Rep. Frank J. Mautino
Filed: 4/1/2008
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1 | AMENDMENT TO HOUSE BILL 4940
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2 | AMENDMENT NO. ______. Amend House Bill 4940, AS AMENDED, by | ||||||
3 | replacing everything after the enacting clause with the | ||||||
4 | following:
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5 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
6 | is amended by changing Section 6.11 as follows:
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7 | (5 ILCS 375/6.11)
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8 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
9 | Code
requirements. The program of health
benefits shall provide | ||||||
10 | the post-mastectomy care benefits required to be covered
by a | ||||||
11 | policy of accident and health insurance under Section 356t of | ||||||
12 | the Illinois
Insurance Code. The program of health benefits | ||||||
13 | shall provide the coverage
required under Sections 356g.5,
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14 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, | ||||||
15 | and 356z.11 and
356z.9 of the
Illinois Insurance Code.
The | ||||||
16 | program of health benefits must comply with Section 155.37 of |
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1 | the
Illinois Insurance Code.
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2 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
3 | 95-520, eff. 8-28-07; revised 12-4-07.)
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4 | Section 10. The Illinois Insurance Code is amended by | ||||||
5 | adding Section 356z.11 as follows: | ||||||
6 | (215 ILCS 5/356z.11 new) | ||||||
7 | Sec. 356z.11. 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 that provides coverage for hospital or | ||||||
12 | medical treatment on an expense incurred basis may offer a | ||||||
13 | reasonably designed program for wellness coverage that allows | ||||||
14 | for a reward, a health spending account contribution, a | ||||||
15 | reduction in premiums or reduced medical, prescription drug, or | ||||||
16 | equipment copayments, coinsurance, or deductibles, or a | ||||||
17 | combination of these incentives, for participation in any | ||||||
18 | health behavior wellness, maintenance, or improvement program | ||||||
19 | approved or offered by the insurer or managed care plan. The | ||||||
20 | insured or enrollee may be required to provide evidence of | ||||||
21 | participation in a program, demonstrative compliance with | ||||||
22 | treatment recommendations, or improvement of the individual's | ||||||
23 | or dependent's health behaviors as determined by the health | ||||||
24 | insurer or managed care plan. |
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1 | (b) For purposes of this Section, "wellness coverage" means | ||||||
2 | health care coverage with the primary purpose to engage and | ||||||
3 | motivate the insured or enrollee through: incentives; | ||||||
4 | provision of health education, counseling, and self-management | ||||||
5 | skills; identification of modifiable health risks; and other | ||||||
6 | activities to influence health behavior changes. | ||||||
7 | (c) Incentives as outlined in this Section are specific and | ||||||
8 | unique to the offering of wellness coverage and have no | ||||||
9 | application to any other required or optional health care | ||||||
10 | benefit. | ||||||
11 | (d) Such wellness coverage shall satisfy the requirements | ||||||
12 | for an exception from the general prohibition against | ||||||
13 | discrimination based on a health factor under the federal | ||||||
14 | Health Insurance Portability and Accountability Act of 1996 | ||||||
15 | (P.L. 104-191; 110 Stat. 1936), including any federal | ||||||
16 | regulations that are adopted pursuant to that Act. | ||||||
17 | (e) A reward, health spending account contribution, or | ||||||
18 | reduction established under this Section does not violate | ||||||
19 | Section 151 of this Code. | ||||||
20 | (f) Notwithstanding any other rulemaking authority that | ||||||
21 | may exist, neither the Governor nor any agency or agency head | ||||||
22 | under the jurisdiction of the Governor has any authority to | ||||||
23 | make or promulgate rules to implement or enforce the provisions | ||||||
24 | of this amendatory Act of the 95th General Assembly. If, | ||||||
25 | however, the Governor believes that rules are necessary to | ||||||
26 | implement or enforce the provisions of this amendatory Act of |
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1 | the 95th General Assembly, the Governor may suggest rules to | ||||||
2 | the General Assembly by filing them with the Clerk of the House | ||||||
3 | and the Secretary of the Senate and by requesting that the | ||||||
4 | General Assembly authorize such rulemaking by law, enact those | ||||||
5 | suggested rules into law, or take any other appropriate action | ||||||
6 | in the General Assembly's discretion. Nothing contained in this | ||||||
7 | amendatory Act of the 95th General Assembly shall be | ||||||
8 | interpreted to grant rulemaking authority under any other | ||||||
9 | Illinois statute where such authority is not otherwise | ||||||
10 | explicitly given. For the purposes of this amendatory Act of | ||||||
11 | the 95th General Assembly, "rules" is given the meaning | ||||||
12 | contained in Section 1-70 of the Illinois Administrative | ||||||
13 | Procedure Act, and "agency" and "agency head" are given the | ||||||
14 | meanings contained in Sections 1-20 and 1-25 of the Illinois | ||||||
15 | Administrative Procedure Act to the extent that such | ||||||
16 | definitions apply to agencies or agency heads under the | ||||||
17 | jurisdiction of the Governor. | ||||||
18 | Section 15. The Health Maintenance Organization Act is | ||||||
19 | amended by changing Section 5-3 as follows:
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20 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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21 | Sec. 5-3. Insurance Code provisions.
