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Public Act 097-0592 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by | ||||
changing Section 356z.16 and adding Section 356z.19 as follows: | ||||
(215 ILCS 5/356z.16) | ||||
Sec. 356z.16. Applicability of mandated benefits to | ||||
supplemental policies. Unless specified otherwise, the | ||||
following Sections of the Illinois Insurance Code do not apply | ||||
to short-term travel, disability income, long-term care, | ||||
accident only, or limited or specified disease policies: 356b, | ||||
356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t, | ||||
356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||||
356z.8, 356z.12, 356z.19, 367.2-5, and 367e.
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(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10; | ||||
96-1034, eff. 1-1-11.) | ||||
(215 ILCS 5/356z.19 new) | ||||
Sec. 356z.19. Tobacco use cessation programs; coverage | ||||
offer. | ||||
(a) Tobacco use is the number one cause of preventable | ||||
disease and death in Illinois, costing $4.1 billion annually in | ||||
direct health care costs and an additional $4.35 billion in |
lost productivity. In Illinois, the smoking rates are highest | ||
among African Americans (25.8%). Smoking rates among lesbian, | ||
gay, and bisexual adults range from 25% to 44%. The U.S. Public | ||
Health Service Clinical Practice Guideline 2008 Update found | ||
that tobacco dependence treatments are both clinically | ||
effective and highly cost effective. A study in the Journal of | ||
Preventive Medicine concluded that comprehensive smoking | ||
cessation treatment is one of the 3 most important and cost | ||
effective preventive services that can be provided in medical | ||
practice. Greater efforts are needed to achieve more of this | ||
potential value by increasing current low
levels of | ||
performance. | ||
(b) In this Section, "tobacco use cessation program" means | ||
a program recommended by a physician that follows | ||
evidence-based treatment, such as is outlined in the United | ||
States Public Health Service guidelines for tobacco use | ||
cessation. "Tobacco use cessation program" includes education | ||
and medical treatment components designed to assist a person in | ||
ceasing the use of tobacco products. "Tobacco use cessation | ||
program" includes education and counseling by physicians or | ||
associated medical personnel and all FDA approved medications | ||
for the treatment of tobacco dependence irrespective of whether | ||
they are available only over the counter, only by prescription, | ||
or both over the counter and by prescription. | ||
(c) On or after the effective date of this amendatory Act | ||
of the 97th General Assembly, every
insurer that amends, |
delivers, issues, or renews group accident and health policies | ||
providing coverage for hospital or medical treatment or | ||
services on an expense-incurred basis shall offer, for an | ||
additional premium and subject to the insurer's standard of | ||
insurability, optional coverage or optional reimbursement of | ||
up to $500 annually for a tobacco use cessation program for a | ||
person enrolled in the plan who is 18 years of age or older. | ||
(d) The coverage required by this Section shall be subject
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to other general exclusions and limitations of the policy,
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including coordination of benefits, participating provider
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requirements, restrictions on services provided by family or | ||
household members, utilization review of health care services, | ||
including review of medical necessity, case management, | ||
experimental and investigational treatments, and other managed | ||
care provisions. | ||
(e) For the coverage provided under this Section, an | ||
insurer may not penalize or reduce or limit the reimbursement | ||
of an attending provider or provide incentives, monetary or | ||
otherwise, to an attending provider to induce the provider to | ||
provide care to an insured in a manner inconsistent with the | ||
coverage under this Section.
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Section 10. The Health Maintenance Organization Act is | ||
amended by changing Section 5-3 as follows:
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(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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Sec. 5-3. Insurance Code provisions.
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(a) Health Maintenance Organizations
shall be subject to | ||
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||
154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||
356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | ||
356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | ||
368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||
409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||
Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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(b) For purposes of the Illinois Insurance Code, except for | ||
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||
Maintenance Organizations in
the following categories are | ||
deemed to be "domestic companies":
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(1) a corporation authorized under the
Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act;
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(2) a corporation organized under the laws of this | ||
State; or
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(3) a corporation organized under the laws of another | ||
state, 30% or more
of the enrollees of which are residents | ||
of this State, except a
corporation subject to | ||
substantially the same requirements in its state of
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organization as is a "domestic company" under Article VIII | ||
1/2 of the
Illinois Insurance Code.
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(c) In considering the merger, consolidation, or other | ||
acquisition of
control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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(1) the Director shall give primary consideration to | ||
the continuation of
benefits to enrollees and the financial | ||
conditions of the acquired Health
Maintenance Organization | ||
after the merger, consolidation, or other
acquisition of | ||
control takes effect;
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(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of
the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making
his determination | ||
with respect to the merger, consolidation, or other
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acquisition of control, need not take into account the | ||
effect on
competition of the merger, consolidation, or | ||
other acquisition of control;
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(3) the Director shall have the power to require the | ||
following
information:
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(A) certification by an independent actuary of the | ||
adequacy
of the reserves of the Health Maintenance | ||
Organization sought to be acquired;
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(B) pro forma financial statements reflecting the | ||
combined balance
sheets of the acquiring company and | ||
the Health Maintenance Organization sought
to be | ||
acquired as of the end of the preceding year and as of | ||
a date 90 days
prior to the acquisition, as well as pro | ||
forma financial statements
reflecting projected |
combined operation for a period of 2 years;
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(C) a pro forma business plan detailing an | ||
acquiring party's plans with
respect to the operation | ||
of the Health Maintenance Organization sought to
be | ||
acquired for a period of not less than 3 years; and
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(D) such other information as the Director shall | ||
require.
