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91_SB0107
LRB9102356JSpc
1 AN ACT concerning the treatment of Lyme disease, amending
2 named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 adding Section 356y as follows:
7 (215 ILCS 5/356y new)
8 Sec. 356y. Lyme disease. A group or individual policy
9 of accident and health insurance or managed care plan that is
10 amended, delivered, issued or renewed after the effective
11 date of this amendatory Act of the 91st General Assembly must
12 provide coverage for the treatment of Lyme disease. The
13 insurance or managed care plan may not impose a special
14 deductible, copayment, waiting period, or any other
15 restriction on the type, nature, or length of treatment for
16 Lyme disease that it does not apply to nonpreventive
17 treatment in general.
18 Section 10. The Health Maintenance Organization Act is
19 amended by changing Section 5-3 as follows:
20 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
21 Sec. 5-3. Insurance Code provisions.
22 (a) Health Maintenance Organizations shall be subject to
23 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
24 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
25 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
26 356y, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
27 444, and 444.1, paragraph (c) of subsection (2) of Section
28 367, and Articles VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
29 XXV, and XXVI of the Illinois Insurance Code.
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1 (b) For purposes of the Illinois Insurance Code, except
2 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
3 Health Maintenance Organizations in the following categories
4 are deemed to be "domestic companies":
5 (1) a corporation authorized under the Dental
6 Service Plan Act or the Voluntary Health Services Plans
7 Act;
8 (2) a corporation organized under the laws of this
9 State; or
10 (3) a corporation organized under the laws of
11 another state, 30% or more of the enrollees of which are
12 residents of this State, except a corporation subject to
13 substantially the same requirements in its state of
14 organization as is a "domestic company" under Article
15 VIII 1/2 of the Illinois Insurance Code.
16 (c) In considering the merger, consolidation, or other
17 acquisition of control of a Health Maintenance Organization
18 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
19 (1) the Director shall give primary consideration
20 to the continuation of benefits to enrollees and the
21 financial conditions of the acquired Health Maintenance
22 Organization after the merger, consolidation, or other
23 acquisition of control takes effect;
24 (2)(i) the criteria specified in subsection (1)(b)
25 of Section 131.8 of the Illinois Insurance Code shall not
26 apply and (ii) the Director, in making his determination
27 with respect to the merger, consolidation, or other
28 acquisition of control, need not take into account the
29 effect on competition of the merger, consolidation, or
30 other acquisition of control;
31 (3) the Director shall have the power to require
32 the following information:
33 (A) certification by an independent actuary of
34 the adequacy of the reserves of the Health
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1 Maintenance Organization sought to be acquired;
2 (B) pro forma financial statements reflecting
3 the combined balance sheets of the acquiring company
4 and the Health Maintenance Organization sought to be
5 acquired as of the end of the preceding year and as
6 of a date 90 days prior to the acquisition, as well
7 as pro forma financial statements reflecting
8 projected combined operation for a period of 2
9 years;
10 (C) a pro forma business plan detailing an
11 acquiring party's plans with respect to the
12 operation of the Health Maintenance Organization
13 sought to be acquired for a period of not less than
14 3 years; and
15 (D) such other information as the Director
16 shall require.
17 (d) The provisions of Article VIII 1/2 of the Illinois
18 Insurance Code and this Section 5-3 shall apply to the sale
19 by any health maintenance organization of greater than 10% of
20 its enrollee population (including without limitation the
21 health maintenance organization's right, title, and interest
22 in and to its health care certificates).
23 (e) In considering any management contract or service
24 agreement subject to Section 141.1 of the Illinois Insurance
25 Code, the Director (i) shall, in addition to the criteria
26 specified in Section 141.2 of the Illinois Insurance Code,
27 take into account the effect of the management contract or
28 service agreement on the continuation of benefits to
29 enrollees and the financial condition of the health
30 maintenance organization to be managed or serviced, and (ii)
31 need not take into account the effect of the management
32 contract or service agreement on competition.
33 (f) Except for small employer groups as defined in the
34 Small Employer Rating, Renewability and Portability Health
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1 Insurance Act and except for medicare supplement policies as
2 defined in Section 363 of the Illinois Insurance Code, a
3 Health Maintenance Organization may by contract agree with a
4 group or other enrollment unit to effect refunds or charge
5 additional premiums under the following terms and conditions:
6 (i) the amount of, and other terms and conditions
7 with respect to, the refund or additional premium are set
8 forth in the group or enrollment unit contract agreed in
9 advance of the period for which a refund is to be paid or
10 additional premium is to be charged (which period shall
11 not be less than one year); and
12 (ii) the amount of the refund or additional premium
13 shall not exceed 20% of the Health Maintenance
14 Organization's profitable or unprofitable experience with
15 respect to the group or other enrollment unit for the
16 period (and, for purposes of a refund or additional
17 premium, the profitable or unprofitable experience shall
18 be calculated taking into account a pro rata share of the
19 Health Maintenance Organization's administrative and
20 marketing expenses, but shall not include any refund to
21 be made or additional premium to be paid pursuant to this
22 subsection (f)). The Health Maintenance Organization and
23 the group or enrollment unit may agree that the
24 profitable or unprofitable experience may be calculated
25 taking into account the refund period and the immediately
26 preceding 2 plan years.
27 The Health Maintenance Organization shall include a
28 statement in the evidence of coverage issued to each enrollee
29 describing the possibility of a refund or additional premium,
30 and upon request of any group or enrollment unit, provide to
31 the group or enrollment unit a description of the method used
32 to calculate (1) the Health Maintenance Organization's
33 profitable experience with respect to the group or enrollment
34 unit and the resulting refund to the group or enrollment unit
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1 or (2) the Health Maintenance Organization's unprofitable
2 experience with respect to the group or enrollment unit and
3 the resulting additional premium to be paid by the group or
4 enrollment unit.
