Illinois General Assembly - Full Text of HB3175
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Full Text of HB3175  102nd General Assembly




HB3175 EnrolledLRB102 16868 BMS 22274 b

1    AN ACT concerning regulation.
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
5changing Section 356z.17 as follows:
6    (215 ILCS 5/356z.17)
7    Sec. 356z.17. Wellness coverage.
8    (a) A group or individual policy of accident and health
9insurance or managed care plan amended, delivered, issued, or
10renewed after January 1, 2010 (the effective date of Public
11Act 96-639) that provides coverage for hospital or medical
12treatment on an expense incurred basis may offer a reasonably
13designed program for wellness coverage that allows for a
14reward, a contribution, a reduction in premiums or reduced
15medical, prescription drug, or equipment copayments,
16coinsurance, or deductibles, or a combination of these
17incentives, for participation in any health behavior wellness,
18maintenance, or improvement program approved or offered by the
19insurer or managed care plan. The insured or enrollee may be
20required to provide evidence of participation in a program.
21Individuals unable to participate in these incentives due to
22an adverse health factor shall not be penalized based upon an
23adverse health status.



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1    (b) For purposes of this Section, "wellness coverage"
2means health care coverage with the primary purpose to engage
3and motivate the insured or enrollee through: incentives;
4provision of health education, counseling, and self-management
5skills; identification of modifiable health risks; and other
6activities to influence health behavior changes.
7    For the purposes of this Section, "reasonably designed
8program" means a program of wellness coverage that has a
9reasonable chance of improving health or preventing disease;
10is not overly burdensome; does not discriminate based upon
11factors of health; and is not otherwise contrary to law.
12    (c) Incentives as outlined in this Section are specific
13and unique to the offering of wellness coverage and have no
14application to any other required or optional health care
16    (d) Such wellness coverage must satisfy the requirements
17for an exception from the general prohibition against
18discrimination based on a health factor under the federal
19Health Insurance Portability and Accountability Act of 1996
20(P.L. 104-191; 110 Stat. 1936), including any federal
21regulations that are adopted pursuant to that Act.
22    (e) A plan offering wellness coverage must do the
24        (i) give participants the opportunity to qualify for
25    offered incentives at least once a year;
26        (ii) allow a reasonable alternative to any individual



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1    for whom it is unreasonably difficult, due to a medical
2    condition, to satisfy otherwise applicable wellness
3    program standards. Plans may seek physician verification
4    that health factors make it unreasonably difficult or
5    medically inadvisable for the participant to satisfy the
6    standards; and
7        (iii) not provide a total incentive that exceeds 30%
8    20% of the cost of self-only or employee-only coverage,
9    except that the incentive may be increased by up to an
10    additional 20%, for a total incentive of 50%, to the
11    extent that the additional percentage is in connection
12    with a program designed to prevent or reduce tobacco use.
13    The cost of employee-only or family coverage provided
14    through group health insurance coverage includes both
15    employer and employee contributions. For group or
16    individual plans offering family coverage, the 20%
17    limitation applies to cost of family coverage and applies
18    to the entire family.
19    (f) A reward, contribution, or reduction established under
20this Section and included in the policy or certificate does
21not violate Section 151 of this Code.
22(Source: P.A. 96-639, eff. 1-1-10; 96-833, eff. 6-1-10.)
23    Section 10. The Navigator Certification Act is amended by
24changing Sections 5, 10, 15, 30, 35, and 45 as follows:



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1    (215 ILCS 121/5)
2    Sec. 5. Definitions. As used in this Act:
3    "Certified application counselor" has the same meaning as
4in federal regulations and guidelines, including 45 CFR
6    "Director" means the Director of Insurance.
7    "Exchange" means any health benefit exchange established
8or operating in this State, including any exchange established
9or operated by the United States Department of Health and
10Human Services.
11    "Navigator" means a person or entity selected to perform
12the activities and duties identified in 42 U.S.C. 18031(i) in
13this State. "Navigator" includes any person or entity who
14receives grant funds from the United States Department of
15Health and Human Services, the State of Illinois, or an
16exchange or private funds to perform any of the activities and
17duties identified in 42 U.S.C. 18031(i), including, but not
18limited to, in-person assisters as defined by federal
19regulations or guidelines.
20(Source: P.A. 98-524, eff. 8-23-13.)
21    (215 ILCS 121/10)
22    Sec. 10. Certificate required.
23    (a) No individual or entity shall perform, offer to
24perform, or advertise any service as a navigator or certified
25application counselor in this State or receive navigator grant



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1funding from the United States Department of Health and Human
2Services, the State of Illinois, or an exchange or private
3funds unless certified as a navigator or certified application
4counselor by the Director under this Act.
5    (b) The Director may establish exemptions from
6certification by rule. A navigator who complies with the
7requirements of this Act shall do the following:
8        (1) conduct public education activities to raise
9    awareness of the availability of qualified health plans;
10        (2) distribute fair and impartial information
11    concerning enrollment in qualified health plans offered
12    within the exchange and the availability of the premium
13    tax credits under Section 36B of the Internal Revenue Code
14    of 1986, 26 U.S.C. 36B, and cost-sharing reductions under
15    Section 1402 of the federal Patient Protection and
16    Affordable Care Act;
17        (3) facilitate enrollment in qualified health plans;
18        (4) provide referrals to appropriate federal and State
19    agencies for any enrollee with a grievance, complaint, or
20    question regarding their health plan or coverage or a
21    determination under such plan or coverage;
22        (5) provide information in a manner that is culturally
23    and linguistically appropriate to the needs of the
24    population being served by the exchange.
25    (c) A navigator or certified application counselor may



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1        (1) sell, solicit, or negotiate, as these terms are
2    defined in Section 500-10 of the Illinois Insurance Code,
3    any of the classes of insurance enumerated in Section 4 of
4    the Illinois Insurance Code;
5        (2) offer advice about which health plan is better or
6    worse for a particular individual or employer;
7        (3) recommend or endorse a particular health plan or
8    advise consumers about which health plan to choose;
9        (4) provide any information or services related to
10    health benefit plans or other insurance products not
11    offered in the exchange, except for health care providers
12    when furnishing information or services related to a
13    patient's existing health benefit plan or other existing
14    health insurance coverage; or
15        (5) accept any compensation or consideration, directly
16    or indirectly, from any issuer of accident and health
17    insurance or stop-loss insurance that is dependent, in
18    whole or in part, on whether a person enrolls in or
19    purchases a particular private health benefit plan; or .
20        (6) engage in an unfair method of competition or a
21    fraudulent, deceptive, or dishonest act or practice with
22    respect to the health insurance marketplace or with
23    respect to that individual's or entity's absence of a
24    conflict of interest in connection with the enrollment of
25    an individual or employee in a particular private health
26    benefit plan.



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1    (d) Items (1), (2), (3), (4), and (5) of subsection (c) of
2this Section do not apply to navigators or certified
3application counselors when assisting individuals with the
4enrollment process in the State Medicaid program or other
5public programs.
6(Source: P.A. 98-524, eff. 8-23-13.)
7    (215 ILCS 121/15)
8    Sec. 15. Application for certificate.
9    (a) An entity or individual applying for an initial or
10renewal a navigator or certified application counselor
11certificate shall make application to the Director on a form
12developed by the Director and declare under penalty of
13refusal, suspension, or revocation of the certificate that the
14statements made in the application are true, correct, and
15complete to the best of the individual's or entity's knowledge
16and belief. Before approving the application, the Director
17shall find that the individual:
18        (1) is at least 18 years of age;
19        (2) resides in this State or maintains his or her
20    principal place of business in this State;
21        (3) is not disqualified due to having committed any
22    act that would be grounds for denial, suspension, or
23    revocation of a navigator certification in accordance with
24    Section 30 of this Act;
25        (4) has successfully completed the federal and State



