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| Public Act 097-0805
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| SB3242 Enrolled | LRB097 13788 RPM 58347 b |
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by adding |
Section 355.3 as follows:
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(215 ILCS 5/355.3 new) |
Sec. 355.3. Noncovered dental services. |
(a) In this Section: |
"Covered services" means dental care services for |
which a reimbursement is available under an
enrollee's plan |
contract, or for which a reimbursement would be available |
but for the application of
contractual limitations such as |
deductibles, copayments, coinsurance, waiting periods, |
annual or
lifetime maximums, frequency limitations, |
alternative benefit payments, or any other limitation. |
"Dental insurance" means any policy of insurance that |
is issued by a company that provides coverage for dental |
services not covered by a medical plan. |
(b) No company that issues, delivers, amends, or renews an |
individual or group policy of accident and health insurance on |
or after the effective date of this amendatory Act of the 97th |
General Assembly that provides dental insurance shall issue a |
service provider contract that requires a dentist to provide |
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services to the insurer's policyholders at a fee set by the |
insurer unless the services are covered services under the |
applicable policyholder agreement.
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Section 10. The Dental Service Plan Act is amended by |
changing Section 25 as follows:
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(215 ILCS 110/25) (from Ch. 32, par. 690.25)
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Sec. 25. Application of Insurance Code provisions. Dental |
service
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, 136, 139, 140, |
143, 143c, 149, 355.2, 355.3, 367.2, 401, 401.1, 402, 403, |
403A, 408,
408.2, and 412, and subsection (15) of Section 367 |
of the Illinois Insurance
Code.
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(Source: P.A. 97-486, eff. 1-1-12.)
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Section 15. 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, 136, 137, 139, 140, 141.1,
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141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, |
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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, 356z.21 356z.19, |
364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, |
370c,
370c.1, 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 |
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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 |
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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 |
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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. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
96-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; |
97-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12; |
97-592, eff. 1-1-12; revised 10-13-11.)
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Section 20. 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, 136, 137, 139,
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, 355.3, 356v, 356z.10, |
356z.21 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
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. 97-486, eff. 1-1-12; 97-592, 1-1-12; revised |
10-13-11.)
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Section 25. 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, 136, 139, 140, |
143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 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,
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356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, |
356z.19, 356z.21 356z.19, 364.01, 367.2, 368a, 401, 401.1,
402,
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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. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; |
96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
97-486, eff. 1-1-12; 97-592, eff. 1-1-12; revised 10-13-11.)
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Section 99. Effective date. This Act takes effect January |
1, 2013.
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