|
||||||||||||||||||||||||||
|
||||||||||||||||||||||||||
| ||||||||||||||||||||||||||
| ||||||||||||||||||||||||||
| ||||||||||||||||||||||||||
1 | AN ACT concerning insurance.
| |||||||||||||||||||||||||
2 | WHEREAS, Hundreds of children in this State are born every | |||||||||||||||||||||||||
3 | year with gastrointestinal disorders, such as Gastrointestinal | |||||||||||||||||||||||||
4 | Reflux Disease (GERD), Eosinophilic Esophagitis (EE), and | |||||||||||||||||||||||||
5 | others or inherited diseases of amino acid, organic acid, or | |||||||||||||||||||||||||
6 | dairy protein allergies, which prevent proper digestion or | |||||||||||||||||||||||||
7 | result in a negative reaction to certain natural milk or soy | |||||||||||||||||||||||||
8 | products, formulas, and multiple foods; | |||||||||||||||||||||||||
9 | WHEREAS, These conditions and others create a situation | |||||||||||||||||||||||||
10 | where a natural sustained existence is virtually impossible and | |||||||||||||||||||||||||
11 | threaten a child's ability to thrive; | |||||||||||||||||||||||||
12 | WHEREAS, As many of these children are unable to process | |||||||||||||||||||||||||
13 | any natural nutritional substance, parents, at the advice and | |||||||||||||||||||||||||
14 | direction of a licensed health care professional, must seek | |||||||||||||||||||||||||
15 | enteral or oral elemental formulas, such as amino acid modified | |||||||||||||||||||||||||
16 | formulas and other specialized formulas, to provide proper and | |||||||||||||||||||||||||
17 | medically necessary nutrition; | |||||||||||||||||||||||||
18 | WHEREAS, Amino acid based elemental formulas and food | |||||||||||||||||||||||||
19 | products are widely available, but expensive in nature due to a | |||||||||||||||||||||||||
20 | complicated scientific manufacturing process; | |||||||||||||||||||||||||
21 | WHEREAS, Health insurance policies currently only cover | |||||||||||||||||||||||||
22 | the cost of specialized amino acid based elemental formulas | |||||||||||||||||||||||||
23 | when administered by tube feeding even though tube feeding is | |||||||||||||||||||||||||
24 | not always the least medically invasive or most cost effective | |||||||||||||||||||||||||
25 | option available; | |||||||||||||||||||||||||
26 | WHEREAS, Proper infant and child nutrition significantly |
| |||||||
| |||||||
1 | reduces digestion problems and other developmental and | ||||||
2 | physical conditions, as well as the need for future, more | ||||||
3 | expensive medical treatments; and | ||||||
4 | WHEREAS, The State of Illinois is committed to giving each | ||||||
5 | and every child proper nutrition and a high quality of life, | ||||||
6 | therefore | ||||||
7 | Be it enacted by the People of the State of Illinois,
| ||||||
8 | represented in the General Assembly:
| ||||||
9 | Section 5. The Illinois Insurance Code is amended by adding | ||||||
10 | Section 356z.9 as follows: | ||||||
11 | (215 ILCS 5/356z.9 new) | ||||||
12 | Sec. 356z.9. Treatment of certain metabolic diseases. An | ||||||
13 | individual or group policy of accident and health insurance or | ||||||
14 | managed care plan amended, delivered, issued, or renewed after | ||||||
15 | the effective date of this amendatory Act of the 95th General | ||||||
16 | Assembly must provide coverage for the following: | ||||||
17 | (1) prescription enteral and oral formulas for home use | ||||||
18 | for which a physician has issued a written order and that | ||||||
19 | are medically necessary for the treatment or management of | ||||||
20 | phenylketonuria or other inherited diseases involving | ||||||
21 | amino acids or other organic acids; | ||||||
22 | (2) up to $2,500 per year worth of food products | ||||||
23 | modified to be low in protein for which a physician has |
| |||||||
| |||||||
1 | issued a written order and that are medically necessary for | ||||||
2 | the management of phenylketonuria or other inherited | ||||||
3 | diseases involving amino acids or other organic acids; and | ||||||
4 | (3) nonprescription amino acid based elemental | ||||||
5 | formulas, regardless of delivery method, that are | ||||||
6 | medically necessary for the management of phenylketonuria | ||||||
7 | or other inherited diseases involving amino acids or other | ||||||
8 | organic acids.
