Sen. M. Maggie Crotty
Filed: 5/21/2008
|
|||||||
| |||||||
| |||||||
1 | AMENDMENT TO HOUSE BILL 5595
| ||||||
2 | AMENDMENT NO. ______. Amend House Bill 5595 by replacing | ||||||
3 | everything after the enacting clause with the following:
| ||||||
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 356g.5,
| ||||||
13 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, | ||||||
14 | and 356z.11 and 356z.9 of the
Illinois Insurance Code.
The | ||||||
15 | program of health benefits must comply with Section 155.37 of | ||||||
16 | the
Illinois Insurance Code.
|
| |||||||
| |||||||
1 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
2 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
3 | Section 10. The Counties Code is amended by changing | ||||||
4 | Section 5-1069.3 as follows: | ||||||
5 | (55 ILCS 5/5-1069.3)
| ||||||
6 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
7 | including a home
rule
county, is a self-insurer for purposes of | ||||||
8 | providing health insurance coverage
for its employees, the | ||||||
9 | coverage shall include coverage for the post-mastectomy
care | ||||||
10 | benefits required to be covered by a policy of accident and | ||||||
11 | health
insurance under Section 356t and the coverage required | ||||||
12 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, | ||||||
13 | 356z.10, and 356z.11 and 356z.9 of
the Illinois Insurance Code. | ||||||
14 | The requirement that health benefits be covered
as provided in | ||||||
15 | this Section is an
exclusive power and function of the State | ||||||
16 | and is a denial and limitation under
Article VII, Section 6, | ||||||
17 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
18 | to which this Section applies must comply with every provision | ||||||
19 | of
this Section.
| ||||||
20 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
21 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
22 | Section 15. The Illinois Municipal Code is amended by | ||||||
23 | changing Section 10-4-2.3 as follows: |
| |||||||
| |||||||
1 | (65 ILCS 5/10-4-2.3)
| ||||||
2 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
3 | municipality, including a
home rule municipality, is a | ||||||
4 | self-insurer for purposes of providing health
insurance | ||||||
5 | coverage for its employees, the coverage shall include coverage | ||||||
6 | for
the post-mastectomy care benefits required to be covered by | ||||||
7 | a policy of
accident and health insurance under Section 356t | ||||||
8 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
9 | 356x, 356z.6, and 356z.9, 356z.10, and 356z.11 and 356z.9 of | ||||||
10 | the Illinois
Insurance
Code. The requirement that health
| ||||||
11 | benefits be covered as provided in this is an exclusive power | ||||||
12 | and function of
the State and is a denial and limitation under | ||||||
13 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
14 | Constitution. A home rule municipality to which
this Section | ||||||
15 | applies must comply with every provision of this Section.
| ||||||
16 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
17 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
18 | Section 20. The School Code is amended by changing Section | ||||||
19 | 10-22.3f as follows: | ||||||
20 | (105 ILCS 5/10-22.3f)
| ||||||
21 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
22 | protection and
benefits
for employees shall provide the | ||||||
23 | post-mastectomy care benefits required to be
covered by a |
| |||||||
| |||||||
1 | policy of accident and health insurance under Section 356t and | ||||||
2 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
| ||||||
3 | 356z.6, and 356z.9 , and 356z.11 of
the
Illinois Insurance Code.
| ||||||
4 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
5 | revised 12-4-07.)
