Full Text of HB2499 103rd General Assembly
HB2499sam002 103RD GENERAL ASSEMBLY | Sen. Laura Fine Filed: 5/20/2024 | | 10300HB2499sam002 | | LRB103 30875 RPS 73636 a |
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| 1 | | AMENDMENT TO HOUSE BILL 2499
| 2 | | AMENDMENT NO. ______. Amend House Bill 2499, AS AMENDED, | 3 | | by replacing everything after the enacting clause with the | 4 | | following: | 5 | | "Section 5. The Illinois Insurance Code is amended by | 6 | | changing Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and | 7 | | by adding Section 352c as follows: | 8 | | (215 ILCS 5/121-2.05) (from Ch. 73, par. 733-2.05) | 9 | | Sec. 121-2.05. Group insurance policies issued and | 10 | | delivered in other State-Transactions in this State. With the | 11 | | exception of insurance transactions authorized under Sections | 12 | | 230.2 or 367.3 of this Code or transactions described under | 13 | | Section 352c , transactions in this State involving group | 14 | | legal, group life and group accident and health or blanket | 15 | | accident and health insurance or group annuities where the | 16 | | master policy of such groups was lawfully issued and delivered |
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| 1 | | in, and under the laws of, a State in which the insurer was | 2 | | authorized to do an insurance business, to a group properly | 3 | | established pursuant to law or regulation, and where the | 4 | | policyholder is domiciled or otherwise has a bona fide situs. | 5 | | (Source: P.A. 86-753.) | 6 | | (215 ILCS 5/352c new) | 7 | | Sec. 352c. Short-term, limited-duration insurance | 8 | | prohibited. | 9 | | (a) In this Section: | 10 | | "Excepted benefits" has the meaning given to that term in | 11 | | 42 U.S.C. 300gg-91 and implementing regulations. "Excepted | 12 | | benefits" includes individual, group, or blanket coverage. | 13 | | "Short-term, limited-duration insurance" means any type of | 14 | | accident and health insurance offered or provided within this | 15 | | State pursuant to a group or individual policy or individual | 16 | | certificate by a company, regardless of the situs state of the | 17 | | delivery of the policy, that has an expiration date specified | 18 | | in the contract that is fewer than 365 days after the original | 19 | | effective date. Regardless of the duration of coverage, | 20 | | "short-term, limited-duration insurance" does not include | 21 | | excepted benefits or any student health insurance coverage. | 22 | | (b) On and after January 1, 2025, no company shall issue, | 23 | | deliver, amend, or renew short-term, limited-duration | 24 | | insurance to any natural or legal person that is a resident or | 25 | | domiciled in this State. |
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| 1 | | (215 ILCS 5/356z.18) | 2 | | (Text of Section before amendment by P.A. 103-512 ) | 3 | | Sec. 356z.18. Prosthetic and customized orthotic devices. | 4 | | (a) For the purposes of this Section: | 5 | | "Customized orthotic device" means a supportive device for | 6 | | the body or a part of the body, the head, neck, or extremities, | 7 | | and includes the replacement or repair of the device based on | 8 | | the patient's physical condition as medically necessary, | 9 | | excluding foot orthotics defined as an in-shoe device designed | 10 | | to support the structural components of the foot during | 11 | | weight-bearing activities. | 12 | | "Licensed provider" means a prosthetist, orthotist, or | 13 | | pedorthist licensed to practice in this State. | 14 | | "Prosthetic device" means an artificial device to replace, | 15 | | in whole or in part, an arm or leg and includes accessories | 16 | | essential to the effective use of the device and the | 17 | | replacement or repair of the device based on the patient's | 18 | | physical condition as medically necessary. | 19 | | (b) This amendatory Act of the 96th General Assembly shall | 20 | | provide benefits to any person covered thereunder for expenses | 21 | | incurred in obtaining a prosthetic or custom orthotic device | 22 | | from any Illinois licensed prosthetist, licensed orthotist, or | 23 | | licensed pedorthist as required under the Orthotics, | 24 | | Prosthetics, and Pedorthics Practice Act. | 25 | | (c) A group or individual major medical policy of accident |