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22 | (a) Health Maintenance Organizations
shall be subject to | ||||||
23 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
24 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, |
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1 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
2 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
3 | 356z.11,
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
4 | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
5 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
6 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
7 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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8 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
9 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
10 | Maintenance Organizations in
the following categories are | ||||||
11 | deemed to be "domestic companies":
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12 | (1) a corporation authorized under the
Dental Service | ||||||
13 | Plan Act or the Voluntary Health Services Plans Act;
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14 | (2) a corporation organized under the laws of this | ||||||
15 | State; or
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16 | (3) a corporation organized under the laws of another | ||||||
17 | state, 30% or more
of the enrollees of which are residents | ||||||
18 | of this State, except a
corporation subject to | ||||||
19 | substantially the same requirements in its state of
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20 | organization as is a "domestic company" under Article VIII | ||||||
21 | 1/2 of the
Illinois Insurance Code.
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22 | (c) In considering the merger, consolidation, or other | ||||||
23 | acquisition of
control of a Health Maintenance Organization | ||||||
24 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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25 | (1) the Director shall give primary consideration to | ||||||
26 | the continuation of
benefits to enrollees and the financial |
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1 | conditions of the acquired Health
Maintenance Organization | ||||||
2 | after the merger, consolidation, or other
acquisition of | ||||||
3 | control takes effect;
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4 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
5 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
6 | apply and (ii) the Director, in making
his determination | ||||||
7 | with respect to the merger, consolidation, or other
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8 | acquisition of control, need not take into account the | ||||||
9 | effect on
competition of the merger, consolidation, or | ||||||
10 | other acquisition of control;
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11 | (3) the Director shall have the power to require the | ||||||
12 | following
information:
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13 | (A) certification by an independent actuary of the | ||||||
14 | adequacy
of the reserves of the Health Maintenance | ||||||
15 | Organization sought to be acquired;
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16 | (B) pro forma financial statements reflecting the | ||||||
17 | combined balance
sheets of the acquiring company and | ||||||
18 | the Health Maintenance Organization sought
to be | ||||||
19 | acquired as of the end of the preceding year and as of | ||||||
20 | a date 90 days
prior to the acquisition, as well as pro | ||||||
21 | forma financial statements
reflecting projected | ||||||
22 | combined operation for a period of 2 years;
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23 | (C) a pro forma business plan detailing an | ||||||
24 | acquiring party's plans with
respect to the operation | ||||||
25 | of the Health Maintenance Organization sought to
be | ||||||
26 | acquired for a period of not less than 3 years; and
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1 | (D) such other information as the Director shall | ||||||
2 | require.
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3 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
4 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
5 | any health maintenance
organization of greater than 10% of its
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6 | enrollee population (including without limitation the health | ||||||
7 | maintenance
organization's right, title, and interest in and to | ||||||
8 | its health care
certificates).
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9 | (e) In considering any management contract or service | ||||||
10 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
11 | Code, the Director (i) shall, in
addition to the criteria | ||||||
12 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
13 | into account the effect of the management contract or
service | ||||||
14 | agreement on the continuation of benefits to enrollees and the
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15 | financial condition of the health maintenance organization to | ||||||
16 | be managed or
serviced, and (ii) need not take into account the | ||||||
17 | effect of the management
contract or service agreement on | ||||||
18 | competition.
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19 | (f) Except for small employer groups as defined in the | ||||||
20 | Small Employer
Rating, Renewability and Portability Health | ||||||
21 | Insurance Act and except for
medicare supplement policies as | ||||||
22 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
23 | Maintenance Organization may by contract agree with a
group or | ||||||
24 | other enrollment unit to effect refunds or charge additional | ||||||
25 | premiums
under the following terms and conditions:
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26 | (i) the amount of, and other terms and conditions with |
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1 | respect to, the
refund or additional premium are set forth | ||||||
2 | in the group or enrollment unit
contract agreed in advance | ||||||
3 | of the period for which a refund is to be paid or
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4 | additional premium is to be charged (which period shall not | ||||||
5 | be less than one
year); and
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6 | (ii) the amount of the refund or additional premium | ||||||
7 | shall not exceed 20%
of the Health Maintenance | ||||||
8 | Organization's profitable or unprofitable experience
with | ||||||
9 | respect to the group or other enrollment unit for the | ||||||
10 | period (and, for
purposes of a refund or additional | ||||||
11 | premium, the profitable or unprofitable
experience shall | ||||||
12 | be calculated taking into account a pro rata share of the
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13 | Health Maintenance Organization's administrative and | ||||||
14 | marketing expenses, but
shall not include any refund to be | ||||||
15 | made or additional premium to be paid
pursuant to this | ||||||
16 | subsection (f)). The Health Maintenance Organization and | ||||||
17 | the
group or enrollment unit may agree that the profitable | ||||||
18 | or unprofitable
experience may be calculated taking into | ||||||
19 | account the refund period and the
immediately preceding 2 | ||||||
20 | plan years.
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21 | The Health Maintenance Organization shall include a | ||||||
22 | statement in the
evidence of coverage issued to each enrollee | ||||||
23 | describing the possibility of a
refund or additional premium, | ||||||
24 | and upon request of any group or enrollment unit,
provide to | ||||||
25 | the group or enrollment unit a description of the method used | ||||||
26 | to
calculate (1) the Health Maintenance Organization's |
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1 | profitable experience with
respect to the group or enrollment | ||||||
2 | unit and the resulting refund to the group
or enrollment unit | ||||||
3 | or (2) the Health Maintenance Organization's unprofitable
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4 | experience with respect to the group or enrollment unit and the | ||||||
5 | resulting
additional premium to be paid by the group or | ||||||
6 | enrollment unit.
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7 | In no event shall the Illinois Health Maintenance | ||||||
8 | Organization
Guaranty Association be liable to pay any | ||||||
9 | contractual obligation of an
insolvent organization to pay any | ||||||
10 | refund authorized under this Section.
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11 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
12 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
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13 | Section 99. Effective date. This Act takes effect January | ||||||
14 | 1, 2009.".
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