97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB0280

 

Introduced 01/28/11, by Rep. Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
New Act

    Creates the Premium and Loss Data Reporting Act. Provides that all insurers subject to the Act shall report to the Director of the Division of Insurance accurate and complete information for each accident and health coverage type requested. Sets forth the specific types of accident and health coverage requested for reporting. Imposes conditions on any rulemaking authority.


LRB097 06640 RPM 46726 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB0280LRB097 06640 RPM 46726 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be cited as the
5Premium and Loss Data Reporting Act.
 
6    Section 5. Application. This Act shall apply to: (i) all
7insurers authorized to transact the class of business set forth
8in subsection (b) of Class 1 and subsection (a) of Class 2 of
9Section 4 of the Illinois Insurance Code; and (ii) all health
10plans authorized under the Health Maintenance Organization
11Act.
 
12    Section 10. Definitions. In this Act:
13    "Accident only" means an insurance contract that provides
14coverage, alone or in combination, for death, dismemberment,
15disability, or hospital and medical care caused by or
16necessitated as a result of accident or specified kinds of
17accidents.
18    "Accidental death and dismemberment" means an insurance
19contract that pays a stated benefit in the event of death or
20dismemberment caused by accident or specified kinds of
21accidents.
22    "Administrative services only" means a contractual

 

 

HB0280- 2 -LRB097 06640 RPM 46726 b

1arrangement utilized by a self-funded employer, whereby a
2separate company processes claims and provides other
3administrative services pertinent to the employer's health
4care plans. The fees associated with these services are
5included in this Act.
6    "Annual statement" means that statement required by
7Section 136 of the Illinois Insurance Code to be filed annually
8by the company with the Director.
9    "Blanket accident/sickness" means a health insurance
10contract that covers all of a class of persons not individually
11identified in the contract.
12    "Champus/Tricare supplement" means Civilian Health and
13Medical Program of the Uniformed Services (Champus).
14"Champus/Tricare supplement" also includes a private health
15plan that provides beneficiaries eligible for Champus with
16supplemental health care coverage.
17    "Code" means the Illinois Insurance Code.
18    "Covered dependents at end of reporting quarter" means the
19total number of individuals covered by the primary insured's
20plan who receive coverage due to his or her dependent
21relationship to the primary insured, as of the final day of the
22reporting quarter.
23    "Dental" means insurance that provides benefits for
24routine dental examinations, preventive dental work, and
25dental procedures needed to treat tooth decay and diseases of
26the teeth and jaw.

 

 

HB0280- 3 -LRB097 06640 RPM 46726 b

1    "Direct premiums earned for new and renewal business" means
2the insurers direct premium earned from the first through the
3final day of the reporting quarter, and includes only premium
4specific to covered Illinois residents.
5    "Director" means the Director of the Division of Insurance
6of the Illinois Department of Financial and Professional
7Regulation.
8    "Direct losses incurred" means direct losses incurred from
9the first through the final day of the reporting quarter and
10includes only premium specific to covered Illinois residents.
11    "Direct premiums earned for new business only" means the
12direct premium earned for new business only from the first
13through the final day of the reporting and includes only
14premium specific to covered Illinois residents.
15    "Disability income" means a policy designed to compensate
16insureds for a portion of the income they lose because of a
17disabling injury or illness. "Disability income" includes
18business overhead expense, short-term, long-term, and combined
19short-term and long-term coverage.
20    "Employers, if group coverage, at end of reporting quarter"
21means for all group categories, the number of employers who
22covered Illinois resident employees, as of the final day of the
23reporting quarter.
24    "Excess/stop loss" means the type of insurance may be
25extended to either a health plan or self-insured employer plan.
26Its purpose is to insure against the risk that any one claim

 

 

