State Codes and Statutes

Statutes > Illinois > Chapter215 > 1276

    (215 ILCS 165/1) (from Ch. 32, par. 595)
    Sec. 1. This Act may be cited as the Voluntary Health Services Plans Act.
(Source: P.A. 86‑1475.)

    (215 ILCS 165/2)(from Ch. 32, par. 596)
    Sec. 2. For the purposes of this Act, the following terms have the respective meanings set forth in this section, unless different meanings are plainly indicated by the context:
    (a) "Health Services Plan Corporation" means a corporation organized under the terms of this Act for the purpose of establishing and operating a voluntary health services plan and providing other medically related services.
    (b) "Voluntary health services plan" means either a plan or system under which medical, hospital, nursing and relating health services may be rendered to a subscriber or beneficiary at the expense of a health services plan corporation, or any contractual arrangement to provide, either directly or through arrangements with others, dental care services to subscribers and beneficiaries.
    (c) "Subscriber" means a natural person to whom a subscription certificate has been issued by a health services plan corporation. Persons eligible under Section 5‑2 of the Illinois Public Aid Code may be subscribers if a written agreement exists, as specified in Section 25 of this Act, between the Health Services Plan Corporation and the Department of Healthcare and Family Services. A subscription certificate may be issued to such persons at no cost.
    (d) "Beneficiary" means a person designated in a subscription certificate as one entitled to receive health services.
    (e) "Health services" means those services ordinarily rendered by physicians licensed in Illinois to practice medicine in all of its branches, by podiatrists licensed in Illinois to practice podiatric medicine, by dentists and dental surgeons licensed to practice in Illinois, by nurses registered in Illinois, by dental hygienists licensed to practice in Illinois, and by assistants and technicians acting under professional supervision; it likewise means hospital services as usually and customarily rendered in Illinois, and the compounding and dispensing of drugs and medicines by pharmacists and assistant pharmacists registered in Illinois.
    (f) "Subscription certificate" means a certificate issued to a subscriber by a health services plan corporation, setting forth the terms and conditions upon which health services shall be rendered to a subscriber or a beneficiary.
    (g) "Physician rendering service for a plan" means a physician licensed in Illinois to practice medicine in all of its branches who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish medical service to the plan's subscribers and beneficiaries.
    (h) "Dentist or dental surgeon rendering service for a plan" means a dentist or dental surgeon licensed in Illinois to practice dentistry or dental surgery who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish dental or dental surgical services to the plan's subscribers and beneficiaries.
    (i) "Director" means the Director of Insurance of the State of Illinois.
    (j) "Person" means any of the following: a natural person, corporation, partnership or unincorporated association.
    (k) "Podiatrist or podiatric surgeon rendering service for a plan" means any podiatrist or podiatric surgeon licensed in Illinois to practice podiatry, who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish podiatric or podiatric surgical services to the plan's subscribers and beneficiaries.
(Source: P.A. 95‑331, eff. 8‑21‑07.)

    (215 ILCS 165/3) (from Ch. 32, par. 597)
    Sec. 3. It shall be unlawful for any person, except a health services plan corporation, incorporated under this Act, to establish, maintain or operate a voluntary health services plan. This prohibition, however, shall not be construed as preventing a person from furnishing health services to his employees or from furnishing such medical services as are required under the workers' compensation laws and related legislation, when the employees are not charged for such services; nor shall it be construed to prohibit an insurance company, or other corporation or society, which is subject to the supervision of the Director from operating in accordance with the laws governing insurance companies or such corporations or societies; nor shall it be construed to prohibit the continued operation of any medical or health service plan in existence and functioning at the effective date of this Act.
(Source: P.A. 88‑364.)

    (215 ILCS 165/3.1) (from Ch. 32, par. 597.1)
    Sec. 3.1. No new plans may be chartered. No voluntary health services plan shall be issued a charter for the purpose of doing business under this Act after the effective date of this Amendatory Act of 1989.
(Source: P.A. 86‑600.)

    (215 ILCS 165/4) (from Ch. 32, par. 598)
    Sec. 4. Five or more persons of legal age all of whom are residents of Illinois and citizens of the United States may incorporate under the provisions of this Act a health services plan corporation for the purpose of establishing and operating a voluntary health services plan. Such corporation shall be subject to regulation and supervision by the Director as hereinafter provided, but shall not be subject to the laws of this state with respect to insurance corporations except as provided in this Act.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/5) (from Ch. 32, par. 599)
    Sec. 5. The business and affairs of a health services plan corporation shall be managed by a board of trustees, which shall have the power to adopt, and to amend from time to time, by‑laws governing the conduct of the corporation's business. The board of trustees shall consist of not less than seven persons, all of whom shall have the same general qualifications as the incorporators, and at least 30% of whom shall, in addition, be physicians or dentists, licensed in Illinois to practice medicine in all of its branches or dentistry, respectively; provided, however, that if in computing the required number of physicians or dentists on the board of trustees, the amount of 30% does not coincide with a whole number, but lies between whole numbers, the smaller whole number shall be controlling as to the number of physicians or dentists. The original board of trustees shall be appointed by the incorporators. Trustees shall serve for a term of three years, except that as to the original appointed board, not more than one‑third of the members thereof shall be appointed for three years, not more than one‑third thereof for two years and the balance thereof for one year. As the terms of the members of the board of trustees expire, they shall be replaced, from time to time, by election by the health services plan subscribers who are members of the health services plan corporation. If the corporation furnishes medical services to the plan's subscribers and beneficiaries and these services are rendered by physicians licensed in Illinois to practice medicine in all of its branches, the board of trustees shall appoint a Medical Director who shall be a physician licensed in Illinois to practice medicine in all of its branches. The Medical Director may participate in all deliberations of the board of trustees but shall not vote in any decisions or determinations made by the board of trustees. The Medical Director, under the board of trustees, shall have complete charge of and responsibility for the medical and medically related scientific aspects of the business of the corporation.
(Source: P.A. 81‑1203.)

