|
|||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||
1 | AN ACT concerning insurance.
| ||||||||||||||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||||||||||||||
4 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||||||||||||||||||||||||||||||||
5 | 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 provide | ||||||||||||||||||||||||||||||||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||||||||||||||||||||||||||||||||
10 | policy of accident and health insurance under Section 356t of | ||||||||||||||||||||||||||||||||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||||||||||||||||||||||||||||||||
12 | shall provide the coverage
required under Sections 356u, 356w, | ||||||||||||||||||||||||||||||||||||
13 | 356x, 356z.2, 356z.4, and 356z.6 , and 356z.9 of the
Illinois | ||||||||||||||||||||||||||||||||||||
14 | Insurance Code.
The program of health benefits must comply with | ||||||||||||||||||||||||||||||||||||
15 | 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 | 93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)
| ||||||||||||||||||||||||||||||||||||
18 | Section 10. The Counties Code is amended by changing | ||||||||||||||||||||||||||||||||||||
19 | Section 5-1069.3 as follows: | ||||||||||||||||||||||||||||||||||||
20 | (55 ILCS 5/5-1069.3)
| ||||||||||||||||||||||||||||||||||||
21 | Sec. 5-1069.3. Required health benefits. If a county, |
| |||||||
| |||||||
1 | including a home
rule
county, is a self-insurer for purposes of | ||||||
2 | providing health insurance coverage
for its employees, the | ||||||
3 | coverage shall include coverage for the post-mastectomy
care | ||||||
4 | benefits required to be covered by a policy of accident and | ||||||
5 | health
insurance under Section 356t and the coverage required | ||||||
6 | under Sections 356u,
356w, 356x ,
and 356z.6 , and 356z.9 of
the | ||||||
7 | Illinois Insurance Code. The requirement that health benefits | ||||||
8 | be covered
as provided in this Section is an
exclusive power | ||||||
9 | and function of the State and is a denial and limitation under
| ||||||
10 | Article VII, Section 6, subsection (h) of the Illinois | ||||||
11 | Constitution. A home
rule county to which this Section applies | ||||||
12 | must comply with every provision of
this Section.
| ||||||
13 | (Source: P.A. 93-853, eff. 1-1-05.)
| ||||||
14 | Section 15. The Illinois Municipal Code is amended by | ||||||
15 | changing Section 10-4-2.3 as follows: | ||||||
16 | (65 ILCS 5/10-4-2.3)
| ||||||
17 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
18 | municipality, including a
home rule municipality, is a | ||||||
19 | self-insurer for purposes of providing health
insurance | ||||||
20 | coverage for its employees, the coverage shall include coverage | ||||||
21 | for
the post-mastectomy care benefits required to be covered by | ||||||
22 | a policy of
accident and health insurance under Section 356t | ||||||
23 | and the coverage required
under Sections 356u, 356w, 356x ,
and
| ||||||
24 | 356z.6 , and 356z.9 of the Illinois
Insurance
Code. The |
| |||||||
| |||||||
1 | requirement that health
benefits be covered as provided in this | ||||||
2 | is an exclusive power and function of
the State and is a denial | ||||||
3 | and limitation under Article VII, Section 6,
subsection (h) of | ||||||
4 | the Illinois Constitution. A home rule municipality to which
| ||||||
5 | this Section applies must comply with every provision of this | ||||||
6 | Section.
| ||||||
7 | (Source: P.A. 93-853, eff. 1-1-05.)
| ||||||
8 | Section 20. The School Code is amended by changing Section | ||||||
9 | 10-22.3f as follows: | ||||||
10 | (105 ILCS 5/10-22.3f)
| ||||||
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 356u, 356w, 356x ,
and
| ||||||
16 | 356z.6 , and 356z.9 of
the
Illinois Insurance Code.
| ||||||
17 | (Source: P.A. 93-853, eff. 1-1-05.)
| ||||||
18 | Section 25. The Illinois Insurance Code is amended by | ||||||
19 | adding Section 356z.9 as follows: | ||||||
20 | (215 ILCS 5/356z.9 new) | ||||||
21 | Sec. 356z.9. Eating disorder treatments. A group or | ||||||
22 | individual policy of accident and health insurance or managed |
| |||||||
| |||||||
1 | care plan amended, delivered, issued, or renewed after the | ||||||
2 | effective date of this amendatory Act of the 95th General | ||||||
3 | Assembly must provide coverage for eating disorder treatments. | ||||||
4 | Section 30. The Health Maintenance Organization Act is | ||||||
5 | amended by changing Section 5-3 as follows:
| ||||||
6 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
7 | Sec. 5-3. Insurance Code provisions.
| ||||||
8 | (a) Health Maintenance Organizations
shall be subject to | ||||||
9 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
10 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
11 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
12 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 364.01, | ||||||
13 | 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | ||||||
14 | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
| ||||||
15 | paragraph (c) of subsection (2) of Section 367, and Articles | ||||||
16 | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | ||||||
17 | the Illinois Insurance Code.
