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| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB0020 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED:
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Amends the Illinois Insurance Code. Sets forth legislative findings concerning nutritional support and hydration. Provides that an individual or group policy of accident and health insurance or managed care plan must provide coverage for intravenous
feeding and for enteral or tube feeding and that the benefits shall be at least as favorable as for other
coverages under the policy and may be subject to the same
dollar amount limits, deductibles, and co-insurance
requirements applicable generally to other coverages under the
policy. Provides that an individual or group policy of accident and health insurance or managed care plan that provides coverage for prescription drugs must
provide coverage for reimbursement for medically appropriate
prescription nutritional supplements, limited to those
products that are issued only by a physician's written order,
when ordered by a physician and the insured suffers from a condition that prevents him or her from taking sufficient oral nourishment to
sustain life. Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Health Maintenance Organization Act, and Voluntary Health Services Plans Act to make conforming changes. Amends the State Mandates Act to require implementation without reimbursement by the State.
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| | | FISCAL NOTE ACT MAY APPLY | | STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT |
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| 1 | | AN ACT concerning insurance.
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| 2 | | Be it enacted by the People of the State of Illinois,
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| 3 | | represented in the General Assembly:
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| 4 | | Section 5. The State Employees Group Insurance Act of 1971 |
| 5 | | is amended by changing Section 6.11 as follows:
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| 6 | | (5 ILCS 375/6.11)
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| 7 | | Sec. 6.11. Required health benefits; Illinois Insurance |
| 8 | | Code
requirements. The program of health
benefits shall provide |
| 9 | | the post-mastectomy care benefits required to be covered
by a |
| 10 | | policy of accident and health insurance under Section 356t of |
| 11 | | the Illinois
Insurance Code. The program of health benefits |
| 12 | | shall provide the coverage
required under Sections 356g, |
| 13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
| 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
| 15 | | 356z.14, 356z.15, and 356z.17 and 356z.19, 356z.22, and 356z.23 |
| 16 | | of the
Illinois Insurance Code.
The program of health benefits |
| 17 | | must comply with Sections 155.22a, 155.37, and 356z.19 of the
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| 18 | | Illinois Insurance Code.
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| 19 | | Rulemaking authority to implement Public Act 95-1045, if |
| 20 | | any, is conditioned on the rules being adopted in accordance |
| 21 | | with all provisions of the Illinois Administrative Procedure |
| 22 | | Act and all rules and procedures of the Joint Committee on |
| 23 | | Administrative Rules; any purported rule not so adopted, for |
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| 1 | | whatever reason, is unauthorized. |
| 2 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
| 3 | | 96-639, eff. 1-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; |
| 4 | | 97-343, eff. 1-1-12; 97-813, eff. 7-13-12.)
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| 5 | | Section 10. The Counties Code is amended by changing |
| 6 | | Section 5-1069.3 as follows:
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| 7 | | (55 ILCS 5/5-1069.3)
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| 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, and 356z.15, 356z.22, and 356z.23 of
the Illinois |
| 17 | | Insurance Code. The coverage shall comply with Sections 155.22a |
| 18 | | and 356z.19 of
the Illinois Insurance Code. The requirement |
| 19 | | that health benefits be covered
as provided in this Section is |
| 20 | | an
exclusive power and function of the State and is a denial |
| 21 | | and limitation under
Article VII, Section 6, subsection (h) of |
| 22 | | the Illinois Constitution. A home
rule county to which this |
| 23 | | Section applies must comply with every provision of
this |
| 24 | | 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. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
| 8 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
| 9 | | 97-813, eff. 7-13-12.)
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| 10 | | Section 15. The Illinois Municipal Code is amended by |
| 11 | | changing Section 10-4-2.3 as follows:
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| 12 | | (65 ILCS 5/10-4-2.3)
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| 13 | | Sec. 10-4-2.3. Required health benefits. If a |
| 14 | | municipality, including a
home rule municipality, is a |
| 15 | | self-insurer for purposes of providing health
insurance |
| 16 | | coverage for its employees, the coverage shall include coverage |
| 17 | | for
the post-mastectomy care benefits required to be covered by |
| 18 | | a policy of
accident and health insurance under Section 356t |
| 19 | | and the coverage required
under Sections 356g, 356g.5, |
| 20 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
| 21 | | 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, 356z.22, and |
| 22 | | 356z.23 of the Illinois
Insurance
Code. The coverage shall |
| 23 | | comply with Sections 155.22a and 356z.19 of
the Illinois |
| 24 | | Insurance Code. The requirement that health
benefits be covered |
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| 1 | | as provided in this is an exclusive power and function of
the |
| 2 | | State and is a denial and limitation under Article VII, Section |
| 3 | | 6,
subsection (h) of the Illinois Constitution. A home rule |
| 4 | | municipality to which
this Section applies must comply with |
| 5 | | every provision of this Section.
