|
|||||||||||||||||||||||||
|
|||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
1 | AN ACT concerning regulation.
| ||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||
4 | Section 1. Short title. This Act may be cited as the | ||||||||||||||||||||||||
5 | Premium and Loss Data Reporting Act. | ||||||||||||||||||||||||
6 | Section 5. Application. This Act shall apply to: (i) all | ||||||||||||||||||||||||
7 | insurers authorized to transact the class of business set forth | ||||||||||||||||||||||||
8 | in subsection (b) of Class 1 and subsection (a) of Class 2 of | ||||||||||||||||||||||||
9 | Section 4 of the Illinois Insurance Code; and (ii) all health | ||||||||||||||||||||||||
10 | plans authorized under the Health Maintenance Organization | ||||||||||||||||||||||||
11 | Act. | ||||||||||||||||||||||||
12 | Section 10. Definitions. In this Act: | ||||||||||||||||||||||||
13 | "Accident only" means an insurance contract that provides | ||||||||||||||||||||||||
14 | coverage, alone or in combination, for death, dismemberment, | ||||||||||||||||||||||||
15 | disability, or hospital and medical care caused by or | ||||||||||||||||||||||||
16 | necessitated as a result of accident or specified kinds of | ||||||||||||||||||||||||
17 | accidents.
| ||||||||||||||||||||||||
18 | "Accidental death and dismemberment" means an insurance | ||||||||||||||||||||||||
19 | contract that pays a stated benefit in the event of death or | ||||||||||||||||||||||||
20 | dismemberment caused by accident or specified kinds of | ||||||||||||||||||||||||
21 | accidents.
| ||||||||||||||||||||||||
22 | "Administrative services only" means a contractual |
| |||||||
| |||||||
1 | arrangement utilized by a self-funded employer, whereby a | ||||||
2 | separate company processes claims and provides other | ||||||
3 | administrative services pertinent to the employer's health | ||||||
4 | care plans. The fees associated with these services are | ||||||
5 | included in this Act.
| ||||||
6 | "Annual statement" means that statement required by | ||||||
7 | Section 136 of the Illinois Insurance Code to be filed annually | ||||||
8 | by the company with the Director. | ||||||
9 | "Blanket accident/sickness" means a health insurance | ||||||
10 | contract that covers all of a class of persons not individually | ||||||
11 | identified in the contract. | ||||||
12 | "Champus/Tricare supplement" means Civilian Health and | ||||||
13 | Medical Program of the Uniformed Services (Champus). | ||||||
14 | "Champus/Tricare supplement" also includes a private health | ||||||
15 | plan that provides beneficiaries eligible for Champus with | ||||||
16 | supplemental health care coverage. | ||||||
17 | "Code" means the Illinois Insurance Code. | ||||||
18 | "Covered dependents at end of reporting quarter" means the | ||||||
19 | total number of individuals covered by the primary insured's | ||||||
20 | plan who receive coverage due to his or her dependent | ||||||
21 | relationship to the primary insured, as of the final day of the | ||||||
22 | reporting quarter. | ||||||
23 | "Dental" means insurance that provides benefits for | ||||||
24 | routine dental examinations, preventive dental work, and | ||||||
25 | dental procedures needed to treat tooth decay and diseases of | ||||||
26 | the teeth and jaw. |
| |||||||
| |||||||
1 | "Direct premiums earned for new and renewal business" means | ||||||
2 | the insurers direct premium earned from the first through the | ||||||
3 | final day of the reporting quarter, and includes only premium | ||||||
4 | specific to covered Illinois residents. | ||||||
5 | "Director" means the Director of the Division of Insurance | ||||||
6 | of the Illinois Department of Financial and Professional | ||||||
7 | Regulation.
| ||||||
8 | "Direct losses incurred" means direct losses incurred from | ||||||
9 | the first through the final day of the reporting quarter and | ||||||
10 | includes only premium specific to covered Illinois residents.
| ||||||
11 | "Direct premiums earned for new business only" means the | ||||||
12 | direct premium earned for new business only from the first | ||||||
13 | through the final day of the reporting and includes only | ||||||
14 | premium specific to covered Illinois residents.
