Bill Text: IL SB3091 | 2013-2014 | 98th General Assembly | Introduced
Bill Title: Amends the Illinois Insurance Code, Health Maintenance Organization Act, Limited Health Service Organization Act, and Voluntary Health Services Plans Act. Provides that no insurer may issue a service provider contract that requires an optometrist or ophthalmologist to provide services or materials to the insurer's policyholders at a fee set by the insurer unless the services or materials are covered services or materials under the applicable policyholder agreement. Provides that de minimis reimbursements shall not qualify a service or material as a covered service or material.
Spectrum: Slight Partisan Bill (Democrat 2-1)
Status: (Failed) 2015-01-13 - Session Sine Die [SB3091 Detail]
Download: Illinois-2013-SB3091-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 Illinois Insurance Code is amended by adding | |||||||||||||||||||||||||
5 | Section 355.4 as follows:
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6 | (215 ILCS 5/355.4 new) | |||||||||||||||||||||||||
7 | Sec. 355.4. Noncovered vision services. | |||||||||||||||||||||||||
8 | (a) In this Section: | |||||||||||||||||||||||||
9 | "Covered services" means vision care services for | |||||||||||||||||||||||||
10 | which a reimbursement is available under an
enrollee's plan | |||||||||||||||||||||||||
11 | contract, or for which a reimbursement would be available | |||||||||||||||||||||||||
12 | but for the application of
contractual limitations such as | |||||||||||||||||||||||||
13 | deductibles, copayments, coinsurance, waiting periods, | |||||||||||||||||||||||||
14 | annual or
lifetime maximums, frequency limitations, | |||||||||||||||||||||||||
15 | alternative benefit payments, or any other limitation. | |||||||||||||||||||||||||
16 | "Vision insurance" means any policy of insurance that | |||||||||||||||||||||||||
17 | is issued by a company that provides coverage for vision | |||||||||||||||||||||||||
18 | services not covered by a medical plan. | |||||||||||||||||||||||||
19 | "Materials" includes, but is not limited to, lenses, | |||||||||||||||||||||||||
20 | devices containing lenses, prisms, lens treatments and | |||||||||||||||||||||||||
21 | coatings, contact lenses, and prosthetic devices to | |||||||||||||||||||||||||
22 | correct, relieve, or treat defects or abnormal conditions | |||||||||||||||||||||||||
23 | of the human eye or its adnexa. |
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1 | (b) No company that issues, delivers, amends, or renews an | ||||||
2 | individual or group policy of accident and health insurance on | ||||||
3 | or after the effective date of this amendatory Act of the 98th | ||||||
4 | General Assembly that provides vision insurance or eye health | ||||||
5 | care coverage shall issue a service provider contract that | ||||||
6 | requires an optometrist or ophthalmologist to provide services | ||||||
7 | or materials to the insurer's policyholders at a fee set by the | ||||||
8 | insurer unless the services or materials are covered services | ||||||
9 | or materials under the applicable policyholder agreement. De | ||||||
10 | minimis reimbursements shall not qualify a service or material | ||||||
11 | as a covered service or material under this Section.
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12 | Section 10. The Health Maintenance Organization Act is | ||||||
13 | amended by changing Section 5-3 as follows:
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14 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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15 | Sec. 5-3. Insurance Code provisions.
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16 | (a) Health Maintenance Organizations
shall be subject to | ||||||
17 | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
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18 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | ||||||
19 | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | ||||||
20 | 355.4, 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, | ||||||
21 | 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, | ||||||
22 | 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, | ||||||
23 | 356z.21, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | ||||||
24 | 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, |
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1 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
2 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
3 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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4 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
5 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
6 | Maintenance Organizations in
the following categories are | ||||||
7 | deemed to be "domestic companies":
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8 | (1) a corporation authorized under the
Dental Service | ||||||
9 | Plan Act or the Voluntary Health Services Plans Act;
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10 | (2) a corporation organized under the laws of this | ||||||
11 | State; or
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12 | (3) a corporation organized under the laws of another | ||||||
13 | state, 30% or more
of the enrollees of which are residents | ||||||
14 | of this State, except a
corporation subject to | ||||||
15 | substantially the same requirements in its state of
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16 | organization as is a "domestic company" under Article VIII | ||||||
17 | 1/2 of the
Illinois Insurance Code.
