98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB3091

 

Introduced 2/7/2014, by Sen. William R. Haine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/355.4 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003  from Ch. 73, par. 1504-3
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the Illinois Insurance Code, Health Maintenance Organization Act, Limited Health Service Organization Act, and Voluntary Health Services Plans Act. Provides that no insurer may issue a service provider contract that requires an optometrist or ophthalmologist to provide services or materials to the insurer's policyholders at a fee set by the insurer unless the services or materials are covered services or materials under the applicable policyholder agreement. Provides that de minimis reimbursements shall not qualify a service or material as a covered service or material.


LRB098 18319 RPM 53454 b

 

 

A BILL FOR

 

SB3091LRB098 18319 RPM 53454 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 355.4 as follows:
 
6    (215 ILCS 5/355.4 new)
7    Sec. 355.4. Noncovered vision services.
8    (a) In this Section:
9        "Covered services" means vision care services for
10    which a reimbursement is available under an enrollee's plan
11    contract, or for which a reimbursement would be available
12    but for the application of contractual limitations such as
13    deductibles, copayments, coinsurance, waiting periods,
14    annual or lifetime maximums, frequency limitations,
15    alternative benefit payments, or any other limitation.
16        "Vision insurance" means any policy of insurance that
17    is issued by a company that provides coverage for vision
18    services not covered by a medical plan.
19        "Materials" includes, but is not limited to, lenses,
20    devices containing lenses, prisms, lens treatments and
21    coatings, contact lenses, and prosthetic devices to
22    correct, relieve, or treat defects or abnormal conditions
23    of the human eye or its adnexa.

 

 

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1    (b) No company that issues, delivers, amends, or renews an
2individual or group policy of accident and health insurance on
3or after the effective date of this amendatory Act of the 98th
4General Assembly that provides vision insurance or eye health
5care coverage shall issue a service provider contract that
6requires an optometrist or ophthalmologist to provide services
7or materials to the insurer's policyholders at a fee set by the
8insurer unless the services or materials are covered services
9or materials under the applicable policyholder agreement. De
10minimis reimbursements shall not qualify a service or material
11as a covered service or material under this Section.
 
12    Section 10. The Health Maintenance Organization Act is
13amended by changing Section 5-3 as follows:
 
14    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
15    Sec. 5-3. Insurance Code provisions.
16    (a) Health Maintenance Organizations shall be subject to
17the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
18141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
19154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
20355.4, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2,
21356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
22356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19,
23356z.21, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
24368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2,

 

 

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1409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
2Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
3XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
4    (b) For purposes of the Illinois Insurance Code, except for
5Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
6Maintenance Organizations in the following categories are
7deemed to be "domestic companies":
8        (1) a corporation authorized under the Dental Service
9    Plan Act or the Voluntary Health Services Plans Act;
10        (2) a corporation organized under the laws of this
11    State; or
12        (3) a corporation organized under the laws of another
13    state, 30% or more of the enrollees of which are residents
14    of this State, except a corporation subject to
15    substantially the same requirements in its state of
16    organization as is a "domestic company" under Article VIII
17    1/2 of the Illinois Insurance Code.
18    (c) In considering the merger, consolidation, or other
19acquisition of control of a Health Maintenance Organization
20pursuant to Article VIII 1/2 of the Illinois Insurance Code,
21        (1) the Director shall give primary consideration to
22    the continuation of benefits to enrollees and the financial
23    conditions of the acquired Health Maintenance Organization
24    after the merger, consolidation, or other acquisition of
25    control takes effect;
26        (2)(i) the criteria specified in subsection (1)(b) of

 

 

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1    Section 131.8 of the Illinois Insurance Code shall not
2    apply and (ii) the Director, in making his determination
3    with respect to the merger, consolidation, or other
4    acquisition of control, need not take into account the
5    effect on competition of the merger, consolidation, or
6    other acquisition of control;
7        (3) the Director shall have the power to require the
8    following information:
9            (A) certification by an independent actuary of the
10        adequacy of the reserves of the Health Maintenance
11        Organization sought to be acquired;
12            (B) pro forma financial statements reflecting the
13        combined balance sheets of the acquiring company and
14        the Health Maintenance Organization sought to be
15        acquired as of the end of the preceding year and as of
16        a date 90 days prior to the acquisition, as well as pro
17        forma financial statements reflecting projected
18        combined operation for a period of 2 years;
19            (C) a pro forma business plan detailing an
20        acquiring party's plans with respect to the operation
21        of the Health Maintenance Organization sought to be
22        acquired for a period of not less than 3 years; and
23            (D) such other information as the Director shall
24        require.
25    (d) The provisions of Article VIII 1/2 of the Illinois
26Insurance Code and this Section 5-3 shall apply to the sale by