5 In no event shall the Illinois Health Maintenance
6 Organization Guaranty Association be liable to pay any
7 contractual obligation of an insolvent organization to pay
8 any refund authorized under this Section.
9 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
10 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; 90-583, eff.
11 5-29-98; 90-655, eff. 7-30-98; 90-741, eff. 1-1-99; revised
12 9-8-98.)
13 Section 15. The Limited Health Service Organization Act
14 is amended by changing Section 3009 as follows:
15 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
16 Sec. 3009. Point-of-service limited health service
17 contracts.
18 (a) An LHSO that offers a POS contract:
19 (1) shall include as in-plan covered services all
20 services required by law to be provided by an LHSO;
21 (2) shall provide incentives, which shall include
22 financial incentives, for enrollees to use in-plan
23 covered services;
24 (3) shall not offer services out-of-plan without
25 providing those services on an in-plan basis;
26 (4) may limit or exclude specific types of services
27 from coverage when obtained out-of-plan;
28 (5) may include annual out-of-pocket limits and
29 lifetime maximum benefits allowances for out-of-plan
30 services that are separate from any limits or allowances
31 applied to in-plan services;
32 (6) shall include an annual maximum benefit
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1 allowance not to exceed $2,500 per year that is separate
2 from any limits or allowances applied to in-plan
3 services;
4 (7) may limit the groups to which a POS product is
5 offered, however, if a POS product is offered to a group,
6 then it must be offered to all eligible members of that
7 group, when an LHSO provider is available;
8 (8) shall not consider emergency services,
9 authorized referral services, or non-routine services
10 obtained out of the service area to be POS services; and
11 (9) may treat as out-of-plan services those
12 services that an enrollee obtains from a participating
13 provider, but for which the proper authorization was not
14 given by the LHSO.
15 (b) An LHSO offering a POS contract shall be subject to
16 the following limitations:
17 (1) The LHSO shall not expend in any calendar
18 quarter more than 20% of its total limited health
19 services expenditures for all its members for out-of-plan
20 covered services.
21 (2) If the amount specified in paragraph (1) is
22 exceeded by 2% in a quarter, the LHSO shall effect
23 compliance with paragraph (1) by the end of the following
24 quarter.
25 (3) If compliance with the amount specified in
26 paragraph (1) is not demonstrated in the LHSO's next
27 quarterly report, the LHSO may not offer the POS contract
28 to new groups or include the POS option in the renewal of
29 an existing group until compliance with the amount
30 specified in paragraph (1) is demonstrated or otherwise
31 allowed by the Director.
32 (4) Any LHSO failing, without just cause, to comply
33 with the provisions of this subsection shall be required,
34 after notice and hearing, to pay a penalty of $250 for
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1 each day out of compliance, to be recovered by the
2 Director of Insurance. Any penalty recovered shall be
3 paid into the General Revenue Fund. The Director may
4 reduce the penalty if the LHSO demonstrates to the
5 Director that the imposition of the penalty would
6 constitute a financial hardship to the LHSO.
7 (c) Any LHSO that offers a POS product shall:
8 (1) File a quarterly financial statement detailing
9 compliance with the requirements of subsection (b).
10 (2) Track out-of-plan POS utilization separately
11 from in-plan or non-POS out-of-plan emergency care,
12 referral care, and urgent care out of the service area
13 utilization.
14 (3) Record out-of-plan utilization in a manner that
15 will permit such utilization and cost reporting as the
16 Director may, by regulation, require.
17 (4) Demonstrate to the Director's satisfaction that
18 the LHSO has the fiscal, administrative, and marketing
19 capacity to control its POS enrollment, utilization, and
20 costs so as not to jeopardize the financial security of
21 the LHSO.
22 (5) Maintain the deposit required by subsection (b)
23 of Section 2006 in addition to any other deposit required
24 under this Act.
25 (d) An LHSO shall not issue a POS contract until it has
26 filed and had approved by the Director a plan to comply with
27 the provisions of this Section. The compliance plan shall at
28 a minimum include provisions demonstrating that the LHSO will
29 do all of the following:
30 (1) Design the benefit levels and conditions of
31 coverage for in-plan covered services and out-of-plan
32 covered services as required by this Article.
33 (2) Provide or arrange for the provision of
34 adequate systems to:
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1 (A) process and pay claims for all out-of-plan
2 covered services;
3 (B) meet the requirements for a POS contract
4 set forth in this Section and any additional
5 requirements that may be set forth by the Director;
6 and
7 (C) generate accurate data and financial and
8 regulatory reports on a timely basis so that the
9 Department can evaluate the LHSO's experience with
10 the POS contract and monitor compliance with POS
11 contract provisions.
12 (3) Comply initially and on an ongoing basis with
13 the requirements of subsections (b) and (c).
14 (e) A limited health service organization that offers a
15 POS contract must comply with Sections 356w, and 356x, and
16 356y of the Illinois Insurance Code.
17 (Source: P.A. 90-741, eff. 1-1-99.)
18 Section 20. The Voluntary Health Services Plans Act is
19 amended by changing Section 10 as follows:
20 (215 ILCS 165/10) (from Ch. 32, par. 604)
21 Sec. 10. Application of Insurance Code provisions.
22 Health services plan corporations and all persons interested
23 therein or dealing therewith shall be subject to the
24 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
25 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
26 356x, 356y, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2,
27 and 412, and paragraphs (7) and (15) of Section 367 of the
28 Illinois Insurance Code.
29 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
30 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 90-741, eff.
31 1-1-99.)
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1 Section 99. Effective date. This Act takes effect upon
2 becoming law.