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| [ Introduced ] | [ House Amendment 003 ] |
90_HB2645ham001
LRB9008967JSgcam01
1 AMENDMENT TO HOUSE BILL 2645
2 AMENDMENT NO. . Amend House Bill 2645 by replacing
3 everything after the enacting clause with the following:
4 "Section 5. The State Employees Group Insurance Act of
5 1971 is amended by changing Section 6.11 as follows:
6 (5 ILCS 375/6.11)
7 Sec. 6.11. 6.9. Required health benefits. The program
8 of health benefits shall provide the post-mastectomy care
9 benefits required to be covered by a policy of accident and
10 health insurance under Section 356t of the Illinois Insurance
11 Code. The program of health benefits shall provide the
12 coverage required under Sections 356g, Section 356u, and 356w
13 of the Illinois Insurance Code.
14 (Source: P.A. 90-7, eff. 6-10-97; revised 11-10-97.)
15 Section 10. The Counties Code is amended by changing
16 Section 5-1069.3 as follows:
17 (55 ILCS 5/5-1069.3)
18 Sec. 5-1069.3. Required health benefits. If a county,
19 including a home rule county, is a self-insurer for purposes
20 of providing health insurance coverage for its employees, the
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1 coverage shall include coverage for the post-mastectomy care
2 benefits required to be covered by a policy of accident and
3 health insurance under Section 356t and the coverage required
4 under Sections 356g, Section 356u, and 356w of the Illinois
5 Insurance Code. The requirement that health benefits be
6 covered as provided in this Section is an exclusive power and
7 function of the State and is a denial and limitation under
8 Article VII, Section 6, subsection (h) of the Illinois
9 Constitution. A home rule county to which this Section
10 applies must comply with every provision of this Section.
11 (Source: P.A. 90-7, eff. 6-10-97.)
12 Section 15. The Illinois Municipal Code is amended by
13 changing Section 10-4-2.3 as follows:
14 (65 ILCS 5/10-4-2.3)
15 Sec. 10-4-2.3. Required health benefits. If a
16 municipality, including a home rule municipality, is a
17 self-insurer for purposes of providing health insurance
18 coverage for its employees, the coverage shall include
19 coverage for the post-mastectomy care benefits required to be
20 covered by a policy of accident and health insurance under
21 Section 356t and the coverage required under Sections 356g,
22 Section 356u, and 356w of the Illinois Insurance Code. The
23 requirement that health benefits be covered as provided in
24 this is an exclusive power and function of the State and is a
25 denial and limitation under Article VII, Section 6,
26 subsection (h) of the Illinois Constitution. A home rule
27 municipality to which this Section applies must comply with
28 every provision of this Section.
29 (Source: P.A. 90-7, eff. 6-10-97.)
30 Section 20. The School Code is amended by changing
31 Section 10-22.3f as follows:
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1 (105 ILCS 5/10-22.3f)
2 Sec. 10-22.3f. Required health benefits. Insurance
3 protection and benefits for employees shall provide the
4 post-mastectomy care benefits required to be covered by a
5 policy of accident and health insurance under Section 356t
6 and the coverage required under Sections 356g, Section 356u,
7 and 356w of the Illinois Insurance Code.
8 (Source: P.A. 90-7, eff. 6-10-97.)
9 Section 25. The Illinois Insurance Code is amended by
10 changing Sections 356g and 356t and adding Section 356w as
11 follows:
12 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
13 Sec. 356g. Mammogram; mastectomy.
14 (a) Every insurer shall provide in each group or
15 individual policy, contract, or certificate of insurance
16 issued or renewed for persons who are residents of this
17 State, coverage for screening by low-dose mammography for all
18 women 35 years of age or older for the presence of occult
19 breast cancer within the provisions of the policy, contract,
20 or certificate. The coverage shall be as follows:
21 (1) A baseline mammogram for women 35 to 39 years
22 of age.
23 (2) An annual mammogram for women 40 years of age
24 or older.
