Full Text of HB4876 101st General Assembly
HB4876 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 HB4876 Introduced 2/18/2020, by Rep. Diane Pappas SYNOPSIS AS INTRODUCED: |
| 55 ILCS 5/5-1069.3 | | 65 ILCS 5/10-4-2.3 | | 215 ILCS 5/356z.43 new | | 215 ILCS 125/5-3 | from Ch. 111 1/2, par. 1411.2 |
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Amends the Illinois Insurance Code to require a group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2021 to provide coverage for a colonoscopy that is a follow-up exam based on an initial screen where the colonoscopy was determined to be medically necessary by a physician licensed to practice medicine in all its branches, an advanced practice registered nurse, or a physician assistant. Provides that a group insurance policy shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on colonoscopy coverage, except to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account under the Internal Revenue Code. Makes conforming changes in the Counties Code, the Illinois Municipal Code, and the Health Maintenance Organization Act. Effective January 1, 2021.
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| | FISCAL NOTE ACT MAY APPLY | | STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT |
| | A BILL FOR |
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| 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 Counties Code is amended by changing Section | 5 | | 5-1069.3 as follows: | 6 | | (55 ILCS 5/5-1069.3)
| 7 | | (Text of Section before amendment by P.A. 101-625 ) | 8 | | Sec. 5-1069.3. Required health benefits. If a county, | 9 | | including a home
rule
county, is a self-insurer for purposes of | 10 | | providing health insurance coverage
for its employees, the | 11 | | coverage shall include coverage for the post-mastectomy
care | 12 | | benefits required to be covered by a policy of accident and | 13 | | health
insurance under Section 356t and the coverage required | 14 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 15 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 16 | | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | 17 | | 356z.30a, and 356z.32, and 356z.33 , 356z.36, and 356z.43 of
the | 18 | | Illinois Insurance Code. The coverage shall comply with | 19 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | 20 | | Insurance Code. The Department of Insurance shall enforce the | 21 | | requirements of this Section. The requirement that health | 22 | | benefits be covered
as provided in this Section is an
exclusive | 23 | | power and function of the State and is a denial and limitation |
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| 1 | | under
Article VII, Section 6, subsection (h) of the Illinois | 2 | | Constitution. A home
rule county to which this Section applies | 3 | | must comply with every provision of
this Section.
| 4 | | Rulemaking authority to implement Public Act 95-1045, if | 5 | | any, is conditioned on the rules being adopted in accordance | 6 | | with all provisions of the Illinois Administrative Procedure | 7 | | Act and all rules and procedures of the Joint Committee on | 8 | | Administrative Rules; any purported rule not so adopted, for | 9 | | whatever reason, is unauthorized. | 10 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 11 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 12 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 13 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 14 | | revised 10-16-19.) | 15 | | (Text of Section after amendment by P.A. 101-625 ) | 16 | | Sec. 5-1069.3. Required health benefits. If a county, | 17 | | including a home
rule
county, is a self-insurer for purposes of | 18 | | providing health insurance coverage
for its employees, the | 19 | | coverage shall include coverage for the post-mastectomy
care | 20 | | benefits required to be covered by a policy of accident and | 21 | | health
insurance under Section 356t and the coverage required | 22 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 23 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 24 | | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | 25 | | 356z.30a, 356z.32, 356z.33, 356z.36, and 356z.41 , and 356z.43 |
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| 1 | | of
the Illinois Insurance Code. The coverage shall comply with | 2 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | 3 | | Insurance Code. The Department of Insurance shall enforce the | 4 | | requirements of this Section. The requirement that health | 5 | | benefits be covered
as provided in this Section is an
exclusive | 6 | | power and function of the State and is a denial and limitation | 7 | | under
Article VII, Section 6, subsection (h) of the Illinois | 8 | | Constitution. A home
rule county to which this Section applies | 9 | | must comply with every provision of
this Section.