 

 

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1any health maintenance organization of greater than 10% of its
2enrollee population (including without limitation the health
3maintenance organization's right, title, and interest in and to
4its health care certificates).
5    (e) In considering any management contract or service
6agreement subject to Section 141.1 of the Illinois Insurance
7Code, the Director (i) shall, in addition to the criteria
8specified in Section 141.2 of the Illinois Insurance Code, take
9into account the effect of the management contract or service
10agreement on the continuation of benefits to enrollees and the
11financial condition of the health maintenance organization to
12be managed or serviced, and (ii) need not take into account the
13effect of the management contract or service agreement on
14competition.
15    (f) Except for small employer groups as defined in the
16Small Employer Rating, Renewability and Portability Health
17Insurance Act and except for medicare supplement policies as
18defined in Section 363 of the Illinois Insurance Code, a Health
19Maintenance Organization may by contract agree with a group or
20other enrollment unit to effect refunds or charge additional
21premiums under the following terms and conditions:
22        (i) the amount of, and other terms and conditions with
23    respect to, the refund or additional premium are set forth
24    in the group or enrollment unit contract agreed in advance
25    of the period for which a refund is to be paid or
26    additional premium is to be charged (which period shall not

 

 

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1    be less than one year); and
2        (ii) the amount of the refund or additional premium
3    shall not exceed 20% of the Health Maintenance
4    Organization's profitable or unprofitable experience with
5    respect to the group or other enrollment unit for the
6    period (and, for purposes of a refund or additional
7    premium, the profitable or unprofitable experience shall
8    be calculated taking into account a pro rata share of the
9    Health Maintenance Organization's administrative and
10    marketing expenses, but shall not include any refund to be
11    made or additional premium to be paid pursuant to this
12    subsection (f)). The Health Maintenance Organization and
13    the group or enrollment unit may agree that the profitable
14    or unprofitable experience may be calculated taking into
15    account the refund period and the immediately preceding 2
16    plan years.
17    The Health Maintenance Organization shall include a
18statement in the evidence of coverage issued to each enrollee
19describing the possibility of a refund or additional premium,
20and upon request of any group or enrollment unit, provide to
21the group or enrollment unit a description of the method used
22to calculate (1) the Health Maintenance Organization's
23profitable experience with respect to the group or enrollment
24unit and the resulting refund to the group or enrollment unit
25or (2) the Health Maintenance Organization's unprofitable
26experience with respect to the group or enrollment unit and the

 

 

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1resulting additional premium to be paid by the group or
2enrollment unit.
3    In no event shall the Illinois Health Maintenance
4Organization Guaranty Association be liable to pay any
5contractual obligation of an insolvent organization to pay any
6refund authorized under this Section.
7    (g) Rulemaking authority to implement Public Act 95-1045,
8if any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437,
14eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805,
15eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)
 
16    Section 15. The Limited Health Service Organization Act is
17amended by changing Section 4003 as follows:
 
18    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
19    Sec. 4003. Illinois Insurance Code provisions. Limited
20health service organizations shall be subject to the provisions
21of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
22143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
23154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355.4, 355b, 356v,
24356z.10, 356z.21, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2,

 

 

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1409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII
21/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance
3Code. For purposes of the Illinois Insurance Code, except for
4Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
5health service organizations in the following categories are
6deemed to be domestic companies:
7        (1) a corporation under the laws of this State; or
8        (2) a corporation organized under the laws of another
9    state, 30% of more of the enrollees of which are residents
10    of this State, except a corporation subject to
11    substantially the same requirements in its state of
12    organization as is a domestic company under Article VIII
13    1/2 of the Illinois Insurance Code.
14(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.
151-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)
 
16    Section 20. The Voluntary Health Services Plans Act is
17amended 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
20services plan corporations and all persons interested therein
21or dealing therewith shall be subject to the provisions of
22Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
23143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355.4,
24355b, 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w,

 

 

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1356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
2356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
3356z.18, 356z.19, 356z.21, 364.01, 367.2, 368a, 401, 401.1,
4402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
5(15) of Section 367 of the Illinois Insurance Code.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
13eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,
14eff. 7-13-12; 98-189, eff. 1-1-14.)