Bill Text: IL HB4876 | 2019-2020 | 101st General Assembly | Introduced
Bill Title: Amends the Illinois Insurance Code to require a group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2021 to provide coverage for a colonoscopy that is a follow-up exam based on an initial screen where the colonoscopy was determined to be medically necessary by a physician licensed to practice medicine in all its branches, an advanced practice registered nurse, or a physician assistant. Provides that a group insurance policy shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on colonoscopy coverage, except to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account under the Internal Revenue Code. Makes conforming changes in the Counties Code, the Illinois Municipal Code, and the Health Maintenance Organization Act. Effective January 1, 2021.
Sponsorship: Partisan Bill (Democrat 8)
Status: (Introduced - Dead) 2020-06-23 - Rule 19(b) / Re-referred to Rules Committee [HB4876 Detail]
Download: Illinois-2019-HB4876-Introduced.html
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| 1 | AN ACT concerning regulation.
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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 Counties Code is amended by changing Section | ||||||||||||||||||||||||||||||
| 5 | 5-1069.3 as follows:
| ||||||||||||||||||||||||||||||
| 6 | (55 ILCS 5/5-1069.3)
| ||||||||||||||||||||||||||||||
| 7 | (Text of Section before amendment by P.A. 101-625) | ||||||||||||||||||||||||||||||
| 8 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||||||||||||||||||||||||||
| 9 | including a home
rule
county, is a self-insurer for purposes of | ||||||||||||||||||||||||||||||
| 10 | providing health insurance coverage
for its employees, the | ||||||||||||||||||||||||||||||
| 11 | coverage shall include coverage for the post-mastectomy
care | ||||||||||||||||||||||||||||||
| 12 | benefits required to be covered by a policy of accident and | ||||||||||||||||||||||||||||||
| 13 | health
insurance under Section 356t and the coverage required | ||||||||||||||||||||||||||||||
| 14 | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | ||||||||||||||||||||||||||||||
| 15 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||||||||||||||||||||||||||
| 16 | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | ||||||||||||||||||||||||||||||
| 17 | 356z.30a, and 356z.32, and 356z.33, 356z.36, and 356z.43 of
the | ||||||||||||||||||||||||||||||
| 18 | Illinois Insurance Code. The coverage shall comply with | ||||||||||||||||||||||||||||||
| 19 | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | ||||||||||||||||||||||||||||||
| 20 | Insurance Code. The Department of Insurance shall enforce the | ||||||||||||||||||||||||||||||
| 21 | requirements of this Section. The requirement that health | ||||||||||||||||||||||||||||||
| 22 | benefits be covered
as provided in this Section is an
exclusive | ||||||||||||||||||||||||||||||
| 23 | power and function of the State and is a denial and limitation | ||||||||||||||||||||||||||||||
| |||||||
| |||||||
| 1 | under
Article VII, Section 6, subsection (h) of the Illinois | ||||||
| 2 | Constitution. A home
rule county to which this Section applies | ||||||
| 3 | must comply with every provision of
this Section.
| ||||||
| 4 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
| 5 | any, is conditioned on the rules being adopted in accordance | ||||||
| 6 | with all provisions of the Illinois Administrative Procedure | ||||||
| 7 | Act and all rules and procedures of the Joint Committee on | ||||||
| 8 | Administrative Rules; any purported rule not so adopted, for | ||||||
| 9 | whatever reason, is unauthorized. | ||||||
| 10 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
| 11 | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
| 12 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
| 13 | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | ||||||
| 14 | revised 10-16-19.)
