96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB0068


 
Introduced 1/30/2009, by Sen. Ira I. Silverstein
 
SYNOPSIS AS INTRODUCED:
 		

















215 ILCS 5/356z.15 new





215 ILCS 125/5-3
  from Ch. 111 1/2, par. 1411.2


215 ILCS 165/10
  from Ch. 32, par. 604







    Amends the Illinois Insurance Code, the Voluntary Health Services Plans Act, and the Voluntary Health Services Plans Act to require coverage for hearing instruments and related services for all individuals
when a hearing care professional prescribes a hearing instrument. Provides that an insurer shall provide coverage for up to $2,500 per hearing aid per insured's hearing impaired ear subject to certain restrictions. Provides that an insurer shall not be required to pay a claim if the insured filed such a claim 36 months prior to the date
of filing the claim with the insurer and the claim was paid by any insurer. Effective immediately.
















LRB096 03606 RPM 13633 b

















 


 


A BILL FOR









 











SB0068

LRB096 03606 RPM 13633 b






1
    AN ACT concerning insurance.

 
2
    Be it enacted by the People of the State of Illinois,
 
3
represented in the General Assembly:


 
4
    Section 5. The Illinois Insurance Code is amended  by adding 
5
Section 356z.15 as follows:
 
6
    (215 ILCS 5/356z.15  new)
7
    Sec. 356z.15. Coverage for hearing aids for all 
8
individuals.
9
    (a) As used in this Section:
10
    "Hearing care professional" means a person who is a

11
licensed audiologist or a licensed physician.
12
    "Hearing instrument" or "hearing aid" means any wearable

13
non-disposable instrument or device designed to aid or

14
compensate for impaired human hearing in cases where functional 
15
ability cannot be restored
either medically or surgically and 
16
any parts, attachments, or accessories for the instrument or 
17
device, including
an ear mold but excluding batteries and 
18
cords.
19
    "Related services" means those services necessary to 
20
assess, select, and adjust or fit the hearing instrument to 
21
ensure optimal performance including but not limited to: 
22
audiological exams, replacement ear molds, and repairs to the 
23
hearing instrument.
 


 






SB0068
- 2 -
LRB096 03606 RPM 13633 b




1
    (b) An individual or group policy of accident and health

2
insurance or managed care plan that is amended, delivered,

3
issued, or renewed after the effective date of this amendatory

4
Act of the 96th General Assembly must provide coverage for

5
hearing instruments and related services for all individuals

6
when a hearing care professional prescribes a hearing 
7
instrument to augment communication.
8
    (c) An insurer shall provide coverage, subject to all 
9
applicable co-payments, co-insurance, deductibles, and 
10
out-of-pocket limits, for up to $2,500 per hearing aid per 
11
insured's hearing impaired ear subject to the following 
12
restrictions:
13
        (1) for all insured individuals, hearing aids may be 
14
    replaced up to once every 36 months as prescribed and 
15
    dispensed by a hearing care professional;
16
        (2) for all insured individuals, any hearing aid may be 
17
    replaced at any time regardless of the above restrictions 
18
    if there is a significant change in the insured 
19
    individual's hearing status; such significant change is 
20
    defined as a change of 10 decibels HL on the  
21
    three-frequency pure-tone average (500 Hz, 1000 Hz and 2000 
22
    Hz) on a valid audiogram provided by a hearing care 
23
    professional; and
24
        (3) for all insured individuals, related services, 
25
    such as audiological exams, ear molds, and hearing aid 
26
    repairs, shall be covered at all times when prescribed by a 
 


 






SB0068
- 3 -
LRB096 03606 RPM 13633 b




1
    hearing care professional.
2
    (d) An insurer shall not be required to pay a claim filed

3
by its insured for the payment of the cost of a hearing aid

4
covered by this Section if less than 36 months prior to the 
5
date
of the claim its insured filed a claim for payment of the 
6
cost
of the hearing aid and the claim was paid by any insurer.
 
7
    Section 10. The Health Maintenance Organization Act is 
8
amended  by changing Section 5-3 as follows:
 


9
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)


10
    (Text of Section before amendment by P.A. 95-958)

11
    Sec. 5-3. Insurance Code provisions. 

12
    (a) Health Maintenance Organizations
shall be subject to 
13
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
14
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
15
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
16
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 
17
356z.13
356z.11, 356z.14, 356z.15,
 364.01, 367.2, 367.2-5, 
18
367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 
19
403A,
408, 408.2, 409, 412, 444,
and
444.1,
paragraph (c) of 
20
subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII,

21
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois 
22
Insurance Code.