| ||||||
6 | Section 25. The Illinois Insurance Code is amended by | ||||||
7 | adding Sections 356z.11 and 370c as follows: | ||||||
8 | (215 ILCS 5/356z.11 new) | ||||||
9 | Sec. 356z.11. Habilitative services for children. | ||||||
10 | (a) As used in this Section, "habilitative services" means | ||||||
11 | occupational therapy, physical therapy, speech therapy, and | ||||||
12 | other services prescribed by the insured's treating physician | ||||||
13 | pursuant to a treatment plan to enhance the ability of a child | ||||||
14 | to function with a congenital, genetic, or early acquired | ||||||
15 | disorder. A congenital or genetic disorder includes, but is not | ||||||
16 | limited to, hereditary disorders. An early acquired disorder | ||||||
17 | refers to a disorder resulting from illness, trauma, injury, or | ||||||
18 | some other event or condition suffered by a child prior to that | ||||||
19 | child developing functional life skills such as, but not | ||||||
20 | limited to, walking, talking, or self-help skills. Congenital, | ||||||
21 | genetic, and early acquired disorders may include, but are not | ||||||
22 | limited to, autism or an autism spectrum disorder, cerebral | ||||||
23 | palsy, and other disorders resulting from early childhood | ||||||
24 | illness, trauma, or injury. |
| |||||||
| |||||||
1 | (b) A group or individual policy of accident and health | ||||||
2 | insurance or managed care plan amended, delivered, issued, or | ||||||
3 | renewed after the effective date of this amendatory Act of the | ||||||
4 | 95th General Assembly must provide coverage for habilitative | ||||||
5 | services for children under 19 years of age with a congenital, | ||||||
6 | genetic, or early acquired disorder so long as all of the | ||||||
7 | following conditions are met: | ||||||
8 | (1) A physician licensed to practice medicine in all | ||||||
9 | its branches has diagnosed the child's congenital, | ||||||
10 | genetic, or early acquired disorder. | ||||||
11 | (2) The treatment is administered by a licensed | ||||||
12 | speech-language pathologist, licensed audiologist, | ||||||
13 | licensed occupational therapist, licensed physical | ||||||
14 | therapist, licensed physician, licensed nurse, licensed | ||||||
15 | optometrist, licensed nutritionist, licensed social | ||||||
16 | worker, or licensed psychologist upon the referral of a | ||||||
17 | physician licensed to practice medicine in all its | ||||||
18 | branches. | ||||||
19 | (3) The initial or continued treatment must be | ||||||
20 | medically necessary and therapeutic and not experimental | ||||||
21 | or investigational. | ||||||
22 | (c) The coverage required by this Section shall be subject | ||||||
23 | to other general exclusions and limitations of the policy, | ||||||
24 | including coordination of benefits, participating provider | ||||||
25 | requirements, restrictions on services provided by family or | ||||||
26 | household members, utilization review of health care services, |
| |||||||
| |||||||
1 | including review of medical necessity, case management, | ||||||
2 | experimental, and investigational treatments, and other | ||||||
3 | managed care provisions. | ||||||
4 | (d) Coverage under this Section does not apply to those | ||||||
5 | services that are solely educational in nature or otherwise | ||||||
6 | paid under State or federal law for purely educational | ||||||
7 | services. Nothing in this subsection (d) relieves an insurer or | ||||||
8 | similar third party from an otherwise valid obligation to | ||||||
9 | provide or to pay for services provided to a child with a | ||||||
10 | disability. | ||||||
11 | (e) Coverage under this Section for children under age 19 | ||||||
12 | shall not apply to treatment of mental or emotional disorders | ||||||
13 | or illnesses as covered under Section 370 of this Code as well | ||||||
14 | as any other benefit based upon a specific diagnosis that may | ||||||
15 | be otherwise required by law. | ||||||
16 | (f) The provisions of this Section do not apply to | ||||||
17 | short-term travel, accident-only, limited, or specific disease | ||||||