25 These benefits shall be at least as favorable as for
26 other radiological examinations and subject to the same
27 dollar limits, deductibles, and co-insurance factors. For
28 purposes of this Section, "low-dose mammography" means the
29 x-ray examination of the breast using equipment dedicated
30 specifically for mammography, including the x-ray tube,
31 filter, compression device, and image receptor, with
32 radiation exposure delivery of less than 1 rad per breast for
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1 2 views of an average size breast.
2 (b) No policy of accident or health insurance that
3 provides for the surgical procedure known as a mastectomy
4 shall be issued, amended, delivered or renewed in this State
5 on or after July 1, 1981, unless coverage is also offered for
6 prosthetic devices or reconstructive surgery incident to the
7 mastectomy, providing that the mastectomy is performed after
8 July 1, 1981.
9 (c) Coverage under this Section shall include benefits
10 for all stages of reconstruction of the breast on which a
11 partial or total mastectomy has been performed in the manner
12 determined by the attending physician and the patient to be
13 appropriate. The coverage shall also include benefits for
14 prosthetic devices and all stages and revisions of
15 reconstructive breast surgery performed on a nondiseased
16 breast to establish symmetry in the manner determined by the
17 attending physician and the patient to be appropriate after
18 reconstructive surgery on a diseased breast is performed.
19 (d) Coverage under this Section must provide benefits
20 for a second medical opinion by an appropriate medical
21 specialist including, but not limited to, a specialist
22 affiliated with a specialty care center for the treatment of
23 cancer in the event of a positive or negative diagnosis of
24 cancer, a recurrence of cancer, or a recommendation of a
25 course of treatment for cancer subject to the following:
26 (1) In the case of coverage that requires, or
27 provides financial incentives for, the insured to receive
28 covered services from health care providers participating
29 in a provider network maintained by or under contract
30 with the insurer, the coverage shall include benefits for
31 a second medical opinion from a nonparticipating
32 specialist when the physician provides a written referral
33 to a nonparticipating specialist at no additional cost to
34 the insured beyond what the insured would have paid for
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1 services from a participating appropriate specialist.
2 Nothing in this provision, however, shall impair an
3 insured's rights, if any, under the policy to obtain the
4 second medical opinion from a nonparticipating specialist
5 without a written referral, subject to the payment of
6 additional coinsurance, if any, required under the policy
7 for services provided by nonparticipating providers. The
8 insurer shall compensate the nonparticipating specialist
9 at the usual, customary, and reasonable rate.
10 (2) In the case of coverage that does not provide
11 financial incentives for, and does not require, the
12 insured to receive covered services from health care
13 providers participating in a provider network maintained
14 by or under contract with the insurer, the coverage shall
15 include benefits for a second medical opinion from a
16 specialist at no additional cost to the insured beyond
17 what the insured would have paid for comparable covered
18 services.
19 (e) An insurer providing coverage under this Section and
20 any participating entity through which the insurer offers
21 health services may not:
22 (1) deny to a covered person eligibility or
23 continued eligibility to obtain coverage or renew
24 coverage under the terms of the policy or vary the terms
25 of the policy for the purpose or with the effect of
26 avoiding compliance with this Section;
27 (2) provide incentives (monetary or otherwise) to
28 encourage a covered person to accept less than the
29 minimum protections available under this Section;
30 (3) penalize in any way or reduce or limit the
31 compensation of a health care practitioner for
32 recommending or providing care to a covered person in
33 accordance with this Section; or
34 (4) provide incentives (monetary or otherwise) to a
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1 health care practitioner relating to the services
2 provided pursuant to this Section intended to induce or
3 having the effect of inducing the practitioner to provide
4 care to a covered person in a manner inconsistent with
5 this Section.