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| 6 | | Rulemaking authority to implement Public Act 95-1045, if |
| 7 | | any, is conditioned on the rules being adopted in accordance |
| 8 | | with all provisions of the Illinois Administrative Procedure |
| 9 | | Act and all rules and procedures of the Joint Committee on |
| 10 | | Administrative Rules; any purported rule not so adopted, for |
| 11 | | whatever reason, is unauthorized. |
| 12 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
| 13 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
| 14 | | 97-813, eff. 7-13-12.)
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| 15 | | Section 20. The School Code is amended by changing Section |
| 16 | | 10-22.3f as follows:
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| 17 | | (105 ILCS 5/10-22.3f)
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| 18 | | Sec. 10-22.3f. Required health benefits. Insurance |
| 19 | | protection and
benefits
for employees shall provide the |
| 20 | | post-mastectomy care benefits required to be
covered by a |
| 21 | | policy of accident and health insurance under Section 356t and |
| 22 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
| 23 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
| 24 | | 356z.13, 356z.14, and 356z.15, 356z.22, and 356z.23 of
the
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| 1 | | Illinois Insurance Code.
Insurance policies shall comply with |
| 2 | | Section 356z.19 of the Illinois Insurance Code. The coverage |
| 3 | | shall comply with Section 155.22a of
the Illinois Insurance |
| 4 | | Code.
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| 5 | | Rulemaking authority to implement Public Act 95-1045, if |
| 6 | | any, is conditioned on the rules being adopted in accordance |
| 7 | | with all provisions of the Illinois Administrative Procedure |
| 8 | | Act and all rules and procedures of the Joint Committee on |
| 9 | | Administrative Rules; any purported rule not so adopted, for |
| 10 | | whatever reason, is unauthorized. |
| 11 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
| 12 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
| 13 | | 97-813, eff. 7-13-12.)
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| 14 | | Section 25. The Illinois Insurance Code is amended by |
| 15 | | adding Sections 356z.22 and 356z.23 as follows:
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| 16 | | (215 ILCS 5/356z.22 new) |
| 17 | | Sec. 356z.22. Nutritional support and hydration. |
| 18 | | (a) The General Assembly finds that people who are
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| 19 | | physically unable to swallow, digest, or absorb food and fluids
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| 20 | | taken by mouth are at risk of malnutrition and dehydration.
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| 21 | | Without nutritional support and hydration, such individuals
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| 22 | | will become increasingly weakened. As their immune system
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| 23 | | functioning is reduced, they may die from infections before |
| 24 | | death can occur from malnutrition or dehydration. |
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| 1 | | (b) A group or individual policy of accident and health
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| 2 | | insurance or managed care plan amended, delivered, issued, or
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| 3 | | renewed after the effective date of this amendatory Act of the
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| 4 | | 98th General Assembly must provide coverage for intravenous
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| 5 | | feeding and for enteral or tube feeding. The benefits under
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| 6 | | this Section shall be at least as favorable as for other
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| 7 | | coverages under the policy and may be subject to the same
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| 8 | | dollar amount limits, deductibles, and co-insurance
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| 9 | | requirements applicable generally to other coverages under the
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| 10 | | policy. |
| 11 | | (c) For the purpose of this Section, "enteral or tube
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| 12 | | feeding" means the process by which nutritional formulas are
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| 13 | | delivered via a tube into the digestive tract.
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| 14 | | (215 ILCS 5/356z.23 new) |
| 15 | | Sec. 356z.23. Prescription nutritional supplements. A
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| 16 | | group or individual policy of accident and health insurance or
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| 17 | | managed care plan amended, delivered, issued, or renewed after
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| 18 | | the effective date of this amendatory Act of the 98th General
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| 19 | | Assembly that provides coverage for prescription drugs must
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| 20 | | provide coverage for reimbursement for medically appropriate
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| 21 | | prescription nutritional supplements, limited to those
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| 22 | | products that are issued only by a physician's written order,
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| 23 | | when ordered by a physician licensed to practice medicine in
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| 24 | | all its branches and the insured suffers from a condition that |
| 25 | | prevents him or her from taking sufficient oral nourishment to
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| 1 | | sustain life.
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| 2 | | Section 30. The Health Maintenance Organization Act is |
| 3 | | amended by changing Section 5-3 as follows:
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| 4 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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| 5 | | Sec. 5-3. Insurance Code provisions.
