96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB1331

 

Introduced 2/10/2009, by Sen. David Koehler

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Creates the Illinois Family and Employers Health Care Act. Creates the Illinois Guaranteed Option Act to establish a program to make health insurance plans and HMOs affordable and accessible to small employers and individuals. Creates the Illinois Health Care Justice Commission Act; creates the Commission to oversee healthcare system reforms. Creates the Illinois Guaranteed Option Premium Assistance Program Act to provide private health insurance premium assistance. Amends the Illinois Insurance Code to make changes including creating the Office of Patient Protection within the Division of Insurance of the Department of Financial and Professional Regulation. Creates the Community Health Center Construction Act to establish a program of grants for various purposes. Creates the Illinois Shared Responsibility and Shared Opportunity Assessment Act; imposes on employers a tax on the wages paid to Illinois full-time equivalent employees; makes the tax applicable to wages paid on or after January 1, 2010, and requires payment of the tax beginning July 1, 2010.


LRB096 09831 DRJ 19994 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB1331 LRB096 09831 DRJ 19994 b

1     AN ACT in relation to health.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4
ARTICLE 1. SHORT TITLE; LEGISLATIVE INTENT

 
5     Section 1-1. Short title. This Act may be cited as the
6 Illinois Family and Employers Health Care Act.
 
7     Section 1-5. Legislative intent. The General Assembly
8 finds that, for the economic and social benefit of all
9 residents of the State it is vital to enable all Illinoisans to
10 access affordable health insurance that provides comprehensive
11 coverage. Therefore, the General Assembly established the
12 Adequate Healthcare Taskforce to develop a comprehensive plan
13 to provide all Illinoisans with access to comprehensive, high
14 quality, affordable healthcare.
15     The Taskforce through extensive research and town hall
16 meetings across the state found that not only are many working
17 families uninsured but numerous others struggle with the high
18 cost of healthcare. Health insurance premiums for Illinois's
19 working families skyrocketed over the last eight years,
20 increasing by 73.1 percent between 2000 - 2007. In addition,
21 the employer's portion of annual premiums for family health
22 coverage in the state rose from $5,581 to $9,587. Health care

 

 

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1 costs are consuming ever-larger portions of family budgets and
2 causing substantial hardships for individuals and small
3 businesses. If this trend continues, more and more families
4 will inevitably join the ranks of the uninsured and
5 underinsured, small businesses will not be able to provide
6 health care for their workers and Illinoisans will face
7 diminishing economic and health security.
8     It is, therefore, the intent of the Illinois Family and
9 Employers Health Care Act to implement findings from the
10 Adequate Healthcare Task Force to provide access to affordable,
11 comprehensive health insurance to all Illinoisans in a
12 cost-effective manner.
13     It is also the intent of this legislation to maximize the
14 coordination of state policy with comprehensive federal
15 healthcare system reforms, to maximize federal funds, ensure
16 the earliest possible access to federal funds, and make the
17 policy and system changes in the Illinois health insurance
18 markets and industry that will facilitate coordination with
19 federal reform.
 
20
ARTICLE 10. AFFORDABLE HEALTHCARE FOR ALL SMALL BUSINESSES AND
21
INDIVIDUALS

 
22     Section 10-1. Short title. This Article may be cited as the
23 Illinois Guaranteed Option Act. All references in this Article
24 to "this Act" mean this Article.
 

 

 

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1     Section 10-5. Purpose. The General Assembly recognizes
2 that small businesses and individuals struggle every day to pay
3 the costs of meaningful health insurance coverage. Individuals
4 with healthcare needs are frequently denied coverage or offered
5 coverage they cannot afford. Small businesses too receive
6 unaffordable offers of coverage, and always pay more for
7 coverage than larger firms. Even small businesses that struggle
8 to pay health insurance premiums for years can quickly be
9 priced out of the market -- premiums skyrocket after just one
10 small business employee gets sick. In essence, the Illinois
11 health insurance market for small businesses and individuals
12 provides affordable coverage for those who need healthcare
13 services the least. Businesses and individuals who need
14 healthcare the most can no longer afford it or are denied
15 coverage. The General Assembly acknowledges that the high cost
16 of health care for individuals and small groups can be driven
17 by unpredictable and high cost catastrophic medical events.
18 Therefore, the General Assembly, in order to provide access to
19 affordable health insurance for every Illinoisan, seeks to
20 reduce the impact of high-cost medical events by enacting this
21 Act.
 
22     Section 10-10. Definitions. In this Act:
23     "Department" means the Department of Healthcare and Family
24 Services.

 

 

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1     "Division" means the Division of Insurance within the
2 Department of Financial and Professional Regulation.
3     "Federal poverty level" means the federal poverty level
4 income guidelines updated periodically in the Federal Register
5 by the U.S. Department of Health and Human Services under
6 authority of 42 U.S.C. 9902(2).
7     "Full-time employee" means a full-time employee as defined
8 by Section 5-5 of the Economic Development for a Growing
9 Economy Tax Credit Act.
10     "Health maintenance organization" means commercial health
11 maintenance organizations as defined by Section 1-2 of the
12 Health Maintenance Organization Act and shall not include
13 health maintenance organizations which participate solely in
14 government-sponsored programs.
15     "Illinois Comprehensive Health Insurance Plan" means the
16 Illinois Comprehensive Health Insurance Plan established by
17 the Comprehensive Health Insurance Plan Act.
18     "Illinois Guaranteed Option" means the program established
19 under this Act.
20     "Individual market" means the individual market as defined
21 by the Illinois Health Insurance Portability and
22 Accountability Act.
23     "Insurer" means any insurance company authorized to sell
24 group or individual policies of hospital, surgical, or major
25 medical insurance coverage, or any combination thereof, that
26 contains agreements or arrangements with providers relating to

 

 

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1 health care services that may be rendered to beneficiaries as
2 defined by the Health Care Reimbursement Reform Act of 1985 in
3 Sections 370f and following of the Illinois Insurance Code (215
4 ILCS 5/370f and following) and its accompanying regulation (50
5 Illinois Administrative Code 2051). The term "insurer" does not
6 include insurers that sell only policies of hospital indemnity,
7 accidental death and dismemberment, workers' compensation,
8 credit accident and health, short-term accident and health,
9 accident only, long term care, Medicare supplement, student
10 blanket, stand-alone policies, dental, vision care,
11 prescription drug benefits, disability income, specified
12 disease, or similar supplementary benefits.
13     "Illinois Guaranteed Option entity" means any health
14 maintenance organization or insurer, as those terms are defined
15 in this Section, whose gross Illinois premium equals or exceeds
16 1% of the applicable market share.
17     "Risk-based capital" means the minimum amount of required
18 capital or net worth to be maintained by an insurer or Illinois
19 Guaranteed Option entity as prescribed by Article IIA of the
20 Insurance Code (215 ILCS 5/35A-1 and following).
21     "Small employer", for purposes of the Illinois Guaranteed
22 Option Act only, means an employer that employs not more than
23 50 employees who receive compensation for at least 25 hours of
24 work per week.
25     "Small group market" means small group market as defined by
26 the Illinois Health Insurance Portability and Accountability

 

 

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1 Act.
 
2     Section 10-15. Illinois Guaranteed Option plans for
3 eligible small employers and individuals.
4     (a) The State hereby establishes a program for the purpose
5 of making health insurance plans and health maintenance
6 organizations affordable and accessible to small employers and
7 individuals as defined in this Section. The program is designed
8 to encourage small employers to offer affordable health
9 insurance to employees and to make affordable health insurance
10 available to eligible Illinoisans, including individuals whose
11 employers do not offer or sponsor group health insurance.
12     (b) Participation in this program is limited to Illinois
13 Guaranteed Option entities as defined by Section 10-10 of this
14 Act. Participation by all insurers and health maintenance
15 organizations in the Illinois Guaranteed Option program is
16 mandatory. On July 1, 2010, all insurers and health maintenance
17 organizations offering health insurance coverage in the small
18 group market shall offer one or more group Illinois Guaranteed
19 Option plans to eligible small employers as defined in
20 subsection (c) of this Section. All insurers and health
21 maintenance organizations offering health insurance coverage
22 in the individual market shall offer one or more individual
23 Illinois Guaranteed Option plans. For purposes of this Section
24 and Section 10-20 of this Act, all Illinois Guaranteed Option
25 entities that comply with the program requirements shall be

 

 

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1 eligible for reimbursement from the stop loss funds created
2 pursuant to Section 10-20 of this Act.
3     (c) For purposes of this Act, an eligible small employer is
4 a small employer that:
5         (1) employs not more than 50 eligible employees; and
6         (2) contributes towards the group health insurance
7     plan at least 50% of an individual employee's premium and
8     at least 50% of an employee's family premium; and
9         (3) uses Illinois as its principal place of business,
10     management, and administration. For purposes of small
11     employer eligibility, there shall be no income limit,
12     except for limitations made necessary by the funds
13     appropriated and available in the "Illinois Shared
14     Responsibility and Shared Opportunities Trust Fund" for
15     this purpose.
16     (d) For purposes of this Section, "eligible employee" shall
17 include any individual who receives compensation from the
18 eligible employer for at least 25 hours of work per week.
19     (e) An Illinois Guaranteed Option entity may enter into an
20 agreement with an employer to offer an Illinois Guaranteed
21 Option plan pursuant to this Section only if that employer
22 offers that plan to all eligible employees.
23     (f) The pro-rated employer premium contribution levels for
24 non-full-time employees shall be based upon employer premium
25 contribution levels required by subdivision (c)(2) of this
26 Section. An eligible small employer shall contribute at least

 

 

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1 the pro-rated premium contribution amount towards an
2 individual part-time employee's premium. An eligible small
3 employer shall contribute at least the pro-rated premium
4 contribution amount towards an individual part-time employee's
5 family premium. The pro-rated premium contribution must be the
6 same percentage for all similarly situated employees and may
7 not vary based on class of employee.
8     (g) Illinois-based chambers of commerce or other
9 associations, including bona fide associations as defined by
10 the Illinois Health Insurance Portability and Accountability
11 Act, may be eligible to participate in Illinois Guaranteed
12 Option policies subject to approval by the Department, as
13 permitted by law, and limitations made necessary by the funds
14 appropriated and available in the Illinois Shared
15 Responsibility and Shared Opportunities Trust Fund.
16     (h) An eligible small employer shall elect whether to make
17 coverage under the Illinois Guaranteed Option plan available to
18 dependents of employees. Any employee or dependent who is
19 enrolled in Medicare is ineligible for coverage, unless
20 required by federal law. Dependents of an employee who is
21 enrolled in Medicare shall be eligible for dependent coverage
22 provided the dependent is not also enrolled in Medicare.
23     (i) An Illinois Guaranteed Option plan must provide the
24 benefits set forth in subsection (o) of this Section. The
25 contract, independently or in combination with other group
26 Illinois Guaranteed Option plans, must insure not less than 50%

 

 

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1 of the eligible employees.
2     (j) For purposes of this Act, an eligible individual is an
3 individual:
4         (1) who is unemployed, not an eligible employee as
5     defined by subsection (d) of Section 10-15, or solely
6     self-employed, or whose employer does not sponsor group
7     health insurance and has not sponsored group health
8     insurance with benefits on an expense-reimbursed or
9     prepaid basis covering employees in effect during the
10     12-month period prior to the individual's application for
11     health insurance under the program established by this
12     Section;
13         (2) who for the first year of operation of the program
14     resides in a household having a household income at or
15     below 400% of the federal poverty level; thereafter, income
16     and asset limits shall be determined by the Health Care
17     Justice Commission established under the Illinois Health
18     Care Justice Commission Act;
19         (3) who is ineligible for Medicare or medical
20     assistance, except that the Department may determine that
21     it shall require an individual who is eligible under
22     subdivision 2(b) of Section 5-2 of the Illinois Public Aid
23     Code to participate as an eligible individual; and
24         (4) who is a resident of Illinois.
25     (l) The requirements set forth in subdivision (j)(1) of
26 this Section shall not be applicable to individuals who had

 

 

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1 health insurance coverage terminated due to:
2         (1) death of a family member that results in
3     termination of coverage under a health insurance contract
4     under which the individual is covered;
5         (2) change of residence so that no employer-based
6     health insurance with benefits on an expense-reimbursed or
7     prepaid basis is available; or
8         (3) legal separation, dissolution of marriage, or
9     declaration of invalidity of marriage that results in
10     termination of coverage under a health insurance contract
11     under which the individual is covered.
12     (m) The 12-month period set forth in item (1) of subsection
13 (j) of this Section may be adjusted by the Division from 12
14 months to an alternative duration if the Healthcare Justice
15 Commission determines that the alternative period sufficiently
16 prevents inappropriate substitution.
17     (o) The contracts issued pursuant to this Section by
18 participating Illinois Guaranteed Option entities and approved
19 by the Department shall provide for a distinct product known as
20 "Guaranteed Option". The insurance product will provide for
21 major medical, mental health, pharmacy, dental and vision
22 benefits that contains in and out of network benefits.
23     (p) Illinois Guaranteed Option entities shall propose the
24 following for approval by the Department:
25         (1) Benefit designs provided in plans created for this
26     Section.