HB0280- 4 -LRB097 06640 RPM 46726 b

1will exceed a specific dollar amount or that an entire plan's
2losses will exceed a specific amount. "Excess/stop loss"
3includes accident and sickness, managed care, provider, and
4self-funded health plan coverage.
5    "FEHBP" means health, vision, and dental coverage provided
6pursuant to the Federal Employees Health Benefits Program.
7    "Hospital indemnity" means an insurance contract that pays
8a fixed dollar amount without regard to the actual expense
9incurred for each day the covered person is confined to the
10hospital as a result of injury, sickness, or medical condition.
11    "Hospital surgical" means an insurance contract that
12provides coverage to or reimburses the covered person for
13hospital, surgical, or medical expense incurred as a result of
14injury, sickness, or medical condition.
15    "In-state" groups means Illinois groups with group master
16contracts issued to a trust sitused in Illinois.
17    "Insurer" means an insurance company authorized to
18transact the class of business as set forth in subsection (b)
19of Class 1 and subsection (a) of Class 2 of Section 4 of the
20Insurance Code, as well as health care plans authorized under
21the Health Maintenance Organization Act.
22    "Limited benefit" means the plan: (1) pays benefits for the
23diagnosis and treatment of a specifically named disease or
24diseases. Benefits can be paid as expense incurred, per diem,
25or a principle sum; (2) provides a daily benefit for
26confinement in a qualified intensive care unit of a certified

 

 

HB0280- 5 -LRB097 06640 RPM 46726 b

1hospital. Benefits are specific to services delivered by the
2staff of a hospital intensive care unit. Benefits are not to
3exceed a stated dollar amount per day; and (3) provides
4benefits for services incurred as a result of human or
5non-human organ transplant. Benefits are specific to the
6delivery of care associated with the covered organ or tissue
7transplant. Benefits are not to exceed a stated dollar amount
8per day. "Limited benefit" includes coverage for specified
9disease, critical illness, dread disease, dread disease-cancer
10only, HIV indemnity, intensive care, and organ and tissue
11transplant.
12    "Long-term care" means coverage that includes long-term
13care, nursing home, and home care contracts that provide
14reimbursement for these services.
15    "Loss-ratio" means the insurer's ratio of direct losses
16incurred to direct premiums earned for new and renewal business
17from the first through the final day of the reporting quarter
18and includes only premium specific to covered Illinois
19residents.
20    "Major medical" means a hospital, surgical, or medical
21expense contract that is designed to cover expenses of serious
22illness, chronic care, or hospitalization. "Major medical"
23does not include hospital indemnity, accidental death and
24dismemberment, workers' compensation, credit accident and
25health, short-term accident and health, accident only,
26long-term care, Medicare supplement, pre-paid products,

 

 

HB0280- 6 -LRB097 06640 RPM 46726 b

1student blanket, stand-alone policies, dental-only,
2vision-only, prescription drug benefits, disability income,
3specified disease, or similar supplementary benefits; coverage
4issued as a supplement to liability insurance; workers'
5compensation or similar insurance; or automobile
6medical-payment insurance.
7    "Medicare supplement" means a group or individual policy of
8accident or health insurance or a subscriber contract of
9hospital and medical service associations, other than a policy
10issued pursuant to a contract under Section 1876 of the federal
11Social Security Act or a policy issued pursuant to a
12demonstration project specified in Section 1395ss(g)(1) of the
13federal Social Security Act, which is advertised, marketed, or
14designed primarily as a supplement to reimbursements under
15Medicare for the hospital, medical, or surgical expenses of
16persons eligible for Medicare.
17    "Member months at end of reporting quarter" means the total
18number of months that each member or policyholder is provided
19coverage from the first day through the final day of the
20reporting quarter.
21    "Out-of-state" groups means groups that have master
22contracts issued to a trust sitused outside of Illinois.
23    "Primary insureds at end of reporting quarter" means the
24total number of resident individual policyholders or resident
25group employee or member certificate holders, as of the final
26day of the reporting quarter.

 

 

HB0280- 7 -LRB097 06640 RPM 46726 b

1    "Quarter" means the following quarter years:
2        (1) October 1 through December 31;
3        (2) January 1 through March 31;
4        (3) April 1 through June 30; and
5        (4) July 1 through September 30.
6     "Short-term care" means coverage that includes medical and
7other services to insureds who need constant care in their own
8home or in a nursing facility for periods of less than one
9year. "Short-term care" includes home health care, nursing
10home, and adult day care.
11    "Student" means a health insurance contract that covers a
12class of students not individually identified in the contract.
13    "Travel" means limited benefit expense policies and
14benefits for loss incurred while traveling generally outside a
15100-mile radius of the US borders, subject to State
16limitations.
17    "Vision" means limited benefit expense policies that
18provide benefits for eye care and eye care accessories and may
19include surgical benefits for injury or sickness associated
20with the eye.
21    "Wellness program participation premium discounts" means
22the dollar value of plan-administered premium discounts,
23rebates of premium or contribution, or waivers of all or part
24of a surcharge or cost-sharing mechanism, such as deductibles,
25co-pays, or coinsurance, provided to individual insureds for
26their participation in a bona fide wellness program, from the

