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1 | AN ACT concerning regulation.
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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.11 as follows: | |||||||||||||||||||||||
6 | (215 ILCS 5/356z.11 new) | |||||||||||||||||||||||
7 | Sec. 356z.11. Audiological services. A group or individual | |||||||||||||||||||||||
8 | policy of accident and health insurance or managed care plan | |||||||||||||||||||||||
9 | amended, delivered, issued, or renewed after the effective date | |||||||||||||||||||||||
10 | of this amendatory Act of the 95th General Assembly must | |||||||||||||||||||||||
11 | provide coverage for audiological services and hearing aids for | |||||||||||||||||||||||
12 | children up to 18 years of age. This coverage shall only apply | |||||||||||||||||||||||
13 | to hearing aids that are prescribed, filled, and dispensed by a | |||||||||||||||||||||||
14 | licensed audiologist. A policy or plan may limit the hearing | |||||||||||||||||||||||
15 | aid benefit payable for each hearing-impaired ear to every 38 | |||||||||||||||||||||||
16 | months. A policy or plan may provide for up to 4 additional ear | |||||||||||||||||||||||
17 | molds per year for children up to 2 years of age. | |||||||||||||||||||||||
18 | Section 10. 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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1 | (a) Health Maintenance Organizations
shall be subject to | ||||||
2 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
3 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
4 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
5 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
6 | 356z.11,
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
7 | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
8 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
9 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
10 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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11 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
12 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
13 | Maintenance Organizations in
the following categories are | ||||||
14 | deemed to be "domestic companies":
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15 | (1) a corporation authorized under the
Dental Service | ||||||
16 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
17 | (2) a corporation organized under the laws of this | ||||||
18 | State; or
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19 | (3) a corporation organized under the laws of another | ||||||
20 | state, 30% or 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
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23 | organization as is a "domestic company" under Article VIII | ||||||
24 | 1/2 of the
Illinois Insurance Code.
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25 | (c) In considering the merger, consolidation, or other | ||||||
26 | acquisition of
control of a Health Maintenance Organization |
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1 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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2 | (1) the Director shall give primary consideration to | ||||||
3 | the continuation of
benefits to enrollees and the financial | ||||||
4 | conditions of the acquired Health
Maintenance Organization | ||||||
5 | after the merger, consolidation, or other
acquisition of | ||||||
6 | control takes effect;
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7 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
8 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
9 | apply and (ii) the Director, in making
his determination | ||||||
10 | with respect to the merger, consolidation, or other
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11 | acquisition of control, need not take into account the | ||||||
12 | effect on
competition of the merger, consolidation, or | ||||||
13 | other acquisition of control;
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14 | (3) the Director shall have the power to require the | ||||||
15 | following
information:
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16 | (A) certification by an independent actuary of the | ||||||
17 | adequacy
of the reserves of the Health Maintenance | ||||||
18 | Organization sought to be acquired;
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19 | (B) pro forma financial statements reflecting the | ||||||
20 | combined balance
sheets of the acquiring company and | ||||||
21 | the Health Maintenance Organization sought
to be | ||||||
22 | acquired as of the end of the preceding year and as of | ||||||
23 | a date 90 days
prior to the acquisition, as well as pro | ||||||
24 | forma financial statements
reflecting projected | ||||||
25 | combined operation for a period of 2 years;
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26 | (C) a pro forma business plan detailing an |
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1 | acquiring party's plans with
respect to the operation | ||||||
2 | of the Health Maintenance Organization sought to
be | ||||||
3 | acquired for a period of not less than 3 years; and
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4 | (D) such other information as the Director shall | ||||||
5 | require.
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6 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
7 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
8 | any health maintenance
organization of greater than 10% of its
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9 | enrollee population (including without limitation the health | ||||||
10 | maintenance
organization's right, title, and interest in and to | ||||||
11 | its health care
certificates).
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12 | (e) In considering any management contract or service | ||||||
13 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
14 | Code, the Director (i) shall, in
addition to the criteria | ||||||
15 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
16 | into account the effect of the management contract or
service | ||||||
17 | agreement on the continuation of benefits to enrollees and the
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18 | financial condition of the health maintenance organization to | ||||||
19 | be managed or
serviced, and (ii) need not take into account the | ||||||
20 | effect of the management
contract or service agreement on | ||||||
21 | competition.
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22 | (f) Except for small employer groups as defined in the | ||||||
23 | Small Employer
Rating, Renewability and Portability Health | ||||||
24 | Insurance Act and except for
medicare supplement policies as | ||||||
25 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
26 | Maintenance Organization may by contract agree with a
group or |
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1 | other enrollment unit to effect refunds or charge additional | ||||||
2 | premiums
under the following terms and conditions:
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3 | (i) the amount of, and other terms and conditions with | ||||||
4 | respect to, the
refund or additional premium are set forth | ||||||
5 | in the group or enrollment unit
contract agreed in advance | ||||||
6 | of the period for which a refund is to be paid or
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7 | additional premium is to be charged (which period shall not | ||||||
8 | be less than one
year); and
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9 | (ii) the amount of the refund or additional premium | ||||||
10 | shall not exceed 20%
of the Health Maintenance | ||||||
11 | Organization's profitable or unprofitable experience
with | ||||||
12 | respect to the group or other enrollment unit for the | ||||||
13 | period (and, for
purposes of a refund or additional | ||||||
14 | premium, the profitable or unprofitable
experience shall | ||||||
15 | be calculated taking into account a pro rata share of the
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16 | Health Maintenance Organization's administrative and | ||||||
17 | marketing expenses, but
shall not include any refund to be | ||||||
18 | made or additional premium to be paid
pursuant to this | ||||||
19 | subsection (f)). The Health Maintenance Organization and | ||||||
20 | the
group or enrollment unit may agree that the profitable | ||||||
21 | or unprofitable
experience may be calculated taking into | ||||||
22 | account the refund period and the
immediately preceding 2 | ||||||
23 | plan years.
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24 | The Health Maintenance Organization shall include a | ||||||
25 | statement in the
evidence of coverage issued to each enrollee | ||||||
26 | describing the possibility of a
refund or additional premium, |
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1 | and upon request of any group or enrollment unit,
provide to | ||||||
2 | the group or enrollment unit a description of the method used | ||||||
3 | to
calculate (1) the Health Maintenance Organization's | ||||||
4 | profitable experience with
respect to the group or enrollment | ||||||
5 | unit and the resulting refund to the group
or enrollment unit | ||||||
6 | or (2) the Health Maintenance Organization's unprofitable
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7 | experience with respect to the group or enrollment unit and the | ||||||
8 | resulting
additional premium to be paid by the group or | ||||||
9 | enrollment unit.
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10 | In no event shall the Illinois Health Maintenance | ||||||
11 | Organization
Guaranty Association be liable to pay any | ||||||
12 | contractual obligation of an
insolvent organization to pay any | ||||||
13 | refund authorized under this Section.
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14 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
15 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
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16 | Section 15. The Voluntary Health Services Plans Act is | ||||||
17 | amended by changing Section 10 as follows:
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18 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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19 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
20 | services
plan corporations and all persons interested therein | ||||||
21 | or dealing therewith
shall be subject to the provisions of | ||||||
22 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
23 | 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | ||||||
24 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, |
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1 | 356z.9,
356z.10, 356z.11,
356z.9 , 364.01, 367.2, 368a, 401, | ||||||
2 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
3 | and (15) of Section 367 of the Illinois
Insurance Code.
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4 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
5 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
6 | 8-28-07; revised 12-5-07.)
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