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Public Act 103-0649 | ||||
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AN ACT concerning regulation. | ||||
Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly: | ||||
Section 5. The Illinois Insurance Code is amended by | ||||
changing Sections 121-2.05, 356z.18, 367.3, 367a, and 368f and | ||||
by adding Section 352c as follows: | ||||
(215 ILCS 5/121-2.05) (from Ch. 73, par. 733-2.05) | ||||
Sec. 121-2.05. Group insurance policies issued and | ||||
delivered in other State-Transactions in this State. With the | ||||
exception of insurance transactions authorized under Sections | ||||
230.2 or 367.3 of this Code or transactions described under | ||||
Section 352c , transactions in this State involving group | ||||
legal, group life and group accident and health or blanket | ||||
accident and health insurance or group annuities where the | ||||
master policy of such groups was lawfully issued and delivered | ||||
in, and under the laws of, a State in which the insurer was | ||||
authorized to do an insurance business, to a group properly | ||||
established pursuant to law or regulation, and where the | ||||
policyholder is domiciled or otherwise has a bona fide situs. | ||||
(Source: P.A. 86-753.) | ||||
(215 ILCS 5/352c new) | ||||
Sec. 352c. Short-term, limited-duration insurance |
prohibited. | ||
(a) In this Section: | ||
"Excepted benefits" has the meaning given to that term in | ||
42 U.S.C. 300gg-91 and implementing regulations. "Excepted | ||
benefits" includes individual, group, or blanket coverage. | ||
"Short-term, limited-duration insurance" means any type of | ||
accident and health insurance offered or provided within this | ||
State pursuant to a group or individual policy or individual | ||
certificate by a company, regardless of the situs state of the | ||
delivery of the policy, that has an expiration date specified | ||
in the contract that is fewer than 365 days after the original | ||
effective date. Regardless of the duration of coverage, | ||
"short-term, limited-duration insurance" does not include | ||
excepted benefits or any student health insurance coverage. | ||
(b) On and after January 1, 2025, no company shall issue, | ||
deliver, amend, or renew short-term, limited-duration | ||
insurance to any natural or legal person that is a resident or | ||
domiciled in this State. | ||
(215 ILCS 5/356z.18) | ||
(Text of Section before amendment by P.A. 103-512 ) | ||
Sec. 356z.18. Prosthetic and customized orthotic devices. | ||
(a) For the purposes of this Section: | ||
"Customized orthotic device" means a supportive device for | ||
the body or a part of the body, the head, neck, or extremities, | ||
and includes the replacement or repair of the device based on |
the patient's physical condition as medically necessary, | ||
excluding foot orthotics defined as an in-shoe device designed | ||
to support the structural components of the foot during | ||
weight-bearing activities. | ||
"Licensed provider" means a prosthetist, orthotist, or | ||
pedorthist licensed to practice in this State. | ||
"Prosthetic device" means an artificial device to replace, | ||
in whole or in part, an arm or leg and includes accessories | ||
essential to the effective use of the device and the | ||
replacement or repair of the device based on the patient's | ||
physical condition as medically necessary. | ||
(b) This amendatory Act of the 96th General Assembly shall | ||
provide benefits to any person covered thereunder for expenses | ||
incurred in obtaining a prosthetic or custom orthotic device | ||
from any Illinois licensed prosthetist, licensed orthotist, or | ||
licensed pedorthist as required under the Orthotics, | ||
Prosthetics, and Pedorthics Practice Act. | ||
(c) A group or individual major medical policy of accident | ||
or health insurance or managed care plan or medical, health, | ||
or hospital service corporation contract that provides | ||
coverage for prosthetic or custom orthotic care and is | ||
amended, delivered, issued, or renewed 6 months after the | ||
effective date of this amendatory Act of the 96th General | ||
Assembly must provide coverage for prosthetic and orthotic | ||
devices in accordance with this subsection (c). The coverage | ||
required under this Section shall be subject to the other |
general exclusions, limitations, and financial requirements of | ||
the policy, including coordination of benefits, participating | ||
provider requirements, utilization review of health care | ||
services, including review of medical necessity, case | ||
management, and experimental and investigational treatments, | ||
and other managed care provisions under terms and conditions | ||
that are no less favorable than the terms and conditions that | ||
apply to substantially all medical and surgical benefits | ||
provided under the plan or coverage. | ||
(d) The policy or plan or contract may require prior | ||
