Sen. Heather A. Steans

Filed: 4/11/2011

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 673

2    AMENDMENT NO. ______. Amend Senate Bill 673 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.16 and adding Section 356z.19 as follows:
 
6    (215 ILCS 5/356z.16)
7    Sec. 356z.16. Applicability of mandated benefits to
8supplemental policies. Unless specified otherwise, the
9following Sections of the Illinois Insurance Code do not apply
10to short-term travel, disability income, long-term care,
11accident only, or limited or specified disease policies: 356b,
12356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t,
13356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
14356z.8, 356z.12, 356z.19, 367.2-5, and 367e.
15(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10;
1696-1034, eff. 1-1-11.)
 

 

 

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1    (215 ILCS 5/356z.19 new)
2    Sec. 356z.19. Tobacco use cessation programs; coverage
3offer.
4    (a) Tobacco use is the number one cause of preventable
5disease and death in Illinois, costing $4.1 billion annually in
6direct health care costs and an additional $4.35 billion in
7lost productivity. In Illinois, the smoking rates are highest
8among African Americans (25.8%). Smoking rates among lesbian,
9gay, and bisexual adults range from 25% to 44%. The U.S. Public
10Health Service Clinical Practice Guideline 2008 Update found
11that tobacco dependence treatments are both clinically
12effective and highly cost effective. A study in the Journal of
13Preventive Medicine concluded that comprehensive smoking
14cessation treatment is one of the 3 most important and cost
15effective preventive services that can be provided in medical
16practice. Greater efforts are needed to achieve more of this
17potential value by increasing current low levels of
18performance.
19    (b) In this Section, "tobacco use cessation program" means
20a program recommended by a physician that follows
21evidence-based treatment, such as is outlined in the United
22States Public Health Service guidelines for tobacco use
23cessation. "Tobacco use cessation program" includes education
24and medical treatment components designed to assist a person in
25ceasing the use of tobacco products. "Tobacco use cessation

 

 

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1program" includes education and counseling by physicians or
2associated medical personnel and all FDA approved medications
3for the treatment of tobacco dependence irrespective of whether
4they are available only over the counter, only by prescription,
5or both over the counter and by prescription.
6    (c) On or after the effective date of this amendatory Act
7of the 97th General Assembly, every insurer that amends,
8delivers, issues, or renews group accident and health policies
9providing coverage for hospital or medical treatment or
10services on an expense-incurred basis shall offer, for an
11additional premium and subject to the insurer's standard of
12insurability, optional coverage or optional reimbursement of
13up to $500 annually for a tobacco use cessation program for a
14person enrolled in the plan who is 18 years of age or older.
15    (d) The coverage required by this Section shall be subject
16to other general exclusions and limitations of the policy,
17including coordination of benefits, participating provider
18requirements, restrictions on services provided by family or
19household members, utilization review of health care services,
20including review of medical necessity, case management,
21experimental and investigational treatments, and other managed
22care provisions.
23    (e) For the coverage provided under this Section, an
24insurer may not penalize or reduce or limit the reimbursement
25of an attending provider or provide incentives, monetary or
26otherwise, to an attending provider to induce the provider to

 

 

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1provide care to an insured in a manner inconsistent with the
2coverage under this Section.
 
3    Section 10. The Health Maintenance Organization Act is
4amended by changing Section 5-3 as follows:
 
5    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
6    Sec. 5-3. Insurance Code provisions.
7    (a) Health Maintenance Organizations shall be subject to
8the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
9141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
10154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
11356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
12356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
13356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
14368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
15409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
16Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
17XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
18    (b) For purposes of the Illinois Insurance Code, except for
19Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
20Maintenance Organizations in the following categories are
21deemed to be "domestic companies":
22        (1) a corporation authorized under the Dental Service
23    Plan Act or the Voluntary Health Services Plans Act;
24        (2) a corporation organized under the laws of this

 

 

