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Full Text of SB1812  97th General Assembly

SB1812 97TH GENERAL ASSEMBLY

  
  

 


 
97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB1812

 

Introduced 2/9/2011, by Sen. Terry Link

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/352b new
215 ILCS 5/356r
215 ILCS 5/356r.1 new
215 ILCS 5/356z.12
215 ILCS 5/356z.19 new
215 ILCS 5/356z.20 new
215 ILCS 5/356z.21 new
215 ILCS 5/356z.23 new
215 ILCS 5/356z.24 new
215 ILCS 5/356z.25 new
215 ILCS 5/359c
215 ILCS 5/359f new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2

    Amends the Illinois Insurance Code. Adds definitions. Makes changes in the provisions concerning woman's principal health care provider and dependent coverage. Sets forth provisions concerning woman's health care providers; coverage of preventative services; annual and lifetime limits; reinstatement of coverage; patient protections; choice of health care professional; access to pediatric care; patient protections; coverage of emergency services; coverage for children with preexisting conditions; and health insurance rescissions and notice and hearing. Makes changes to the provision concerning accident and health reporting (now, accident and health expense reporting). Amends the Health Maintenance Organization Act to comport with the Illinois Insurance Code. Effective immediately.


LRB097 09496 RPM 49633 b

 

 

A BILL FOR

 

SB1812LRB097 09496 RPM 49633 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
5Sections 352b, 356r.1, 356z.19, 356z.20, 356z.21, 356z.23,
6356z.24, 356z.25, and 359f and by changing Sections 356r,
7356z.12, and 359c as follows:
 
8    (215 ILCS 5/352b new)
9    Sec. 352b. Definitions. Unless otherwise provided, as used
10in this Article the terms listed in this Section have the
11following meanings:
12    "Grandfathered health plan" has the same meaning given the
13term in Section 1251 of the Patient Protection and Affordable
14Care Act and applicable regulations.
15    "Health insurance issuer" has the same meaning given the
16term in the Illinois Health Insurance Portability and
17Accountability Act.
18    "Health insurance coverage" has the same meaning given the
19term in the Illinois Health Insurance Portability and
20Accountability Act.
21    "Group health insurance" has the same meaning given the
22term in the Illinois Health Insurance Portability and
23Accountability Act.

 

 

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1    "Individual health insurance" has the same meaning given
2the term in the Illinois Health Insurance Portability and
3Accountability Act.
 
4    (215 ILCS 5/356r)
5    Sec. 356r. Woman's principal health care provider.
6    (a) An individual or group policy of accident and health
7insurance or a managed care plan not subject to Section 356r.1
8of this Code amended, delivered, issued, or renewed in this
9State after November 14, 1996 that requires an insured or
10enrollee to designate an individual to coordinate care or to
11control access to health care services shall also permit a
12female insured or enrollee to designate a participating woman's
13principal health care provider, and the insurer or managed care
14plan shall provide the following written notice to all female
15insureds or enrollees no later than 120 days after the
16effective date of this amendatory Act of 1998; to all new
17enrollees at the time of enrollment; and thereafter to all
18existing enrollees at least annually, as a part of a regular
19publication or informational mailing:
20
"NOTICE TO ALL FEMALE PLAN MEMBERS:
21
YOUR RIGHT TO SELECT A WOMAN'S PRINCIPAL
22
HEALTH CARE PROVIDER.
23        Illinois law allows you to select "a woman's principal
24    health care provider" in addition to your selection of a
25    primary care physician. A woman's principal health care

 

 

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1    provider is a physician licensed to practice medicine in
2    all its branches specializing in obstetrics or gynecology
3    or specializing in family practice. A woman's principal
4    health care provider may be seen for care without referrals
5    from your primary care physician. If you have not already
6    selected a woman's principal health care provider, you may
7    do so now or at any other time. You are not required to
8    have or to select a woman's principal health care provider.
9        Your woman's principal health care provider must be a
10    part of your plan. You may get the list of participating
11    obstetricians, gynecologists, and family practice
12    specialists from your employer's employee benefits
13    coordinator, or for your own copy of the current list, you
14    may call [insert plan's toll free number]. The list will be
15    sent to you within 10 days after your call. To designate a
16    woman's principal health care provider from the list, call
17    [insert plan's toll free number] and tell our staff the
18    name of the physician you have selected.".
19If the insurer or managed care plan exercises the option set
20forth in subsection (a-5), the notice shall also state:
21        "Your plan requires that your primary care physician
22    and your woman's principal health care provider have a
23    referral arrangement with one another. If the woman's
24    principal health care provider that you select does not
25    have a referral arrangement with your primary care
26    physician, you will have to select a new primary care

 

 

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1    physician who has a referral arrangement with your woman's
2    principal health care provider or you may select a woman's
3    principal health care provider who has a referral
4    arrangement with your primary care physician. The list of
5    woman's principal health care providers will also have the
6    names of the primary care physicians and their referral
7    arrangements.".
8    No later than 120 days after the effective date of this
9amendatory Act of 1998, the insurer or managed care plan shall
10provide each employer who has a policy of insurance or a
11managed care plan with the insurer or managed care plan with a
12list of physicians licensed to practice medicine in all its
13branches specializing in obstetrics or gynecology or
14specializing in family practice who have contracted with the
15plan. At the time of enrollment and thereafter within 10 days
16after a request by an insured or enrollee, the insurer or
17managed care plan also shall provide this list directly to the
18insured or enrollee. The list shall include each physician's
19address, telephone number, and specialty. No insurer or plan
20formal or informal policy may restrict a female insured's or
21enrollee's right to designate a woman's principal health care
22provider, except as set forth in subsection (a-5). If the
23female enrollee is an enrollee of a managed care plan under
24contract with the Department of Healthcare and Family Services,
25the physician chosen by the enrollee as her woman's principal
26health care provider must be a Medicaid-enrolled provider. This

 

 

SB1812- 5 -LRB097 09496 RPM 49633 b

1requirement does not require a female insured or enrollee to
2make a selection of a woman's principal health care provider.
3The female insured or enrollee may designate a physician
4licensed to practice medicine in all its branches specializing
5in family practice as her woman's principal health care
6provider.
7    (a-5) The insured or enrollee may be required by the
8insurer or managed care plan to select a woman's principal
9health care provider who has a referral arrangement with the
10insured's or enrollee's individual who coordinates care or
11controls access to health care services if such referral
12arrangement exists or to select a new individual to coordinate
13care or to control access to health care services who has a
14referral arrangement with the woman's principal health care
15provider chosen by the insured or enrollee, if such referral
16arrangement exists. If an insurer or a managed care plan
17requires an insured or enrollee to select a new physician under
18this subsection (a-5), the insurer or managed care plan must
19provide the insured or enrollee with both options to select a
20new physician provided in this subsection (a-5).
21    Notwithstanding a plan's restrictions of the frequency or
22timing of making designations of primary care providers, a
23female enrollee or insured who is subject to the selection
24requirements of this subsection, may, at any time, effect a
25change in primary care physicians in order to make a selection
26of a woman's principal health care provider.