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| 1 | | or health insurance or managed care plan or medical, health, | 2 | | or hospital service corporation contract that provides | 3 | | coverage for prosthetic or custom orthotic care and is | 4 | | amended, delivered, issued, or renewed 6 months after the | 5 | | effective date of this amendatory Act of the 96th General | 6 | | Assembly must provide coverage for prosthetic and orthotic | 7 | | devices in accordance with this subsection (c). The coverage | 8 | | required under this Section shall be subject to the other | 9 | | general exclusions, limitations, and financial requirements of | 10 | | the policy, including coordination of benefits, participating | 11 | | provider requirements, utilization review of health care | 12 | | services, including review of medical necessity, case | 13 | | management, and experimental and investigational treatments, | 14 | | and other managed care provisions under terms and conditions | 15 | | that are no less favorable than the terms and conditions that | 16 | | apply to substantially all medical and surgical benefits | 17 | | provided under the plan or coverage. | 18 | | (d) The policy or plan or contract may require prior | 19 | | authorization for the prosthetic or orthotic devices in the | 20 | | same manner that prior authorization is required for any other | 21 | | covered benefit. | 22 | | (e) Repairs and replacements of prosthetic and orthotic | 23 | | devices are also covered, subject to the co-payments and | 24 | | deductibles, unless necessitated by misuse or loss. | 25 | | (f) A policy or plan or contract may require that, if | 26 | | coverage is provided through a managed care plan, the benefits |
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| 1 | | mandated pursuant to this Section shall be covered benefits | 2 | | only if the prosthetic or orthotic devices are provided by a | 3 | | licensed provider employed by a provider service who contracts | 4 | | with or is designated by the carrier, to the extent that the | 5 | | carrier provides in-network and out-of-network service, the | 6 | | coverage for the prosthetic or orthotic device shall be | 7 | | offered no less extensively. | 8 | | (g) The policy or plan or contract shall also meet | 9 | | adequacy requirements as established by the Health Care | 10 | | Reimbursement Reform Act of 1985 of the Illinois Insurance | 11 | | Code. | 12 | | (h) This Section shall not apply to accident only, | 13 | | specified disease, short-term travel hospital or medical , | 14 | | hospital confinement indemnity or other fixed indemnity , | 15 | | credit, dental, vision, Medicare supplement, long-term care, | 16 | | basic hospital and medical-surgical expense coverage, | 17 | | disability income insurance coverage, coverage issued as a | 18 | | supplement to liability insurance, workers' compensation | 19 | | insurance, or automobile medical payment insurance. | 20 | | (Source: P.A. 96-833, eff. 6-1-10 .) | 21 | | (Text of Section after amendment by P.A. 103-512 ) | 22 | | Sec. 356z.18. Prosthetic and customized orthotic devices. | 23 | | (a) For the purposes of this Section: | 24 | | "Customized orthotic device" means a supportive device for | 25 | | the body or a part of the body, the head, neck, or extremities, |
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| 1 | | and includes the replacement or repair of the device based on | 2 | | the patient's physical condition as medically necessary, | 3 | | excluding foot orthotics defined as an in-shoe device designed | 4 | | to support the structural components of the foot during | 5 | | weight-bearing activities. | 6 | | "Licensed provider" means a prosthetist, orthotist, or | 7 | | pedorthist licensed to practice in this State. | 8 | | "Prosthetic device" means an artificial device to replace, | 9 | | in whole or in part, an arm or leg and includes accessories | 10 | | essential to the effective use of the device and the | 11 | | replacement or repair of the device based on the patient's | 12 | | physical condition as medically necessary. | 13 | | (b) This amendatory Act of the 96th General Assembly shall | 14 | | provide benefits to any person covered thereunder for expenses | 15 | | incurred in obtaining a prosthetic or custom orthotic device | 16 | | from any Illinois licensed prosthetist, licensed orthotist, or | 17 | | licensed pedorthist as required under the Orthotics, | 18 | | Prosthetics, and Pedorthics Practice Act. | 19 | | (c) A group or individual major medical policy of accident | 20 | | or health insurance or managed care plan or medical, health, | 21 | | or hospital service corporation contract that provides | 22 | | coverage for prosthetic or custom orthotic care and is | 23 | | amended, delivered, issued, or renewed 6 months after the | 24 | | effective date of this amendatory Act of the 96th General | 25 | | Assembly must provide coverage for prosthetic and orthotic | 26 | | devices in accordance with this subsection (c). The coverage |