| 10 | | Rulemaking authority to implement Public Act 95-1045, if | 11 | | 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. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 17 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 18 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 19 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 20 | | 101-625, eff. 1-1-21.) | 21 | | Section 10. The Illinois Municipal Code is amended by | 22 | | changing Section 10-4-2.3 as follows: | 23 | | (65 ILCS 5/10-4-2.3)
| 24 | | (Text of Section before amendment by P.A. 101-625 ) |
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| 1 | | Sec. 10-4-2.3. Required health benefits. If a | 2 | | municipality, including a
home rule municipality, is a | 3 | | self-insurer for purposes of providing health
insurance | 4 | | coverage for its employees, the coverage shall include coverage | 5 | | for
the post-mastectomy care benefits required to be covered by | 6 | | a policy of
accident and health insurance under Section 356t | 7 | | and the coverage required
under Sections 356g, 356g.5, | 8 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 9 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | 10 | | 356z.26, 356z.29, 356z.30a, and 356z.32, and 356z.33 , 356z.36, | 11 | | and 356z.43 of the Illinois
Insurance
Code. The coverage shall | 12 | | comply with Sections 155.22a, 355b, 356z.19, and 370c of
the | 13 | | Illinois Insurance Code. The Department of Insurance shall | 14 | | enforce the requirements of this Section. The requirement that | 15 | | health
benefits be covered as provided in this is an exclusive | 16 | | power and function of
the State and is a denial and limitation | 17 | | under Article VII, Section 6,
subsection (h) of the Illinois | 18 | | Constitution. A home rule municipality to which
this Section | 19 | | applies must comply with every provision of this Section.
| 20 | | Rulemaking authority to implement Public Act 95-1045, if | 21 | | any, is conditioned on the rules being adopted in accordance | 22 | | with all provisions of the Illinois Administrative Procedure | 23 | | Act and all rules and procedures of the Joint Committee on | 24 | | Administrative Rules; any purported rule not so adopted, for | 25 | | whatever reason, is unauthorized. | 26 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
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| 1 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 2 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 3 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 4 | | revised 10-16-19.) | 5 | | (Text of Section after amendment by P.A. 101-625 ) | 6 | | Sec. 10-4-2.3. Required health benefits. If a | 7 | | municipality, including a
home rule municipality, is a | 8 | | self-insurer for purposes of providing health
insurance | 9 | | coverage for its employees, the coverage shall include coverage | 10 | | for
the post-mastectomy care benefits required to be covered by | 11 | | a policy of
accident and health insurance under Section 356t | 12 | | and the coverage required
under Sections 356g, 356g.5, | 13 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 14 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | 15 | | 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, and | 16 | | 356z.41 , and 356z.43 of the Illinois
Insurance
Code. The | 17 | | coverage shall comply with Sections 155.22a, 355b, 356z.19, and | 18 | | 370c of
the Illinois Insurance Code. The Department of | 19 | | Insurance shall enforce the requirements of this Section. The | 20 | | requirement that health
benefits be covered as provided in this | 21 | | is an exclusive power and function of
the State and is a denial | 22 | | and limitation under Article VII, Section 6,
subsection (h) of | 23 | | the Illinois Constitution. A home rule municipality to which
| 24 | | this Section applies must comply with every provision of this | 25 | | Section.
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| 1 | | Rulemaking authority to implement Public Act 95-1045, if | 2 | | any, is conditioned on the rules being adopted in accordance | 3 | | with all provisions of the Illinois Administrative Procedure | 4 | | Act and all rules and procedures of the Joint Committee on | 5 | | Administrative Rules; any purported rule not so adopted, for | 6 | | whatever reason, is unauthorized. | 7 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 8 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 9 | | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | 10 | | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | 11 | | 101-625, eff. 1-1-21.) | 12 | | Section 15. The Illinois Insurance Code is amended by | 13 | | adding Section 356z.43 as follows: | 14 | | (215 ILCS 5/356z.43 new) | 15 | | Sec. 356z.43. Colonoscopy coverage. | 16 | | (a) A group policy of accident and health insurance that is | 17 | | amended, delivered, issued, or renewed on or after January 1, | 18 | | 2021 shall provide coverage for a colonoscopy that is a | 19 | | follow-up exam based on an initial screen where the colonoscopy | 20 | | was determined to be medically necessary by a physician | 21 | | licensed to practice medicine in all its branches, an advanced | 22 | | practice registered nurse, or a physician assistant. | 23 | | (b) A policy subject to this Section shall not impose a | 24 | | deductible, coinsurance, copayment, or any other cost-sharing |
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| 1 | | requirement on the coverage provided; except that this | 2 | | subsection does not apply to coverage of colonoscopies to the | 3 | | extent such coverage would disqualify a high-deductible health | 4 | | plan from eligibility for a health savings account pursuant to | 5 | | Section 223 of the Internal Revenue Code. | 6 | | Section 20. The Health Maintenance Organization Act is | 7 | | amended by changing Section 5-3 as follows:
| 8 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 9 | | (Text of Section before amendment by P.A. 101-625 ) | 10 | | Sec. 5-3. Insurance Code provisions.
| 11 | | (a) Health Maintenance Organizations
shall be subject to | 12 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 13 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 14 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 15 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 16 | | 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | 17 | | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, | 18 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | 19 | | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.43, 364, | 20 | | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | 21 | | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | 22 | | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | 23 | | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | 24 | | XXVI, and XXXIIB of the Illinois Insurance Code.
