95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
SB2901

 

Introduced 2/15/2008, by Sen. Jeffrey M. Schoenberg

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.11 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


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A BILL FOR

 

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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 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. Emergency ambulance service. A group or
8 individual policy of accident and health insurance or managed
9 care plan amended, delivered, issued, or renewed after the
10 effective date of this amendatory Act of the 95th General
11 Assembly must provide coverage for emergency ambulance service
12 regardless of whether the ambulance service provider is
13 considered in-network by the insurer. As used in this Section,
14 "emergency ambulance service" means ambulance service
15 initiated by a call to 911 or its local equivalent.
 
16     Section 10. The Health Maintenance Organization Act is
17 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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1 141.3, 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, 356z.10,
4 356z.11 356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
5 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409,
6 412, 444, and 444.1, paragraph (c) of subsection (2) of Section
7 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
8 XXV, and XXVI of 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
12 deemed to be "domestic companies":
13         (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
18     state, 30% or more of the enrollees of which are residents
19     of this State, except a corporation subject to
20     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,
26         (1) the Director shall give primary consideration to

 

 

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1     the continuation of benefits to enrollees and the financial
2     conditions of the acquired Health Maintenance Organization
3     after the merger, consolidation, or other acquisition of
4     control takes effect;
5         (2)(i) the criteria specified in subsection (1)(b) of
6     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
9     acquisition of control, need not take into account the
10     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:
14             (A) certification by an independent actuary of the
15         adequacy of the reserves of the Health Maintenance
16         Organization sought to be acquired;
17             (B) pro forma financial statements reflecting the
18         combined balance sheets of the acquiring company and
19         the Health Maintenance Organization sought to be
20         acquired as of the end of the preceding year and as of
21         a date 90 days prior to the acquisition, as well as pro
22         forma financial statements reflecting projected
23         combined operation for a period of 2 years;
24             (C) a pro forma business plan detailing an
25         acquiring party's plans with respect to the operation
26         of the Health Maintenance Organization sought to be

 

 

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1         acquired for a period of not less than 3 years; and
2             (D) such other information as the Director shall
3         require.
4     (d) The provisions of Article VIII 1/2 of the Illinois
5 Insurance Code and this Section 5-3 shall apply to the sale by
6 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
21 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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1         (i) the amount of, and other terms and conditions with
2     respect to, the refund or additional premium are set forth
3     in the group or enrollment unit contract agreed in advance
4     of the period for which a refund is to be paid or
5     additional premium is to be charged (which period shall not
6     be less than one year); and
7         (ii) the amount of the refund or additional premium
8     shall not exceed 20% of the Health Maintenance
9     Organization's profitable or unprofitable experience with
10     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
13     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
17     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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1 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. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
13 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 
14     Section 15. The Voluntary Health Services Plans Act is
15 amended by changing Section 10 as follows:
 
16     (215 ILCS 165/10)  (from Ch. 32, par. 604)
17     Sec. 10. Application of Insurance Code provisions. Health
18 services plan corporations and all persons interested therein
19 or dealing therewith shall be subject to the provisions of
20 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
21 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
22 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
23 356z.9, 356z.10, 356z.11 356z.9, 364.01, 367.2, 368a, 401,
24 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)

 

 

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1 and (15) of Section 367 of the Illinois Insurance Code.
2 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
3 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
4 8-28-07; revised 12-5-07.)
 
5     Section 99. Effective date. This Act takes effect upon
6 becoming law.