| ||||||
| 15 | (Text of Section after amendment by P.A. 101-625) | ||||||
| 16 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
| 17 | including a home
rule
county, is a self-insurer for purposes of | ||||||
| 18 | providing health insurance coverage
for its employees, the | ||||||
| 19 | coverage shall include coverage for the post-mastectomy
care | ||||||
| 20 | benefits required to be covered by a policy of accident and | ||||||
| 21 | health
insurance under Section 356t and the coverage required | ||||||
| 22 | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | ||||||
| 23 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
| 24 | 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, | ||||||
| 25 | 356z.30a, 356z.32, 356z.33, 356z.36, and 356z.41, and 356z.43 | ||||||
| |||||||
| |||||||
| 1 | of
the Illinois Insurance Code. The coverage shall comply with | ||||||
| 2 | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | ||||||
| 3 | Insurance Code. The Department of Insurance shall enforce the | ||||||
| 4 | requirements of this Section. The requirement that health | ||||||
| 5 | benefits be covered
as provided in this Section is an
exclusive | ||||||
| 6 | power and function of the State and is a denial and limitation | ||||||
| 7 | under
Article VII, Section 6, subsection (h) of the Illinois | ||||||
| 8 | Constitution. A home
rule county to which this Section applies | ||||||
| 9 | must comply with every provision of
this Section.
| ||||||
| 10 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
| 11 | any, is conditioned on the rules being adopted in accordance | ||||||
| 12 | with all provisions of the Illinois Administrative Procedure | ||||||
| 13 | Act and all rules and procedures of the Joint Committee on | ||||||
| 14 | Administrative Rules; any purported rule not so adopted, for | ||||||
| 15 | whatever reason, is unauthorized. | ||||||
| 16 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
| 17 | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
| 18 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
| 19 | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | ||||||
| 20 | 101-625, eff. 1-1-21.)
| ||||||
| 21 | Section 10. The Illinois Municipal Code is amended by | ||||||
| 22 | changing Section 10-4-2.3 as follows:
| ||||||
| 23 | (65 ILCS 5/10-4-2.3)
| ||||||
| 24 | (Text of Section before amendment by P.A. 101-625) | ||||||
| |||||||
| |||||||
| 1 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
| 2 | municipality, including a
home rule municipality, is a | ||||||
| 3 | self-insurer for purposes of providing health
insurance | ||||||
| 4 | coverage for its employees, the coverage shall include coverage | ||||||
| 5 | for
the post-mastectomy care benefits required to be covered by | ||||||
| 6 | a policy of
accident and health insurance under Section 356t | ||||||
| 7 | and the coverage required
under Sections 356g, 356g.5, | ||||||
| 8 | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
| 9 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | ||||||
| 10 | 356z.26, 356z.29, 356z.30a, and 356z.32, and 356z.33, 356z.36, | ||||||
| 11 | and 356z.43 of the Illinois
Insurance
Code. The coverage shall | ||||||
| 12 | comply with Sections 155.22a, 355b, 356z.19, and 370c of
the | ||||||
| 13 | Illinois Insurance Code. The Department of Insurance shall | ||||||
| 14 | enforce the requirements of this Section. The requirement that | ||||||
| 15 | health
benefits be covered as provided in this is an exclusive | ||||||
| 16 | power and function of
the State and is a denial and limitation | ||||||
| 17 | under Article VII, Section 6,
subsection (h) of the Illinois | ||||||
| 18 | Constitution. A home rule municipality to which
this Section | ||||||
| 19 | applies must comply with every provision of this Section.
| ||||||
| 20 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
| 21 | any, is conditioned on the rules being adopted in accordance | ||||||
| 22 | with all provisions of the Illinois Administrative Procedure | ||||||
| 23 | Act and all rules and procedures of the Joint Committee on | ||||||
| 24 | Administrative Rules; any purported rule not so adopted, for | ||||||
| 25 | whatever reason, is unauthorized. | ||||||
| 26 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
| |||||||
| |||||||
| 1 | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
| 2 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
| 3 | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | ||||||
| 4 | revised 10-16-19.)
