Sen. William R. Haine

Filed: 2/28/2012

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 3242

2    AMENDMENT NO. ______. Amend Senate Bill 3242 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5adding Section 355.3 as follows:
 
6    (215 ILCS 5/355.3 new)
7    Sec. 355.3. Noncovered dental services.
8    (a) In this Section:
9        "Covered services" means dental 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        "Dental insurance" means any policy of insurance that

 

 

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1    is issued by a company that provides coverage for dental
2    services not covered by a medical plan.
3    (b) No company that issues, delivers, amends, or renews an
4individual or group policy of accident and health insurance on
5or after the effective date of this amendatory Act of the 97th
6General Assembly that provides dental insurance shall issue a
7service provider contract that requires a dentist to provide
8services to the insurer's policyholders at a fee set by the
9insurer unless the services are covered services under the
10applicable policyholder agreement.
 
11    Section 10. The Dental Service Plan Act is amended by
12changing Section 25 as follows:
 
13    (215 ILCS 110/25)  (from Ch. 32, par. 690.25)
14    Sec. 25. Application of Insurance Code provisions. Dental
15service plan corporations and all persons interested therein or
16dealing therewith shall be subject to the provisions of
17Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
18143, 143c, 149, 355.2, 355.3, 367.2, 401, 401.1, 402, 403,
19403A, 408, 408.2, and 412, and subsection (15) of Section 367
20of the Illinois Insurance Code.
21(Source: P.A. 97-486, eff. 1-1-12.)
 
22    Section 15. The Health Maintenance Organization Act is
23amended by changing Section 5-3 as follows:
 

 

 

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1    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
2    Sec. 5-3. Insurance Code provisions.
3    (a) Health Maintenance Organizations shall be subject to
4the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
5141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
6154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
7356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4, 356z.5,
8356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
9356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21 356z.19,
10364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
11370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
12444, and 444.1, paragraph (c) of subsection (2) of Section 367,
13and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
14and XXVI of the Illinois Insurance Code.
15    (b) For purposes of the Illinois Insurance Code, except for
16Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
17Maintenance Organizations in the following categories are
18deemed to be "domestic companies":
19        (1) a corporation authorized under the Dental Service
20    Plan Act or the Voluntary Health Services Plans Act;
21        (2) a corporation organized under the laws of this
22    State; or
23        (3) a corporation organized under the laws of another
24    state, 30% or more of the enrollees of which are residents
25    of this State, except a corporation subject to

 

 

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1    substantially the same requirements in its state of
2    organization as is a "domestic company" under Article VIII
3    1/2 of the Illinois Insurance Code.
4    (c) In considering the merger, consolidation, or other
5acquisition of control of a Health Maintenance Organization
6pursuant to Article VIII 1/2 of the Illinois Insurance Code,
7        (1) the Director shall give primary consideration to
8    the continuation of benefits to enrollees and the financial
9    conditions of the acquired Health Maintenance Organization
10    after the merger, consolidation, or other acquisition of
11    control takes effect;
12        (2)(i) the criteria specified in subsection (1)(b) of
13    Section 131.8 of the Illinois Insurance Code shall not
14    apply and (ii) the Director, in making his determination
15    with respect to the merger, consolidation, or other
16    acquisition of control, need not take into account the
17    effect on competition of the merger, consolidation, or
18    other acquisition of control;
19        (3) the Director shall have the power to require the
20    following information:
21            (A) certification by an independent actuary of the
22        adequacy of the reserves of the Health Maintenance
23        Organization sought to be acquired;
24            (B) pro forma financial statements reflecting the
25        combined balance sheets of the acquiring company and
26        the Health Maintenance Organization sought to be

 

 

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1        acquired as of the end of the preceding year and as of
2        a date 90 days prior to the acquisition, as well as pro
3        forma financial statements reflecting projected
4        combined operation for a period of 2 years;
5            (C) a pro forma business plan detailing an
6        acquiring party's plans with respect to the operation
7        of the Health Maintenance Organization sought to be
8        acquired for a period of not less than 3 years; and
9            (D) such other information as the Director shall
10        require.
11    (d) The provisions of Article VIII 1/2 of the Illinois
12Insurance Code and this Section 5-3 shall apply to the sale by
13any health maintenance organization of greater than 10% of its
14enrollee population (including without limitation the health
15maintenance organization's right, title, and interest in and to
16its health care certificates).
17    (e) In considering any management contract or service
18agreement subject to Section 141.1 of the Illinois Insurance
19Code, the Director (i) shall, in addition to the criteria
20specified in Section 141.2 of the Illinois Insurance Code, take
21into account the effect of the management contract or service
22agreement on the continuation of benefits to enrollees and the
23financial condition of the health maintenance organization to
24be managed or serviced, and (ii) need not take into account the
25effect of the management contract or service agreement on
26competition.

