Sen. Ira I. Silverstein
Filed: 5/13/2005
 
 

 




 

 		












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AMENDMENT TO HOUSE BILL 3498




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    AMENDMENT NO. ______. Amend House Bill 3498 on page 1, 
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immediately below line 3, by inserting the following:

 
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    "Section 5. The Illinois Insurance Code is amended by 
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adding Section 356z.7
as
follows:


 
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    (215 ILCS 5/356z.7 new)

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    Sec. 356z.7. Coverage for hearing aids for minors.
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    (a) An individual or group policy of accident and health 
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insurance or
managed
care plan that is amended, delivered, 
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issued, or renewed after the effective
date of this
amendatory 
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Act of the 94th General Assembly must provide coverage for 
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hearing instruments and related services for children from 
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birth to the age of 18 years when a hearing care professional 
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prescribes a hearing instrument to augment communication.

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    (b) As used in this Section:

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    "Hearing care professional" means a person who is a 
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licensed
audiologist or a licensed
physician.

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    "Hearing instrument" or "hearing aid" means any wearable 
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non-disposable instrument or device
designed to aid or 
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compensate for impaired human hearing that cannot be restored 
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either medically or surgically and any parts, attachments, or 
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accessories for the instrument or device, including an ear mold 
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but excluding batteries and cords.

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    "Related services" means those services necessary to 
 


 






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assess, select, and adjust or fit the hearing instrument to 
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ensure optimal performance.

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    (c) An insurer shall provide coverage, subject to all 
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applicable co-payments, co-insurance, deductibles, and 
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out-of-pocket limits, for the full cost of one hearing aid per 
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hearing impaired ear, up to $1,400 every 36 months, for insured 
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individuals under 18 years of age and all related services that 
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may be prescribed by a hearing care professional and dispensed 
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by a hearing care professional. The insured may choose a higher 
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priced hearing aid and may pay the difference in cost above the 
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$1,400 limit without any financial or contractual penalty to 
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the insured or the provider of the hearing aid.
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    (d) An insurer shall not be required to pay a claim filed 
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by its insured for the payment of the cost of a hearing aid 
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covered by this Section if less than 3 years prior to the date 
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of the claim its insured filed a claim for payment of the cost 
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of the hearing aid and the claim was paid by any insurer.


 
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    Section 10. The Health Maintenance Organization Act is 
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amended by changing
Section 5-3 as follows:


 



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    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


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    Sec. 5-3. Insurance Code provisions. 

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    (a) Health Maintenance Organizations
shall be subject to 
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the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
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141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
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154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
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356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01, 367.2, 
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367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
401, 401.1, 402, 
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403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) 
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of subsection (2) of Section 367, and Articles IIA, VIII 1/2,

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XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois 
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Insurance Code.

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    (b) For purposes of the Illinois Insurance Code, except for 
 


 






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Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
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Maintenance Organizations in
the following categories are 
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deemed to be "domestic companies":


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        (1) a corporation authorized under the
Dental Service 
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    Plan Act or the Voluntary Health Services Plans Act;


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        (2) a corporation organized under the laws of this 
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    State; or


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        (3) a corporation organized under the laws of another 
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    state, 30% or more
of the enrollees of which are residents 
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    of this State, except a
corporation subject to 
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    substantially the same requirements in its state of

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    organization as is a "domestic company" under Article VIII 
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    1/2 of the
Illinois Insurance Code.

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    (c) In considering the merger, consolidation, or other 
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acquisition of
control of a Health Maintenance Organization 
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pursuant to Article VIII 1/2
of the Illinois Insurance Code,


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        (1) the Director shall give primary consideration to 
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    the continuation of
benefits to enrollees and the financial 
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    conditions of the acquired Health
Maintenance Organization 
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    after the merger, consolidation, or other
acquisition of 
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    control takes effect;


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        (2)(i) the criteria specified in subsection (1)(b) of 
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    Section 131.8 of
the Illinois Insurance Code shall not 
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    apply and (ii) the Director, in making
his determination 
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    with respect to the merger, consolidation, or other

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    acquisition of control, need not take into account the 
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    effect on
competition of the merger, consolidation, or 
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    other acquisition of control;


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        (3) the Director shall have the power to require the 
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    following
information:


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            (A) certification by an independent actuary of the 
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        adequacy
of the reserves of the Health Maintenance 
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        Organization sought to be acquired;


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            (B) pro forma financial statements reflecting the 
 


 






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        combined balance
sheets of the acquiring company and 
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        the Health Maintenance Organization sought
to be 
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        acquired as of the end of the preceding year and as of 
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        a date 90 days
prior to the acquisition, as well as pro 
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        forma financial statements
reflecting projected 
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        combined operation for a period of 2 years;


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            (C) a pro forma business plan detailing an 
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        acquiring party's plans with
respect to the operation 
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        of the Health Maintenance Organization sought to
be 
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        acquired for a period of not less than 3 years; and


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            (D) such other information as the Director shall 
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        require.