    (215 ILCS 165/6) (from Ch. 32, par. 600)
    Sec. 6. A health services plan corporation may, in the discretion of its board of trustees, through its by‑laws, limit or define the classes of persons who shall be eligible to become subscribers or beneficiaries, limit and define the benefits which it will furnish, and may divide such benefits as it undertakes to furnish into classes or kinds.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/7) (from Ch. 32, par. 601)
    Sec. 7. Every physician licensed in Illinois to practice medicine in all of its branches, every podiatrist licensed to practice podiatric medicine in Illinois, and every dentist and dental surgeon licensed to practice in Illinois may be eligible to render medical, podiatric or dental services respectively, upon such terms and conditions as may be mutually acceptable to such physician, podiatrist, dentist or dental surgeon and to the health services plan corporation involved. Such a corporation shall impose no restrictions on the physicians, podiatrists, dentists or dental surgeons who treat its subscribers as to methods of diagnosis or treatment. The private physician‑patient relationship shall be maintained, and subscribers shall at all times have free choice of any physician, podiatrist, dentist or dental surgeon who is rendering service on behalf of the corporation. All of the records, charts, files and other data of a health services plan corporation pertaining to the condition of health of its subscribers and beneficiaries shall be and remain confidential, and no disclosure of the contents thereof shall be made by the corporation to any person, except upon the prior written authorization of the particular subscriber or beneficiary concerned.
(Source: P.A. 81‑1456.)

    (215 ILCS 165/8) (from Ch. 32, par. 602)
    Sec. 8. Except as otherwise provided by Section 3 of this Act, no person shall offer to the public any voluntary health service plan or otherwise engage in the business of a health service plan corporation without having first received a charter from the Director. No charter under this Act shall be approved by the Director for any organization seeking to provide medical or hospital services unless the organization files a concomitant application for a certificate of authority, and is approved by the Director, as a health maintenance organization pursuant to the requirements of the Health Maintenance Organization Act. Application therefor shall be made to the Director upon forms prescribed by him and shall include the following information:
    (a) The names, places of residence, occupations, and qualifications of the incorporators;
    (b) The location of the corporation's registered office, and the name and address of its registered agent;
    (c) A detailed financial statement, including the amount of original capital to be contributed to the corporation before it shall commence doing business, as well as the name of each contributor, and the amount by him contributed and the terms of such contribution;
    (d) A copy of the by‑laws to be adopted by the board of trustees upon the issuance of a charter;
    (e) Specimen copies of all subscription certificates which it is proposed the corporation shall issue to subscribers, which certificates shall set forth in detail the rates to be charged subscribers and the nature and extent of the services which the subscriber or other beneficiary shall be entitled to receive;
    (f) A detailed statement as to the health services plan or plans which the corporation proposes to offer, including the rates to be charged, the benefits to be provided and the names of the counties in which it is proposed the corporation shall have authority to engage in business;
    (g) A copy of the proposed charter under which the corporation intends to operate.
    (h) Specimen copies of all agreements to be entered into between the corporation and hospitals, physicians, dentists, pharmacists and nurses, which agreements shall set forth in detail the terms and conditions upon which each shall be obliged to render service to subscribers of the corporations.
    After consideration of the statements and documents submitted to him and such additional investigation as he deems necessary, the Director shall issue a charter to the applicant corporation if he finds:
    (1) The corporation has complied with the requirements of this Act,
    (2) The subscription certificates to be offered by the corporation and its methods of operation would not work a fraud on the subscriber,
    (3) The rates to be charged and the benefits to be provided are fair and reasonable to both the subscriber and to the corporation,
    (4) The amount of money actually available for original capital is sufficient to carry all acquisition costs and operating expenses for a reasonable period of time from the issuance of the charter and is not less than the minimum requirements set forth in subsection (5) of Section 8 of this Act.
    (5) The amounts contributed as original capital of the corporation shall aggregate not less than $100,000 at the start of business.
    (6) Adequate and reasonable reserves are provided to insure the contracts; and
    (7) The corporation has contracts or agreements with hospitals, physicians, dentists, pharmacists, nurses and dental hygienists sufficient in number to carry out the terms of the contracts to be issued to these subscribers.
    Amendments to a charter shall be made by application to the Director in the same manner as on original application.
(Source: P.A. 85‑1246.)

    (215 ILCS 165/9) (from Ch. 32, par. 603)
    Sec. 9. After the issuance of a charter, the Director as he deems in the public interest may authorize or require a health services plan corporation to charge rates or to utilize soliciting methods different from those on which the charter was based, provided that such contracts and practices are in compliance with provisions of this Act and are not violative of other laws of this State.
    The Director may revoke or amend, after reasonable notice and hearing, any charter, certificates, order, authority or consent made by him to a health services plan corporation on having found (1) that the further solicitation of subscribers or further continuance of the practices in question will work a fraud on subscribers, or (2) that the rates charged or the benefits provided are not fair and reasonable to both the subscriber and the corporation.
(Source: Laws 1951, p. 569.)

    (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, 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, 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. 95‑189, eff. 8‑16‑07; 95‑331, eff. 8‑21‑07; 95‑422, eff. 8‑24‑07; 95‑520, eff. 8‑28‑07; 95‑876, eff. 8‑21‑08; 95‑958, eff. 6‑1‑09; 95‑978, eff. 1‑1‑09; 95‑1005, eff. 12‑12‑08; 95‑1045, eff. 3‑27‑09; 95‑1049, eff. 1‑1‑10; 96‑328, eff. 8‑11‑09; 96‑833, eff. 6‑1‑10; 96‑1000, eff. 7‑2‑10.)

    (215 ILCS 165/11) (from Ch. 32, par. 605)
    Sec. 11. Examination of corporations. The Director shall have with respect to health services plan corporations the powers of examination conferred upon him relative to insurance companies by Sections 132 through 132.7 of the Illinois Insurance Code. The cost of any examination shall be paid by the corporation examined.
(Source: P.A. 89‑97, eff. 7‑7‑95.)

