HB5865eng 95TH GENERAL ASSEMBLY



 


 
HB5865 Engrossed LRB095 19773 KBJ 46147 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 1. Short title. This Act may be cited as the
5 Premium and Loss Data Reporting Act.
 
6     Section 5. Application. This Act shall apply to: (i) all
7 insurers authorized to transact the class of business set forth
8 in subsection (b) of Class 1 and subsection (a) of Class 2 of
9 Section 4 of the Illinois Insurance Code; and (ii) all health
10 plans authorized under the Health Maintenance Organization
11 Act.
 
12     Section 10. Definitions. In this Act:
13     "Accident only" means an insurance contract that provides
14 coverage, alone or in combination, for death, dismemberment,
15 disability, or hospital and medical care caused by or
16 necessitated as a result of accident or specified kinds of
17 accidents.
18     "Accidental death and dismemberment" means an insurance
19 contract that pays a stated benefit in the event of death or
20 dismemberment caused by accident or specified kinds of
21 accidents.
22     "Administrative services only" means a contractual

 

 

HB5865 Engrossed - 2 - LRB095 19773 KBJ 46147 b

1 arrangement utilized by a self-funded employer, whereby a
2 separate company processes claims and provides other
3 administrative services pertinent to the employer's health
4 care plans. The fees associated with these services are
5 included in this Act.
6     "Annual statement" means that statement required by
7 Section 136 of the Illinois Insurance Code to be filed annually
8 by the company with the Director.
9     "Blanket accident/sickness" means a health insurance
10 contract that covers all of a class of persons not individually
11 identified in the contract.
12     "Champus/Tricare supplement" means Civilian Health and
13 Medical Program of the Uniformed Services (Champus).
14 "Champus/Tricare supplement" also includes a private health
15 plan that provides beneficiaries eligible for Champus with
16 supplemental health care coverage.
17     "Code" means the Illinois Insurance Code.
18     "Covered dependents at end of reporting quarter" means the
19 total number of individuals covered by the primary insured's
20 plan who receive coverage due to his or her dependent
21 relationship to the primary insured, as of the final day of the
22 reporting quarter.
23     "Dental" means insurance that provides benefits for
24 routine dental examinations, preventive dental work, and
25 dental procedures needed to treat tooth decay and diseases of
26 the teeth and jaw.

 

 

HB5865 Engrossed - 3 - LRB095 19773 KBJ 46147 b

1     "Direct premiums earned for new and renewal business" means
2 the insurers direct premium earned from the first through the
3 final day of the reporting quarter, and includes only premium
4 specific to covered Illinois residents.
5     "Director" means the Director of the Division of Insurance
6 of the Illinois Department of Financial and Professional
7 Regulation.
8     "Direct losses incurred" means direct losses incurred from
9 the first through the final day of the reporting quarter and
10 includes only premium specific to covered Illinois residents.
11     "Direct premiums earned for new business only" means the
12 direct premium earned for new business only from the first
13 through the final day of the reporting and includes only
14 premium specific to covered Illinois residents.
15     "Disability income" means a policy designed to compensate
16 insureds for a portion of the income they lose because of a
17 disabling injury or illness. "Disability income" includes
18 business overhead expense, short-term, long-term, and combined
19 short-term and long-term coverage.
20     "Employers, if group coverage, at end of reporting quarter"
21 means for all group categories, the number of employers who
22 covered Illinois resident employees, as of the final day of the
23 reporting quarter.
24     "Excess/stop loss" means the type of insurance may be
25 extended to either a health plan or self-insured employer plan.
26 Its purpose is to insure against the risk that any one claim

 

 

HB5865 Engrossed - 4 - LRB095 19773 KBJ 46147 b

1 will exceed a specific dollar amount or that an entire plan's
2 losses will exceed a specific amount. "Excess/stop loss"
3 includes accident and sickness, managed care, provider, and
4 self-funded health plan coverage.
5     "FEHBP" means health, vision, and dental coverage provided
6 pursuant to the Federal Employees Health Benefits Program.
7     "Hospital indemnity" means an insurance contract that pays
8 a fixed dollar amount without regard to the actual expense
9 incurred for each day the covered person is confined to the
10 hospital as a result of injury, sickness, or medical condition.
11     "Hospital surgical" means an insurance contract that
12 provides coverage to or reimburses the covered person for
13 hospital, surgical, or medical expense incurred as a result of
14 injury, sickness, or medical condition.
15     "In-state" groups means Illinois groups with group master
16 contracts issued to a trust sitused in Illinois.
17     "Insurer" means an insurance company authorized to
18 transact the class of business as set forth in subsection (b)
19 of Class 1 and subsection (a) of Class 2 of Section 4 of the
20 Insurance Code, as well as health care plans authorized under
21 the Health Maintenance Organization Act.
22     "Limited benefit" means the plan: (1) pays benefits for the
23 diagnosis and treatment of a specifically named disease or
24 diseases. Benefits can be paid as expense incurred, per diem,
25 or a principle sum; (2) provides a daily benefit for
26 confinement in a qualified intensive care unit of a certified