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| 1 | | required under this Section shall be subject to the other | 2 | | general exclusions, limitations, and financial requirements of | 3 | | the policy, including coordination of benefits, participating | 4 | | provider requirements, utilization review of health care | 5 | | services, including review of medical necessity, case | 6 | | management, and experimental and investigational treatments, | 7 | | and other managed care provisions under terms and conditions | 8 | | that are no less favorable than the terms and conditions that | 9 | | apply to substantially all medical and surgical benefits | 10 | | provided under the plan or coverage. | 11 | | (d) With respect to an enrollee at any age, in addition to | 12 | | coverage of a prosthetic or custom orthotic device required by | 13 | | this Section, benefits shall be provided for a prosthetic or | 14 | | custom orthotic device determined by the enrollee's provider | 15 | | to be the most appropriate model that is medically necessary | 16 | | for the enrollee to perform physical activities, as | 17 | | applicable, such as running, biking, swimming, and lifting | 18 | | weights, and to maximize the enrollee's whole body health and | 19 | | strengthen the lower and upper limb function. | 20 | | (e) The requirements of this Section do not constitute an | 21 | | addition to this State's essential health benefits that | 22 | | requires defrayal of costs by this State pursuant to 42 U.S.C. | 23 | | 18031(d)(3)(B). | 24 | | (f) The policy or plan or contract may require prior | 25 | | authorization for the prosthetic or orthotic devices in the | 26 | | same manner that prior authorization is required for any other |
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| 1 | | covered benefit. | 2 | | (g) Repairs and replacements of prosthetic and orthotic | 3 | | devices are also covered, subject to the co-payments and | 4 | | deductibles, unless necessitated by misuse or loss. | 5 | | (h) A policy or plan or contract may require that, if | 6 | | coverage is provided through a managed care plan, the benefits | 7 | | mandated pursuant to this Section shall be covered benefits | 8 | | only if the prosthetic or orthotic devices are provided by a | 9 | | licensed provider employed by a provider service who contracts | 10 | | with or is designated by the carrier, to the extent that the | 11 | | carrier provides in-network and out-of-network service, the | 12 | | coverage for the prosthetic or orthotic device shall be | 13 | | offered no less extensively. | 14 | | (i) The policy or plan or contract shall also meet | 15 | | adequacy requirements as established by the Health Care | 16 | | Reimbursement Reform Act of 1985 of the Illinois Insurance | 17 | | Code. | 18 | | (j) This Section shall not apply to accident only, | 19 | | specified disease, short-term travel hospital or medical , | 20 | | hospital confinement indemnity or other fixed indemnity , | 21 | | credit, dental, vision, Medicare supplement, long-term care, | 22 | | basic hospital and medical-surgical expense coverage, | 23 | | disability income insurance coverage, coverage issued as a | 24 | | supplement to liability insurance, workers' compensation | 25 | | insurance, or automobile medical payment insurance. | 26 | | (Source: P.A. 103-512, eff. 1-1-25.) |
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| 1 | | (215 ILCS 5/367.3) (from Ch. 73, par. 979.3) | 2 | | Sec. 367.3. Group accident and health insurance; | 3 | | discretionary groups. | 4 | | (a) No group health insurance offered to a resident of | 5 | | this State under a policy issued to a group, other than one | 6 | | specifically described in Section 367(1), shall be delivered | 7 | | or issued for delivery in this State unless the Director | 8 | | determines that: | 9 | | (1) the issuance of the policy is not contrary to the | 10 | | public interest; | 11 | | (2) the issuance of the policy will result in | 12 | | economies of acquisition and administration; and | 13 | | (3) the benefits under the policy are reasonable in | 14 | | relation to the premium charged. | 15 | | (b) No such group health insurance may be offered in this | 16 | | State under a policy issued in another state unless this State | 17 | | or the state in which the group policy is issued has made a | 18 | | determination that the requirements of subsection (a) have | 19 | | been met. | 20 | | Where insurance is to be offered in this State under a | 21 | | policy described in this subsection, the insurer shall file | 22 | | for informational review purposes: | 23 | | (1) a copy of the group master contract; | 24 | | (2) a copy of the statute authorizing the issuance of | 25 | | the group policy in the state of situs, which statute has |
