsection (h) of the |
10 | | Illinois Constitution. A home
rule county to which this |
11 | | Section applies must comply with every provision of
this |
12 | | Section.
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13 | | Rulemaking authority to implement Public Act 95-1045, if |
14 | | any, is conditioned on the rules being adopted in accordance |
15 | | with all provisions of the Illinois Administrative Procedure |
16 | | Act and all rules and procedures of the Joint Committee on |
17 | | Administrative Rules; any purported rule not so adopted, for |
18 | | whatever reason, is unauthorized. |
19 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
20 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
21 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
22 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; |
23 | | 101-625, eff. 1-1-21 .) |
24 | | Section 15. The Illinois Municipal Code is amended by |
25 | | changing Section 10-4-2.3 as follows: |
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1 | | (65 ILCS 5/10-4-2.3)
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2 | | Sec. 10-4-2.3. Required health benefits. If a |
3 | | municipality, including a
home rule municipality, is a |
4 | | self-insurer for purposes of providing health
insurance |
5 | | coverage for its employees, the coverage shall include |
6 | | coverage for
the post-mastectomy care benefits required to be |
7 | | covered by a policy of
accident and health insurance under |
8 | | Section 356t and the coverage required
under Sections 356g, |
9 | | 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, |
10 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, |
11 | | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, |
12 | | 356z.36, and 356z.41 , and 356z.43 of the Illinois
Insurance
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13 | | Code. The coverage shall comply with Sections 155.22a, 355b, |
14 | | 356z.19, and 370c of
the Illinois Insurance Code. The |
15 | | Department of Insurance shall enforce the requirements of this |
16 | | Section. The requirement that health
benefits be covered as |
17 | | provided in this is an exclusive power and function of
the |
18 | | State and is a denial and limitation under Article VII, |
19 | | Section 6,
subsection (h) of the Illinois Constitution. A home |
20 | | rule municipality to which
this Section applies must comply |
21 | | with every provision of this Section.
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22 | | Rulemaking authority to implement Public Act 95-1045, if |
23 | | any, is conditioned on the rules being adopted in accordance |
24 | | with all provisions of the Illinois Administrative Procedure |
25 | | Act and all rules and procedures of the Joint Committee on |
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1 | | Administrative Rules; any purported rule not so adopted, for |
2 | | whatever reason, is unauthorized. |
3 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
4 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
5 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
6 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; |
7 | | 101-625, eff. 1-1-21 .) |
8 | | Section 20. The School Code is amended by changing Section |
9 | | 10-22.3f as follows: |
10 | | (105 ILCS 5/10-22.3f)
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11 | | Sec. 10-22.3f. Required health benefits. Insurance |
12 | | protection and
benefits
for employees shall provide the |
13 | | post-mastectomy care benefits required to be
covered by a |
14 | | policy of accident and health insurance under Section 356t and |
15 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
16 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
17 | | 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, |
18 | | 356z.30a, 356z.32, 356z.33, 356z.36, and 356z.41 , and 356z.43 |
19 | | of
the
Illinois Insurance Code.
Insurance policies shall |
20 | | comply with Section 356z.19 of the Illinois Insurance Code. |
21 | | The coverage shall comply with Sections 155.22a, 355b, and |
22 | | 370c of
the Illinois Insurance Code. The Department of |
23 | | Insurance shall enforce the requirements of this Section.
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24 | | Rulemaking authority to implement Public Act 95-1045, if |
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1 | | any, is conditioned on the rules being adopted in accordance |
2 | | with all provisions of the Illinois Administrative Procedure |
3 | | Act and all rules and procedures of the Joint Committee on |
4 | | Administrative Rules; any purported rule not so adopted, for |
5 | | whatever reason, is unauthorized. |
6 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
7 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. |
8 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
9 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; |
10 | | 101-625, eff. 1-1-21 .) |
11 | | Section 25. The Illinois Insurance Code is amended by |
12 | | changing Section 356w and by adding Section 356z.43 as |
13 | | follows:
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14 | | (215 ILCS 5/356w)
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15 | | Sec. 356w. Diabetes self-management training and |
16 | | education.
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17 | | (a) A group policy of accident and health insurance that |
18 | | is amended,
delivered,
issued, or renewed after the
effective |
19 | | date of this amendatory Act of 1998 shall provide coverage for
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20 | | outpatient self-management
training and education, equipment, |
21 | | and supplies, as set forth in this Section,
for the treatment |
22 | | of type 1 diabetes, type 2 diabetes, and gestational diabetes
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23 | | mellitus.