    (215 ILCS 165/12) (from Ch. 32, par. 606)
    Sec. 12. All rates or formula base for experience rate subscriber contracts shall be submitted to the Director prior to use. The Director may disapprove rates or formula base for rates for specific reason and must do so within 45 days of receipt of supporting information or rates will be deemed approved.
(Source: P.A. 81‑1203.)

    (215 ILCS 165/13) (from Ch. 32, par. 607)
    Sec. 13. No subscription certificate shall be issued by any health services plan corporation until the form thereof has been filed with and approved by the Director, together with all applications, riders and endorsements for use in connection with the issuance or renewal thereof. It shall be the duty of the Director of Insurance to withhold approval of any contract form filed with him if it violates any provisions of this Act, or if it violates or is contrary to any provisions of Sections 143, 355, and 355a of the "Illinois Insurance Code", approved June 29, 1937, as amended, which are not inconsistent or in conflict with provisions of this Act.
(Source: P.A. 79‑681.)

    (215 ILCS 165/14) (from Ch. 32, par. 608)
    Sec. 14. Every subscription certificate issued by a health services plan corporation shall provide for the rendering of health services as therein specified for a period of 12 months from the date of issuance of the subscription certificate subject to compliance with the by‑laws and rules and regulations of the corporation by the subscriber. Any such certificate may provide that it shall ordinarily be renewed from year to year unless there has been one month's written notice of termination either by the subscriber or by the corporation. During the first contract year the provisions of the contract may provide that the coverage by the contract may be deferred for not more than two months from date of issue of the contract and may exclude treatment for illness or other conditions requiring service existing at the time of executing the contract.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/15) (from Ch. 32, par. 609)
    Sec. 15.
    Every contract entered into by a health services plan corporation and a subscriber shall be in writing and a certificate stating the terms and conditions thereof shall be furnished the subscriber. No such subscription certificate shall be issued unless it contains the following provisions:
    (a) A statement of the nature of the health services to be provided and the period during which the certificate shall be effective; and if there are any types of services to be excepted, a detailed statement of such exceptions printed as hereinafter specified;
    (b) A statement of the terms or conditions, if any, upon which the certificate may be cancelled or otherwise terminated at the option of either party;
    (c) A statement that the subscription certificate constitutes the entire contract between the corporation and the subscriber and includes any endorsements attached;
    (d) A statement that no statement by the subscriber in his application for a certificate shall void the contract or be used in any legal proceeding thereunder, unless such application or an exact copy thereof is included in or attached to the certificate, and that no agent or representative of such corporation other than an officer or officers designated in the certificate, are authorized to change the contract or waive any of its provisions;
    (e) A statement that if the subscriber defaults in making any payment under the certificate, the subsequent acceptance of a payment by the corporation or by one of its duly authorized agents shall reinstate the certificate, but with respect to sickness and injury may cover only such sickness or injury as may be first manifested more than a specified number of days, not exceeding ten, after the date of such acceptance;
    (f) A statement of the period of grace which will be allowed the subscriber for making any payment due under the contract. Such period shall not be less than ten days;
    (g) A statement that indemnity in the form of cash will not be paid to any subscriber except in reimbursement for payments made by the subscriber to a physician, dentist or dental surgeon for which the subscriber had received express authorization by the corporation and for which the corporation was liable at the time of such payment.
    (h) Every voluntary health services plan and each subscription certificate issued by a health services plan corporation and providing coverage for hospital treatment shall provide coverage for treatment of alcoholism in a hospital licensed under the Hospital Licensing Act approved July 1, 1953 as amended or an approved public or private alcoholism treatment facility meeting the standards prescribed in Section 9 (1) of the Uniform Alcoholism and Intoxication Treatment Act enacted by the 78th General Assembly and approved under Section 9 (3) of the Uniform Alcoholism and Intoxication Treatment Act enacted by the 78th General Assembly.
(Source: P. A. 78‑767.)

    (215 ILCS 165/15.1) (from Ch. 32, par. 609.1)
    Sec. 15.1.
    No contract issued by a voluntary health services plan shall contain any exception or exclusion from coverage which would preclude the payment of expenses incurred for the processing and administration of blood and its components.
(Source: P. A. 77‑2724.)

    (215 ILCS 165/15.2) (from Ch. 32, par. 609.2)
    Sec. 15.2.
    No claim shall be denied, under a contract issued or renewed by a voluntary health services plan after the effective date of this Amendatory Act, for treatment or services for mental illness rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P. A. 78‑708.)

    (215 ILCS 165/15.3) (from Ch. 32, par. 609.3)
    Sec. 15.3. (1) No service plan contract of a health service plan corporation which in addition to covering the subscriber, also covers members of the subscriber's immediate family, shall contain any disclaimer, waiver, or other limitation of coverage relative to the health service benefits for or insurability of newborn infants of the subscriber from and after the moment of birth.
    (2) Each such contract shall contain a provision stating that the health service benefits applicable for children shall be granted immediately with respect to a newly born child from the moment of birth. The coverage for newly born children shall include coverage of illness, injury, congenital defects, birth abnormalities and premature birth.
    (3) If payment of a specific subscription fee is required to provide coverage for a child, the contract may require that notification of birth of a newly born child must be furnished to the corporation within 31 days after the date of birth in order to have the coverage continue beyond such 31 day period and may require payment of the appropriate fee.
    (4) The requirements of this Section shall apply to all contracts delivered, issued for delivery, renewed, or amended on or after the sixtieth day following the effective date of this Section.
(Source: P.A. 79‑74.)

    (215 ILCS 165/15.4) (from Ch. 32, par. 609.4)
    Sec. 15.4. (1) No service plan contract of a health service plan corporation which in addition to covering the subscriber, also covers the subscriber's spouse shall contain a provision for termination of coverage for a spouse covered under the service plan contract solely as a result of a break in the marital relationship except by reason of an entry of a valid judgment of dissolution of marriage between the parties.
    (2) Every such service plan contract, other than a contract whose continuance is contingent upon continued employment or membership, which contains a provision for termination of coverage of the spouse upon dissolution of marriage shall contain a provision to the effect that upon the entry of a valid judgment of dissolution of marriage between the covered parties the spouse whose marriage was dissolved shall be entitled to have issued to her or him, without evidence of insurability, and upon application made to the corporation within 60 days following the entry of such judgment, upon the payment of the appropriate subscription fee, an individual service plan contract. Such contract shall provide the coverage then being issued by the corporation which is most nearly similar to, but not greater than, such terminated coverage. Any and all probationary or waiting periods set forth in the conversion contract shall be considered as being met to the extent coverage was in force under the prior contract.
    (3) The requirements of this Section shall apply to all contracts delivered, issued for delivery, renewed, or amended on or after the 60th day following the effective date of this Section.
(Source: P.A. 81‑230.)

