2005 Illinois 215 ILCS 5/ Illinois Insurance Code. Article XIXb - Small Employer Group Health Insurance Law
(215 ILCS 5/Art. XIXB heading)ARTICLE XIXB
SMALL EMPLOYER GROUP HEALTH INSURANCE LAW
(215 ILCS 5/351B‑1) (from Ch. 73, par. 963B‑1)
Sec. 351B‑1.
Short title.
This Article may be cited as the Small
Employer Group Health Insurance Law.
(Source: P.A. 86‑1407.)
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(215 ILCS 5/351B‑2) (from Ch. 73, par. 963B‑2)
Sec. 351B‑2.
Findings and purpose.
(a) The General Assembly finds that the cost of group health insurance
is becoming unaffordable to many small employers and their employees.
Further, because of the unaffordability of this type of insurance, in some
cases due to the cost of mandated benefits, a significant segment of the
State's working population is unable to pay for many health care services
which is increasing the cost of health insurance for current purchasers
through a cost shift.
(b) It is the purpose and intent of this amendatory Act of 1990 to
authorize a program whereby small employers may obtain affordable group
health insurance that will increase access to health care, assist in the
reduction of the amount of uncompensated care, and reduce the number of
uninsured people in this State.
(Source: P.A. 86‑1407.)
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(215 ILCS 5/351B‑3) (from Ch. 73, par. 963B‑3)
Sec. 351B‑3.
Small employer group accident and health insurance.
(a) Small employer group accident and health insurance is
hereby declared to be that form of accident and health insurance that
provides coverage for each person insured under the group policy for the
expenses incurred because of care rendered by a physician or hospital for
the treatment of an injury or sickness and which covers not more than 25
employees, members, or employees of members (exclusive of dependents)
written under a master policy issued to any governmental corporation, unit,
agency, or department thereof or to any corporation, copartnership,
or individual employer or to any association upon application of an executive
officer or trustee of an association having a constitution or bylaws and
formed in good faith for purposes other than that of obtaining insurance,
where officers, members, employees, or employees of members or classes or
departments thereof may be insured for their individual benefit. In
addition, a small employer group accident and health policy may be written
to insure any group that may be insured under a group life insurance
policy as long as the number of employees, members, or employees of members
(exclusive of dependents) does not exceed 25. The term "employees" shall
include the officers, managers, and employees of subsidiary or affiliated
corporations, and the individual proprietors, partners, and employees of
affiliated individuals or firms when the business of the subsidiary or
affiliated corporations or affiliated firms or individuals is controlled by
a common employer through stock ownership, contract, or otherwise.
(b) For the purpose of providing coverage authorized under this Article
a trust composed of employers or members each of which has 25 or fewer
employees (exclusive of dependents) may serve as the master policyholder.
(Source: P.A. 86‑1407.)
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(215 ILCS 5/351B‑4) (from Ch. 73, par. 963B‑4)
Sec. 351B‑4.
Small employer group accident and health insurance
policy requirements.
(a) Any insurance company authorized to write accident and health
insurance in this State shall have power to issue small employer group
accident and health policies. No policy of small employer group accident
and health insurance may be issued or delivered in this State unless a copy
of the form thereof has been filed with the Department and approved by it
in accordance with Section 355, unless it contains in substance those
provisions contained in Sections 357.1 through 357.30 as may be applicable
to small employer group accident and health insurance and unless it
contains the provisions set forth in this Section.
(b) The policy must provide that the policy, the application of the
employer or the executive officer or trustee of any association and the
individual applications, if any, of the employees, members, or employees of
members insured shall constitute the entire contract between the parties,
and that all statements made by the employer or executive officer or
trustee, or by the individual employees, members, or employees of members
shall (in the absence of fraud) be deemed representations and not
warranties, and that none of those statements may be used in defense to a
claim under the policy unless it is contained in a written application.
(c) The policy must provide that the insurer will issue to the employer
or to the executive officer or trustee of the association, for delivery to
the employee, member, or employee of a member who is insured under the
policy, an individual certificate setting forth a statement as to the
insurance protection to which he is entitled and to whom payable.
(d) The policy must provide that all new employees of the employer, new
members of the association, or new employees of members eligible and
applying for insurance in the group or class shall be added periodically to
the group or class originally insured.
