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1 | AN ACT in relation to insurance.
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2 | Be it enacted by the People of the State of Illinois, | |||||||||||||||||||||||||||||
3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by | |||||||||||||||||||||||||||||
5 | changing Section
351B-5 and adding Section 367.4 as follows:
| |||||||||||||||||||||||||||||
6 | (215 ILCS 5/351B-5) (from Ch. 73, par. 963B-5)
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7 | Sec. 351B-5. Applicability of other Code provisions. All | |||||||||||||||||||||||||||||
8 | policies of
accident and health insurance issued
under this | |||||||||||||||||||||||||||||
9 | Article shall be subject to the provisions of Sections 356c,
| |||||||||||||||||||||||||||||
10 | subsection (a) of Section 356g, 356h, 356n, 367.4, 367c, 367d, | |||||||||||||||||||||||||||||
11 | 370, 370a,
and 370e of this Code.
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12 | (Source: P.A. 86-1407; 87-792; 87-1066.)
| |||||||||||||||||||||||||||||
13 | insert 367.4
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14 | (215 ILCS 5/367.4 new)
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15 | Sec. 367.4. Reporting of claims information to group health | |||||||||||||||||||||||||||||
16 | plan sponsor.
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17 | (a) In this Section, "group health plan", "health insurance | |||||||||||||||||||||||||||||
18 | coverage",
"health insurance issuer", and "plan sponsor" have | |||||||||||||||||||||||||||||
19 | the meanings ascribed to
those terms in the Illinois Health | |||||||||||||||||||||||||||||
20 | Insurance Portability and Accountability
Act.
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21 | (b) Upon the written request of a sponsor of a group health | |||||||||||||||||||||||||||||
22 | plan, the health
insurance issuer providing health insurance | |||||||||||||||||||||||||||||
23 | coverage under the plan must report
to the sponsor information | |||||||||||||||||||||||||||||
24 | from the 12 months preceding the date of the report
regarding | |||||||||||||||||||||||||||||
25 | the following:
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26 | (1) The total amount of charges submitted to the health | |||||||||||||||||||||||||||||
27 | insurance issuer
for persons covered under the plan.
| |||||||||||||||||||||||||||||
28 | (2) The total amount of payments made by the health | |||||||||||||||||||||||||||||
29 | insurance issuer to
health care providers for persons | |||||||||||||||||||||||||||||
30 | covered under the plan.
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31 | (3) To the extent available, information on claims paid |
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1 | by type of health
care provider, including the total | ||||||
2 | hospital charges, physician charges,
pharmaceutical | ||||||
3 | charges, and other charges.
| ||||||
4 | (4) The diagnosis codes for payment of claims that | ||||||
5 | exceed $25,000 made by the health insurance issuer to | ||||||
6 | health care providers for persons covered under the plan.
| ||||||
7 | (c) A health insurance issuer must provide information | ||||||
8 | requested by a plan
sponsor under this Section annually not | ||||||
9 | later than the 45th day before the
anniversary or renewal date | ||||||
10 | of the sponsor's group health plan. Notwithstanding
any other | ||||||
11 | provision of this subsection, a health insurance issuer is not
| ||||||
12 | required to provide information under this Section earlier than | ||||||
13 | the 45th day
after the date of the sponsor's initial written | ||||||
14 | request.
| ||||||
15 | (d) A health insurance issuer may not report any | ||||||
16 | information required under
this Section the release of which is | ||||||
17 | prohibited by State or federal law or
regulation.
| ||||||
18 | (e) A health insurance issuer must provide information | ||||||
19 | under this Section in
the aggregate, without any information | ||||||
20 | through which a specific individual
covered under the plan may | ||||||
21 | be identified.
| ||||||
22 | (f) Information obtained by a plan sponsor under this | ||||||
23 | Section is
confidential. The sponsor may use the information | ||||||
24 | only for purposes relating to
obtaining and maintaining health | ||||||
25 | insurance coverage for the sponsor's
employees (if the sponsor | ||||||
26 | is an employer) or members (if the sponsor is an
employee | ||||||
27 | organization).
| ||||||
28 | Section 10. The Health Care Purchasing Group Act is amended | ||||||
29 | by changing
Section 5 as follows:
| ||||||
30 | (215 ILCS 123/5)
| ||||||
31 | Sec. 5. Purpose; applicability of Illinois Health | ||||||
32 | Insurance Portability
and Accountability Act.
| ||||||
33 | (a) The purpose and intent of this Act is
to authorize the | ||||||
34 | formation, operation, and regulation of health care
purchasing |
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1 | groups (referred to in this Act as "HPGs") as described by
this | ||||||
2 | Act, to authorize the sale and regulation of health
insurance | ||||||
3 | products for employers that are sold to HPGs, and to
encourage | ||||||
4 | the development of financially secure and cost
effective | ||||||
5 | markets for the basic health care needs of employers,
| ||||||
6 | employees, and their dependents in this State.