authorization for the prosthetic or orthotic devices in the | ||
same manner that prior authorization is required for any other | ||
covered benefit. | ||
(e) Repairs and replacements of prosthetic and orthotic | ||
devices are also covered, subject to the co-payments and | ||
deductibles, unless necessitated by misuse or loss. | ||
(f) A policy or plan or contract may require that, if | ||
coverage is provided through a managed care plan, the benefits | ||
mandated pursuant to this Section shall be covered benefits | ||
only if the prosthetic or orthotic devices are provided by a | ||
licensed provider employed by a provider service who contracts | ||
with or is designated by the carrier, to the extent that the | ||
carrier provides in-network and out-of-network service, the | ||
coverage for the prosthetic or orthotic device shall be | ||
offered no less extensively. | ||
(g) The policy or plan or contract shall also meet |
adequacy requirements as established by the Health Care | ||
Reimbursement Reform Act of 1985 of the Illinois Insurance | ||
Code. | ||
(h) This Section shall not apply to accident only, | ||
specified disease, short-term travel hospital or medical , | ||
hospital confinement indemnity or other fixed indemnity , | ||
credit, dental, vision, Medicare supplement, long-term care, | ||
basic hospital and medical-surgical expense coverage, | ||
disability income insurance coverage, coverage issued as a | ||
supplement to liability insurance, workers' compensation | ||
insurance, or automobile medical payment insurance. | ||
(Source: P.A. 96-833, eff. 6-1-10 .) | ||
(Text of Section after amendment by P.A. 103-512 ) | ||
Sec. 356z.18. Prosthetic and customized orthotic devices. | ||
(a) For the purposes of this Section: | ||
"Customized orthotic device" means a supportive device for | ||
the body or a part of the body, the head, neck, or extremities, | ||
and includes the replacement or repair of the device based on | ||
the patient's physical condition as medically necessary, | ||
excluding foot orthotics defined as an in-shoe device designed | ||
to support the structural components of the foot during | ||
weight-bearing activities. | ||
"Licensed provider" means a prosthetist, orthotist, or | ||
pedorthist licensed to practice in this State. | ||
"Prosthetic device" means an artificial device to replace, |
in whole or in part, an arm or leg and includes accessories | ||
essential to the effective use of the device and the | ||
replacement or repair of the device based on the patient's | ||
physical condition as medically necessary. | ||
(b) This amendatory Act of the 96th General Assembly shall | ||
provide benefits to any person covered thereunder for expenses | ||
incurred in obtaining a prosthetic or custom orthotic device | ||
from any Illinois licensed prosthetist, licensed orthotist, or | ||
licensed pedorthist as required under the Orthotics, | ||
Prosthetics, and Pedorthics Practice Act. | ||
(c) A group or individual major medical policy of accident | ||
or health insurance or managed care plan or medical, health, | ||
or hospital service corporation contract that provides | ||
coverage for prosthetic or custom orthotic care and is | ||
amended, delivered, issued, or renewed 6 months after the | ||
effective date of this amendatory Act of the 96th General | ||
Assembly must provide coverage for prosthetic and orthotic | ||
devices in accordance with this subsection (c). The coverage | ||
required under this Section shall be subject to the other | ||
general exclusions, limitations, and financial requirements of | ||
the policy, including coordination of benefits, participating | ||
provider requirements, utilization review of health care | ||
services, including review of medical necessity, case | ||
management, and experimental and investigational treatments, | ||
and other managed care provisions under terms and conditions | ||
that are no less favorable than the terms and conditions that |
apply to substantially all medical and surgical benefits | ||
provided under the plan or coverage. | ||
(d) With respect to an enrollee at any age, in addition to | ||
coverage of a prosthetic or custom orthotic device required by | ||
this Section, benefits shall be provided for a prosthetic or | ||
custom orthotic device determined by the enrollee's provider | ||
to be the most appropriate model that is medically necessary | ||
for the enrollee to perform physical activities, as | ||
applicable, such as running, biking, swimming, and lifting | ||
weights, and to maximize the enrollee's whole body health and | ||
strengthen the lower and upper limb function. | ||
(e) The requirements of this Section do not constitute an | ||
addition to this State's essential health benefits that | ||
requires defrayal of costs by this State pursuant to 42 U.S.C. | ||
18031(d)(3)(B). | ||
(f) The policy or plan or contract may require prior | ||