 

 

HB0280- 8 -LRB097 06640 RPM 46726 b

1first day through the final day of the reporting quarter. To
2qualify as a bona fide wellness program, the program must:
3        (1) offer a limited reward or discount;
4        (2) be reasonably designed to promote good health and
5    disease prevention;
6        (3) allow policyholders to qualify for the program's
7    reward at least once per year; and
8        (4) be available to all similarly situated employees,
9    with reasonable alternative standards for those for which
10    the general standard is unreasonably difficult or
11    medically inadvisable.
 
12    Section 15. Reports.
13    (a) All insurers subject to this Act shall, beginning at
14the current quarter and year, and continuing through all
15subsequent quarters and years, report accurate and complete
16information for each accident and health coverage type
17requested to the Director. The following reports are requested:
18        (1) on the final day of each quarter, file a quarterly
19    report for the prior quarter (not for the quarter on which
20    the due date falls) regarding information on health benefit
21    plans currently in force in this State; and
22        (2) on or before April 1 for the preceding year ending
23    December 31, file an annual report for the prior year (not
24    for the year on which the due date falls) regarding
25    information on health benefit plans currently at force in

 

 

HB0280- 9 -LRB097 06640 RPM 46726 b

1    this State.
2In addition, insurers with comprehensive major medical
3business currently in force in this State that covers more than
4500 unduplicated persons (primary insureds plus dependents)
5shall, on or before April 1 for the preceding year ending
6December 31, file a completed annual supplemental report with
7premium and loss data on health benefit plans currently in
8force in this State.
9    Information reported under this Section must be reported in
10an aggregate format. This Section does not allow for the
11collection of any information that allows for the
12identification of an individual provider.
13    (b) The following comprehensive major medical, major
14medical, and other hospital-surgical coverage types are
15requested in this Act:
16        (1) major medical;
17        (2) hospital surgical;
18        (3) in-state groups;
19        (4) out-of-state groups;
20        (5) administrative services only;
21        (6) accident only;
22        (7) accidental death and dismemberment;
23        (8) blanket accident/sickness;
24        (9) dental;
25        (10) disability income (includes business overhead
26    expense, short-term, and long-term);

 

 

HB0280- 10 -LRB097 06640 RPM 46726 b

1        (11) combined short-term and long-term;
2        (12) excess/stop loss (includes accident and sickness,
3    managed care, provider, and self-funded health plan);
4        (13) FEHBP coverage provided pursuant to the federal
5    employees health benefits program.
6        (14) limited benefit (includes specified disease,
7    critical illness, dread disease, dread disease-cancer
8    only, HIV indemnity, intensive care, and organ and tissue
9    transplant);
10        (15) short-term care (includes home health care,
11    nursing home, and adult day care) Medicare supplement;
12        (16) Champus/Tricare supplement;
13        (17) travel;
14        (18) vision; and
15        (19) other accident and health care coverage not
16    specifically described.
17    (c) The following information is requested for each
18accident and coverage type requested:
19        (1) direct premiums earned for new and renewal
20    business;
21        (2) direct losses incurred;
22        (3) direct premiums earned for new business;
23        (4) loss-ratio;
24        (5) employers, if group coverage, at end of reporting
25    quarter;
26        (6) primary insureds at end of reporting quarter;

 

 

HB0280- 11 -LRB097 06640 RPM 46726 b

1        (7) covered dependents at end of reporting quarter;
2        (8) member months at end of reporting quarter; and
3        (9) wellness program participation premium discounts.
 
4    Section 20. Rulemaking conditions. Rulemaking authority to
5implement this Act, if any, is conditioned on the rules being
6adopted in accordance with all provisions of the Illinois
7Administrative Procedure Act and all rules and procedures of
8the Joint Committee on Administrative Rules; any purported rule
9not so adopted, for whatever reason, is unauthorized.