95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
SB1330


 
Introduced 2/9/2007, by Sen. Jeffrey M. Schoenberg
 
SYNOPSIS AS INTRODUCED:
 		

















215 ILCS 5/356z.9 new





215 ILCS 125/5-3
  from Ch. 111 1/2, par. 1411.2


215 ILCS 165/10
  from Ch. 32, par. 604







    Amends the Illinois Insurance Code, the Health Maintenance Organization Act, and the Voluntary Health Services Plans Act to require coverage of emergency ambulance services regardless of whether the ambulance service provider is considered in-network by the insurer. Effective immediately.
















LRB095 10738 KBJ 30978 b

















 


 


A BILL FOR









 









SB1330

LRB095 10738 KBJ 30978 b






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    AN ACT concerning insurance.

 
2
    Be it enacted by the People of the State of Illinois,
 
3
represented in the General Assembly:


 
4
    Section 5. The Illinois Insurance Code is amended  by adding 
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Section 356z.9 as follows:
 
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    (215 ILCS 5/356z.9 new)

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    Sec. 356z.9. Emergency ambulance service. A  group or 
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individual policy of accident and health insurance or managed 
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care plan amended, delivered, issued, or renewed after the 
10
effective date of this amendatory  Act  of the 95th General 
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Assembly must provide coverage for emergency ambulance service 
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regardless of whether the ambulance service provider is 
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considered in-network by the insurer. As used in this Section, 
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"emergency ambulance service" means ambulance service 
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initiated by a call to 911 or its local equivalent.

 
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    Section 10. The Health Maintenance Organization Act is 
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amended  by changing Section 5-3 as follows:
 



18
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


19
    Sec. 5-3. Insurance Code provisions. 

20
    (a) Health Maintenance Organizations
shall be subject to 
21
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
 


 






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141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
2
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
3
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 364.01, 
4
367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 
5
401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,

6
paragraph (c) of subsection (2) of Section 367, and Articles 
7
IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of 
8
the Illinois Insurance Code.

9
    (b) For purposes of the Illinois Insurance Code, except for 
10
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
11
Maintenance Organizations in
the following categories are 
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deemed to be "domestic companies":


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        (1) a corporation authorized under the
Dental Service 
14
    Plan Act or the Voluntary Health Services Plans Act;


15
        (2) a corporation organized under the laws of this 
16
    State; or


17
        (3) a corporation organized under the laws of another 
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    state, 30% or more
of the enrollees of which are residents 
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    of this State, except a
corporation subject to 
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    substantially the same requirements in its state of

21
    organization as is a "domestic company" under Article VIII 
22
    1/2 of the
Illinois Insurance Code.

23
    (c) In considering the merger, consolidation, or other 
24
acquisition of
control of a Health Maintenance Organization 
25
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


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        (1) the Director shall give primary consideration to 
 


 






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    the continuation of
benefits to enrollees and the financial 
2
    conditions of the acquired Health
Maintenance Organization 
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    after the merger, consolidation, or other
acquisition of 
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    control takes effect;


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        (2)(i) the criteria specified in subsection (1)(b) of 
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    Section 131.8 of
the Illinois Insurance Code shall not 
7
    apply and (ii) the Director, in making
his determination 
8
    with respect to the merger, consolidation, or other

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    acquisition of control, need not take into account the 
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    effect on
competition of the merger, consolidation, or 
11
    other acquisition of control;


12
        (3) the Director shall have the power to require the 
13
    following
information:


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            (A) certification by an independent actuary of the 
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        adequacy
of the reserves of the Health Maintenance 
16
        Organization sought to be acquired;


17
            (B) pro forma financial statements reflecting the 
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        combined balance
sheets of the acquiring company and 
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        the Health Maintenance Organization sought
to be 
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        acquired as of the end of the preceding year and as of 
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        a date 90 days
prior to the acquisition, as well as pro 
22
        forma financial statements
reflecting projected 
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        combined operation for a period of 2 years;


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            (C) a pro forma business plan detailing an 
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        acquiring party's plans with
respect to the operation 
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        of the Health Maintenance Organization sought to
be 
 


 






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        acquired for a period of not less than 3 years; and


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            (D) such other information as the Director shall 
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        require.