18 | policies. | ||||||
19 | (g) Any denial of care for habilitative services shall be | ||||||
20 | subject to appeal and external independent review procedures as | ||||||
21 | provided by Section 45 of the Managed Care Reform and Patient | ||||||
22 | Rights Act. | ||||||
23 | (h) Upon request of the reimbursing insurer, the provider | ||||||
24 | under whose supervision the habilitative services are being | ||||||
25 | provided shall furnish medical records, clinical notes, or | ||||||
26 | other necessary data to allow the insurer to substantiate that |
| |||||||
| |||||||
1 | initial or continued medical treatment is medically necessary | ||||||
2 | and that the patient's condition is clinically improving. When | ||||||
3 | the treating provider anticipates that continued treatment is | ||||||
4 | or will be required to permit the patient to achieve | ||||||
5 | demonstrable progress, the insurer may request that the | ||||||
6 | provider furnish a treatment plan consisting of diagnosis, | ||||||
7 | proposed treatment by type, frequency, anticipated duration of | ||||||
8 | treatment, the anticipated goals of treatment, and how | ||||||
9 | frequently the treatment plan will be updated. | ||||||
10 | (i) Notwithstanding any other rulemaking authority that | ||||||
11 | may exist, neither the Governor nor any agency or agency head | ||||||
12 | under the jurisdiction of the Governor has any authority to | ||||||
13 | make or promulgate rules to implement or enforce the provisions | ||||||
14 | of this amendatory Act of the 95th General Assembly. If, | ||||||
15 | however, the Governor believes that rules are necessary to | ||||||
16 | implement or enforce the provisions of this amendatory Act of | ||||||
17 | the 95th General Assembly, the Governor may suggest rules to | ||||||
18 | the General Assembly by filing them with the Clerk of the House | ||||||
19 | and the Secretary of the Senate and by requesting that the | ||||||
20 | General Assembly authorize such rulemaking by law, enact those | ||||||
21 | suggested rules into law, or take any other appropriate action | ||||||
22 | in the General Assembly's discretion. Nothing contained in this | ||||||
23 | amendatory Act of the 95th General Assembly shall be | ||||||
24 | interpreted to grant rulemaking authority under any other | ||||||
25 | Illinois statute where such authority is not otherwise | ||||||
26 | explicitly given. For the purposes of this amendatory Act of |
| |||||||
| |||||||
1 | the 95th General Assembly, "rules" is given the meaning | ||||||
2 | contained in Section 1-70 of the Illinois Administrative | ||||||
3 | Procedure Act, and "agency" and "agency head" are given the | ||||||
4 | meanings contained in Sections 1-20 and 1-25 of the Illinois | ||||||
5 | Administrative Procedure Act to the extent that such | ||||||
6 | definitions apply to agencies or agency heads under the | ||||||
7 | jurisdiction of the Governor.
| ||||||
8 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| ||||||
9 | Sec. 370c. Mental and emotional disorders.
| ||||||
10 | (a) (1) On and after the effective date of this Section,
| ||||||
11 | every insurer which delivers, issues for delivery or renews or | ||||||
12 | modifies
group A&H policies providing coverage for hospital or | ||||||
13 | medical treatment or
services for illness on an | ||||||
14 | expense-incurred basis shall offer to the
applicant or group | ||||||
15 | policyholder subject to the insurers standards of
| ||||||
16 | insurability, coverage for reasonable and necessary treatment | ||||||
17 | and services
for mental, emotional or nervous disorders or | ||||||
18 | conditions, other than serious
mental illnesses as defined in | ||||||
19 | item (2) of subsection (b), up to the limits
provided in the | ||||||
20 | policy for other disorders or conditions, except (i) the
| ||||||
21 | insured may be required to pay up to 50% of expenses incurred | ||||||
22 | as a result
of the treatment or services, and (ii) the annual | ||||||
23 | benefit limit may be
limited to the lesser of $10,000 or 25% of | ||||||
24 | the lifetime policy limit.