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| 6 | | (a) Health Maintenance Organizations
shall be subject to |
| 7 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
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| 8 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
| 9 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, |
| 10 | | 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, 356z.5, |
| 11 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
| 12 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, |
| 13 | | 356z.23, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, |
| 14 | | 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, |
| 15 | | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of |
| 16 | | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, |
| 17 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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| 18 | | (b) For purposes of the Illinois Insurance Code, except for |
| 19 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
| 20 | | Maintenance Organizations in
the following categories are |
| 21 | | deemed to be "domestic companies":
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| 22 | | (1) a corporation authorized under the
Dental Service |
| 23 | | Plan Act or the Voluntary Health Services Plans Act;
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| 24 | | (2) a corporation organized under the laws of this |
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| 1 | | State; or
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| 2 | | (3) a corporation organized under the laws of another |
| 3 | | state, 30% or more
of the enrollees of which are residents |
| 4 | | of this State, except a
corporation subject to |
| 5 | | substantially the same requirements in its state of
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| 6 | | organization as is a "domestic company" under Article VIII |
| 7 | | 1/2 of the
Illinois Insurance Code.
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| 8 | | (c) In considering the merger, consolidation, or other |
| 9 | | acquisition of
control of a Health Maintenance Organization |
| 10 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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| 11 | | (1) the Director shall give primary consideration to |
| 12 | | the continuation of
benefits to enrollees and the financial |
| 13 | | conditions of the acquired Health
Maintenance Organization |
| 14 | | after the merger, consolidation, or other
acquisition of |
| 15 | | control takes effect;
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| 16 | | (2)(i) the criteria specified in subsection (1)(b) of |
| 17 | | Section 131.8 of
the Illinois Insurance Code shall not |
| 18 | | apply and (ii) the Director, in making
his determination |
| 19 | | with respect to the merger, consolidation, or other
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| 20 | | acquisition of control, need not take into account the |
| 21 | | effect on
competition of the merger, consolidation, or |
| 22 | | other acquisition of control;
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| 23 | | (3) the Director shall have the power to require the |
| 24 | | following
information:
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| 25 | | (A) certification by an independent actuary of the |
| 26 | | adequacy
of the reserves of the Health Maintenance |
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| 1 | | Organization sought to be acquired;
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| 2 | | (B) pro forma financial statements reflecting the |
| 3 | | combined balance
sheets of the acquiring company and |
| 4 | | the Health Maintenance Organization sought
to be |
| 5 | | acquired as of the end of the preceding year and as of |
| 6 | | a date 90 days
prior to the acquisition, as well as pro |
| 7 | | forma financial statements
reflecting projected |
| 8 | | combined operation for a period of 2 years;
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| 9 | | (C) a pro forma business plan detailing an |
| 10 | | acquiring party's plans with
respect to the operation |
| 11 | | of the Health Maintenance Organization sought to
be |
| 12 | | acquired for a period of not less than 3 years; and
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| 13 | | (D) such other information as the Director shall |
| 14 | | require.
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| 15 | | (d) The provisions of Article VIII 1/2 of the Illinois |
| 16 | | Insurance Code
and this Section 5-3 shall apply to the sale by |
| 17 | | any health maintenance
organization of greater than 10% of its
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| 18 | | enrollee population (including without limitation the health |
| 19 | | maintenance
organization's right, title, and interest in and to |
| 20 | | its health care
certificates).
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| 21 | | (e) In considering any management contract or service |
| 22 | | agreement subject
to Section 141.1 of the Illinois Insurance |
| 23 | | Code, the Director (i) shall, in
addition to the criteria |
| 24 | | specified in Section 141.2 of the Illinois
Insurance Code, take |
| 25 | | into account the effect of the management contract or
service |
| 26 | | agreement on the continuation of benefits to enrollees and the
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| 1 | | financial condition of the health maintenance organization to |
| 2 | | be managed or
serviced, and (ii) need not take into account the |
| 3 | | effect of the management
contract or service agreement on |
| 4 | | competition.