    (215 ILCS 165/15.5) (from Ch. 32, par. 609.5)
    Sec. 15.5. Conversion Privilege‑Group Type Contracts.
    (1) Every service plan contract of a health service plan corporation which provides that the continued coverage of a beneficiary is contingent upon the continued employment or membership of the subscriber with a particular employer, union, or association shall further provide for the right of said person to make application for an individual service plan contract under the circumstances and in accordance with the requirements set forth in Sections 367e and 367e.1 of the "Illinois Insurance Code". The application of Sections 367e and 367e.1 of the Code shall not be construed in such a manner as to require a health service plan corporation to furnish a service or kind of benefit not customarily provided by such corporation and which is inconsistent with the provision of this Act.
    (2) The requirements of this Section shall apply to all such contracts delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this Section.
(Source: P.A. 93‑477, eff. 1‑1‑04.)

    (215 ILCS 165/15.6‑1) (from Ch. 32, par. 609.6‑1)
    Sec. 15.6‑1. Continuance privilege ‑ Group type contacts. (1) Every service plan contract of a health service plan corporation which provides that the continued coverage of a beneficiary is contingent upon the continued employment of the subscriber with a particular employer shall further provide for the continuance of such contract in accordance with the requirements set forth in Section 367.2 of the "Illinois Insurance Code", approved June 29, 1937, as amended.
    (2) The requirements of this Section shall apply to all such contracts delivered, issued for delivery, renewed or amended on or after the effective date of this amendatory Act of 1985.
(Source: P.A. 84‑556.)

    (215 ILCS 165/15.7) (from Ch. 32, par. 609.7)
    Sec. 15.7. No claim shall be denied, under a contract issued or renewed by a voluntary health services plan after the effective day of this amendatory Act, for treatment or services for rehabilitation following either a physical or mental illness, rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P.A. 79‑303; 79‑1454.)

    (215 ILCS 165/15.8) (from Ch. 32, par. 609.8)
    Sec. 15.8. Sexual assault or abuse victims.
    (1) Policies, contracts or subscription certificates issued by a health services plan corporation, which provide benefits for hospital or medical expenses based upon the actual expenses incurred, shall to the full extent of coverage provided for any other emergency or accident care, provide for the payment of actual expenses incurred, without offset or reduction for benefit deductibles or co‑insurance amounts, in the examination and testing of a victim of an offense defined in Sections 12‑13 through 12‑16 of the Criminal Code of 1961, as now or hereafter amended, or attempt to commit such offense, to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense.
    (2) For purposes of enabling the recovery of State Funds, any health services plan corporation subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its insureds or subscribers entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay, hospital or medical expenses for which a health care service corporation is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section.
    (3) Whenever the Department of Public Health finds that it has paid all or part of any hospital or medical expenses which a health services plan corporation is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such corporation provided that the Department of Public Health has notified the corporation of its claims before the corporation has paid such benefits to its subscribers or in behalf of its subscribers.
(Source: P.A. 89‑187, eff. 7‑19‑95.)

    (215 ILCS 165/15.9) (from Ch. 32, par. 609.9)
    Sec. 15.9. Coverage of services for mental illness. To the extent not inconsistent with this Act every Health Service Corporation shall be subject to the provisions of Section 370c of the "Illinois Insurance Code", approved June 29, 1937, as amended.
(Source: P.A. 81‑1509.)

State Codes and Statutes

Statutes > Illinois > Chapter215 > 1276

    (215 ILCS 165/1) (from Ch. 32, par. 595)
    Sec. 1. This Act may be cited as the Voluntary Health Services Plans Act.
(Source: P.A. 86‑1475.)

    (215 ILCS 165/2)(from Ch. 32, par. 596)
    Sec. 2. For the purposes of this Act, the following terms have the respective meanings set forth in this section, unless different meanings are plainly indicated by the context:
    (a) "Health Services Plan Corporation" means a corporation organized under the terms of this Act for the purpose of establishing and operating a voluntary health services plan and providing other medically related services.
    (b) "Voluntary health services plan" means either a plan or system under which medical, hospital, nursing and relating health services may be rendered to a subscriber or beneficiary at the expense of a health services plan corporation, or any contractual arrangement to provide, either directly or through arrangements with others, dental care services to subscribers and beneficiaries.
    (c) "Subscriber" means a natural person to whom a subscription certificate has been issued by a health services plan corporation. Persons eligible under Section 5‑2 of the Illinois Public Aid Code may be subscribers if a written agreement exists, as specified in Section 25 of this Act, between the Health Services Plan Corporation and the Department of Healthcare and Family Services. A subscription certificate may be issued to such persons at no cost.
    (d) "Beneficiary" means a person designated in a subscription certificate as one entitled to receive health services.
    (e) "Health services" means those services ordinarily rendered by physicians licensed in Illinois to practice medicine in all of its branches, by podiatrists licensed in Illinois to practice podiatric medicine, by dentists and dental surgeons licensed to practice in Illinois, by nurses registered in Illinois, by dental hygienists licensed to practice in Illinois, and by assistants and technicians acting under professional supervision; it likewise means hospital services as usually and customarily rendered in Illinois, and the compounding and dispensing of drugs and medicines by pharmacists and assistant pharmacists registered in Illinois.
    (f) "Subscription certificate" means a certificate issued to a subscriber by a health services plan corporation, setting forth the terms and conditions upon which health services shall be rendered to a subscriber or a beneficiary.
    (g) "Physician rendering service for a plan" means a physician licensed in Illinois to practice medicine in all of its branches who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish medical service to the plan's subscribers and beneficiaries.
    (h) "Dentist or dental surgeon rendering service for a plan" means a dentist or dental surgeon licensed in Illinois to practice dentistry or dental surgery who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish dental or dental surgical services to the plan's subscribers and beneficiaries.
    (i) "Director" means the Director of Insurance of the State of Illinois.
    (j) "Person" means any of the following: a natural person, corporation, partnership or unincorporated association.
    (k) "Podiatrist or podiatric surgeon rendering service for a plan" means any podiatrist or podiatric surgeon licensed in Illinois to practice podiatry, who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish podiatric or podiatric surgical services to the plan's subscribers and beneficiaries.
(Source: P.A. 95‑331, eff. 8‑21‑07.)