6 (f) Coverage under subsections (b), (c), and (d) may be
7 subject to annual deductibles and coinsurance that are
8 consistent with those established for other benefits under
9 the policy. The offered coverage for prosthetic devices and
10 reconstructive surgery shall be subject to the deductible and
11 coinsurance conditions applied to the mastectomy, and all
12 other terms and conditions applicable to other benefits.
13 When a mastectomy is performed and there is no evidence of
14 malignancy then the offered coverage may be limited to the
15 provision of prosthetic devices and reconstructive surgery to
16 within 2 years after the date of the mastectomy.
17 (g) As used in this Section, "mastectomy" means the
18 removal of all or part of the breast for medically necessary
19 reasons, as determined by a licensed physician.
20 (Source: P.A. 90-7, eff. 6-10-97.)
21 (215 ILCS 5/356t)
22 Sec. 356t. Post-mastectomy care. An individual or group
23 policy of accident and health insurance or managed care plan
24 that provides surgical coverage and is amended, delivered,
25 issued, or renewed after the effective date of this
26 amendatory Act of 1997 shall provide inpatient coverage
27 following a lymph node dissection, lumpectomy, or mastectomy
28 for a length of time determined by the attending physician to
29 be medically necessary and in accordance with protocols and
30 guidelines based on sound scientific evidence and upon
31 evaluation of the patient and the coverage for and
32 availability of a post-discharge physician office visit or
33 in-home nurse visit to verify the condition of the patient in
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1 the first 48 hours after discharge.
2 (Source: P.A. 90-7, eff. 6-10-97.)
3 (215 ILCS 5/356w new)
4 Sec. 356w. Reconstructive surgery for children's
5 deformities.
6 (a) A group or individual policy of accident and health
7 insurance and a managed care plan, as defined in Section
8 356r, that is amended, delivered, issued, or renewed in this
9 State on or after the effective date of this amendatory Act
10 of 1998 shall include coverage for all outpatient and
11 inpatient diagnosis and treatment of a minor child's
12 congenital or developmental deformity, disease, or injury due
13 to accident or trauma. The coverage shall include treatment
14 that, in the opinion of the treating physician, is medically
15 necessary to return the patient to a more normal appearance,
16 even if the procedure does not materially affect the function
17 of the body part being treated, including benefits for
18 secondary conditions and follow-up treatment. Benefits shall
19 include, without limitation, coverage of the following:
20 (1) birth abnormalities of the cranium and face,
21 such as cleft lip and palate;
22 (2) musculoskeletal disorders affecting any bone or
23 joint in the face, neck, or head;
24 (3) craniofacial and maxillofacial surgery and
25 prosthetic devices, including restoration of head and
26 facial structures; and
27 (4) restoring facial configuration and functions
28 such as speech, swallowing, and chewing.
29 (b) An insurance policy or managed care plan subject to
30 this Section may not deny coverage for benefits described in
31 subsection (a) as a pre-existing condition if the insured's
32 insurance coverage changes before treatment is either
33 initiated or completed.
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1 (c) Any provision in an insurance policy or managed care
2 plan subject to this Section, that is amended, delivered,
3 issued, or renewed after the effective date of this
4 amendatory Act of 1998 that is contrary to this Section
5 shall, to the extent of such conflict, be void, and the
6 provisions shall be construed as to comply with the
7 requirements of this Section.
8 Section 30. The Health Maintenance Organization Act is
9 amended by changing Sections 4-6.1 and 5-3 as follows:
10 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
11 Sec. 4-6.1. Mammograms.
12 (a) Every contract or evidence of coverage issued by a
13 Health Maintenance Organization for persons who are residents
14 of this State shall contain coverage for screening by
15 low-dose mammography for all women 35 years of age or older
16 for the presence of occult breast cancer. The coverage shall
17 be as follows:
18 (1) A baseline mammogram for women 35 to 39 years
19 of age.
20 (2) An annual mammogram for women 40 years of age
21 or older.
