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| Public Act 096-0639 |
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The State Employees Group Insurance Act of 1971 | ||||
is amended by changing Section 6.11 as follows:
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(5 ILCS 375/6.11)
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(Text of Section before amendment by P.A. 95-958) | ||||
Sec. 6.11. Required health benefits; Illinois Insurance | ||||
Code
requirements. The program of health
benefits shall provide | ||||
the post-mastectomy care benefits required to be covered
by a | ||||
policy of accident and health insurance under Section 356t of | ||||
the Illinois
Insurance Code. The program of health benefits | ||||
shall provide the coverage
required under Sections 356g.5,
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356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10, | ||||
356z.13 356z.11, and 356z.14, and 356z.15
of the
Illinois | ||||
Insurance Code.
The program of health benefits must comply with | ||||
Section 155.37 of the
Illinois Insurance Code.
| ||||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-978, eff. | ||||
1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
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(Text of Section after amendment by P.A. 95-958)
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Sec. 6.11. Required health benefits; Illinois Insurance | ||||
Code
requirements. The program of health
benefits shall provide | ||
the post-mastectomy care benefits required to be covered
by a | ||
policy of accident and health insurance under Section 356t of | ||
the Illinois
Insurance Code. The program of health benefits | ||
shall provide the coverage
required under Sections 356g.5,
| ||
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, 356z.9, 356z.10, | ||
356z.11, and 356z.12, 356z.13
356z.11, and 356z.14, and 356z.15 | ||
of the
Illinois Insurance Code.
The program of health benefits | ||
must comply with Section 155.37 of the
Illinois Insurance Code.
| ||
(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||
95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||
6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||
12-15-08.) | ||
Section 10. The Illinois Insurance Code is amended by | ||
adding Section 356z.15 as follows: | ||
(215 ILCS 5/356z.15 new)
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Sec. 356z.15. Wellness coverage. | ||
(a) A group or individual policy of accident and health | ||
insurance or managed care plan amended, delivered, issued, or | ||
renewed after the effective date of this amendatory Act of the | ||
96th General Assembly that provides coverage for hospital or | ||
medical treatment on an expense incurred basis may offer a | ||
reasonably designed program for wellness coverage that allows | ||
for a reward, a contribution, a reduction in premiums or | ||
reduced medical, prescription drug, or equipment copayments, | ||
coinsurance, or deductibles, or a combination of these | ||
incentives, for participation in any health behavior wellness, | ||
maintenance, or improvement program approved or offered by the | ||
insurer or managed care plan. The insured or enrollee may be | ||
required to provide evidence of participation in a program. | ||
Individuals unable to participate in these incentives due to an | ||
adverse health factor shall not be penalized based upon an | ||
adverse health status. | ||
(b) For purposes of this Section, "wellness coverage" means | ||
health care coverage with the primary purpose to engage and | ||
motivate the insured or enrollee through: incentives; | ||
provision of health education, counseling, and self-management | ||
skills; identification of modifiable health risks; and other | ||
activities to influence health behavior changes. | ||
For the purposes of this Section, "reasonably designed | ||
program" means a program of wellness coverage that has a | ||
reasonable chance of improving health or preventing disease; is | ||
not overly burdensome; does not discriminate based upon factors | ||
of health; and is not otherwise contrary to law. | ||
(c) Incentives as outlined in this Section are specific and | ||
unique to the offering of wellness coverage and have no | ||
application to any other required or optional health care | ||
benefit. | ||
(d) Such wellness coverage must satisfy the requirements | ||
for an exception from the general prohibition against | ||
discrimination based on a health factor under the federal | ||
Health Insurance Portability and Accountability Act of 1996 | ||
(P.L. 104-191; 110 Stat. 1936), including any federal | ||
regulations that are adopted pursuant to that Act. | ||
(e) A plan offering wellness coverage must do the | ||
following: | ||
(i) give participants the opportunity to qualify for | ||
offered incentives at least once a year; | ||
(ii) allow a reasonable alternative to any individual | ||
for whom it is unreasonably difficult, due to a medical | ||
condition, to satisfy otherwise applicable wellness | ||
program standards. Plans may seek physician verification | ||
that health factors make it unreasonably difficult or | ||
medically inadvisable for the participant to satisfy the | ||
standards; and | ||
(iii) not provide a total incentive that exceeds 20% of | ||
the cost of employee-only coverage. The cost of | ||
employee-only coverage includes both employer and employee | ||
contributions. For plans offering family coverage, the 20% | ||
limitation applies to cost of family coverage and applies | ||
to the entire family. | ||
(f) A reward, contribution, or reduction established under | ||
this Section and included in the policy or certificate does not | ||
violate Section 151 of this Code. | ||
Section 15. The Health Maintenance Organization Act is | ||
amended by changing Section 5-3 as follows:
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(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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(Text of Section before amendment by P.A. 95-958)
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Sec. 5-3. Insurance Code provisions.
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(a) Health Maintenance Organizations
shall be subject to | ||
the provisions of Sections 133, 134, 137, 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, 355.2, 356m, 356v, 356w, 356x, | ||
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||
356z.13
356z.11, 356z.14, 356z.15,
364.01, 367.2, 367.2-5, | ||
367i, 368a, 368b, 368c, 368d, 368e, 370c,
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,
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XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois | ||
Insurance Code.
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(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":
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(1) a corporation authorized under the
Dental Service | ||
Plan Act or the Voluntary Health Services Plans Act;
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(2) a corporation organized under the laws of this | ||
State; or
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(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.
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(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,
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(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;
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(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;
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(3) the Director shall have the power to require the | ||
following
information:
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(A) certification by an independent actuary of the | ||
adequacy
of the reserves of the Health Maintenance | ||
Organization sought to be acquired;
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(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;
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(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
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(D) such other information as the Director shall | ||
require.
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(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
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enrollee population (including without limitation the health | ||
maintenance
organization's right, title, and interest in and to | ||
its health care
certificates).
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(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
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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
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(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.
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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.
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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.
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(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||
8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised | ||
12-15-08.)
| ||
(Text of Section after amendment by P.A. 95-958) | ||
Sec. 5-3. Insurance Code provisions.
| ||
(a) Health Maintenance Organizations
shall be subject to | ||
the provisions of Sections 133, 134, 137, 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, 355.2, 356m, 356v, 356w, 356x, | ||
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, | ||
356z.11, 356z.12, 356z.13
356z.11, 356z.14, 356z.15, 364.01, | ||
367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, | ||
401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,
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paragraph (c) of subsection (2) of Section 367, and Articles | ||
IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI 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.
| ||
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||
8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||
eff. 12-12-08; revised 12-15-08.) | ||
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, 2010.
| ||