 

 

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1         (2) Co-pays and deductible amounts applicable to
2     plans, which shall not exceed the maximum allowable amount
3     under the Illinois Insurance Code.
4     (q) Under the Guaranteed Option product hospitals shall be
5 reimbursed by Illinois Guaranteed Option entities in an amount
6 that equals 110 percent of Medicare for Critical Access
7 hospitals and equals the actuarial equivalent of 135 percent of
8 Medicare for all other hospitals as prescribed for the
9 hospital's designated region. "All other hospitals" includes
10 Sole Community Hospitals, Medicare Dependent Hospitals and
11 Rural Referral Centers. "Medicare" refers to the appropriate,
12 Medicare federal standardized rate which is adjusted for the
13 individual DRG weighting factors used by Medicare, the
14 hospital's specific area wage index, capital costs, outlier
15 payments, disproportionate share hospital payments, direct and
16 indirect medical education payments, the costs of nursing and
17 allied health education programs, and organ procurement costs.
18 For hospital services provided for which a Medicare rate is not
19 prescribed or cannot be calculated, the hospital shall be
20 reimbursed 90% of the lowest rate paid by the applicable
21 insurer under its contract with that hospital for that same
22 type of product and applicable service.
23     (r) On and after January 1, 2010, all providers that
24 contract with an insurer or health maintenance organization
25 must participate as a network provider under the same Illinois
26 Guaranteed Option entity's Guaranteed Option product.

 

 

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1     (s) Nothing in this Act shall be used by any private or
2 public Illinois Guaranteed Option entity as a basis for
3 reducing the Illinois Guaranteed Option entity's rates or
4 policies with any hospital. Illinois Guaranteed Option
5 entities are prohibited from using contractual provisions in
6 provider contracts that would require the provider or providers
7 to accept the rates under subsection (c) as the payment rates
8 for any other type of product or service of the Illinois
9 Guaranteed Option entity. Notwithstanding any other provision
10 of law, rates authorized under this Act shall not be used by
11 any private or public Illinois Guaranteed Option entities to
12 determine a hospital's usual and customary charges for any
13 health care service.
14     (t) Other non-hospital providers shall be reimbursed at a
15 rate no less than 105% of the Medicare reimbursement rate for
16 the designated region.
17     (u) No Illinois Guaranteed Option entity shall issue a
18 group Illinois Guaranteed Option plan or individual Illinois
19 Guaranteed Option plan until the plan has been certified as
20 such by the Department.
21     (v) A participating Illinois Guaranteed Option plan shall
22 obtain from the employer or individual, on forms approved by
23 the Department or in a manner prescribed by the Department,
24 written certification at the time of initial application and
25 annually thereafter 90 days prior to the contract renewal date
26 that the employer or individual meets and expects to continue

 

 

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1 to meet the requirements of an eligible small employer or an
2 eligible individual pursuant to this Section. A participating
3 Illinois Guaranteed Option plan may require the submission of
4 appropriate documentation in support of the certification,
5 including proof of income status.
6     (w) Applications to enroll in group Illinois Guaranteed
7 Option plans and individual Illinois Guaranteed Option plans
8 must be received and processed from any eligible individual and
9 any eligible small employer during the open enrollment period
10 each year. This provision does not restrict open enrollment
11 guidelines set by Illinois Guaranteed Option plan contracts,
12 but every such contract must include standard employer group
13 open enrollment guidelines.
14     (x) All coverage under group Illinois Guaranteed Option
15 plans and individual Illinois Guaranteed Option plans must be
16 subject to a pre-existing condition limitation provision,
17 including the crediting requirements thereunder. Pre-existing
18 conditions may be evaluated and considered by the Department
19 when determining appropriate co-pay amounts, deductible
20 levels, and benefit levels. Prenatal care shall be available
21 without consideration of pregnancy as a preexisting condition.
22 Waiver of deductibles and other cost-sharing payments by
23 insurer may be made for individuals participating in chronic
24 care management or wellness and prevention programs.
25     (y) In order to arrive at the actual premium charged to any
26 particular group or individual, a participating Illinois

 

 

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1 Guaranteed Option entity may adjust its base rate.
2         (1) Adjustments to base rates may be made using only
3     the following factors:
4             (A) geographic area;
5             (B) age;
6             (C) smoking or non-smoking status; and
7             (D) participation in wellness or chronic disease
8         management activities.
9         (2) The adjustment for age in item (1) of this
10     subsection may not use age brackets smaller than 5-year
11     increments, which shall begin with age 20 and end with age
12     65. Eligible individuals, sole proprietors, and employees
13     under the age of 20 shall be treated as those age 20.
14         (3) Permitted rates for any age group shall not exceed
15     the rate for any other age group by more than 25%.
16         (4) If geographic rating areas are utilized, such
17     geographic areas must be reasonable and in a given case may
18     include a single county. The geographic areas utilized must
19     be the same for the contracts issued to eligible small
20     employers and to eligible individuals. The Division shall
21     not require the inclusion of any specific geographic region
22     within the proposed region selected by the participating
23     Illinois Guaranteed Option entity, but the participating
24     Illinois Guaranteed Option entity's proposed regions shall
25     not contain configurations designed to avoid or segregate
26     particular areas within a county covered by the

 

 

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1     participating Illinois Guaranteed Option plan's community
2     rates. Rates from one geographic region to another may not
3     vary by more than 30% and must be actuarially supported.
4         (5) Permitted rates for any small employer shall not
5     exceed the rate for any other small employer by more than
6     25%.
7         (6) A discount of up to 10% for participation in
8     wellness or chronic disease management activities shall be
9     permitted if based upon actuarially justified differences
10     in utilization or cost attributed to such programs.
11         (7) Claims experience under contracts issued to
12     eligible small employers and to eligible individuals must
13     be combined for rate setting purposes.
14         (8) Rate-based provisions in this subsection may be
15     modified due to claims experience and subject to
16     limitations made necessary by funds appropriated and
17     available in the Illinois Shared Opportunity and Shared
18     Responsibility Trust Fund.
19     (z) Participating Illinois Guaranteed Option entities
20 shall submit reports to the Department in such form and such
21 media as the Department shall prescribe. The reports shall be
22 submitted at times as may be reasonably required by the
23 Department to evaluate the operations and results of Illinois
24 Guaranteed Option plans established by this Section. The
25 Department shall make such reports available to the Division.
26     (aa) The Department shall conduct public education and

 

 

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1 outreach to facilitate enrollment of small employers, eligible
2 employees, and eligible individuals in the Program.
 
3     Section 10-20. Stop loss funding for Illinois Guaranteed
4 Option contracts issued to eligible small employers and
5 eligible individuals.
6     (a) The Department shall provide a claims reimbursement
7 program for participating Illinois Guaranteed Option entities
8 and shall annually seek appropriations to support the program.
9     (b) The claims reimbursement program, also known as
10 "Illinois Stop Loss Protection", shall operate as a stop loss
11 program for participating Illinois Guaranteed Option entities
12 and shall reimburse participating Illinois Guaranteed Option
13 entities for a certain percentage of health care claims above a
14 certain attachment amount or within certain attachment
15 amounts. The stop loss attachment amount or amounts shall be
16 determined by the Division consistent with the purpose of the
17 Illinois Program and subject to limitations made necessary by
18 the amount appropriated and available in the Illinois Shared
19 Opportunity and Shared Responsibility Trust Fund.
20     (c) Commencing on July 1, 2009, participating Illinois
21 Guaranteed Option entities shall be eligible to receive
22 reimbursement for 80% of claims paid in a calendar year in
23 excess of the attachment point for any member covered under a
24 contract issued pursuant to Section 10-15 of this Act after the
25 participating Illinois Guaranteed Option entity pays claims

 

 

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1 for that same member in the same calendar year. Based on
2 pre-determined attachment amounts, verified claims paid for
3 members covered under group and individual Illinois Guaranteed
4 Option plans shall be reimbursable from the Illinois Stop Loss
5 Protection Program. For purposes of this Section, claims shall
6 include health care claims paid by or on behalf of a covered
7 member pursuant to such contracts.
8     (d) Consistent with the purpose of Illinois Act and subject
9 to limitations made necessary by the amount appropriated and
10 available in the Illinois Shared Opportunity and Shared
11 Responsibility Trust Fund, the Department shall set forth
12 procedures for operation of the Illinois Stop Loss Protection
13 Program and distribution of monies therefrom.
14     (e) Claims shall be reported and funds shall be distributed
15 by the Department on a calendar year basis. Claims shall be
16 eligible for reimbursement only for the calendar year in which
17 the claims are paid.
18     (f) Each participating Illinois Guaranteed Option entity
19 shall submit a request for reimbursement from the Illinois Stop
20 Loss Protection Program on forms prescribed by the Department.
21 Each request for reimbursement shall be submitted no later than
22 April 1 following the end of the calendar year for which the
23 reimbursement requests are being made. In connection with
24 reimbursement requests, the Department may require
25 participating Illinois Guaranteed Option entities to submit
26 such claims data deemed necessary to enable proper distribution

 

 

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1 of funds and to oversee the effective operation of the Illinois
2 Stop Loss Protection Program. The Department may require that
3 such data be submitted on a per-member, aggregate, or
4 categorical basis, or any combination of those. Data shall be
5 reported separately for group Illinois Guaranteed Option plans
6 and individual Illinois Guaranteed Option plans issued
7 pursuant to Section 10-15 of this Act.
8     (f-5) In each request for reimbursement from the Illinois
9 Stop Loss Protection Program, Illinois Guaranteed Option
10 entities shall certify that provider reimbursement rates are
11 consistent with the reimbursement rates as defined by
12 subdivision (r)(3) of Section 10-15 of this Act. The
13 Department, in collaboration with the Division, shall audit, as
14 necessary, claims data submitted pursuant to subsection (f) of
15 this Section to ensure that reimbursement rates paid by
16 Illinois Guaranteed Option entities are consistent with
17 reimbursement rates as defined by subsection (m) of Section
18 10-15.
19     (g) At all times, the Illinois Stop Loss Protection Program
20 shall be implemented and operated subject to the limitations
21 made necessary by the funds appropriated and available in the
22 Illinois Shared Opportunity and Shared Responsibility Trust
23 Fund. The Department shall calculate the total claims
24 reimbursement amount for all participating Illinois Guaranteed
25 Option entities for the calendar year for which claims are
26 being reported. In the event that the total amount requested

 

 

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1 for reimbursement for a calendar year exceeds appropriations
2 available for distribution for claims paid during that same
3 calendar year, the Department shall provide for the pro-rata
4 distribution of the available funds. Each participating
5 Illinois Guaranteed Option entity shall be eligible to receive
6 only such proportionate amount of the available appropriations
7 as the individual participating Illinois Guaranteed Option
8 entity's total eligible claims paid bears to the total eligible
9 claims paid by all participating Illinois Guaranteed Option
10 entities.
11     (h) Each participating Illinois Guaranteed Option entity
12 shall provide the Department with monthly reports of the total
13 enrollment under the group Illinois Guaranteed Option plans and
14 individual Illinois Guaranteed Option plans issued pursuant to
15 Section 10-15 of this Act. The reports shall be in a form
16 prescribed by the Department.
17     (i) The Department shall separately estimate the per member
18 annual cost of total claims reimbursement from each stop loss
19 program for group Illinois Guaranteed Option plans and
20 individual Illinois Guaranteed Option plans based upon
21 available data and appropriate actuarial assumptions. Upon
22 request, each participating Illinois Guaranteed Option plan
23 shall furnish to the Department claims experience data for use
24 in such estimations.
25     (j) Every participating Illinois Guaranteed Option entity
26 shall file with the Division the base rates and rating

