97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB1611

 

Introduced 2/15/2011, by Rep. Karen May

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/355b new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Illinois Insurance Code, Health Maintenance Organization Act, and Voluntary Health Services Plans Act to provide that if an accident and health insurance policy is to be in effect during more than one calendar year, then all deductibles and annual maximum out-of-pocket payment limits under the policy shall be applicable to the term of the policy and shall not be applicable to each calendar year in which the policy is in effect. Effective immediately.


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FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.17 of the Illinois Insurance Code.
16The program of health benefits must comply with Sections
17Section 155.37 and 355b of the Illinois Insurance Code.
18    Rulemaking authority to implement Public Act 95-1045, if
19any, is conditioned on the rules being adopted in accordance
20with all provisions of the Illinois Administrative Procedure
21Act and all rules and procedures of the Joint Committee on
22Administrative Rules; any purported rule not so adopted, for
23whatever reason, is unauthorized.

 

 

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1(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
295-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
36-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044,
4eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
596-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
696-1000, eff. 7-2-10.)
 
7    Section 10. The Counties Code is amended by changing
8Section 5-1069.3 as follows:
 
9    (55 ILCS 5/5-1069.3)
10    Sec. 5-1069.3. Required health benefits. If a county,
11including a home rule county, is a self-insurer for purposes of
12providing health insurance coverage for its employees, the
13coverage shall include coverage for the post-mastectomy care
14benefits required to be covered by a policy of accident and
15health insurance under Section 356t and the coverage required
16under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
17356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
18356z.14, and 356z.15 of the Illinois Insurance Code. The
19coverage shall comply with Section 355b of the Illinois
20Insurance Code. The requirement that health benefits be covered
21as provided in this Section is an exclusive power and function
22of the State and is a denial and limitation under Article VII,
23Section 6, subsection (h) of the Illinois Constitution. A home
24rule county to which this Section applies must comply with

 

 

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1every provision of this Section.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
995-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
106-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
11eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
1296-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
13    Section 15. The Illinois Municipal Code is amended by
14changing Section 10-4-2.3 as follows:
 
15    (65 ILCS 5/10-4-2.3)
16    Sec. 10-4-2.3. Required health benefits. If a
17municipality, including a home rule municipality, is a
18self-insurer for purposes of providing health insurance
19coverage for its employees, the coverage shall include coverage
20for the post-mastectomy care benefits required to be covered by
21a policy of accident and health insurance under Section 356t
22and the coverage required under Sections 356g, 356g.5,
23356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
24356z.11, 356z.12, 356z.13, 356z.14, and 356z.15 of the Illinois

 

 

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1Insurance Code. The coverage shall comply with Section 355b of
2the Illinois Insurance Code. The requirement that health
3benefits be covered as provided in this is an exclusive power
4and function of the State and is a denial and limitation under
5Article VII, Section 6, subsection (h) of the Illinois
6Constitution. A home rule municipality to which this Section
7applies must comply with every provision of this Section.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1595-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
166-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
17eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
1896-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
19    Section 20. The School Code is amended by changing Section
2010-22.3f as follows:
 
21    (105 ILCS 5/10-22.3f)
22    Sec. 10-22.3f. Required health benefits. Insurance
23protection and benefits for employees shall provide the
24post-mastectomy care benefits required to be covered by a

 

 

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1policy of accident and health insurance under Section 356t and
2the coverage required under Sections 356g, 356g.5, 356g.5-1,
3356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
4356z.13, 356z.14, and 356z.15 of the Illinois Insurance Code.
5The coverage shall comply with Section 355b of the Illinois
6Insurance Code.
7    Rulemaking authority to implement Public Act 95-1045, if
8any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1495-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
1595-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
161-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-1000,
17eff. 7-2-10.)
 
18    Section 25. The Illinois Insurance Code is amended by
19adding Section 355b as follows:
 
20    (215 ILCS 5/355b new)
21    Sec. 355b. Annual payment limits. If a group or individual
22accident and health insurance policy amended, delivered,
23issued, or renewed after the effective date of this amendatory
24Act of the 97th General Assembly is to be in effect during more

 

 

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1than one calendar year, then all deductibles and annual maximum
2out-of-pocket payment limits under the policy shall be
3applicable to the term of the policy and shall not be
4applicable to each calendar year in which the policy is in
5effect.
 
6    Section 30. The Health Maintenance Organization Act is
7amended by changing Section 5-3 as follows:
 
8    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
9    Sec. 5-3. Insurance Code provisions.
10    (a) Health Maintenance Organizations shall be subject to
11the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
12141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
13154.6, 154.7, 154.8, 155.04, 355.2, 355b, 356g.5-1, 356m, 356v,
14356w, 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,
15356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
16356z.17, 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
17368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
18409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
19Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
20XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
21    (b) For purposes of the Illinois Insurance Code, except for
22Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
23Maintenance Organizations in the following categories are
24deemed to be "domestic companies":

 

 

