093_HB0211eng HB0211 Engrossed LRB093 04018 JLS 04057 b 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 3. 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, 356x,and356z.2, and 356z.4 of the 14 Illinois Insurance Code. The program of health benefits must 15 comply with Section 155.37 of the Illinois Insurance Code. 16 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03.) 17 Section 5. The Illinois Insurance Code is amended by 18 adding Section 356z.4 as follows: 19 (215 ILCS 5/356z.4 new) 20 Sec. 356z.4. Coverage for contraceptives. 21 (a) An individual or group policy of accident and health 22 insurance amended, delivered, issued, or renewed in this 23 State after the effective date of this amendatory Act of the 24 93rd General Assembly that provides coverage for outpatient 25 services and outpatient prescription drugs or devices must 26 provide coverage for the insured and any dependent of the 27 insured covered by the policy for all outpatient 28 contraceptive services and all outpatient contraceptive drugs 29 and devices approved by the Food and Drug Administration. HB0211 Engrossed -2- LRB093 04018 JLS 04057 b 1 Coverage required under this Section may not impose any 2 deductible, coinsurance, waiting period, or other 3 cost-sharing or limitation that is greater than that required 4 for any outpatient service or outpatient prescription drug or 5 device otherwise covered by the policy. 6 (b) As used in this Section, "outpatient contraceptive 7 service" means consultations, examinations, procedures, and 8 medical services, provided on an outpatient basis and related 9 to the use of contraceptive methods (including natural family 10 planning) to prevent an unintended pregnancy. 11 Section 10. The Health Maintenance Organization Act is 12 amended by changing Section 5-3 as follows: 13 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) 14 Sec. 5-3. Insurance Code provisions. 15 (a) Health Maintenance Organizations shall be subject to 16 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2, 17 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 18 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 19 356y, 356z.2, 356z.4, 367i, 368a, 401, 401.1, 402, 403, 403A, 20 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of 21 subsection (2) of Section 367, and Articles IIA, VIII 1/2, 22 XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois 23 Insurance Code. 24 (b) For purposes of the Illinois Insurance Code, except 25 for Sections 444 and 444.1 and Articles XIII and XIII 1/2, 26 Health Maintenance Organizations in the following categories 27 are deemed to be "domestic companies": 28 (1) a corporation authorized under the Dental 29 Service Plan Act or the Voluntary Health Services Plans 30 Act; 31 (2) a corporation organized under the laws of this 32 State; or HB0211 Engrossed -3- LRB093 04018 JLS 04057 b 1 (3) a corporation organized under the laws of 2 another state, 30% or more of the enrollees of which are 3 residents of this State, except a corporation subject to 4 substantially the same requirements in its state of 5 organization as is a "domestic company" under Article 6 VIII 1/2 of the Illinois Insurance Code. 7 (c) In considering the merger, consolidation, or other 8 acquisition of control of a Health Maintenance Organization 9 pursuant to Article VIII 1/2 of the Illinois Insurance Code, 10 (1) the Director shall give primary consideration 11 to the continuation of benefits to enrollees and the 12 financial conditions of the acquired Health Maintenance 13 Organization after the merger, consolidation, or other 14 acquisition of control takes effect; 15 (2)(i) the criteria specified in subsection (1)(b) 16 of Section 131.8 of the Illinois Insurance Code shall not 17 apply and (ii) the Director, in making his determination 18 with respect to the merger, consolidation, or other 19 acquisition of control, need not take into account the 20 effect on competition of the merger, consolidation, or 21 other acquisition of control; 22 (3) the Director shall have the power to require 23 the following information: 24 (A) certification by an independent actuary of 25 the adequacy of the reserves of the Health 26 Maintenance Organization sought to be acquired; 27 (B) pro forma financial statements reflecting 28 the combined balance sheets of the acquiring company 29 and the Health Maintenance Organization sought to be 30 acquired as of the end of the preceding year and as 31 of a date 90 days prior to the acquisition, as well 32 as pro forma financial statements reflecting 33 projected combined operation for a period of 2 34 years; HB0211 Engrossed -4- LRB093 04018 JLS 04057 b 1 (C) a pro forma business plan detailing an 2 acquiring party's plans with respect to the 3 operation of the Health Maintenance Organization 4 sought to be acquired for a period of not less than 5 3 years; and 6 (D) such other information as the Director 7 shall require. 