| ||||||
25 | (2) Each insured that is covered for mental, emotional or |
| |||||||
| |||||||
1 | nervous
disorders or conditions shall be free to select the | ||||||
2 | physician licensed to
practice medicine in all its branches, | ||||||
3 | licensed clinical psychologist,
licensed clinical social | ||||||
4 | worker, or licensed clinical professional counselor of
his | ||||||
5 | choice to treat such disorders, and
the insurer shall pay the | ||||||
6 | covered charges of such physician licensed to
practice medicine | ||||||
7 | in all its branches, licensed clinical psychologist,
licensed | ||||||
8 | clinical social worker, or licensed clinical professional | ||||||
9 | counselor up
to the limits of coverage, provided (i)
the | ||||||
10 | disorder or condition treated is covered by the policy, and | ||||||
11 | (ii) the
physician, licensed psychologist, licensed clinical | ||||||
12 | social worker, or licensed
clinical professional counselor is
| ||||||
13 | authorized to provide said services under the statutes of this | ||||||
14 | State and in
accordance with accepted principles of his | ||||||
15 | profession.
| ||||||
16 | (3) Insofar as this Section applies solely to licensed | ||||||
17 | clinical social
workers and licensed clinical professional | ||||||
18 | counselors, those persons who may
provide services to | ||||||
19 | individuals shall do so
after the licensed clinical social | ||||||
20 | worker or licensed clinical professional
counselor has | ||||||
21 | informed the patient of the
desirability of the patient | ||||||
22 | conferring with the patient's primary care
physician and the | ||||||
23 | licensed clinical social worker or licensed clinical
| ||||||
24 | professional counselor has
provided written
notification to | ||||||
25 | the patient's primary care physician, if any, that services
are | ||||||
26 | being provided to the patient. That notification may, however, |
| |||||||
| |||||||
1 | be
waived by the patient on a written form. Those forms shall | ||||||
2 | be retained by
the licensed clinical social worker or licensed | ||||||
3 | clinical professional counselor
for a period of not less than 5 | ||||||
4 | years.
| ||||||
5 | (b) (1) An insurer that provides coverage for hospital or | ||||||
6 | medical
expenses under a group policy of accident and health | ||||||
7 | insurance or
health care plan amended, delivered, issued, or | ||||||
8 | renewed after the effective
date of this amendatory Act of the | ||||||
9 | 92nd General Assembly shall provide coverage
under the policy | ||||||
10 | for treatment of serious mental illness under the same terms
| ||||||
11 | and conditions as coverage for hospital or medical expenses | ||||||
12 | related to other
illnesses and diseases. The coverage required | ||||||
13 | under this Section must provide
for same durational limits, | ||||||
14 | amount limits, deductibles, and co-insurance
requirements for | ||||||
15 | serious mental illness as are provided for other illnesses
and | ||||||
16 | diseases. This subsection does not apply to coverage provided | ||||||
17 | to
employees by employers who have 50 or fewer employees.
| ||||||
18 | (2) "Serious mental illness" means the following | ||||||
19 | psychiatric illnesses as
defined in the most current edition of | ||||||
20 | the Diagnostic and Statistical Manual
(DSM) published by the | ||||||
21 | American Psychiatric Association:
| ||||||
22 | (A) schizophrenia;
| ||||||
23 | (B) paranoid and other psychotic disorders;
| ||||||
24 | (C) bipolar disorders (hypomanic, manic, depressive, | ||||||
25 | and mixed);
| ||||||
26 | (D) major depressive disorders (single episode or |
| |||||||
| |||||||
1 | recurrent);
| ||||||
2 | (E) schizoaffective disorders (bipolar or depressive);
| ||||||
3 | (F) pervasive developmental disorders;
| ||||||
4 | (G) obsessive-compulsive disorders;
| ||||||
5 | (H) depression in childhood and adolescence;
| ||||||
6 | (I) panic disorder; and | ||||||
7 | (J) post-traumatic stress disorders (acute, chronic, | ||||||
8 | or with delayed onset).