 

 

HB5865 Engrossed - 5 - LRB095 19773 KBJ 46147 b

1 hospital. Benefits are specific to services delivered by the
2 staff of a hospital intensive care unit. Benefits are not to
3 exceed a stated dollar amount per day; and (3) provides
4 benefits for services incurred as a result of human or
5 non-human organ transplant. Benefits are specific to the
6 delivery of care associated with the covered organ or tissue
7 transplant. Benefits are not to exceed a stated dollar amount
8 per day. "Limited benefit" includes coverage for specified
9 disease, critical illness, dread disease, dread disease-cancer
10 only, HIV indemnity, intensive care, and organ and tissue
11 transplant.
12     "Long-term care" means coverage that includes long-term
13 care, nursing home, and home care contracts that provide
14 reimbursement for these services.
15     "Loss-ratio" means the insurer's ratio of direct losses
16 incurred to direct premiums earned for new and renewal business
17 from the first through the final day of the reporting quarter
18 and includes only premium specific to covered Illinois
19 residents.
20     "Major medical" means a hospital, surgical, or medical
21 expense contract that is designed to cover expenses of serious
22 illness, chronic care, or hospitalization. "Major medical"
23 does not include hospital indemnity, accidental death and
24 dismemberment, workers' compensation, credit accident and
25 health, short-term accident and health, accident only,
26 long-term care, Medicare supplement, pre-paid products,

 

 

HB5865 Engrossed - 6 - LRB095 19773 KBJ 46147 b

1 student blanket, stand-alone policies, dental-only,
2 vision-only, prescription drug benefits, disability income,
3 specified disease, or similar supplementary benefits; coverage
4 issued as a supplement to liability insurance; workers'
5 compensation or similar insurance; or automobile
6 medical-payment insurance.
7     "Medicare supplement" means a group or individual policy of
8 accident or health insurance or a subscriber contract of
9 hospital and medical service associations, other than a policy
10 issued pursuant to a contract under Section 1876 of the federal
11 Social Security Act or a policy issued pursuant to a
12 demonstration project specified in Section 1395ss(g)(1) of the
13 federal Social Security Act, which is advertised, marketed, or
14 designed primarily as a supplement to reimbursements under
15 Medicare for the hospital, medical, or surgical expenses of
16 persons eligible for Medicare.
17     "Member months at end of reporting quarter" means the total
18 number of months that each member or policyholder is provided
19 coverage from the first day through the final day of the
20 reporting quarter.
21     "Out-of-state" groups means groups that have master
22 contracts issued to a trust sitused outside of Illinois.
23     "Primary insureds at end of reporting quarter" means the
24 total number of resident individual policyholders or resident
25 group employee or member certificate holders, as of the final
26 day of the reporting quarter.

 

 

HB5865 Engrossed - 7 - LRB095 19773 KBJ 46147 b

1     "Quarter" means the following quarter years:
2         (1) October 1 through December 31;
3         (2) January 1 through March 31;
4         (3) April 1 through June 30; and
5         (4) July 1 through September 30.
6      "Short-term care" means coverage that includes medical and
7 other services to insureds who need constant care in their own
8 home or in a nursing facility for periods of less than one
9 year. "Short-term care" includes home health care, nursing
10 home, and adult day care.
11     "Student" means a health insurance contract that covers a
12 class of students not individually identified in the contract.
13     "Travel" means limited benefit expense policies and
14 benefits for loss incurred while traveling generally outside a
15 100-mile radius of the US borders, subject to State
16 limitations.
17     "Vision" means limited benefit expense policies that
18 provide benefits for eye care and eye care accessories and may
19 include surgical benefits for injury or sickness associated
20 with the eye.
21     "Wellness program participation premium discounts" means
22 the dollar value of plan-administered premium discounts,
23 rebates of premium or contribution, or waivers of all or part
24 of a surcharge or cost-sharing mechanism, such as deductibles,
25 co-pays, or coinsurance, provided to individual insureds for
26 their participation in a bona fide wellness program, from the

 

 

HB5865 Engrossed - 8 - LRB095 19773 KBJ 46147 b

1 first day through the final day of the reporting quarter. To
2 qualify as a bona fide wellness program, the program must:
3         (1) offer a limited reward or discount;
4         (2) be reasonably designed to promote good health and
5     disease prevention;
6         (3) allow policyholders to qualify for the program's
7     reward at least once per year; and
8         (4) be available to all similarly situated employees,
9     with reasonable alternative standards for those for which
10     the general standard is unreasonably difficult or
11     medically inadvisable.
 