    (215 ILCS 165/3) (from Ch. 32, par. 597)
    Sec. 3. It shall be unlawful for any person, except a health services plan corporation, incorporated under this Act, to establish, maintain or operate a voluntary health services plan. This prohibition, however, shall not be construed as preventing a person from furnishing health services to his employees or from furnishing such medical services as are required under the workers' compensation laws and related legislation, when the employees are not charged for such services; nor shall it be construed to prohibit an insurance company, or other corporation or society, which is subject to the supervision of the Director from operating in accordance with the laws governing insurance companies or such corporations or societies; nor shall it be construed to prohibit the continued operation of any medical or health service plan in existence and functioning at the effective date of this Act.
(Source: P.A. 88‑364.)

    (215 ILCS 165/3.1) (from Ch. 32, par. 597.1)
    Sec. 3.1. No new plans may be chartered. No voluntary health services plan shall be issued a charter for the purpose of doing business under this Act after the effective date of this Amendatory Act of 1989.
(Source: P.A. 86‑600.)

    (215 ILCS 165/4) (from Ch. 32, par. 598)
    Sec. 4. Five or more persons of legal age all of whom are residents of Illinois and citizens of the United States may incorporate under the provisions of this Act a health services plan corporation for the purpose of establishing and operating a voluntary health services plan. Such corporation shall be subject to regulation and supervision by the Director as hereinafter provided, but shall not be subject to the laws of this state with respect to insurance corporations except as provided in this Act.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/5) (from Ch. 32, par. 599)
    Sec. 5. The business and affairs of a health services plan corporation shall be managed by a board of trustees, which shall have the power to adopt, and to amend from time to time, by‑laws governing the conduct of the corporation's business. The board of trustees shall consist of not less than seven persons, all of whom shall have the same general qualifications as the incorporators, and at least 30% of whom shall, in addition, be physicians or dentists, licensed in Illinois to practice medicine in all of its branches or dentistry, respectively; provided, however, that if in computing the required number of physicians or dentists on the board of trustees, the amount of 30% does not coincide with a whole number, but lies between whole numbers, the smaller whole number shall be controlling as to the number of physicians or dentists. The original board of trustees shall be appointed by the incorporators. Trustees shall serve for a term of three years, except that as to the original appointed board, not more than one‑third of the members thereof shall be appointed for three years, not more than one‑third thereof for two years and the balance thereof for one year. As the terms of the members of the board of trustees expire, they shall be replaced, from time to time, by election by the health services plan subscribers who are members of the health services plan corporation. If the corporation furnishes medical services to the plan's subscribers and beneficiaries and these services are rendered by physicians licensed in Illinois to practice medicine in all of its branches, the board of trustees shall appoint a Medical Director who shall be a physician licensed in Illinois to practice medicine in all of its branches. The Medical Director may participate in all deliberations of the board of trustees but shall not vote in any decisions or determinations made by the board of trustees. The Medical Director, under the board of trustees, shall have complete charge of and responsibility for the medical and medically related scientific aspects of the business of the corporation.
(Source: P.A. 81‑1203.)

    (215 ILCS 165/6) (from Ch. 32, par. 600)
    Sec. 6. A health services plan corporation may, in the discretion of its board of trustees, through its by‑laws, limit or define the classes of persons who shall be eligible to become subscribers or beneficiaries, limit and define the benefits which it will furnish, and may divide such benefits as it undertakes to furnish into classes or kinds.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/7) (from Ch. 32, par. 601)
    Sec. 7. Every physician licensed in Illinois to practice medicine in all of its branches, every podiatrist licensed to practice podiatric medicine in Illinois, and every dentist and dental surgeon licensed to practice in Illinois may be eligible to render medical, podiatric or dental services respectively, upon such terms and conditions as may be mutually acceptable to such physician, podiatrist, dentist or dental surgeon and to the health services plan corporation involved. Such a corporation shall impose no restrictions on the physicians, podiatrists, dentists or dental surgeons who treat its subscribers as to methods of diagnosis or treatment. The private physician‑patient relationship shall be maintained, and subscribers shall at all times have free choice of any physician, podiatrist, dentist or dental surgeon who is rendering service on behalf of the corporation. All of the records, charts, files and other data of a health services plan corporation pertaining to the condition of health of its subscribers and beneficiaries shall be and remain confidential, and no disclosure of the contents thereof shall be made by the corporation to any person, except upon the prior written authorization of the particular subscriber or beneficiary concerned.
(Source: P.A. 81‑1456.)

