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1 | AN ACT concerning insurance coverage for certain | |||||||||||||||||||||||||
2 | conditions.
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3 | Be it enacted by the People of the State of Illinois, | |||||||||||||||||||||||||
4 | represented in the General Assembly:
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5 | Section 5. The Illinois Insurance Code is amended by adding | |||||||||||||||||||||||||
6 | Section 356z.6 as follows: | |||||||||||||||||||||||||
7 | (215 ILCS 5/356z.6 new)
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8 | Sec. 356z.6. Treatment of certain metabolic diseases.
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9 | (a) An individual or group policy of accident and health | |||||||||||||||||||||||||
10 | insurance that is
issued, delivered, amended, or renewed in | |||||||||||||||||||||||||
11 | this State on or after January 1,
2005 shall include the | |||||||||||||||||||||||||
12 | following: | |||||||||||||||||||||||||
13 | (1) Coverage for prescription enteral and oral | |||||||||||||||||||||||||
14 | formulas for home use,
for which
a physician has issued a | |||||||||||||||||||||||||
15 | written order and which are medically necessary for
the | |||||||||||||||||||||||||
16 | treatment or management of inherited diseases involving | |||||||||||||||||||||||||
17 | amino acids or
organic acids (including, but not limited | |||||||||||||||||||||||||
18 | to, phenylketonuria).
| |||||||||||||||||||||||||
19 | (2) Coverage for up to $2,500 per year worth of food | |||||||||||||||||||||||||
20 | products modified to
be low in protein, for which a | |||||||||||||||||||||||||
21 | physician has issued a written order and which
are | |||||||||||||||||||||||||
22 | medically necessary for the management of phenylketonuria | |||||||||||||||||||||||||
23 | or other
inherited diseases involving amino acids or other | |||||||||||||||||||||||||
24 | organic acids.
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25 | (b) The coverage required under subsection (a) shall also | |||||||||||||||||||||||||
26 | be provided by
health maintenance organizations, limited | |||||||||||||||||||||||||
27 | health service organizations, and
voluntary health services | |||||||||||||||||||||||||
28 | plans.
| |||||||||||||||||||||||||
29 | Section 10. The Health Maintenance Organization Act is | |||||||||||||||||||||||||
30 | amended by changing
Section 5-3 as follows:
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1 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
2 | Sec. 5-3. Insurance Code provisions.
| ||||||
3 | (a) Health Maintenance Organizations
shall be subject to | ||||||
4 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
5 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
6 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
7 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 367.2, 367.2-5, 367i, | ||||||
8 | 368a, 368b, 368c, 368d, 368e,
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, and XXVI of the Illinois Insurance Code.
| ||||||
12 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
13 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
14 | Maintenance Organizations in
the following categories are | ||||||
15 | deemed to be "domestic companies":
| ||||||
16 | (1) a corporation authorized under the
Dental Service | ||||||
17 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
18 | (2) a corporation organized under the laws of this | ||||||
19 | State; or
| ||||||
20 | (3) 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 | ||||||
25 | 1/2 of the
Illinois Insurance Code.
| ||||||
26 | (c) In considering the merger, consolidation, or other | ||||||
27 | acquisition of
control of a Health Maintenance Organization | ||||||
28 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
29 | (1) the Director shall give primary consideration to | ||||||
30 | the continuation of
benefits to enrollees and the financial | ||||||
31 | conditions of the acquired Health
Maintenance Organization | ||||||
32 | after the merger, consolidation, or other
acquisition of | ||||||
33 | control takes effect;
| ||||||
34 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
35 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
36 | apply and (ii) the Director, in making
his determination |
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1 | with respect to the merger, consolidation, or other
| ||||||
2 | acquisition of control, need not take into account the | ||||||
3 | effect on
competition of the merger, consolidation, or | ||||||
4 | other acquisition of control;
| ||||||
5 | (3) the Director shall have the power to require the | ||||||
6 | following
information:
| ||||||
7 | (A) certification by an independent actuary of the | ||||||
8 | adequacy
of the reserves of the Health Maintenance | ||||||
9 | Organization sought to be acquired;
| ||||||
10 | (B) pro forma financial statements reflecting the | ||||||
11 | combined balance
sheets of the acquiring company and | ||||||
12 | the Health Maintenance Organization sought
to be | ||||||
13 | acquired as of the end of the preceding year and as of | ||||||
14 | a date 90 days
prior to the acquisition, as well as pro | ||||||
15 | forma financial statements
reflecting projected | ||||||
16 | combined operation for a period of 2 years;
| ||||||
17 | (C) a pro forma business plan detailing an | ||||||
18 | acquiring party's plans with
respect to the operation | ||||||
19 | of the Health Maintenance Organization sought to
be | ||||||
20 | acquired for a period of not less than 3 years; and
| ||||||
21 | (D) such other information as the Director shall | ||||||
22 | require.
| ||||||
23 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
24 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
25 | any health maintenance
organization of greater than 10% of its
| ||||||
26 | enrollee population (including without limitation the health | ||||||
27 | maintenance
organization's right, title, and interest in and to | ||||||
28 | its health care
certificates).