4
    (d) The provisions of Article VIII 1/2 of the Illinois 
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Insurance Code
and this Section 5-3 shall apply to the sale by 
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any health maintenance
organization of greater than 10% of its

7
enrollee population (including without limitation the health 
8
maintenance
organization's right, title, and interest in and to 
9
its health care
certificates).

10
    (e) In considering any management contract or service 
11
agreement subject
to Section 141.1 of the Illinois Insurance 
12
Code, the Director (i) shall, in
addition to the criteria 
13
specified in Section 141.2 of the Illinois
Insurance Code, take 
14
into account the effect of the management contract or
service 
15
agreement on the continuation of benefits to enrollees and the

16
financial condition of the health maintenance organization to 
17
be managed or
serviced, and (ii) need not take into account the 
18
effect of the management
contract or service agreement on 
19
competition.

20
    (f) Except for small employer groups as defined in the 
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Small Employer
Rating, Renewability and Portability Health 
22
Insurance Act and except for
medicare supplement policies as 
23
defined in Section 363 of the Illinois
Insurance Code, a Health 
24
Maintenance Organization may by contract agree with a
group or 
25
other enrollment unit to effect refunds or charge additional 
26
premiums
under the following terms and conditions:


 


 






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        (i) the amount of, and other terms and conditions with 
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    respect to, the
refund or additional premium are set forth 
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    in the group or enrollment unit
contract agreed in advance 
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    of the period for which a refund is to be paid or

5
    additional premium is to be charged (which period shall not 
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    be less than one
year); and


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        (ii) the amount of the refund or additional premium 
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    shall not exceed 20%
of the Health Maintenance 
9
    Organization's profitable or unprofitable experience
with 
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    respect to the group or other enrollment unit for the 
11
    period (and, for
purposes of a refund or additional 
12
    premium, the profitable or unprofitable
experience shall 
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    be calculated taking into account a pro rata share of the

14
    Health Maintenance Organization's administrative and 
15
    marketing expenses, but
shall not include any refund to be 
16
    made or additional premium to be paid
pursuant to this 
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    subsection (f)).  The Health Maintenance Organization and 
18
    the
group or enrollment unit may agree that the profitable 
19
    or unprofitable
experience may be calculated taking into 
20
    account the refund period and the
immediately preceding 2 
21
    plan years.

22
    The Health Maintenance Organization shall include a 
23
statement in the
evidence of coverage issued to each enrollee 
24
describing the possibility of a
refund or additional premium, 
25
and upon request of any group or enrollment unit,
provide to 
26
the group or enrollment unit a description of the method used 
 


 






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to
calculate (1) the Health Maintenance Organization's 
2
profitable experience with
respect to the group or enrollment 
3
unit and the resulting refund to the group
or enrollment unit 
4
or (2) the Health Maintenance Organization's unprofitable

5
experience with respect to the group or enrollment unit and the 
6
resulting
additional premium to be paid by the group or 
7
enrollment unit.

8
    In no event shall the Illinois Health Maintenance 
9
Organization
Guaranty Association be liable to pay any 
10
contractual obligation of an
insolvent organization to pay any 
11
refund authorized under this Section.

12
(Source: P.A. 93-102, eff. 1-1-04; 93-261, eff. 1-1-04; 93-477, 
13
eff. 8-8-03; 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 
14
93-1000, eff. 1-1-05; 94-906, eff. 1-1-07; 94-1076, eff. 
15
12-29-06; revised 1-5-07.)



 
16
    Section 15. The Voluntary Health Services Plans Act is 
17
amended  by changing Section 10 as follows:
 



18
    (215 ILCS 165/10)  (from Ch. 32, par. 604)


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, 356r, 356t, 356u, 356v,
356w, 356x, 
24
356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,

 


 






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364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, 
2
and 412, and paragraphs (7) and (15) of Section 367 of the 
3
Illinois
Insurance Code.

4
(Source: P.A. 93-102, eff. 1-1-04; 93-529, eff. 8-14-03; 
5
93-853, eff. 1-1-05; 93-1000, eff. 1-1-05; 94-1076, eff. 
6
12-29-06.)



 
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    Section 99. Effective date. This Act takes effect upon 
8
becoming law.