| ||||||
9 | (3) Upon request of the reimbursing insurer, a provider of | ||||||
10 | treatment of
serious mental illness shall furnish medical | ||||||
11 | records or other necessary data
that substantiate that initial | ||||||
12 | or continued treatment is at all times medically
necessary. An | ||||||
13 | insurer shall provide a mechanism for the timely review by a
| ||||||
14 | provider holding the same license and practicing in the same | ||||||
15 | specialty as the
patient's provider, who is unaffiliated with | ||||||
16 | the insurer, jointly selected by
the patient (or the patient's | ||||||
17 | next of kin or legal representative if the
patient is unable to | ||||||
18 | act for himself or herself), the patient's provider, and
the | ||||||
19 | insurer in the event of a dispute between the insurer and | ||||||
20 | patient's
provider regarding the medical necessity of a | ||||||
21 | treatment proposed by a patient's
provider. If the reviewing | ||||||
22 | provider determines the treatment to be medically
necessary, | ||||||
23 | the insurer shall provide reimbursement for the treatment. | ||||||
24 | Future
contractual or employment actions by the insurer | ||||||
25 | regarding the patient's
provider may not be based on the | ||||||
26 | provider's participation in this procedure.
Nothing prevents
|
| |||||||
| |||||||
1 | the insured from agreeing in writing to continue treatment at | ||||||
2 | his or her
expense. When making a determination of the medical | ||||||
3 | necessity for a treatment
modality for serous mental illness, | ||||||
4 | an insurer must make the determination in a
manner that is | ||||||
5 | consistent with the manner used to make that determination with
| ||||||
6 | respect to other diseases or illnesses covered under the | ||||||
7 | policy, including an
appeals process.
| ||||||
8 | (4) A group health benefit plan:
| ||||||
9 | (A) shall provide coverage based upon medical | ||||||
10 | necessity for the following
treatment of mental illness in | ||||||
11 | each calendar year:
| ||||||
12 | (i) 45 days of inpatient treatment; and
| ||||||
13 | (ii) beginning on June 26, 2006 (the effective date | ||||||
14 | of Public Act 94-921), 60 visits for outpatient | ||||||
15 | treatment including group and individual
outpatient | ||||||
16 | treatment; and | ||||||
17 | (iii) for plans or policies delivered, issued for | ||||||
18 | delivery, renewed, or modified after January 1, 2007 | ||||||
19 | (the effective date of Public Act 94-906),
20 | ||||||
20 | additional outpatient visits for speech therapy for | ||||||
21 | treatment of pervasive developmental disorders that | ||||||
22 | will be in addition to speech therapy provided pursuant | ||||||
23 | to item (ii) of this subparagraph (A);
| ||||||
24 | (B) may not include a lifetime limit on the number of | ||||||
25 | days of inpatient
treatment or the number of outpatient | ||||||
26 | visits covered under the plan; and
|
| |||||||
| |||||||
1 | (C) shall include the same amount limits, deductibles, | ||||||
2 | copayments, and
coinsurance factors for serious mental | ||||||
3 | illness as for physical illness.
| ||||||
4 | (5) An issuer of a group health benefit plan may not count | ||||||
5 | toward the number
of outpatient visits required to be covered | ||||||
6 | under this Section an outpatient
visit for the purpose of | ||||||
7 | medication management and shall cover the outpatient
visits | ||||||
8 | under the same terms and conditions as it covers outpatient | ||||||
9 | visits for
the treatment of physical illness.
| ||||||
10 | (6) An issuer of a group health benefit
plan may provide or | ||||||
11 | offer coverage required under this Section through a
managed | ||||||
12 | care plan.
| ||||||
13 | (7) This Section shall not be interpreted to require a | ||||||
14 | group health benefit
plan to provide coverage for treatment of:
| ||||||
15 | (A) an addiction to a controlled substance or cannabis | ||||||
16 | that is used in
violation of law; or
| ||||||
17 | (B) mental illness resulting from the use of a | ||||||
18 | controlled substance or
cannabis in violation of law.
| ||||||
19 | (8)
(Blank).
| ||||||
20 | (c) This Section shall not be interpreted to require | ||||||
21 | coverage for speech therapy or other habilitative services for | ||||||
22 | those individuals covered under Section 356z.11 of this Code. | ||||||
23 | (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; | ||||||
24 | 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff. | ||||||
25 | 8-21-07.)