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| 1 | | the same or similar requirements as this State, or in the | 2 | | absence of such statute, a certification by an officer of | 3 | | the company that the policy meets the Illinois minimum | 4 | | standards required for individual accident and health | 5 | | policies under authority of Section 401 of this Code, as | 6 | | now or hereafter amended, as promulgated by rule at 50 | 7 | | Illinois Administrative Code, Ch. I, Sec. 2007, et seq., | 8 | | as now or hereafter amended, or by a successor rule; | 9 | | (3) evidence of approval by the state of situs of the | 10 | | group master policy; and | 11 | | (4) copies of all supportive material furnished to the | 12 | | state of situs to satisfy the criteria for approval. | 13 | | (c) The Director may, at any time after receipt of the | 14 | | information required under subsection (b) and after finding | 15 | | that the standards of subsection (a) have not been met, order | 16 | | the insurer to cease the issuance or marketing of that | 17 | | coverage in this State. | 18 | | (d) Notwithstanding subsections (a) and (b), group Group | 19 | | accident and health insurance subject to the provisions of | 20 | | this Section is also subject to the provisions of Sections | 21 | | 352c and Section 367i of this Code and rules thereunder . | 22 | | (Source: P.A. 90-655, eff. 7-30-98.) | 23 | | (215 ILCS 5/367a) (from Ch. 73, par. 979a) | 24 | | Sec. 367a. Blanket accident and health insurance. | 25 | | (1) Blanket accident and health insurance is the that form |
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| 1 | | of accident and health insurance providing excepted benefits, | 2 | | as defined in Section 352c, that covers covering special | 3 | | groups of persons as enumerated in one of the following | 4 | | paragraphs (a) to (g), inclusive: | 5 | | (a) Under a policy or contract issued to any carrier for | 6 | | hire, which shall be deemed the policyholder, covering a group | 7 | | defined as all persons who may become passengers on such | 8 | | carrier. | 9 | | (b) Under a policy or contract issued to an employer, who | 10 | | shall be deemed the policyholder, covering all employees or | 11 | | any group of employees defined by reference to exceptional | 12 | | hazards incident to such employment. | 13 | | (c) Under a policy or contract issued to a college, | 14 | | school, or other institution of learning or to the head or | 15 | | principal thereof, who or which shall be deemed the | 16 | | policyholder, covering students or teachers. However, student | 17 | | health insurance coverage, as defined in 45 CFR 147.145, shall | 18 | | remain subject to the standards and requirements for | 19 | | individual health insurance coverage except where inconsistent | 20 | | with that regulation. An issuer providing student health | 21 | | insurance coverage or a policy or contract covering students | 22 | | for limited-scope dental or vision under 45 CFR 148.220 shall | 23 | | require an individual application or enrollment form and shall | 24 | | furnish each insured individual a certificate, which shall | 25 | | have been approved by the Director under Section 355. | 26 | | (d) Under a policy or contract issued in the name of any |
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| 1 | | volunteer fire department, first aid, or other such volunteer | 2 | | group, which shall be deemed the policyholder, covering all of | 3 | | the members of such department or group. | 4 | | (e) Under a policy or contract issued to a creditor, who | 5 | | shall be deemed the policyholder, to insure debtors of the | 6 | | creditors; Provided, however, that in the case of a loan which | 7 | | is subject to the Small Loans Act, no insurance premium or | 8 | | other cost shall be directly or indirectly charged or assessed | 9 | | against, or collected or received from the borrower. | 10 | | (f) Under a policy or contract issued to a sports team or | 11 | | to a camp, which team or camp sponsor shall be deemed the | 12 | | policyholder, covering members or campers. | 13 | | (g) Under a policy or contract issued to any other | 14 | | substantially similar group which, in the discretion of the | 15 | | Director, may be subject to the issuance of a blanket accident | 16 | | and health policy or contract. | 17 | | (2) Any insurance company authorized to write accident and | 18 | | health insurance in this state shall have the power to issue | 19 | | blanket accident and health insurance. No such blanket policy | 20 | | may be issued or delivered in this State unless a copy of the | 21 | | form thereof shall have been filed in accordance with Section | 22 | | 355, and it contains in substance such of those provisions | 23 | | contained in Sections 357.1 through 357.30 as may be | 24 | | applicable to blanket accident and health insurance and the | 25 | | following provisions: | 26 | | (a) A provision that the policy and the application shall |