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    (d) The provisions of Article VIII 1/2 of the Illinois 
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Insurance Code
and this Section 5-3 shall apply to the sale by 
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any health maintenance
organization of greater than 10% of its

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enrollee population (including without limitation the health 
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maintenance
organization's right, title, and interest in and to 
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its health care
certificates).

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    (e) In considering any management contract or service 
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agreement subject
to Section 141.1 of the Illinois Insurance 
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Code, the Director (i) shall, in
addition to the criteria 
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specified in Section 141.2 of the Illinois
Insurance Code, take 
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into account the effect of the management contract or
service 
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agreement on the continuation of benefits to enrollees and the

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financial condition of the health maintenance organization to 
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be managed or
serviced, and (ii) need not take into account the 
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effect of the management
contract or service agreement on 
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competition.

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    (f) Except for small employer groups as defined in the 
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Small Employer
Rating, Renewability and Portability Health 
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Insurance Act and except for
medicare supplement policies as 
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defined in Section 363 of the Illinois
Insurance Code, a Health 
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Maintenance Organization may by contract agree with a
group or 
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other enrollment unit to effect refunds or charge additional 
 


 






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premiums
under the following terms and conditions:


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        (i) the amount of, and other terms and conditions with 
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    respect to, the
refund or additional premium are set forth 
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    in the group or enrollment unit
contract agreed in advance 
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    of the period for which a refund is to be paid or

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    additional premium is to be charged (which period shall not 
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    be less than one
year); and


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        (ii) the amount of the refund or additional premium 
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    shall not exceed 20%
of the Health Maintenance 
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    Organization's profitable or unprofitable experience
with 
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    respect to the group or other enrollment unit for the 
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    period (and, for
purposes of a refund or additional 
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    premium, the profitable or unprofitable
experience shall 
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    be calculated taking into account a pro rata share of the

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    Health Maintenance Organization's administrative and 
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    marketing expenses, but
shall not include any refund to be 
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    made or additional premium to be paid
pursuant to this 
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    subsection (f)).  The Health Maintenance Organization and 
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    the
group or enrollment unit may agree that the profitable 
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    or unprofitable
experience may be calculated taking into 
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    account the refund period and the
immediately preceding 2 
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    plan years.

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    The Health Maintenance Organization shall include a 
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statement in the
evidence of coverage issued to each enrollee 
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describing the possibility of a
refund or additional premium, 
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and upon request of any group or enrollment unit,
provide to 
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the group or enrollment unit a description of the method used 
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to
calculate (1) the Health Maintenance Organization's 
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profitable experience with
respect to the group or enrollment 
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unit and the resulting refund to the group
or enrollment unit 
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or (2) the Health Maintenance Organization's unprofitable

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experience with respect to the group or enrollment unit and the 
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resulting
additional premium to be paid by the group or 
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enrollment unit.

 


 






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    In no event shall the Illinois Health Maintenance 
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Organization
Guaranty Association be liable to pay any 
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contractual obligation of an
insolvent organization to pay any 
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refund authorized under this Section.

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(Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261, 
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eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, 
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eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)



 
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    Section 15. The Voluntary Health Services Plans Act is 
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amended by changing
Section 10 as follows:


 



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    (215 ILCS 165/10)  (from Ch. 32, par. 604)


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    Sec. 10. Application of Insurance Code provisions. Health 
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services
plan corporations and all persons interested therein 
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or dealing therewith
shall be subject to the provisions of 
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Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
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149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, 
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356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01, 
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367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, 
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and paragraphs (7) and (15) of Section 367 of the Illinois

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Insurance Code.

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(Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01; 
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92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 
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93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 93-1000, eff. 
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1-1-05; revised 10-14-04.)"; and



 
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on page 1, line 4, by replacing "Section 5." with "Section 
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20.".