authorization for the prosthetic or orthotic devices in the | ||
same manner that prior authorization is required for any other | ||
covered benefit. | ||
(g) Repairs and replacements of prosthetic and orthotic | ||
devices are also covered, subject to the co-payments and | ||
deductibles, unless necessitated by misuse or loss. | ||
(h) A policy or plan or contract may require that, if | ||
coverage is provided through a managed care plan, the benefits | ||
mandated pursuant to this Section shall be covered benefits | ||
only if the prosthetic or orthotic devices are provided by a |
licensed provider employed by a provider service who contracts | ||
with or is designated by the carrier, to the extent that the | ||
carrier provides in-network and out-of-network service, the | ||
coverage for the prosthetic or orthotic device shall be | ||
offered no less extensively. | ||
(i) The policy or plan or contract shall also meet | ||
adequacy requirements as established by the Health Care | ||
Reimbursement Reform Act of 1985 of the Illinois Insurance | ||
Code. | ||
(j) This Section shall not apply to accident only, | ||
specified disease, short-term travel hospital or medical , | ||
hospital confinement indemnity or other fixed indemnity , | ||
credit, dental, vision, Medicare supplement, long-term care, | ||
basic hospital and medical-surgical expense coverage, | ||
disability income insurance coverage, coverage issued as a | ||
supplement to liability insurance, workers' compensation | ||
insurance, or automobile medical payment insurance. | ||
(Source: P.A. 103-512, eff. 1-1-25.) | ||
(215 ILCS 5/367.3) (from Ch. 73, par. 979.3) | ||
Sec. 367.3. Group accident and health insurance; | ||
discretionary groups. | ||
(a) No group health insurance offered to a resident of | ||
this State under a policy issued to a group, other than one | ||
specifically described in Section 367(1), shall be delivered | ||
or issued for delivery in this State unless the Director |
determines that: | ||
(1) the issuance of the policy is not contrary to the | ||
public interest; | ||
(2) the issuance of the policy will result in | ||
economies of acquisition and administration; and | ||
(3) the benefits under the policy are reasonable in | ||
relation to the premium charged. | ||
(b) No such group health insurance may be offered in this | ||
State under a policy issued in another state unless this State | ||
or the state in which the group policy is issued has made a | ||
determination that the requirements of subsection (a) have | ||
been met. | ||
Where insurance is to be offered in this State under a | ||
policy described in this subsection, the insurer shall file | ||
for informational review purposes: | ||
(1) a copy of the group master contract; | ||
(2) a copy of the statute authorizing the issuance of | ||
the group policy in the state of situs, which statute has | ||
the same or similar requirements as this State, or in the | ||
absence of such statute, a certification by an officer of | ||
the company that the policy meets the Illinois minimum | ||
standards required for individual accident and health | ||
policies under authority of Section 401 of this Code, as | ||
now or hereafter amended, as promulgated by rule at 50 | ||
Illinois Administrative Code, Ch. I, Sec. 2007, et seq., | ||
as now or hereafter amended, or by a successor rule; |
(3) evidence of approval by the state of situs of the | ||
group master policy; and | ||
(4) copies of all supportive material furnished to the | ||
state of situs to satisfy the criteria for approval. | ||
(c) The Director may, at any time after receipt of the | ||
information required under subsection (b) and after finding | ||
that the standards of subsection (a) have not been met, order | ||
the insurer to cease the issuance or marketing of that | ||
coverage in this State. | ||
(d) Notwithstanding subsections (a) and (b), group Group | ||
accident and health insurance subject to the provisions of | ||
this Section is also subject to the provisions of Sections | ||
352c and Section 367i of this Code and rules thereunder . | ||
(Source: P.A. 90-655, eff. 7-30-98.) | ||
(215 ILCS 5/367a) (from Ch. 73, par. 979a) | ||
Sec. 367a. Blanket accident and health insurance. | ||
(1) Blanket accident and health insurance is the that form | ||
of accident and health insurance providing excepted benefits, | ||
as defined in Section 352c, that covers covering special | ||
groups of persons as enumerated in one of the following | ||
paragraphs (a) to (g), inclusive: | ||
(a) Under a policy or contract issued to any carrier for | ||
hire, which shall be deemed the policyholder, covering a group | ||
defined as all persons who may become passengers on such | ||
carrier. |
(b) Under a policy or contract issued to an employer, who | ||
shall be deemed the policyholder, covering all employees or | ||
any group of employees defined by reference to exceptional | ||