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| 1 | | constitute the entire contract between the parties, and that | 2 | | all statements made by the policyholder shall, in absence of | 3 | | fraud, be deemed representations and not warranties, and that | 4 | | no such statements shall be used in defense to a claim under | 5 | | the policy, unless it is contained in a written application. | 6 | | (b) A provision that to the group or class thereof | 7 | | originally insured shall be added from time to time all new | 8 | | persons or individuals eligible for coverage. | 9 | | (3) An individual application shall not be required from a | 10 | | person covered under a blanket accident or health policy or | 11 | | contract, nor shall it be necessary for the insurer to furnish | 12 | | each person a certificate. | 13 | | (4) All benefits under any blanket accident and health | 14 | | policy shall be payable to the person insured, or to his | 15 | | designated beneficiary or beneficiaries, or to his or her | 16 | | estate, except that if the person insured be a minor or person | 17 | | under legal disability, such benefits may be made payable to | 18 | | his or her parent, guardian, or other person actually | 19 | | supporting him or her. Provided further, however, that the | 20 | | policy may provide that all or any portion of any indemnities | 21 | | provided by any such policy on account of hospital, nursing, | 22 | | medical or surgical services may, at the insurer's option, be | 23 | | paid directly to the hospital or person rendering such | 24 | | services; but the policy may not require that the service be | 25 | | rendered by a particular hospital or person. Payment so made | 26 | | shall discharge the insurer's obligation with respect to the |
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| 1 | | amount of insurance so paid. | 2 | | (5) Nothing contained in this section shall be deemed to | 3 | | affect the legal liability of policyholders for the death of | 4 | | or injury to, any such member of such group. | 5 | | (Source: P.A. 83-1362.) | 6 | | (215 ILCS 5/368f) | 7 | | Sec. 368f. Military service member insurance | 8 | | reinstatement. | 9 | | (a) No Illinois resident activated for military service | 10 | | and no spouse or dependent of the resident who becomes | 11 | | eligible for a federal government-sponsored health insurance | 12 | | program, including the TriCare program providing coverage for | 13 | | civilian dependents of military personnel, as a result of the | 14 | | activation shall be denied reinstatement into the same | 15 | | individual health insurance coverage with the health insurer | 16 | | that the resident lapsed as a result of activation or becoming | 17 | | covered by the federal government-sponsored health insurance | 18 | | program. The resident shall have the right to reinstatement in | 19 | | the same individual health insurance coverage without medical | 20 | | underwriting, subject to payment of the current premium | 21 | | charged to other persons of the same age and gender that are | 22 | | covered under the same individual health coverage. Except in | 23 | | the case of birth or adoption that occurs during the period of | 24 | | activation, reinstatement must be into the same coverage type | 25 | | as the resident held prior to lapsing the individual health |
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| 1 | | insurance coverage and at the same or, at the option of the | 2 | | resident, higher deductible level. The reinstatement rights | 3 | | provided under this subsection (a) are not available to a | 4 | | resident or dependents if the activated person is discharged | 5 | | from the military under other than honorable conditions. | 6 | | (b) The health insurer with which the reinstatement is | 7 | | being requested must receive a request for reinstatement no | 8 | | later than 63 days following the later of (i) deactivation or | 9 | | (ii) loss of coverage under the federal government-sponsored | 10 | | health insurance program. The health insurer may request proof | 11 | | of loss of coverage and the timing of the loss of coverage of | 12 | | the government-sponsored coverage in order to determine | 13 | | eligibility for reinstatement into the individual coverage. | 14 | | The effective date of the reinstatement of individual health | 15 | | coverage shall be the first of the month following receipt of | 16 | | the notice requesting reinstatement. | 17 | | (c) All insurers must provide written notice to the | 18 | | policyholder of individual health coverage of the rights | 19 | | described in subsection (a) of this Section. In lieu of the | 20 | | inclusion of the notice in the individual health insurance | 21 | | policy, an insurance company may satisfy the notification | 22 | | requirement by providing a single written notice: | 23 | | (1) in conjunction with the enrollment process for a | 24 | | policyholder initially enrolling in the individual | 25 | | coverage on or after the effective date of this amendatory | 26 | | Act of the 94th General Assembly; or |