| ||||||
15 | "Disability income" means a policy designed to compensate | ||||||
16 | insureds for a portion of the income they lose because of a | ||||||
17 | disabling injury or illness. "Disability income" includes | ||||||
18 | business overhead expense, short-term, long-term, and combined | ||||||
19 | short-term and long-term coverage.
| ||||||
20 | "Employers, if group coverage, at end of reporting quarter" | ||||||
21 | means for all group categories, the number of employers who | ||||||
22 | covered Illinois resident employees, as of the final day of the | ||||||
23 | reporting quarter.
| ||||||
24 | "Excess/stop loss" means the type of insurance may be | ||||||
25 | extended to either a health plan or self-insured employer plan. | ||||||
26 | Its purpose is to insure against the risk that any one claim |
| |||||||
| |||||||
1 | will exceed a specific dollar amount or that an entire plan's | ||||||
2 | losses will exceed a specific amount. "Excess/stop loss" | ||||||
3 | includes accident and sickness, managed care, provider, and | ||||||
4 | self-funded health plan coverage.
| ||||||
5 | "FEHBP" means health, vision, and dental coverage provided | ||||||
6 | pursuant to the Federal Employees Health Benefits Program. | ||||||
7 | "Hospital indemnity" means an insurance contract that pays | ||||||
8 | a fixed dollar amount without regard to the actual expense | ||||||
9 | incurred for each day the covered person is confined to the | ||||||
10 | hospital as a result of injury, sickness, or medical condition. | ||||||
11 | "Hospital surgical" means an insurance contract that | ||||||
12 | provides coverage to or reimburses the covered person for | ||||||
13 | hospital, surgical, or medical expense incurred as a result of | ||||||
14 | injury, sickness, or medical condition. | ||||||
15 | "In-state" groups means Illinois groups with group master | ||||||
16 | contracts issued to a trust sitused in Illinois.
| ||||||
17 | "Insurer" means an insurance company authorized to | ||||||
18 | transact the class of business as set forth in subsection (b) | ||||||
19 | of Class 1 and subsection (a) of Class 2 of Section 4 of the | ||||||
20 | Insurance Code, as well as health care plans authorized under | ||||||
21 | the Health Maintenance Organization Act.
| ||||||
22 | "Limited benefit" means the plan:
(1) pays benefits for the | ||||||
23 | diagnosis and treatment of a specifically named disease or
| ||||||
24 | diseases. Benefits can be paid as expense incurred, per diem, | ||||||
25 | or a principle sum;
(2) provides a daily benefit for | ||||||
26 | confinement in a qualified intensive care unit of a
certified |
| |||||||
| |||||||
1 | hospital. Benefits are specific to services delivered by the | ||||||
2 | staff of a
hospital intensive care unit. Benefits are not to | ||||||
3 | exceed a stated dollar amount per
day; and
(3) provides | ||||||
4 | benefits for services incurred as a result of human or | ||||||
5 | non-human
organ transplant. Benefits are specific to the | ||||||
6 | delivery of care associated with the
covered organ or tissue | ||||||
7 | transplant. Benefits are not to exceed a stated dollar
amount | ||||||
8 | per day.