|
| |||||||
| |||||||
1 | Section 30. The Health Maintenance Organization Act is | ||||||
2 | amended by changing Section 5-3 as follows:
| ||||||
3 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
4 | Sec. 5-3. Insurance Code provisions.
| ||||||
5 | (a) Health Maintenance Organizations
shall be subject to | ||||||
6 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
7 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
8 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
9 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
10 | 356z.11 356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
11 | 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | ||||||
12 | 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | ||||||
13 | 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | ||||||
14 | XXV, and XXVI of the Illinois Insurance Code.
| ||||||
15 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
16 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
17 | Maintenance Organizations in
the following categories are | ||||||
18 | deemed to be "domestic companies":
| ||||||
19 | (1) a corporation authorized under the
Dental Service | ||||||
20 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
21 | (2) a corporation organized under the laws of this | ||||||
22 | State; or
| ||||||
23 | (3) a corporation organized under the laws of another | ||||||
24 | state, 30% or more
of the enrollees of which are residents | ||||||
25 | of this State, except a
corporation subject to |
| |||||||
| |||||||
1 | substantially the same requirements in its state of
| ||||||
2 | organization as is a "domestic company" under Article VIII | ||||||
3 | 1/2 of the
Illinois Insurance Code.
| ||||||
4 | (c) In considering the merger, consolidation, or other | ||||||
5 | acquisition of
control of a Health Maintenance Organization | ||||||
6 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
7 | (1) the Director shall give primary consideration to | ||||||
8 | the continuation of
benefits to enrollees and the financial | ||||||
9 | conditions of the acquired Health
Maintenance Organization | ||||||
10 | after the merger, consolidation, or other
acquisition of | ||||||
11 | control takes effect;
| ||||||
12 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
13 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
14 | apply and (ii) the Director, in making
his determination | ||||||
15 | with respect to the merger, consolidation, or other
| ||||||
16 | acquisition of control, need not take into account the | ||||||
17 | effect on
competition of the merger, consolidation, or | ||||||
18 | other acquisition of control;
| ||||||
19 | (3) the Director shall have the power to require the | ||||||
20 | following
information:
| ||||||
21 | (A) certification by an independent actuary of the | ||||||
22 | adequacy
of the reserves of the Health Maintenance | ||||||
23 | Organization sought to be acquired;
| ||||||
24 | (B) pro forma financial statements reflecting the | ||||||
25 | combined balance
sheets of the acquiring company and | ||||||
26 | the Health Maintenance Organization sought
to be |
| |||||||
| |||||||
1 | acquired as of the end of the preceding year and as of | ||||||
2 | a date 90 days
prior to the acquisition, as well as pro | ||||||
3 | forma financial statements
reflecting projected | ||||||
4 | combined operation for a period of 2 years;
| ||||||
5 | (C) a pro forma business plan detailing an | ||||||
6 | acquiring party's plans with
respect to the operation | ||||||
7 | of the Health Maintenance Organization sought to
be | ||||||
8 | acquired for a period of not less than 3 years; and
| ||||||
9 | (D) such other information as the Director shall | ||||||
10 | require.
| ||||||
11 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
12 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
13 | any health maintenance
organization of greater than 10% of its
| ||||||
14 | enrollee population (including without limitation the health | ||||||
15 | maintenance
organization's right, title, and interest in and to | ||||||
16 | its health care
certificates).
| ||||||
17 | (e) In considering any management contract or service | ||||||
18 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
19 | Code, the Director (i) shall, in
addition to the criteria | ||||||
20 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
21 | into account the effect of the management contract or
service | ||||||
22 | agreement on the continuation of benefits to enrollees and the
| ||||||
23 | financial condition of the health maintenance organization to | ||||||
24 | be managed or
serviced, and (ii) need not take into account the | ||||||
25 | effect of the management
contract or service agreement on | ||||||
26 | competition.