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24 | | (b) As used in this Section:
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1 | | "Diabetes self-management training"
means instruction in |
2 | | an outpatient setting
which enables a diabetic patient to |
3 | | understand the diabetic management process
and daily |
4 | | management of
diabetic therapy as a means of avoiding frequent |
5 | | hospitalization and
complications. Diabetes self-management |
6 | | training shall include
the content areas listed in the |
7 | | National Standards for Diabetes Self-Management
Education |
8 | | Programs as published by the American Diabetes Association, |
9 | | including
medical nutrition therapy and education programs, as |
10 | | defined by the contract of insurance, that allow the patient |
11 | | to maintain an A1c level within the range identified in |
12 | | nationally recognized standards of care.
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13 | | "Medical nutrition therapy" shall have the meaning
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14 | | ascribed to that term in the Dietitian Nutritionist
Practice |
15 | | Act.
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16 | | "Physician" means a
physician licensed to practice |
17 | | medicine in all of
its branches providing care to the |
18 | | individual.
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19 | | "Qualified provider" for an
individual that is enrolled |
20 | | in:
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21 | | (1) a health maintenance organization that uses a
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22 | | primary
care physician to
control access to specialty care |
23 | | means (A) the individual's primary care
physician licensed |
24 | | to practice
medicine in all of its branches, (B) a |
25 | | physician licensed to practice
medicine in all of its |
26 | | branches to
whom the individual has been referred by the |
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1 | | primary care physician, or (C) a
certified, registered, or
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2 | | licensed network health care professional with expertise |
3 | | in diabetes management
to whom the individual
has been |
4 | | referred by the primary care physician.
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5 | | (2) an insurance plan
means (A) a physician licensed |
6 | | to practice medicine in
all of its branches or (B) a
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7 | | certified, registered, or licensed health care |
8 | | professional with expertise in
diabetes management to whom |
9 | | the individual has been referred by a physician.
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10 | | (c) Coverage under this Section for diabetes |
11 | | self-management training,
including medical nutrition
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12 | | education, shall be limited to the following:
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13 | | (1) Up to 3 medically necessary visits to a qualified |
14 | | provider upon
initial diagnosis of diabetes
by the |
15 | | patient's
physician or, if diagnosis of diabetes was made |
16 | | within one year prior to the
effective date of
this |
17 | | amendatory Act
of 1998 where the insured was a covered |
18 | | individual, up to 3 medically necessary
visits to a |
19 | | qualified provider within one
year after that
effective
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20 | | date.
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21 | | (2) Up to 2 medically necessary visits to a qualified |
22 | | provider upon a
determination by a
patient's
physician |
23 | | that a significant change in the patient's symptoms or |
24 | | medical
condition has
occurred. A "significant change" in |
25 | | condition means symptomatic
hyperglycemia (greater than |
26 | | 250 mg/dl on repeated occasions), severe
hypoglycemia |
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1 | | (requiring the assistance of another person), onset or |
2 | | progression
of diabetes, or a significant change in |
3 | | medical condition that would require a
significantly |
4 | | different treatment regimen.
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5 | | Payment by the insurer or health maintenance organization |
6 | | for the coverage
required for diabetes self-management |
7 | | training pursuant to the provisions of
this Section is only |
8 | | required to be made for services provided.
No coverage is |
9 | | required for additional visits beyond those specified in items
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10 | | (1) and (2) of this subsection.
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11 | | Coverage under this subsection (c) for diabetes |
12 | | self-management training
shall
be subject to the same
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13 | | deductible, co-payment, and co-insurance provisions that apply |
14 | | to coverage
under
the policy for other
services provided by |
15 | | the same type of provider.
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16 | | (d) Coverage shall be provided for the following
equipment |
17 | | when medically necessary
and prescribed by a physician |
18 | | licensed to practice medicine in all
of its branches.
Coverage |
19 | | for the following items shall be subject to deductible, |
20 | | co-payment
and co-insurance provisions
provided for under the |
21 | | policy or a durable medical equipment rider to the
policy:
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22 | | (1) blood glucose monitors;
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23 | | (2) blood glucose monitors for the legally blind;
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24 | | (3) cartridges for the legally blind; and
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25 | | (4) lancets and lancing devices.
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26 | | This subsection does not apply to a group policy of |
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1 | | accident and health
insurance that does not provide a durable |
2 | | medical equipment benefit.