Nothing in this | ||||||
7 | Act authorizes an employer to join with other employers to
| ||||||
8 | self-insure through risk pooling.
| ||||||
9 | (b) All health insurance contracts issued under this Act | ||||||
10 | are subject to
the Illinois Health Insurance Portability and | ||||||
11 | Accountability Act.
| ||||||
12 | (c) All health insurance contracts issued under this Act | ||||||
13 | are subject to
Section 367.4 of the Illinois Insurance Code.
| ||||||
14 | (Source: P.A. 90-337, eff. 1-1-98; 90-567, eff. 1-23-98.)
| ||||||
15 | Section 15. The Health Maintenance Organization Act is | ||||||
16 | amended by changing
Section 5-3 as follows:
| ||||||
17 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
18 | Sec. 5-3. Insurance Code provisions.
| ||||||
19 | (a) Health Maintenance Organizations
shall be subject to | ||||||
20 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
21 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
22 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
23 | 356y,
356z.2, 356z.4, 356z.5, 367.2, 367.2-5, 367.4, 367i, | ||||||
24 | 368a, 368b, 368c,
368d, 368e,
401, 401.1, 402, 403, 403A,
408, | ||||||
25 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||||||
26 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
27 | XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
28 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
29 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
30 | Maintenance Organizations in
the following categories are | ||||||
31 | deemed to be "domestic companies":
| ||||||
32 | (1) a corporation authorized under the
Dental Service | ||||||
33 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
34 | (2) a corporation organized under the laws of this |
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1 | State; or
| ||||||
2 | (3) a corporation organized under the laws of another | ||||||
3 | state, 30% or more
of the enrollees of which are residents | ||||||
4 | of this State, except a
corporation subject to | ||||||
5 | substantially the same requirements in its state of
| ||||||
6 | organization as is a "domestic company" under Article VIII | ||||||
7 | 1/2 of the
Illinois Insurance Code.
| ||||||
8 | (c) In considering the merger, consolidation, or other | ||||||
9 | acquisition of
control of a Health Maintenance Organization | ||||||
10 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
11 | (1) the Director shall give primary consideration to | ||||||
12 | the continuation of
benefits to enrollees and the financial | ||||||
13 | conditions of the acquired Health
Maintenance Organization | ||||||
14 | after the merger, consolidation, or other
acquisition of | ||||||
15 | control takes effect;
| ||||||
16 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
17 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
18 | apply and (ii) the Director, in making
his determination | ||||||
19 | with respect to the merger, consolidation, or other
| ||||||
20 | acquisition of control, need not take into account the | ||||||
21 | effect on
competition of the merger, consolidation, or | ||||||
22 | other acquisition of control;
| ||||||
23 | (3) the Director shall have the power to require the | ||||||
24 | following
information:
| ||||||
25 | (A) certification by an independent actuary of the | ||||||
26 | adequacy
of the reserves of the Health Maintenance | ||||||
27 | Organization sought to be acquired;
| ||||||
28 | (B) pro forma financial statements reflecting the | ||||||
29 | combined balance
sheets of the acquiring company and | ||||||
30 | the Health Maintenance Organization sought
to be | ||||||
31 | acquired as of the end of the preceding year and as of | ||||||
32 | a date 90 days
prior to the acquisition, as well as pro | ||||||
33 | forma financial statements
reflecting projected | ||||||
34 | combined operation for a period of 2 years;
| ||||||
35 | (C) a pro forma business plan detailing an | ||||||
36 | acquiring party's plans with
respect to the operation |
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1 | of the Health Maintenance Organization sought to
be | ||||||
2 | acquired for a period of not less than 3 years; and
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3 | (D) such other information as the Director shall | ||||||
4 | require.
| ||||||
5 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
6 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
7 | any health maintenance
organization of greater than 10% of its
| ||||||
8 | enrollee population (including without limitation the health | ||||||
9 | maintenance
organization's right, title, and interest in and to | ||||||
10 | its health care
certificates).
| ||||||
11 | (e) In considering any management contract or service | ||||||
12 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
13 | Code, the Director (i) shall, in
addition to the criteria | ||||||
14 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
15 | into account the effect of the management contract or
service | ||||||
16 | agreement on the continuation of benefits to enrollees and the
| ||||||
17 | financial condition of the health maintenance organization to | ||||||
18 | be managed or
serviced, and (ii) need not take into account the | ||||||
19 | effect of the management
contract or service agreement on | ||||||
20 | competition.