"Limited benefit" includes coverage for specified | ||||||
9 | disease, critical illness, dread disease, dread disease-cancer | ||||||
10 | only, HIV indemnity, intensive care, and organ and tissue | ||||||
11 | transplant. | ||||||
12 | "Long-term care" means coverage that includes long-term | ||||||
13 | care, nursing home, and home care contracts that provide | ||||||
14 | reimbursement for these services. | ||||||
15 | "Loss-ratio" means the insurer's ratio of direct losses | ||||||
16 | incurred to direct premiums earned for new and renewal business | ||||||
17 | from the first through the final day of the reporting quarter | ||||||
18 | and includes only premium specific to covered Illinois | ||||||
19 | residents. | ||||||
20 | "Major medical" means a hospital, surgical, or medical | ||||||
21 | expense contract that is designed to cover expenses of serious | ||||||
22 | illness, chronic care, or hospitalization. "Major medical" | ||||||
23 | does not include hospital indemnity, accidental death and | ||||||
24 | dismemberment, workers' compensation, credit accident and | ||||||
25 | health, short-term accident and health, accident only, | ||||||
26 | long-term care, Medicare supplement, pre-paid products, |
| |||||||
| |||||||
1 | student blanket, stand-alone policies, dental-only, | ||||||
2 | vision-only, prescription drug benefits, disability income, | ||||||
3 | specified disease, or similar supplementary benefits; coverage | ||||||
4 | issued as a supplement to liability insurance; workers' | ||||||
5 | compensation or similar insurance; or automobile | ||||||
6 | medical-payment insurance. | ||||||
7 | "Medicare supplement" means a group or individual policy of | ||||||
8 | accident or health insurance or a subscriber contract of | ||||||
9 | hospital and medical service associations, other than a policy | ||||||
10 | issued pursuant to a contract under Section 1876 of the federal | ||||||
11 | Social Security Act or a policy issued pursuant to a | ||||||
12 | demonstration project specified in Section 1395ss(g)(1) of the | ||||||
13 | federal Social Security Act, which is advertised, marketed, or | ||||||
14 | designed primarily as a supplement to reimbursements under | ||||||
15 | Medicare for the hospital, medical, or surgical expenses of | ||||||
16 | persons eligible for Medicare.
| ||||||
17 | "Member months at end of reporting quarter" means the total | ||||||
18 | number of months that each member or policyholder is provided | ||||||
19 | coverage from the first day through the final day of the | ||||||
20 | reporting quarter.
| ||||||
21 | "Out-of-state" groups means groups that have master | ||||||
22 | contracts issued to a trust sitused outside of Illinois.
| ||||||
23 | "Primary insureds at end of reporting quarter" means the | ||||||
24 | total number of resident individual policyholders or resident | ||||||
25 | group employee or member certificate holders, as of the final | ||||||
26 | day of the reporting quarter.
|
| |||||||
| |||||||
1 | "Quarter" means the following quarter years:
| ||||||
2 | (1) October 1 through December 31; | ||||||
3 | (2) January 1 through March 31;
| ||||||
4 | (3) April 1 through June 30; | ||||||
5 | (4) July 1 through September 30. | ||||||
6 |
"Short-term care" means coverage that includes medical and | ||||||
7 | other services to insureds who need constant care in their own | ||||||
8 | home or in a nursing facility for periods of less than one | ||||||
9 | year. "Short-term care" includes home health care, nursing | ||||||
10 | home, and adult day care. | ||||||
11 | "Student" means a health insurance contract that covers a | ||||||
12 | class of students not individually identified in the contract. | ||||||
13 | "Travel" means limited benefit expense policies and | ||||||
14 | benefits for loss incurred while traveling generally outside a | ||||||
15 | 100-mile radius of the US borders, subject to State | ||||||
16 | limitations. | ||||||
17 | "Vision" means limited benefit expense policies that | ||||||
18 | provide benefits for eye care and eye care accessories and may | ||||||
19 | include surgical benefits for injury or sickness associated | ||||||
20 | with the eye. | ||||||
21 | "Wellness program participation premium discounts" means | ||||||
22 | the dollar value of plan-administered premium discounts, | ||||||
23 | rebates of premium or contribution, or waivers of all or part | ||||||
24 | of a surcharge or cost-sharing mechanism, such as deductibles, | ||||||
25 | co-pays, or coinsurance, provided to individual insureds for | ||||||
26 | their participation in a bona fide wellness program, from the |
| |||||||
| |||||||
1 | first day through the final day of the reporting quarter. To | ||||||
2 | qualify as a bona fide wellness program, the program must:
| ||||||
3 | (1) offer a limited reward or discount;
| ||||||
4 | (2) be reasonably designed to promote good health and
| ||||||
5 | disease prevention; | ||||||
6 | (3) allow policyholders to qualify for the program's | ||||||
7 | reward at least once per
year; and | ||||||
8 | (4) be available to all similarly situated employees, | ||||||
9 | with reasonable alternative
standards for those for which | ||||||
10 | the general standard is unreasonably difficult or | ||||||
11 | medically
inadvisable.