 

 

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1 schedules it uses to provide group Illinois Guaranteed Option
2 plans and individual Illinois Guaranteed Option plans. All
3 rates proposed for Illinois Guaranteed Option plans are subject
4 to the prior regulatory review of the Division and shall be
5 effective only upon approval by the Division. The Division has
6 authority to approve, reject, or modify the proposed base rate
7 subject to the following:
8         (1) Rates for Illinois Guaranteed Option plans must
9     account for the availability of reimbursement pursuant to
10     this Section.
11         (2) Rates must not be excessive or inadequate nor shall
12     the rates be unfairly discriminatory.
13         (3) Consideration shall be given, to the extent
14     applicable and among other factors, to the Illinois
15     Guaranteed Option entity's past and prospective medical
16     loss experience within the State for the product for which
17     the base rate is proposed, to past and prospective expenses
18     both countrywide and those especially applicable to this
19     State, and to all other factors, including judgment
20     factors, deemed relevant within and outside the State.
21         (4) Consideration shall be given to the Illinois
22     Guaranteed Option entity's actuarial support, enrollment
23     levels, premium volume, risk-based capital, and the ratio
24     of incurred claims to earned premiums.
25     (k) If the Department deems it appropriate for the proper
26 administration of the program, the Department shall be

 

 

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1 authorized to purchase stop loss insurance or reinsurance, or
2 both, from an insurance company licensed to write such type of
3 insurance in Illinois.
4     (k-5) Nothing in this Section 10-20 shall require
5 modification of stop loss provisions of an existing contract
6 between the Illinois Guaranteed Option entity and a healthcare
7 provider.
8     (l) The Division shall assess insurers as defined in
9 Section 12 of the Comprehensive Health Insurance Plan Act in
10 accordance with the provisions of this subsection:
11         (1) By March 1, 2009, the Illinois Comprehensive Health
12     Insurance Plan shall report to the Division the total
13     assessment paid pursuant to subsection d of Section 12 of
14     the Comprehensive Health Insurance Plan Act for fiscal
15     years 2004 through 2008. By March 1, 2009, the Division
16     shall determine the total direct Illinois premiums for
17     calendar years 2004 through 2008 for the kinds of business
18     described in clause (b) of Class 1 or clause (a) of Class 2
19     of Section 4 of the Illinois Insurance Code, and direct
20     premium income of a health maintenance organization or a
21     voluntary health services plan, except that it shall not
22     include credit health insurance as defined in Article IX
23     1/2 of the Illinois Insurance Code. The Division shall
24     create a fraction, the numerator of which equals the total
25     assessment as reported by the Illinois Comprehensive
26     Health Insurance Plan pursuant to this subsection, and the

 

 

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1     denominator of which equals the total direct Illinois
2     premiums determined by the Division pursuant to this
3     subsection. The resulting percentage shall be the
4     "baseline percentage assessment".
5         (2) For purposes of the program, and to the extent that
6     in any fiscal year the Illinois Comprehensive Health
7     Insurance Plan does not collect an amount equal to or
8     greater than the equivalent dollar amount of the baseline
9     percentage assessment to cover deficits established
10     pursuant to subsection d of Section 12 of the Comprehensive
11     Health Insurance Plan Act, the Division shall impose the
12     "baseline assessment" in accordance with paragraph (3) of
13     this subsection.
14         (3) An insurer's assessment shall be determined by
15     multiplying the equivalent dollar amount of the baseline
16     percentage assessment, as determined by paragraph (1), by a
17     fraction, the numerator of which equals that insurer's
18     direct Illinois premiums during the preceding calendar
19     year and the denominator of which equals the total of all
20     insurers' direct Illinois premiums for the preceding
21     calendar year. The Division may exempt those insurers whose
22     share as determined under this subsection would be so
23     minimal as to not exceed the estimated cost of levying the
24     assessment.
25         (4) The Division shall charge and collect from each
26     insurer the amounts determined to be due under this

 

 

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1     subsection.
2         (5) The difference between the total assessments paid
3     pursuant to imposition of the baseline assessment and the
4     total assessments paid to cover deficits established
5     pursuant to subsection d of Section 12 of the Comprehensive
6     Health Insurance Plan Act shall be paid to the Illinois
7     Shared Opportunity and Shared Responsibility Trust Fund.
8         (6) When used in this subsection (l), "insurer" means
9     "insurer" as defined in Section 2 of the Comprehensive
10     Health Insurance Plan Act.
 
11     Section 10-25. Program publicity duties of Illinois
12 Guaranteed Option entities and Department.
13     (a) In conjunction with the Department, all Illinois
14 Guaranteed Option entities shall participate in and share the
15 cost of annually publishing and disseminating a consumer's
16 shopping guide or guides for group Illinois Guaranteed Option
17 plans and individual Illinois Guaranteed Option plans issued
18 pursuant to Section 10-15 of this Act. The contents of all
19 consumer shopping guides published pursuant to this Section
20 shall be subject to review and approval by the Department.
21     (b) Participating Illinois Guaranteed Option entities may
22 distribute additional sales or marketing brochures describing
23 group Illinois Guaranteed Option plans and individual Illinois
24 Guaranteed Option plans subject to review and approval by the
25 Department.

 

 

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1     (c) Commissions available to insurance producers from
2 Illinois Guaranteed Option entities for sales of plans under
3 the Illinois Program shall not be less than those available for
4 sale of plans other than plans issued pursuant to the Illinois
5 Guaranteed Option Program. Information on such commissions
6 shall be reported to the Division in the rate approval process.
 
7     Section 10-30. Data reporting.
8     (a) The Department, in consultation with the Division and
9 other State agencies, shall report on the program established
10 pursuant to Sections 10-15 and 10-20 of this Act. The report
11 shall examine:
12         (1) employer and individual participation, including
13     an income profile of covered employees and individuals and
14     an estimate of the per-member annual cost of total claims
15     reimbursement as required by subsection (i) of Section
16     10-20 of this Act;
17         (2) claims experience and the program's projected
18     costs through December 31, 2015;
19         (3) the impact of the program on the uninsured
20     population in Illinois and the impact of the program on
21     health insurance rates paid by Illinois residents; and
22         (4) the amount of funds in the Illinois Shared
23     Opportunity and Shared Responsibility Trust Fund generated
24     by the Illinois Shared Opportunity and Shared
25     Responsibility Assessment Act, by category of employer.

 

 

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1     (b) The study shall be completed and a report submitted by
2 October 1, 2010 to the Governor, the President of the Senate,
3 and the Speaker of the House of Representatives.
 
4     Section 10-35. Duties assigned to the Department. Unless
5 otherwise specified, all duties assigned to the Department by
6 this Act shall be carried out in consultation with the
7 Division.
 
8     Section 10-40. Applicability of other Illinois Insurance
9 Code provisions. Unless otherwise specified in this Section,
10 policies for all group Illinois Guaranteed Option plans and
11 individual Illinois Guaranteed Option plans must meet all other
12 applicable provisions of the Illinois Insurance Code.
 
13
ARTICLE 12. ILLINOIS HEALTHCARE JUSTICE COMMISSION

 
14     Section 12-1. Short title. This Article may be cited as the
15 Illinois Health Care Justice Commission Act. All references in
16 this Article to "this Act" means this Article.
 
17     Section 12-5. Purpose. This Act creates the bipartisan
18 Illinois Health Care Justice Commission (HCJC). The purpose of
19 the HCJC is to carry out the functions given to it elsewhere by
20 law and to monitor and oversee generally the reforms of the
21 Illinois healthcare system and the coordination of those

 

 

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1 reforms with federal reforms, to create regular opportunities
2 to report to the public and learn public reaction through
3 forums and otherwise, to report annually on the progress and
4 status of healthcare reform to the General Assembly, and to
5 generate recommendations for improvements to the system as the
6 implementation proceeds.
 
7     Section 12-10. Makeup of Commission.
8     (a) The Illinois Health Care Justice Commission shall
9 consist of 29 voting members appointed as follows: 5 shall be
10 appointed by the Governor; 6 shall be appointed by the
11 President of the Senate; 6 shall be appointed by the Minority
12 Leader of the Senate; 6 shall be appointed by the Speaker of
13 the House of Representatives; and 6 shall be appointed by the
14 Minority Leader of the House of Representatives. Appointed
15 members shall include representatives from state healthcare
16 associations, advocacy organizations, providers, organized
17 labor, and businesses with a primary focus that includes
18 chronic disease prevention, public health delivery, medicine,
19 mental health, oral health, health care and disease management,
20 consumer advocacy or community health, minority healthcare,
21 and quality healthcare improvement. Members of the HCJC shall
22 serve without compensation and be reimbursed for expenses.
23     (b) The members of the Commission shall be appointed within
24 30 days after the effective date of this Act. The Commission
25 shall have a chairperson and a vice-chairperson who shall be

 

 

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1 elected by the voting members at the first meeting of the
2 Commission. The Director of the Department of Healthcare and
3 Family Services or his or her designee, the Director of the
4 Department of Public Health or his or her designee, the
5 Director of Aging or his or her designee, the Director of
6 Insurance or his or her designee, and the Secretary of the
7 Department of Human Services or his or her designee shall
8 represent their respective departments and shall be invited to
9 attend Commission meetings, but shall not be voting members of
10 the Commission. The departments of State government
11 represented on the Commission shall work cooperatively to
12 provide administrative support for the Commission; the
13 Department of Healthcare and Family Services shall be the
14 primary agency in providing that administrative support.
15     (c) Voting members of the Commission shall serve for a term
16 of 3 years or until a replacement is named. Of the initial
17 appointees, as determined by lot, 9 members shall serve a term
18 of one year; 9 shall serve for a term of 2 years; and 11 shall
19 serve for a term of 3 years. Any member appointed to fill a
20 vacancy occurring prior to the expiration of the term for which
21 his or her predecessor was appointed shall be appointed for the
22 remainder of that term. In the event of a vacancy on the
23 Commission, the replacement commissioner shall satisfy the
24 same criteria specified in subsection (a) for appointment (as
25 to who appoints the commissioner and which interest group the
26 commissioner represents) as the prior commissioner being

 

 

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1 replaced. The Commission shall adopt its own operating rules
2 for matters such as quorums, executive committees, and
3 scheduling of meetings.
 
4     Section 12-15. Public forums and reports. The Illinois
5 Health Care Justice Commission shall provide opportunities for
6 6 regional public hearings annually beginning during its first
7 year of operation. In addition, on January 1, 2010 and each
8 January 1 thereafter, the Commission shall issue a report to
9 the General Assembly on progress in complying with the Illinois
10 Family and Employers Health Care Act, impediments thereto,
11 recommendations of the Commission, and any recommendations for
12 legislative changes necessary to implement the Illinois Family
13 and Employers Health Care Act.
 
14     Section 12-20. Powers. The responsibilities of the
15 Illinois Health Care Justice Commission shall include:
16         (1) Making decisions regarding eligibility and premium
17     assistance for the new health insurance product (Illinois
18     Guaranteed Option).
19         (2) Making decisions regarding the structure of the
20     employer tax, credit and exemption scenarios outlined in
21     Sections 50-301, 50-302, and 50-303 of the Illinois Shared
22     Responsibility and Shared Opportunity Assessment Act.
23         (3) Responding to federal and state partnership
24     opportunities regarding health care reform and expansion.

 

 

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1         (4) In consultation with the Governor, helping to
2     appoint members of the Illinois Shared Responsibility and
3     Shared Opportunity Trust Fund Financial Oversight Panel,
4     as established in Section 50-703 of the Illinois Shared
5     Responsibility and Shared Opportunity Assessment Act.
6         (5) Establishing ad hoc commissions to consider the
7     following health care workforce and cost containment
8     issues:
9             (A) Assessment of state healthcare workforce
10         trends, training issues and financing policies
11         including workforce supply and distribution, cultural
12         competence and minority participation in health
13         professions education, primary care training and
14         practice.
15             (B) Assessment of loan repayment assistance for
16         physicians, dentists and allied health professionals.
17             (C) Creation of a strategic plan to implement a
18         statewide system of chronic care infrastructure,
19         prevention of chronic conditions and chronic care
20         management.
21             (D) Lowering of administrative costs by
22         simplifying the claims administration process for
23         consumers, healthcare providers, and others and where
24         possible, harmonizing the claims processing system for
25         state healthcare programs with those used by private
26         insurers.
 

