98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB1547

 

Introduced 2/13/2013, by Sen. William R. Haine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/355.4 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003  from Ch. 73, par. 1504-3
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the Illinois Insurance Code, Health Maintenance Organization Act, Limited Health Service Organization Act, and Voluntary Health Services Plans Act. Provides that no insurer may issue a service provider contract that requires an optometrist or ophthalmologist to provide services or materials to the insurer's policyholders at a fee set by the insurer unless the services or materials are covered services or materials under the applicable policyholder agreement. Effective January 1, 2014.


LRB098 07852 RPM 37936 b

 

 

A BILL FOR

 

SB1547LRB098 07852 RPM 37936 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 5. The Illinois Insurance Code is amended by adding
5Section 355.4 as follows:
 
6    (215 ILCS 5/355.4 new)
7    Sec. 355.4. Noncovered vision services.
8    (a) In this Section:
9        "Covered services" means vision care services for
10    which a reimbursement is available under an enrollee's plan
11    contract, or for which a reimbursement would be available
12    but for the application of contractual limitations such as
13    deductibles, copayments, coinsurance, waiting periods,
14    annual or lifetime maximums, frequency limitations,
15    alternative benefit payments, or any other limitation.
16        "Vision insurance" means any policy of insurance that
17    is issued by a company that provides coverage for vision
18    services not covered by a medical plan.
19    (b) No company that issues, delivers, amends, or renews an
20individual or group policy of accident and health insurance on
21or after the effective date of this amendatory Act of the 98th
22General Assembly that provides vision insurance shall issue a
23service provider contract that requires an optometrist or

 

 

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1ophthalmologist to provide services or materials to the
2insurer's policyholders at a fee set by the insurer unless the
3services or materials are covered services or materials under
4the applicable policyholder agreement.
 
5    Section 10. The Health Maintenance Organization Act is
6amended by changing Section 5-3 as follows:
 
7    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
8    Sec. 5-3. Insurance Code provisions.
9    (a) Health Maintenance Organizations shall be subject to
10the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
11141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
12154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
13355.4, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
14356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
15356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
16364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
17370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
18444, and 444.1, paragraph (c) of subsection (2) of Section 367,
19and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
20and 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. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
796-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11;
897-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12;
997-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff.
107-13-12.)
 
11    Section 15. The Limited Health Service Organization Act is
12amended by changing Section 4003 as follows:
 
13    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
14    Sec. 4003. Illinois Insurance Code provisions. Limited
15health service organizations shall be subject to the provisions
16of Sections 133, 134, 136, 137, 139, 140, 141.1, 141.2, 141.3,
17143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6,
18154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355.4, 356v,
19356z.10, 356z.21, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2,
20409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII
211/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance
22Code. For purposes of the Illinois Insurance Code, except for
23Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
24health service organizations in the following categories are

 

 

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1deemed to be domestic companies:
2        (1) a corporation under the laws of this State; or
3        (2) a corporation organized under the laws of another
4    state, 30% of more of the enrollees of which are residents
5    of this State, except a corporation subject to
6    substantially the same requirements in its state of
7    organization as is a domestic company under Article VIII
8    1/2 of the Illinois Insurance Code.
9(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.
101-1-13; 97-813, eff. 7-13-12.)
 
11    Section 20. 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, 136, 139, 140,
18143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355.4,
19356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x,
20356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
21356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
22356z.19, 356z.21, 364.01, 367.2, 368a, 401, 401.1, 402, 403,
23403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
24Section 367 of the Illinois Insurance Code.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10;
896-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12;
997-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13;
1097-813, eff. 7-13-12.)
 
11    Section 99. Effective date. This Act takes effect January
121, 2014.