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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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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:
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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,
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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.)
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13 | (215 ILCS 5/367.4 new)
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14 | Sec. 367.4. Reporting of claims information to group health | ||||||
15 | plan sponsor.
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16 | (a) In this Section, "group health plan", "health insurance | ||||||
17 | coverage",
"health insurance issuer", and "plan sponsor" have | ||||||
18 | the meanings ascribed to
those terms in the Illinois Health | ||||||
19 | Insurance Portability and Accountability
Act.
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20 | "Summary health information" means information that may be
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21 | individually identifiable health information and
(i) that | ||||||
22 | summarizes the claims history, claims expenses, or type of
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1 | claims experienced by individuals for whom a plan sponsor has | ||||||
2 | provided
health benefits under a group health plan and
(ii) | ||||||
3 | from which the information identifying an individual, a | ||||||
4 | relative or employer of the individual, or a member of the | ||||||
5 | individual's household
has been deleted, except that | ||||||
6 | information describing geographic subdivisions of a State need | ||||||
7 | only be aggregated to the level of a 5-digit zip code.
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8 | (b) A group health plan, or a health insurance issuer or | ||||||
9 | health maintenance organization with
respect to a group health | ||||||
10 | plan, shall disclose summary health
information to a plan | ||||||
11 | sponsor with 50 or more employees if the plan sponsor requests | ||||||
12 | the
summary health information for the purpose of (i) obtaining | ||||||
13 | premium bids from health plans for providing health
insurance | ||||||
14 | coverage under the group health plan or (ii) modifying, | ||||||
15 | amending, or terminating the group health plan. | ||||||
16 | The plan documents of the group health plan must be amended | ||||||
17 | to
incorporate provisions to do the following: | ||||||
18 | (1) Establish the permitted and required uses and | ||||||
19 | disclosures of
such information by the plan sponsor. | ||||||
20 | (2) Provide that the plan sponsor agrees to not use or | ||||||
21 | further disclose the information other than as
permitted or | ||||||
22 | required by the plan documents or as required by law.
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23 | (3) Provide that the plan sponsor agrees to not use or | ||||||
24 | disclose the information for employment-related
actions | ||||||
25 | and decisions or in connection with any other benefit or
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26 | employee benefit plan of the plan sponsor. |
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1 | (4) Provide that the plan sponsor agrees to report to | ||||||
2 | the group health plan any use or disclosure of the
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3 | information that is inconsistent with the uses or | ||||||
4 | disclosures provided
for of which it becomes aware. | ||||||
5 | (5) Provide that the plan sponsor agrees to make | ||||||
6 | available the information required to provide an | ||||||
7 | accounting
of disclosures. | ||||||
8 | (6) Provide that the plan sponsor agrees to make its | ||||||
9 | internal practices, books, and records relating to the
use | ||||||
10 | and disclosure of the summary health information received | ||||||
11 | from the
group health plan available to the Director for | ||||||
12 | purposes of determining
compliance by the group health plan | ||||||
13 | with this Section. | ||||||
14 | (7) Provide that the plan sponsor agrees to, if | ||||||
15 | feasible, return or destroy all protected health | ||||||
16 | information
received from the group health plan that the | ||||||
17 | sponsor still maintains in
any form and retain no copies of | ||||||
18 | such information when no longer needed
for the purpose for | ||||||
19 | which disclosure was made, except that, if such
return or | ||||||
20 | destruction is not feasible, limit further uses and
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21 | disclosures to those purposes that make the return or | ||||||
22 | destruction of the
information infeasible. | ||||||
23 | (c) A health insurance issuer may not report any | ||||||
24 | information required under
this Section the release of which is | ||||||
25 | prohibited by State or federal law or
regulation.
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26 | (d) A health insurance issuer must provide information |
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1 | under this Section in
the aggregate, without any information | ||||||
2 | through which a specific individual
covered under the plan may | ||||||
3 | be identified.
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4 | (e) Information obtained by a plan sponsor under this | ||||||
5 | Section is
confidential. The sponsor may use the information | ||||||
6 | only for purposes relating to
obtaining and maintaining health | ||||||
7 | insurance coverage for the sponsor's
employees (if the sponsor | ||||||
8 | is an employer) or members (if the sponsor is an
employee | ||||||
9 | organization).
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10 | Section 10. The Health Care Purchasing Group Act is amended | ||||||
11 | by changing
Section 5 as follows:
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12 | (215 ILCS 123/5)
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13 | Sec. 5. Purpose; applicability of Illinois Health | ||||||
14 | Insurance Portability
and Accountability Act.