 

 

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1     Section 12-25. Funding. The Illinois Health Care Justice
2 Commission shall be funded, in part, through the budget of the
3 Illinois Department of Healthcare and Family Services and funds
4 designated to the State of Illinois through federal economic
5 stimulus plan of 2009.
 
6
ARTICLE 15. HELPING FAMILIES AFFORD HEALTH INSURANCE

 
7     Section 15-1. Short title. This Article may be cited as the
8 Illinois Guaranteed Option Premium Assistance Program Act. All
9 references in this Article to "this Act" mean this Article.
 
10     Section 15-80. The Illinois Public Aid Code is amended by
11 adding Sections 1-12 and 1-13 as follows:
 
12     (305 ILCS 5/1-12 new)
13     Sec. 1-12. Premium Assistance.
14     (a) Subject to the availability of funds, the Department
15 may provide premium assistance for eligible persons under this
16 Section to assist such persons or families in affording
17 qualified private health insurance including
18 employer-sponsored health insurance for themselves or their
19 family members. Such premium assistance will be based on
20 financial need with greater levels of assistance being provided
21 to those with lowest income. Based on the availability of

 

 

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1 funding, the Department in consultation with the Illinois
2 Health Care Justice Commission will determine the level of
3 premium assistance available to individuals and families. If
4 necessary to maximize receipt of federal matching funds, the
5 Department may by rule make modifications to the premium
6 assistance program.
7     (b) To be eligible for premium assistance, a person must:
8         (1) be a resident of Illinois,
9         (2) reside legally in the United States, and
10         (3) have family income at or below the level set by the
11     Department based on the availability of funds but in no
12     instance will such income threshold be above 400% of the
13     federal poverty income guidelines.
14     (c) Premium assistance payments will commence only after a
15 person is actually enrolled in qualified health insurance.
16     (d) The Department shall coordinate eligibility for
17 premium assistance with eligibility for other public
18 healthcare benefit programs.
19     (e) The following definitions shall apply to this Section:
20         (1) "Department" means the Department of Healthcare
21     and Family Services.
22         (2) "Employer-sponsored health insurance" means health
23     insurance obtained as a benefit of employment.
24         (3) "Qualified health insurance" means any health
25     insurance coverage as defined in Section 2 of the
26     Comprehensive Health Insurance Plan Act.

 

 

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1         (4) "Premium assistance" means payments made on behalf
2     of an individual to offset the costs of paying premiums to
3     secure qualified health insurance for that individual or
4     that individual's family under family coverage.
5     (f) The Department may promulgate rules to implement this
6 Section.
 
7     (305 ILCS 5/1-13 new)
8     Sec. 1-13. Exchange of information. The Director of Revenue
9 may exchange information with the Department of Healthcare and
10 Family Services and the Department of Human Services for the
11 purpose of determining eligibility for health benefit programs
12 administered by those departments, for verifying sources and
13 amounts of income, and for other purposes directly connected
14 with the administration of those programs.
 
15
ARTICLE 18. INSURANCE FAIRNESS ACT

 
16     Section 18-5. The Illinois Insurance Code is amended by
17 changing Sections 359a and 370c, by adding Section 352b, and by
18 adding the heading of Article XLV and Sections 1500-5, 1500-10,
19 1500-15, 1500-20, 1500-25, and 1500-30 as follows:
 
20     (215 ILCS 5/352b new)
21     Sec. 352b. Group health plan non-discrimination
22 requirement. On and after June 1, 2009, no group policy or

 

 

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1 certificate of accident and health insurance otherwise subject
2 to applicable provisions of this Code shall be delivered or
3 issued for delivery to an employer group in this State unless
4 such policy or certificate is offered by that employer to all
5 full-time employees who live in Illinois; provided, however,
6 the employer shall not make a smaller health insurance premium
7 contribution percentage amount to an employee than the employer
8 makes to any other employee who receives an equal or greater
9 total hourly or annual salary for each policy or certificate of
10 accident and health insurance for all employees.
11 Notwithstanding any provision of this Section, an insurer may
12 deliver or issue a group policy or certificate of accident and
13 health insurance to an employer group that establishes separate
14 contribution percentages for employees covered by collective
15 bargaining agreements as negotiated in those agreements.
 
16     (215 ILCS 5/359a)  (from Ch. 73, par. 971a)
17     Sec. 359a. Application.
18     (1) No On and after June 1, 2009, no individual or group
19 policy or certificate of insurance except an Industrial
20 Accident and Health Policy provided for by this article shall
21 be issued, except upon the signed application of the person or
22 persons sought to be insured. Any information or statement of
23 the applicant shall plainly appear upon such application in the
24 form of interrogatories by the insurer and answers by the
25 applicant. The insured shall not be bound by any statement made

 

 

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1 in an application for any policy, including an Industrial
2 Accident and Health Policy, unless a copy of such application
3 is attached to or endorsed on the policy when issued as a part
4 thereof. If any such policy delivered or issued for delivery to
5 any person in this state shall be reinstated or renewed, and
6 the insured or the beneficiary or assignee of such policy shall
7 make written request to the insurer for a copy of the
8 application, if any, for such reinstatement or renewal, the
9 insurer shall within fifteen days after the receipt of such
10 request at its home office or any branch office of the insurer,
11 deliver or mail to the person making such request, a copy of
12 such application. If such copy shall not be so delivered or
13 mailed, the insurer shall be precluded from introducing such
14 application as evidence in any action or proceeding based upon
15 or involving such policy or its reinstatement or renewal. On
16 and after June 1, 2009, all individual and group applications
17 for insurance that require health information or questions
18 shall comply with the following standards:
19         (A) Insurers may ask diagnostic questions on
20     applications for insurance.
21         (B) Application questions shall be formed in a manner
22     designed to elicit specific medical information and not
23     other inferential information.
24         (C) Questions which are vague, subjective, unfairly
25     discriminatory, or so technical as to inhibit a clear
26     understanding by the applicant are prohibited.

 

 

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1         (D) Questions that ask an applicant to verify diagnosis
2     or treatment for specific diseases or conditions must
3     stipulate that such diagnoses must have been made and such
4     treatment must have been performed by an appropriately
5     licensed health care service provider.
6         (E) All underwriting shall be based on individual
7     review of specific health information furnished on the
8     application, any reports provided as a result of medical
9     examinations performed at the company's request, medical
10     record information obtained from the applicant's health
11     care providers, or any combination of the foregoing.
12     Adverse underwriting decisions shall not be based on
13     ambiguous responses to application questions.
14         (F) Preexisting condition exclusions imposed based
15     solely on responses to an application question may exclude
16     only a condition that was specifically elicited in the
17     application and may not be broadened to similar, but
18     separate conditions that were not specifically identified
19     by an application question.
20     (2) No alteration of any written application for any such
21 policy shall be made by any person other than the applicant
22 without his written consent, except that insertions may be made
23 by the insurer, for administrative purposes only, in such
24 manner as to indicate clearly that such insertions are not to
25 be ascribed to the applicant.
26     (3) On and after June 1, 2009, the falsity of any statement

 

 

SB1331 - 36 - LRB096 09831 DRJ 19994 b

1 in the application for any policy covered by this Act may not
2 bar the right to recovery thereunder unless such false
3 statement has actually contributed to the contingency or event
4 on which the policy is to become due and payable and unless
5 such false statement materially affected either the acceptance
6 of the risk or the hazard assumed by the insurer. Provided,
7 however, that any recovery resulting from the operation of this
8 Section shall not bar the right to render the policy void in
9 accordance with its provisions. The falsity of any statement in
10 the application for any policy covered by this act may not bar
11 the right to recovery thereunder unless such false statement
12 materially affected either the acceptance of the risk or the
13 hazard assumed by the insurer.
14 (Source: Laws 1951, p. 611.)
 
15     (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
16     Sec. 370c. Mental and emotional disorders.
17     (a) (1) On and after the effective date of this Section,
18 every insurer which delivers, issues for delivery or renews or
19 modifies group A&H policies providing coverage for hospital or
20 medical treatment or services for illness on an
21 expense-incurred basis shall offer to the applicant or group
22 policyholder subject to the insurers standards of
23 insurability, coverage for reasonable and necessary treatment
24 and services for mental, emotional or nervous disorders or
25 conditions, other than serious mental illnesses as defined in

 

 

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1 item (2) of subsection (b), up to the limits provided in the
2 policy for other disorders or conditions, except (i) the
3 insured may be required to pay up to 50% of expenses incurred
4 as a result of the treatment or services, and (ii) the annual
5 benefit limit may be limited to the lesser of $10,000 or 25% of
6 the lifetime policy limit.
7     (2) Each insured that is covered for mental, emotional or
8 nervous disorders or conditions shall be free to select the
9 physician licensed to practice medicine in all its branches,
10 licensed clinical psychologist, licensed clinical social
11 worker, licensed clinical professional counselor, or licensed
12 marriage and family therapist of his choice to treat such
13 disorders, and the insurer shall pay the covered charges of
14 such physician licensed to practice medicine in all its
15 branches, licensed clinical psychologist, licensed clinical
16 social worker, licensed clinical professional counselor, or
17 licensed marriage and family therapist up to the limits of
18 coverage, provided (i) the disorder or condition treated is
19 covered by the policy, and (ii) the physician, licensed
20 psychologist, licensed clinical social worker, licensed
21 clinical professional counselor, or licensed marriage and
22 family therapist is authorized to provide said services under
23 the statutes of this State and in accordance with accepted
24 principles of his profession.
25     (3) Insofar as this Section applies solely to licensed
26 clinical social workers, licensed clinical professional

 

 

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1 counselors, and licensed marriage and family therapists, those
2 persons who may provide services to individuals shall do so
3 after the licensed clinical social worker, licensed clinical
4 professional counselor, or licensed marriage and family
5 therapist has informed the patient of the desirability of the
6 patient conferring with the patient's primary care physician
7 and the licensed clinical social worker, licensed clinical
8 professional counselor, or licensed marriage and family
9 therapist has provided written notification to the patient's
10 primary care physician, if any, that services are being
11 provided to the patient. That notification may, however, be
12 waived by the patient on a written form. Those forms shall be
13 retained by the licensed clinical social worker, licensed
14 clinical professional counselor, or licensed marriage and
15 family therapist for a period of not less than 5 years.
16     (b) (1) An insurer that provides coverage for hospital or
17 medical expenses under a group policy of accident and health
18 insurance or health care plan amended, delivered, issued, or
19 renewed after the effective date of this amendatory Act of the
20 92nd General Assembly shall provide coverage under the policy
21 for treatment of serious mental illness under the same terms
22 and conditions as coverage for hospital or medical expenses
23 related to other illnesses and diseases. The coverage required
24 under this Section must provide for same durational limits,
25 amount limits, deductibles, and co-insurance requirements for
26 serious mental illness as are provided for other illnesses and

 

 

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1 diseases. This subsection does not apply to coverage provided
2 to employees by employers who have 50 or fewer employees.
3     (2) "Serious mental illness" means the following
4 psychiatric illnesses as defined in the most current edition of
5 the Diagnostic and Statistical Manual (DSM) published by the
6 American Psychiatric Association:
7         (A) schizophrenia;
8         (B) paranoid and other psychotic disorders;
9         (C) bipolar disorders (hypomanic, manic, depressive,
10     and mixed);
11         (D) major depressive disorders (single episode or
12     recurrent);
13         (E) schizoaffective disorders (bipolar or depressive);
14         (F) pervasive developmental disorders;
15         (G) obsessive-compulsive disorders;
16         (H) depression in childhood and adolescence;
17         (I) panic disorder;
18         (J) post-traumatic stress disorders (acute, chronic,
19     or with delayed onset); and
20         (K) anorexia nervosa and bulimia nervosa.
21     (3) (Blank). Upon request of the reimbursing insurer, a
22 provider of treatment of serious mental illness shall furnish
23 medical records or other necessary data that substantiate that
24 initial or continued treatment is at all times medically
25 necessary. An insurer shall provide a mechanism for the timely
26 review by a provider holding the same license and practicing in