 

 

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1    (f) Except for small employer groups as defined in the
2Small Employer Rating, Renewability and Portability Health
3Insurance Act and except for medicare supplement policies as
4defined in Section 363 of the Illinois Insurance Code, a Health
5Maintenance Organization may by contract agree with a group or
6other enrollment unit to effect refunds or charge additional
7premiums under the following terms and conditions:
8        (i) the amount of, and other terms and conditions with
9    respect to, the refund or additional premium are set forth
10    in the group or enrollment unit contract agreed in advance
11    of the period for which a refund is to be paid or
12    additional premium is to be charged (which period shall not
13    be less than one year); and
14        (ii) the amount of the refund or additional premium
15    shall not exceed 20% of the Health Maintenance
16    Organization's profitable or unprofitable experience with
17    respect to the group or other enrollment unit for the
18    period (and, for purposes of a refund or additional
19    premium, the profitable or unprofitable experience shall
20    be calculated taking into account a pro rata share of the
21    Health Maintenance Organization's administrative and
22    marketing expenses, but shall not include any refund to be
23    made or additional premium to be paid pursuant to this
24    subsection (f)). The Health Maintenance Organization and
25    the group or enrollment unit may agree that the profitable
26    or unprofitable experience may be calculated taking into

 

 

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1    account the refund period and the immediately preceding 2
2    plan years.
3    The Health Maintenance Organization shall include a
4statement in the evidence of coverage issued to each enrollee
5describing the possibility of a refund or additional premium,
6and upon request of any group or enrollment unit, provide to
7the group or enrollment unit a description of the method used
8to calculate (1) the Health Maintenance Organization's
9profitable experience with respect to the group or enrollment
10unit and the resulting refund to the group or enrollment unit
11or (2) the Health Maintenance Organization's unprofitable
12experience with respect to the group or enrollment unit and the
13resulting additional premium to be paid by the group or
14enrollment unit.
15    In no event shall the Illinois Health Maintenance
16Organization Guaranty Association be liable to pay any
17contractual obligation of an insolvent organization to pay any
18refund authorized under this Section.
19    (g) Rulemaking authority to implement Public Act 95-1045,
20if any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25(Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
2696-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11;

 

 

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197-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12;
297-592, eff. 1-1-12; revised 10-13-11.)
 
3    Section 20. The Limited Health Service Organization Act is
4amended by changing Section 4003 as follows:
 
5    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
6    Sec. 4003. Illinois Insurance Code provisions. Limited
7health service organizations shall be subject to the provisions
8of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
9143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
10154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 356v, 356z.10,
11356z.21 356z.19, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2,
12409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII
131/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance
14Code. For purposes of the Illinois Insurance Code, except for
15Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
16health service organizations in the following categories are
17deemed to be domestic companies:
18        (1) a corporation under the laws of this State; or
19        (2) a corporation organized under the laws of another
20    state, 30% of more of the enrollees of which are residents
21    of this State, except a corporation subject to
22    substantially the same requirements in its state of
23    organization as is a domestic company under Article VIII
24    1/2 of the Illinois Insurance Code.

 

 

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1(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; revised
210-13-11.)
 
3    Section 25. The Voluntary Health Services Plans Act is
4amended by changing Section 10 as follows:
 
5    (215 ILCS 165/10)  (from Ch. 32, par. 604)
6    Sec. 10. Application of Insurance Code provisions. Health
7services plan corporations and all persons interested therein
8or dealing therewith shall be subject to the provisions of
9Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
10143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 356g,
11356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
12356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
13356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
14356z.19, 356z.21 356z.19, 364.01, 367.2, 368a, 401, 401.1, 402,
15403, 403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
16Section 367 of the Illinois Insurance Code.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23(Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10;
2496-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;

 

 

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197-486, eff. 1-1-12; 97-592, eff. 1-1-12; revised 10-13-11.)
 
2    Section 99. Effective date. This Act takes effect January
31, 2013.".