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| 1 | | (2) by mailing written notice to policyholders whose | 2 | | coverage was effective prior to the effective date of this | 3 | | amendatory Act of the 94th General Assembly no later than | 4 | | 90 days following the effective date of this amendatory | 5 | | Act of the 94th General Assembly. | 6 | | (d) The provisions of subsection (a) of this Section do | 7 | | not apply to any policy or certificate providing coverage for | 8 | | any specified disease, specified accident or accident-only | 9 | | coverage, credit, dental, disability income, hospital | 10 | | indemnity or other fixed indemnity , long-term care, Medicare | 11 | | supplement, vision care, or short-term travel nonrenewable | 12 | | health policy or other limited-benefit supplemental insurance, | 13 | | or any coverage issued as a supplement to any liability | 14 | | insurance, workers' compensation or similar insurance, or any | 15 | | insurance under which benefits are payable with or without | 16 | | regard to fault, whether written on a group, blanket, or | 17 | | individual basis. | 18 | | (e) Nothing in this Section shall require an insurer to | 19 | | reinstate the resident if the insurer requires residency in an | 20 | | enrollment area and those residency requirements are not met | 21 | | after deactivation or loss of coverage under the | 22 | | government-sponsored health insurance program. | 23 | | (f) All terms, conditions, and limitations of the | 24 | | individual coverage into which reinstatement is made apply | 25 | | equally to all insureds enrolled in the coverage. | 26 | | (g) The Secretary may adopt rules as may be necessary to |
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| 1 | | carry out the provisions of this Section. | 2 | | (Source: P.A. 94-1037, eff. 7-20-06.) | 3 | | Section 10. The Health Maintenance Organization Act is | 4 | | amended by changing Section 5-3 as follows: | 5 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | 6 | | Sec. 5-3. Insurance Code provisions. | 7 | | (a) Health Maintenance Organizations shall be subject to | 8 | | the provisions of Sections 133, 134, 136, 137, 139, 140, | 9 | | 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | 10 | | 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | 11 | | 352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | 12 | | 356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | 13 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 14 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | 15 | | 356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | 16 | | 356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | 17 | | 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | 18 | | 356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | 19 | | 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | 20 | | 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | 21 | | 356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | 22 | | 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | 23 | | 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | 24 | | subsection (2) of Section 367, and Articles IIA, VIII 1/2, |
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| 1 | | XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | 2 | | Illinois Insurance Code. | 3 | | (b) For purposes of the Illinois Insurance Code, except | 4 | | for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | 5 | | Health Maintenance Organizations in the following categories | 6 | | are deemed to be "domestic companies": | 7 | | (1) a corporation authorized under the Dental Service | 8 | | Plan Act or the Voluntary Health Services Plans Act; | 9 | | (2) a corporation organized under the laws of this | 10 | | State; or | 11 | | (3) a corporation organized under the laws of another | 12 | | state, 30% or more of the enrollees of which are residents | 13 | | of this State, except a corporation subject to | 14 | | substantially the same requirements in its state of | 15 | | organization as is a "domestic company" under Article VIII | 16 | | 1/2 of the Illinois Insurance Code. | 17 | | (c) In considering the merger, consolidation, or other | 18 | | acquisition of control of a Health Maintenance Organization | 19 | | pursuant to Article VIII 1/2 of the Illinois Insurance Code, | 20 | | (1) the Director shall give primary consideration to | 21 | | the continuation of benefits to enrollees and the | 22 | | financial conditions of the acquired Health Maintenance | 23 | | Organization after the merger, consolidation, or other | 24 | | acquisition of control takes effect; | 25 | | (2)(i) the criteria specified in subsection (1)(b) of | 26 | | Section 131.8 of the Illinois Insurance Code shall not |