 

 

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1    (a-6) If an insurer or managed care plan exercises the
2option in subsection (a-5), the list to be provided under
3subsection (a) shall identify the referral arrangements that
4exist between the individual who coordinates care or controls
5access to health care services and the woman's principal health
6care provider in order to assist the female insured or enrollee
7to make a selection within the insurer's or managed care plan's
8requirement.
9    (b) If a female insured or enrollee has designated a
10woman's principal health care provider, then the insured or
11enrollee must be given direct access to the woman's principal
12health care provider for services covered by the policy or plan
13without the need for a referral or prior approval. Nothing
14shall prohibit the insurer or managed care plan from requiring
15prior authorization or approval from either a primary care
16provider or the woman's principal health care provider for
17referrals for additional care or services.
18    (c) For the purposes of this Section the following terms
19are defined:
20        (1) "Woman's principal health care provider" means a
21    physician licensed to practice medicine in all of its
22    branches specializing in obstetrics or gynecology or
23    specializing in family practice.
24        (2) "Managed care entity" means any entity including a
25    licensed insurance company, hospital or medical service
26    plan, health maintenance organization, limited health

 

 

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1    service organization, preferred provider organization,
2    third party administrator, an employer or employee
3    organization, or any person or entity that establishes,
4    operates, or maintains a network of participating
5    providers.
6        (3) "Managed care plan" means a plan operated by a
7    managed care entity that provides for the financing of
8    health care services to persons enrolled in the plan
9    through:
10            (A) organizational arrangements for ongoing
11        quality assurance, utilization review programs, or
12        dispute resolution; or
13            (B) financial incentives for persons enrolled in
14        the plan to use the participating providers and
15        procedures covered by the plan.
16        (4) "Participating provider" means a physician who has
17    contracted with an insurer or managed care plan to provide
18    services to insureds or enrollees as defined by the
19    contract.
20    (d) The original provisions of this Section became law on
21July 17, 1996 and took effect November 14, 1996, which is 120
22days after becoming law.
23(Source: P.A. 95-331, eff. 8-21-07.)
 
24    (215 ILCS 5/356r.1 new)
25    Sec. 356r.1. Woman's health care provider.

 

 

SB1812- 8 -LRB097 09496 RPM 49633 b

1    (a) A health insurance issuer offering group or individual
2health insurance coverage described in subsection (c) of this
3Section may not require authorization or referral by the plan,
4issuer, or any person, including a primary care provider
5described in paragraph (2) of subsection (c) of this Section,
6in the case of a female insured who seeks coverage for
7obstetrical or gynecological care provided by a participating
8health care professional who specializes in obstetrics or
9gynecology. The issuer may require such a professional to agree
10to otherwise adhere to such issuer's policies and procedures,
11including procedures regarding referrals and obtaining prior
12authorization and providing services pursuant to a treatment
13plan, if any, approved by the issuer.
14    (b) A health insurance issuer described in subsection (c)
15of this Section shall treat the provision of obstetrical and
16gynecological care, and the ordering of related obstetrical and
17gynecological items and services, pursuant to the direct access
18described under subsection (a) of this Section, by a
19participating health care professional who specializes in
20obstetrics or gynecology as the authorization of the primary
21care provider.
22    (c) A health insurance issuer offering group or individual
23health insurance coverage described in this Subsection is a
24group health plan or coverage that:
25        (1) provides coverage for obstetric or gynecologic
26    care; and

 

 

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1        (2) requires the designation by an insured or enrollee
2    of a participating primary care provider.
3    (d) Nothing in subsection (a) of this Section shall be
4construed to:
5        (1) waive any exclusions of coverage under the terms
6    and conditions of the health insurance coverage with
7    respect to coverage of obstetrical or gynecological care;
8    or
9        (2) preclude the health insurance issuer involved from
10    requiring that the obstetrical or gynecological provider
11    notify the primary care health care professional or issuer
12    of treatment decisions.
13    (e) A health insurance issuer subject to this Section shall
14provide the following written notice to all new insureds at the
15time of enrollment and to all insureds at the time such
16insured's insurance coverage is amended or renewed;
17thereafter, to all existing insureds at least annually, as a
18part of a regular publication or informational mailing:
19
"NOTICE TO ALL FEMALE PLAN MEMBERS:
20
YOUR RIGHT TO A WOMAN'S
21
HEALTH CARE PROVIDER.
22        Illinois law allows you to visit "a woman's health care
23    provider" without obtaining authorization or referral from
24    your primary care physician, insurer, or any other person
25    or entity. A woman's health care provider is a physician
26    licensed to practice medicine in all its branches

 

 

SB1812- 10 -LRB097 09496 RPM 49633 b

1    specializing in obstetrics or gynecology or specializing
2    in family practice.
3        Your woman's health care provider must be a part of
4    your plan. You may get the list of participating
5    obstetricians, gynecologists, and family practice
6    specialists from your employer's employee benefits
7    coordinator, or for your own copy of the current list, you
8    may call [insert plan's toll free number]. The list will be
9    sent to you within 10 days after your call.".
10    No later than 120 days after the effective date of this
11amendatory Act of the 97th General Assembly, the health
12insurance issuer shall provide each employer who has a policy
13of health insurance coverage with the insurer with a list of
14physicians licensed to practice medicine in all its branches
15specializing in obstetrics or gynecology or specializing in
16family practice who have contracted with the plan. At the time
17of enrollment and thereafter within 10 days after a request by
18an insured, the health insurance issuer also shall provide this
19list directly to the insured. The list shall include each
20physician's address, telephone number, and specialty.
21    (f) For the purposes of this Section.
22        (1) "Woman's health care provider" means a physician
23    licensed to practice medicine in all of its branches
24    specializing in obstetrics or gynecology or specializing
25    in family practice.
26        (2) "Participating provider" means a physician who has

 

 

SB1812- 11 -LRB097 09496 RPM 49633 b

1    contracted with a health insurance issuer to provide
2    services to insureds or enrollees as defined by the
3    contract.
4    (g) This Section shall not apply to grandfathered health
5plans.
6    (h) This Section shall apply to any health insurance
7coverage amended, delivered, issued, or renewed on and after
8the effective date of this amendatory Act of the 97th General
9Assembly.
 