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18 | (c) In considering the merger, consolidation, or other | ||||||
19 | acquisition of
control of a Health Maintenance Organization | ||||||
20 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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21 | (1) the Director shall give primary consideration to | ||||||
22 | the continuation of
benefits to enrollees and the financial | ||||||
23 | conditions of the acquired Health
Maintenance Organization | ||||||
24 | after the merger, consolidation, or other
acquisition of | ||||||
25 | control takes effect;
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26 | (2)(i) the criteria specified in subsection (1)(b) of |
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1 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
2 | apply and (ii) the Director, in making
his determination | ||||||
3 | with respect to the merger, consolidation, or other
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4 | acquisition of control, need not take into account the | ||||||
5 | effect on
competition of the merger, consolidation, or | ||||||
6 | other acquisition of control;
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7 | (3) the Director shall have the power to require the | ||||||
8 | following
information:
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9 | (A) certification by an independent actuary of the | ||||||
10 | adequacy
of the reserves of the Health Maintenance | ||||||
11 | Organization sought to be acquired;
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12 | (B) pro forma financial statements reflecting the | ||||||
13 | combined balance
sheets of the acquiring company and | ||||||
14 | the Health Maintenance Organization sought
to be | ||||||
15 | acquired as of the end of the preceding year and as of | ||||||
16 | a date 90 days
prior to the acquisition, as well as pro | ||||||
17 | forma financial statements
reflecting projected | ||||||
18 | combined operation for a period of 2 years;
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19 | (C) a pro forma business plan detailing an | ||||||
20 | acquiring party's plans with
respect to the operation | ||||||
21 | of the Health Maintenance Organization sought to
be | ||||||
22 | acquired for a period of not less than 3 years; and
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23 | (D) such other information as the Director shall | ||||||
24 | require.
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25 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
26 | Insurance Code
and this Section 5-3 shall apply to the sale by |
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1 | any health maintenance
organization of greater than 10% of its
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2 | enrollee population (including without limitation the health | ||||||
3 | maintenance
organization's right, title, and interest in and to | ||||||
4 | its health care
certificates).
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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, take | ||||||
9 | into account the effect of the management contract or
service | ||||||
10 | agreement on the continuation of benefits to enrollees and the
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11 | financial condition of the health maintenance organization to | ||||||
12 | be managed or
serviced, and (ii) need not take into account the | ||||||
13 | effect of the management
contract or service agreement on | ||||||
14 | competition.
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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 Health | ||||||
19 | Maintenance Organization may by contract agree with a
group or | ||||||
20 | other enrollment unit to effect refunds or charge additional | ||||||
21 | premiums
under the following terms and conditions:
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22 | (i) the amount of, and other terms and conditions with | ||||||
23 | respect to, the
refund or additional premium are set forth | ||||||
24 | in the group or enrollment unit
contract agreed in advance | ||||||
25 | of the period for which a refund is to be paid or
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26 | additional premium is to be charged (which period shall not |
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1 | be less than one
year); and
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2 | (ii) the amount of the refund or additional premium | ||||||
3 | shall not exceed 20%
of the Health Maintenance | ||||||
4 | Organization's profitable or unprofitable experience
with | ||||||
5 | respect to the group or other enrollment unit for the | ||||||
6 | period (and, for
purposes of a refund or additional | ||||||
7 | premium, the profitable or unprofitable
experience shall | ||||||
8 | be calculated taking into account a pro rata share of the
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9 | Health Maintenance Organization's administrative and | ||||||
10 | marketing expenses, but
shall not include any refund to be | ||||||
11 | made or additional premium to be paid
pursuant to this | ||||||
12 | subsection (f)). The Health Maintenance Organization and | ||||||
13 | the
group or enrollment unit may agree that the profitable | ||||||
14 | or unprofitable
experience may be calculated taking into | ||||||
15 | account the refund period and the
immediately preceding 2 | ||||||
16 | plan years.