22 These benefits shall be at least as favorable as for
23 other radiological examinations and subject to the same
24 dollar limits, deductibles, and co-insurance factors. For
25 purposes of this Section, "low-dose mammography" means the
26 x-ray examination of the breast using equipment dedicated
27 specifically for mammography, including the x-ray tube,
28 filter, compression device, and image receptor, with
29 radiation exposure delivery of less than 1 rad per breast for
30 2 views of an average size breast.
31 (b) A contract or evidence of coverage amended,
32 delivered, issued, or renewed after the effective date of
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1 this amendatory Act of 1998 for persons who are residents of
2 this State shall include benefits for all stages of
3 reconstruction of the breast on which a partial or total
4 mastectomy has been performed in the manner determined by the
5 attending physician and the patient to be appropriate. The
6 coverage shall also include benefits for prosthetic devices
7 and all stages and revisions of reconstructive breast surgery
8 performed on a nondiseased breast to establish symmetry in
9 the manner determined by the attending physician and the
10 patient to be appropriate after reconstructive surgery on a
11 diseased breast is performed.
12 (c) Coverage under this Section must provide benefits
13 for a second medical opinion by an appropriate medical
14 specialist including, but not limited to, a specialist
15 affiliated with a specialty care center for the treatment of
16 cancer in the event of a positive or negative diagnosis of
17 cancer, a recurrence of cancer, or a recommendation of a
18 course of treatment for cancer subject to the following:
19 (1) In the case of coverage that requires, or
20 provides financial incentives for, the enrollee to
21 receive covered services from health care providers
22 participating in a provider network maintained by or
23 under contract with the organization, the coverage shall
24 include benefits for a second medical opinion from a
25 nonparticipating specialist when the physician provides a
26 written referral to a nonparticipating specialist at no
27 additional cost to the enrollee beyond what the enrollee
28 would have paid for services from a participating
29 appropriate specialist. Nothing in this provision,
30 however, shall impair an enrollee's rights, if any, under
31 the contract to obtain the second medical opinion from a
32 nonparticipating specialist without a written referral,
33 subject to the payment of additional coinsurance, if any,
34 required under the contract for services provided by
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1 nonparticipating providers. The organization shall
2 compensate the nonparticipating specialist at the usual,
3 customary, and reasonable rate.
4 (2) In the case of coverage that does not provide
5 financial incentives for, and does not require, the
6 enrollee to receive covered services from health care
7 providers participating in a provider network maintained
8 by or under contract with the organization, the coverage
9 shall include benefits for a second medical opinion from
10 a specialist at no additional cost to the enrollee beyond
11 what the enrollee would have paid for comparable covered
12 services.
13 (d) An organization providing coverage under this
14 Section and any participating entity through which the
15 organization offers health services may not:
16 (1) deny to an enrollee eligibility or continued
17 eligibility to obtain coverage or renew coverage under
18 the terms of the contract or vary the terms of the
19 contract for the purpose or with the effect of avoiding
20 compliance with this Section;
21 (2) provide incentives (monetary or otherwise) to
22 encourage an enrollee to accept less than the minimum
23 protections available under this Section;
24 (3) penalize in any way or reduce or limit the
25 compensation of a health care practitioner for
26 recommending or providing care to an enrollee in
27 accordance with this Section; or
28 (4) provide incentives (monetary or otherwise) to a
29 health care practitioner relating to the services
30 provided pursuant to this Section intended to induce or
31 having the effect of inducing the practitioner to provide
32 care to an enrollee a manner inconsistent with this
33 Section.
34 (e) Coverage under subsections (b) and (c) may be
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1 subject to annual deductibles and coinsurance that are
2 consistent with those established for other benefits under
3 the policy.
4 (Source: P.A. 90-7, eff. 6-10-97; revised 7-29-97.)
