HB4924 Engrossed LRB096 16233 RPM 31489 b

1     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
5 Section 356z.19 as follows:
 
6     (215 ILCS 5/356z.19 new)
7     Sec. 356z.19. Cochlear implants; audiological services.
8     (a) A group or individual policy of accident and health
9 insurance or managed care plan amended, delivered, issued, or
10 renewed after the effective date of this amendatory Act of the
11 96th General Assembly must provide coverage for an operation,
12 either monaurally or binaurally, to implant cochlear implants
13 and cochlear devices, including all internal and external
14 components, and provide post-treatment services, including,
15 but not limited to, programming, troubleshooting, repairs,
16 replacement components, such as external speech processors,
17 microphones, coils, headsets, cables, and batteries, FM
18 systems, auditory training, aural rehabilitation, and speech
19 therapy for children identified by 18 years of age as having
20 hearing impairment to the degree that they would benefit from
21 implantation. These services must be provided by a
22 speech-language pathologist, audiologist, or physician
23 licensed to practice in this State.

 

 

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1     (b) A group or individual policy of accident and health
2 insurance or managed care plan amended, delivered, issued, or
3 renewed after the effective date of this amendatory Act of the
4 96th General Assembly must provide coverage for audiological
5 services and hearing aids for children up to 18 years of age.
6 This coverage shall only apply to hearing aids that are
7 prescribed, filled, and dispensed by a licensed audiologist. A
8 policy or plan may limit the hearing aid benefit payable for
9 each hearing-impaired ear to every 38 months. A policy or plan
10 may provide for up to 4 additional ear molds per year for
11 children up to 2 years of age.
 
12     Section 10. The Health Maintenance Organization Act is
13 amended by changing Section 5-3 as follows:
 
14     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
15     (Text of Section before amendment by P.A. 96-833)
16     Sec. 5-3. Insurance Code provisions.
17     (a) Health Maintenance Organizations shall be subject to
18 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
19 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
20 154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
21 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
22 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14,
23 356z.17 356z.15, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a,
24 368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408,

 

 

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1 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
2 (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
3 XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
4     (b) For purposes of the Illinois Insurance Code, except for
5 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
6 Maintenance Organizations in the following categories are
7 deemed 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
19 acquisition of control of a Health Maintenance Organization
20 pursuant 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
26 Insurance Code and this Section 5-3 shall apply to the sale by

 

 

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1 any health maintenance organization of greater than 10% of its
2 enrollee population (including without limitation the health
3 maintenance organization's right, title, and interest in and to
4 its health care certificates).
5     (e) In considering any management contract or service
6 agreement subject to Section 141.1 of the Illinois Insurance
7 Code, the Director (i) shall, in addition to the criteria
8 specified in Section 141.2 of the Illinois Insurance Code, take
9 into account the effect of the management contract or service
10 agreement on the continuation of benefits to enrollees and the
11 financial condition of the health maintenance organization to
12 be managed or serviced, and (ii) need not take into account the
13 effect of the management contract or service agreement on
14 competition.
15     (f) Except for small employer groups as defined in the
16 Small Employer Rating, Renewability and Portability Health
17 Insurance Act and except for medicare supplement policies as
18 defined in Section 363 of the Illinois Insurance Code, a Health
19 Maintenance Organization may by contract agree with a group or
20 other enrollment unit to effect refunds or charge additional
21 premiums 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
18 statement in the evidence of coverage issued to each enrollee
19 describing the possibility of a refund or additional premium,
20 and upon request of any group or enrollment unit, provide to
21 the group or enrollment unit a description of the method used
22 to calculate (1) the Health Maintenance Organization's
23 profitable experience with respect to the group or enrollment
24 unit and the resulting refund to the group or enrollment unit
25 or (2) the Health Maintenance Organization's unprofitable
26 experience with respect to the group or enrollment unit and the

 

 

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1 resulting additional premium to be paid by the group or
2 enrollment unit.
3     In no event shall the Illinois Health Maintenance
4 Organization Guaranty Association be liable to pay any
5 contractual obligation of an insolvent organization to pay any
6 refund authorized under this Section.
7     (g) Rulemaking authority to implement Public Act 95-1045
8 this amendatory Act of the 95th General Assembly, if any, is
9 conditioned on the rules being adopted in accordance with all
10 provisions of the Illinois Administrative Procedure Act and all
11 rules and procedures of the Joint Committee on Administrative
12 Rules; any purported rule not so adopted, for whatever reason,
13 is unauthorized.
14 (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
15 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
16 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
17 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised
18 10-23-09.)
 
19     (Text of Section after amendment by P.A. 96-833)
20     Sec. 5-3. Insurance Code provisions.
21     (a) Health Maintenance Organizations shall be subject to
22 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
23 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
24 154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
25 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,

 

 

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1 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
2 356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
3 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
4 409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
5 Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
6 XIII 1/2, 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     (g) Rulemaking authority to implement Public Act 95-1045,
11 if any, is conditioned on the rules being adopted in accordance
12 with all provisions of the Illinois Administrative Procedure
13 Act and all rules and procedures of the Joint Committee on
14 Administrative Rules; any purported rule not so adopted, for
15 whatever reason, is unauthorized.
16 (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
17 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
18 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
19 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
20 6-1-10.)
 
21     Section 15. The Voluntary Health Services Plans Act is
22 amended by changing Section 10 as follows:
 
23     (215 ILCS 165/10)  (from Ch. 32, par. 604)
24     (Text of Section before amendment by P.A. 96-833)

 

 

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1     Sec. 10. Application of Insurance Code provisions. Health
2 services plan corporations and all persons interested therein
3 or dealing therewith shall be subject to the provisions of
4 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
5 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
6 356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
7 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
8 356z.14, 356z.15 356z.14, 356z.19, 364.01, 367.2, 368a, 401,
9 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
10 and (15) of Section 367 of the Illinois Insurance Code.
11     Rulemaking authority to implement Public Act 95-1045 this
12 amendatory Act of the 95th General Assembly, if any, is
13 conditioned on the rules being adopted in accordance with all
14 provisions of the Illinois Administrative Procedure Act and all
15 rules and procedures of the Joint Committee on Administrative
16 Rules; any purported rule not so adopted, for whatever reason,
17 is unauthorized.
18 (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
19 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
20 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
21 eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
22 96-328, eff. 8-11-09; revised 9-25-09.)
 
23     (Text of Section after amendment by P.A. 96-833)
24     Sec. 10. Application of Insurance Code provisions. Health
25 services plan corporations and all persons interested therein

 

 

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1 or dealing therewith shall be subject to the provisions of
2 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
3 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
4 356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
5 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
6 356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401,
7 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
8 and (15) of Section 367 of the Illinois Insurance Code.
9     Rulemaking authority to implement Public Act 95-1045, if
10 any, is conditioned on the rules being adopted in accordance
11 with all provisions of the Illinois Administrative Procedure
12 Act and all rules and procedures of the Joint Committee on
13 Administrative Rules; any purported rule not so adopted, for
14 whatever reason, is unauthorized.
15 (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
16 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
17 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
18 eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
19 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.)
 
20     Section 95. No acceleration or delay. Where this Act makes
21 changes in a statute that is represented in this Act by text
22 that is not yet or no longer in effect (for example, a Section
23 represented by multiple versions), the use of that text does
24 not accelerate or delay the taking effect of (i) the changes
25 made by this Act or (ii) provisions derived from any other

 

 

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1 Public Act.