23
    (b) For purposes of the Illinois Insurance Code, except for 
24
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
 


 






SB0068
- 4 -
LRB096 03606 RPM 13633 b




1
Maintenance Organizations in
the following categories are 
2
deemed to be "domestic companies":


3
        (1) a corporation authorized under the
Dental Service 
4
    Plan Act or the Voluntary Health Services Plans Act;


5
        (2) a corporation organized under the laws of this 
6
    State; or


7
        (3) a corporation organized under the laws of another 
8
    state, 30% or more
of the enrollees of which are residents 
9
    of this State, except a
corporation subject to 
10
    substantially the same requirements in its state of

11
    organization as is a "domestic company" under Article VIII 
12
    1/2 of the
Illinois Insurance Code.

13
    (c) In considering the merger, consolidation, or other 
14
acquisition of
control of a Health Maintenance Organization 
15
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


16
        (1) the Director shall give primary consideration to 
17
    the continuation of
benefits to enrollees and the financial 
18
    conditions of the acquired Health
Maintenance Organization 
19
    after the merger, consolidation, or other
acquisition of 
20
    control takes effect;


21
        (2)(i) the criteria specified in subsection (1)(b) of 
22
    Section 131.8 of
the Illinois Insurance Code shall not 
23
    apply and (ii) the Director, in making
his determination 
24
    with respect to the merger, consolidation, or other

25
    acquisition of control, need not take into account the 
26
    effect on
competition of the merger, consolidation, or 
 


 






SB0068
- 5 -
LRB096 03606 RPM 13633 b




1
    other acquisition of control;


2
        (3) the Director shall have the power to require the 
3
    following
information:


4
            (A) certification by an independent actuary of the 
5
        adequacy
of the reserves of the Health Maintenance 
6
        Organization sought to be acquired;


7
            (B) pro forma financial statements reflecting the 
8
        combined balance
sheets of the acquiring company and 
9
        the Health Maintenance Organization sought
to be 
10
        acquired as of the end of the preceding year and as of 
11
        a date 90 days
prior to the acquisition, as well as pro 
12
        forma financial statements
reflecting projected 
13
        combined operation for a period of 2 years;


14
            (C) a pro forma business plan detailing an 
15
        acquiring party's plans with
respect to the operation 
16
        of the Health Maintenance Organization sought to
be 
17
        acquired for a period of not less than 3 years; and


18
            (D) such other information as the Director shall 
19
        require.

20
    (d) The provisions of Article VIII 1/2 of the Illinois 
21
Insurance Code
and this Section 5-3 shall apply to the sale by 
22
any health maintenance
organization of greater than 10% of its

23
enrollee population (including without limitation the health 
24
maintenance
organization's right, title, and interest in and to 
25
its health care
certificates).

26
    (e) In considering any management contract or service 
 


 






SB0068
- 6 -
LRB096 03606 RPM 13633 b




1
agreement subject
to Section 141.1 of the Illinois Insurance 
2
Code, the Director (i) shall, in
addition to the criteria 
3
specified in Section 141.2 of the Illinois
Insurance Code, take 
4
into account the effect of the management contract or
service 
5
agreement on the continuation of benefits to enrollees and the

6
financial condition of the health maintenance organization to 
7
be managed or
serviced, and (ii) need not take into account the 
8
effect of the management
contract or service agreement on 
9
competition.

10
    (f) Except for small employer groups as defined in the 
11
Small Employer
Rating, Renewability and Portability Health 
12
Insurance Act and except for
medicare supplement policies as 
13
defined in Section 363 of the Illinois
Insurance Code, a Health 
14
Maintenance Organization may by contract agree with a
group or 
15
other enrollment unit to effect refunds or charge additional 
16
premiums
under the following terms and conditions:


17
        (i) the amount of, and other terms and conditions with 
18
    respect to, the
refund or additional premium are set forth 
19
    in the group or enrollment unit
contract agreed in advance 
20
    of the period for which a refund is to be paid or

21
    additional premium is to be charged (which period shall not 
22
    be less than one
year); and


23
        (ii) the amount of the refund or additional premium 
24
    shall not exceed 20%
of the Health Maintenance 
25
    Organization's profitable or unprofitable experience
with 
26
    respect to the group or other enrollment unit for the 
 


 






SB0068
- 7 -
LRB096 03606 RPM 13633 b




1
    period (and, for
purposes of a refund or additional 
2
    premium, the profitable or unprofitable
experience shall 
3
    be calculated taking into account a pro rata share of the

4
    Health Maintenance Organization's administrative and 
5
    marketing expenses, but
shall not include any refund to be 
6
    made or additional premium to be paid
pursuant to this 
7
    subsection (f)).  The Health Maintenance Organization and 
8
    the
group or enrollment unit may agree that the profitable 
9
    or unprofitable
experience may be calculated taking into 
10
    account the refund period and the
immediately preceding 2 
11
    plan years.