5 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
6 (Text of Section before amendment by P.A. 90-372)
7 Sec. 5-3. Insurance Code provisions.
8 (a) Health Maintenance Organizations shall be subject to
9 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
10 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
11 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
12 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
13 paragraph (c) of subsection (2) of Section 367, and Articles
14 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
15 Illinois Insurance Code.
16 (b) For purposes of the Illinois Insurance Code, except
17 for Articles XIII and XIII 1/2, Health Maintenance
18 Organizations in the following categories are deemed to be
19 "domestic companies":
20 (1) a corporation authorized under the Medical
21 Service Plan Act, the Dental Service Plan Act, the
22 Pharmaceutical Service Plan Act, or the Voluntary Health
23 Services Plans Plan Act, or the Nonprofit Health Care
24 Service Plan Act;
25 (2) a corporation organized under the laws of this
26 State; or
27 (3) a corporation organized under the laws of
28 another state, 30% or more of the enrollees of which are
29 residents of this State, except a corporation subject to
30 substantially the same requirements in its state of
31 organization as is a "domestic company" under Article
32 VIII 1/2 of the Illinois Insurance Code.
33 (c) In considering the merger, consolidation, or other
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1 acquisition of control of a Health Maintenance Organization
2 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
3 (1) the Director shall give primary consideration
4 to the continuation of benefits to enrollees and the
5 financial conditions of the acquired Health Maintenance
6 Organization after the merger, consolidation, or other
7 acquisition of control takes effect;
8 (2)(i) the criteria specified in subsection (1)(b)
9 of Section 131.8 of the Illinois Insurance Code shall not
10 apply and (ii) the Director, in making his determination
11 with respect to the merger, consolidation, or other
12 acquisition of control, need not take into account the
13 effect on competition of the merger, consolidation, or
14 other acquisition of control;
15 (3) the Director shall have the power to require
16 the following information:
17 (A) certification by an independent actuary of
18 the adequacy of the reserves of the Health
19 Maintenance Organization sought to be acquired;
20 (B) pro forma financial statements reflecting
21 the combined balance sheets of the acquiring company
22 and the Health Maintenance Organization sought to be
23 acquired as of the end of the preceding year and as
24 of a date 90 days prior to the acquisition, as well
25 as pro forma financial statements reflecting
26 projected combined operation for a period of 2
27 years;
28 (C) a pro forma business plan detailing an
29 acquiring party's plans with respect to the
30 operation of the Health Maintenance Organization
31 sought to be acquired for a period of not less than
32 3 years; and
33 (D) such other information as the Director
34 shall require.
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1 (d) The provisions of Article VIII 1/2 of the Illinois
2 Insurance Code and this Section 5-3 shall apply to the sale
3 by any health maintenance organization of greater than 10% of
4 its enrollee population (including without limitation the
5 health maintenance organization's right, title, and interest
6 in and to its health care certificates).
7 (e) In considering any management contract or service
8 agreement subject to Section 141.1 of the Illinois Insurance
9 Code, the Director (i) shall, in addition to the criteria
10 specified in Section 141.2 of the Illinois Insurance Code,
11 take into account the effect of the management contract or
12 service agreement on the continuation of benefits to
13 enrollees and the financial condition of the health
14 maintenance organization to be managed or serviced, and (ii)
15 need not take into account the effect of the management
16 contract or service agreement on competition.
17 (f) Except for small employer groups as defined in the
18 Small Employer Rating, Renewability and Portability Health
19 Insurance Act and except for medicare supplement policies as
20 defined in Section 363 of the Illinois Insurance Code, a
21 Health Maintenance Organization may by contract agree with a
22 group or other enrollment unit to effect refunds or charge
23 additional premiums under the following terms and conditions:
24 (i) the amount of, and other terms and conditions
25 with respect to, the refund or additional premium are set
26 forth in the group or enrollment unit contract agreed in
27 advance of the period for which a refund is to be paid or
28 additional premium is to be charged (which period shall
29 not be less than one year); and
30 (ii) the amount of the refund or additional premium
31 shall not exceed 20% of the Health Maintenance
32 Organization's profitable or unprofitable experience with
33 respect to the group or other enrollment unit for the
34 period (and, for purposes of a refund or additional
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1 premium, the profitable or unprofitable experience shall
2 be calculated taking into account a pro rata share of the
3 Health Maintenance Organization's administrative and
4 marketing expenses, but shall not include any refund to
5 be made or additional premium to be paid pursuant to this
6 subsection (f)). The Health Maintenance Organization and
7 the group or enrollment unit may agree that the
8 profitable or unprofitable experience may be calculated
9 taking into account the refund period and the immediately
10 preceding 2 plan years.