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3 | | (e) Coverage shall be provided for the following |
4 | | pharmaceuticals and
supplies when
medically necessary and |
5 | | prescribed by a physician licensed to
practice medicine in all |
6 | | of its
branches.
Coverage for the following items shall be |
7 | | subject to the same coverage,
deductible,
co-payment, and |
8 | | co-insurance
provisions under the policy or a drug rider to |
9 | | the policy, except as otherwise provided for under Sections |
10 | | Section 356z.41 and 356z.43 :
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11 | | (1) insulin;
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12 | | (2) syringes and needles;
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13 | | (3) test strips for glucose monitors;
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14 | | (4) FDA approved oral agents used to control blood |
15 | | sugar; and
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16 | | (5) glucagon emergency kits.
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17 | | This subsection does not apply to a group policy of |
18 | | accident and health
insurance that does not provide a drug |
19 | | benefit.
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20 | | (f) Coverage shall be provided for regular foot care exams |
21 | | by a
physician or by a
physician to whom a physician has |
22 | | referred the patient. Coverage
for regular foot care exams
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23 | | shall be subject to the same deductible, co-payment, and |
24 | | co-insurance
provisions
that apply under the policy for
other |
25 | | services provided by the same type of provider.
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26 | | (g) If authorized by a physician, diabetes self-management
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1 | | training may be provided as a part of an office visit, group |
2 | | setting, or home
visit.
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3 | | (h) This Section shall not apply to agreements, contracts, |
4 | | or policies that
provide coverage for a specified diagnosis or |
5 | | other limited benefit coverage.
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6 | | (Source: P.A. 101-625, eff. 1-1-21 .)
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7 | | (215 ILCS 5/356z.43 new) |
8 | | Sec. 356z.43. Cost sharing in diabetic self-management |
9 | | supplies; limits; confidentiality of rebate information. |
10 | | (a) As used in this Section, "diabetic self-management |
11 | | supplies" means items determined to be medically necessary for |
12 | | a person with diabetes for diabetic self-management, including |
13 | | blood test strips for glucose monitors and the monthly lease |
14 | | of an insulin pump. "Diabetic self-management supplies" do not |
15 | | include insulin drugs. |
16 | | (b) This Section applies to a group or individual policy |
17 | | of accident and health insurance amended, delivered, issued, |
18 | | or renewed on or after the effective date of this amendatory |
19 | | Act of the 102nd General Assembly. |
20 | | (c) An insurer that provides coverage for diabetic |
21 | | self-management supplies pursuant to the terms of a health |
22 | | coverage plan the insurer offers shall limit the total amount |
23 | | that an insured is required to pay for a 30-day supply of |
24 | | diabetic self-management supplies at an amount not to exceed |
25 | | $100, regardless of the quantity or type of diabetic |
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1 | | self-management supplies required by an insured with diabetes |
2 | | for diabetic self-management. |
3 | | (d) Nothing in this Section prevents an insurer from |
4 | | reducing an insured's cost sharing by an amount greater than |
5 | | the amount specified in subsection (c). |
6 | | (e) The Director may use any of the Director's enforcement |
7 | | powers to obtain an insurer's compliance with this Section. |
8 | | (f) The Department may adopt rules as necessary to |
9 | | implement and administer this Section and to align it with |
10 | | federal requirements. |
11 | | (g) On January 1 of each year, the limit on the amount that |
12 | | an insured is required to pay for a 30-day supply of diabetic |
13 | | self-management supplies shall increase by a percentage equal |
14 | | to the percentage change from the preceding year in the |
15 | | medical care component of the Consumer Price Index of the |
16 | | Bureau of Labor Statistics of the United States Department of |
17 | | Labor. |
18 | | Section 30. The Health Maintenance Organization Act is |
19 | | amended by changing Section 5-3 as follows:
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20 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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21 | | Sec. 5-3. Insurance Code provisions.
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22 | | (a) Health Maintenance Organizations
shall be subject to |
23 | | the provisions of Sections 133, 134, 136, 137, 139, 140, |
24 | | 141.1,
141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, |
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1 | | 154, 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, |
2 | | 355.3, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, |
3 | | 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, |
4 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, |
5 | | 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, |
6 | | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41, |
7 | | 356z.43, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, |
8 | | 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, |
9 | | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection |
10 | | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, |
11 | | XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois |
12 | | Insurance Code.