10    (215 ILCS 5/356z.12)
11    Sec. 356z.12. Dependent coverage.
12    (a) A group or individual policy of accident and health
13insurance or managed care plan that provides coverage for
14dependents and that is amended, delivered, issued, or renewed
15after the effective date of this amendatory Act of the 95th
16General Assembly shall not terminate coverage or deny the
17election of coverage for a an unmarried dependent by reason of
18the dependent's age before the dependent's 26th birthday.
19    (b) A policy or plan subject to this Section shall, upon
20amendment, delivery, issuance, or renewal, establish an
21initial enrollment period of not less than 90 days during which
22an insured may make a written election for coverage of a an
23unmarried person as a dependent under this Section. After the
24initial enrollment period, enrollment by a dependent pursuant
25to this Section shall be consistent with the enrollment terms

 

 

SB1812- 12 -LRB097 09496 RPM 49633 b

1of the plan or policy.
2    (c) A policy or plan subject to this Section shall allow
3for dependent coverage during the annual open enrollment date
4or the annual renewal date if the dependent, as of the date on
5which the insured elects dependent coverage under this
6subsection, has:
7        (1) a period of continuous creditable coverage of 90
8    days or more; and
9        (2) not been without creditable coverage for more than
10    63 days.
11An insured may elect coverage for a dependent who does not meet
12the continuous creditable coverage requirements of this
13subsection (c) and that dependent shall not be denied coverage
14due to age.
15    For purposes of this subsection (c), "creditable coverage"
16shall have the meaning provided under subsection (C)(1) of
17Section 20 of the Illinois Health Insurance Portability and
18Accountability Act.
19    (d) Military personnel. A group or individual policy of
20accident and health insurance or managed care plan that
21provides coverage for dependents and that is amended,
22delivered, issued, or renewed after the effective date of this
23amendatory Act of the 95th General Assembly shall not terminate
24coverage or deny the election of coverage for a an unmarried
25dependent by reason of the dependent's age before the
26dependent's 30th birthday if the dependent (i) is an Illinois

 

 

SB1812- 13 -LRB097 09496 RPM 49633 b

1resident, (ii) served as a member of the active or reserve
2components of any of the branches of the Armed Forces of the
3United States, and (iii) has received a release or discharge
4other than a dishonorable discharge. To be eligible for
5coverage under this subsection (d), the eligible dependent
6shall submit to the insurer a form approved by the Illinois
7Department of Veterans' Affairs stating the date on which the
8dependent was released from service.
9    (e) Calculation of the cost of coverage provided to a an
10unmarried dependent under this Section shall be identical.
11    (f) Nothing in this Section shall prohibit an employer from
12requiring an employee to pay all or part of the cost of
13coverage provided under this Section.
14    (g) No exclusions or limitations may be applied to coverage
15elected pursuant to this Section that do not apply to all
16dependents covered under the policy.
17    (h) A policy or plan subject to this Section shall not
18condition eligibility for dependent coverage provided pursuant
19to this Section on enrollment in any educational institution,
20the presence or absence of financial dependency upon the
21insured or any other person, residency with the insured or with
22any other person, marital status, employment, or any
23combination of these factors.
24    (i) Notice regarding coverage for a dependent as provided
25pursuant to this Section shall be provided to an insured by the
26insurer:

 

 

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1        (1) upon application or enrollment;
2        (2) in the certificate of coverage or equivalent
3    document prepared for an insured and delivered on or about
4    the date on which the coverage commences; and
5        (3) in a notice delivered to an insured on a
6    semi-annual basis.
7    (j) The requirements of this amendatory Act of the 97th
8General Assembly shall apply to any health insurance coverage
9amended, delivered, issued, or renewed on and after the
10effective date of this amendatory Act of the 97th General
11Assembly.
12(Source: P.A. 95-958, eff. 6-1-09.)
 
13    (215 ILCS 5/356z.19 new)
14    Sec. 356z.19. Coverage of preventative services.
15    (a) Notwithstanding any other provision of law, except as
16provided in subsection (f) of this Section, a health insurance
17issuer offering group or individual health insurance coverage
18shall, at a minimum, provide coverage for and shall not impose
19any cost sharing requirements, such as a copayment,
20coinsurance, or deductible, for the following items and
21services:
22        (1) except as provided in subsection (b) of this
23    Section, evidence-based items or services that have in
24    effect a rating of "A" or "B" in the recommendations of the
25    United States Preventive Services Task Force as of

 

 

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1    September 23, 2010, with respect to the individual
2    involved;
3        (2) immunizations for routine use in children,
4    adolescents, and adults that have in effect a
5    recommendation from the Advisory Committee on Immunization
6    Practices of the Centers for Disease Control and Prevention
7    with respect to the individual involved; for purposes of
8    this paragraph (2), a recommendation from the Advisory
9    Committee on Immunization Practices of the Centers for
10    Disease Control and Prevention is considered in effect
11    after it has been adopted by the Director of the Centers
12    for Disease Control and Prevention, and a recommendation is
13    considered to be for routine use if it is listed on the
14    Immunization Schedules of the Centers for Disease Control
15    and Prevention;
16        (3) with respect to infants, children, and
17    adolescents, evidence-informed preventive care and
18    screenings provided for in the comprehensive guidelines
19    supported by the Health Resources and Services
20    Administration;
21        (4) with respect to women, to the extent not described
22    in paragraph (1) of this subsection (a), such additional
23    evidence-informed preventive care and screenings provided
24    for in comprehensive guidelines supported by the Health
25    Resources and Services Administration.
26    (b) Unless otherwise required by law, a health insurance

 

 