| ||||||
29 | (e) In considering any management contract or service | ||||||
30 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
31 | Code, the Director (i) shall, in
addition to the criteria | ||||||
32 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
33 | into account the effect of the management contract or
service | ||||||
34 | agreement on the continuation of benefits to enrollees and the
| ||||||
35 | financial condition of the health maintenance organization to | ||||||
36 | be managed or
serviced, and (ii) need not take into account the |
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1 | effect of the management
contract or service agreement on | ||||||
2 | competition.
| ||||||
3 | (f) Except for small employer groups as defined in the | ||||||
4 | Small Employer
Rating, Renewability and Portability Health | ||||||
5 | Insurance Act and except for
medicare supplement policies as | ||||||
6 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
7 | Maintenance Organization may by contract agree with a
group or | ||||||
8 | other enrollment unit to effect refunds or charge additional | ||||||
9 | premiums
under the following terms and conditions:
| ||||||
10 | (i) the amount of, and other terms and conditions with | ||||||
11 | respect to, the
refund or additional premium are set forth | ||||||
12 | in the group or enrollment unit
contract agreed in advance | ||||||
13 | of the period for which a refund is to be paid or
| ||||||
14 | additional premium is to be charged (which period shall not | ||||||
15 | be less than one
year); and
| ||||||
16 | (ii) the amount of the refund or additional premium | ||||||
17 | shall not exceed 20%
of the Health Maintenance | ||||||
18 | Organization's profitable or unprofitable experience
with | ||||||
19 | respect to the group or other enrollment unit for the | ||||||
20 | period (and, for
purposes of a refund or additional | ||||||
21 | premium, the profitable or unprofitable
experience shall | ||||||
22 | be calculated taking into account a pro rata share of the
| ||||||
23 | Health Maintenance Organization's administrative and | ||||||
24 | marketing expenses, but
shall not include any refund to be | ||||||
25 | made or additional premium to be paid
pursuant to this | ||||||
26 | subsection (f)). The Health Maintenance Organization and | ||||||
27 | the
group or enrollment unit may agree that the profitable | ||||||
28 | or unprofitable
experience may be calculated taking into | ||||||
29 | account the refund period and the
immediately preceding 2 | ||||||
30 | plan years.
| ||||||
31 | The Health Maintenance Organization shall include a | ||||||
32 | statement in the
evidence of coverage issued to each enrollee | ||||||
33 | describing the possibility of a
refund or additional premium, | ||||||
34 | and upon request of any group or enrollment unit,
provide to | ||||||
35 | the group or enrollment unit a description of the method used | ||||||
36 | to
calculate (1) the Health Maintenance Organization's |
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|
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1 | profitable experience with
respect to the group or enrollment | ||||||
2 | unit and the resulting refund to the group
or enrollment unit | ||||||
3 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
4 | experience with respect to the group or enrollment unit and the | ||||||
5 | resulting
additional premium to be paid by the group or | ||||||
6 | enrollment unit.
| ||||||
7 | In no event shall the Illinois Health Maintenance | ||||||
8 | Organization
Guaranty Association be liable to pay any | ||||||
9 | contractual obligation of an
insolvent organization to pay any | ||||||
10 | refund authorized under this Section.
| ||||||
11 | (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, | ||||||
12 | eff. 1-1-04;
93-477, eff. 8-8-03; 93-529, eff. 8-14-03; revised | ||||||
13 | 9-25-03.)
| ||||||
14 | Section 15. The Limited Health Service Organization Act is | ||||||
15 | amended by changing Section 4003 as follows:
| ||||||
16 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| ||||||
17 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
18 | health service
organizations shall be subject to the provisions | ||||||
19 | of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | ||||||
20 | 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | ||||||
21 | 155.04, 155.37, 355.2, 356v, 356z.6, 368a, 401, 401.1,
402,
| ||||||
22 | 403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles | ||||||
23 | IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of | ||||||
24 | the Illinois Insurance Code. For purposes of the
Illinois | ||||||
25 | Insurance Code, except for Sections 444 and 444.1 and Articles | ||||||
26 | XIII
and XIII 1/2, limited health service organizations in the | ||||||
27 | following categories
are deemed to be domestic companies:
| ||||||
28 | (1) a corporation under the laws of this State; or
| ||||||
29 | (2) a corporation organized under the laws of another | ||||||
30 | state, 30% of more
of the enrollees of which are residents | ||||||
31 | of this State, except a corporation
subject to | ||||||
32 | substantially the same requirements in its state of | ||||||
33 | organization as
is a domestic company under Article VIII | ||||||
34 | 1/2 of the Illinois Insurance Code.
|
| |||||||
|
|||||||
1 | (Source: P.A. 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; | ||||||
2 | 91-788, eff.
6-9-00; 92-440, eff. 8-17-01.)
| ||||||
3 | Section 20. 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. Health | ||||||
7 | services
plan corporations and all persons interested therein | ||||||
8 | or dealing therewith
shall be subject to the provisions of | ||||||
9 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
10 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
11 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 367.2, 368a, 401, | ||||||
12 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
13 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
14 | (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
| ||||||
15 | 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; | ||||||
16 | 93-529, eff.
8-14-03; revised 9-25-03.)
| ||||||
17 | Section 99. Effective date. This Act takes effect upon | ||||||
18 | becoming law. |