Full Text of SB1547 98th General Assembly
SB1547eng 98TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning insurance.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by adding | 5 | | Section 355.4 as follows: | 6 | | (215 ILCS 5/355.4 new) | 7 | | Sec. 355.4. Noncovered vision services. | 8 | | (a) In this Section: | 9 | | "Covered services" means vision care services for | 10 | | which a reimbursement is available under an
enrollee's plan | 11 | | contract, or for which a reimbursement would be available | 12 | | but for the application of
contractual limitations such as | 13 | | deductibles, copayments, coinsurance, waiting periods, | 14 | | annual or
lifetime maximums, frequency limitations, | 15 | | alternative benefit payments, or any other limitation. | 16 | | "Vision insurance" means any policy of insurance that | 17 | | is issued by a company that provides coverage for vision | 18 | | services not covered by a medical plan. | 19 | | (b) No company that issues, delivers, amends, or renews an | 20 | | individual or group policy of accident and health insurance on | 21 | | or after the effective date of this amendatory Act of the 98th | 22 | | General Assembly that provides vision insurance shall issue a | 23 | | service provider contract that requires an optometrist or |
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| 1 | | ophthalmologist to provide services or materials to the | 2 | | insurer's policyholders at a fee set by the insurer unless the | 3 | | services or materials are covered services or materials under | 4 | | the applicable policyholder agreement. | 5 | | Section 10. The Health Maintenance Organization Act is | 6 | | amended by changing Section 5-3 as follows:
| 7 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 8 | | Sec. 5-3. Insurance Code provisions.
| 9 | | (a) Health Maintenance Organizations
shall be subject to | 10 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 11 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 12 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 13 | | 355.4, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | 14 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 15 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 16 | | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | 17 | | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | 18 | | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | 19 | | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | 20 | | and XXVI of the Illinois Insurance Code.
| 21 | | (b) For purposes of the Illinois Insurance Code, except for | 22 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 23 | | Maintenance Organizations in
the following categories are | 24 | | deemed to be "domestic companies":
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| 1 | | (1) a corporation authorized under the
Dental Service | 2 | | Plan Act or the Voluntary Health Services Plans Act;
| 3 | | (2) a corporation organized under the laws of this | 4 | | State; or
| 5 | | (3) a corporation organized under the laws of another | 6 | | state, 30% or more
of the enrollees of which are residents | 7 | | of this State, except a
corporation subject to | 8 | | substantially the same requirements in its state of
| 9 | | organization as is a "domestic company" under Article VIII | 10 | | 1/2 of the
Illinois Insurance Code.
| 11 | | (c) In considering the merger, consolidation, or other | 12 | | acquisition of
control of a Health Maintenance Organization | 13 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 14 | | (1) the Director shall give primary consideration to | 15 | | the continuation of
benefits to enrollees and the financial | 16 | | conditions of the acquired Health
Maintenance Organization | 17 | | after the merger, consolidation, or other
acquisition of | 18 | | control takes effect;
| 19 | | (2)(i) the criteria specified in subsection (1)(b) of | 20 | | Section 131.8 of
the Illinois Insurance Code shall not | 21 | | apply and (ii) the Director, in making
his determination | 22 | | with respect to the merger, consolidation, or other
| 23 | | acquisition of control, need not take into account the | 24 | | effect on
competition of the merger, consolidation, or | 25 | | other acquisition of control;
| 26 | | (3) the Director shall have the power to require the |
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| 1 | | following
information:
| 2 | | (A) certification by an independent actuary of the | 3 | | adequacy
of the reserves of the Health Maintenance | 4 | | Organization sought to be acquired;
| 5 | | (B) pro forma financial statements reflecting the | 6 | | combined balance
sheets of the acquiring company and | 7 | | the Health Maintenance Organization sought
to be | 8 | | acquired as of the end of the preceding year and as of | 9 | | a date 90 days
prior to the acquisition, as well as pro | 10 | | forma financial statements
reflecting projected | 11 | | combined operation for a period of 2 years;
| 12 | | (C) a pro forma business plan detailing an | 13 | | acquiring party's plans with
respect to the operation | 14 | | of the Health Maintenance Organization sought to
be | 15 | | acquired for a period of not less than 3 years; and
| 16 | | (D) such other information as the Director shall | 17 | | require.
| 18 | | (d) The provisions of Article VIII 1/2 of the Illinois | 19 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 20 | | any health maintenance
organization of greater than 10% of its
| 21 | | enrollee population (including without limitation the health | 22 | | maintenance
organization's right, title, and interest in and to | 23 | | its health care
certificates).
| 24 | | (e) In considering any management contract or service | 25 | | agreement subject
to Section 141.1 of the Illinois Insurance | 26 | | Code, the Director (i) shall, in
addition to the criteria |
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| 1 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 2 | | into account the effect of the management contract or
service | 3 | | agreement on the continuation of benefits to enrollees and the
| 4 | | financial condition of the health maintenance organization to | 5 | | be managed or
serviced, and (ii) need not take into account the | 6 | | effect of the management
contract or service agreement on | 7 | | competition.