| ||||||
| 5 | (Text of Section after amendment by P.A. 101-625) | ||||||
| 6 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
| 7 | municipality, including a
home rule municipality, is a | ||||||
| 8 | self-insurer for purposes of providing health
insurance | ||||||
| 9 | coverage for its employees, the coverage shall include coverage | ||||||
| 10 | for
the post-mastectomy care benefits required to be covered by | ||||||
| 11 | a policy of
accident and health insurance under Section 356t | ||||||
| 12 | and the coverage required
under Sections 356g, 356g.5, | ||||||
| 13 | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
| 14 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | ||||||
| 15 | 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, and | ||||||
| 16 | 356z.41, and 356z.43 of the Illinois
Insurance
Code. The | ||||||
| 17 | coverage shall comply with Sections 155.22a, 355b, 356z.19, and | ||||||
| 18 | 370c of
the Illinois Insurance Code. The Department of | ||||||
| 19 | Insurance shall enforce the requirements of this Section. The | ||||||
| 20 | requirement that health
benefits be covered as provided in this | ||||||
| 21 | is an exclusive power and function of
the State and is a denial | ||||||
| 22 | and limitation under Article VII, Section 6,
subsection (h) of | ||||||
| 23 | the Illinois Constitution. A home rule municipality to which
| ||||||
| 24 | this Section applies must comply with every provision of this | ||||||
| 25 | Section.
| ||||||
| |||||||
| |||||||
| 1 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
| 2 | any, is conditioned on the rules being adopted in accordance | ||||||
| 3 | with all provisions of the Illinois Administrative Procedure | ||||||
| 4 | Act and all rules and procedures of the Joint Committee on | ||||||
| 5 | Administrative Rules; any purported rule not so adopted, for | ||||||
| 6 | whatever reason, is unauthorized. | ||||||
| 7 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
| 8 | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | ||||||
| 9 | 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19; 101-281, | ||||||
| 10 | eff. 1-1-20; 101-393, eff. 1-1-20; 101-461, eff. 1-1-20; | ||||||
| 11 | 101-625, eff. 1-1-21.)
| ||||||
| 12 | Section 15. The Illinois Insurance Code is amended by | ||||||
| 13 | adding Section 356z.43 as follows:
| ||||||
| 14 | (215 ILCS 5/356z.43 new) | ||||||
| 15 | Sec. 356z.43. Colonoscopy coverage. | ||||||
| 16 | (a) A group policy of accident and health insurance that is | ||||||
| 17 | amended, delivered, issued, or renewed on or after January 1, | ||||||
| 18 | 2021 shall provide coverage for a colonoscopy that is a | ||||||
| 19 | follow-up exam based on an initial screen where the colonoscopy | ||||||
| 20 | was determined to be medically necessary by a physician | ||||||
| 21 | licensed to practice medicine in all its branches, an advanced | ||||||
| 22 | practice registered nurse, or a physician assistant. | ||||||
| 23 | (b) A policy subject to this Section shall not impose a | ||||||
| 24 | deductible, coinsurance, copayment, or any other cost-sharing | ||||||
| |||||||
| |||||||
| 1 | requirement on the coverage provided; except that this | ||||||
| 2 | subsection does not apply to coverage of colonoscopies to the | ||||||
| 3 | extent such coverage would disqualify a high-deductible health | ||||||
| 4 | plan from eligibility for a health savings account pursuant to | ||||||
| 5 | Section 223 of the Internal Revenue Code.
| ||||||
| 6 | Section 20. The Health Maintenance Organization Act is | ||||||
| 7 | amended by changing Section 5-3 as follows:
| ||||||
| 8 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
| 9 | (Text of Section before amendment by P.A. 101-625) | ||||||
| 10 | Sec. 5-3. Insurance Code provisions.
| ||||||
| 11 | (a) Health Maintenance Organizations
shall be subject to | ||||||
| 12 | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| ||||||
| 13 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | ||||||
| 14 | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | ||||||
| 15 | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | ||||||
| 16 | 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | ||||||
| 17 | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, | ||||||
| 18 | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | ||||||
| 19 | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.43, 364, | ||||||
| 20 | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | ||||||
| 21 | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | ||||||
| 22 | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | ||||||
| 23 | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | ||||||
| 24 | XXVI, and XXXIIB of the Illinois Insurance Code.
