Illinois General Assembly - Full Text of HB4516
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Full Text of HB4516  100th General Assembly


Rep. Laura Fine

Filed: 4/20/2018





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2    AMENDMENT NO. ______. Amend House Bill 4516 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Insurance Code is amended by
5adding Section 356z.29 as follows:
6    (215 ILCS 5/356z.29 new)
7    Sec. 356z.29. Coverage for hearing aids for individuals
8under the age of 18.
9    (a) As used in this Section:
10    "Hearing care professional" means a person who is a
11licensed hearing instrument dispenser, licensed audiologist,
12or licensed physician.
13    "Hearing instrument" or "hearing aid" means any wearable
14non-disposable, non-experimental instrument or device designed
15to aid or compensate for impaired human hearing and any parts,
16attachments, or accessories for the instrument or device,



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1including an ear mold but excluding batteries and cords.
2    (b) An individual or group policy of accident and health
3insurance or managed care plan that is amended, delivered,
4issued, or renewed after the effective date of this amendatory
5Act of the 100th General Assembly must provide coverage for
6medically necessary hearing instruments and related services
7for all individuals under the age of 18 when a hearing care
8professional prescribes a hearing instrument to augment
10    (c) An insurer shall provide coverage, subject to all
11applicable co-payments, co-insurance, deductibles, and
12out-of-pocket limits, subject to the following restrictions:
13        (1) one hearing instrument shall be covered for each
14    ear every 36 months;
15        (2) related services, such as audiological exams and
16    selection, fitting, and adjustment of ear molds to maintain
17    optimal fit shall be covered when deemed medically
18    necessary by a hearing care professional; and
19        (3) hearing instrument repairs may be covered when
20    deemed medically necessary.
21    Section 10. The Health Maintenance Organization Act is
22amended by changing Section 5-3 as follows:
23    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
24    Sec. 5-3. Insurance Code provisions.



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1    (a) Health Maintenance Organizations shall be subject to
2the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
3141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
4154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
5355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
6356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
7356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
8356z.22, 356z.25, 356z.26, 356z.29, 364, 364.01, 367.2,
9367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401,
10401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
11paragraph (c) of subsection (2) of Section 367, and Articles
12IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
13the Illinois Insurance Code.
14    (b) For purposes of the Illinois Insurance Code, except for
15Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
16Maintenance Organizations in the following categories are
17deemed to be "domestic companies":
18        (1) a corporation authorized under the Dental Service
19    Plan Act or the Voluntary Health Services Plans Act;
20        (2) a corporation organized under the laws of this
21    State; or
22        (3) a corporation organized under the laws of another
23    state, 30% or more of the enrollees of which are residents
24    of this State, except a corporation subject to
25    substantially the same requirements in its state of
26    organization as is a "domestic company" under Article VIII



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1    1/2 of the Illinois Insurance Code.
2    (c) In considering the merger, consolidation, or other
3acquisition of control of a Health Maintenance Organization
4pursuant to Article VIII 1/2 of the Illinois Insurance Code,
5        (1) the Director shall give primary consideration to
6    the continuation of benefits to enrollees and the financial
7    conditions of the acquired Health Maintenance Organization
8    after the merger, consolidation, or other acquisition of
9    control takes effect;
10        (2)(i) the criteria specified in subsection (1)(b) of
11    Section 131.8 of the Illinois Insurance Code shall not
12    apply and (ii) the Director, in making his determination
13    with respect to the merger, consolidation, or other
14    acquisition of control, need not take into account the
15    effect on competition of the merger, consolidation, or
16    other acquisition of control;
17        (3) the Director shall have the power to require the
18    following information:
19            (A) certification by an independent actuary of the
20        adequacy of the reserves of the Health Maintenance
21        Organization sought to be acquired;
22            (B) pro forma financial statements reflecting the
23        combined balance sheets of the acquiring company and
24        the Health Maintenance Organization sought to be
25        acquired as of the end of the preceding year and as of
26        a date 90 days prior to the acquisition, as well as pro



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



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



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1    The Health Maintenance Organization shall include a
2statement in the evidence of coverage issued to each enrollee
3describing the possibility of a refund or additional premium,
4and upon request of any group or enrollment unit, provide to
5the group or enrollment unit a description of the method used
6to calculate (1) the Health Maintenance Organization's
7profitable experience with respect to the group or enrollment
8unit and the resulting refund to the group or enrollment unit
9or (2) the Health Maintenance Organization's unprofitable
10experience with respect to the group or enrollment unit and the
11resulting additional premium to be paid by the group or
12enrollment unit.
13    In no event shall the Illinois Health Maintenance
14Organization Guaranty Association be liable to pay any
15contractual obligation of an insolvent organization to pay any
16refund authorized under this Section.
17    (g) Rulemaking authority to implement Public Act 95-1045,
18if any, 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. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
24100-138, eff. 8-18-17; revised 10-5-17.)
25    Section 15. The Voluntary Health Services Plans Act is



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1amended by changing Section 10 as follows:
2    (215 ILCS 165/10)  (from Ch. 32, par. 604)
3    Sec. 10. Application of Insurance Code provisions. Health
4services plan corporations and all persons interested therein
5or dealing therewith shall be subject to the provisions of
6Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
7143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
8356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
9356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
10356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
11356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 364.01,
12367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
13and paragraphs (7) and (15) of Section 367 of the Illinois
14Insurance Code.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
22revised 10-5-17.)
23    Section 99. Effective date. This Act takes effect upon
24becoming law.".