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1        (1) a corporation authorized under the Dental Service
2    Plan Act or the Voluntary Health Services Plans Act;
3        (2) a corporation organized under the laws of this
4    State; or
5        (3) a corporation organized under the laws of another
6    state, 30% or more of the enrollees of which are residents
7    of this State, except a corporation subject to
8    substantially the same requirements in its state of
9    organization as is a "domestic company" under Article VIII
10    1/2 of the Illinois Insurance Code.
11    (c) In considering the merger, consolidation, or other
12acquisition of control of a Health Maintenance Organization
13pursuant to Article VIII 1/2 of the Illinois Insurance Code,
14        (1) the Director shall give primary consideration to
15    the continuation of benefits to enrollees and the financial
16    conditions of the acquired Health Maintenance Organization
17    after the merger, consolidation, or other acquisition of
18    control takes effect;
19        (2)(i) the criteria specified in subsection (1)(b) of
20    Section 131.8 of the Illinois Insurance Code shall not
21    apply and (ii) the Director, in making his determination
22    with respect to the merger, consolidation, or other
23    acquisition of control, need not take into account the
24    effect on competition of the merger, consolidation, or
25    other acquisition of control;
26        (3) the Director shall have the power to require the

 

 

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1    following information:
2            (A) certification by an independent actuary of the
3        adequacy of the reserves of the Health Maintenance
4        Organization sought to be acquired;
5            (B) pro forma financial statements reflecting the
6        combined balance sheets of the acquiring company and
7        the Health Maintenance Organization sought to be
8        acquired as of the end of the preceding year and as of
9        a date 90 days prior to the acquisition, as well as pro
10        forma financial statements reflecting projected
11        combined operation for a period of 2 years;
12            (C) a pro forma business plan detailing an
13        acquiring party's plans with respect to the operation
14        of the Health Maintenance Organization sought to be
15        acquired for a period of not less than 3 years; and
16            (D) such other information as the Director shall
17        require.
18    (d) The provisions of Article VIII 1/2 of the Illinois
19Insurance Code and this Section 5-3 shall apply to the sale by
20any health maintenance organization of greater than 10% of its
21enrollee population (including without limitation the health
22maintenance organization's right, title, and interest in and to
23its health care certificates).
24    (e) In considering any management contract or service
25agreement subject to Section 141.1 of the Illinois Insurance
26Code, the Director (i) shall, in addition to the criteria

 

 

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1specified in Section 141.2 of the Illinois Insurance Code, take
2into account the effect of the management contract or service
3agreement on the continuation of benefits to enrollees and the
4financial condition of the health maintenance organization to
5be managed or serviced, and (ii) need not take into account the
6effect of the management contract or service agreement on
7competition.
8    (f) Except for small employer groups as defined in the
9Small Employer Rating, Renewability and Portability Health
10Insurance Act and except for medicare supplement policies as
11defined in Section 363 of the Illinois Insurance Code, a Health
12Maintenance Organization may by contract agree with a group or
13other enrollment unit to effect refunds or charge additional
14premiums under the following terms and conditions:
15        (i) the amount of, and other terms and conditions with
16    respect to, the refund or additional premium are set forth
17    in the group or enrollment unit contract agreed in advance
18    of the period for which a refund is to be paid or
19    additional premium is to be charged (which period shall not
20    be less than one year); and
21        (ii) the amount of the refund or additional premium
22    shall not exceed 20% of the Health Maintenance
23    Organization's profitable or unprofitable experience with
24    respect to the group or other enrollment unit for the
25    period (and, for purposes of a refund or additional
26    premium, the profitable or unprofitable experience shall

 

 

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1    be calculated taking into account a pro rata share of the
2    Health Maintenance Organization's administrative and
3    marketing expenses, but shall not include any refund to be
4    made or additional premium to be paid pursuant to this
5    subsection (f)). The Health Maintenance Organization and
6    the group or enrollment unit may agree that the profitable
7    or unprofitable experience may be calculated taking into
8    account the refund period and the immediately preceding 2
9    plan years.
10    The Health Maintenance Organization shall include a
11statement in the evidence of coverage issued to each enrollee
12describing the possibility of a refund or additional premium,
13and upon request of any group or enrollment unit, provide to
14the group or enrollment unit a description of the method used
15to calculate (1) the Health Maintenance Organization's
16profitable experience with respect to the group or enrollment
17unit and the resulting refund to the group or enrollment unit
18or (2) the Health Maintenance Organization's unprofitable
19experience with respect to the group or enrollment unit and the
20resulting additional premium to be paid by the group or
21enrollment unit.
22    In no event shall the Illinois Health Maintenance
23Organization Guaranty Association be liable to pay any
24contractual obligation of an insolvent organization to pay any
25refund authorized under this Section.
26    (g) Rulemaking authority to implement Public Act 95-1045,

 

 

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1if any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
795-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
895-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
91-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
106-1-10; 96-1000, eff. 7-2-10.)
 
11    Section 35. The Voluntary Health Services Plans Act is
12amended by changing Section 10 as follows:
 
13    (215 ILCS 165/10)  (from Ch. 32, par. 604)
14    Sec. 10. Application of Insurance Code provisions. Health
15services plan corporations and all persons interested therein
16or dealing therewith shall be subject to the provisions of
17Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
18149, 155.37, 354, 355.2, 355b, 356g, 356g.5, 356g.5-1, 356r,
19356t, 356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4,
20356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
21356z.13, 356z.14, 356z.15, 356z.18, 364.01, 367.2, 368a, 401,
22401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
23and (15) of Section 367 of the Illinois Insurance Code.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

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1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
795-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
88-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
9eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
1096-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff.
117-2-10.)
 
12    Section 99. Effective date. This Act takes effect upon
13becoming law.