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1    training provided by the exchange or equivalent State
2    requirements as determined by the Department; and
3        (5) when applicable, has the written consent of the
4    Director pursuant to 18 U.S.C. 1033, or any successor
5    statute regulating crimes by or affecting persons engaged
6    in the business of insurance whose activities affect
7    interstate commerce.
8    (b) The Director shall establish certification terms and
9requirements for completed applications, including educational
10requirements, by rule. An entity that acts as a navigator,
11supervises the activities of individual navigators, or
12receives funding to perform such activities shall obtain a
13navigator entity certificate. An entity applying for a
14navigator entity certificate shall make application on a form
15containing the information prescribed by the Director and
16shall list the individuals acting as navigators under the
17entity certificate.
18        (1) The entity shall designate a certified navigator
19    responsible for the navigator entity's compliance with the
20    laws of this State and the exchange.
21        (2) The entity, under penalty of revocation,
22    suspension, or other discipline prescribed by the
23    Director, shall certify that each individual completes the
24    mandatory training required by item (4) of subsection (a)
25    of Section 15 of this Act.
26    (c) The Director may require any documents deemed



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1necessary to verify the information contained in an
2application submitted in accordance with subsections (a) and
3(b) of this Section.
4    (d) Any navigator or certified application counselor who
5fails to timely file for certificate renewal shall be charged
6a late fee in an amount prescribed by the Director Entities
7certified as navigators shall provide the Director with a list
8of all individual navigators that it employs, supervises, or
9is affiliated with at renewal.
10    (e) The Director may require, in a manner determined by
11the Director, that each entity that acts as a navigator or
12certified application counselor demonstrate a level of
13financial responsibility capable of protecting all persons
14against the wrongful acts, misrepresentations, or negligence
15of the navigator or certified application counselor.
16    (f) Prior to any exchange becoming operational in this
17State, the Director, in coordination with the exchange, shall
18prescribe the initial training and continuing education
19requirements for navigators and certified application
21    (g) Certificate holders must inform the Director, in
22writing, of a change of address within 30 days after the
24    (h) In order to assist in the performance of the
25Director's duties, the Director may contract with the National
26Association of Insurance Commissioners (NAIC), or any



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1affiliates or subsidiaries that the NAIC oversees, to perform
2any ministerial functions, including the collection of fees,
3related to certification that the Director and the
4nongovernmental entity may deem appropriate.
5(Source: P.A. 98-524, eff. 8-23-13.)
6    (215 ILCS 121/30)
7    Sec. 30. Certificate denial, nonrenewal, or revocation.
8    (a) The Director may place on probation, suspend, revoke,
9or refuse to issue or renew a navigator or certified
10application counselor navigator's certificate or may levy a
11civil penalty as established by rule.
12    (b) If an action by the Director is to nonrenew, suspend,
13or revoke a certificate or to deny an application for a
14certificate, then the Director shall notify the applicant or
15certificate holder and advise, in writing, the applicant or
16certificate holder of the reason for the suspension,
17revocation, or denial or nonrenewal of the applicant's or
18certificate holder's certificate. The applicant or certificate
19holder may make written demand upon the Director within 30
20days after the date of mailing for a hearing before the
21Director to determine the reasonableness of the Director's
22action. The hearing must be held within not fewer than 20 days
23nor more than 30 days after the mailing of the notice of
24hearing and shall be held pursuant to Part 2402 of Title 50 of
25the Illinois Administrative Code.