12
    The Health Maintenance Organization shall include a 
13
statement in the
evidence of coverage issued to each enrollee 
14
describing the possibility of a
refund or additional premium, 
15
and upon request of any group or enrollment unit,
provide to 
16
the group or enrollment unit a description of the method used 
17
to
calculate (1) the Health Maintenance Organization's 
18
profitable experience with
respect to the group or enrollment 
19
unit and the resulting refund to the group
or enrollment unit 
20
or (2) the Health Maintenance Organization's unprofitable

21
experience with respect to the group or enrollment unit and the 
22
resulting
additional premium to be paid by the group or 
23
enrollment unit.

24
    In no event shall the Illinois Health Maintenance 
25
Organization
Guaranty Association be liable to pay any 
26
contractual obligation of an
insolvent organization to pay any 
 


 






SB0068
- 8 -
LRB096 03606 RPM 13633 b




1
refund authorized under this Section.

2
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
3
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. 
4
8-21-08; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; revised 
5
12-15-08.)

 
6
    (Text of Section after amendment by P.A. 95-958)
7
    Sec. 5-3. Insurance Code provisions. 

8
    (a) Health Maintenance Organizations
shall be subject to 
9
the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, 
10
141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, 
11
154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 
12
356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 
13
356z.11, 356z.12, 356z.13
356z.11, 356z.14, 356z.15, 364.01, 
14
367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 370c,
401, 
15
401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444,
and
444.1,

16
paragraph (c) of subsection (2) of Section 367, and Articles 
17
IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of 
18
the Illinois Insurance Code.

19
    (b) For purposes of the Illinois Insurance Code, except for 
20
Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health 
21
Maintenance Organizations in
the following categories are 
22
deemed to be "domestic companies":


23
        (1) a corporation authorized under the
Dental Service 
24
    Plan Act or the Voluntary Health Services Plans Act;


25
        (2) a corporation organized under the laws of this 
 


 






SB0068
- 9 -
LRB096 03606 RPM 13633 b




1
    State; or


2
        (3) a corporation organized under the laws of another 
3
    state, 30% or more
of the enrollees of which are residents 
4
    of this State, except a
corporation subject to 
5
    substantially the same requirements in its state of

6
    organization as is a "domestic company" under Article VIII 
7
    1/2 of the
Illinois Insurance Code.

8
    (c) In considering the merger, consolidation, or other 
9
acquisition of
control of a Health Maintenance Organization 
10
pursuant to Article VIII 1/2
of the Illinois Insurance Code,


11
        (1) the Director shall give primary consideration to 
12
    the continuation of
benefits to enrollees and the financial 
13
    conditions of the acquired Health
Maintenance Organization 
14
    after the merger, consolidation, or other
acquisition of 
15
    control takes effect;


16
        (2)(i) the criteria specified in subsection (1)(b) of 
17
    Section 131.8 of
the Illinois Insurance Code shall not 
18
    apply and (ii) the Director, in making
his determination 
19
    with respect to the merger, consolidation, or other

20
    acquisition of control, need not take into account the 
21
    effect on
competition of the merger, consolidation, or 
22
    other acquisition of control;


23
        (3) the Director shall have the power to require the 
24
    following
information:


25
            (A) certification by an independent actuary of the 
26
        adequacy
of the reserves of the Health Maintenance 
 


 






SB0068
- 10 -
LRB096 03606 RPM 13633 b




1
        Organization sought to be acquired;


2
            (B) pro forma financial statements reflecting the 
3
        combined balance
sheets of the acquiring company and 
4
        the Health Maintenance Organization sought
to be 
5
        acquired as of the end of the preceding year and as of 
6
        a date 90 days
prior to the acquisition, as well as pro 
7
        forma financial statements
reflecting projected 
8
        combined operation for a period of 2 years;


9
            (C) a pro forma business plan detailing an 
10
        acquiring party's plans with
respect to the operation 
11
        of the Health Maintenance Organization sought to
be 
12
        acquired for a period of not less than 3 years; and


13
            (D) such other information as the Director shall 
14
        require.

15
    (d) The provisions of Article VIII 1/2 of the Illinois 
16
Insurance Code
and this Section 5-3 shall apply to the sale by 
17
any health maintenance
organization of greater than 10% of its

18
enrollee population (including without limitation the health 
19
maintenance
organization's right, title, and interest in and to 
20
its health care
certificates).

21
    (e) In considering any management contract or service 
22
agreement subject
to Section 141.1 of the Illinois Insurance 
23
Code, the Director (i) shall, in
addition to the criteria 
24
specified in Section 141.2 of the Illinois
Insurance Code, take 
25
into account the effect of the management contract or
service 
26
agreement on the continuation of benefits to enrollees and the

 


 






SB0068
- 11 -
LRB096 03606 RPM 13633 b




1
financial condition of the health maintenance organization to 
2
be managed or
serviced, and (ii) need not take into account the 
3
effect of the management
contract or service agreement on 
4
competition.