| ||||||
21 | (f) Except for small employer groups as defined in the | ||||||
22 | Small Employer
Rating, Renewability and Portability Health | ||||||
23 | Insurance Act and except for
medicare supplement policies as | ||||||
24 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
25 | Maintenance Organization may by contract agree with a
group or | ||||||
26 | other enrollment unit to effect refunds or charge additional | ||||||
27 | premiums
under the following terms and conditions:
| ||||||
28 | (i) the amount of, and other terms and conditions with | ||||||
29 | respect to, the
refund or additional premium are set forth | ||||||
30 | in the group or enrollment unit
contract agreed in advance | ||||||
31 | of the period for which a refund is to be paid or
| ||||||
32 | additional premium is to be charged (which period shall not | ||||||
33 | be less than one
year); and
| ||||||
34 | (ii) the amount of the refund or additional premium | ||||||
35 | shall not exceed 20%
of the Health Maintenance | ||||||
36 | Organization's profitable or unprofitable experience
with |
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1 | respect to the group or other enrollment unit for the | ||||||
2 | period (and, for
purposes of a refund or additional | ||||||
3 | premium, the profitable or unprofitable
experience shall | ||||||
4 | be calculated taking into account a pro rata share of the
| ||||||
5 | Health Maintenance Organization's administrative and | ||||||
6 | marketing expenses, but
shall not include any refund to be | ||||||
7 | made or additional premium to be paid
pursuant to this | ||||||
8 | subsection (f)). The Health Maintenance Organization and | ||||||
9 | the
group or enrollment unit may agree that the profitable | ||||||
10 | or unprofitable
experience may be calculated taking into | ||||||
11 | account the refund period and the
immediately preceding 2 | ||||||
12 | plan years.
| ||||||
13 | The Health Maintenance Organization shall include a | ||||||
14 | statement in the
evidence of coverage issued to each enrollee | ||||||
15 | describing the possibility of a
refund or additional premium, | ||||||
16 | and upon request of any group or enrollment unit,
provide to | ||||||
17 | the group or enrollment unit a description of the method used | ||||||
18 | to
calculate (1) the Health Maintenance Organization's | ||||||
19 | profitable experience with
respect to the group or enrollment | ||||||
20 | unit and the resulting refund to the group
or enrollment unit | ||||||
21 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
22 | experience with respect to the group or enrollment unit and the | ||||||
23 | resulting
additional premium to be paid by the group or | ||||||
24 | enrollment unit.
| ||||||
25 | In no event shall the Illinois Health Maintenance | ||||||
26 | Organization
Guaranty Association be liable to pay any | ||||||
27 | contractual obligation of an
insolvent organization to pay any | ||||||
28 | refund authorized under this Section.
| ||||||
29 | (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, | ||||||
30 | eff. 1-1-04;
93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised | ||||||
31 | 9-25-03.)
| ||||||
32 | Section 20. The Limited Health Service Organization Act is | ||||||
33 | amended by
changing Section 4003 as follows:
| ||||||
34 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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1 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
2 | health service
organizations shall be subject to the provisions | ||||||
3 | of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | ||||||
4 | 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | ||||||
5 | 155.04, 155.37, 355.2, 356v, 367.4, 368a, 401, 401.1,
402,
403, | ||||||
6 | 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles IIA, | ||||||
7 | VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of the | ||||||
8 | Illinois Insurance Code. For purposes of the
Illinois Insurance | ||||||
9 | Code, except for Sections 444 and 444.1 and Articles XIII
and | ||||||
10 | XIII 1/2, limited health service organizations in the following | ||||||
11 | categories
are deemed to be domestic companies:
| ||||||
12 | (1) a corporation under the laws of this State; or
| ||||||
13 | (2) a corporation organized under the laws of another | ||||||
14 | state, 30% of more
of the enrollees of which are residents | ||||||
15 | of this State, except a corporation
subject to | ||||||
16 | substantially the same requirements in its state of | ||||||
17 | organization as
is a domestic company under Article VIII | ||||||
18 | 1/2 of the Illinois Insurance Code.
| ||||||
19 | (Source: P.A. 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; | ||||||
20 | 91-788, eff.
6-9-00; 92-440, eff. 8-17-01.)
| ||||||
21 | Section 25. The Voluntary Health Services Plans Act is | ||||||
22 | amended by changing
Section 10 as follows:
| ||||||
23 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
24 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
25 | services
plan corporations and all persons interested therein | ||||||
26 | or dealing therewith
shall be subject to the provisions of | ||||||
27 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
28 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
29 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 367.2, 367.4, 368a,
401, | ||||||
30 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
31 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
32 | (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
| ||||||
33 | 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; | ||||||
34 | 93-529, eff.
8-14-03; revised 9-25-03.)
|