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| 1 | | apply and (ii) the Director, in making his determination | 2 | | with respect to the merger, consolidation, or other | 3 | | acquisition of control, need not take into account the | 4 | | effect on competition of the merger, consolidation, or | 5 | | other acquisition of control; | 6 | | (3) the Director shall have the power to require the | 7 | | following information: | 8 | | (A) certification by an independent actuary of the | 9 | | adequacy of the reserves of the Health Maintenance | 10 | | Organization sought to be acquired; | 11 | | (B) pro forma financial statements reflecting the | 12 | | combined balance sheets of the acquiring company and | 13 | | the Health Maintenance Organization sought to be | 14 | | acquired as of the end of the preceding year and as of | 15 | | a date 90 days prior to the acquisition, as well as pro | 16 | | forma financial statements reflecting projected | 17 | | combined operation for a period of 2 years; | 18 | | (C) a pro forma business plan detailing an | 19 | | acquiring party's plans with respect to the operation | 20 | | of the Health Maintenance Organization sought to be | 21 | | acquired for a period of not less than 3 years; and | 22 | | (D) such other information as the Director shall | 23 | | require. | 24 | | (d) The provisions of Article VIII 1/2 of the Illinois | 25 | | Insurance Code and this Section 5-3 shall apply to the sale by | 26 | | any health maintenance organization of greater than 10% of its |
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| 1 | | enrollee population (including , without limitation , the health | 2 | | maintenance organization's right, title, and interest in and | 3 | | to its health care certificates). | 4 | | (e) In considering any management contract or service | 5 | | agreement subject to Section 141.1 of the Illinois Insurance | 6 | | Code, the Director (i) shall, in addition to the criteria | 7 | | specified in Section 141.2 of the Illinois Insurance Code, | 8 | | take into account the effect of the management contract or | 9 | | service agreement on the continuation of benefits to enrollees | 10 | | and the financial condition of the health maintenance | 11 | | organization to be managed or serviced, and (ii) need not take | 12 | | into account the effect of the management contract or service | 13 | | agreement on competition. | 14 | | (f) Except for small employer groups as defined in the | 15 | | Small Employer Rating, Renewability and Portability Health | 16 | | Insurance Act and except for medicare supplement policies as | 17 | | defined in Section 363 of the Illinois Insurance Code, a | 18 | | Health Maintenance Organization may by contract agree with a | 19 | | group or other enrollment unit to effect refunds or charge | 20 | | additional premiums under the following terms and conditions: | 21 | | (i) the amount of, and other terms and conditions with | 22 | | respect to, the refund or additional premium are set forth | 23 | | in the group or enrollment unit contract agreed in advance | 24 | | of the period for which a refund is to be paid or | 25 | | additional premium is to be charged (which period shall | 26 | | not be less than one year); and |
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| 1 | | (ii) the amount of the refund or additional premium | 2 | | shall not exceed 20% of the Health Maintenance | 3 | | Organization's profitable or unprofitable experience with | 4 | | respect to the group or other enrollment unit for the | 5 | | period (and, for purposes of a refund or additional | 6 | | premium, the profitable or unprofitable experience shall | 7 | | be calculated taking into account a pro rata share of the | 8 | | Health Maintenance Organization's administrative and | 9 | | marketing expenses, but shall not include any refund to be | 10 | | made or additional premium to be paid pursuant to this | 11 | | subsection (f)). The Health Maintenance Organization and | 12 | | the group or enrollment unit may agree that the profitable | 13 | | or unprofitable experience may be calculated taking into | 14 | | account the refund period and the immediately preceding 2 | 15 | | plan years. | 16 | | The Health Maintenance Organization shall include a | 17 | | statement in the evidence of coverage issued to each enrollee | 18 | | describing the possibility of a refund or additional premium, | 19 | | and upon request of any group or enrollment unit, provide to | 20 | | the group or enrollment unit a description of the method used | 21 | | to calculate (1) the Health Maintenance Organization's | 22 | | profitable experience with respect to the group or enrollment | 23 | | unit and the resulting refund to the group or enrollment unit | 24 | | or (2) the Health Maintenance Organization's unprofitable | 25 | | experience with respect to the group or enrollment unit and | 26 | | the resulting additional premium to be paid by the group or |
