093_HB0211enr

 
HB0211 Enrolled                      LRB093 04018 JLS 04057 b

 1        AN ACT concerning insurance coverage.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

 4        Section  3.  The  State  Employees Group Insurance Act of
 5    1971 is amended by changing Section 6.11 as follows:

 6        (5 ILCS 375/6.11)
 7        Sec. 6.11.  Required health benefits; Illinois  Insurance
 8    Code  requirements.   The  program  of  health benefits shall
 9    provide the post-mastectomy  care  benefits  required  to  be
10    covered  by  a  policy of accident and health insurance under
11    Section 356t of the Illinois Insurance Code.  The program  of
12    health  benefits  shall  provide  the coverage required under
13    Sections 356u, 356w, 356x, and  356z.2,  and  356z.4  of  the
14    Illinois  Insurance Code. The program of health benefits must
15    comply with Section 155.37 of the Illinois Insurance Code.
16    (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03.)

17        Section 5.  The Illinois Insurance  Code  is  amended  by
18    adding Section 356z.4 as follows:

19        (215 ILCS 5/356z.4 new)
20        Sec. 356z.4.  Coverage for contraceptives.
21        (a)  An individual or group policy of accident and health
22    insurance  amended,  delivered,  issued,  or  renewed in this
23    State after the effective date of this amendatory Act of  the
24    93rd  General  Assembly that provides coverage for outpatient
25    services and outpatient prescription drugs  or  devices  must
26    provide  coverage  for  the  insured and any dependent of the
27    insured  covered   by   the   policy   for   all   outpatient
28    contraceptive services and all outpatient contraceptive drugs
29    and  devices  approved  by  the Food and Drug Administration.



 
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 1    Coverage required under  this  Section  may  not  impose  any
 2    deductible,    coinsurance,    waiting   period,   or   other
 3    cost-sharing or limitation that is greater than that required
 4    for any outpatient service or outpatient prescription drug or
 5    device otherwise covered by the policy.
 6        (b)  As used in this Section,  "outpatient  contraceptive
 7    service"  means  consultations, examinations, procedures, and
 8    medical services, provided on an outpatient basis and related
 9    to the use of contraceptive methods (including natural family
10    planning) to prevent an unintended pregnancy.
11        (c)  Nothing  in  this  Section  shall  be  construed  to
12    require an insurance company to cover services related to  an
13    abortion  as  the  term "abortion" is defined in the Illinois
14    Abortion Law of 1975.
15        (d)  Nothing  in  this  Section  shall  be  construed  to
16    require an insurance company to  cover  services  related  to
17    permanent sterilization that requires a surgical procedure.

18        Section  10.  The  Health Maintenance Organization Act is
19    amended by changing Section 5-3 as follows:

20        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
21        Sec. 5-3.  Insurance Code provisions.
22        (a)  Health Maintenance Organizations shall be subject to
23    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
24    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
25    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
26    356y, 356z.2, 356z.4, 367i, 368a, 401, 401.1, 402, 403, 403A,
27    408,  408.2,  409,  412,  444,  and  444.1,  paragraph (c) of
28    subsection (2) of Section 367, and Articles  IIA,  VIII  1/2,
29    XII,  XII  1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
30    Insurance Code.
31        (b)  For purposes of the Illinois Insurance Code,  except
32    for  Sections  444  and 444.1 and Articles XIII and XIII 1/2,
 
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 1    Health Maintenance Organizations in the following  categories
 2    are deemed to be "domestic companies":
 3             (1)  a   corporation  authorized  under  the  Dental
 4        Service Plan Act or the Voluntary Health  Services  Plans
 5        Act;
 6             (2)  a  corporation organized under the laws of this
 7        State; or
 8             (3)  a  corporation  organized  under  the  laws  of
 9        another state, 30% or more of the enrollees of which  are
10        residents  of this State, except a corporation subject to
11        substantially the  same  requirements  in  its  state  of
12        organization  as  is  a  "domestic company" under Article
13        VIII 1/2 of the Illinois Insurance Code.
14        (c)  In considering the merger, consolidation,  or  other
15    acquisition  of  control of a Health Maintenance Organization
16    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
17             (1)  the Director shall give  primary  consideration
18        to  the  continuation  of  benefits  to enrollees and the
19        financial conditions of the acquired  Health  Maintenance
20        Organization  after  the  merger, consolidation, or other
21        acquisition of control takes effect;
22             (2)(i)  the criteria specified in subsection  (1)(b)
23        of Section 131.8 of the Illinois Insurance Code shall not
24        apply  and (ii) the Director, in making his determination
25        with respect  to  the  merger,  consolidation,  or  other
26        acquisition  of  control,  need not take into account the
27        effect on competition of the  merger,  consolidation,  or
28        other acquisition of control;
29             (3)  the  Director  shall  have the power to require
30        the following information:
31                  (A)  certification by an independent actuary of
32             the  adequacy  of  the  reserves   of   the   Health
33             Maintenance Organization sought to be acquired;
34                  (B)  pro  forma financial statements reflecting
 