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15 | (a) The purpose and intent of this Act is
to authorize the | ||||||
16 | formation, operation, and regulation of health care
purchasing | ||||||
17 | groups (referred to in this Act as "HPGs") as described by
this | ||||||
18 | Act, to authorize the sale and regulation of health
insurance | ||||||
19 | products for employers that are sold to HPGs, and to
encourage | ||||||
20 | the development of financially secure and cost
effective | ||||||
21 | markets for the basic health care needs of employers,
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22 | employees, and their dependents in this State.
Nothing in this | ||||||
23 | Act authorizes an employer to join with other employers to
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24 | self-insure through risk pooling.
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1 | (b) All health insurance contracts issued under this Act | ||||||
2 | are subject to
the Illinois Health Insurance Portability and | ||||||
3 | Accountability Act.
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4 | (c) All health insurance contracts issued under this Act | ||||||
5 | are subject to
Section 367.4 of the Illinois Insurance Code.
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6 | (Source: P.A. 90-337, eff. 1-1-98; 90-567, eff. 1-23-98.)
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7 | Section 15. The Health Maintenance Organization Act is | ||||||
8 | amended by changing
Section 5-3 as follows:
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9 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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10 | Sec. 5-3. Insurance Code provisions.
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11 | (a) Health Maintenance Organizations
shall be subject to | ||||||
12 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
13 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
14 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
15 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 364.01, 367.2, | ||||||
16 | 367.2-5, 367.4, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | ||||||
17 | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
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18 | paragraph (c) of subsection (2) of Section 367, and Articles | ||||||
19 | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | ||||||
20 | the Illinois Insurance Code.
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21 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
22 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
23 | Maintenance Organizations in
the following categories are | ||||||
24 | deemed to be "domestic companies":
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1 | (1) a corporation authorized under the
Dental Service | ||||||
2 | Plan Act or the Voluntary Health Services Plans Act;
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3 | (2) a corporation organized under the laws of this | ||||||
4 | State; or
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5 | (3) a corporation organized under the laws of another | ||||||
6 | state, 30% or more
of the enrollees of which are residents | ||||||
7 | of this State, except a
corporation subject to | ||||||
8 | substantially the same requirements in its state of
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9 | organization as is a "domestic company" under Article VIII | ||||||
10 | 1/2 of the
Illinois Insurance Code.
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11 | (c) In considering the merger, consolidation, or other | ||||||
12 | acquisition of
control of a Health Maintenance Organization | ||||||
13 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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14 | (1) the Director shall give primary consideration to | ||||||
15 | the continuation of
benefits to enrollees and the financial | ||||||
16 | conditions of the acquired Health
Maintenance Organization | ||||||
17 | after the merger, consolidation, or other
acquisition of | ||||||
18 | control takes effect;
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19 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
20 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
21 | apply and (ii) the Director, in making
his determination | ||||||
22 | with respect to the merger, consolidation, or other
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23 | acquisition of control, need not take into account the | ||||||
24 | effect on
competition of the merger, consolidation, or | ||||||
25 | other acquisition of control;
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26 | (3) the Director shall have the power to require the |
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1 | following
information:
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2 | (A) certification by an independent actuary of the | ||||||
3 | adequacy
of the reserves of the Health Maintenance | ||||||
4 | Organization sought to be acquired;
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5 | (B) pro forma financial statements reflecting the | ||||||
6 | combined balance
sheets of the acquiring company and | ||||||
7 | the Health Maintenance Organization sought
to be | ||||||
8 | acquired as of the end of the preceding year and as of | ||||||
9 | a date 90 days
prior to the acquisition, as well as pro | ||||||
10 | forma financial statements
reflecting projected | ||||||
11 | combined operation for a period of 2 years;
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12 | (C) a pro forma business plan detailing an | ||||||
13 | acquiring party's plans with
respect to the operation | ||||||
14 | of the Health Maintenance Organization sought to
be | ||||||
15 | acquired for a period of not less than 3 years; and
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16 | (D) such other information as the Director shall | ||||||
17 | require.
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18 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
19 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
20 | any health maintenance
organization of greater than 10% of its
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21 | enrollee population (including without limitation the health | ||||||
22 | maintenance
organization's right, title, and interest in and to | ||||||
23 | its health care
certificates).
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24 | (e) In considering any management contract or service | ||||||
25 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
26 | Code, the Director (i) shall, in
addition to the criteria |
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1 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
2 | into account the effect of the management contract or
service | ||||||
3 | agreement on the continuation of benefits to enrollees and the
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4 | financial condition of the health maintenance organization to | ||||||
5 | be managed or
serviced, and (ii) need not take into account the | ||||||
6 | effect of the management
contract or service agreement on | ||||||
7 | competition.
