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90_SB0277
215 ILCS 5/155.31 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003 from Ch. 73, par. 1504-3
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code, Health Maintenance
Organization Act, Limited Health Service Organization Act,
and Voluntary Health Services Plans Act. Provides that
health care plans operated under those Acts must cover
emergency medical care provided by non-designated providers
when designated providers are not reasonably available or
accessible.
LRB9002230JSmg
LRB9002230JSmg
1 AN ACT concerning access to emergency health care
2 services, amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 adding Section 155.31 as follows:
7 (215 ILCS 5/155.31 new)
8 Sec. 155.31. Access to emergency health care services.
9 (a) A company that is subject to this Article and that
10 provides coverage for health care services under individual
11 or group policies of accident and health insurance or
12 administers, arranges, pays for, or provides health care
13 services as a health care plan, as defined in the Health
14 Maintenance Organization Act, must comply with this Section.
15 (b) If at the time of an emergency providers designated
16 by the company as providers the utilization of which will
17 result in a lower cost to the covered individual are not
18 reasonably available or accessible for provision of a covered
19 service, the covered individual may obtain the service from
20 any provider at no greater cost to the covered individual.
21 The provisions of this Section apply to all health care plan
22 coverage amended, delivered, issued, or renewed after the
23 effective date of this amendatory Act of 1997.
24 (c) As used in this Section, "emergency" means a medical
25 condition of recent onset and severity that would lead a
26 prudent lay person, possessing an average knowledge of
27 medicine and health, to believe that urgent or unscheduled
28 medical care is required.
29 Section 10. The Health Maintenance Organization Act is
30 amended by changing Section 5-3 as follows:
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1 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
2 Sec. 5-3. Insurance Code provisions.
3 (a) Health Maintenance Organizations shall be subject to
4 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
5 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
6 154.6, 154.7, 154.8, 155.04, 155.31, 355.2, 356m, 367i, 401,
7 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
8 subsection (2) of Section 367, and Articles VIII 1/2, XII,
9 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
10 Code.
11 (b) For purposes of the Illinois Insurance Code, except
12 for Articles XIII and XIII 1/2, Health Maintenance
13 Organizations in the following categories are deemed to be
14 "domestic companies":
15 (1) a corporation authorized under the Medical
16 Service Plan Act, the Dental Service Plan Act, the Vision
17 Service Plan Act, the Pharmaceutical Service Plan Act,
18 the Voluntary Health Services Plan Act, or the Nonprofit
19 Health Care Service Plan Act;
20 (2) a corporation organized under the laws of this
21 State; or
22 (3) a corporation organized under the laws of
23 another state, 30% or more of the enrollees of which are
24 residents of this State, except a corporation subject to
25 substantially the same requirements in its state of
26 organization as is a "domestic company" under Article
27 VIII 1/2 of the Illinois Insurance Code.
28 (c) In considering the merger, consolidation, or other
29 acquisition of control of a Health Maintenance Organization
30 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
31 (1) the Director shall give primary consideration
32 to the continuation of benefits to enrollees and the
33 financial conditions of the acquired Health Maintenance
34 Organization after the merger, consolidation, or other
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1 acquisition of control takes effect;
2 (2)(i) the criteria specified in subsection (1)(b)
3 of Section 131.8 of the Illinois Insurance Code shall not
4 apply and (ii) the Director, in making his determination
5 with respect to the merger, consolidation, or other
6 acquisition of control, need not take into account the
7 effect on competition of the merger, consolidation, or
8 other acquisition of control;
9 (3) the Director shall have the power to require
10 the following information:
11 (A) certification by an independent actuary of
12 the adequacy of the reserves of the Health
13 Maintenance Organization sought to be acquired;
14 (B) pro forma financial statements reflecting
15 the combined balance sheets of the acquiring company
16 and the Health Maintenance Organization sought to be
17 acquired as of the end of the preceding year and as
18 of a date 90 days prior to the acquisition, as well
19 as pro forma financial statements reflecting
20 projected combined operation for a period of 2
21 years;
22 (C) a pro forma business plan detailing an
23 acquiring party's plans with respect to the
24 operation of the Health Maintenance Organization
25 sought to be acquired for a period of not less than
26 3 years; and
27 (D) such other information as the Director
28 shall require.