 

 

SB1331 - 40 - LRB096 09831 DRJ 19994 b

1 the same specialty as the patient's provider, who is
2 unaffiliated with the insurer, jointly selected by the patient
3 (or the patient's next of kin or legal representative if the
4 patient is unable to act for himself or herself), the patient's
5 provider, and the insurer in the event of a dispute between the
6 insurer and patient's provider regarding the medical necessity
7 of a treatment proposed by a patient's provider. If the
8 reviewing provider determines the treatment to be medically
9 necessary, the insurer shall provide reimbursement for the
10 treatment. Future contractual or employment actions by the
11 insurer regarding the patient's provider may not be based on
12 the provider's participation in this procedure. Nothing
13 prevents the insured from agreeing in writing to continue
14 treatment at his or her expense. When making a determination of
15 the medical necessity for a treatment modality for serous
16 mental illness, an insurer must make the determination in a
17 manner that is consistent with the manner used to make that
18 determination with respect to other diseases or illnesses
19 covered under the policy, including an appeals process.
20     (4) A group health benefit plan:
21         (A) shall provide coverage based upon medical
22     necessity for the following treatment of mental illness in
23     each calendar year:
24             (i) 45 days of inpatient treatment; and
25             (ii) beginning on June 26, 2006 (the effective date
26         of Public Act 94-921), 60 visits for outpatient

 

 

SB1331 - 41 - LRB096 09831 DRJ 19994 b

1         treatment including group and individual outpatient
2         treatment; and
3             (iii) for plans or policies delivered, issued for
4         delivery, renewed, or modified after July 1, 2009
5         January 1, 2007 (the effective date of Public Act
6         94-906), 20 additional outpatient visits for speech
7         therapy for treatment of pervasive developmental
8         disorders that will be in addition to speech therapy
9         provided pursuant to item (ii) of this subparagraph
10         (A);
11         (B) may not include a lifetime limit on the number of
12     days of inpatient treatment or the number of outpatient
13     visits covered under the plan; and
14         (C) shall include the same amount limits, deductibles,
15     copayments, and coinsurance factors for serious mental
16     illness as for physical illness.
17     (5) An issuer of a group health benefit plan may not count
18 toward the number of outpatient visits required to be covered
19 under this Section an outpatient visit for the purpose of
20 medication management and shall cover the outpatient visits
21 under the same terms and conditions as it covers outpatient
22 visits for the treatment of physical illness.
23     (6) An issuer of a group health benefit plan may provide or
24 offer coverage required under this Section through a managed
25 care plan.
26     (7) This Section shall not be interpreted to require a

 

 

SB1331 - 42 - LRB096 09831 DRJ 19994 b

1 group health benefit plan to provide coverage for treatment of:
2         (A) an addiction to a controlled substance or cannabis
3     that is used in violation of law; or
4         (B) mental illness resulting from the use of a
5     controlled substance or cannabis in violation of law.
6     (8) (Blank).
7     (c)(1) On and after June 1, 2009, coverage for the
8 treatment of mental and emotional disorders as provided by
9 subsections (a) and (b) shall not be denied under the policy
10 provided that services are medically necessary as determined by
11 the insured's treating physician. For purposes of this
12 subsection, "medically necessary" means health care services
13 appropriate, in terms of type, frequency, level, setting, and
14 duration, to the enrollee's diagnosis or condition, and
15 diagnostic testing and preventive services. Medically
16 necessary care must be consistent with generally accepted
17 practice parameters as determined by health care providers in
18 the same or similar general specialty as typically manages the
19 condition, procedure, or treatment at issue and must be
20 intended to either help restore or maintain the enrollee's
21 health or prevent deterioration of the enrollee's condition.
22 Upon request of the reimbursing insurer, a provider of
23 treatment of serious mental illness shall furnish medical
24 records or other necessary data that substantiate that initial
25 or continued treatment is at all times medically necessary.
26     (2) On and after January 1, 2010, all of the provisions for

 

 

SB1331 - 43 - LRB096 09831 DRJ 19994 b

1 the treatment of and services for mental, emotional, or nervous
2 disorders or conditions, including the treatment of serious
3 mental illness, contained in subsections (a) and (b), and the
4 requirements relating to determinations based on medical
5 necessity contained in subdivision (c)(1) of this Section must
6 be contained in all group and individual Illinois Guaranteed
7 Option plans as defined by the Illinois Guaranteed Option Act.
8 (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05;
9 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; 95-331, eff.
10 8-21-07; 95-972, eff. 9-22-08; 95-973, eff. 1-1-09; revised
11 10-14-08.)
 
12     (215 ILCS 5/Art. XLV heading new)
13
ARTICLE XLV.

 
14     (215 ILCS 5/1500-5 new)
15     Sec. 1500-5. Office of Patient Protection. There is hereby
16 established within the Division of Insurance an Office of
17 Patient Protection to ensure that persons covered by health
18 insurance companies are provided the benefits due them under
19 this Code and related statutes and are protected from health
20 insurance company actions or policy provisions that are unjust,
21 unfair, inequitable, ambiguous, misleading, inconsistent,
22 deceptive, or contrary to law or to the public policy of this
23 State or that unreasonably or deceptively affect the risk
24 purported to be assumed.
 

 

 

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1     (215 ILCS 5/1500-10 new)
2     Sec. 1500-10. Powers of Office of Patient Protection.
3 Acting under the authority of the Director, the Office of
4 Patient Protection shall:
5     (1) have the power as established by Section 401 of this
6 Code to institute such actions or other lawful proceedings as
7 may be necessary for the enforcement of this Code; and
8     (2) oversee the responsibilities of the Office of Consumer
9 Health, including, but not limited to, responding to consumer
10 questions relating to health insurance.
 
11     (215 ILCS 5/1500-15 new)
12     Sec. 1500-15. Responsibility of Office of Patient
13 Protection. The Office of Patient Protection shall assist
14 health insurance company consumers with respect to the exercise
15 of the grievance and appeals rights established by Section 45
16 of the Managed Care Reform and Patient Rights Act.
 
17     (215 ILCS 5/1500-20 new)
18     Sec. 1500-20. Health insurance oversight. The
19 responsibilities of the Office of Patient Protection shall
20 include, but not be limited to, the oversight of health
21 insurance companies with respect to:
22     (1) Improper claims practices (Sections 154.5 and 154.6 of
23 this Code).

 

 

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1     (2) Emergency services.
2     (3) Compliance with the Managed Care Reform and Patient
3 Rights Act.
4     (4) Requiring health insurance companies to pay claims when
5 internal appeal time frames exceed requirements established by
6 the Managed Care Reform and Patient Rights Act.
7     (5) Ensuring coverage for mental health treatment,
8 including insurance company procedures for internal and
9 external review of denials for mental health coverage as
10 provided by Section 370c of this Code.
11     (6) Reviewing health insurance company eligibility,
12 underwriting, and claims practices.
 
13     (215 ILCS 5/1500-25 new)
14     Sec. 1500-25. Powers of the Director.
15     (a) The Director, in his or her discretion, may issue a
16 Notice of Hearing requiring a health insurance company to
17 appear at a hearing for the purpose of determining the health
18 insurance company's compliance with the duties and
19 responsibilities listed in Section 1500-15.
20     (b) Nothing in this Article XLV shall diminish or affect
21 the powers and authority of the Director of Insurance otherwise
22 set forth in this Code.
 
23     (215 ILCS 5/1500-30 new)
24     Sec. 1500-30. Operative date. This Article XLV is operative

 

 

SB1331 - 46 - LRB096 09831 DRJ 19994 b

1 on and after January 1, 2009.
 
2     Section 18-10. The Health Maintenance Organization Act is
3 amended by changing Section 5-3 as follows:
 
4     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
5     (Text of Section before amendment by P.A. 95-958)
6     Sec. 5-3. Insurance Code provisions.
7     (a) Health Maintenance Organizations shall be subject to
8 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
9 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
10 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
11 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
12 356z.13 356z.11, 356z.14, 359a, 364.01, 367.2, 367.2-5, 367i,
13 368a, 368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A,
14 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
15 subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,
16 XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
17 Insurance Code.
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":
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
9 acquisition of control of a Health Maintenance Organization
10 pursuant 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
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
18 enrollee population (including without limitation the health
19 maintenance organization's right, title, and interest in and to
20 its health care certificates).
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.
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:
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

 

 

SB1331 - 50 - LRB096 09831 DRJ 19994 b

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
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
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.
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.
23 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
24 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
25 8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised
26 12-15-08.)
 

 

 

SB1331 - 51 - LRB096 09831 DRJ 19994 b

1     (Text of Section after amendment by P.A. 95-958)
2     Sec. 5-3. Insurance Code provisions.
3     (a) Health Maintenance Organizations shall be subject to
4 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
5 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
6 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
7 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
8 356z.11, 356z.12, 356z.13 356z.11, 356z.14, 359a, 364.01,
9 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c, 401,
10 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
11 paragraph (c) of subsection (2) of Section 367, and Articles
12 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
13 the Illinois Insurance Code.
14     (b) For purposes of the Illinois Insurance Code, except for
15 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
16 Maintenance Organizations in the following categories are
17 deemed to be "domestic companies":
18         (1) a corporation authorized under the Dental Service
19     Plan Act or the Voluntary Health Services Plans Act;
20         (2) a corporation organized under the laws of this
21     State; or
22         (3) a corporation organized under the laws of another
23     state, 30% or more of the enrollees of which are residents
24     of this State, except a corporation subject to
25     substantially the same requirements in its state of

 

 

SB1331 - 52 - LRB096 09831 DRJ 19994 b

1     organization as is a "domestic company" under Article VIII
2     1/2 of the Illinois Insurance Code.
3     (c) In considering the merger, consolidation, or other
4 acquisition of control of a Health Maintenance Organization
5 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
6         (1) the Director shall give primary consideration to
7     the continuation of benefits to enrollees and the financial
8     conditions of the acquired Health Maintenance Organization
9     after the merger, consolidation, or other acquisition of
10     control takes effect;
11         (2)(i) the criteria specified in subsection (1)(b) of
12     Section 131.8 of the Illinois Insurance Code shall not
13     apply and (ii) the Director, in making his determination
14     with respect to the merger, consolidation, or other
15     acquisition of control, need not take into account the
16     effect on competition of the merger, consolidation, or
17     other acquisition of control;
18         (3) the Director shall have the power to require the
19     following information:
20             (A) certification by an independent actuary of the
21         adequacy of the reserves of the Health Maintenance
22         Organization sought to be acquired;
23             (B) pro forma financial statements reflecting the
24         combined balance sheets of the acquiring company and
25         the Health Maintenance Organization sought to be
26         acquired as of the end of the preceding year and as of

 

 

SB1331 - 53 - LRB096 09831 DRJ 19994 b

1         a date 90 days prior to the acquisition, as well as pro
2         forma financial statements reflecting projected
3         combined operation for a period of 2 years;
4             (C) a pro forma business plan detailing an
5         acquiring party's plans with respect to the operation
6         of the Health Maintenance Organization sought to be
7         acquired for a period of not less than 3 years; and
8             (D) such other information as the Director shall
9         require.
10     (d) The provisions of Article VIII 1/2 of the Illinois
11 Insurance Code and this Section 5-3 shall apply to the sale by
12 any health maintenance organization of greater than 10% of its
13 enrollee population (including without limitation the health
14 maintenance organization's right, title, and interest in and to
15 its health care certificates).
16     (e) In considering any management contract or service
17 agreement subject to Section 141.1 of the Illinois Insurance
18 Code, the Director (i) shall, in addition to the criteria
19 specified in Section 141.2 of the Illinois Insurance Code, take
20 into account the effect of the management contract or service
21 agreement on the continuation of benefits to enrollees and the
22 financial condition of the health maintenance organization to
23 be managed or serviced, and (ii) need not take into account the
24 effect of the management contract or service agreement on
25 competition.
26     (f) Except for small employer groups as defined in the

 

 