11 The Health Maintenance Organization shall include a
12 statement in the evidence of coverage issued to each enrollee
13 describing the possibility of a refund or additional premium,
14 and upon request of any group or enrollment unit, provide to
15 the group or enrollment unit a description of the method used
16 to calculate (1) the Health Maintenance Organization's
17 profitable experience with respect to the group or enrollment
18 unit and the resulting refund to the group or enrollment unit
19 or (2) the Health Maintenance Organization's unprofitable
20 experience with respect to the group or enrollment unit and
21 the resulting additional premium to be paid by the group or
22 enrollment unit.
23 In no event shall the Illinois Health Maintenance
24 Organization Guaranty Association be liable to pay any
25 contractual obligation of an insolvent organization to pay
26 any refund authorized under this Section.
27 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
28 90-177, eff. 7-23-97; revised 11-21-97.)
29 (Text of Section after amendment by P.A. 90-372)
30 Sec. 5-3. Insurance Code provisions.
31 (a) Health Maintenance Organizations shall be subject to
32 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
33 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
34 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
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1 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
2 paragraph (c) of subsection (2) of Section 367, and Articles
3 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
4 Illinois Insurance Code.
5 (b) For purposes of the Illinois Insurance Code, except
6 for Articles XIII and XIII 1/2, Health Maintenance
7 Organizations in the following categories are deemed to be
8 "domestic companies":
9 (1) a corporation authorized under the Medical
10 Service Plan Act, the Dental Service Plan Act or, the
11 Voluntary Health Services Plans Plan Act, or the
12 Nonprofit Health Care Service Plan Act;
13 (2) a corporation organized under the laws of this
14 State; or
15 (3) a corporation organized under the laws of
16 another state, 30% or more of the enrollees of which are
17 residents 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
20 VIII 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
25 to the continuation of benefits to enrollees and the
26 financial conditions of the acquired Health Maintenance
27 Organization after the merger, consolidation, or other
28 acquisition of control takes effect;
29 (2)(i) the criteria specified in subsection (1)(b)
30 of Section 131.8 of the Illinois Insurance Code shall not
31 apply and (ii) the Director, in making his determination
32 with respect to the merger, consolidation, or other
33 acquisition of control, need not take into account the
34 effect on competition of the merger, consolidation, or
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1 other acquisition of control;
2 (3) the Director shall have the power to require
3 the following information:
4 (A) certification by an independent actuary of
5 the adequacy of the reserves of the Health
6 Maintenance Organization sought to be acquired;
7 (B) pro forma financial statements reflecting
8 the combined balance sheets of the acquiring company
9 and the Health Maintenance Organization sought to be
10 acquired as of the end of the preceding year and as
11 of a date 90 days prior to the acquisition, as well
12 as pro forma financial statements reflecting
13 projected combined operation for a period of 2
14 years;
15 (C) a pro forma business plan detailing an
16 acquiring party's plans with respect to the
17 operation of the Health Maintenance Organization
18 sought to be acquired for a period of not less than
19 3 years; and
20 (D) such other information as the Director
21 shall 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
24 by any health maintenance organization of greater than 10% of
25 its enrollee population (including without limitation the
26 health maintenance organization's right, title, and interest
27 in and to its health care certificates).