(e) Anything in this Code to the contrary notwithstanding, any small
employer group accident and health insurance policy may provide that all or
any portion of any indemnities provided by the policy on account of
hospital, nursing, medical, or surgical services may, at the insurer's
option, be paid directly to the hospital or person rendering the services;
but the policy may not require that the service be rendered by a particular
hospital or person. Payment so made shall discharge the insurer's
obligation with respect to the amount of insurance so paid. Nothing in
this subsection shall prohibit an insurer from providing incentives for
insureds to utilize the services of a particular hospital or person.
(f) Whenever the Department of Public Health finds that it has paid all
or part of any hospital or medical expenses that an insurance carrier is
obligated to pay under this Article, the Department of Public Health shall
be entitled to receive reimbursement for its payments from the insurance
carrier, provided that the Department of Public Health has notified the
insurance carrier of its claim before the carrier has paid the benefits to
its insureds or the insureds' assignees.
(g) No group hospital, medical, or surgical expense policy under this
Article shall contain any provision whereby benefits otherwise payable
thereunder are subject to reduction solely on account of the existence of
similar benefits provided under other group or group type accident and
sickness insurance policies where the reduction would operate to reduce
total benefits payable under the policies below an amount equal to 100% of
total allowable expenses provided under the policies.
(h) When dependents of insureds are covered under 2 policies, both of
which contain coordination of benefits provisions, benefits of the policy
of the insured whose birthday falls earlier in the year are determined
before those of the policy of the insured whose birthday falls later in the
year. "Birthday", as used herein, refers only to the month and day in a
calendar year, not the year in which the person was born. The Department
shall promulgate rules defining the order of benefit determination under this subsection.
(i) Discrimination between individuals of the same class of risk in the
issuance of policies, in the amount of premiums or rates charged for
any insurance covered by this Article, in benefits payable thereon,
in any of the terms or conditions of the policy, or in any other manner
whatsoever is prohibited. Nothing in this subsection shall prohibit an
insurer from providing incentives for insureds to utilize the services of a
particular hospital or person.
(j) No company shall make or permit any distinction or discrimination
against individuals solely because of handicaps or disabilities in (i) the
amount of payment of premiums or rates charged for policies of insurance,
(ii) the amount of any dividends or other benefits payable thereon, or
(iii) any other terms and conditions of the contract it makes, except where
the distinction or discrimination is based on sound actuarial principles or
is related to actual or reasonably anticipated experience.
(k) No company shall refuse to insure or refuse to continue to insure,
limit the amount or extent or kind of coverage available to an individual,
or charge an individual a different rate for the same coverage solely
because of blindness or partial blindness. With respect to all other
conditions, including the underlying cause of the blindness or partial
blindness, persons who are blind or partially blind shall be subject to the
same standards of sound actuarial principles or actual or reasonably
anticipated experience as are sighted persons. Refusal to insure includes
denial by an insurer of disability insurance coverage on the grounds that
the policy defines "disability" as being presumed in the event that the
insured loses his or her eyesight. However, an insurer may exclude from
coverage disability consisting solely of blindness or partial blindness
when the condition existed at the time the policy was issued.
(Source: P.A. 86‑1407.)
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(215 ILCS 5/351B‑5) (from Ch. 73, par. 963B‑5)
Sec. 351B‑5.
Applicability of other Code provisions.
All policies of
accident and health insurance issued
under this Article shall be subject to the provisions of Sections 356c,
subsection (a) of Section 356g, 356h, 356n, 367c, 367d, 370, 370a, and
370e of
this Code.
(Source: P.A. 86‑1407; 87‑792; 87‑1066.)
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(215 ILCS 5/351B‑6) (from Ch. 73, par. 963B‑6)
Sec. 351B‑6.
The Director shall by rule prescribe a method to collect
data from health insurers and employers relating to the coverage sold under
this Article. The data shall include the number of groups purchasing this
coverage, the extent to which other coverage has been replaced with this
coverage, if any, the number of insureds, and a summary of the types of
coverage provided by policies authorized by this Article. Statistically
valid survey methods may be used to compile this data.
Not later than March 31, 1993, the Director shall provide a written
report of this data to the Governor and to the General Assembly.
(Source: P.A. 86‑1407.)
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(215 ILCS 5/351B‑7) (from Ch. 73, par. 963B‑7)
Sec. 351B‑7.
(Repealed).
(Source: Repealed by P.A. 88‑190.)
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