SB1331 - 54 - LRB096 09831 DRJ 19994 b

1 Small Employer Rating, Renewability and Portability Health
2 Insurance Act and except for medicare supplement policies as
3 defined in Section 363 of the Illinois Insurance Code, a Health
4 Maintenance Organization may by contract agree with a group or
5 other enrollment unit to effect refunds or charge additional
6 premiums under the following terms and conditions:
7         (i) the amount of, and other terms and conditions with
8     respect to, the refund or additional premium are set forth
9     in the group or enrollment unit contract agreed in advance
10     of the period for which a refund is to be paid or
11     additional premium is to be charged (which period shall not
12     be less than one year); and
13         (ii) the amount of the refund or additional premium
14     shall not exceed 20% of the Health Maintenance
15     Organization's profitable or unprofitable experience with
16     respect to the group or other enrollment unit for the
17     period (and, for purposes of a refund or additional
18     premium, the profitable or unprofitable experience shall
19     be calculated taking into account a pro rata share of the
20     Health Maintenance Organization's administrative and
21     marketing expenses, but shall not include any refund to be
22     made or additional premium to be paid pursuant to this
23     subsection (f)). The Health Maintenance Organization and
24     the group or enrollment unit may agree that the profitable
25     or unprofitable experience may be calculated taking into
26     account the refund period and the immediately preceding 2

 

 

SB1331 - 55 - LRB096 09831 DRJ 19994 b

1     plan years.
2     The Health Maintenance Organization shall include a
3 statement in the evidence of coverage issued to each enrollee
4 describing the possibility of a refund or additional premium,
5 and upon request of any group or enrollment unit, provide to
6 the group or enrollment unit a description of the method used
7 to calculate (1) the Health Maintenance Organization's
8 profitable experience with respect to the group or enrollment
9 unit and the resulting refund to the group or enrollment unit
10 or (2) the Health Maintenance Organization's unprofitable
11 experience with respect to the group or enrollment unit and the
12 resulting additional premium to be paid by the group or
13 enrollment unit.
14     In no event shall the Illinois Health Maintenance
15 Organization Guaranty Association be liable to pay any
16 contractual obligation of an insolvent organization to pay any
17 refund authorized under this Section.
18 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
19 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
20 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
21 eff. 12-12-08; revised 12-15-08.)
 
22     Section 18-15. The Managed Care Reform and Patient Rights
23 Act is amended by changing Section 45 as follows:
 
24     (215 ILCS 134/45)

 

 

SB1331 - 56 - LRB096 09831 DRJ 19994 b

1     Sec. 45. Health care services appeals, complaints, and
2 external independent reviews.
3     (a) A health insurance care plan shall establish and
4 maintain an appeals procedure as outlined in this Act.
5 Compliance with this Act's appeals procedures shall satisfy a
6 health insurance care plan's obligation to provide appeal
7 procedures under any other State law or rules. All appeals of a
8 health insurance care plan's administrative determinations and
9 complaints regarding its administrative decisions shall be
10 handled as required under Section 50.
11     (b) Internal appeals.
12         (1) When an appeal concerns a decision or action by a
13     health insurance care plan, its employees, or its
14     subcontractors that relates to (i) health care services,
15     including, but not limited to, procedures or treatments,
16     for an enrollee with an ongoing course of treatment ordered
17     by a health care provider, the denial of which could
18     significantly increase the risk to an enrollee's health, or
19     (ii) a treatment referral, service, procedure, or other
20     health care service, the denial of which could
21     significantly increase the risk to an enrollee's health,
22     the health insurance care plan must allow for the filing of
23     an appeal either orally or in writing.
24         (2) On and after June 1, 2009, a health plan must
25     prominently display a brief summary of its appeal
26     requirements as established by this Section, including the

 

 

SB1331 - 57 - LRB096 09831 DRJ 19994 b

1     manner in which an enrollee may initiate such appeals, in
2     all of its printed material sent to the enrollee as well as
3     on its website.
4         (3) Upon submission of the appeal, a health insurance
5     care plan must notify the party filing the appeal, as soon
6     as possible, but in no event more than 24 hours after the
7     submission of the appeal, of all information that the plan
8     requires to evaluate the appeal.
9         (4) The health insurance care plan shall render a
10     decision on the appeal within 24 hours after receipt of the
11     required information.
12         (5) The health insurance care plan shall notify the
13     party filing the appeal and the enrollee, enrollee's
14     primary care physician, and any health care provider who
15     recommended the health care service involved in the appeal
16     of its decision orally followed-up by a written notice of
17     the determination.
18         (6) For all denials of treatment for mental and
19     emotional disorders on and after June 1, 2009, the
20     following requirements shall apply:
21             (A) A plan's determination that care rendered or to
22         be rendered is inappropriate shall not be made until
23         the plan has communicated with the enrollee's
24         attending mental health professional concerning that
25         medical care. The review shall be made prior to or
26         concurrent with the treatment.

 

 

SB1331 - 58 - LRB096 09831 DRJ 19994 b

1             (B) A determination that care rendered or to be
2         rendered is inappropriate shall include the written
3         evaluation and findings of the mental health
4         professional whose training and expertise is at least
5         comparable to that of the treating clinician.
6             (C) Any determination regarding services rendered
7         or to be rendered for the treatment of mental and
8         emotional disorders for an enrollee which may result in
9         a denial of reimbursement or a denial of
10         pre-certification for that service shall, at the
11         request of the affected enrollee or provider as defined
12         by Section 370c of the Illinois Insurance Code, include
13         the specific review criteria, the procedures and
14         methods used in evaluating proposed or delivered
15         mental health care services, and the credentials of the
16         peer reviewer.
17             (D) In making any communication, a plan shall
18         ensure that all applicable State and federal laws to
19         protect the confidentiality of individual mental
20         health records are followed.
21             (E) A plan shall ensure that it provides
22         appropriate notification to and receives concurrence
23         from enrollees and their attending mental health
24         professional before any enrollee interviews are
25         conducted by the plan.
26         (7) On and after June 1, 2009, if the enrollee, the

 

 

SB1331 - 59 - LRB096 09831 DRJ 19994 b

1     enrollee's treating physician, and the health insurance
2     plan agree, or if the Office of Patient Protection
3     established under Section 1500-5 of the Illinois Insurance
4     Code explicitly allows, the claim determination may be
5     appealed directly to the external independent review as
6     described under subsection (f).
7         (8) On and after June 1, 2009, except as provided in
8     paragraph (7), an enrollee must exhaust the internal appeal
9     process prior to requesting an external independent
10     review.
11     (c) For all appeals related to health care services
12 including, but not limited to, procedures or treatments for an
13 enrollee and not covered by subsection (b) above, the health
14 care plan shall establish a procedure for the filing of such
15 appeals. Upon submission of an appeal under this subsection, a
16 health insurance care plan must notify the party filing an
17 appeal, within 3 business days, of all information that the
18 plan requires to evaluate the appeal. The health insurance care
19 plan shall render a decision on the appeal within 15 business
20 days after receipt of the required information. The health
21 insurance care plan shall notify the party filing the appeal,
22 the enrollee, the enrollee's primary care physician, and any
23 health care provider who recommended the health care service
24 involved in the appeal orally of its decision followed-up by a
25 written notice of the determination.
26     (d) An appeal under subsection (b) or (c) may be filed by

 

 

SB1331 - 60 - LRB096 09831 DRJ 19994 b

1 the enrollee, the enrollee's designee or guardian, the
2 enrollee's primary care physician, or the enrollee's health
3 care provider. A health insurance care plan shall designate a
4 clinical peer to review appeals, because these appeals pertain
5 to medical or clinical matters and such an appeal must be
6 reviewed by an appropriate health care professional. No one
7 reviewing an appeal may have had any involvement in the initial
8 determination that is the subject of the appeal. The written
9 notice of determination required under subsections (b) and (c)
10 shall include (i) clear and detailed reasons for the
11 determination, (ii) the medical or clinical criteria for the
12 determination, which shall be based upon sound clinical
13 evidence and reviewed on a periodic basis, and (iii) in the
14 case of an adverse determination, the procedures for requesting
15 an external independent review under subsection (f).
16     (e) If an appeal filed under subsection (b) or (c) is
17 denied for a reason including, but not limited to, the service,
18 procedure, or treatment is not viewed as medically necessary,
19 denial of specific tests or procedures, denial of referral to
20 specialist physicians or denial of hospitalization requests or
21 length of stay requests, and on and after June 1, 2009, if the
22 amount of the denial exceeds $250, any involved party may
23 request an external independent review under subsection (f) of
24 the adverse determination.
25     (f) External independent review.
26         (1) The party seeking an external independent review

 

 

SB1331 - 61 - LRB096 09831 DRJ 19994 b

1     shall so notify the health insurance care plan. The health
2     insurance care plan shall seek to resolve all external
3     independent reviews in the most expeditious manner and
4     shall make a determination and provide notice of the
5     determination no more than 24 hours after the receipt of
6     all necessary information when a delay would significantly
7     increase the risk to an enrollee's health or when extended
8     health care services for an enrollee undergoing a course of
9     treatment prescribed by a health care provider are at
10     issue.
11         (2) On and after June 1, 2009, within 180 Within 30
12     days after the enrollee receives written notice of an
13     adverse determination, if the enrollee decides to initiate
14     an external independent review, the enrollee shall send to
15     the health insurance care plan a written request for an
16     external independent review, including any information or
17     documentation to support the enrollee's request for the
18     covered service or claim for a covered service.
19         (3) Within 30 days after the health insurance care plan
20     receives a request for an external independent review from
21     an enrollee, the health insurance care plan shall:
22             (A) provide a mechanism for joint selection of an
23         external independent reviewer by the enrollee, the
24         enrollee's physician or other health care provider,
25         and the health insurance care plan; and
26             (B) forward to the independent reviewer all

 

 

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1         medical records and supporting documentation
2         pertaining to the case, a summary description of the
3         applicable issues including a statement of the health
4         care plan's decision, the criteria used, and the
5         medical and clinical reasons for that decision.
6         (4) Within 5 days after receipt of all necessary
7     information, the independent reviewer shall evaluate and
8     analyze the case and render a decision that is based on
9     whether or not the health care service or claim for the
10     health care service is medically appropriate. The decision
11     by the independent reviewer is final. If the external
12     independent reviewer determines the health care service to
13     be medically appropriate, the health insurance care plan
14     shall pay for the health care service. On and after June 1,
15     2009, an external independent review decision may be
16     appealed to the Office of Patient Protection established
17     under Section 1500-5 of the Illinois Insurance Code. In
18     cases in which the Division finds the external independent
19     review determination to have been arbitrary and
20     capricious, the Division, through the Office of Patient
21     Protection, may reverse the external independent review
22     determination.
23         (5) The health insurance care plan shall be solely
24     responsible for paying the fees of the external independent
25     reviewer who is selected to perform the review.
26         (6) An external independent reviewer who acts in good

 

 

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1     faith shall have immunity from any civil or criminal
2     liability or professional discipline as a result of acts or
3     omissions with respect to any external independent review,
4     unless the acts or omissions constitute wilful and wanton
5     misconduct. For purposes of any proceeding, the good faith
6     of the person participating shall be presumed.
7         (7) Future contractual or employment action by the
8     health insurance care plan regarding the patient's
9     physician or other health care provider shall not be based
10     solely on the physician's or other health care provider's
11     participation in this procedure.
12         (8) For the purposes of this Section, an external
13     independent reviewer shall:
14             (A) be a clinical peer;
15             (B) have no direct financial interest in
16         connection with the case; and
17             (C) have not been informed of the specific identity
18         of the enrollee.
19     (g) Nothing in this Section shall be construed to require a
20 health insurance care plan to pay for a health care service not
21 covered under the enrollee's certificate of coverage or policy.
22 (Source: P.A. 91-617, eff. 1-1-00.)
 
23
ARTICLE 30. COMMUNITY HEALTH CENTER CONSTRUCTION ACT

 
24     Section 30-1. Short title. This Article may be cited as the

 

 

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1 Community Health Center Construction Act. All references in
2 this Article to "this Act" mean this Article.
 