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| 1 | | (b) For purposes of the Illinois Insurance Code, except for | 2 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 3 | | Maintenance Organizations in
the following categories are | 4 | | deemed to be "domestic companies":
| 5 | | (1) a corporation authorized under the
Dental Service | 6 | | Plan Act or the Voluntary Health Services Plans Act;
| 7 | | (2) a corporation organized under the laws of this | 8 | | State; or
| 9 | | (3) a corporation organized under the laws of another | 10 | | state, 30% or more
of the enrollees of which are residents | 11 | | of this State, except a
corporation subject to | 12 | | substantially the same requirements in its state of
| 13 | | organization as is a "domestic company" under Article VIII | 14 | | 1/2 of the
Illinois Insurance Code.
| 15 | | (c) In considering the merger, consolidation, or other | 16 | | acquisition of
control of a Health Maintenance Organization | 17 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 18 | | (1) the Director shall give primary consideration to | 19 | | the continuation of
benefits to enrollees and the financial | 20 | | conditions of the acquired Health
Maintenance Organization | 21 | | after the merger, consolidation, or other
acquisition of | 22 | | control takes effect;
| 23 | | (2)(i) the criteria specified in subsection (1)(b) of | 24 | | Section 131.8 of
the Illinois Insurance Code shall not | 25 | | apply and (ii) the Director, in making
his determination | 26 | | with respect to the merger, consolidation, or other
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| 1 | | acquisition of control, need not take into account the | 2 | | effect on
competition of the merger, consolidation, or | 3 | | other acquisition of control;
| 4 | | (3) the Director shall have the power to require the | 5 | | following
information:
| 6 | | (A) certification by an independent actuary of the | 7 | | adequacy
of the reserves of the Health Maintenance | 8 | | Organization sought to be acquired;
| 9 | | (B) pro forma financial statements reflecting the | 10 | | combined balance
sheets of the acquiring company and | 11 | | the Health Maintenance Organization sought
to be | 12 | | acquired as of the end of the preceding year and as of | 13 | | a date 90 days
prior to the acquisition, as well as pro | 14 | | forma financial statements
reflecting projected | 15 | | combined operation for a period of 2 years;
| 16 | | (C) a pro forma business plan detailing an | 17 | | acquiring party's plans with
respect to the operation | 18 | | of the Health Maintenance Organization sought to
be | 19 | | acquired for a period of not less than 3 years; and
| 20 | | (D) such other information as the Director shall | 21 | | require.
| 22 | | (d) The provisions of Article VIII 1/2 of the Illinois | 23 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 24 | | any health maintenance
organization of greater than 10% of its
| 25 | | enrollee population (including without limitation the health | 26 | | maintenance
organization's right, title, and interest in and to |
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| 1 | | its health care
certificates).
| 2 | | (e) In considering any management contract or service | 3 | | agreement subject
to Section 141.1 of the Illinois Insurance | 4 | | Code, the Director (i) shall, in
addition to the criteria | 5 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 6 | | into account the effect of the management contract or
service | 7 | | agreement on the continuation of benefits to enrollees and the
| 8 | | financial condition of the health maintenance organization to | 9 | | be managed or
serviced, and (ii) need not take into account the | 10 | | effect of the management
contract or service agreement on | 11 | | competition.
| 12 | | (f) Except for small employer groups as defined in the | 13 | | Small Employer
Rating, Renewability and Portability Health | 14 | | Insurance Act and except for
medicare supplement policies as | 15 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 16 | | Maintenance Organization may by contract agree with a
group or | 17 | | other enrollment unit to effect refunds or charge additional | 18 | | premiums
under the following terms and conditions:
| 19 | | (i) the amount of, and other terms and conditions with | 20 | | respect to, the
refund or additional premium are set forth | 21 | | in the group or enrollment unit
contract agreed in advance | 22 | | of the period for which a refund is to be paid or
| 23 | | additional premium is to be charged (which period shall not | 24 | | be less than one
year); and
| 25 | | (ii) the amount of the refund or additional premium | 26 | | shall not exceed 20%
of the Health Maintenance |
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| 1 | | Organization's profitable or unprofitable experience
with | 2 | | respect to the group or other enrollment unit for the | 3 | | period (and, for
purposes of a refund or additional | 4 | | premium, the profitable or unprofitable
experience shall | 5 | | be calculated taking into account a pro rata share of the
| 6 | | Health Maintenance Organization's administrative and | 7 | | marketing expenses, but
shall not include any refund to be | 8 | | made or additional premium to be paid
pursuant to this | 9 | | subsection (f)). The Health Maintenance Organization and | 10 | | the
group or enrollment unit may agree that the profitable | 11 | | or unprofitable
experience may be calculated taking into | 12 | | account the refund period and the
immediately preceding 2 | 13 | | plan years.