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1    (c) A navigator or certified application counselor entity
2certificate may be suspended, revoked, or refused or
3information turned over to the U.S. Department of Health and
4Human Services and applicable state agencies if the Director
5finds, after hearing, that a certified individual's violation
6was known or should have been known by one or more of the
7partners, officers, or managers acting on behalf of the
8navigator entity.
9    (d) In addition to or instead of any applicable denial,
10suspension, or revocation of a certificate, a person may,
11after hearing, be subject to a civil penalty in accordance
12with emergency rules issued by the Director.
13    (e) The Director has the authority to enforce the
14provisions of and impose any penalty or remedy authorized by
15this Act against any person who is under investigation of or
16charged with a violation of this Act or rules, even if the
17person's certificate has been surrendered or has lapsed by
18operation of law.
19    (f) Upon the suspension, denial, or revocation of a
20certificate, the certificate holder or other person having
21possession or custody of the certificate shall promptly
22deliver it to the Director in person or by mail. The Director
23shall publish all suspensions, denials, or revocations after
24the suspensions, denials, or revocations become final in a
25manner designed to notify the public.
26    (g) A person whose certificate is revoked or whose



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1application is denied pursuant to this Section is ineligible
2to apply for any certificate for 3 years after the revocation
3or denial. A person whose certificate as a navigator or
4certified application counselor has been revoked, suspended,
5or denied may not be employed, contracted, or engaged in an
6exchange-related capacity during the time the revocation,
7suspension, or denial is in effect.
8(Source: P.A. 98-524, eff. 8-23-13.)
9    (215 ILCS 121/35)
10    Sec. 35. Reporting to the Director.
11    (a) Each navigator or certified application counselor
12shall report to the Director within 30 calendar days after the
13final disposition of a matter that violates the provisions set
14forth in this Act that results in any administrative action
15taken against the navigator or certified application counselor
16him in another jurisdiction or by another governmental agency
17in this State. The report shall include a copy of the order,
18consent to order, or other relevant legal documents.
19    (b) Within 30 days after the initial pretrial hearing
20date, a navigator or certified application counselor shall
21report to the Director any criminal prosecution of the
22navigator or certified application counselor of a matter that
23violates the provisions set forth in this Act taken in any
24jurisdiction. The report shall include a copy of the initial
25complaint filed, the order resulting from the hearing, and any



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1other relevant legal documents.
2    (c) An entity that is certified acts as a navigator or
3certified application counselor that terminates the
4employment, engagement, affiliation, or other relationship
5with an individual navigator or certified application
6counselor shall notify the Director within 30 days following
7the effective date of the termination, using a format
8prescribed by the Director, if the reason for termination is
9related to the requirements or standards one of the reasons
10set forth in this Act or the rules adopted by the Director
11pursuant to this Act, or the entity has knowledge the
12navigator or certified application counselor was found by a
13court or government body to have engaged in any of the
14activities prohibited by this Act or the rules adopted by the
15Director pursuant to this Act. Upon the written request of the
16Director, the entity shall provide additional information,
17documents, records, or other data pertaining to the
18termination or activity of the individual.
19(Source: P.A. 98-524, eff. 8-23-13.)
20    (215 ILCS 121/45)
21    Sec. 45. Other laws; rulemaking authority.
22    (a) The requirements of this Act shall not apply to any
23individual or entity licensed as an insurance producer in this
25    (b) Pursuant to the authority granted by this Act, the



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1Director may adopt rules as may be necessary or appropriate
2for the administration and enforcement of this Act. Such rules
3may not conflict with or prevent the application of the
4provisions of Title I of the Patient Protection and Affordable
5Care Act or the federal regulations promulgated under such
7(Source: P.A. 98-524, eff. 8-23-13.)
8    (215 ILCS 121/20 rep.)
9    (215 ILCS 121/25 rep.)
10    (215 ILCS 121/40 rep.)
11    Section 15. The Navigator Certification Act is amended by
12repealing Sections 20, 25, and 40.
13    Section 99. Effective date. This Act takes effect upon
14becoming law.



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2 Statutes amended in order of appearance
3    215 ILCS 5/356z.17
4    215 ILCS 121/5
5    215 ILCS 121/10
6    215 ILCS 121/15
7    215 ILCS 121/30
8    215 ILCS 121/35
9    215 ILCS 121/45
10    215 ILCS 121/20 rep.
11    215 ILCS 121/25 rep.
12    215 ILCS 121/40 rep.