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92_HB1889enr HB1889 Enrolled LRB9200925JSpcB 1 AN ACT concerning insurance coverage. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 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. Required health benefits; Illinois Insurance 8 Code requirements. The program of health benefits shall 9 provide the post-mastectomy care benefits required to be 10 covered by a policy of accident and health insurance under 11 Section 356t of the Illinois Insurance Code. The program of 12 health benefits shall provide the coverage required under 13 Sections 356u, 356w,and356x, and 356z.2 of the Illinois 14 Insurance Code. The program of health benefits must comply 15 with Section 155.37 of the Illinois Insurance Code. 16 (Source: P.A. 92-440, eff. 8-17-01.) 17 Section 10. The Illinois Insurance Code is amended by 18 adding Section 356z.2 as follows: 19 (215 ILCS 5/356z.2 new) 20 Sec. 356z.2. Coverage for adjunctive services in dental 21 care. 22 (a) An individual or group policy of accident and health 23 insurance amended, delivered, issued, or renewed after the 24 effective date of this amendatory Act of the 92nd General 25 Assembly shall cover charges incurred, and anesthetics 26 provided, in conjunction with dental care that is provided to 27 a covered individual in a hospital or an ambulatory surgical 28 treatment center if any of the following applies: 29 (1) the individual is a child age 6 or under; HB1889 Enrolled -2- LRB9200925JSpcB 1 (2) the individual has a medical condition that 2 requires hospitalization or general anesthesia for dental 3 care; or 4 (3) the individual is disabled. 5 (b) For purposes of this Section, "ambulatory surgical 6 treatment center" has the meaning given to that term in 7 Section 3 of the Ambulatory Surgical Treatment Center Act. 8 For purposes of this Section, "disabled" means a person, 9 regardless of age, with a chronic disability if the chronic 10 disability meets all of the following conditions: 11 (1) It is attributable to a mental or physical 12 impairment or combination of mental and physical 13 impairments. 14 (2) It is likely to continue. 15 (3) It results in substantial functional limitations 16 in one or more of the following areas of major life 17 activity: 18 (A) self-care; 19 (B) receptive and expressive language; 20 (C) learning; 21 (D) mobility; 22 (E) capacity for independent living; or 23 (F) economic self-sufficiency. 24 (c) The coverage required under this Section may be 25 subject to any limitations, exclusions, or cost-sharing 26 provisions that apply generally under the insurance policy. 27 (d) This Section does not apply to a policy that covers 28 only dental care. 29 (e) Nothing in this Section requires that the dental 30 services be covered. 31 (f) The provisions of this Section do not apply to 32 short-term travel, accident-only, limited, or specified 33 disease policies, nor to policies or contracts designed for 34 issuance to persons eligible for coverage under Title XVIII HB1889 Enrolled -3- LRB9200925JSpcB 1 of the Social Security Act, known as Medicare, or any other 2 similar coverage under State or federal governmental plans. 3 Section 15. The Health Maintenance Organization Act is 4 amended by changing Section 5-3 as follows: 5 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) 6 Sec. 5-3. Insurance Code provisions. 7 (a) Health Maintenance Organizations shall be subject to 8 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2, 9 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 10 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 11 356y, 356z.2, 367i, 368a, 401, 401.1, 402, 403, 403A, 408, 12 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection 13 (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, 14 XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. 15 (b) For purposes of the Illinois Insurance Code, except 16 for Sections 444 and 444.1 and Articles XIII and XIII 1/2, 17 Health Maintenance Organizations in the following categories 18 are deemed to be "domestic companies": 19 (1) a corporation authorized under the Dental 20 Service Plan Act or the Voluntary Health Services Plans 21 Act; 22 (2) a corporation organized under the laws of this 23 State; or 24 (3) a corporation organized under the laws of 25 another state, 30% or more of the enrollees of which are 26 residents of this State, except a corporation subject to 27 substantially the same requirements in its state of 28 organization as is a "domestic company" under Article 29 VIII 1/2 of the Illinois Insurance Code. 30 (c) In considering the merger, consolidation, or other 31 acquisition of control of a Health Maintenance Organization 32 pursuant to Article VIII 1/2 of the Illinois Insurance Code, HB1889 Enrolled -4- LRB9200925JSpcB 1 (1) the Director shall give primary consideration 2 to the continuation of benefits to enrollees and the 3 financial conditions of the acquired Health Maintenance 4 Organization after the merger, consolidation, or other 5 acquisition of control takes effect; 6 (2)(i) the criteria specified in subsection (1)(b) 7 of Section 131.8 of the Illinois Insurance Code shall not 8 apply and (ii) the Director, in making his determination 9 with respect to the merger, consolidation, or other 10 acquisition of control, need not take into account the 11 effect on competition of the merger, consolidation, or 12 other acquisition of control; 13 (3) the Director shall