| ||||||
| |||||||
| |||||||
| 1 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
| 2 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
| 3 | Maintenance Organizations in
the following categories are | ||||||
| 4 | deemed to be "domestic companies":
| ||||||
| 5 | (1) a corporation authorized under the
Dental Service | ||||||
| 6 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
| 7 | (2) a corporation organized under the laws of this | ||||||
| 8 | State; or
| ||||||
| 9 | (3) a corporation organized under the laws of another | ||||||
| 10 | state, 30% or more
of the enrollees of which are residents | ||||||
| 11 | of this State, except a
corporation subject to | ||||||
| 12 | substantially the same requirements in its state of
| ||||||
| 13 | organization as is a "domestic company" under Article VIII | ||||||
| 14 | 1/2 of the
Illinois Insurance Code.
| ||||||
| 15 | (c) In considering the merger, consolidation, or other | ||||||
| 16 | acquisition of
control of a Health Maintenance Organization | ||||||
| 17 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
| 18 | (1) the Director shall give primary consideration to | ||||||
| 19 | the continuation of
benefits to enrollees and the financial | ||||||
| 20 | conditions of the acquired Health
Maintenance Organization | ||||||
| 21 | after the merger, consolidation, or other
acquisition of | ||||||
| 22 | control takes effect;
| ||||||
| 23 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
| 24 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
| 25 | apply and (ii) the Director, in making
his determination | ||||||
| 26 | with respect to the merger, consolidation, or other
| ||||||
| |||||||
| |||||||
| 1 | acquisition of control, need not take into account the | ||||||
| 2 | effect on
competition of the merger, consolidation, or | ||||||
| 3 | other acquisition of control;
| ||||||
| 4 | (3) the Director shall have the power to require the | ||||||
| 5 | following
information:
| ||||||
| 6 | (A) certification by an independent actuary of the | ||||||
| 7 | adequacy
of the reserves of the Health Maintenance | ||||||
| 8 | Organization sought to be acquired;
| ||||||
| 9 | (B) pro forma financial statements reflecting the | ||||||
| 10 | combined balance
sheets of the acquiring company and | ||||||
| 11 | the Health Maintenance Organization sought
to be | ||||||
| 12 | acquired as of the end of the preceding year and as of | ||||||
| 13 | a date 90 days
prior to the acquisition, as well as pro | ||||||
| 14 | forma financial statements
reflecting projected | ||||||
| 15 | combined operation for a period of 2 years;
| ||||||
| 16 | (C) a pro forma business plan detailing an | ||||||
| 17 | acquiring party's plans with
respect to the operation | ||||||
| 18 | of the Health Maintenance Organization sought to
be | ||||||
| 19 | acquired for a period of not less than 3 years; and
| ||||||
| 20 | (D) such other information as the Director shall | ||||||
| 21 | require.
| ||||||
| 22 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
| 23 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
| 24 | any health maintenance
organization of greater than 10% of its
| ||||||
| 25 | enrollee population (including without limitation the health | ||||||
| 26 | maintenance
organization's right, title, and interest in and to | ||||||
| |||||||
| |||||||
| 1 | its health care
certificates).
| ||||||
| 2 | (e) In considering any management contract or service | ||||||
| 3 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
| 4 | Code, the Director (i) shall, in
addition to the criteria | ||||||
| 5 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
| 6 | into account the effect of the management contract or
service | ||||||
| 7 | agreement on the continuation of benefits to enrollees and the
| ||||||
| 8 | financial condition of the health maintenance organization to | ||||||
| 9 | be managed or
serviced, and (ii) need not take into account the | ||||||
| 10 | effect of the management
contract or service agreement on | ||||||
| 11 | competition.