| ||||||
18 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
19 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
20 | Maintenance Organizations in
the following categories are | ||||||
21 | deemed to be "domestic companies":
| ||||||
22 | (1) a corporation authorized under the
Dental Service | ||||||
23 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
24 | (2) a corporation organized under the laws of this |
| |||||||
| |||||||
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 |
| |||||||
| |||||||
1 | Organization sought to be acquired;
| ||||||
2 | (B) pro forma financial statements reflecting the | ||||||
3 | combined balance
sheets of the acquiring company and | ||||||
4 | the Health Maintenance Organization sought
to be | ||||||
5 | acquired as of the end of the preceding year and as of | ||||||
6 | a date 90 days
prior to the acquisition, as well as pro | ||||||
7 | forma financial statements
reflecting projected | ||||||
8 | combined operation for a period of 2 years;
| ||||||
9 | (C) a pro forma business plan detailing an | ||||||
10 | acquiring party's plans with
respect to the operation | ||||||
11 | of the Health Maintenance Organization sought to
be | ||||||
12 | acquired for a period of not less than 3 years; and
| ||||||
13 | (D) such other information as the Director shall | ||||||
14 | require.
| ||||||
15 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
16 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
17 | any health maintenance
organization of greater than 10% of its
| ||||||
18 | enrollee population (including without limitation the health | ||||||
19 | maintenance
organization's right, title, and interest in and to | ||||||
20 | its health care
certificates).
| ||||||
21 | (e) In considering any management contract or service | ||||||
22 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
23 | Code, the Director (i) shall, in
addition to the criteria | ||||||
24 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
25 | into account the effect of the management contract or
service | ||||||
26 | agreement on the continuation of benefits to enrollees and the
|
| |||||||
| |||||||
1 | financial condition of the health maintenance organization to | ||||||
2 | be managed or
serviced, and (ii) need not take into account the | ||||||
3 | effect of the management
contract or service agreement on | ||||||
4 | competition.
| ||||||
5 | (f) Except for small employer groups as defined in the | ||||||
6 | Small Employer
Rating, Renewability and Portability Health | ||||||
7 | Insurance Act and except for
medicare supplement policies as | ||||||
8 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
9 | Maintenance Organization may by contract agree with a
group or | ||||||
10 | other enrollment unit to effect refunds or charge additional | ||||||
11 | premiums
under the following terms and conditions:
| ||||||
12 | (i) the amount of, and other terms and conditions with | ||||||
13 | respect to, the
refund or additional premium are set forth | ||||||
14 | in the group or enrollment unit
contract agreed in advance | ||||||
15 | of the period for which a refund is to be paid or
| ||||||
16 | additional premium is to be charged (which period shall not | ||||||
17 | be less than one
year); and
| ||||||
18 | (ii) the amount of the refund or additional premium | ||||||
19 | shall not exceed 20%
of the Health Maintenance | ||||||
20 | Organization's profitable or unprofitable experience
with | ||||||
21 | respect to the group or other enrollment unit for the | ||||||
22 | period (and, for
purposes of a refund or additional | ||||||
23 | premium, the profitable or unprofitable
experience shall | ||||||
24 | be calculated taking into account a pro rata share of the
| ||||||
25 | Health Maintenance Organization's administrative and | ||||||
26 | marketing expenses, but
shall not include any refund to be |
| |||||||
| |||||||
1 | made or additional premium to be paid
pursuant to this | ||||||
2 | subsection (f)). The Health Maintenance Organization and | ||||||
3 | the
group or enrollment unit may agree that the profitable | ||||||
4 | or unprofitable
experience may be calculated taking into | ||||||
5 | account the refund period and the
immediately preceding 2 | ||||||
6 | plan years.
| ||||||
7 | The Health Maintenance Organization shall include a | ||||||
8 | statement in the
evidence of coverage issued to each enrollee | ||||||
9 | describing the possibility of a
refund or additional premium, | ||||||
10 | and upon request of any group or enrollment unit,
provide to | ||||||
11 | the group or enrollment unit a description of the method used | ||||||
12 | to
calculate (1) the Health Maintenance Organization's | ||||||
13 | profitable experience with
respect to the group or enrollment | ||||||
14 | unit and the resulting refund to the group
or enrollment unit | ||||||
15 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
16 | experience with respect to the group or enrollment unit and the | ||||||
17 | resulting
additional premium to be paid by the group or | ||||||
18 | enrollment unit.
| ||||||
19 | In no event shall the Illinois Health Maintenance | ||||||
20 | Organization
Guaranty Association be liable to pay any | ||||||
21 | contractual obligation of an
insolvent organization to pay any | ||||||
22 | refund authorized under this Section.
| ||||||
23 | (Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, | ||||||
24 | eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; | ||||||
25 | 93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff. | ||||||
26 | 12-29-06; revised 1-5-07.)
|
| |||||||
| |||||||
1 | Section 35. The Voluntary Health Services Plans Act is | ||||||
2 | amended by changing Section 10 as follows:
| ||||||
3 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
4 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
5 | services
plan corporations and all persons interested therein | ||||||
6 | or dealing therewith
shall be subject to the provisions of | ||||||
7 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
8 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
9 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| ||||||
10 | 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | ||||||
11 | and 412, and paragraphs (7) and (15) of Section 367 of the | ||||||
12 | Illinois
Insurance Code.
| ||||||
13 | (Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; | ||||||
14 | 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. | ||||||
15 | 12-29-06.)
|