28 (e) In considering any management contract or service
29 agreement subject to Section 141.1 of the Illinois Insurance
30 Code, the Director (i) shall, in addition to the criteria
31 specified in Section 141.2 of the Illinois Insurance Code,
32 take into account the effect of the management contract or
33 service agreement on the continuation of benefits to
34 enrollees and the financial condition of the health
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1 maintenance organization to be managed or serviced, and (ii)
2 need not take into account the effect of the management
3 contract or service agreement on competition.
4 (f) Except for small employer groups as defined in the
5 Small Employer Rating, Renewability and Portability Health
6 Insurance Act and except for medicare supplement policies as
7 defined in Section 363 of the Illinois Insurance Code, a
8 Health Maintenance Organization may by contract agree with a
9 group or other enrollment unit to effect refunds or charge
10 additional premiums under the following terms and conditions:
11 (i) the amount of, and other terms and conditions
12 with respect to, the refund or additional premium are set
13 forth in the group or enrollment unit contract agreed in
14 advance of the period for which a refund is to be paid or
15 additional premium is to be charged (which period shall
16 not be less than one year); and
17 (ii) the amount of the refund or additional premium
18 shall not exceed 20% of the Health Maintenance
19 Organization's profitable or unprofitable experience with
20 respect to the group or other enrollment unit for the
21 period (and, for purposes of a refund or additional
22 premium, the profitable or unprofitable experience shall
23 be calculated taking into account a pro rata share of the
24 Health Maintenance Organization's administrative and
25 marketing expenses, but shall not include any refund to
26 be made or additional premium to be paid pursuant to this
27 subsection (f)). The Health Maintenance Organization and
28 the group or enrollment unit may agree that the
29 profitable or unprofitable experience may be calculated
30 taking into account the refund period and the immediately
31 preceding 2 plan years.
32 The Health Maintenance Organization shall include a
33 statement in the evidence of coverage issued to each enrollee
34 describing the possibility of a refund or additional premium,
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1 and upon request of any group or enrollment unit, provide to
2 the group or enrollment unit a description of the method used
3 to calculate (1) the Health Maintenance Organization's
4 profitable experience with respect to the group or enrollment
5 unit and the resulting refund to the group or enrollment unit
6 or (2) the Health Maintenance Organization's unprofitable
7 experience with respect to the group or enrollment unit and
8 the resulting additional premium to be paid by the group or
9 enrollment unit.
10 In no event shall the Illinois Health Maintenance
11 Organization Guaranty Association be liable to pay any
12 contractual obligation of an insolvent organization to pay
13 any refund authorized under this Section.
14 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
15 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; revised 11-21-97.)
16 Section 35. The Limited Health Service Organization Act
17 is amended by changing Section 3009 as follows:
18 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
19 Sec. 3009. Point-of-service limited health service
20 contracts.
21 (a) An LHSO that offers a POS contract:
22 (1) shall include as in-plan covered services all
23 services required by law to be provided by an LHSO;
24 (2) shall provide incentives, which shall include
25 financial incentives, for enrollees to use in-plan
26 covered services;
27 (3) shall not offer services out-of-plan without
28 providing those services on an in-plan basis;
29 (4) may limit or exclude specific types of services
30 from coverage when obtained out-of-plan;
31 (5) may include annual out-of-pocket limits and
32 lifetime maximum benefits allowances for out-of-plan
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1 services that are separate from any limits or allowances
2 applied to in-plan services;
3 (6) shall include an annual maximum benefit
4 allowance not to exceed $2,500 per year that is separate
5 from any limits or allowances applied to in-plan
6 services;
7 (7) may limit the groups to which a POS product is
8 offered, however, if a POS product is offered to a group,
9 then it must be offered to all eligible members of that
10 group, when an LHSO provider is available;
11 (8) shall not consider emergency services,
12 authorized referral services, or non-routine services
13 obtained out of the service area to be POS services; and
14 (9) may treat as out-of-plan services those
15 services that an enrollee obtains from a participating
16 provider, but for which the proper authorization was not
17 given by the LHSO.