SB1812- 16 -LRB097 09496 RPM 49633 b

1issuer is not required to provide coverage for any items or
2services specified in any recommendation or guideline
3described in subsection (a) after the recommendation or
4guideline is no longer described in subsection (a).
5    (c) For the purposes of this Section, the current
6recommendations of the United States Preventive Service Task
7Force regarding breast cancer screening, mammography, and
8prevention shall be considered the most current other than
9those issued in or around November 2009.
10    (d) A recommendation described in paragraphs (1) or (2) of
11subsection (a) of this Section or a guideline described under
12paragraphs (3) or (4) of subsection (a) of this Section that is
13issued after September 23, 2010, shall be effective with
14respect to a plan amended, delivered, issued, or renewed one
15year after such recommendation or guideline is issued.
16    (e) A health insurance issuer offering group or individual
17health insurance coverage may utilize value-based insurance
18designs to the extent such designs are permitted by guidelines
19issued by the Secretary of the United States Department of
20Health and Human Service.
21    (f) At least annually, a health insurance issuer shall
22visit the website maintained by the U.S. Department of Health
23and Human Services to determine whether any additional items or
24services must be covered without cost-sharing requirements and
25shall incorporate changes to coverage and cost-sharing
26requirements based on any new recommendations or guidelines as

 

 

SB1812- 17 -LRB097 09496 RPM 49633 b

1set forth in subsection (d) of this Section.
2    (g) The following provisions shall apply concerning office
3visits:
4        (1) A health insurance issuer may impose cost-sharing
5    requirements with respect to an office visit if an item or
6    service described in subsection (a) of this Section is
7    billed separately or is tracked as individual encounter
8    data separately from the office visit.
9        (2) A health carrier shall not impose cost-sharing
10    requirements with respect to an office visit if an item or
11    service described in subsection (a) of this Section is not
12    billed separately or is not tracked as individual encounter
13    data separately from the office visit and the primary
14    purpose of the office visit is the delivery of the item or
15    service.
16        (3) A health carrier may impose cost-sharing
17    requirements with respect to an office visit if an item or
18    service described in subsection (a) of this Section is not
19    billed separately or is not tracked as individual encounter
20    data separately from the office visit and the primary
21    purpose of the office visit is not the delivery of the item
22    or service.
23    (h) Nothing in this Section requires a health carrier that
24has a network of providers to provide benefits for items and
25services described in subsection (a) of this Section that are
26delivered by an out-of-network provider or precludes a health

 

 

SB1812- 18 -LRB097 09496 RPM 49633 b

1carrier that has a network of providers from imposing
2cost-sharing requirements for items or services described in
3subsection (a) of this Section that are delivered by an
4out-of-network provider.
5    (i) Nothing in this Section prohibits a health carrier from
6providing coverage for items and services in addition to those
7recommended by the United States Preventive Services Task Force
8or the Advisory Committee on Immunization Practices of the
9Centers for Disease Control and Prevention or provided by
10guidelines supported by the Health Resources and Services
11Administration, or from denying coverage for items and services
12that are not recommended by that task force or that advisory
13committee or under those guidelines. A health carrier may
14impose cost-sharing requirements for a treatment not described
15in this Section even if the treatments result from an item or
16service described in this Section.
17    (j) This Section shall not apply to grandfathered health
18plans.
19    (k) The requirements of this Section shall apply to any
20health insurance coverage amended, delivered, issued, or
21renewed on and after the effective date of the amendatory Act
22of the 97th General Assembly.
 
23    (215 ILCS 5/356z.20 new)
24    Sec. 356z.20. Annual and lifetime limits.
25    (a) Notwithstanding any other provision of law, except as

 

 

SB1812- 19 -LRB097 09496 RPM 49633 b

1provided in subsection (d) of this Section, a health insurance
2issuer offering group or individual health insurance coverage
3shall not establish a lifetime limit on the dollar amount of
4essential health benefits for any insured.
5    (b) Notwithstanding any other provision of law, except as
6provided in subsection (c) of this Section, a health insurance
7issuer offering group or individual health insurance coverage
8shall not establish any annual limit on the dollar amount of
9essential health benefits for any insured.
10    (c) With respect to a plan amended, delivered, issued, or
11renewed before January 1, 2014, a health insurance issuer
12offering group or individual health insurance coverage may
13establish an annual limit on the dollar amount of essential
14health benefits provided the limit is no less than the
15following:
16        (1) for a plan amended, delivered, issued, or renewed
17    beginning after September 22, 2010, but before September
18    23, 2011, $750,000;
19        (2) for a plan amended, delivered, issued, or renewed
20    beginning after September 22, 2011, but before September
21    23, 2012, $1,250,000; and
22        (3) for a plan amended, delivered, issued, or renewed
23    beginning after September 22, 2012, but before January 1,
24    2014, $2,000,000.
25    In determining whether an insured has received benefits
26that meet or exceed the allowable limits as provided in this

 

 

SB1812- 20 -LRB097 09496 RPM 49633 b

1subsection, a health carrier shall take into account only
2essential health benefits.
3    A plan amended, delivered, issued, or renewed prior to
4January 1, 2014, is exempt from the annual limit requirements
5if the plan is approved for a waiver from such requirements by
6the U.S. Department of Health and Human Services, but such
7exemption only applies for the specified period of time that
8the waiver from the U.S. Department of Health and Human
9Services is applicable.
10    At the time a plan receives a waiver from the U.S.
11Department of Health and Human Services, the plan shall notify
12the Department, prospective applicants, and affected
13policyholders in each state where prospective applicants and
14any affected insured are known to reside.
15    At the time the waiver expires or is otherwise no longer in
16effect, the plan shall notify the Department and affected
17policyholders in each state where any affected insured is known
18to reside.
19    (d) Subsections (a) and (b) of this Section shall not be
20construed to prevent a health insurance issuer offering group
21or individual health insurance coverage from placing annual or
22lifetime dollar limits for any insured on specific covered
23benefits that are not essential health benefits to the extent
24that such limits are otherwise permitted under federal or State
25law.
26    (e) Nothing in this Section prohibits a health insurance

 

 

SB1812- 21 -LRB097 09496 RPM 49633 b

1issuer from excluding all benefits for a given condition.
2    (f) Subsection (b) of this Section shall not apply to
3grandfathered health plans that are individual health plans, a
4health flexible spending arrangement as defined in Section
5106(a)(2)(i) of the federal Internal Revenue Code, a medical
6savings account as defined in Section 220 of the federal
7Internal Revenue Code, and a health savings account as defined
8in Section 223 of the federal Internal Revenue Code.
9    (g) The requirements of this Section shall apply to any
10health insurance coverage amended, delivered, issued, or
11renewed on and after September 23, 2010.
12    (h) For purposes of this Section, "essential health
13benefits" has the same meaning given the term in Section
141302(b) of the Patient Protection and Affordable Care Act and
15applicable regulations.
 
