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(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, 155.49, |
355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v, |
356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 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.20, 356z.21, 356z.22, |
356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, |
356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35, |
356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, 356z.44, |
356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, |
356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, |
356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, 356z.68, |
356z.71, 364, 364.01, 364.3, 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, XXVI, and XXXIIB 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 |
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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; |
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(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 |
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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 |
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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. |
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(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. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; |
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. |
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, |
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; |
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. |
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, |
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; |
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. |
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, |
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
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Section 15. The Limited Health Service Organization Act is |
amended by changing Section 4003 as follows:
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