| ||||||
| 12 | (f) Except for small employer groups as defined in the | ||||||
| 13 | Small Employer
Rating, Renewability and Portability Health | ||||||
| 14 | Insurance Act and except for
medicare supplement policies as | ||||||
| 15 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
| 16 | Maintenance Organization may by contract agree with a
group or | ||||||
| 17 | other enrollment unit to effect refunds or charge additional | ||||||
| 18 | premiums
under the following terms and conditions:
| ||||||
| 19 | (i) the amount of, and other terms and conditions with | ||||||
| 20 | respect to, the
refund or additional premium are set forth | ||||||
| 21 | in the group or enrollment unit
contract agreed in advance | ||||||
| 22 | of the period for which a refund is to be paid or
| ||||||
| 23 | additional premium is to be charged (which period shall not | ||||||
| 24 | be less than one
year); and
| ||||||
| 25 | (ii) the amount of the refund or additional premium | ||||||
| 26 | shall not exceed 20%
of the Health Maintenance | ||||||
| |||||||
| |||||||
| 1 | Organization's profitable or unprofitable experience
with | ||||||
| 2 | respect to the group or other enrollment unit for the | ||||||
| 3 | period (and, for
purposes of a refund or additional | ||||||
| 4 | premium, the profitable or unprofitable
experience shall | ||||||
| 5 | be calculated taking into account a pro rata share of the
| ||||||
| 6 | Health Maintenance Organization's administrative and | ||||||
| 7 | marketing expenses, but
shall not include any refund to be | ||||||
| 8 | made or additional premium to be paid
pursuant to this | ||||||
| 9 | subsection (f)). The Health Maintenance Organization and | ||||||
| 10 | the
group or enrollment unit may agree that the profitable | ||||||
| 11 | or unprofitable
experience may be calculated taking into | ||||||
| 12 | account the refund period and the
immediately preceding 2 | ||||||
| 13 | plan years.
| ||||||
| 14 | The Health Maintenance Organization shall include a | ||||||
| 15 | statement in the
evidence of coverage issued to each enrollee | ||||||
| 16 | describing the possibility of a
refund or additional premium, | ||||||
| 17 | and upon request of any group or enrollment unit,
provide to | ||||||
| 18 | the group or enrollment unit a description of the method used | ||||||
| 19 | to
calculate (1) the Health Maintenance Organization's | ||||||
| 20 | profitable experience with
respect to the group or enrollment | ||||||
| 21 | unit and the resulting refund to the group
or enrollment unit | ||||||
| 22 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
| 23 | experience with respect to the group or enrollment unit and the | ||||||
| 24 | resulting
additional premium to be paid by the group or | ||||||
| 25 | enrollment unit.
| ||||||
| 26 | In no event shall the Illinois Health Maintenance | ||||||
| |||||||
| |||||||
| 1 | Organization
Guaranty Association be liable to pay any | ||||||
| 2 | contractual obligation of an
insolvent organization to pay any | ||||||
| 3 | refund authorized under this Section.
| ||||||
| 4 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
| 5 | if any, is conditioned on the rules being adopted in accordance | ||||||
| 6 | with all provisions of the Illinois Administrative Procedure | ||||||
| 7 | Act and all rules and procedures of the Joint Committee on | ||||||
| 8 | Administrative Rules; any purported rule not so adopted, for | ||||||
| 9 | whatever reason, is unauthorized. | ||||||
| 10 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
| 11 | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | ||||||
| 12 | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | ||||||
| 13 | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | ||||||
| 14 | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | ||||||
| 15 | 1-1-20; revised 10-16-19.)
| ||||||
| 16 | (Text of Section after amendment by P.A. 101-625) | ||||||
| 17 | Sec. 5-3. Insurance Code provisions.
| ||||||
| 18 | (a) Health Maintenance Organizations
shall be subject to | ||||||
| 19 | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| ||||||
| 20 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | ||||||
| 21 | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | ||||||
| 22 | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | ||||||
| 23 | 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | ||||||
| 24 | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, | ||||||
| 25 | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | ||||||
| |||||||
| |||||||
| 1 | 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36, 356z.41, | ||||||
| 2 | 356z.43, 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
| 3 | 368d, 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, | ||||||
| 4 | 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of subsection | ||||||
| 5 | (2) of Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, | ||||||
| 6 | XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the Illinois Insurance | ||||||
| 7 | Code.