| ||||||
12 | Section 15. Reports. | ||||||
13 | (a) All insurers subject to this Act shall, beginning at | ||||||
14 | the current quarter and year, and continuing through all | ||||||
15 | subsequent quarters and years, report accurate and complete | ||||||
16 | information for each accident and health coverage type | ||||||
17 | requested to the Director. The following reports are requested: | ||||||
18 | (1) on the final day of each quarter, file a quarterly | ||||||
19 | report for the prior quarter (not for the quarter on which | ||||||
20 | the due date falls) regarding information on health benefit | ||||||
21 | plans currently in force in this State; | ||||||
22 | (2) on or before April 1 for the preceding year ending | ||||||
23 | December 31,
file an annual report for the prior year (not | ||||||
24 | for the year on which the due date falls) regarding | ||||||
25 | information on health benefit plans currently at force in |
| |||||||
| |||||||
1 | this State; and | ||||||
2 | (3) insurers and comprehensive major medical business | ||||||
3 | currently in force in this State that covers more than 500 | ||||||
4 | unduplicated persons (primary insureds plus dependents) | ||||||
5 | shall, on or before April 1 for the preceding year ending | ||||||
6 | December 31, file a completed annual supplemental report | ||||||
7 | with average provider reimbursement rates on health | ||||||
8 | benefit plans currently in force in this State.
| ||||||
9 | The format of the report will be at the discretion of the | ||||||
10 | Director. | ||||||
11 | (b) The following comprehensive major medical, major | ||||||
12 | medical, and other hospital-surgical, coverage types are | ||||||
13 | requested in this Act: | ||||||
14 | (1) major medical; | ||||||
15 | (2) hospital surgical; | ||||||
16 | (3) in-state groups; | ||||||
17 | (4) out-of-state groups; | ||||||
18 | (5) administrative services only;
| ||||||
19 | (6) accident only; | ||||||
20 | (7) accidental death and dismemberment; | ||||||
21 | (8) blanket accident/sickness | ||||||
22 | (9) dental; | ||||||
23 | (10) disability income (includes business overhead | ||||||
24 | expense, short-term, and long-term); | ||||||
25 | (11) combined short-term and long-term;
| ||||||
26 | (12) excess/stop loss (includes accident and sickness, |
| |||||||
| |||||||
1 | managed care, provider, and self-funded health plan); | ||||||
2 | (13) FEHBP coverage provided pursuant to the federal | ||||||
3 | employees health benefits program. | ||||||
4 | (14) limited benefit (includes specified disease, | ||||||
5 | critical illness, dread disease, dread disease-cancer | ||||||
6 | only, HIV indemnity, intensive care, and organ and tissue | ||||||
7 | transplant); | ||||||
8 | (15) short-term care (includes home health care, | ||||||
9 | nursing home, and adult day care) Medicare supplement | ||||||
10 | (16) Champus/Tricare supplement; | ||||||
11 | (17) travel; | ||||||
12 | (18) vision; and | ||||||
13 | (19) other accident and health care coverage not | ||||||
14 | specifically described. | ||||||
15 | (c) The following information is requested for each | ||||||
16 | accident and coverage type requested:
| ||||||
17 | (1) direct premiums earned for new and renewal | ||||||
18 | business; | ||||||
19 | (2) direct losses incurred; | ||||||
20 | (3) direct premiums earned for new business; | ||||||
21 | (4) loss-ratio; | ||||||
22 | (5) employers, if group coverage, at end of reporting | ||||||
23 | quarter; | ||||||
24 | (6) primary insureds at end of reporting quarter; | ||||||
25 | (7) covered dependents at end of reporting quarter | ||||||
26 | (8) member months at end of reporting quarter; and
|
| |||||||
| |||||||
1 | (9) wellness program participation premium discounts.
|