Public Act 92-0764
HB1889 Enrolled                               LRB9200925JSpcB
    AN ACT concerning insurance coverage.
    Be it enacted by the People of  the  State  of  Illinois,
represented in the General Assembly:
    Section  5.  The  State  Employees Group Insurance Act of
1971 is amended by changing Section 6.11 as follows:
    (5 ILCS 375/6.11)
    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 356u, 356w, and 356x, and  356z.2  of  the  Illinois
Insurance  Code.  The  program of health benefits must comply
with Section 155.37 of the Illinois Insurance Code.
(Source: P.A. 92-440, eff. 8-17-01.)
    Section 10.  The Illinois Insurance Code  is  amended  by
adding Section 356z.2 as follows:
    (215 ILCS 5/356z.2 new)
    Sec.  356z.2.  Coverage for adjunctive services in dental
    (a)  An individual or group policy of accident and health
insurance amended, delivered, issued, or  renewed  after  the
effective  date  of  this  amendatory Act of the 92nd General
Assembly  shall  cover  charges  incurred,  and   anesthetics
provided, in conjunction with dental care that is provided to
a  covered individual in a hospital or an ambulatory surgical
treatment center if any of the following applies:
         (1)  the individual is a child age 6 or under;
         (2)  the individual has  a  medical  condition  that
    requires hospitalization or general anesthesia for dental
    care; or
         (3)  the individual is disabled.
    (b)  For  purposes  of this Section, "ambulatory surgical
treatment center" has the  meaning  given  to  that  term  in
Section 3 of the Ambulatory Surgical Treatment Center Act.
    For  purposes of this Section, "disabled" means a person,
regardless of age, with a chronic disability if  the  chronic
disability meets all of the following conditions:
         (1)  It  is  attributable  to  a  mental or physical
    impairment  or   combination  of  mental   and   physical
         (2)  It is likely to continue.
         (3) It results in substantial functional limitations
    in  one  or  more  of  the  following areas of major life
              (A)  self-care;
              (B)  receptive and expressive language;
              (C)  learning;
              (D)  mobility;
              (E)  capacity for independent living; or
              (F)  economic self-sufficiency.
    (c)  The coverage required  under  this  Section  may  be
subject  to  any  limitations,  exclusions,  or  cost-sharing
provisions that apply generally under the insurance policy.
    (d)  This  Section does not apply to a policy that covers
only dental care.
    (e)  Nothing in this Section  requires  that  the  dental
services be covered.
    (f)  The  provisions  of  this  Section  do  not apply to
short-term  travel,  accident-only,  limited,  or   specified
disease  policies,  nor to policies or contracts designed for
issuance to persons eligible for coverage under  Title  XVIII
of  the  Social Security Act, known as Medicare, or any other
similar coverage under State or federal governmental plans.
    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, 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, 367i, 368a, 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
         (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
              (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.  90-25,  eff.  1-1-98;  90-177,  eff.  7-23-97;
90-372, eff.  7-1-98;  90-583,  eff.  5-29-98;  90-655,  eff.
7-30-98;  90-741,  eff. 1-1-99; 91-357, eff. 7-29-99; 91-406,
eff. 1-1-00; 91-549, eff.  8-14-99;  91-605,  eff.  12-14-99;
91-788, eff. 6-9-00.)
    Section  20.  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,
140,  143,  143c,  149, 155.37, 354, 355.2, 356r, 356t, 356u,
356v, 356w, 356x, 356y, 356z.1,  356z.2,  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.
(Source: P.A. 91-406,  eff.  1-1-00;  91-549,  eff.  8-14-99;
91-605,  eff.  12-14-99;  91-788,  eff.  6-9-00; 92-130, eff.
7-20-01; 92-440, eff. 8-17-01; revised 9-12-01.)
    Passed in the General Assembly May 29, 2002.
    Approved August 06, 2002.