29 (d) The provisions of Article VIII 1/2 of the Illinois
30 Insurance Code and this Section 5-3 shall apply to the sale
31 by any health maintenance organization of greater than 10% of
32 its enrollee population (including without limitation the
33 health maintenance organization's right, title, and interest
34 in and to its health care certificates).
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1 (e) In considering any management contract or service
2 agreement subject to Section 141.1 of the Illinois Insurance
3 Code, the Director (i) shall, in addition to the criteria
4 specified in Section 141.2 of the Illinois Insurance Code,
5 take into account the effect of the management contract or
6 service agreement on the continuation of benefits to
7 enrollees and the financial condition of the health
8 maintenance organization to be managed or serviced, and (ii)
9 need not take into account the effect of the management
10 contract or service agreement on competition.
11 (f) Except for small employer groups as defined in the
12 Small Employer Rating, Renewability and Portability Health
13 Insurance Act and except for medicare supplement policies as
14 defined in Section 363 of the Illinois Insurance Code, a
15 Health Maintenance Organization may by contract agree with a
16 group or other enrollment unit to effect refunds or charge
17 additional premiums under the following terms and conditions:
18 (i) the amount of, and other terms and conditions
19 with respect to, the refund or additional premium are set
20 forth in the group or enrollment unit contract agreed in
21 advance of the period for which a refund is to be paid or
22 additional premium is to be charged (which period shall
23 not be less than one year); and
24 (ii) the amount of the refund or additional premium
25 shall not exceed 20% of the Health Maintenance
26 Organization's profitable or unprofitable experience with
27 respect to the group or other enrollment unit for the
28 period (and, for purposes of a refund or additional
29 premium, the profitable or unprofitable experience shall
30 be calculated taking into account a pro rata share of the
31 Health Maintenance Organization's administrative and
32 marketing expenses, but shall not include any refund to
33 be made or additional premium to be paid pursuant to this
34 subsection (f)). The Health Maintenance Organization and
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1 the group or enrollment unit may agree that the
2 profitable or unprofitable experience may be calculated
3 taking into account the refund period and the immediately
4 preceding 2 plan years.
5 The Health Maintenance Organization shall include a
6 statement in the evidence of coverage issued to each enrollee
7 describing the possibility of a refund or additional premium,
8 and upon request of any group or enrollment unit, provide to
9 the group or enrollment unit a description of the method used
10 to calculate (1) the Health Maintenance Organization's
11 profitable experience with respect to the group or enrollment
12 unit and the resulting refund to the group or enrollment unit
13 or (2) the Health Maintenance Organization's unprofitable
14 experience with respect to the group or enrollment unit and
15 the resulting additional premium to be paid by the group or
16 enrollment unit.
17 In no event shall the Illinois Health Maintenance
18 Organization Guaranty Association be liable to pay any
19 contractual obligation of an insolvent organization to pay
20 any refund authorized under this Section.
21 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
22 Section 15. The Limited Health Service Organization Act
23 is amended by changing Section 4003 as follows:
24 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
25 Sec. 4003. Illinois Insurance Code provisions. Limited
26 health service organizations shall be subject to the
27 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
28 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
29 154.6, 154.7, 154.8, 155.04, 155.31, 355.2, 401, 401.1, 402,
30 403, 403A, 408, 408.2, and 412, and Articles VIII 1/2, XII,
31 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
32 Code. For purposes of the Illinois Insurance Code, except
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1 for Articles XIII and XIII 1/2, limited health service
2 organizations in the following categories are deemed to be
3 domestic companies:
4 (1) a corporation under the laws of this State; or
5 (2) a corporation organized under the laws of
6 another state, 30% of more of the enrollees of which are
7 residents of this State, except a corporation subject to
8 substantially the same requirements in its state of
9 organization as is a domestic company under Article VIII
10 1/2 of the Illinois Insurance Code.
11 (Source: P.A. 86-600; 87-587; 87-1090.)
12 Section 20. The Voluntary Health Services Plans Act is
13 amended by changing Section 10 as follows:
14 (215 ILCS 165/10) (from Ch. 32, par. 604)
15 Sec. 10. Application of Insurance Code provisions.
16 Health services plan corporations and all persons interested
17 therein or dealing therewith shall be subject to the
18 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
19 143, 143c, 149, 155.31, 354, 355.2, 356r, 367.2, 401, 401.1,
20 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
21 (15) of Section 367 of the Illinois Insurance Code.
22 (Source: P.A. 89-514, eff. 7-17-96.)