| 14 | | The Health Maintenance Organization shall include a | 15 | | statement in the
evidence of coverage issued to each enrollee | 16 | | describing the possibility of a
refund or additional premium, | 17 | | and upon request of any group or enrollment unit,
provide to | 18 | | the group or enrollment unit a description of the method used | 19 | | to
calculate (1) the Health Maintenance Organization's | 20 | | profitable experience with
respect to the group or enrollment | 21 | | unit and the resulting refund to the group
or enrollment unit | 22 | | or (2) the Health Maintenance Organization's unprofitable
| 23 | | experience with respect to the group or enrollment unit and the | 24 | | resulting
additional premium to be paid by the group or | 25 | | enrollment unit.
| 26 | | In no event shall the Illinois Health Maintenance |
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| 1 | | Organization
Guaranty Association be liable to pay any | 2 | | contractual obligation of an
insolvent organization to pay any | 3 | | refund authorized under this Section.
| 4 | | (g) Rulemaking authority to implement Public Act 95-1045, | 5 | | if any, is conditioned on the rules being adopted in accordance | 6 | | with all provisions of the Illinois Administrative Procedure | 7 | | Act and all rules and procedures of the Joint Committee on | 8 | | Administrative Rules; any purported rule not so adopted, for | 9 | | whatever reason, is unauthorized. | 10 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 11 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | 12 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | 13 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | 14 | | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | 15 | | 1-1-20; revised 10-16-19.) | 16 | | (Text of Section after amendment by P.A. 101-625 ) | 17 | | Sec. 5-3. Insurance Code provisions.
| 18 | | (a) Health Maintenance Organizations
shall be subject to | 19 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 20 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 21 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 22 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 23 | | 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | 24 | | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, | 25 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, |
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| 1 | | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41, | 2 | | 356z.43, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | 3 | | 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, | 4 | | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | 5 | | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | 6 | | XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois Insurance | 7 | | Code.
| 8 | | (b) For purposes of the Illinois Insurance Code, except for | 9 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 10 | | Maintenance Organizations in
the following categories are | 11 | | deemed to be "domestic companies":
| 12 | | (1) a corporation authorized under the
Dental Service | 13 | | Plan Act or the Voluntary Health Services Plans Act;
| 14 | | (2) a corporation organized under the laws of this | 15 | | State; or
| 16 | | (3) a corporation organized under the laws of another | 17 | | state, 30% or more
of the enrollees of which are residents | 18 | | of this State, except a
corporation subject to | 19 | | substantially the same requirements in its state of
| 20 | | organization as is a "domestic company" under Article VIII | 21 | | 1/2 of the
Illinois Insurance Code.
| 22 | | (c) In considering the merger, consolidation, or other | 23 | | acquisition of
control of a Health Maintenance Organization | 24 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 25 | | (1) the Director shall give primary consideration to | 26 | | the continuation of
benefits to enrollees and the financial |
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| 1 | | conditions of the acquired Health
Maintenance Organization | 2 | | after the merger, consolidation, or other
acquisition of | 3 | | control takes effect;
| 4 | | (2)(i) the criteria specified in subsection (1)(b) of | 5 | | Section 131.8 of
the Illinois Insurance Code shall not | 6 | | apply and (ii) the Director, in making
his determination | 7 | | with respect to the merger, consolidation, or other
| 8 | | acquisition of control, need not take into account the | 9 | | effect on
competition of the merger, consolidation, or | 10 | | other acquisition of control;
| 11 | | (3) the Director shall have the power to require the | 12 | | following
information:
| 13 | | (A) certification by an independent actuary of the | 14 | | adequacy
of the reserves of the Health Maintenance | 15 | | Organization sought to be acquired;
| 16 | | (B) pro forma financial statements reflecting the | 17 | | combined balance
sheets of the acquiring company and | 18 | | the Health Maintenance Organization sought
to be | 19 | | acquired as of the end of the preceding year and as of | 20 | | a date 90 days
prior to the acquisition, as well as pro | 21 | | forma financial statements
reflecting projected | 22 | | combined operation for a period of 2 years;
| 23 | | (C) a pro forma business plan detailing an | 24 | | acquiring party's plans with
respect to the operation | 25 | | of the Health Maintenance Organization sought to
be | 26 | | acquired for a period of not less than 3 years; and
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| 1 | | (D) such other information as the Director shall | 2 | | require.
