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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 adding | |||||||||||||||||||||||
5 | Section 356z.9 as follows: | |||||||||||||||||||||||
6 | (215 ILCS 5/356z.9 new) | |||||||||||||||||||||||
7 | Sec. 356z.9. Wellness coverage. | |||||||||||||||||||||||
8 | (a) A group or individual policy of accident and health | |||||||||||||||||||||||
9 | insurance or managed care plan amended, delivered, issued, or | |||||||||||||||||||||||
10 | renewed after the effective date of this amendatory Act of the | |||||||||||||||||||||||
11 | 95th General Assembly must provide coverage for individual, | |||||||||||||||||||||||
12 | family, or group wellness programs. Wellness coverage may | |||||||||||||||||||||||
13 | provide for an appropriate rebate or reduction in premiums or | |||||||||||||||||||||||
14 | for reduced copayments, coinsurance, or deductibles or a | |||||||||||||||||||||||
15 | combination of these incentives for participation in any health | |||||||||||||||||||||||
16 | behavior wellness, maintenance, or improvement program offered | |||||||||||||||||||||||
17 | by the employer. The insured or enrollee shall provide evidence | |||||||||||||||||||||||
18 | of demonstrative maintenance or improvement of the insureds' or | |||||||||||||||||||||||
19 | enrollees' health behaviors, as determined by assessments of | |||||||||||||||||||||||
20 | agreed-upon health status indicators between the employer and | |||||||||||||||||||||||
21 | the insurer. Any rebate of premium provided by the insurer is | |||||||||||||||||||||||
22 | presumed to be appropriate unless credible data demonstrates | |||||||||||||||||||||||
23 | otherwise. Each insurer must make available to employers all |
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1 | wellness coverage plans that the insurer markets to employers | ||||||
2 | in this State. | ||||||
3 | (b) An insurer providing a group or individual policy of | ||||||
4 | accident and health insurance or a managed care plan is not | ||||||
5 | required to continue any health behavior wellness, | ||||||
6 | maintenance, or improvement program or to continue any | ||||||
7 | incentive associated with a health behavior wellness, | ||||||
8 | maintenance, or improvement program.
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9 | Section 10. The Health Maintenance Organization Act is | ||||||
10 | amended by changing Section 5-3 as follows:
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11 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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12 | Sec. 5-3. Insurance Code provisions.
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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,
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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.
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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 |
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1 | Maintenance Organizations in
the following categories are | ||||||
2 | deemed to be "domestic companies":
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3 | (1) a corporation authorized under the
Dental Service | ||||||
4 | Plan Act or the Voluntary Health Services Plans Act;
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5 | (2) a corporation organized under the laws of this | ||||||
6 | State; or
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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
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11 | organization as is a "domestic company" under Article VIII | ||||||
12 | 1/2 of the
Illinois Insurance Code.
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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,
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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;
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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
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25 | acquisition of control, need not take into account the | ||||||
26 | effect on
competition of the merger, consolidation, or |
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1 | other acquisition of control;
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2 | (3) the Director shall have the power to require the | ||||||
3 | following
information:
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4 | (A) certification by an independent actuary of the | ||||||
5 | adequacy
of the reserves of the Health Maintenance | ||||||
6 | Organization sought to be acquired;
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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;
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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
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18 | (D) such other information as the Director shall | ||||||
19 | require.
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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
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23 | enrollee population (including without limitation the health | ||||||
24 | maintenance
organization's right, title, and interest in and to | ||||||
25 | its health care
certificates).
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26 | (e) In considering any management contract or service |
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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
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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.
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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:
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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
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21 | additional premium is to be charged (which period shall not | ||||||
22 | be less than one
year); and
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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 |
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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
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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.
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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
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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.
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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 |
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1 | refund authorized under this Section.
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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.)
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6 | Section 15. The Voluntary Health Services Plans Act is | ||||||
7 | amended by changing Section 10 as follows:
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8 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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9 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
10 | services
plan corporations and all persons interested therein | ||||||
11 | or dealing therewith
shall be subject to the provisions of | ||||||
12 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
13 | 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v,
356w, 356x, | ||||||
14 | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
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15 | 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | ||||||
16 | and 412, and paragraphs (7) and (15) of Section 367 of the | ||||||
17 | Illinois
Insurance Code.
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18 | (Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; | ||||||
19 | 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. | ||||||
20 | 12-29-06.)
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