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Public Act 097-0805
Public Act 0805 97TH GENERAL ASSEMBLY
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Public Act 097-0805
| | SB3242 Enrolled | LRB097 13788 RPM 58347 b |
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| AN ACT concerning insurance.
| 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 adding | Section 355.3 as follows:
| (215 ILCS 5/355.3 new) | Sec. 355.3. Noncovered dental services. | (a) In this Section: | "Covered services" means dental care services for | which a reimbursement is available under an
enrollee's plan | contract, or for which a reimbursement would be available | but for the application of
contractual limitations such as | deductibles, copayments, coinsurance, waiting periods, | annual or
lifetime maximums, frequency limitations, | alternative benefit payments, or any other limitation. | "Dental insurance" means any policy of insurance that | is issued by a company that provides coverage for dental | services not covered by a medical plan. | (b) No company that issues, delivers, amends, or renews an | individual or group policy of accident and health insurance on | or after the effective date of this amendatory Act of the 97th | General Assembly that provides dental insurance shall issue a | service provider contract that requires a dentist to provide |
| services to the insurer's policyholders at a fee set by the | insurer unless the services are covered services under the | applicable policyholder agreement.
| Section 10. The Dental Service Plan Act is amended by | changing Section 25 as follows:
| (215 ILCS 110/25) (from Ch. 32, par. 690.25)
| Sec. 25. Application of Insurance Code provisions. Dental | service
plan corporations and all persons interested therein or | dealing therewith
shall be subject to the provisions of | Articles IIA and XII 1/2
and
Sections 3.1,
133, 136, 139, 140, | 143, 143c, 149, 355.2, 355.3, 367.2, 401, 401.1, 402, 403, | 403A, 408,
408.2, and 412, and subsection (15) of Section 367 | of the Illinois Insurance
Code.
| (Source: P.A. 97-486, eff. 1-1-12.)
| Section 15. 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, 355.2, 355.3, |
| 356g.5-1, 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.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21 356z.19, | 364.01, 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, | 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.
| (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. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | 96-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; | 97-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12; | 97-592, eff. 1-1-12; revised 10-13-11.)
| Section 20. 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, 355.2, 355.3, 356v, 356z.10, | 356z.21 356z.19, 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. 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% of 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. 97-486, eff. 1-1-12; 97-592, 1-1-12; revised | 10-13-11.)
| Section 25. The Voluntary Health Services Plans Act is | amended by changing Section 10 as follows:
| (215 ILCS 165/10) (from Ch. 32, par. 604)
|
| Sec. 10. Application of Insurance Code provisions. Health | services
plan corporations and all persons interested therein | or dealing therewith
shall be subject to the provisions of | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 356g, | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | 356z.19, 356z.21 356z.19, 364.01, 367.2, 368a, 401, 401.1,
402,
| 403, 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | Section 367 of the Illinois
Insurance Code.
| 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. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; | 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; revised 10-13-11.)
| Section 99. Effective date. This Act takes effect January | 1, 2013.
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Effective Date: 1/1/2013
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