3     Section 30-5. Definitions. In this Act:
4     "Board" means the Illinois Capital Development Board.
5     "Community health center site" means a new physical site
6 where a community health center will provide primary health
7 care services either to a medically underserved population or
8 area or to the uninsured population of this State.
9     "Community provider" means a Federally Qualified Health
10 Center (FQHC) or FQHC Look-Alike (Community Health Center or
11 health center), designated as such by the Secretary of the
12 United States Department of Health and Human Services, that
13 operates at least one federally designated primary health care
14 delivery site in the State of Illinois.
15     "Department" means the Illinois Department of Public
16 Health.
17     "Medically underserved area" means an urban or rural area
18 designated by the Secretary of the United States Department of
19 Health and Human Services as an area with a shortage of
20 personal health services.
21     "Medically underserved population" means (i) the
22 population of an urban or rural area designated by the
23 Secretary of the United States Department of Health and Human
24 Services as an area with a shortage of personal health services
25 or (ii) a population group designated by the Secretary as

 

 

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1 having a shortage of those services.
2     "Primary health care services" means the following:
3         (1) Basic health services consisting of the following:
4             (A) Health services related to family medicine,
5         internal medicine, pediatrics, obstetrics, or
6         gynecology that are furnished by physicians and, if
7         appropriate, physician assistants, nurse
8         practitioners, and nurse midwives.
9             (B) Diagnostic laboratory and radiologic services.
10             (C) Preventive health services, including the
11         following:
12                 (i) Prenatal and perinatal services.
13                 (ii) Screenings for breast, ovarian, and
14             cervical cancer.
15                 (iii) Well-child services.
16                 (iv) Immunizations against vaccine-preventable
17             diseases.
18                 (v) Screenings for elevated blood lead levels,
19             communicable diseases, and cholesterol.
20                 (vi) Pediatric eye, ear, and dental screenings
21             to determine the need for vision and hearing
22             correction and dental care.
23                 (vii) Voluntary family planning services.
24                 (viii) Preventive dental services.
25             (D) Emergency medical services.
26             (E) Pharmaceutical services as appropriate for

 

 

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1         particular health centers.
2         (2) Referrals to providers of medical services and
3     other health-related services (including substance abuse
4     and mental health services).
5         (3) Patient case management services (including
6     counseling, referral, and follow-up services) and other
7     services designed to assist health center patients in
8     establishing eligibility for and gaining access to
9     federal, State, and local programs that provide or
10     financially support the provision of medical, social,
11     educational, or other related services.
12         (4) Services that enable individuals to use the
13     services of the health center (including outreach and
14     transportation services and, if a substantial number of the
15     individuals in the population are of limited
16     English-speaking ability, the services of appropriate
17     personnel fluent in the language spoken by a predominant
18     number of those individuals).
19         (5) Education of patients and the general population
20     served by the health center regarding the availability and
21     proper use of health services.
22         (6) Additional health services consisting of services
23     that are appropriate to meet the health needs of the
24     population served by the health center involved and that
25     may include the following:
26             (A) Environmental health services, including the

 

 

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1         following:
2                 (i) Detection and alleviation of unhealthful
3             conditions associated with water supply.
4                 (ii) Sewage treatment.
5                 (iii) Solid waste disposal.
6                 (iv) Detection and alleviation of rodent and
7             parasite infestation.
8                 (v) Field sanitation.
9                 (vi) Housing.
10                 (vii) Other environmental factors related to
11             health.
12             (B) Special occupation-related health services for
13         migratory and seasonal agricultural workers, including
14         the following:
15                 (i) Screening for and control of infectious
16             diseases, including parasitic diseases.
17                 (ii) Injury prevention programs, which may
18             include prevention of exposure to unsafe levels of
19             agricultural chemicals, including pesticides.
20     "Uninsured population" means persons who do not own private
21 health care insurance, are not part of a group insurance plan,
22 and are not eligible for any State or federal
23 government-sponsored health care program.
 
24     Section 30-10. Operation of the grant program.
25     (a) The Board, in consultation with the Department, shall

 

 

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1 establish the Community Health Center Construction Grant
2 Program and may make grants to eligible community providers
3 subject to appropriations out of funds reserved for capital
4 improvements or expenditures as provided for in this Act. The
5 Program shall operate in a manner so that the estimated cost of
6 the Program during the fiscal year will not exceed the total
7 appropriation for the Program. The grants shall be for the
8 purpose of constructing or renovating new community health
9 center sites, renovating existing community health center
10 sites, and purchasing equipment to provide primary health care
11 services to medically underserved populations or areas as
12 defined in Section 30-5 of this Act or providing primary health
13 care services to the uninsured population of Illinois.
14     (b) A recipient of a grant to establish a new community
15 health center site must add each such site to the recipient's
16 established service area for the purpose of extending federal
17 FQHC or FQHC Look Alike status to the new site in accordance
18 with federal regulations.
 
19     Section 30-15. Eligibility for grant. To be eligible for a
20 grant under this Act, a recipient must be a community provider
21 as defined in Section 30-5 of this Act.
 
22     Section 30-20. Use of grant moneys. A recipient of a grant
23 under this Act may use the grant moneys to do any one or more of
24 the following:

 

 

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1         (1) Purchase equipment.
2         (2) Acquire a new physical location for the purpose of
3     delivering primary health care services.
4         (3) Construct or renovate new or existing community
5     health center sites.
 
6     Section 30-25. Reporting. Within 60 days after the first
7 year of a grant under this Act, the grant recipient must submit
8 a progress report to the Department. The Department may assist
9 each grant recipient in meeting the goals and objectives stated
10 in the original grant proposal submitted by the recipient, that
11 grant moneys are being used for appropriate purposes, and that
12 residents of the community are being served by the new
13 community health center sites established with grant moneys.
 
14
ARTICLE 50. PROMOTING RESPONSIBILITY FOR HEALTH INSURANCE AND
15
HEALTHCARE COSTS

 
16     Section 50-5. Findings. A majority of Illinoisans receive
17 their healthcare through employer sponsored health insurance.
18 The cost of such healthcare has been rising faster than wage
19 inflation. A majority of businesses offer and subsidize such
20 health insurance. However, a growing number of businesses are
21 not offering health insurance. When a business does not offer
22 subsidized health insurance, employees are far more likely to
23 be uninsured and the costs of their healthcare are borne by

 

 

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1 other payors including other businesses. Likewise, when
2 individuals choose to forgo paying for health insurance, they
3 may still experience illness or be involved in an accident
4 resulting in high medical costs that are borne by others. This
5 cost shifting is driving up the cost of insurance for
6 responsible businesses who are offering health insurance and
7 other individuals who are purchasing health insurance in the
8 non-group market. It is also shifting costs to State
9 government, and therefore taxpayers, by expanding the costs of
10 current State healthcare programs. Therefore, the General
11 Assembly finds that it is equitable to assess businesses a fee
12 to offset such costs when such a business is not contributing
13 adequately to the cost of healthcare insurance and services for
14 its employees.
 
15
PART 1. SHORT TITLE AND CONSTRUCTION

 
16     Section 50-101. Short title. This Article may be cited as
17 the Illinois Shared Responsibility and Shared Opportunity
18 Assessment Act. References in this Article to "this Act" mean
19 this Article.
 
20     Section 50-105. Construction. Except as otherwise
21 expressly provided or clearly appearing from the context, any
22 term used in this Act shall have the same meaning as when used
23 in a comparable context in the Illinois Income Tax Act as in

 

 

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1 effect for the taxable year.
 
2
PART 2. DEFINITIONS AND MISCELLANEOUS PROVISIONS

 
3     Section 50-201. Definitions.
4     (a) When used in this Act, where not otherwise distinctly
5 expressed or manifestly incompatible with the intent thereof:
6     "Department" means the Department of Revenue.
7     "Director" means the Director of Revenue.
8     "Employer" means any individual, partnership, association,
9 corporation or other legal entity who employs 2 or more full
10 time equivalent employees during the taxable year. The word
11 "employer" shall not include nonprofit entities, as defined by
12 the Internal Revenue Code, that are exclusively staffed by
13 volunteers. The term "employer" does not include the government
14 of the United States, of any foreign country, or of any of the
15 states, or of any agency, instrumentality, or political
16 subdivision of any such government. In the case of a unitary
17 business group, as defined in Section 1501(a)(27) of the
18 Illinois Income Tax Act, the employer is the unitary business
19 group.
20     "Expenditures for health care" means any amount paid by an
21 employer to provide health care to its employees or their
22 families or reimburse its employees or their families for
23 health care, including but not limited to amounts paid or
24 reimbursed for health insurance premiums where the underlying

 

 

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1 policy provides or has provided coverage to employees of such
2 employer or their families. Such expenditures include but are
3 not limited to payment or reimbursement for medical care,
4 prescription drugs, vision care, medical savings accounts, and
5 any other costs to provide health care to an employer's
6 employees or their families.
7     "Full-time equivalent employees". The number of "full-time
8 equivalent employees" employed by an employer during a taxable
9 year shall be the lesser of (i) the number of persons who were
10 employees of the employer at any time during the taxable year
11 and (ii) the total number of hours worked by all employees of
12 the employer during the taxable year, divided by 1500. In the
13 case of a short taxable year, the denominator shall be 1500
14 multiplied by the number of days in the taxable year, divided
15 by the number of days in the calendar year.
16     "Illinois employee" means an employee who is an Illinois
17 resident during the time he or she is performing services for
18 the employer or who has compensation from the employer that is
19 "paid in this State" during the taxable year within the meaning
20 of Section 304(a)(2)(B) of the Illinois Income Tax Act. For
21 purposes of computing the liability under Section 50-301 for a
22 taxable year and the credit under Section 50-302 of this Act,
23 an employee with health care coverage provided by another
24 employer of that employee, or with health care coverage as a
25 dependent through another employer, is not an "Illinois
26 employee" for that taxable year.

 

 

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1     "Wages" means wages as defined in Section 3401(a) of the
2 Internal Revenue Code, without regard to the exceptions
3 contained in that Section and without reduction for exemptions
4 allowed in computing withholding.
5     (b) Other definitions.
6         (1) Words denoting number, gender, and so forth, when
7     used in this Act, where not otherwise distinctly expressed
8     or manifestly incompatible with the intent thereof:
9             (A) Words importing the singular include and apply
10         to several persons, parties or things;
11             (B) Words importing the plural include the
12         singular; and
13             (C) Words importing the masculine gender include
14         the feminine as well.
15         (2) "Company" or "association" as including successors
16     and assigns. The word "company" or "association", when used
17     in reference to a corporation, shall be deemed to embrace
18     the words "successors and assigns of such company or
19     association", and in like manner as if these last-named
20     words, or words of similar import, were expressed.
21         (3) Other terms. Any term used in any Section of this
22     Act with respect to the application of, or in connection
23     with, the provisions of any other Section of this Act shall
24     have the same meaning as in such other Section.
 
25     Section 50-202. Applicable Sections of the Illinois Income

 

 

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1 Tax Act. All of the provisions of Articles 5, 6, 9, 10, 11, 12,
2 13 and 14 of the Illinois Income Tax Act which are not
3 inconsistent with this Act shall apply, as far as practicable,
4 to the subject matter of this Act to the same extent as if such
5 provisions were included herein.
 
6     Section 50-203. Severability. It is the purpose of Section
7 50-301 of this Act to impose a tax upon the privilege of doing
8 business in this State, so far as the same may be done under
9 the Constitution and statutes of the United States and the
10 Constitution of the State of Illinois. If any clause, sentence,
11 Section, provision, part, or credit included in this Act, or
12 the application thereof to any person or circumstance, is
13 adjudged to be unconstitutional, then it is the intent of the
14 General Assembly that the tax imposed and the remainder of this
15 Act, or its application to persons or circumstances other than
16 those to which it is held invalid, shall not be affected
17 thereby.
 