| ||||||
| 8 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
| 9 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
| 10 | Maintenance Organizations in
the following categories are | ||||||
| 11 | deemed to be "domestic companies":
| ||||||
| 12 | (1) a corporation authorized under the
Dental Service | ||||||
| 13 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
| 14 | (2) a corporation organized under the laws of this | ||||||
| 15 | State; or
| ||||||
| 16 | (3) a corporation organized under the laws of another | ||||||
| 17 | state, 30% or more
of the enrollees of which are residents | ||||||
| 18 | of this State, except a
corporation subject to | ||||||
| 19 | substantially the same requirements in its state of
| ||||||
| 20 | organization as is a "domestic company" under Article VIII | ||||||
| 21 | 1/2 of the
Illinois Insurance Code.
| ||||||
| 22 | (c) In considering the merger, consolidation, or other | ||||||
| 23 | acquisition of
control of a Health Maintenance Organization | ||||||
| 24 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
| 25 | (1) the Director shall give primary consideration to | ||||||
| 26 | the continuation of
benefits to enrollees and the financial | ||||||
| |||||||
| |||||||
| 1 | conditions of the acquired Health
Maintenance Organization | ||||||
| 2 | after the merger, consolidation, or other
acquisition of | ||||||
| 3 | control takes effect;
| ||||||
| 4 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
| 5 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
| 6 | apply and (ii) the Director, in making
his determination | ||||||
| 7 | with respect to the merger, consolidation, or other
| ||||||
| 8 | acquisition of control, need not take into account the | ||||||
| 9 | effect on
competition of the merger, consolidation, or | ||||||
| 10 | other acquisition of control;
| ||||||
| 11 | (3) the Director shall have the power to require the | ||||||
| 12 | following
information:
| ||||||
| 13 | (A) certification by an independent actuary of the | ||||||
| 14 | adequacy
of the reserves of the Health Maintenance | ||||||
| 15 | Organization sought to be acquired;
| ||||||
| 16 | (B) pro forma financial statements reflecting the | ||||||
| 17 | combined balance
sheets of the acquiring company and | ||||||
| 18 | the Health Maintenance Organization sought
to be | ||||||
| 19 | acquired as of the end of the preceding year and as of | ||||||
| 20 | a date 90 days
prior to the acquisition, as well as pro | ||||||
| 21 | forma financial statements
reflecting projected | ||||||
| 22 | combined operation for a period of 2 years;
| ||||||
| 23 | (C) a pro forma business plan detailing an | ||||||
| 24 | acquiring party's plans with
respect to the operation | ||||||
| 25 | of the Health Maintenance Organization sought to
be | ||||||
| 26 | acquired for a period of not less than 3 years; and
| ||||||
| |||||||
| |||||||
| 1 | (D) such other information as the Director shall | ||||||
| 2 | require.
| ||||||
| 3 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
| 4 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
| 5 | any health maintenance
organization of greater than 10% of its
| ||||||
| 6 | enrollee population (including without limitation the health | ||||||
| 7 | maintenance
organization's right, title, and interest in and to | ||||||
| 8 | its health care
certificates).
| ||||||
| 9 | (e) In considering any management contract or service | ||||||
| 10 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
| 11 | Code, the Director (i) shall, in
addition to the criteria | ||||||
| 12 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
| 13 | into account the effect of the management contract or
service | ||||||
| 14 | agreement on the continuation of benefits to enrollees and the
| ||||||
| 15 | financial condition of the health maintenance organization to | ||||||
| 16 | be managed or
serviced, and (ii) need not take into account the | ||||||
| 17 | effect of the management
contract or service agreement on | ||||||
| 18 | competition.