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 10 by any health maintenance organization of greater than 10% of 11 its enrollee population (including without limitation the 12 health maintenance organization's right, title, and interest 13 in and to its health care certificates). 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 20 enrollees and the financial condition of the health 21 maintenance organization to be managed or serviced, and (ii) 22 need not take into account the effect of the management 23 contract or service 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 27 defined in Section 363 of the Illinois Insurance Code, a 28 Health Maintenance Organization may by contract agree with a 29 group or other enrollment unit to effect refunds or charge 30 additional premiums under the following terms and conditions: 31 (i) the amount of, and other terms and conditions 32 with respect to, the refund or additional premium are set 33 forth in the group or enrollment unit contract agreed in 34 advance of the period for which a refund is to be paid or HB0211 Engrossed -5- LRB093 04018 JLS 04057 b 1 additional premium is to be charged (which period shall 2 not be less than one year); and 3 (ii) the amount of the refund or additional premium 4 shall not exceed 20% of the Health Maintenance 5 Organization's profitable or unprofitable experience with 6 respect to the group or other enrollment unit for the 7 period (and, for purposes of a refund or additional 8 premium, the profitable or unprofitable experience shall 9 be calculated taking into account a pro rata share of the 10 Health Maintenance Organization's administrative and 11 marketing expenses, but shall not include any refund to 12 be made or additional premium to be paid pursuant to this 13 subsection (f)). The Health Maintenance Organization and 14 the group or enrollment unit may agree that the 15 profitable or unprofitable experience may be calculated 16 taking into account the refund period and the immediately 17 preceding 2 plan years. 18 The Health Maintenance Organization shall include a 19 statement in the evidence of coverage issued to each enrollee 20 describing the possibility of a refund or additional premium, 21 and upon request of any group or enrollment unit, provide to 22 the group or enrollment unit a description of the method used 23 to calculate (1) the Health Maintenance Organization's 24 profitable experience with respect to the group or enrollment 25 unit and the resulting refund to the group or enrollment unit 26 or (2) the Health Maintenance Organization's unprofitable 27 experience with respect to the group or enrollment unit and 28 the resulting additional premium to be paid by the group or 29 enrollment unit. 30 In no event shall the Illinois Health Maintenance 31 Organization Guaranty Association be liable to pay any 32 contractual obligation of an insolvent organization to pay 33 any refund authorized under this Section. 34 (Source: P.A. 91-357, eff. 7-29-99; 91-406, eff. 1-1-00; HB0211 Engrossed -6- LRB093 04018 JLS 04057 b 1 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; 91-788, eff. 2 6-9-00; 92-764, eff. 1-1-03.) 3 Section 15. The Voluntary Health Services Plans Act is 4 amended by changing Section 10 as follows: 5 (215 ILCS 165/10) (from Ch. 32, par. 604) 6 Sec. 10. Application of Insurance Code provisions. 7 Health services plan corporations and all persons interested 8 therein or dealing therewith shall be subject to the 9 provisions of Articles IIA and XII 1/2 and Sections 3.1, 133, 10 140, 143, 143c, 149, 155.37, 354, 355.2, 356r, 356t, 356u, 11 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 367.2, 368a, 12 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and 13 paragraphs (7) and (15) of Section 367 of the Illinois 14 Insurance Code. 15 (Source: P.A. 91-406, eff. 1-1-00; 91-549, eff. 8-14-99; 16 91-605, eff. 12-14-99; 91-788, eff. 6-9-00; 92-130, eff. 17 7-20-01; 92-440, eff. 8-17-01; 92-651, eff. 7-11-02; 92-764, 18 eff. 1-1-03.)