| 8 | | (f) Except for small employer groups as defined in the | 9 | | Small Employer
Rating, Renewability and Portability Health | 10 | | Insurance Act and except for
medicare supplement policies as | 11 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 12 | | Maintenance Organization may by contract agree with a
group or | 13 | | other enrollment unit to effect refunds or charge additional | 14 | | premiums
under the following terms and conditions:
| 15 | | (i) the amount of, and other terms and conditions with | 16 | | respect to, the
refund or additional premium are set forth | 17 | | in the group or enrollment unit
contract agreed in advance | 18 | | of the period for which a refund is to be paid or
| 19 | | additional premium is to be charged (which period shall not | 20 | | be less than one
year); and
| 21 | | (ii) the amount of the refund or additional premium | 22 | | shall not exceed 20%
of the Health Maintenance | 23 | | Organization's profitable or unprofitable experience
with | 24 | | respect to the group or other enrollment unit for the | 25 | | period (and, for
purposes of a refund or additional | 26 | | premium, the profitable or unprofitable
experience shall |
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| 1 | | be calculated taking into account a pro rata share of the
| 2 | | Health Maintenance Organization's administrative and | 3 | | marketing expenses, but
shall not include any refund to be | 4 | | made or additional premium to be paid
pursuant to this | 5 | | subsection (f)). The Health Maintenance Organization and | 6 | | the
group or enrollment unit may agree that the profitable | 7 | | or unprofitable
experience may be calculated taking into | 8 | | account the refund period and the
immediately preceding 2 | 9 | | plan years.
| 10 | | The Health Maintenance Organization shall include a | 11 | | statement in the
evidence of coverage issued to each enrollee | 12 | | describing the possibility of a
refund or additional premium, | 13 | | and upon request of any group or enrollment unit,
provide to | 14 | | the group or enrollment unit a description of the method used | 15 | | to
calculate (1) the Health Maintenance Organization's | 16 | | profitable experience with
respect to the group or enrollment | 17 | | unit and the resulting refund to the group
or enrollment unit | 18 | | or (2) the Health Maintenance Organization's unprofitable
| 19 | | experience with respect to the group or enrollment unit and the | 20 | | resulting
additional premium to be paid by the group or | 21 | | enrollment unit.
| 22 | | In no event shall the Illinois Health Maintenance | 23 | | Organization
Guaranty Association be liable to pay any | 24 | | contractual obligation of an
insolvent organization to pay any | 25 | | refund authorized under this Section.
| 26 | | (g) Rulemaking authority to implement Public Act 95-1045, |
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| 1 | | if any, is conditioned on the rules being adopted in accordance | 2 | | with all provisions of the Illinois Administrative Procedure | 3 | | Act and all rules and procedures of the Joint Committee on | 4 | | Administrative Rules; any purported rule not so adopted, for | 5 | | whatever reason, is unauthorized. | 6 | | (Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | 7 | | 96-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; | 8 | | 97-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12; | 9 | | 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff. | 10 | | 7-13-12.) | 11 | | Section 15. The Limited Health Service Organization Act is | 12 | | amended by changing Section 4003 as follows:
| 13 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
| 14 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 15 | | health service
organizations shall be subject to the provisions | 16 | | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, | 17 | | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, | 18 | | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 355.4, 356v, | 19 | | 356z.10, 356z.21, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, | 20 | | 409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII | 21 | | 1/2,
XIII,
XIII 1/2, XXV, and XXVI of the Illinois Insurance | 22 | | Code. For purposes of the
Illinois Insurance Code, except for | 23 | | Sections 444 and 444.1 and Articles XIII
and XIII 1/2, limited | 24 | | health service organizations in the following categories
are |
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| 1 | | deemed to be domestic companies:
| 2 | | (1) a corporation under the laws of this State; or
| 3 | | (2) a corporation organized under the laws of another | 4 | | state, 30% of more
of the enrollees of which are residents | 5 | | of this State, except a corporation
subject to | 6 | | substantially the same requirements in its state of | 7 | | organization as
is a domestic company under Article VIII | 8 | | 1/2 of the Illinois Insurance Code.
| 9 | | (Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff. | 10 | | 1-1-13; 97-813, eff. 7-13-12.)
| 11 | | Section 20. The Voluntary Health Services Plans Act is | 12 | | amended by changing Section 10 as follows:
| 13 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
| 14 | | Sec. 10. Application of Insurance Code provisions. Health | 15 | | services
plan corporations and all persons interested therein | 16 | | or dealing therewith
shall be subject to the provisions of | 17 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 18 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355.4, | 19 | | 356g, 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, | 20 | | 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| 21 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | 22 | | 356z.19, 356z.21, 364.01, 367.2, 368a, 401, 401.1,
402,
403, | 23 | | 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | 24 | | Section 367 of the Illinois
Insurance Code.
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| 1 | | Rulemaking authority to implement Public Act 95-1045, if | 2 | | any, is conditioned on the rules being adopted in accordance | 3 | | with all provisions of the Illinois Administrative Procedure | 4 | | Act and all rules and procedures of the Joint Committee on | 5 | | Administrative Rules; any purported rule not so adopted, for | 6 | | whatever reason, is unauthorized. | 7 | | (Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; | 8 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; | 9 | | 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; | 10 | | 97-813, eff. 7-13-12.)
| 11 | | Section 99. Effective date. This Act takes effect January | 12 | | 1, 2014.
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