hazards incident to such employment. | ||
(c) Under a policy or contract issued to a college, | ||
school, or other institution of learning or to the head or | ||
principal thereof, who or which shall be deemed the | ||
policyholder, covering students or teachers. However, student | ||
health insurance coverage, as defined in 45 CFR 147.145, shall | ||
remain subject to the standards and requirements for | ||
individual health insurance coverage except where inconsistent | ||
with that regulation. An issuer providing student health | ||
insurance coverage or a policy or contract covering students | ||
for limited-scope dental or vision under 45 CFR 148.220 shall | ||
require an individual application or enrollment form and shall | ||
furnish each insured individual a certificate, which shall | ||
have been approved by the Director under Section 355. | ||
(d) Under a policy or contract issued in the name of any | ||
volunteer fire department, first aid, or other such volunteer | ||
group, which shall be deemed the policyholder, covering all of | ||
the members of such department or group. | ||
(e) Under a policy or contract issued to a creditor, who | ||
shall be deemed the policyholder, to insure debtors of the | ||
creditors; Provided, however, that in the case of a loan which | ||
is subject to the Small Loans Act, no insurance premium or | ||
other cost shall be directly or indirectly charged or assessed |
against, or collected or received from the borrower. | ||
(f) Under a policy or contract issued to a sports team or | ||
to a camp, which team or camp sponsor shall be deemed the | ||
policyholder, covering members or campers. | ||
(g) Under a policy or contract issued to any other | ||
substantially similar group which, in the discretion of the | ||
Director, may be subject to the issuance of a blanket accident | ||
and health policy or contract. | ||
(2) Any insurance company authorized to write accident and | ||
health insurance in this state shall have the power to issue | ||
blanket accident and health insurance. No such blanket policy | ||
may be issued or delivered in this State unless a copy of the | ||
form thereof shall have been filed in accordance with Section | ||
355, and it contains in substance such of those provisions | ||
contained in Sections 357.1 through 357.30 as may be | ||
applicable to blanket accident and health insurance and the | ||
following provisions: | ||
(a) A provision that the policy and the application shall | ||
constitute the entire contract between the parties, and that | ||
all statements made by the policyholder shall, in absence of | ||
fraud, be deemed representations and not warranties, and that | ||
no such statements shall be used in defense to a claim under | ||
the policy, unless it is contained in a written application. | ||
(b) A provision that to the group or class thereof | ||
originally insured shall be added from time to time all new | ||
persons or individuals eligible for coverage. |
(3) An individual application shall not be required from a | ||
person covered under a blanket accident or health policy or | ||
contract, nor shall it be necessary for the insurer to furnish | ||
each person a certificate. | ||
(4) All benefits under any blanket accident and health | ||
policy shall be payable to the person insured, or to his | ||
designated beneficiary or beneficiaries, or to his or her | ||
estate, except that if the person insured be a minor or person | ||
under legal disability, such benefits may be made payable to | ||
his or her parent, guardian, or other person actually | ||
supporting him or her. Provided further, however, that the | ||
policy may provide that all or any portion of any indemnities | ||
provided by any such policy on account of hospital, nursing, | ||
medical or surgical services may, at the insurer's option, be | ||
paid directly to the hospital or person rendering such | ||
services; but the policy may not require that the service be | ||
rendered by a particular hospital or person. Payment so made | ||
shall discharge the insurer's obligation with respect to the | ||
amount of insurance so paid. | ||
(5) Nothing contained in this section shall be deemed to | ||
affect the legal liability of policyholders for the death of | ||
or injury to, any such member of such group. | ||
(Source: P.A. 83-1362.) | ||
(215 ILCS 5/368f) | ||
Sec. 368f. Military service member insurance |
reinstatement. | ||
(a) No Illinois resident activated for military service | ||
and no spouse or dependent of the resident who becomes | ||
eligible for a federal government-sponsored health insurance | ||
program, including the TriCare program providing coverage for | ||
civilian dependents of military personnel, as a result of the | ||
activation shall be denied reinstatement into the same | ||
individual health insurance coverage with the health insurer | ||
that the resident lapsed as a result of activation or becoming | ||