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13 | | (b) For purposes of the Illinois Insurance Code, except |
14 | | for Sections 444
and 444.1 and Articles XIII and XIII 1/2, |
15 | | Health Maintenance Organizations in
the following categories |
16 | | are deemed to be "domestic companies":
|
17 | | (1) a corporation authorized under the
Dental Service |
18 | | Plan Act or the Voluntary Health Services Plans Act;
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19 | | (2) a corporation organized under the laws of this |
20 | | State; or
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21 | | (3) a corporation organized under the laws of another |
22 | | state, 30% or more
of the enrollees of which are residents |
23 | | of this State, except a
corporation subject to |
24 | | substantially the same requirements in its state of
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25 | | organization as is a "domestic company" under Article VIII |
26 | | 1/2 of the
Illinois Insurance Code.
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1 | | (c) In considering the merger, consolidation, or other |
2 | | acquisition of
control of a Health Maintenance Organization |
3 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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4 | | (1) the Director shall give primary consideration to |
5 | | the continuation of
benefits to enrollees and the |
6 | | financial conditions of the acquired Health
Maintenance |
7 | | Organization after the merger, consolidation, or other
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8 | | acquisition of control takes effect;
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9 | | (2)(i) the criteria specified in subsection (1)(b) of |
10 | | Section 131.8 of
the Illinois Insurance Code shall not |
11 | | apply and (ii) the Director, in making
his determination |
12 | | with respect to the merger, consolidation, or other
|
13 | | acquisition of control, need not take into account the |
14 | | effect on
competition of the merger, consolidation, or |
15 | | other acquisition of control;
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16 | | (3) the Director shall have the power to require the |
17 | | following
information:
|
18 | | (A) certification by an independent actuary of the |
19 | | adequacy
of the reserves of the Health Maintenance |
20 | | Organization sought to be acquired;
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21 | | (B) pro forma financial statements reflecting the |
22 | | combined balance
sheets of the acquiring company and |
23 | | the Health Maintenance Organization sought
to be |
24 | | acquired as of the end of the preceding year and as of |
25 | | a date 90 days
prior to the acquisition, as well as pro |
26 | | forma financial statements
reflecting projected |
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1 | | combined operation for a period of 2 years;
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2 | | (C) a pro forma business plan detailing an |
3 | | acquiring party's plans with
respect to the operation |
4 | | of the Health Maintenance Organization sought to
be |
5 | | acquired for a period of not less than 3 years; and
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6 | | (D) such other information as the Director shall |
7 | | require.
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8 | | (d) The provisions of Article VIII 1/2 of the Illinois |
9 | | Insurance Code
and this Section 5-3 shall apply to the sale by |
10 | | any health maintenance
organization of greater than 10% of its
|
11 | | enrollee population (including without limitation the health |
12 | | maintenance
organization's right, title, and interest in and |
13 | | to its health care
certificates).
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14 | | (e) In considering any management contract or service |
15 | | agreement subject
to Section 141.1 of the Illinois Insurance |
16 | | Code, the Director (i) shall, in
addition to the criteria |
17 | | specified in Section 141.2 of the Illinois
Insurance Code, |
18 | | take into account the effect of the management contract or
|
19 | | service agreement on the continuation of benefits to enrollees |
20 | | and the
financial condition of the health maintenance |
21 | | organization to be managed or
serviced, and (ii) need not take |
22 | | into account the effect of the management
contract or service |
23 | | agreement on competition.
|
24 | | (f) Except for small employer groups as defined in the |
25 | | Small Employer
Rating, Renewability and Portability Health |
26 | | Insurance Act and except for
medicare supplement policies as |
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1 | | defined in Section 363 of the Illinois
Insurance Code, a |
2 | | Health Maintenance Organization may by contract agree with a
|
3 | | group or other enrollment unit to effect refunds or charge |
4 | | additional premiums
under the following terms and conditions:
|
5 | | (i) the amount of, and other terms and conditions with |
6 | | respect to, the
refund or additional premium are set forth |
7 | | in the group or enrollment unit
contract agreed in advance |
8 | | of the period for which a refund is to be paid or
|
9 | | additional premium is to be charged (which period shall |
10 | | not be less than one
year); and
|
11 | | (ii) the amount of the refund or additional premium |
12 | | shall not exceed 20%
of the Health Maintenance |
13 | | Organization's profitable or unprofitable experience
with |
14 | | respect to the group or other enrollment unit for the |
15 | | period (and, for
purposes of a refund or additional |
16 | | premium, the profitable or unprofitable
experience shall |
17 | | be calculated taking into account a pro rata share of the
|
18 | | Health Maintenance Organization's administrative and |
19 | | marketing expenses, but
shall not include any refund to be |
20 | | made or additional premium to be paid
pursuant to this |
21 | | subsection (f)). The Health Maintenance Organization and |
22 | | the
group or enrollment unit may agree that the profitable |
23 | | or unprofitable
experience may be calculated taking into |
24 | | account the refund period and the
immediately preceding 2 |
25 | | plan years.