    (215 ILCS 165/8) (from Ch. 32, par. 602)
    Sec. 8. Except as otherwise provided by Section 3 of this Act, no person shall offer to the public any voluntary health service plan or otherwise engage in the business of a health service plan corporation without having first received a charter from the Director. No charter under this Act shall be approved by the Director for any organization seeking to provide medical or hospital services unless the organization files a concomitant application for a certificate of authority, and is approved by the Director, as a health maintenance organization pursuant to the requirements of the Health Maintenance Organization Act. Application therefor shall be made to the Director upon forms prescribed by him and shall include the following information:
    (a) The names, places of residence, occupations, and qualifications of the incorporators;
    (b) The location of the corporation's registered office, and the name and address of its registered agent;
    (c) A detailed financial statement, including the amount of original capital to be contributed to the corporation before it shall commence doing business, as well as the name of each contributor, and the amount by him contributed and the terms of such contribution;
    (d) A copy of the by‑laws to be adopted by the board of trustees upon the issuance of a charter;
    (e) Specimen copies of all subscription certificates which it is proposed the corporation shall issue to subscribers, which certificates shall set forth in detail the rates to be charged subscribers and the nature and extent of the services which the subscriber or other beneficiary shall be entitled to receive;
    (f) A detailed statement as to the health services plan or plans which the corporation proposes to offer, including the rates to be charged, the benefits to be provided and the names of the counties in which it is proposed the corporation shall have authority to engage in business;
    (g) A copy of the proposed charter under which the corporation intends to operate.
    (h) Specimen copies of all agreements to be entered into between the corporation and hospitals, physicians, dentists, pharmacists and nurses, which agreements shall set forth in detail the terms and conditions upon which each shall be obliged to render service to subscribers of the corporations.
    After consideration of the statements and documents submitted to him and such additional investigation as he deems necessary, the Director shall issue a charter to the applicant corporation if he finds:
    (1) The corporation has complied with the requirements of this Act,
    (2) The subscription certificates to be offered by the corporation and its methods of operation would not work a fraud on the subscriber,
    (3) The rates to be charged and the benefits to be provided are fair and reasonable to both the subscriber and to the corporation,
    (4) The amount of money actually available for original capital is sufficient to carry all acquisition costs and operating expenses for a reasonable period of time from the issuance of the charter and is not less than the minimum requirements set forth in subsection (5) of Section 8 of this Act.
    (5) The amounts contributed as original capital of the corporation shall aggregate not less than $100,000 at the start of business.
    (6) Adequate and reasonable reserves are provided to insure the contracts; and
    (7) The corporation has contracts or agreements with hospitals, physicians, dentists, pharmacists, nurses and dental hygienists sufficient in number to carry out the terms of the contracts to be issued to these subscribers.
    Amendments to a charter shall be made by application to the Director in the same manner as on original application.
(Source: P.A. 85‑1246.)

    (215 ILCS 165/9) (from Ch. 32, par. 603)
    Sec. 9. After the issuance of a charter, the Director as he deems in the public interest may authorize or require a health services plan corporation to charge rates or to utilize soliciting methods different from those on which the charter was based, provided that such contracts and practices are in compliance with provisions of this Act and are not violative of other laws of this State.
    The Director may revoke or amend, after reasonable notice and hearing, any charter, certificates, order, authority or consent made by him to a health services plan corporation on having found (1) that the further solicitation of subscribers or further continuance of the practices in question will work a fraud on subscribers, or (2) that the rates charged or the benefits provided are not fair and reasonable to both the subscriber and the corporation.
(Source: Laws 1951, p. 569.)

    (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, 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, 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. 95‑189, eff. 8‑16‑07; 95‑331, eff. 8‑21‑07; 95‑422, eff. 8‑24‑07; 95‑520, eff. 8‑28‑07; 95‑876, eff. 8‑21‑08; 95‑958, eff. 6‑1‑09; 95‑978, eff. 1‑1‑09; 95‑1005, eff. 12‑12‑08; 95‑1045, eff. 3‑27‑09; 95‑1049, eff. 1‑1‑10; 96‑328, eff. 8‑11‑09; 96‑833, eff. 6‑1‑10; 96‑1000, eff. 7‑2‑10.)

    (215 ILCS 165/11) (from Ch. 32, par. 605)
    Sec. 11. Examination of corporations. The Director shall have with respect to health services plan corporations the powers of examination conferred upon him relative to insurance companies by Sections 132 through 132.7 of the Illinois Insurance Code. The cost of any examination shall be paid by the corporation examined.
(Source: P.A. 89‑97, eff. 7‑7‑95.)

    (215 ILCS 165/12) (from Ch. 32, par. 606)
    Sec. 12. All rates or formula base for experience rate subscriber contracts shall be submitted to the Director prior to use. The Director may disapprove rates or formula base for rates for specific reason and must do so within 45 days of receipt of supporting information or rates will be deemed approved.
(Source: P.A. 81‑1203.)

    (215 ILCS 165/13) (from Ch. 32, par. 607)
    Sec. 13. No subscription certificate shall be issued by any health services plan corporation until the form thereof has been filed with and approved by the Director, together with all applications, riders and endorsements for use in connection with the issuance or renewal thereof. It shall be the duty of the Director of Insurance to withhold approval of any contract form filed with him if it violates any provisions of this Act, or if it violates or is contrary to any provisions of Sections 143, 355, and 355a of the "Illinois Insurance Code", approved June 29, 1937, as amended, which are not inconsistent or in conflict with provisions of this Act.
(Source: P.A. 79‑681.)