|
| |||||||
| |||||||
1 | (f) Except for small employer groups as defined in the | ||||||
2 | Small Employer
Rating, Renewability and Portability Health | ||||||
3 | Insurance Act and except for
medicare supplement policies as | ||||||
4 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
5 | Maintenance Organization may by contract agree with a
group or | ||||||
6 | other enrollment unit to effect refunds or charge additional | ||||||
7 | premiums
under the following terms and conditions:
| ||||||
8 | (i) the amount of, and other terms and conditions with | ||||||
9 | respect to, the
refund or additional premium are set forth | ||||||
10 | in the group or enrollment unit
contract agreed in advance | ||||||
11 | of the period for which a refund is to be paid or
| ||||||
12 | additional premium is to be charged (which period shall not | ||||||
13 | be less than one
year); and
| ||||||
14 | (ii) the amount of the refund or additional premium | ||||||
15 | shall not exceed 20%
of the Health Maintenance | ||||||
16 | Organization's profitable or unprofitable experience
with | ||||||
17 | respect to the group or other enrollment unit for the | ||||||
18 | period (and, for
purposes of a refund or additional | ||||||
19 | premium, the profitable or unprofitable
experience shall | ||||||
20 | be calculated taking into account a pro rata share of the
| ||||||
21 | Health Maintenance Organization's administrative and | ||||||
22 | marketing expenses, but
shall not include any refund to be | ||||||
23 | made or additional premium to be paid
pursuant to this | ||||||
24 | subsection (f)). The Health Maintenance Organization and | ||||||
25 | the
group or enrollment unit may agree that the profitable | ||||||
26 | or unprofitable
experience may be calculated taking into |
| |||||||
| |||||||
1 | account the refund period and the
immediately preceding 2 | ||||||
2 | plan years.
| ||||||
3 | The Health Maintenance Organization shall include a | ||||||
4 | statement in the
evidence of coverage issued to each enrollee | ||||||
5 | describing the possibility of a
refund or additional premium, | ||||||
6 | and upon request of any group or enrollment unit,
provide to | ||||||
7 | the group or enrollment unit a description of the method used | ||||||
8 | to
calculate (1) the Health Maintenance Organization's | ||||||
9 | profitable experience with
respect to the group or enrollment | ||||||
10 | unit and the resulting refund to the group
or enrollment unit | ||||||
11 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
12 | experience with respect to the group or enrollment unit and the | ||||||
13 | resulting
additional premium to be paid by the group or | ||||||
14 | enrollment unit.
| ||||||
15 | In no event shall the Illinois Health Maintenance | ||||||
16 | Organization
Guaranty Association be liable to pay any | ||||||
17 | contractual obligation of an
insolvent organization to pay any | ||||||
18 | refund authorized under this Section.
| ||||||
19 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
20 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
21 | Section 35. The Voluntary Health Services Plans Act is | ||||||
22 | amended by changing Section 10 as follows:
| ||||||
23 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
24 | Sec. 10. Application of Insurance Code provisions. Health |
| |||||||
| |||||||
1 | services
plan corporations and all persons interested therein | ||||||
2 | or dealing therewith
shall be subject to the provisions of | ||||||
3 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
4 | 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | ||||||
5 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||||||
6 | 356z.9,
356z.10, 356z.11 356z.9 , 364.01, 367.2, 368a, 401, | ||||||
7 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
8 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
9 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
10 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
11 | 8-28-07; revised 12-5-07.)
| ||||||
12 | Section 90. The State Mandates Act is amended by adding | ||||||
13 | Section 8.32 as follows: | ||||||
14 | (30 ILCS 805/8.32 new) | ||||||
15 | Sec. 8.32. Exempt mandate. Notwithstanding Sections 6 and 8 | ||||||
16 | of this Act, no reimbursement by the State is required for the | ||||||
17 | implementation of any mandate created by this amendatory Act of | ||||||
18 | the 95th General Assembly. ".
|