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| 5 | | (f) Except for small employer groups as defined in the |
| 6 | | Small Employer
Rating, Renewability and Portability Health |
| 7 | | Insurance Act and except for
medicare supplement policies as |
| 8 | | defined in Section 363 of the Illinois
Insurance Code, a Health |
| 9 | | Maintenance Organization may by contract agree with a
group or |
| 10 | | other enrollment unit to effect refunds or charge additional |
| 11 | | premiums
under the following terms and conditions:
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| 12 | | (i) the amount of, and other terms and conditions with |
| 13 | | respect to, the
refund or additional premium are set forth |
| 14 | | in the group or enrollment unit
contract agreed in advance |
| 15 | | of the period for which a refund is to be paid or
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| 16 | | additional premium is to be charged (which period shall not |
| 17 | | be less than one
year); and
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| 18 | | (ii) the amount of the refund or additional premium |
| 19 | | shall not exceed 20%
of the Health Maintenance |
| 20 | | Organization's profitable or unprofitable experience
with |
| 21 | | respect to the group or other enrollment unit for the |
| 22 | | period (and, for
purposes of a refund or additional |
| 23 | | premium, the profitable or unprofitable
experience shall |
| 24 | | be calculated taking into account a pro rata share of the
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| 25 | | Health Maintenance Organization's administrative and |
| 26 | | marketing expenses, but
shall not include any refund to be |
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| 1 | | made or additional premium to be paid
pursuant to this |
| 2 | | subsection (f)). The Health Maintenance Organization and |
| 3 | | the
group or enrollment unit may agree that the profitable |
| 4 | | or unprofitable
experience may be calculated taking into |
| 5 | | account the refund period and the
immediately preceding 2 |
| 6 | | plan years.
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| 7 | | The Health Maintenance Organization shall include a |
| 8 | | statement in the
evidence of coverage issued to each enrollee |
| 9 | | describing the possibility of a
refund or additional premium, |
| 10 | | and upon request of any group or enrollment unit,
provide to |
| 11 | | the group or enrollment unit a description of the method used |
| 12 | | to
calculate (1) the Health Maintenance Organization's |
| 13 | | profitable experience with
respect to the group or enrollment |
| 14 | | unit and the resulting refund to the group
or enrollment unit |
| 15 | | or (2) the Health Maintenance Organization's unprofitable
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| 16 | | experience with respect to the group or enrollment unit and the |
| 17 | | resulting
additional premium to be paid by the group or |
| 18 | | enrollment unit.
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| 19 | | In no event shall the Illinois Health Maintenance |
| 20 | | Organization
Guaranty Association be liable to pay any |
| 21 | | contractual obligation of an
insolvent organization to pay any |
| 22 | | refund authorized under this Section.
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| 23 | | (g) Rulemaking authority to implement Public Act 95-1045, |
| 24 | | if any, is conditioned on the rules being adopted in accordance |
| 25 | | with all provisions of the Illinois Administrative Procedure |
| 26 | | Act and all rules and procedures of the Joint Committee on |
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| 1 | | Administrative Rules; any purported rule not so adopted, for |
| 2 | | whatever reason, is unauthorized. |
| 3 | | (Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
| 4 | | 96-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; |
| 5 | | 97-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12; |
| 6 | | 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff. |
| 7 | | 7-13-12.)
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| 8 | | Section 35. The Voluntary Health Services Plans Act is |
| 9 | | amended by changing Section 10 as follows:
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| 10 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
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| 11 | | Sec. 10. Application of Insurance Code provisions. Health |
| 12 | | services
plan corporations and all persons interested therein |
| 13 | | or dealing therewith
shall be subject to the provisions of |
| 14 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, |
| 15 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 356g, |
| 16 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, |
| 17 | | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
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| 18 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, |
| 19 | | 356z.19, 356z.21, 356z.22, 356z.23, 364.01, 367.2, 368a, 401, |
| 20 | | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) |
| 21 | | and (15) of Section 367 of the Illinois
Insurance Code.
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| 22 | | Rulemaking authority to implement Public Act 95-1045, if |
| 23 | | any, is conditioned on the rules being adopted in accordance |
| 24 | | with all provisions of the Illinois Administrative Procedure |
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| 1 | | Act and all rules and procedures of the Joint Committee on |
| 2 | | Administrative Rules; any purported rule not so adopted, for |
| 3 | | whatever reason, is unauthorized. |
| 4 | | (Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; |
| 5 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
| 6 | | 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; |
| 7 | | 97-813, eff. 7-13-12.)
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| 8 | | Section 90. The State Mandates Act is amended by adding |
| 9 | | Section 8.37 as follows:
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| 10 | | (30 ILCS 805/8.37 new) |
| 11 | | Sec. 8.37. Exempt mandate. Notwithstanding Sections 6 and 8 |
| 12 | | of this Act, no reimbursement by the State is required for the |
| 13 | | implementation of any mandate created by this amendatory Act of |
| 14 | | the 98th General Assembly.
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INDEX
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Statutes amended in order of appearance
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