95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
SB2544

 

Introduced 2/15/2008, by Sen. Dale E. Risinger

 

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 provide coverage for Continuous Glucose Monitoring Systems that are approved by the federal Food and Drug Administration and deemed medically necessary by a physician.


LRB095 19041 KBJ 45221 b

 

 

A BILL FOR

 

SB2544 LRB095 19041 KBJ 45221 b

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. Continuous Glucose Monitoring Systems. A
8 group or individual policy of accident and health insurance or
9 managed care plan amended, delivered, issued, or renewed after
10 the effective date of this amendatory Act of the 95th General
11 Assembly must provide coverage for Continuous Glucose
12 Monitoring Systems approved by the federal Food and Drug
13 Administration and deemed necessary by a physician.
 
14     Section 10. The Health Maintenance Organization Act is
15 amended by changing Section 5-3 as follows:
 
16     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
17     Sec. 5-3. Insurance Code provisions.
18     (a) Health Maintenance Organizations shall be subject to
19 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
20 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
21 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,

 

 

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1 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
2 356z.11 356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
3 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409,
4 412, 444, and 444.1, paragraph (c) of subsection (2) of Section
5 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
6 XXV, and XXVI of the Illinois Insurance Code.
7     (b) For purposes of the Illinois Insurance Code, except for
8 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
9 Maintenance Organizations in the following categories are
10 deemed to be "domestic companies":
11         (1) a corporation authorized under the Dental Service
12     Plan Act or the Voluntary Health Services Plans Act;
13         (2) a corporation organized under the laws of this
14     State; or
15         (3) a corporation organized under the laws of another
16     state, 30% or more of the enrollees of which are residents
17     of this State, except a corporation subject to
18     substantially the same requirements in its state of
19     organization as is a "domestic company" under Article VIII
20     1/2 of the Illinois Insurance Code.
21     (c) In considering the merger, consolidation, or other
22 acquisition of control of a Health Maintenance Organization
23 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
24         (1) the Director shall give primary consideration to
25     the continuation of benefits to enrollees and the financial
26     conditions of the acquired Health Maintenance Organization

 

 

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

 

 

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

 

 

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

 

 

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1 unit and the resulting refund to the group or enrollment unit
2 or (2) the Health Maintenance Organization's unprofitable
3 experience with respect to the group or enrollment unit and the
4 resulting additional premium to be paid by the group or
5 enrollment unit.
6     In no event shall the Illinois Health Maintenance
7 Organization Guaranty Association be liable to pay any
8 contractual obligation of an insolvent organization to pay any
9 refund authorized under this Section.
10 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
11 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 
12     Section 15. The Voluntary Health Services Plans Act is
13 amended by changing Section 10 as follows:
 
14     (215 ILCS 165/10)  (from Ch. 32, par. 604)
15     Sec. 10. Application of Insurance Code provisions. Health
16 services plan corporations and all persons interested therein
17 or dealing therewith shall be subject to the provisions of
18 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
19 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,
20 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
21 356z.9, 356z.10, 356z.11 356z.9, 364.01, 367.2, 368a, 401,
22 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
23 and (15) of Section 367 of the Illinois Insurance Code.
24 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;

 

 

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1 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
2 8-28-07; revised 12-5-07.)