covered by the federal government-sponsored health insurance | ||
program. The resident shall have the right to reinstatement in | ||
the same individual health insurance coverage without medical | ||
underwriting, subject to payment of the current premium | ||
charged to other persons of the same age and gender that are | ||
covered under the same individual health coverage. Except in | ||
the case of birth or adoption that occurs during the period of | ||
activation, reinstatement must be into the same coverage type | ||
as the resident held prior to lapsing the individual health | ||
insurance coverage and at the same or, at the option of the | ||
resident, higher deductible level. The reinstatement rights | ||
provided under this subsection (a) are not available to a | ||
resident or dependents if the activated person is discharged | ||
from the military under other than honorable conditions. | ||
(b) The health insurer with which the reinstatement is | ||
being requested must receive a request for reinstatement no | ||
later than 63 days following the later of (i) deactivation or |
(ii) loss of coverage under the federal government-sponsored | ||
health insurance program. The health insurer may request proof | ||
of loss of coverage and the timing of the loss of coverage of | ||
the government-sponsored coverage in order to determine | ||
eligibility for reinstatement into the individual coverage. | ||
The effective date of the reinstatement of individual health | ||
coverage shall be the first of the month following receipt of | ||
the notice requesting reinstatement. | ||
(c) All insurers must provide written notice to the | ||
policyholder of individual health coverage of the rights | ||
described in subsection (a) of this Section. In lieu of the | ||
inclusion of the notice in the individual health insurance | ||
policy, an insurance company may satisfy the notification | ||
requirement by providing a single written notice: | ||
(1) in conjunction with the enrollment process for a | ||
policyholder initially enrolling in the individual | ||
coverage on or after the effective date of this amendatory | ||
Act of the 94th General Assembly; or | ||
(2) by mailing written notice to policyholders whose | ||
coverage was effective prior to the effective date of this | ||
amendatory Act of the 94th General Assembly no later than | ||
90 days following the effective date of this amendatory | ||
Act of the 94th General Assembly. | ||
(d) The provisions of subsection (a) of this Section do | ||
not apply to any policy or certificate providing coverage for | ||
any specified disease, specified accident or accident-only |
coverage, credit, dental, disability income, hospital | ||
indemnity or other fixed indemnity , long-term care, Medicare | ||
supplement, vision care, or short-term travel nonrenewable | ||
health policy or other limited-benefit supplemental insurance, | ||
or any coverage issued as a supplement to any liability | ||
insurance, workers' compensation or similar insurance, or any | ||
insurance under which benefits are payable with or without | ||
regard to fault, whether written on a group, blanket, or | ||
individual basis. | ||
(e) Nothing in this Section shall require an insurer to | ||
reinstate the resident if the insurer requires residency in an | ||
enrollment area and those residency requirements are not met | ||
after deactivation or loss of coverage under the | ||
government-sponsored health insurance program. | ||
(f) All terms, conditions, and limitations of the | ||
individual coverage into which reinstatement is made apply | ||
equally to all insureds enrolled in the coverage. | ||
(g) The Secretary may adopt rules as may be necessary to | ||
carry out the provisions of this Section. | ||
(Source: P.A. 94-1037, eff. 7-20-06.) | ||
Section 10. The Health Maintenance Organization Act is | ||
amended by changing Section 5-3 as follows: | ||
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) | ||
Sec. 5-3. Insurance Code provisions. |
(a) Health Maintenance Organizations shall be subject to | ||
the provisions of Sections 133, 134, 136, 137, 139, 140, | ||
141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, | ||
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49, | ||
352c, 355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, | ||
356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, | ||
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||
356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, | ||
356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, | ||
356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, | ||
356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, | ||
356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, | ||
356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, | ||
356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, | ||
356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, | ||