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(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code
and this Section 5-3 shall apply to the sale by | ||
any health maintenance
organization of greater than 10% of its
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enrollee population (including without limitation the health | ||
maintenance
organization's right, title, and interest in and to | ||
its health care
certificates).
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(e) In considering any management contract or service | ||
agreement subject
to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in
addition to the criteria | ||
specified in Section 141.2 of the Illinois
Insurance Code, take | ||
into account the effect of the management contract or
service | ||
agreement on the continuation of benefits to enrollees and the
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financial condition of the health maintenance organization to | ||
be managed or
serviced, and (ii) need not take into account the | ||
effect of the management
contract or service agreement on | ||
competition.
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(f) Except for small employer groups as defined in the | ||
Small Employer
Rating, Renewability and Portability Health | ||
Insurance Act and except for
medicare supplement policies as |
defined in Section 363 of the Illinois
Insurance Code, a Health | ||
Maintenance Organization may by contract agree with a
group or | ||
other enrollment unit to effect refunds or charge additional | ||
premiums
under the following terms and conditions:
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(i) the amount of, and other terms and conditions with | ||
respect to, the
refund or additional premium are set forth | ||
in the group or enrollment unit
contract agreed in advance | ||
of the period for which a refund is to be paid or
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additional premium is to be charged (which period shall not | ||
be less than one
year); and
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(ii) the amount of the refund or additional premium | ||
shall not exceed 20%
of the Health Maintenance | ||
Organization's profitable or unprofitable experience
with | ||
respect to the group or other enrollment unit for the | ||
period (and, for
purposes of a refund or additional | ||
premium, the profitable or unprofitable
experience shall | ||
be calculated taking into account a pro rata share of the
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Health Maintenance Organization's administrative and | ||
marketing expenses, but
shall not include any refund to be | ||
made or additional premium to be paid
pursuant to this | ||
subsection (f)). The Health Maintenance Organization and | ||
the
group or enrollment unit may agree that the profitable | ||
or unprofitable
experience may be calculated taking into | ||
account the refund period and the
immediately preceding 2 | ||
plan years.
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The Health Maintenance Organization shall include a |
statement in the
evidence of coverage issued to each enrollee | ||
describing the possibility of a
refund or additional premium, | ||
and upon request of any group or enrollment unit,
provide to | ||
the group or enrollment unit a description of the method used | ||
to
calculate (1) the Health Maintenance Organization's | ||
profitable experience with
respect to the group or enrollment | ||
unit and the resulting refund to the group
or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable
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experience with respect to the group or enrollment unit and the | ||
resulting
additional premium to be paid by the group or | ||
enrollment unit.
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In no event shall the Illinois Health Maintenance | ||
Organization
Guaranty Association be liable to pay any | ||
contractual obligation of an
insolvent organization to pay any | ||
refund authorized under this Section.
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(g) Rulemaking authority to implement Public Act 95-1045, | ||
if any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||
95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||
95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||
1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | ||
6-1-10; 96-1000, eff. 7-2-10.) |
Section 15. The Limited Health Service Organization Act is | ||
amended by changing Section 4003 as follows:
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(215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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Sec. 4003. Illinois Insurance Code provisions. Limited | ||
health service
organizations shall be subject to the provisions | ||
of Sections 133, 134, 137,
140, 141.1, 141.2, 141.3, 143, 143c, | ||
147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, | ||
155.04, 155.37, 355.2, 356v, 356z.10, 356z.19, 368a, 401, | ||
401.1,
402,
403, 403A, 408,
408.2, 409, 412, 444, and 444.1 and | ||
Articles IIA, VIII 1/2, XII, XII 1/2,
XIII,
XIII 1/2, XXV, and | ||
XXVI of the Illinois Insurance Code. For purposes of the
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Illinois Insurance Code, except for Sections 444 and 444.1 and | ||
Articles XIII
and XIII 1/2, limited health service | ||
organizations in the following categories
are deemed to be | ||
domestic companies:
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(1) a corporation under the laws of this State; or
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(2) a corporation organized under the laws of another | ||
state, 30% of more
of the enrollees of which are residents | ||
of this State, except a corporation
subject to | ||
substantially the same requirements in its state of | ||
organization as
is a domestic company under Article VIII | ||
1/2 of the Illinois Insurance Code.
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(Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
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Section 20. The Voluntary Health Services Plans Act is | ||
amended by changing Section 10 as follows:
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(215 ILCS 165/10) (from Ch. 32, par. 604)
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Sec. 10. Application of Insurance Code provisions. Health | ||
services
plan corporations and all persons interested therein | ||
or dealing therewith
shall be subject to the provisions of | ||
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||
149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | ||
356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | ||
356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | ||
356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401, | ||
401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||
and (15) of Section 367 of the Illinois
Insurance Code.
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Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | ||
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||
8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||
eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||
96-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff. | ||
7-2-10.)
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