16    (215 ILCS 5/356z.21 new)
17    Sec. 356z.21. Reinstatement of coverage.
18    (a) This Section applies to any individual:
19        (1) whose coverage or benefits under a health plan
20    ended by reason of reaching a lifetime limit on the dollar
21    value of all benefits for the individual; and
22        (2) who, due to the provisions of Section 356z.20 of
23    this Code, becomes eligible or is required to become
24    eligible for benefits not subject to a lifetime limit on
25    the dollar value of all benefits under the health plan:

 

 

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1            (A) for group health insurance coverage, on the
2        first day of the first plan year beginning on or after
3        September 23, 2010; or
4            (B) for individual health insurance coverage, on
5        the first day of the first policy year beginning on or
6        after September 23, 2010.
7    (b) For individual health insurance coverage, an
8individual is not entitled to reinstatement under the health
9plan under this Section if the individual reached his or her
10lifetime limit and the contract is not renewed or is otherwise
11no longer in effect. However, this Section applies to a family
12member who reached his or her lifetime limit in a family plan
13and other family members remain covered under the plan.
14    (c) If an individual described in subsection (a) of this
15Section is eligible for benefits or is required to become
16eligible for benefits under the health plan, then the health
17carrier shall provide the individual written notice that:
18        (1) the lifetime limit on the dollar value of all
19    benefits no longer applies; and
20        (2) the individual, if still covered under the plan is
21    again eligible to receive benefits under the plan.
22    (d) If the individual is not enrolled in the plan or if an
23enrolled individual is eligible for, but not enrolled in, any
24benefit package under the plan, then the health plan shall
25provide an opportunity for the individual to enroll in the plan
26for a period of at least 30 days.

 

 

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1    (e) The notices and enrollment opportunity under this
2Section shall be provided beginning no later than the following
3time frames:
4        (1) for group health insurance coverage, the first day
5    of the first plan year beginning on or after September 23,
6    2010; or
7        (2) for individual health insurance coverage, the
8    first day of the first policy year beginning on or after
9    September 23, 2010.
10    (f) The notices required under this Section may be provided
11according to the following provisions:
12        (1) for group health insurance coverage, to an employee
13    on behalf of the employee's dependent; or
14        (2) for individual health insurance coverage, to the
15    primary subscriber on behalf of the primary subscriber's
16    dependent.
17    (g) For group health insurance coverage, the notices may be
18included with other enrollment materials that a health benefit
19plan distributes to employees, provided the statement is
20prominent. If a notice satisfying the requirements of this
21subsection is provided to an individual, then a health
22carrier's requirement to provide the notice with respect to
23that individual is satisfied.
24    (h) For any individual who enrolls in a health benefit plan
25in accordance with this Section, coverage under the plan shall
26take effect no later than the following time frames:

 

 

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1        (1) for group health insurance coverage, the first day
2    of the first plan year beginning on or after September 23,
3    2010; or
4        (2) for individual health insurance coverage, the
5    first day of the first policy year beginning on or after
6    September 23, 2010.
7    (i) An individual enrolling in a health plan for group
8health insurance coverage in accordance with this Section shall
9be treated as if the individual were a special enrollee in the
10plan, as provided under federal regulations 45 CFR §146.117(d).
11In such instances, the following provisions shall apply:
12        (1) the individual shall be offered all of the benefit
13    packages available to similarly situated individuals who
14    did not lose coverage under the plan by reason of reaching
15    a lifetime limit on the dollar value of all benefits; and
16        (2) the individual shall not be required to pay more
17    for coverage than similarly situated individuals who did
18    not lose coverage by reason of reaching a lifetime limit on
19    the dollar value of all benefits.
20    (j) For purposes of paragraph (1) of subsection (i) of this
21Section, any difference in benefits or cost-sharing
22constitutes a different benefit package.
23    (k) For purposes of this Section:
24    "Essential health benefits" has the same meaning given the
25term in Section 1302(b) of the Patient Protection and
26Affordable Care Act and applicable regulations.

 

 

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1    "Policy year" means, in the individual health insurance
2market, the 12-month period that is designated as the policy
3year in the policy documents of the individual health insurance
4coverage. If there is no designation of a policy year in the
5policy document or no such policy document is available, then
6the policy year is the deductible or limit year used under the
7coverage. If deductibles or other limits are not imposed on a
8yearly basis, then the policy year is the calendar year.
 
9    (215 ILCS 5/356z.23 new)
10    Sec. 356z.23. Patient protections; choice of health care
11professional; access to pediatric care.
12    (a) Notwithstanding any other provision of law, a health
13insurance issuer offering group or individual health insurance
14coverage that requires or provides for designation by an
15insured of a participating primary care provider shall permit
16each participant or beneficiary to designate any participating
17primary care provider who is available to accept such
18individual.
19    (b) Notwithstanding any other provision of law, in the case
20of a person who has a child who is a participant or beneficiary
21under health insurance coverage offered by a health insurance
22issuer in the group or individual market, if the issuer
23requires or provides for the designation of a participating
24primary care provider for the child, the issuer shall permit
25such person to designate any participating physician who

 

 

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1specializes in pediatrics as the child's primary care provider
2if such provider is available to accept the child. Nothing in
3this subsection shall be construed to waive any exclusions of
4coverage under the terms and conditions of the health insurance
5coverage with respect to coverage of pediatric care.
6    (c) A health insurance issuer subject to this Section shall
7provide the following written notice to all new insureds at the
8time of enrollment and to all insureds at the time such
9insured's insurance coverage is amended or renewed;
10thereafter, to all existing insureds at least annually, as a
11part of a regular publication or informational mailing:
12
"YOUR RIGHT TO DESIGNATE A
13
HEALTH CARE PROVIDER.
14    [Name of health carrier] generally [requires/allows] the
15    designation of a primary care health care professional. You
16    have the right to designate any primary care health care
17    professional who participates in our network and who is
18    available to accept you or your family members. [If the
19    health carrier designates a primary care health care
20    professional automatically, insert:] Until you make this
21    designation, [name of health carrier] designates one for
22    you. [For health carriers that require or allow for the
23    designation or a primary care health care professional for
24    a child, add:] For children, you may designate a
25    pediatrician as the primary care health care professional.
26    For information on how to select a primary care health care

 

 

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1    professional, and for a list of participating primary care
2    health care professionals, contact the [health carrier] at
3    [insert toll-free number].".
4    (d) This Section shall not apply to grandfathered health
5plans.
6    (e) The requirements of this Section shall apply to any
7health insurance coverage amended, delivered, issued, or
8renewed on or after the effective date of this amendatory Act
9of the 97th General Assembly.
 