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17 | The Health Maintenance Organization shall include a | ||||||
18 | statement in the
evidence of coverage issued to each enrollee | ||||||
19 | describing the possibility of a
refund or additional premium, | ||||||
20 | and upon request of any group or enrollment unit,
provide to | ||||||
21 | the group or enrollment unit a description of the method used | ||||||
22 | to
calculate (1) the Health Maintenance Organization's | ||||||
23 | profitable experience with
respect to the group or enrollment | ||||||
24 | unit and the resulting refund to the group
or enrollment unit | ||||||
25 | or (2) the Health Maintenance Organization's unprofitable
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26 | experience with respect to the group or enrollment unit and the |
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1 | resulting
additional premium to be paid by the group or | ||||||
2 | enrollment unit.
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3 | In no event shall the Illinois Health Maintenance | ||||||
4 | Organization
Guaranty Association be liable to pay any | ||||||
5 | contractual obligation of an
insolvent organization to pay any | ||||||
6 | refund authorized under this Section.
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7 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
8 | if any, is conditioned on the rules being adopted in accordance | ||||||
9 | with all provisions of the Illinois Administrative Procedure | ||||||
10 | Act and all rules and procedures of the Joint Committee on | ||||||
11 | Administrative Rules; any purported rule not so adopted, for | ||||||
12 | whatever reason, is unauthorized. | ||||||
13 | (Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437, | ||||||
14 | eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, | ||||||
15 | eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)
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16 | Section 15. The Limited Health Service Organization Act is | ||||||
17 | amended by changing Section 4003 as follows:
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18 | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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19 | Sec. 4003. Illinois Insurance Code provisions. Limited | ||||||
20 | health service
organizations shall be subject to the provisions | ||||||
21 | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | ||||||
22 | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | ||||||
23 | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355.4, 355b, 356v, | ||||||
24 | 356z.10, 356z.21, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, |
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1 | 409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII | ||||||
2 | 1/2,
XIII,
XIII 1/2, XXV, and XXVI of the Illinois Insurance | ||||||
3 | Code. For purposes of the
Illinois Insurance Code, except for | ||||||
4 | Sections 444 and 444.1 and Articles XIII
and XIII 1/2, limited | ||||||
5 | health service organizations in the following categories
are | ||||||
6 | deemed to be domestic companies:
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7 | (1) a corporation under the laws of this State; or
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8 | (2) a corporation organized under the laws of another | ||||||
9 | state, 30% of more
of the enrollees of which are residents | ||||||
10 | of this State, except a corporation
subject to | ||||||
11 | substantially the same requirements in its state of | ||||||
12 | organization as
is a domestic company under Article VIII | ||||||
13 | 1/2 of the Illinois Insurance Code.
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14 | (Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff. | ||||||
15 | 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14.)
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16 | Section 20. The Voluntary Health Services Plans Act is | ||||||
17 | amended by changing Section 10 as follows:
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18 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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19 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
20 | services
plan corporations and all persons interested therein | ||||||
21 | or dealing therewith
shall be subject to the provisions of | ||||||
22 | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | ||||||
23 | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355.4, | ||||||
24 | 355b, 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, |
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1 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||||||
2 | 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, | ||||||
3 | 356z.18, 356z.19, 356z.21, 364.01, 367.2, 368a, 401, 401.1,
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4 | 402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) and | ||||||
5 | (15) of Section 367 of the Illinois
Insurance Code.
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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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486, | ||||||
13 | eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, | ||||||
14 | eff. 7-13-12; 98-189, eff. 1-1-14.)
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