| 3 | | (d) The provisions of Article VIII 1/2 of the Illinois | 4 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 5 | | any health maintenance
organization of greater than 10% of its
| 6 | | enrollee population (including without limitation the health | 7 | | maintenance
organization's right, title, and interest in and to | 8 | | its health care
certificates).
| 9 | | (e) In considering any management contract or service | 10 | | agreement subject
to Section 141.1 of the Illinois Insurance | 11 | | Code, the Director (i) shall, in
addition to the criteria | 12 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 13 | | into account the effect of the management contract or
service | 14 | | agreement on the continuation of benefits to enrollees and the
| 15 | | financial condition of the health maintenance organization to | 16 | | be managed or
serviced, and (ii) need not take into account the | 17 | | effect of the management
contract or service agreement on | 18 | | competition.
| 19 | | (f) Except for small employer groups as defined in the | 20 | | Small Employer
Rating, Renewability and Portability Health | 21 | | Insurance Act and except for
medicare supplement policies as | 22 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 23 | | Maintenance Organization may by contract agree with a
group or | 24 | | other enrollment unit to effect refunds or charge additional | 25 | | premiums
under the following terms and conditions:
| 26 | | (i) the amount of, and other terms and conditions with |
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| 1 | | respect to, the
refund or additional premium are set forth | 2 | | in the group or enrollment unit
contract agreed in advance | 3 | | of the period for which a refund is to be paid or
| 4 | | additional premium is to be charged (which period shall not | 5 | | be less than one
year); and
| 6 | | (ii) the amount of the refund or additional premium | 7 | | shall not exceed 20%
of the Health Maintenance | 8 | | Organization's profitable or unprofitable experience
with | 9 | | respect to the group or other enrollment unit for the | 10 | | period (and, for
purposes of a refund or additional | 11 | | premium, the profitable or unprofitable
experience shall | 12 | | be calculated taking into account a pro rata share of the
| 13 | | Health Maintenance Organization's administrative and | 14 | | marketing expenses, but
shall not include any refund to be | 15 | | made or additional premium to be paid
pursuant to this | 16 | | subsection (f)). The Health Maintenance Organization and | 17 | | the
group or enrollment unit may agree that the profitable | 18 | | or unprofitable
experience may be calculated taking into | 19 | | account the refund period and the
immediately preceding 2 | 20 | | plan years.
| 21 | | The Health Maintenance Organization shall include a | 22 | | statement in the
evidence of coverage issued to each enrollee | 23 | | describing the possibility of a
refund or additional premium, | 24 | | and upon request of any group or enrollment unit,
provide to | 25 | | the group or enrollment unit a description of the method used | 26 | | to
calculate (1) the Health Maintenance Organization's |
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| 1 | | profitable experience with
respect to the group or enrollment | 2 | | unit and the resulting refund to the group
or enrollment unit | 3 | | or (2) the Health Maintenance Organization's unprofitable
| 4 | | experience with respect to the group or enrollment unit and the | 5 | | resulting
additional premium to be paid by the group or | 6 | | enrollment unit.
| 7 | | In no event shall the Illinois Health Maintenance | 8 | | Organization
Guaranty Association be liable to pay any | 9 | | contractual obligation of an
insolvent organization to pay any | 10 | | refund authorized under this Section.
| 11 | | (g) Rulemaking authority to implement Public Act 95-1045, | 12 | | if any, is conditioned on the rules being adopted in accordance | 13 | | with all provisions of the Illinois Administrative Procedure | 14 | | Act and all rules and procedures of the Joint Committee on | 15 | | Administrative Rules; any purported rule not so adopted, for | 16 | | whatever reason, is unauthorized. | 17 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 18 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | 19 | | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | 20 | | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | 21 | | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | 22 | | 1-1-20; 101-625, eff. 1-1-21.) | 23 | | Section 95. No acceleration or delay. Where this Act makes | 24 | | changes in a statute that is represented in this Act by text | 25 | | that is not yet or no longer in effect (for example, a Section |
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| 1 | | represented by multiple versions), the use of that text does | 2 | | not accelerate or delay the taking effect of (i) the changes | 3 | | made by this Act or (ii) provisions derived from any other | 4 | | Public Act.
| 5 | | Section 99. Effective date. This Act takes effect January | 6 | | 1, 2021.
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