18 (b) An LHSO offering a POS contract shall be subject to
19 the following limitations:
20 (1) The LHSO shall not expend in any calendar
21 quarter more than 20% of its total limited health
22 services expenditures for all its members for out-of-plan
23 covered services.
24 (2) If the amount specified in paragraph (1) is
25 exceeded by 2% in a quarter, the LHSO shall effect
26 compliance with paragraph (1) by the end of the following
27 quarter.
28 (3) If compliance with the amount specified in
29 paragraph (1) is not demonstrated in the LHSO's next
30 quarterly report, the LHSO may not offer the POS contract
31 to new groups or include the POS option in the renewal of
32 an existing group until compliance with the amount
33 specified in paragraph (1) is demonstrated or otherwise
34 allowed by the Director.
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1 (4) Any LHSO failing, without just cause, to comply
2 with the provisions of this subsection shall be required,
3 after notice and hearing, to pay a penalty of $250 for
4 each day out of compliance, to be recovered by the
5 Director of Insurance. Any penalty recovered shall be
6 paid into the General Revenue Fund. The Director may
7 reduce the penalty if the LHSO demonstrates to the
8 Director that the imposition of the penalty would
9 constitute a financial hardship to the LHSO.
10 (c) Any LHSO that offers a POS product shall:
11 (1) File a quarterly financial statement detailing
12 compliance with the requirements of subsection (b).
13 (2) Track out-of-plan POS utilization separately
14 from in-plan or non-POS out-of-plan emergency care,
15 referral care, and urgent care out of the service area
16 utilization.
17 (3) Record out-of-plan utilization in a manner that
18 will permit such utilization and cost reporting as the
19 Director may, by regulation, require.
20 (4) Demonstrate to the Director's satisfaction that
21 the LHSO has the fiscal, administrative, and marketing
22 capacity to control its POS enrollment, utilization, and
23 costs so as not to jeopardize the financial security of
24 the LHSO.
25 (5) Maintain the deposit required by subsection (b)
26 of Section 2006 in addition to any other deposit required
27 under this Act.
28 (d) An LHSO shall not issue a POS contract until it has
29 filed and had approved by the Director a plan to comply with
30 the provisions of this Section. The compliance plan shall at
31 a minimum include provisions demonstrating that the LHSO will
32 do all of the following:
33 (1) Design the benefit levels and conditions of
34 coverage for in-plan covered services and out-of-plan
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1 covered services as required by this Article.
2 (2) Provide or arrange for the provision of
3 adequate systems to:
4 (A) process and pay claims for all out-of-plan
5 covered services;
6 (B) meet the requirements for a POS contract
7 set forth in this Section and any additional
8 requirements that may be set forth by the Director;
9 and
10 (C) generate accurate data and financial and
11 regulatory reports on a timely basis so that the
12 Department can evaluate the LHSO's experience with
13 the POS contract and monitor compliance with POS
14 contract provisions.
15 (3) Comply initially and on an ongoing basis with
16 the requirements of subsections (b) and (c).
17 (e) A limited health service organization shall comply
18 with the provisions of Sections 356g, 356t, and 356w of the
19 Illinois Insurance Code.
20 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
21 Section 40. 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 Sec. 10. Application of Insurance Code provisions.
25 Health services plan corporations and all persons interested
26 therein or dealing therewith shall be subject to the
27 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
28 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
29 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
30 paragraphs (7) and (15) of Section 367 of the Illinois
31 Insurance Code.
32 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
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1 90-25, eff. 1-1-98; revised 10-14-97.)
2 Section 95. No acceleration or delay. Where this Act
3 makes changes in a statute that is represented in this Act by
4 text that is not yet or no longer in effect (for example, a
5 Section represented by multiple versions), the use of that
6 text does not accelerate or delay the taking effect of (i)
7 the changes made by this Act or (ii) provisions derived from
8 any other Public Act.
9 Section 99. Effective date. This Act takes effect upon
10 becoming law.".