18
PART 3. TAX IMPOSED

 
19     Section 50-301. Tax imposed.
20     (a) A tax is hereby imposed on each employer for the
21 privilege of doing business in this State at the rate of 1.5%
22 of the wages paid to Illinois employees by the employer during
23 the taxable year for firms with fewer than 10 full-time

 

 

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1 equivalent employees; at the rate of 3.0% of the wages paid to
2 Illinois full-time equivalent employees by the employer during
3 the taxable year for employers with between 10 and 24 full-time
4 equivalent employees; at the rate of 4.0% of the wages paid to
5 Illinois full-time equivalent employees by the employer during
6 the taxable year for firms with between 25 and 99 full-time
7 equivalent employees; at the rate of 5.0% of the wages paid to
8 Illinois full-time equivalent employees by the employer during
9 the taxable year for firms with between 100 and 999 full-time
10 equivalent employees; and at the rate of 6% of the wages paid
11 to Illinois full-time equivalent employees by the employer
12 during the taxable year for firms with 1000 or more employees,
13 provided that the tax on wages paid by the employer to any
14 single full-time equivalent employee shall not exceed $15,000
15 for the taxable year.
16     (b) The tax imposed under this Act shall apply to wages
17 paid on or after January 1, 2010 and shall be paid beginning
18 July 1, 2010 as set forth in Part 4 of this Act and thereafter.
19     (c) The tax imposed under this Act is a tax on the
20 employer, and shall not be withheld from wages paid to
21 employees or otherwise be collected from employees or reduce
22 the compensation paid to employees.
23     (d) The tax collected pursuant to this Section shall be
24 deposited in the Illinois Shared Responsibility and Shared
25 Opportunity Trust Fund established by Section 50-701 of this
26 Act.
 

 

 

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1     Section 50-302. Credits.
2     (a) For each taxable year, an employer whose total
3 expenditures for health care for Illinois employees equal or
4 exceed 4% of the wages paid to Illinois employees for that
5 taxable year shall be entitled to a full credit against the tax
6 imposed under Section 50-301.
7     (b) For each taxable year, an employer whose total
8 expenditures for health care for Illinois employees are less
9 than 4% of the wages paid to Illinois employees for that
10 taxable year shall be entitled to a partial credit against the
11 tax imposed under Section 50-301. The partial credit shall be
12 determined by the Illinois Health Care Justice Commission.
13     (c) If the tax otherwise due under subsection (a) of
14 Section 50-301 of this Act with respect to the wages of any
15 employee of the employer is $15,000, the credit allowed in
16 subsection (a) of this Section shall be computed without taking
17 into account any wages paid to that employee or any
18 expenditures for health care incurred with respect to that
19 Employee.
20     (d) For purposes of determining whether total expenditures
21 for health care for Illinois employees equal or exceed 4% of
22 the wages paid to Illinois employees for a taxable year, the
23 wages paid to and expenditures for health care for any Illinois
24 employee with health care coverage provided by another employer
25 of that employee, or with health care coverage as a dependent

 

 

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1 through another employer, shall be disregarded.
 
2     Section 50-303. Exemptions. Start-up businesses with 5 or
3 fewer full-time equivalent employees will be exempt from paying
4 this tax during their first 3 tax years of operation.
 
5
PART 4. PAYMENT OF ESTIMATED TAX

 
6     Section 50-401. Returns and notices.
7     (a) In General. Except as provided by the Department by
8 regulation, every employer qualified to do business in this
9 State at any time during a taxable year shall make a return
10 under this Act for that taxable year.
11     (b) Every employer shall keep such records, render such
12 statements, make such returns and notices, and comply with such
13 rules and regulations as the Department may from time to time
14 prescribe. Whenever in the judgment of the Director it is
15 necessary, he or she may require any person, by notice served
16 upon such person or by regulations, to make such returns and
17 notices, render such statements, or keep such records, as the
18 Director deems sufficient to show whether or not such person is
19 liable for the tax under this Act.
 
20     Section 50-402. Payment on due date of return. Every
21 employer required to file a return under this Act shall,
22 without assessment, notice, or demand, pay any tax due thereon

 

 

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1 to the Department, at the place fixed for filing, on or before
2 the date fixed for filing such return pursuant to regulations
3 prescribed by the Department. In making payment as provided in
4 this Section, there shall remain payable only the balance of
5 such tax remaining due after giving effect to payments of
6 estimated tax made by the employer under Section 50-403 of this
7 Act for the taxable year, which payments shall be deemed to
8 have been paid on account of the tax imposed by this Act for
9 the taxable year.
 
10     Section 50-403. Payment of estimated tax.
11     (a) Each taxpayer is required to pay estimated tax in
12 installments for each taxable year in the form and manner that
13 the Department requires by rule.
14     (b) Payment of an installment of estimated tax is due no
15 later than each due date during the taxable year under Article
16 7 of the Illinois Income Tax Act for payment of amounts
17 withheld from employee compensation by the employer.
18     (c) The amount of each installment shall be (1) the
19 percentage of employees' wages outlined in Section 50-301
20 during the period during which the employer withheld the amount
21 of Illinois income withholding that is due on the same date as
22 the installment, minus (2) the credit allowed for the taxable
23 year under Section 50-302 of this Act, multiplied by the number
24 of days during the period in clause (1), divided by 365.
25     (d) For purposes of Section 3-3 of the Uniform Penalty and

 

 

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1 Interest Act, a taxpayer shall be deemed to have failed to make
2 timely payment of an installment of estimated taxes due under
3 this Section only if the amount timely paid for that
4 installment is less than 90% of the amount due under subsection
5 (c) of this Section.
 
6
PART 7. ILLINOIS SHARED RESPONSIBILITY AND SHARED OPPORTUNITY
7
TRUST FUND

 
8     Section 50-701. Establishment of Fund.
9     (a) There is hereby established a fund to be known as the
10 Illinois Shared Responsibility and Shared Opportunity Trust
11 Fund. There shall be credited to this Fund all taxes collected
12 pursuant to this Act. The Illinois Shared Responsibility and
13 Shared Opportunity Trust Fund shall not be subject to sweeps,
14 administrative charges, or charge-backs, including but not
15 limited to those authorized under Section 8h of the State
16 Finance Act or any other fiscal or budgeting transfer that
17 would in any way transfer any funds from the Illinois Shared
18 Responsibility and Shared Opportunity Trust Fund into any other
19 fund of the State, except to repay funds transferred into this
20 Fund.
21     (b) Interest earnings, income from investments, and other
22 income earned by the Fund shall be credited to and deposited
23 into the Fund.
 

 

 

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1     Section 50-702. Use of Fund.
2     (a) Amounts credited to the Illinois Shared Responsibility
3 and Shared Opportunity Trust Fund shall be available
4 exclusively for providing affordable health care coverage for
5 working families and employers in Illinois, including, without
6 limitation, premium assistance, establishing and maintaining
7 reinsurance to keep health care affordable, and administering
8 and enforcing insurance market reforms, as well as providing
9 additional improvements to the healthcare system. Moneys that
10 have been deposited in the Trust Fund may be used to maximize
11 federal funds, so long as all moneys are expended in a manner
12 fully consistent with the purposes set forth in this Section.
13     (b) Not later than December 31 of each fiscal year, the
14 Governor's Office of Management and Budget shall prepare
15 estimates of the revenues to be credited to the Trust Fund in
16 the subsequent fiscal year and shall provide this report to the
17 General Assembly. In order to maintain the integrity of the
18 Illinois Shared Responsibility and Shared Opportunity Trust
19 Fund, for fiscal year 2010 through fiscal year 2012, the total
20 amount of expenditures from the Illinois Shared Responsibility
21 and Shared Opportunity Trust Fund shall be limited to each
22 fiscal year in relation to 90% of revenues generated during
23 such fiscal year.
24     (c) Beginning on or after July 1 of Fiscal Year 2009, the
25 General Assembly shall make appropriations of such estimated
26 revenues to the various programs authorized to be funded. If

 

 

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1 revenues credited to the Illinois Shared Responsibility and
2 Shared Opportunity Trust Fund are less than the amounts
3 estimated, the Governor's Office of Management and Budget shall
4 notify the General Assembly of such deficiency and shall notify
5 the Departments administering the programs funded from the
6 Trust Fund that the revenue deficiency shall require
7 proportionate reductions in expenditures from the revenues
8 available to support programs appropriated from the Illinois
9 Shared Responsibility and Shared Opportunity Trust Fund.
 
10     Section 50-703. The Illinois Shared Responsibility and
11 Shared Opportunity Trust Fund Financial Oversight Panel.
12     (a) Creation. In order to maintain the integrity of the
13 Illinois Shared Responsibility and Shared Opportunity Trust
14 Fund, prior to July 1, 2010, the Department shall create the
15 Illinois Shared Responsibility and Shared Opportunity Trust
16 Fund Financial Oversight Panel to monitor the revenues and
17 expenditures of the Trust Fund and to furnish information
18 regarding the Illinois programs to the Governor and the members
19 of the General Assembly.
20     (b) Membership. The Oversight Panel shall consist of 7
21 non-State employee members appointed by the Governor in
22 consultation with the Healthcare Justice Commission. Each
23 Panel member shall possess knowledge, skill, and experience in
24 at least one of the following areas of expertise: accounting,
25 actuarial practice, risk management, investment management,

 

 

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1 management and accounting practices specific to health
2 insurance administration, administration of public aid public
3 programs, or public sector fiscal management. Panel members
4 shall serve 3-year terms. If appropriate, the terms may be
5 modified at the Panel's inception to ensure a quorum. The
6 Governor shall bi-annually appoint a Chairman and
7 Vice-Chairman. Any person appointed to fill a vacancy on the
8 Panel shall be appointed in a like manner and shall serve only
9 the unexpired term. Panel members shall be eligible for
10 reappointment. Panel members shall serve without compensation
11 and be reimbursed for expenses.
12     (c) Statements of economic interest. Before being
13 installed as a member of the Panel, each appointee shall file
14 verified statements of economic interest with the Secretary of
15 State as required by the Illinois Governmental Ethics Act and
16 with the Board of Ethics as required by the Executive Order of
17 the Governor.
18     (d) Advice and review. The Panel shall offer advice and
19 counsel regarding the Illinois Shared Responsibility and
20 Shared Opportunity Trust Fund with the objective of expanding
21 access to affordable health care within the financial
22 constraints of the Trust Fund. The Panel is required to review,
23 and advise the Department, the General Assembly, and the
24 Governor on, the financial condition of the Trust Fund.
25     (e) Management. Upon the vote of a majority of the Panel,
26 the Panel shall have the authority to compensate for

 

 

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1 professional services rendered with respect to its duties and
2 shall also have the authority to compensate for accounting,
3 computing, and other necessary services.
4     (f) Semi-annual accounting and audit. The Panel shall
5 semi-annually prepare or cause to be prepared a semi-annual
6 report setting forth in appropriate detail an accounting of the
7 Trust Fund and a description of the financial condition of the
8 Trust Fund at the close of each fiscal year, including:
9 semi-annual revenues to the Trust Fund, semi-annual
10 expenditures from the Trust Fund, implementation and results of
11 cost-saving measures, program utilization, and projections for
12 program development.
13     If the Panel determines that insufficient funds exist in
14 the Trust Fund to pay anticipated obligations in the next
15 succeeding fiscal year, the Panel shall so certify in the
16 semi-annual report the amount necessary to meet the anticipated
17 obligations. The Panel's semi-annual report shall be directed
18 to the President of the Senate, the Speaker of the House of
19 Representatives, the Minority Leader of the Senate, and the
20 Minority Leader of the House of Representatives.
 
21
PART 8. SEVERABILITY

 
22     Section 50-801. Severability. It is the purpose of Section
23 50-301 of this Act to impose a tax upon the privilege of doing
24 business in this State, so far as the same may be done under

 

 

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1 the Constitution and statutes of the United States and the
2 Constitution of the State of Illinois. If any clause, sentence,
3 Section, provision, part, or credit included in this Act, or
4 the application thereof to any person or circumstance, is
5 adjudged to be unconstitutional, then it is the intent of the
6 General Assembly that the tax imposed and the remainder of this
7 Act, or its application to persons or circumstances other than
8 those to which it is held invalid, shall not be affected
9 thereby.

 

 

SB1331 - 85 - LRB096 09831 DRJ 19994 b

1 INDEX
2 Statutes amended in order of appearance
3     New Act
4     305 ILCS 5/1-12 new
5     305 ILCS 5/1-13 new
6     215 ILCS 5/352b new
7     215 ILCS 5/359a from Ch. 73, par. 971a
8     215 ILCS 5/370c from Ch. 73, par. 982c
9     215 ILCS 5/Art. XLV
10     heading new
11     215 ILCS 5/1500-5 new
12     215 ILCS 5/1500-10 new
13     215 ILCS 5/1500-15 new
14     215 ILCS 5/1500-20 new
15     215 ILCS 5/1500-25 new
16     215 ILCS 5/1500-30 new
17     215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
18     215 ILCS 134/45