| ||||||
9 | Section 10. The Health Maintenance Organization Act is | ||||||
10 | amended by changing Section 5-3 as follows:
| ||||||
11 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
12 | Sec. 5-3. Insurance Code provisions.
| ||||||
13 | (a) Health Maintenance Organizations
shall be subject to | ||||||
14 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
15 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
16 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
17 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 364.01, | ||||||
18 | 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | ||||||
19 | 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
| ||||||
20 | paragraph (c) of subsection (2) of Section 367, and Articles | ||||||
21 | IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of | ||||||
22 | the Illinois Insurance Code.
| ||||||
23 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
24 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
| |||||||
| |||||||
1 | Maintenance Organizations in
the following categories are | ||||||
2 | deemed to be "domestic companies":
| ||||||
3 | (1) a corporation authorized under the
Dental Service | ||||||
4 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
5 | (2) a corporation organized under the laws of this | ||||||
6 | State; or
| ||||||
7 | (3) a corporation organized under the laws of another | ||||||
8 | state, 30% or more
of the enrollees of which are residents | ||||||
9 | of this State, except a
corporation subject to | ||||||
10 | substantially the same requirements in its state of
| ||||||
11 | organization as is a "domestic company" under Article VIII | ||||||
12 | 1/2 of the
Illinois Insurance Code.
| ||||||
13 | (c) In considering the merger, consolidation, or other | ||||||
14 | acquisition of
control of a Health Maintenance Organization | ||||||
15 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
16 | (1) the Director shall give primary consideration to | ||||||
17 | the continuation of
benefits to enrollees and the financial | ||||||
18 | conditions of the acquired Health
Maintenance Organization | ||||||
19 | after the merger, consolidation, or other
acquisition of | ||||||
20 | control takes effect;
| ||||||
21 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
22 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
23 | apply and (ii) the Director, in making
his determination | ||||||
24 | with respect to the merger, consolidation, or other
| ||||||
25 | acquisition of control, need not take into account the | ||||||
26 | effect on
competition of the merger, consolidation, or |
| |||||||
| |||||||
1 | other acquisition of control;
| ||||||
2 | (3) the Director shall have the power to require the | ||||||
3 | following
information:
| ||||||
4 | (A) certification by an independent actuary of the | ||||||
5 | adequacy
of the reserves of the Health Maintenance | ||||||
6 | Organization sought to be acquired;
| ||||||
7 | (B) pro forma financial statements reflecting the | ||||||
8 | combined balance
sheets of the acquiring company and | ||||||
9 | the Health Maintenance Organization sought
to be | ||||||
10 | acquired as of the end of the preceding year and as of | ||||||
11 | a date 90 days
prior to the acquisition, as well as pro | ||||||
12 | forma financial statements
reflecting projected | ||||||
13 | combined operation for a period of 2 years;
| ||||||
14 | (C) a pro forma business plan detailing an | ||||||
15 | acquiring party's plans with
respect to the operation | ||||||
16 | of the Health Maintenance Organization sought to
be | ||||||
17 | acquired for a period of not less than 3 years; and
| ||||||
18 | (D) such other information as the Director shall | ||||||
19 | require.
| ||||||
20 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
21 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
22 | any health maintenance
organization of greater than 10% of its
| ||||||
23 | enrollee population (including without limitation the health | ||||||
24 | maintenance
organization's right, title, and interest in and to | ||||||
25 | its health care
certificates).
| ||||||
26 | (e) In considering any management contract or service |
| |||||||
| |||||||
1 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
2 | Code, the Director (i) shall, in
addition to the criteria | ||||||
3 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
4 | into account the effect of the management contract or
service | ||||||
5 | agreement on the continuation of benefits to enrollees and the
| ||||||
6 | financial condition of the health maintenance organization to | ||||||
7 | be managed or
serviced, and (ii) need not take into account the | ||||||
8 | effect of the management
contract or service agreement on | ||||||
9 | competition.