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26 | | The Health Maintenance Organization shall include a |
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1 | | statement in the
evidence of coverage issued to each enrollee |
2 | | describing the possibility of a
refund or additional premium, |
3 | | and upon request of any group or enrollment unit,
provide to |
4 | | the group or enrollment unit a description of the method used |
5 | | to
calculate (1) the Health Maintenance Organization's |
6 | | profitable experience with
respect to the group or enrollment |
7 | | unit and the resulting refund to the group
or enrollment unit |
8 | | or (2) the Health Maintenance Organization's unprofitable
|
9 | | experience with respect to the group or enrollment unit and |
10 | | the resulting
additional premium to be paid by the group or |
11 | | enrollment unit.
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12 | | In no event shall the Illinois Health Maintenance |
13 | | Organization
Guaranty Association be liable to pay any |
14 | | contractual obligation of an
insolvent organization to pay any |
15 | | refund authorized under this Section.
|
16 | | (g) Rulemaking authority to implement Public Act 95-1045, |
17 | | if any, is conditioned on the rules being adopted in |
18 | | accordance with all provisions of the Illinois Administrative |
19 | | Procedure Act and all rules and procedures of the Joint |
20 | | Committee on Administrative Rules; any purported rule not so |
21 | | adopted, for whatever reason, is unauthorized. |
22 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
23 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. |
24 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, |
25 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; |
26 | | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. |
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1 | | 1-1-20; 101-625, eff. 1-1-21 .) |
2 | | Section 35. The Limited Health Service Organization Act is |
3 | | amended by changing Section 4003 as follows:
|
4 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
|
5 | | Sec. 4003. Illinois Insurance Code provisions. Limited |
6 | | health service
organizations shall be subject to the |
7 | | provisions of Sections 133, 134, 136, 137, 139,
140, 141.1, |
8 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, |
9 | | 154.5,
154.6, 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, |
10 | | 355b, 356v, 356z.10, 356z.21, 356z.22, 356z.25, 356z.26, |
11 | | 356z.29, 356z.30a, 356z.32, 356z.33, 356z.41, 356z.43, 368a, |
12 | | 401, 401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and |
13 | | 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, |
14 | | XXV, and XXVI of the Illinois Insurance Code. For purposes of |
15 | | the
Illinois Insurance Code, except for Sections 444 and 444.1 |
16 | | and Articles XIII
and XIII 1/2, limited health service |
17 | | organizations in the following categories
are deemed to be |
18 | | domestic companies:
|
19 | | (1) a corporation under the laws of this State; or
|
20 | | (2) a corporation organized under the laws of another |
21 | | state, 30% or more
of the enrollees of which are residents |
22 | | 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 VIII |
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1 | | 1/2 of the Illinois Insurance Code.
|
2 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
3 | | 100-201, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. |
4 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, |
5 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff. 1-1-21 .)
|
6 | | Section 40. The Voluntary Health Services Plans Act is |
7 | | amended by changing Section 10 as follows:
|
8 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
|
9 | | Sec. 10. Application of Insurance Code provisions. Health |
10 | | services
plan corporations and all persons interested therein |
11 | | or dealing therewith
shall be subject to the provisions of |
12 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, |
13 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, |
14 | | 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, |
15 | | 356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, |
16 | | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, |
17 | | 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, |
18 | | 356z.30, 356z.30a, 356z.32, 356z.33, 356z.41, 356z.43, 364.01, |
19 | | 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, |
20 | | and paragraphs (7) and (15) of Section 367 of the Illinois
|
21 | | Insurance Code.
|
22 | | Rulemaking authority to implement Public Act 95-1045, if |
23 | | any, is conditioned on the rules being adopted in accordance |
24 | | with all provisions of the Illinois Administrative Procedure |
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1 | | Act and all rules and procedures of the Joint Committee on |
2 | | Administrative Rules; any purported rule not so adopted, for |
3 | | whatever reason, is unauthorized. |
4 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
5 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. |
6 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, |
7 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-393, eff. 1-1-20; |
8 | | 101-625, eff. 1-1-21 .)
|
9 | | Section 99. Effective date. This Act takes effect January |
10 | | 1, 2022.
|