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| 1 | | enrollment unit. | 2 | | In no event shall the Illinois Health Maintenance | 3 | | Organization Guaranty Association be liable to pay any | 4 | | contractual obligation of an insolvent organization to pay any | 5 | | refund authorized under this Section. | 6 | | (g) Rulemaking authority to implement Public Act 95-1045, | 7 | | if any, is conditioned on the rules being adopted in | 8 | | accordance with all provisions of the Illinois Administrative | 9 | | Procedure Act and all rules and procedures of the Joint | 10 | | Committee on Administrative Rules; any purported rule not so | 11 | | adopted, for whatever reason, is unauthorized. | 12 | | (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | 13 | | 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | 14 | | 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | 15 | | eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | 16 | | 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | 17 | | 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | 18 | | eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | 19 | | 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | 20 | | 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 21 | | eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | 22 | | Section 15. The Limited Health Service Organization Act is | 23 | | amended by changing Section 4003 as follows: | 24 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) |
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| 1 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 2 | | health service organizations shall be subject to the | 3 | | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | 4 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | 5 | | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, | 6 | | 355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | 7 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | 8 | | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | 9 | | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | 10 | | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | 11 | | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | 12 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | 13 | | Nothing in this Section shall require a limited health care | 14 | | plan to cover any service that is not a limited health service. | 15 | | For purposes of the Illinois Insurance Code, except for | 16 | | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | 17 | | health service organizations in the following categories are | 18 | | deemed to be domestic companies: | 19 | | (1) a corporation under the laws of this State; or | 20 | | (2) a corporation organized under the laws of another | 21 | | state, 30% or more of the enrollees of which are residents | 22 | | of this State, except a corporation subject to | 23 | | substantially the same requirements in its state of | 24 | | organization as is a domestic company under Article VIII | 25 | | 1/2 of the Illinois Insurance Code. | 26 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; |
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| 1 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | 2 | | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | 3 | | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | 4 | | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | 5 | | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 6 | | eff. 1-1-24; revised 8-29-23.) | 7 | | (215 ILCS 190/Act rep.) | 8 | | Section 20. The Short-Term, Limited-Duration Health | 9 | | Insurance Coverage Act is repealed. | 10 | | Section 95. No acceleration or delay. Where this Act makes | 11 | | changes in a statute that is represented in this Act by text | 12 | | that is not yet or no longer in effect (for example, a Section | 13 | | represented by multiple versions), the use of that text does | 14 | | not accelerate or delay the taking effect of (i) the changes | 15 | | made by this Act or (ii) provisions derived from any other | 16 | | Public Act. | 17 | | Section 99. Effective date. This Act takes effect January | 18 | | 1, 2025.". |
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