| ||||||
| 19 | (f) Except for small employer groups as defined in the | ||||||
| 20 | Small Employer
Rating, Renewability and Portability Health | ||||||
| 21 | Insurance Act and except for
medicare supplement policies as | ||||||
| 22 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
| 23 | Maintenance Organization may by contract agree with a
group or | ||||||
| 24 | other enrollment unit to effect refunds or charge additional | ||||||
| 25 | premiums
under the following terms and conditions:
| ||||||
| 26 | (i) the amount of, and other terms and conditions with | ||||||
| |||||||
| |||||||
| 1 | respect to, the
refund or additional premium are set forth | ||||||
| 2 | in the group or enrollment unit
contract agreed in advance | ||||||
| 3 | of the period for which a refund is to be paid or
| ||||||
| 4 | additional premium is to be charged (which period shall not | ||||||
| 5 | be less than one
year); and
| ||||||
| 6 | (ii) the amount of the refund or additional premium | ||||||
| 7 | shall not exceed 20%
of the Health Maintenance | ||||||
| 8 | Organization's profitable or unprofitable experience
with | ||||||
| 9 | respect to the group or other enrollment unit for the | ||||||
| 10 | period (and, for
purposes of a refund or additional | ||||||
| 11 | premium, the profitable or unprofitable
experience shall | ||||||
| 12 | be calculated taking into account a pro rata share of the
| ||||||
| 13 | Health Maintenance Organization's administrative and | ||||||
| 14 | marketing expenses, but
shall not include any refund to be | ||||||
| 15 | made or additional premium to be paid
pursuant to this | ||||||
| 16 | subsection (f)). The Health Maintenance Organization and | ||||||
| 17 | the
group or enrollment unit may agree that the profitable | ||||||
| 18 | or unprofitable
experience may be calculated taking into | ||||||
| 19 | account the refund period and the
immediately preceding 2 | ||||||
| 20 | plan years.
| ||||||
| 21 | The Health Maintenance Organization shall include a | ||||||
| 22 | statement in the
evidence of coverage issued to each enrollee | ||||||
| 23 | describing the possibility of a
refund or additional premium, | ||||||
| 24 | and upon request of any group or enrollment unit,
provide to | ||||||
| 25 | the group or enrollment unit a description of the method used | ||||||
| 26 | to
calculate (1) the Health Maintenance Organization's | ||||||
| |||||||
| |||||||
| 1 | profitable experience with
respect to the group or enrollment | ||||||
| 2 | unit and the resulting refund to the group
or enrollment unit | ||||||
| 3 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
| 4 | experience with respect to the group or enrollment unit and the | ||||||
| 5 | resulting
additional premium to be paid by the group or | ||||||
| 6 | enrollment unit.
| ||||||
| 7 | In no event shall the Illinois Health Maintenance | ||||||
| 8 | Organization
Guaranty Association be liable to pay any | ||||||
| 9 | contractual obligation of an
insolvent organization to pay any | ||||||
| 10 | refund authorized under this Section.
| ||||||
| 11 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
| 12 | if any, is conditioned on the rules being adopted in accordance | ||||||
| 13 | with all provisions of the Illinois Administrative Procedure | ||||||
| 14 | Act and all rules and procedures of the Joint Committee on | ||||||
| 15 | Administrative Rules; any purported rule not so adopted, for | ||||||
| 16 | whatever reason, is unauthorized. | ||||||
| 17 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
| 18 | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | ||||||
| 19 | 1-1-19; 100-1102, eff. 1-1-19; 101-13, eff. 6-12-19; 101-81, | ||||||
| 20 | eff. 7-12-19; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; | ||||||
| 21 | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | ||||||
| 22 | 1-1-20; 101-625, eff. 1-1-21.)
| ||||||
| 23 | Section 95. No acceleration or delay. Where this Act makes | ||||||
| 24 | changes in a statute that is represented in this Act by text | ||||||
| 25 | that is not yet or no longer in effect (for example, a Section | ||||||
| |||||||
| |||||||
| 1 | represented by multiple versions), the use of that text does | ||||||
| 2 | not accelerate or delay the taking effect of (i) the changes | ||||||
| 3 | made by this Act or (ii) provisions derived from any other | ||||||
| 4 | Public Act.
| ||||||
| 5 | Section 99. Effective date. This Act takes effect January | ||||||
| 6 | 1, 2021.
| ||||||
