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Public Act 096-0639
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| SB1877 Enrolled |
LRB096 11290 RPM 21719 b |
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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.
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(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.
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(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.)
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Section 10. The Illinois Insurance Code is amended by |
adding Section 356z.15 as follows:
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(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 |
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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 |
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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.
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Section 15. The Health Maintenance Organization Act is |
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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 |
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of this State, except a
corporation subject to |
substantially the same requirements in its state of
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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
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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 |
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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 |
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competition.
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(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:
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(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
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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
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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 |
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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
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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.
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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":
|
(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.
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