368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, | ||
408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of | ||
subsection (2) of Section 367, and Articles IIA, VIII 1/2, | ||
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the | ||
Illinois Insurance Code. | ||
(b) For purposes of the Illinois Insurance Code, except | ||
for Sections 444 and 444.1 and Articles XIII and XIII 1/2, | ||
Health Maintenance Organizations in the following categories | ||
are deemed to be "domestic companies": | ||
(1) a corporation authorized under the Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act; |
(2) a corporation organized under the laws of this | ||
State; or | ||
(3) a corporation organized under the laws of another | ||
state, 30% or more of the enrollees of which are residents | ||
of this State, except a corporation subject to | ||
substantially the same requirements in its state of | ||
organization as is a "domestic company" under Article VIII | ||
1/2 of the Illinois Insurance Code. | ||
(c) In considering the merger, consolidation, or other | ||
acquisition of control of a Health Maintenance Organization | ||
pursuant to Article VIII 1/2 of the Illinois Insurance Code, | ||
(1) the Director shall give primary consideration to | ||
the continuation of benefits to enrollees and the | ||
financial conditions of the acquired Health Maintenance | ||
Organization after the merger, consolidation, or other | ||
acquisition of control takes effect; | ||
(2)(i) the criteria specified in subsection (1)(b) of | ||
Section 131.8 of the Illinois Insurance Code shall not | ||
apply and (ii) the Director, in making his determination | ||
with respect to the merger, consolidation, or other | ||
acquisition of control, need not take into account the | ||
effect on competition of the merger, consolidation, or | ||
other acquisition of control; | ||
(3) the Director shall have the power to require the | ||
following information: | ||
(A) certification by an independent actuary of the |
adequacy of the reserves of the Health Maintenance | ||
Organization sought to be acquired; | ||
(B) pro forma financial statements reflecting the | ||
combined balance sheets of the acquiring company and | ||
the Health Maintenance Organization sought to be | ||
acquired as of the end of the preceding year and as of | ||
a date 90 days prior to the acquisition, as well as pro | ||
forma financial statements reflecting projected | ||
combined operation for a period of 2 years; | ||
(C) a pro forma business plan detailing an | ||
acquiring party's plans with respect to the operation | ||
of the Health Maintenance Organization sought to be | ||
acquired for a period of not less than 3 years; and | ||
(D) such other information as the Director shall | ||
require. | ||
(d) The provisions of Article VIII 1/2 of the Illinois | ||
Insurance Code and this Section 5-3 shall apply to the sale by | ||
any health maintenance organization of greater than 10% of its | ||
enrollee population (including , without limitation , the health | ||
maintenance organization's right, title, and interest in and | ||
to its health care certificates). | ||
(e) In considering any management contract or service | ||
agreement subject to Section 141.1 of the Illinois Insurance | ||
Code, the Director (i) shall, in addition to the criteria | ||
specified in Section 141.2 of the Illinois Insurance Code, | ||
take into account the effect of the management contract or |
service agreement on the continuation of benefits to enrollees | ||
and the financial condition of the health maintenance | ||
organization to be managed or serviced, and (ii) need not take | ||
into account the effect of the management contract or service | ||
agreement on competition. | ||
(f) Except for small employer groups as defined in the | ||
Small Employer Rating, Renewability and Portability Health | ||
Insurance Act and except for medicare supplement policies as | ||
defined in Section 363 of the Illinois Insurance Code, a | ||
Health Maintenance Organization may by contract agree with a | ||
group or other enrollment unit to effect refunds or charge | ||
additional premiums under the following terms and conditions: | ||
(i) the amount of, and other terms and conditions with | ||
respect to, the refund or additional premium are set forth | ||
in the group or enrollment unit contract agreed in advance | ||
of the period for which a refund is to be paid or | ||
additional premium is to be charged (which period shall | ||
not be less than one year); and | ||
(ii) the amount of the refund or additional premium | ||
shall not exceed 20% of the Health Maintenance | ||
Organization's profitable or unprofitable experience with | ||
respect to the group or other enrollment unit for the | ||
period (and, for purposes of a refund or additional | ||
premium, the profitable or unprofitable experience shall | ||
be calculated taking into account a pro rata share of the | ||