| ||||||
10 | (f) Except for small employer groups as defined in the | ||||||
11 | Small Employer
Rating, Renewability and Portability Health | ||||||
12 | Insurance Act and except for
medicare supplement policies as | ||||||
13 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
14 | Maintenance Organization may by contract agree with a
group or | ||||||
15 | other enrollment unit to effect refunds or charge additional | ||||||
16 | premiums
under the following terms and conditions:
| ||||||
17 | (i) the amount of, and other terms and conditions with | ||||||
18 | respect to, the
refund or additional premium are set forth | ||||||
19 | in the group or enrollment unit
contract agreed in advance | ||||||
20 | of the period for which a refund is to be paid or
| ||||||
21 | additional premium is to be charged (which period shall not | ||||||
22 | be less than one
year); and
| ||||||
23 | (ii) the amount of the refund or additional premium | ||||||
24 | shall not exceed 20%
of the Health Maintenance | ||||||
25 | Organization's profitable or unprofitable experience
with | ||||||
26 | respect to the group or other enrollment unit for the |
| |||||||
| |||||||
1 | period (and, for
purposes of a refund or additional | ||||||
2 | premium, the profitable or unprofitable
experience shall | ||||||
3 | be calculated taking into account a pro rata share of the
| ||||||
4 | Health Maintenance Organization's administrative and | ||||||
5 | marketing expenses, but
shall not include any refund to be | ||||||
6 | made or additional premium to be paid
pursuant to this | ||||||
7 | subsection (f)). The Health Maintenance Organization and | ||||||
8 | the
group or enrollment unit may agree that the profitable | ||||||
9 | or unprofitable
experience may be calculated taking into | ||||||
10 | account the refund period and the
immediately preceding 2 | ||||||
11 | plan years.
| ||||||
12 | The Health Maintenance Organization shall include a | ||||||
13 | statement in the
evidence of coverage issued to each enrollee | ||||||
14 | describing the possibility of a
refund or additional premium, | ||||||
15 | and upon request of any group or enrollment unit,
provide to | ||||||
16 | the group or enrollment unit a description of the method used | ||||||
17 | to
calculate (1) the Health Maintenance Organization's | ||||||
18 | profitable experience with
respect to the group or enrollment | ||||||
19 | unit and the resulting refund to the group
or enrollment unit | ||||||
20 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
21 | experience with respect to the group or enrollment unit and the | ||||||
22 | resulting
additional premium to be paid by the group or | ||||||
23 | enrollment unit.
| ||||||
24 | In no event shall the Illinois Health Maintenance | ||||||
25 | Organization
Guaranty Association be liable to pay any | ||||||
26 | contractual obligation of an
insolvent organization to pay any |
| |||||||
| |||||||
1 | refund authorized under this Section.
| ||||||
2 | (Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, | ||||||
3 | eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; | ||||||
4 | 93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff. | ||||||
5 | 12-29-06; revised 1-5-07.)
| ||||||
6 | Section 15. The Limited Health Service Organization Act is | ||||||
7 | amended by changing Section 4003 as follows:
| ||||||
8 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| ||||||
9 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
10 | health service
organizations shall be subject to the provisions | ||||||
11 | of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | ||||||
12 | 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | ||||||
13 | 155.04, 155.37, 355.2, 356v, 356z.9, 368a, 401, 401.1,
402,
| ||||||
14 | 403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and Articles | ||||||
15 | IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and XXVI of | ||||||
16 | the Illinois Insurance Code. For purposes of the
Illinois | ||||||
17 | Insurance Code, except for Sections 444 and 444.1 and Articles | ||||||
18 | XIII
and XIII 1/2, limited health service organizations in the | ||||||
19 | following categories
are deemed to be domestic companies:
| ||||||
20 | (1) a corporation under the laws of this State; or
| ||||||
21 | (2) a corporation organized under the laws of another | ||||||
22 | state, 30% of more
of the enrollees of which are residents | ||||||
23 | of this State, except a corporation
subject to | ||||||
24 | substantially the same requirements in its state of |
| |||||||
| |||||||
1 | organization as
is a domestic company under Article VIII | ||||||
2 | 1/2 of the Illinois Insurance Code.
| ||||||
3 | (Source: P.A. 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; | ||||||
4 | 91-788, eff.
6-9-00; 92-440, eff. 8-17-01.)
| ||||||
5 | Section 20. The Voluntary Health Services Plans Act is | ||||||
6 | amended by changing Section 10 as follows:
| ||||||
7 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
8 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
9 | services
plan corporations and all persons interested therein | ||||||
10 | or dealing therewith
shall be subject to the provisions of | ||||||
11 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
12 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
13 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| ||||||
14 | 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | ||||||
15 | and 412, and paragraphs (7) and (15) of Section 367 of the | ||||||
16 | Illinois
Insurance Code.
| ||||||
17 | (Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; | ||||||
18 | 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. | ||||||
19 | 12-29-06.)
| ||||||
20 | Section 99. Effective date. This Act takes effect upon | ||||||
21 | becoming law.
|