10    (215 ILCS 5/356z.24 new)
11    Sec. 356z.24. Patient protections; coverage of emergency
12services.
13    (a) Notwithstanding any other provision of law, a health
14insurance issuer offering group or individual health insurance
15that provides or covers any benefits with respect to services
16in an emergency department of a hospital shall cover emergency
17services:
18        (1) without the need for any prior authorization
19    determination, even if the emergency services are provided
20    on an out-of-network basis;
21        (2) without regard to whether the health care provider
22    furnishing the emergency services is a participating
23    network provider with respect to such services;
24        (3) in a manner so that, if the emergency services are
25    provided out of network:

 

 

SB1812- 28 -LRB097 09496 RPM 49633 b

1            (A) without imposing any administrative
2        requirement or limitation on coverage that is more
3        restrictive than the requirements or limitations that
4        apply to emergency services received from in-network
5        providers; and
6            (B) the emergency services are provided at no
7        greater cost to the insured than if the services were
8        provided in network;
9        (4) without regard to any other term or condition of
10    such coverage, other than exclusion or coordination of
11    benefits, or an affiliation or waiting period permitted
12    under part 7 of the Employee Retirement Income Security Act
13    of 1974, part A of title XXVII of the Public Health Service
14    Act, or chapter 100 of the Internal Revenue Code of 1986.
15    (b) As used in this Section:
16        "Emergency medical condition" has the same meaning as
17    in the Managed Care Reform and Patient Rights Act.
18        "Emergency services" has the same meaning as in the
19    Managed Care Reform and Patient Rights Act.
20        "Stabilize" has the same meaning as in the Managed Care
21    Reform and Patient Rights Act.
22    (c) This Section shall not apply to grandfathered health
23plans.
24    (d) The requirements of this Section shall apply to any
25health insurance coverage amended, delivered, issued, or
26renewed on and after the effective date of this amendatory Act

 

 

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1of the 97th General Assembly.
 
2    (215 ILCS 5/356z.25 new)
3    Sec. 356z.25. Coverage for children with preexisting
4conditions.
5    (a) A health insurance issuer offering group or individual
6health insurance shall not limit or exclude coverage for an
7individual under the age of 19 by imposing a preexisting
8condition exclusion on that individual.
9    (b) Notwithstanding any other provision of law, a health
10insurance issuer offering individual health insurance must
11offer a child-only plan and shall accept applications for
12child-only plans and offer coverage without any limitations or
13riders based on health status according to the following
14provisions:
15        (1) during the open enrollment periods outlined in
16    subsection (c) of this Section; and
17        (2) within 30 days after a qualifying event.
18    (c) Beginning July 1, 2011, and each January and July
19thereafter, a health insurance issuer offering a child only
20plan shall hold an open enrollment period for child-only plan
21applicants for the duration of the entire month. During these
22open enrollment periods, all child-only plan applicants under
23the age of 19 shall be offered coverage without any limitations
24or riders based on health status.
25    (d) Notice of the open enrollment opportunity and open

 

 

SB1812- 30 -LRB097 09496 RPM 49633 b

1enrollment dates for new applicants, as well as the opportunity
2to enroll due to a qualifying event, must be displayed
3prominently on the health insurance issuer's web site
4throughout the year.
5    (e) Applications for coverage during a January open
6enrollment period shall become effective no later than March 1
7following the open enrollment during which the application is
8received. Applications for coverage during a July open
9enrollment period shall become effective no later than
10September 1 following the open enrollment during which the
11application is received.
12    (f) To encourage continuous coverage, a child enrolling in
13an individual market child-only plan may be subject to a
14surcharge of up to 50% of the standard rate for up to 12 months
15if the child has a lapse in a child only plan within the past 12
16months. The 50% surcharge may be on top of the rate that would
17be charged for the same child demonstrating continuous
18coverage.
19    (g) To ensure parents cannot temporarily obtain family
20coverage at any point in the year only to subsequently drop
21coverage to make the child a child-only subscriber, health
22insurance issuers are allowed to cancel coverage for dependents
23in the individual market if the parent subscriber drops
24coverage. The health insurance issuer must allow the child to
25enroll on a child-only basis during the next open enrollment
26period without assessing a surcharge for lapse in coverage.

 

 

SB1812- 31 -LRB097 09496 RPM 49633 b

1    (h) For the purposes of this Section:
2    "Child-only plan" means renewable individual health
3insurance coverage (as defined in 42 U.S.C. 300gg-91) issued
4with an effective date on or after September 23, 2010, that
5provides coverage to an individual under the age of 19. This
6shall not include individual health insurance coverage that
7covers children under age 19 as dependents.
8    "Qualifying event" includes the following:
9        (1) For individuals under age 19 covered as a dependent
10    under the plan of another (the insured), and for
11    individuals under age 19 with their own coverage:
12            (A) loss of the insured's or the individual's
13        employer-sponsored insurance, including termination of
14        employment or reduction in the number of hours of
15        employment;
16            (B) involuntary loss of the insured's or the
17        individual's other existing coverage for any reason
18        other than fraud, misrepresentation or failure to pay
19        premium so long as the individual is under age 19 when
20        the qualifying event occurs;
21            (C) exhaustion of the insured's or the
22        individual's COBRA continuation coverage;
23            (D) a situation in which a claim is incurred that
24        would meet or exceed a lifetime or annual limit on all
25        benefits;
26            (E) termination of employer contributions towards

 

 

SB1812- 32 -LRB097 09496 RPM 49633 b

1        the insured's or the individual's coverage, including
2        any current or former employers;
3            (F) legal separation or divorce of the insured or
4        the individual; and
5            (G) in the case of coverage offered through an HMO
6        or other arrangement that does not provide benefits to
7        persons who no longer reside, live, or work in a
8        service area, loss of the insured's or the individual's
9        coverage because a person no longer resides in the
10        service area (whether or not within the choice of the
11        person).
12        (2) For individuals under age 19 who have been covered
13    as a dependent under the plan of another (the insured).
14        (3) For individuals under age 19 with their own
15    coverage:
16            (A) birth, adoption, or placement for adoption of
17        an individual; and
18            (B) a person under age 19 becomes a dependent of
19        the individual through marriage, birth, adoption, or
20        placement for adoption.
21        (4) Birth, adoption, or placement for adoption.
22    "Preexisting condition" means a limitation or exclusion of
23benefits, including a denial of coverage, based on the fact
24that the condition was present before the effective date of
25coverage, or if the coverage is denied, the date of denial,
26under a health benefit plan whether or not any medical advice,

 

 

SB1812- 33 -LRB097 09496 RPM 49633 b

1diagnosis, care or treatment was recommended or received before
2the effective date of coverage.
3    "Preexisting condition exclusion" includes any limitation
4or exclusion of benefits, including a denial of coverage,
5applicable to an individual as a result of information relating
6to an individual's health status before the individual's
7effective date of coverage or, if the coverage is denied, the
8date of denial under the health benefit plan, such as a
9condition identified as a result of a pre-enrollment
10questionnaire or physical examination given to the individual
11or review of medical records relating to the pre-enrollment
12period.
 