    (215 ILCS 165/14) (from Ch. 32, par. 608)
    Sec. 14. Every subscription certificate issued by a health services plan corporation shall provide for the rendering of health services as therein specified for a period of 12 months from the date of issuance of the subscription certificate subject to compliance with the by‑laws and rules and regulations of the corporation by the subscriber. Any such certificate may provide that it shall ordinarily be renewed from year to year unless there has been one month's written notice of termination either by the subscriber or by the corporation. During the first contract year the provisions of the contract may provide that the coverage by the contract may be deferred for not more than two months from date of issue of the contract and may exclude treatment for illness or other conditions requiring service existing at the time of executing the contract.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/15) (from Ch. 32, par. 609)
    Sec. 15.
    Every contract entered into by a health services plan corporation and a subscriber shall be in writing and a certificate stating the terms and conditions thereof shall be furnished the subscriber. No such subscription certificate shall be issued unless it contains the following provisions:
    (a) A statement of the nature of the health services to be provided and the period during which the certificate shall be effective; and if there are any types of services to be excepted, a detailed statement of such exceptions printed as hereinafter specified;
    (b) A statement of the terms or conditions, if any, upon which the certificate may be cancelled or otherwise terminated at the option of either party;
    (c) A statement that the subscription certificate constitutes the entire contract between the corporation and the subscriber and includes any endorsements attached;
    (d) A statement that no statement by the subscriber in his application for a certificate shall void the contract or be used in any legal proceeding thereunder, unless such application or an exact copy thereof is included in or attached to the certificate, and that no agent or representative of such corporation other than an officer or officers designated in the certificate, are authorized to change the contract or waive any of its provisions;
    (e) A statement that if the subscriber defaults in making any payment under the certificate, the subsequent acceptance of a payment by the corporation or by one of its duly authorized agents shall reinstate the certificate, but with respect to sickness and injury may cover only such sickness or injury as may be first manifested more than a specified number of days, not exceeding ten, after the date of such acceptance;
    (f) A statement of the period of grace which will be allowed the subscriber for making any payment due under the contract. Such period shall not be less than ten days;
    (g) A statement that indemnity in the form of cash will not be paid to any subscriber except in reimbursement for payments made by the subscriber to a physician, dentist or dental surgeon for which the subscriber had received express authorization by the corporation and for which the corporation was liable at the time of such payment.
    (h) Every voluntary health services plan and each subscription certificate issued by a health services plan corporation and providing coverage for hospital treatment shall provide coverage for treatment of alcoholism in a hospital licensed under the Hospital Licensing Act approved July 1, 1953 as amended or an approved public or private alcoholism treatment facility meeting the standards prescribed in Section 9 (1) of the Uniform Alcoholism and Intoxication Treatment Act enacted by the 78th General Assembly and approved under Section 9 (3) of the Uniform Alcoholism and Intoxication Treatment Act enacted by the 78th General Assembly.
(Source: P. A. 78‑767.)

    (215 ILCS 165/15.1) (from Ch. 32, par. 609.1)
    Sec. 15.1.
    No contract issued by a voluntary health services plan shall contain any exception or exclusion from coverage which would preclude the payment of expenses incurred for the processing and administration of blood and its components.
(Source: P. A. 77‑2724.)

    (215 ILCS 165/15.2) (from Ch. 32, par. 609.2)
    Sec. 15.2.
    No claim shall be denied, under a contract issued or renewed by a voluntary health services plan after the effective date of this Amendatory Act, for treatment or services for mental illness rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P. A. 78‑708.)

    (215 ILCS 165/15.3) (from Ch. 32, par. 609.3)
    Sec. 15.3. (1) No service plan contract of a health service plan corporation which in addition to covering the subscriber, also covers members of the subscriber's immediate family, shall contain any disclaimer, waiver, or other limitation of coverage relative to the health service benefits for or insurability of newborn infants of the subscriber from and after the moment of birth.
    (2) Each such contract shall contain a provision stating that the health service benefits applicable for children shall be granted immediately with respect to a newly born child from the moment of birth. The coverage for newly born children shall include coverage of illness, injury, congenital defects, birth abnormalities and premature birth.
    (3) If payment of a specific subscription fee is required to provide coverage for a child, the contract may require that notification of birth of a newly born child must be furnished to the corporation within 31 days after the date of birth in order to have the coverage continue beyond such 31 day period and may require payment of the appropriate fee.
    (4) The requirements of this Section shall apply to all contracts delivered, issued for delivery, renewed, or amended on or after the sixtieth day following the effective date of this Section.
(Source: P.A. 79‑74.)

    (215 ILCS 165/15.4) (from Ch. 32, par. 609.4)
    Sec. 15.4. (1) No service plan contract of a health service plan corporation which in addition to covering the subscriber, also covers the subscriber's spouse shall contain a provision for termination of coverage for a spouse covered under the service plan contract solely as a result of a break in the marital relationship except by reason of an entry of a valid judgment of dissolution of marriage between the parties.
    (2) Every such service plan contract, other than a contract whose continuance is contingent upon continued employment or membership, which contains a provision for termination of coverage of the spouse upon dissolution of marriage shall contain a provision to the effect that upon the entry of a valid judgment of dissolution of marriage between the covered parties the spouse whose marriage was dissolved shall be entitled to have issued to her or him, without evidence of insurability, and upon application made to the corporation within 60 days following the entry of such judgment, upon the payment of the appropriate subscription fee, an individual service plan contract. Such contract shall provide the coverage then being issued by the corporation which is most nearly similar to, but not greater than, such terminated coverage. Any and all probationary or waiting periods set forth in the conversion contract shall be considered as being met to the extent coverage was in force under the prior contract.
    (3) The requirements of this Section shall apply to all contracts delivered, issued for delivery, renewed, or amended on or after the 60th day following the effective date of this Section.
(Source: P.A. 81‑230.)

    (215 ILCS 165/15.5) (from Ch. 32, par. 609.5)
    Sec. 15.5. Conversion Privilege‑Group Type Contracts.
    (1) Every service plan contract of a health service plan corporation which provides that the continued coverage of a beneficiary is contingent upon the continued employment or membership of the subscriber with a particular employer, union, or association shall further provide for the right of said person to make application for an individual service plan contract under the circumstances and in accordance with the requirements set forth in Sections 367e and 367e.1 of the "Illinois Insurance Code". The application of Sections 367e and 367e.1 of the Code shall not be construed in such a manner as to require a health service plan corporation to furnish a service or kind of benefit not customarily provided by such corporation and which is inconsistent with the provision of this Act.
    (2) The requirements of this Section shall apply to all such contracts delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this Section.
(Source: P.A. 93‑477, eff. 1‑1‑04.)

    (215 ILCS 165/15.6‑1) (from Ch. 32, par. 609.6‑1)
    Sec. 15.6‑1. Continuance privilege ‑ Group type contacts. (1) Every service plan contract of a health service plan corporation which provides that the continued coverage of a beneficiary is contingent upon the continued employment of the subscriber with a particular employer shall further provide for the continuance of such contract in accordance with the requirements set forth in Section 367.2 of the "Illinois Insurance Code", approved June 29, 1937, as amended.
    (2) The requirements of this Section shall apply to all such contracts delivered, issued for delivery, renewed or amended on or after the effective date of this amendatory Act of 1985.
(Source: P.A. 84‑556.)