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1    State; or
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
6    organization as is a "domestic company" under Article VIII
7    1/2 of the Illinois Insurance Code.
8    (c) In considering the merger, consolidation, or other
9acquisition of control of a Health Maintenance Organization
10pursuant to Article VIII 1/2 of the Illinois Insurance Code,
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;
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
20    acquisition of control, need not take into account the
21    effect on competition of the merger, consolidation, or
22    other acquisition of control;
23        (3) the Director shall have the power to require the
24    following information:
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;
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;
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
13            (D) such other information as the Director shall
14        require.
15    (d) The provisions of Article VIII 1/2 of the Illinois
16Insurance Code and this Section 5-3 shall apply to the sale by
17any health maintenance organization of greater than 10% of its
18enrollee population (including without limitation the health
19maintenance organization's right, title, and interest in and to
20its health care certificates).
21    (e) In considering any management contract or service
22agreement subject to Section 141.1 of the Illinois Insurance
23Code, the Director (i) shall, in addition to the criteria
24specified in Section 141.2 of the Illinois Insurance Code, take
25into account the effect of the management contract or service
26agreement on the continuation of benefits to enrollees and the

 

 

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1financial condition of the health maintenance organization to
2be managed or serviced, and (ii) need not take into account the
3effect of the management contract or service agreement on
4competition.
5    (f) Except for small employer groups as defined in the
6Small Employer Rating, Renewability and Portability Health
7Insurance Act and except for medicare supplement policies as
8defined in Section 363 of the Illinois Insurance Code, a Health
9Maintenance Organization may by contract agree with a group or
10other enrollment unit to effect refunds or charge additional
11premiums under the following terms and conditions:
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
16    additional premium is to be charged (which period shall not
17    be less than one year); and
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
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.
7    The Health Maintenance Organization shall include a
8statement in the evidence of coverage issued to each enrollee
9describing the possibility of a refund or additional premium,
10and upon request of any group or enrollment unit, provide to
11the group or enrollment unit a description of the method used
12to calculate (1) the Health Maintenance Organization's
13profitable experience with respect to the group or enrollment
14unit and the resulting refund to the group or enrollment unit
15or (2) the Health Maintenance Organization's unprofitable
16experience with respect to the group or enrollment unit and the
17resulting additional premium to be paid by the group or
18enrollment unit.
19    In no event shall the Illinois Health Maintenance
20Organization Guaranty Association be liable to pay any
21contractual obligation of an insolvent organization to pay any
22refund authorized under this Section.
23    (g) Rulemaking authority to implement Public Act 95-1045,
24if any, is conditioned on the rules being adopted in accordance
25with all provisions of the Illinois Administrative Procedure
26Act and all rules and procedures of the Joint Committee on

 

 

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1Administrative Rules; any purported rule not so adopted, for
2whatever reason, is unauthorized.
3(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
495-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
595-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
61-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
76-1-10; 96-1000, eff. 7-2-10.)
 
8    Section 15. The Limited Health Service Organization Act is
9amended by changing Section 4003 as follows:
 
10    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
11    Sec. 4003. Illinois Insurance Code provisions. Limited
12health service organizations shall be subject to the provisions
13of Sections 133, 134, 137, 140, 141.1, 141.2, 141.3, 143, 143c,
14147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8,
15155.04, 155.37, 355.2, 356v, 356z.10, 356z.19, 368a, 401,
16401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and
17Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and
18XXVI of the Illinois Insurance Code. For purposes of the
19Illinois Insurance Code, except for Sections 444 and 444.1 and
20Articles XIII and XIII 1/2, limited health service
21organizations in the following categories are deemed to be
22domestic companies:
23        (1) a corporation under the laws of this State; or
24        (2) a corporation organized under the laws of another

 

 

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1    state, 30% of more of the enrollees of which are residents
2    of this State, except a corporation subject to
3    substantially the same requirements in its state of
4    organization as is a domestic company under Article VIII
5    1/2 of the Illinois Insurance Code.
6(Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
7    Section 20. The Voluntary Health Services Plans Act is
8amended by changing Section 10 as follows:
 
9    (215 ILCS 165/10)  (from Ch. 32, par. 604)
10    Sec. 10. Application of Insurance Code provisions. Health
11services plan corporations and all persons interested therein
12or dealing therewith shall be subject to the provisions of
13Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
14149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
15356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
16356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
17356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401,
18401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
19and (15) of Section 367 of the Illinois Insurance Code.
20    Rulemaking authority to implement Public Act 95-1045, if
21any, is conditioned on the rules being adopted in accordance
22with all provisions of the Illinois Administrative Procedure
23Act and all rules and procedures of the Joint Committee on
24Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
395-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
48-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
5eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
696-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff.
77-2-10.)".