13    (215 ILCS 5/359c)
14    Sec. 359c. Accident and health expense reporting.
15    (a) Beginning January 1, 2011 and every 6 months
16thereafter, any health insurance issuer offering group or
17individual health insurance coverage carrier providing a group
18or individual major medical policy of accident or health
19insurance shall prepare and provide to the Department of
20Insurance a statement of the aggregate administrative expenses
21of the health insurance issuer carrier, based on the premiums
22earned in the immediately preceding 6-month period on the
23health insurance coverage accident or health insurance
24business of the issuer carrier. The semi-annual statements
25shall be filed on or before July 31 for the preceding 6-month

 

 

SB1812- 34 -LRB097 09496 RPM 49633 b

1period ending June 30 and on or before February 1 for the
2preceding 6-month period ending December 31. The statements
3shall itemize and separately detail all of the following
4information with respect to the health insurance issuer's
5health insurance coverage carrier's accident or health
6insurance business:
7        (1) the amount of premiums earned by the health
8    insurance issuer carrier both before and after any costs
9    related to the issuer's carrier's purchase of reinsurance
10    coverage;
11        (2) the total amount of claims for losses paid by the
12    health insurance issuer carrier both before and after any
13    reimbursement from reinsurance coverage including any
14    costs incurred related to:
15            (A) disease, case, or chronic care management
16        programs;
17            (B) wellness and health education programs;
18            (C) fraud prevention;
19            (D) maintaining provider networks and provider
20        credentialing;
21            (E) health information technology for personal
22        electronic health records; and
23            (F) utilization review and utilization management;
24        (3) the amount of any losses incurred by the health
25    insurance issuer carrier but not reported to the issuer
26    carrier in the current or prior reporting period;

 

 

SB1812- 35 -LRB097 09496 RPM 49633 b

1        (4) the amount of costs incurred by the carrier for
2    State fees and federal and State taxes including:
3            (A) any high risk pool and guaranty fund
4        assessments levied on the health insurance issuer
5        carrier by the State; and
6            (B) any regulatory compliance costs including
7        State fees for form and rate filings, licensures,
8        market conduct exams, and financial reports;
9        (5) the amount of costs incurred by the health
10    insurance issuer carrier for reinsurance coverage;
11        (6) the amount of costs incurred by the health
12    insurance issuer carrier that are related to the issuer's
13    carrier's payment of marketing expenses including
14    commissions; and
15        (7) any other administrative expenses incurred by the
16    health insurance issuer carrier.
17    (b) The information provided pursuant to subsection (a) of
18this Section shall be separately aggregated for the following
19lines of health insurance coverage major medical insurance:
20        (1) individual health insurance individually
21    underwritten;
22        (2) group health insurance covering groups of 2 to 25
23    members;
24        (3) group health insurance covering groups of 26 to 50
25    members;
26        (4) group health insurance covering groups of 51 or

 

 

SB1812- 36 -LRB097 09496 RPM 49633 b

1    more members.
2    (b-5) Beginning January 1, 2011, any health insurance
3issuer offering group or individual health insurance coverage
4shall provide to the Department of Insurance any information
5required to be submitted to the Secretary of the U.S.
6Department of Health and Human Services under Section 2718 of
7the Public Health Service Act, as amended by the Patient
8Protection and Affordable Care Act, or under regulations
9promulgated pursuant thereto.
10    (b-10) Any health insurance issuer offering group or
11individual health insurance coverage shall provide to the
12Department of Insurance and make available to the public any
13information required under Section 2715A of the Public Health
14Service Act, as amended by the Patient Protection and
15Affordable Care Act, or under regulations promulgated pursuant
16thereto.
17    (c) The Department shall make the submitted information
18publicly available on the Department's website or such other
19media as appropriate in a form useful for consumers.
20(Source: P.A. 96-857, eff. 1-5-10.)
 
21    (215 ILCS 5/359f new)
22    Sec. 359f. Health insurance rescissions; notice and
23hearing.
24    (a) Notwithstanding any other provision of law, no health
25insurance issuer shall rescind any health insurance coverage

 

 

SB1812- 37 -LRB097 09496 RPM 49633 b

1unless:
2        (1) as set forth in Section 2712 of the Public Health
3    Service Act, as amended by the Patient Protection and
4    Affordable Care Act, the insured or someone seeking
5    coverage on behalf of the insured has performed an act,
6    practice, or omission that constitutes fraud or has made an
7    intentional misrepresentation of material fact as
8    prohibited by the terms of the health insurance coverage;
9        (2) the health insurance issuer provides a notice of
10    rescission to the named insured pursuant to subsection (b)
11    of this Section;
12        (3) the proposed effective date of such rescission is
13    no more than 9 months after the date of issuance of the
14    policy, certificate, or contract of health insurance
15    coverage; and
16        (4) if such rescission is initiated after a claim is
17    submitted under the policy, certificate, or contract of
18    health insurance coverage, then the condition that relates
19    to the submitted claim bears a direct relationship to the
20    condition which is the subject of the act or practice
21    described in paragraph (1) of subsection (a) of this
22    Section.
23    (b) No rescission shall be effective unless, at least 60
24days prior to the effective date of such rescission, a notice
25of rescission is mailed by the health insurance issuer to the
26named insured at the last mailing address known by the health

 

 

SB1812- 38 -LRB097 09496 RPM 49633 b

1insurance issuer. The health insurance issuer shall maintain
2proof of mailing of such notice on a recognized U.S. Post
3Office form or a form acceptable to the U.S. Post Office or
4other commercial mail delivery service. A copy of all such
5notices shall be sent to the insured's broker, if known, or the
6agent of record, if known, at the last mailing address known to
7the health insurance issuer. All notices of rescission shall
8include a specific explanation of the reason or reasons for
9rescission and shall advise the named insured of his right to
10appeal the rescission under the Health Carrier Grievance
11Procedure Act and the Health Carrier External Review Act. The
12health insurance issuer must provide continued coverage
13pending the outcome of any appeal of a rescission.
14    (c) The requirements of this Section shall apply to any
15health insurance coverage amended, delivered, issued, or
16renewed on and after the effective date of this amendatory Act
17of the 97th General Assembly.
 