12     Section 15. Reports.
13     (a) All insurers subject to this Act shall, beginning at
14 the current quarter and year, and continuing through all
15 subsequent quarters and years, report accurate and complete
16 information for each accident and health coverage type
17 requested to the Director. The following reports are requested:
18         (1) on the final day of each quarter, file a quarterly
19     report for the prior quarter (not for the quarter on which
20     the due date falls) regarding information on health benefit
21     plans currently in force in this State; and
22         (2) on or before April 1 for the preceding year ending
23     December 31, file an annual report for the prior year (not
24     for the year on which the due date falls) regarding
25     information on health benefit plans currently at force in

 

 

HB5865 Engrossed - 9 - LRB095 19773 KBJ 46147 b

1     this State.
2 In addition, insurers with comprehensive major medical
3 business currently in force in this State that covers more than
4 500 unduplicated persons (primary insureds plus dependents)
5 shall, on or before April 1 for the preceding year ending
6 December 31, file a completed annual supplemental report with
7 premium and loss data on health benefit plans currently in
8 force in this State.
9     Information reported under this Section must be reported in
10 an aggregate format. This Section does not allow for the
11 collection of any information that allows for the
12 identification of an individual provider.
13     (b) The following comprehensive major medical, major
14 medical, and other hospital-surgical coverage types are
15 requested in this Act:
16         (1) major medical;
17         (2) hospital surgical;
18         (3) in-state groups;
19         (4) out-of-state groups;
20         (5) administrative services only;
21         (6) accident only;
22         (7) accidental death and dismemberment;
23         (8) blanket accident/sickness;
24         (9) dental;
25         (10) disability income (includes business overhead
26     expense, short-term, and long-term);

 

 

HB5865 Engrossed - 10 - LRB095 19773 KBJ 46147 b

1         (11) combined short-term and long-term;
2         (12) excess/stop loss (includes accident and sickness,
3     managed care, provider, and self-funded health plan);
4         (13) FEHBP coverage provided pursuant to the federal
5     employees health benefits program.
6         (14) limited benefit (includes specified disease,
7     critical illness, dread disease, dread disease-cancer
8     only, HIV indemnity, intensive care, and organ and tissue
9     transplant);
10         (15) short-term care (includes home health care,
11     nursing home, and adult day care) Medicare supplement;
12         (16) Champus/Tricare supplement;
13         (17) travel;
14         (18) vision; and
15         (19) other accident and health care coverage not
16     specifically described.
17     (c) The following information is requested for each
18 accident and coverage type requested:
19         (1) direct premiums earned for new and renewal
20     business;
21         (2) direct losses incurred;
22         (3) direct premiums earned for new business;
23         (4) loss-ratio;
24         (5) employers, if group coverage, at end of reporting
25     quarter;
26         (6) primary insureds at end of reporting quarter;

 

 

HB5865 Engrossed - 11 - LRB095 19773 KBJ 46147 b

1         (7) covered dependents at end of reporting quarter;
2         (8) member months at end of reporting quarter; and
3         (9) wellness program participation premium discounts.
 
4     Section 20. No authority to make or promulgate rules.
5 Notwithstanding any other rulemaking authority that may exist,
6 neither the Governor nor any agency or agency head under the
7 jurisdiction of the Governor has any authority to make or
8 promulgate rules to implement or enforce the provisions of this
9 Act. If, however, the Governor believes that rules are
10 necessary to implement or enforce the provisions of this Act,
11 the Governor may suggest rules to the General Assembly by
12 filing them with the Clerk of the House and Secretary of the
13 Senate and by requesting that the General Assembly authorize
14 such rulemaking by law, enact those suggested rules into law,
15 or take any other appropriate action in the General Assembly's
16 discretion. Nothing contained in this Act shall be interpreted
17 to grant rulemaking authority under any other Illinois statute
18 where such authority is not otherwise explicitly given. For the
19 purposes of this Act, "rules" is given the meaning contained in
20 Section 1-70 of the Illinois Administrative Procedure Act, and
21 "agency" and "agency head" are given the meanings contained in
22 Sections 1-20 and 1-25 of the Illinois Administrative Procedure
23 Act to the extent that such definitions apply to agencies or
24 agency heads under the jurisdiction of the Governor.