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 1             the combined balance sheets of the acquiring company
 2             and the Health Maintenance Organization sought to be
 3             acquired as of the end of the preceding year and  as
 4             of  a date 90 days prior to the acquisition, as well
 5             as  pro  forma   financial   statements   reflecting
 6             projected  combined  operation  for  a  period  of 2
 7             years;
 8                  (C)  a pro forma  business  plan  detailing  an
 9             acquiring   party's   plans   with  respect  to  the
10             operation of  the  Health  Maintenance  Organization
11             sought  to be acquired for a period of not less than
12             3 years; and
13                  (D)  such other  information  as  the  Director
14             shall 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
17    by any health maintenance organization of greater than 10% of
18    its  enrollee  population  (including  without limitation the
19    health maintenance organization's right, title, and  interest
20    in and to 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,
25    take  into  account  the effect of the management contract or
26    service  agreement  on  the  continuation  of   benefits   to
27    enrollees   and   the   financial  condition  of  the  health
28    maintenance organization to be managed or serviced, and  (ii)
29    need  not  take  into  account  the  effect of the management
30    contract or service agreement on competition.
31        (f)  Except for small employer groups as defined  in  the
32    Small  Employer  Rating,  Renewability and Portability Health
33    Insurance Act and except for medicare supplement policies  as
34    defined  in  Section  363  of  the Illinois Insurance Code, a
 
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 1    Health Maintenance Organization may by contract agree with  a
 2    group  or  other  enrollment unit to effect refunds or charge
 3    additional premiums under the following terms and conditions:
 4             (i)  the amount of, and other terms  and  conditions
 5        with respect to, the refund or additional premium are set
 6        forth  in the group or enrollment unit contract agreed in
 7        advance of the period for which a refund is to be paid or
 8        additional premium is to be charged (which  period  shall
 9        not be less than one year); and
10             (ii)  the amount of the refund or additional premium
11        shall   not   exceed   20%   of  the  Health  Maintenance
12        Organization's profitable or unprofitable experience with
13        respect to the group or other  enrollment  unit  for  the
14        period  (and,  for  purposes  of  a  refund or additional
15        premium, the profitable or unprofitable experience  shall
16        be calculated taking into account a pro rata share of the
17        Health   Maintenance  Organization's  administrative  and
18        marketing expenses, but shall not include any  refund  to
19        be made or additional premium to be paid pursuant to this
20        subsection (f)).  The Health Maintenance Organization and
21        the   group   or  enrollment  unit  may  agree  that  the
22        profitable or unprofitable experience may  be  calculated
23        taking into account the refund period and the immediately
24        preceding 2 plan years.
25        The  Health  Maintenance  Organization  shall  include  a
26    statement in the evidence of coverage issued to each enrollee
27    describing the possibility of a refund or additional premium,
28    and  upon request of any group or enrollment unit, provide to
29    the group or enrollment unit a description of the method used
30    to  calculate  (1)  the  Health  Maintenance   Organization's
31    profitable experience with respect to the group or enrollment
32    unit and the resulting refund to the group or enrollment unit
33    or  (2)  the  Health  Maintenance Organization's unprofitable
34    experience with respect to the group or enrollment  unit  and
 
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 1    the  resulting  additional premium to be paid by the group or
 2    enrollment unit.
 3        In  no  event  shall  the  Illinois  Health   Maintenance
 4    Organization  Guaranty  Association  be  liable  to  pay  any
 5    contractual  obligation  of  an insolvent organization to pay
 6    any refund authorized under this Section.
 7    (Source: P.A. 91-357,  eff.  7-29-99;  91-406,  eff.  1-1-00;
 8    91-549,  eff.  8-14-99;  91-605,  eff. 12-14-99; 91-788, eff.
 9    6-9-00; 92-764, eff. 1-1-03.)

10        Section 15.  The Voluntary Health Services Plans  Act  is
11    amended by changing Section 10 as follows:

12        (215 ILCS 165/10) (from Ch. 32, par. 604)
13        Sec.   10.  Application  of  Insurance  Code  provisions.
14    Health services plan corporations and all persons  interested
15    therein   or  dealing  therewith  shall  be  subject  to  the
16    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
17    140, 143, 143c, 149, 155.37, 354, 355.2,  356r,  356t,  356u,
18    356v,  356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 367.2, 368a,
19    401,  401.1,  402,  403,  403A,  408,  408.2,  and  412,  and
20    paragraphs (7) and  (15)  of  Section  367  of  the  Illinois
21    Insurance Code.
22    (Source: P.A.  91-406,  eff.  1-1-00;  91-549,  eff. 8-14-99;
23    91-605, eff. 12-14-99;  91-788,  eff.  6-9-00;  92-130,  eff.
24    7-20-01;  92-440, eff. 8-17-01; 92-651, eff. 7-11-02; 92-764,
25    eff. 1-1-03.)