18    Section 10. The Health Maintenance Organization Act is
19amended 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
23the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
24141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,

 

 

SB1812- 39 -LRB097 09496 RPM 49633 b

1154.6, 154.7, 154.8, 155.04, 352b, 355.2, 356g.5-1, 356m, 356r,
2356r.1, 356v, 356w, 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6,
3356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
4356z.12, 356z.19, 356z.20, 356z.21, 356z.23, 356z.24, 356z.25,
5359c, 359f, 356z.15, 356z.17, 356z.18, 364.01, 367.2, 367.2-5,
6367i, 368a, 368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403,
7403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
8subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,
9XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
10Insurance Code.
11    (b) For purposes of the Illinois Insurance Code, except for
12Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
13Maintenance Organizations in the following categories are
14deemed to be "domestic companies":
15        (1) a corporation authorized under the Dental Service
16    Plan Act or the Voluntary Health Services Plans Act;
17        (2) a corporation organized under the laws of this
18    State; or
19        (3) a corporation organized under the laws of another
20    state, 30% or more of the enrollees of which are residents
21    of this State, except a corporation subject to
22    substantially the same requirements in its state of
23    organization as is a "domestic company" under Article VIII
24    1/2 of the Illinois Insurance Code.
25    (c) In considering the merger, consolidation, or other
26acquisition of control of a Health Maintenance Organization

 

 

SB1812- 40 -LRB097 09496 RPM 49633 b

1pursuant to Article VIII 1/2 of the Illinois Insurance Code,
2        (1) the Director shall give primary consideration to
3    the continuation of benefits to enrollees and the financial
4    conditions of the acquired Health Maintenance Organization
5    after the merger, consolidation, or other acquisition of
6    control takes effect;
7        (2)(i) the criteria specified in subsection (1)(b) of
8    Section 131.8 of the Illinois Insurance Code shall not
9    apply and (ii) the Director, in making his determination
10    with respect to the merger, consolidation, or other
11    acquisition of control, need not take into account the
12    effect on competition of the merger, consolidation, or
13    other acquisition of control;
14        (3) the Director shall have the power to require the
15    following information:
16            (A) certification by an independent actuary of the
17        adequacy of the reserves of the Health Maintenance
18        Organization sought to be acquired;
19            (B) pro forma financial statements reflecting the
20        combined balance sheets of the acquiring company and
21        the Health Maintenance Organization sought to be
22        acquired as of the end of the preceding year and as of
23        a date 90 days prior to the acquisition, as well as pro
24        forma financial statements reflecting projected
25        combined operation for a period of 2 years;
26            (C) a pro forma business plan detailing an

 

 

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1        acquiring party's plans with respect to the operation
2        of the Health Maintenance Organization sought to be
3        acquired for a period of not less than 3 years; and
4            (D) such other information as the Director shall
5        require.
6    (d) The provisions of Article VIII 1/2 of the Illinois
7Insurance Code and this Section 5-3 shall apply to the sale by
8any health maintenance organization of greater than 10% of its
9enrollee population (including without limitation the health
10maintenance organization's right, title, and interest in and to
11its health care certificates).
12    (e) In considering any management contract or service
13agreement subject to Section 141.1 of the Illinois Insurance
14Code, the Director (i) shall, in addition to the criteria
15specified in Section 141.2 of the Illinois Insurance Code, take
16into account the effect of the management contract or service
17agreement on the continuation of benefits to enrollees and the
18financial condition of the health maintenance organization to
19be managed or serviced, and (ii) need not take into account the
20effect of the management contract or service agreement on
21competition.
22    (f) Except for small employer groups as defined in the
23Small Employer Rating, Renewability and Portability Health
24Insurance Act and except for medicare supplement policies as
25defined in Section 363 of the Illinois Insurance Code, a Health
26Maintenance Organization may by contract agree with a group or

 

 

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1other enrollment unit to effect refunds or charge additional
2premiums under the following terms and conditions:
3        (i) the amount of, and other terms and conditions with
4    respect to, the refund or additional premium are set forth
5    in the group or enrollment unit contract agreed in advance
6    of the period for which a refund is to be paid or
7    additional premium is to be charged (which period shall not
8    be less than one year); and
9        (ii) the amount of the refund or additional premium
10    shall not exceed 20% of the Health Maintenance
11    Organization's profitable or unprofitable experience with
12    respect to the group or other enrollment unit for the
13    period (and, for purposes of a refund or additional
14    premium, the profitable or unprofitable experience shall
15    be calculated taking into account a pro rata share of the
16    Health Maintenance Organization's administrative and
17    marketing expenses, but shall not include any refund to be
18    made or additional premium to be paid pursuant to this
19    subsection (f)). The Health Maintenance Organization and
20    the group or enrollment unit may agree that the profitable
21    or unprofitable experience may be calculated taking into
22    account the refund period and the immediately preceding 2
23    plan years.
24    The Health Maintenance Organization shall include a
25statement in the evidence of coverage issued to each enrollee
26describing the possibility of a refund or additional premium,

 

 

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1and upon request of any group or enrollment unit, provide to
2the group or enrollment unit a description of the method used
3to calculate (1) the Health Maintenance Organization's
4profitable experience with respect to the group or enrollment
5unit and the resulting refund to the group or enrollment unit
6or (2) the Health Maintenance Organization's unprofitable
7experience with respect to the group or enrollment unit and the
8resulting additional premium to be paid by the group or
9enrollment unit.
10    In no event shall the Illinois Health Maintenance
11Organization Guaranty Association be liable to pay any
12contractual obligation of an insolvent organization to pay any
13refund authorized under this Section.
14    (g) Rulemaking authority to implement Public Act 95-1045,
15if any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
2195-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
2295-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
231-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
246-1-10; 96-1000, eff. 7-2-10.)
 
25    Section 99. Effective date. This Act takes effect upon
26becoming law.