have the power to require 14 the following information: 15 (A) certification by an independent actuary of 16 the adequacy of the reserves of the Health 17 Maintenance Organization sought to be acquired; 18 (B) pro forma financial statements reflecting 19 the combined balance sheets of the acquiring company 20 and the Health Maintenance Organization sought to be 21 acquired as of the end of the preceding year and as 22 of a date 90 days prior to the acquisition, as well 23 as pro forma financial statements reflecting 24 projected combined operation for a period of 2 25 years; 26 (C) a pro forma business plan detailing an 27 acquiring party's plans with respect to the 28 operation of the Health Maintenance Organization 29 sought to be acquired for a period of not less than 30 3 years; and 31 (D) such other information as the Director 32 shall require. 33 (d) The provisions of Article VIII 1/2 of the Illinois 34 Insurance Code and this Section 5-3 shall apply to the sale HB1889 Enrolled -5- LRB9200925JSpcB 1 by any health maintenance organization of greater than 10% of 2 its enrollee population (including without limitation the 3 health maintenance organization's right, title, and interest 4 in and to its health care certificates). 5 (e) In considering any management contract or service 6 agreement subject to Section 141.1 of the Illinois Insurance 7 Code, the Director (i) shall, in addition to the criteria 8 specified in Section 141.2 of the Illinois Insurance Code, 9 take into account the effect of the management contract or 10 service agreement on the continuation of benefits to 11 enrollees and the financial condition of the health 12 maintenance organization to be managed or serviced, and (ii) 13 need not take into account the effect of the management 14 contract or service agreement on competition. 15 (f) Except for small employer groups as defined in the 16 Small Employer Rating, Renewability and Portability Health 17 Insurance Act and except for medicare supplement policies as 18 defined in Section 363 of the Illinois Insurance Code, a 19 Health Maintenance Organization may by contract agree with a 20 group or other enrollment unit to effect refunds or charge 21 additional premiums under the following terms and conditions: 22 (i) the amount of, and other terms and conditions 23 with respect to, the refund or additional premium are set 24 forth in the group or enrollment unit contract agreed in 25 advance of the period for which a refund is to be paid or 26 additional premium is to be charged (which period shall 27 not be less than one year); and 28 (ii) the amount of the refund or additional premium 29 shall not exceed 20% of the Health Maintenance 30 Organization's profitable or unprofitable experience with 31 respect to the group or other enrollment unit for the 32 period (and, for purposes of a refund or additional 33 premium, the profitable or unprofitable experience shall 34 be calculated taking into account a pro rata share of the HB1889 Enrolled -6- LRB9200925JSpcB 1 Health Maintenance Organization's administrative and 2 marketing expenses, but shall not include any refund to 3 be made or additional premium to be paid pursuant to this 4 subsection (f)). The Health Maintenance Organization and 5 the group or enrollment unit may agree that the 6 profitable or unprofitable experience may be calculated 7 taking into account the refund period and the immediately 8 preceding 2 plan years. 9 The Health Maintenance Organization shall include a 10 statement in the evidence of coverage issued to each enrollee 11 describing the possibility of a refund or additional premium, 12 and upon request of any group or enrollment unit, provide to 13 the group or enrollment unit a description of the method used 14 to calculate (1) the Health Maintenance Organization's 15 profitable experience with respect to the group or enrollment 16 unit and the resulting refund to the group or enrollment unit 17 or (2) the Health Maintenance Organization's unprofitable 18 experience with respect to the group or enrollment unit and 19 the resulting additional premium to be paid by the group or 20 enrollment unit. 21 In no event shall the Illinois Health Maintenance 22 Organization Guaranty Association be liable to pay any 23 contractual obligation of an insolvent organization to pay 24 any refund authorized under this Section. 25 (Source: P.A. 90-25, eff. 1-1-98; 90-177, eff. 7-23-97; 26 90-372, eff. 7-1-98; 90-583, eff. 5-29-98; 90-655, eff. 27 7-30-98; 90-741, eff. 1-1-99; 91-357, eff. 7-29-99; 91-406, 28 eff. 1-1-00; 91-549, eff. 8-14-99; 91-605, eff. 12-14-99; 29 91-788, eff. 6-9-00.) 30 Section 20. The Voluntary Health Services Plans Act is 31 amended by changing Section 10 as follows: 32 (215 ILCS 165/10) (from Ch. 32, par. 604) HB1889 Enrolled -7- LRB9200925JSpcB 1 Sec. 10. Application of Insurance Code provisions. 2 Health services plan corporations and all persons interested 3 therein or dealing therewith shall be subject to the 4 provisions of Articles IIA and XII 1/2 and Sections 3.1, 133, 5 140, 143, 143c, 149, 155.37, 354, 355.2, 356r, 356t, 356u, 6 356v, 356w, 356x, 356y, 356z.1, 356z.2, 367.2, 368a, 401, 7 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs 8 (7) and (15) of Section 367 of the Illinois Insurance Code. 9 (Source: P.A. 91-406, eff. 1-1-00; 91-549, eff. 8-14-99; 10 91-605, eff. 12-14-99; 91-788, eff. 6-9-00; 92-130, eff. 11 7-20-01; 92-440, eff. 8-17-01; revised 9-12-01.)