5
    (f) Except for small employer groups as defined in the 
6
Small Employer
Rating, Renewability and Portability Health 
7
Insurance Act and except for
medicare supplement policies as 
8
defined in Section 363 of the Illinois
Insurance Code, a Health 
9
Maintenance Organization may by contract agree with a
group or 
10
other enrollment unit to effect refunds or charge additional 
11
premiums
under the following terms and conditions:


12
        (i) the amount of, and other terms and conditions with 
13
    respect to, the
refund or additional premium are set forth 
14
    in the group or enrollment unit
contract agreed in advance 
15
    of the period for which a refund is to be paid or

16
    additional premium is to be charged (which period shall not 
17
    be less than one
year); and


18
        (ii) the amount of the refund or additional premium 
19
    shall not exceed 20%
of the Health Maintenance 
20
    Organization's profitable or unprofitable experience
with 
21
    respect to the group or other enrollment unit for the 
22
    period (and, for
purposes of a refund or additional 
23
    premium, the profitable or unprofitable
experience shall 
24
    be calculated taking into account a pro rata share of the

25
    Health Maintenance Organization's administrative and 
26
    marketing expenses, but
shall not include any refund to be 
 


 






SB0068
- 12 -
LRB096 03606 RPM 13633 b




1
    made or additional premium to be paid
pursuant to this 
2
    subsection (f)).  The Health Maintenance Organization and 
3
    the
group or enrollment unit may agree that the profitable 
4
    or unprofitable
experience may be calculated taking into 
5
    account the refund period and the
immediately preceding 2 
6
    plan years.

7
    The Health Maintenance Organization shall include a 
8
statement in the
evidence of coverage issued to each enrollee 
9
describing the possibility of a
refund or additional premium, 
10
and upon request of any group or enrollment unit,
provide to 
11
the group or enrollment unit a description of the method used 
12
to
calculate (1) the Health Maintenance Organization's 
13
profitable experience with
respect to the group or enrollment 
14
unit and the resulting refund to the group
or enrollment unit 
15
or (2) the Health Maintenance Organization's unprofitable

16
experience with respect to the group or enrollment unit and the 
17
resulting
additional premium to be paid by the group or 
18
enrollment unit.

19
    In no event shall the Illinois Health Maintenance 
20
Organization
Guaranty Association be liable to pay any 
21
contractual obligation of an
insolvent organization to pay any 
22
refund authorized under this Section.

23
(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; 
24
95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. 
25
8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, 
26
eff. 12-12-08; revised 12-15-08.)
 
 


 






SB0068
- 13 -
LRB096 03606 RPM 13633 b




1
    Section 15. The Voluntary Health Services Plans Act is 
2
amended  by changing Section 10 as follows:
 


3
    (215 ILCS 165/10)  (from Ch. 32, par. 604)

4
    (Text of Section before amendment by P.A. 95-958)

5
    Sec. 10. Application of Insurance Code provisions. Health 
6
services
plan corporations and all persons interested therein 
7
or dealing therewith
shall be subject to the provisions of 
8
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
9
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
10
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
11
356z.9,
356z.10, 356z.13
356z.11, 356z.14, 356z.15,
 364.01, 
12
367.2, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, and 412, 
13
and paragraphs (7) and (15) of Section 367 of the Illinois

14
Insurance Code.

15
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
16
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
17
8-28-07; 95-876, eff. 8-21-08; 95-978, eff. 1-1-09; 95-1005, 
18
eff. 12-12-08; revised 12-15-08.)

 
19
    (Text of Section after amendment by P.A. 95-958)
20
    Sec. 10. Application of Insurance Code provisions. Health 
21
services
plan corporations and all persons interested therein 
22
or dealing therewith
shall be subject to the provisions of 
23
Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, 
 


 






SB0068
- 14 -
LRB096 03606 RPM 13633 b




1
149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, 
2
356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 
3
356z.9,
356z.10, 356z.11, 356z.12, 356z.13
356z.11, 356z.14, 
4
356z.15, 364.01, 367.2, 368a, 401, 401.1,
402,
403, 403A, 408,

5
408.2, and 412, and paragraphs (7) and (15) of Section 367 of 
6
the Illinois
Insurance Code.

7
(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; 
8
95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. 
9
8-28-07; 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, 
10
eff. 1-1-09; 95-1005, eff. 12-12-08; revised 12-15-08.)
 
11
    Section 95. No acceleration or delay. Where this Act makes 
12
changes in a statute that is represented in this Act by text 
13
that is not yet or no longer in effect (for example, a Section 
14
represented by multiple versions), the use of that text does 
15
not accelerate or delay the taking effect of (i) the changes 
16
made by this Act or (ii) provisions derived from any other 
17
Public Act.
 

18
    Section 99. Effective date. This Act takes effect upon 
19
becoming law.