Health Maintenance Organization's administrative and |
marketing expenses, but shall not include any refund to be | ||
made or additional premium to be paid pursuant to this | ||
subsection (f)). The Health Maintenance Organization and | ||
the group or enrollment unit may agree that the profitable | ||
or unprofitable experience may be calculated taking into | ||
account the refund period and the immediately preceding 2 | ||
plan years. | ||
The Health Maintenance Organization shall include a | ||
statement in the evidence of coverage issued to each enrollee | ||
describing the possibility of a refund or additional premium, | ||
and upon request of any group or enrollment unit, provide to | ||
the group or enrollment unit a description of the method used | ||
to calculate (1) the Health Maintenance Organization's | ||
profitable experience with respect to the group or enrollment | ||
unit and the resulting refund to the group or enrollment unit | ||
or (2) the Health Maintenance Organization's unprofitable | ||
experience with respect to the group or enrollment unit and | ||
the resulting additional premium to be paid by the group or | ||
enrollment unit. | ||
In no event shall the Illinois Health Maintenance | ||
Organization Guaranty Association be liable to pay any | ||
contractual obligation of an insolvent organization to pay any | ||
refund authorized under this Section. | ||
(g) Rulemaking authority to implement Public Act 95-1045, | ||
if any, is conditioned on the rules being adopted in | ||
accordance with all provisions of the Illinois Administrative |
Procedure Act and all rules and procedures of the Joint | ||
Committee on Administrative Rules; any purported rule not so | ||
adopted, for whatever reason, is unauthorized. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; | ||
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. | ||
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, | ||
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; | ||
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. | ||
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, | ||
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; | ||
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. | ||
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.) | ||
Section 15. The Limited Health Service Organization Act is | ||
amended by changing Section 4003 as follows: | ||
(215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | ||
Sec. 4003. Illinois Insurance Code provisions. Limited | ||
health service organizations shall be subject to the | ||
provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | ||
141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | ||
154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 352c, | ||
355.2, 355.3, 355b, 356q, 356v, 356z.4, 356z.4a, 356z.10, | ||
356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | ||
356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, |
356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | ||
364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | ||
444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | ||
XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | ||
Nothing in this Section shall require a limited health care | ||
plan to cover any service that is not a limited health service. | ||
For purposes of the Illinois Insurance Code, except for | ||
Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | ||
health service organizations in the following categories are | ||
deemed to be domestic companies: | ||
(1) a corporation under the laws of this State; or | ||
(2) a corporation organized under the laws of another | ||
state, 30% or more of the enrollees of which are residents | ||
of this State, except a corporation subject to | ||
substantially the same requirements in its state of | ||
organization as is a domestic company under Article VIII | ||
1/2 of the Illinois Insurance Code. | ||
(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | ||
102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | ||
1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | ||
eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||
102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | ||
1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | ||
eff. 1-1-24; revised 8-29-23.) | ||
(215 ILCS 190/Act rep.) |
Section 20. The Short-Term, Limited-Duration Health | ||
Insurance Coverage Act is repealed. | ||
Section 95. No acceleration or delay. Where this Act makes | ||
changes in a statute that is represented in this Act by text | ||
that is not yet or no longer in effect (for example, a Section | ||
represented by multiple versions), the use of that text does | ||
not accelerate or delay the taking effect of (i) the changes | ||
made by this Act or (ii) provisions derived from any other | ||
Public Act. | ||
Section 99. Effective date. This Act takes effect January | ||
1, 2025. |