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8 | (f) Except for small employer groups as defined in the | ||||||
9 | Small Employer
Rating, Renewability and Portability Health | ||||||
10 | Insurance Act and except for
medicare supplement policies as | ||||||
11 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
12 | Maintenance Organization may by contract agree with a
group or | ||||||
13 | other enrollment unit to effect refunds or charge additional | ||||||
14 | premiums
under the following terms and conditions:
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15 | (i) the amount of, and other terms and conditions with | ||||||
16 | respect to, the
refund or additional premium are set forth | ||||||
17 | in the group or enrollment unit
contract agreed in advance | ||||||
18 | of the period for which a refund is to be paid or
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19 | additional premium is to be charged (which period shall not | ||||||
20 | be less than one
year); and
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21 | (ii) the amount of the refund or additional premium | ||||||
22 | shall not exceed 20%
of the Health Maintenance | ||||||
23 | Organization's profitable or unprofitable experience
with | ||||||
24 | respect to the group or other enrollment unit for the | ||||||
25 | period (and, for
purposes of a refund or additional | ||||||
26 | premium, the profitable or unprofitable
experience shall |
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1 | be calculated taking into account a pro rata share of the
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2 | Health Maintenance Organization's administrative and | ||||||
3 | marketing expenses, but
shall not include any refund to be | ||||||
4 | made or additional premium to be paid
pursuant to this | ||||||
5 | subsection (f)). The Health Maintenance Organization and | ||||||
6 | the
group or enrollment unit may agree that the profitable | ||||||
7 | or unprofitable
experience may be calculated taking into | ||||||
8 | account the refund period and the
immediately preceding 2 | ||||||
9 | plan years.
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10 | The Health Maintenance Organization shall include a | ||||||
11 | statement in the
evidence of coverage issued to each enrollee | ||||||
12 | describing the possibility of a
refund or additional premium, | ||||||
13 | and upon request of any group or enrollment unit,
provide to | ||||||
14 | the group or enrollment unit a description of the method used | ||||||
15 | to
calculate (1) the Health Maintenance Organization's | ||||||
16 | profitable experience with
respect to the group or enrollment | ||||||
17 | unit and the resulting refund to the group
or enrollment unit | ||||||
18 | or (2) the Health Maintenance Organization's unprofitable
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19 | experience with respect to the group or enrollment unit and the | ||||||
20 | resulting
additional premium to be paid by the group or | ||||||
21 | enrollment unit.
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22 | In no event shall the Illinois Health Maintenance | ||||||
23 | Organization
Guaranty Association be liable to pay any | ||||||
24 | contractual obligation of an
insolvent organization to pay any | ||||||
25 | refund authorized under this Section.
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26 | (Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, |
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1 | eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; | ||||||
2 | 93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff. | ||||||
3 | 12-29-06; revised 1-5-07.)
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4 | Section 20. The Limited Health Service Organization Act is | ||||||
5 | amended by
changing Section 4003 as follows:
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6 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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7 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
8 | health service
organizations shall be subject to the provisions | ||||||
9 | of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | ||||||
10 | 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | ||||||
11 | 155.04, 155.37, 355.2, 356v, 367.4, 368a, 401, 401.1,
402,
403, | ||||||
12 | 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles IIA, | ||||||
13 | VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of the | ||||||
14 | Illinois Insurance Code. For purposes of the
Illinois Insurance | ||||||
15 | Code, except for Sections 444 and 444.1 and Articles XIII
and | ||||||
16 | XIII 1/2, limited health service organizations in the following | ||||||
17 | categories
are deemed to be domestic companies:
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18 | (1) a corporation under the laws of this State; or
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19 | (2) a corporation organized under the laws of another | ||||||
20 | state, 30% of more
of the enrollees of which are residents | ||||||
21 | of this State, except a corporation
subject to | ||||||
22 | substantially the same requirements in its state of | ||||||
23 | organization as
is a domestic company under Article VIII | ||||||
24 | 1/2 of the Illinois Insurance Code.
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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.)
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3 | Section 25. The Voluntary Health Services Plans Act is | ||||||
4 | amended by changing
Section 10 as follows:
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5 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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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, 356z.8, 364.01, | ||||||
12 | 367.2, 367.4, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and | ||||||
13 | 412, and paragraphs (7) and (15) of Section 367 of the Illinois
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14 | Insurance Code.
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15 | (Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; | ||||||
16 | 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. | ||||||
17 | 12-29-06.)
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