    (215 ILCS 165/15.7) (from Ch. 32, par. 609.7)
    Sec. 15.7. No claim shall be denied, under a contract issued or renewed by a voluntary health services plan after the effective day of this amendatory Act, for treatment or services for rehabilitation following either a physical or mental illness, rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P.A. 79‑303; 79‑1454.)

    (215 ILCS 165/15.8) (from Ch. 32, par. 609.8)
    Sec. 15.8. Sexual assault or abuse victims.
    (1) Policies, contracts or subscription certificates issued by a health services plan corporation, which provide benefits for hospital or medical expenses based upon the actual expenses incurred, shall to the full extent of coverage provided for any other emergency or accident care, provide for the payment of actual expenses incurred, without offset or reduction for benefit deductibles or co‑insurance amounts, in the examination and testing of a victim of an offense defined in Sections 12‑13 through 12‑16 of the Criminal Code of 1961, as now or hereafter amended, or attempt to commit such offense, to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense.
    (2) For purposes of enabling the recovery of State Funds, any health services plan corporation subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its insureds or subscribers entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay, hospital or medical expenses for which a health care service corporation is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section.
    (3) Whenever the Department of Public Health finds that it has paid all or part of any hospital or medical expenses which a health services plan corporation is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such corporation provided that the Department of Public Health has notified the corporation of its claims before the corporation has paid such benefits to its subscribers or in behalf of its subscribers.
(Source: P.A. 89‑187, eff. 7‑19‑95.)

    (215 ILCS 165/15.9) (from Ch. 32, par. 609.9)
    Sec. 15.9. Coverage of services for mental illness. To the extent not inconsistent with this Act every Health Service Corporation shall be subject to the provisions of Section 370c of the "Illinois Insurance Code", approved June 29, 1937, as amended.
(Source: P.A. 81‑1509.)

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Statutes > Illinois > Chapter215 > 1276

    (215 ILCS 165/1) (from Ch. 32, par. 595)
    Sec. 1. This Act may be cited as the Voluntary Health Services Plans Act.
(Source: P.A. 86‑1475.)

    (215 ILCS 165/2)(from Ch. 32, par. 596)
    Sec. 2. For the purposes of this Act, the following terms have the respective meanings set forth in this section, unless different meanings are plainly indicated by the context:
    (a) "Health Services Plan Corporation" means a corporation organized under the terms of this Act for the purpose of establishing and operating a voluntary health services plan and providing other medically related services.
    (b) "Voluntary health services plan" means either a plan or system under which medical, hospital, nursing and relating health services may be rendered to a subscriber or beneficiary at the expense of a health services plan corporation, or any contractual arrangement to provide, either directly or through arrangements with others, dental care services to subscribers and beneficiaries.
    (c) "Subscriber" means a natural person to whom a subscription certificate has been issued by a health services plan corporation. Persons eligible under Section 5‑2 of the Illinois Public Aid Code may be subscribers if a written agreement exists, as specified in Section 25 of this Act, between the Health Services Plan Corporation and the Department of Healthcare and Family Services. A subscription certificate may be issued to such persons at no cost.
    (d) "Beneficiary" means a person designated in a subscription certificate as one entitled to receive health services.
    (e) "Health services" means those services ordinarily rendered by physicians licensed in Illinois to practice medicine in all of its branches, by podiatrists licensed in Illinois to practice podiatric medicine, by dentists and dental surgeons licensed to practice in Illinois, by nurses registered in Illinois, by dental hygienists licensed to practice in Illinois, and by assistants and technicians acting under professional supervision; it likewise means hospital services as usually and customarily rendered in Illinois, and the compounding and dispensing of drugs and medicines by pharmacists and assistant pharmacists registered in Illinois.
    (f) "Subscription certificate" means a certificate issued to a subscriber by a health services plan corporation, setting forth the terms and conditions upon which health services shall be rendered to a subscriber or a beneficiary.
    (g) "Physician rendering service for a plan" means a physician licensed in Illinois to practice medicine in all of its branches who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish medical service to the plan's subscribers and beneficiaries.
    (h) "Dentist or dental surgeon rendering service for a plan" means a dentist or dental surgeon licensed in Illinois to practice dentistry or dental surgery who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish dental or dental surgical services to the plan's subscribers and beneficiaries.
    (i) "Director" means the Director of Insurance of the State of Illinois.
    (j) "Person" means any of the following: a natural person, corporation, partnership or unincorporated association.
    (k) "Podiatrist or podiatric surgeon rendering service for a plan" means any podiatrist or podiatric surgeon licensed in Illinois to practice podiatry, who has undertaken or agreed, upon terms and conditions acceptable both to himself and to the health services plan corporation involved, to furnish podiatric or podiatric surgical services to the plan's subscribers and beneficiaries.
(Source: P.A. 95‑331, eff. 8‑21‑07.)

    (215 ILCS 165/3) (from Ch. 32, par. 597)
    Sec. 3. It shall be unlawful for any person, except a health services plan corporation, incorporated under this Act, to establish, maintain or operate a voluntary health services plan. This prohibition, however, shall not be construed as preventing a person from furnishing health services to his employees or from furnishing such medical services as are required under the workers' compensation laws and related legislation, when the employees are not charged for such services; nor shall it be construed to prohibit an insurance company, or other corporation or society, which is subject to the supervision of the Director from operating in accordance with the laws governing insurance companies or such corporations or societies; nor shall it be construed to prohibit the continued operation of any medical or health service plan in existence and functioning at the effective date of this Act.
(Source: P.A. 88‑364.)

    (215 ILCS 165/3.1) (from Ch. 32, par. 597.1)
    Sec. 3.1. No new plans may be chartered. No voluntary health services plan shall be issued a charter for the purpose of doing business under this Act after the effective date of this Amendatory Act of 1989.
(Source: P.A. 86‑600.)

    (215 ILCS 165/4) (from Ch. 32, par. 598)
    Sec. 4. Five or more persons of legal age all of whom are residents of Illinois and citizens of the United States may incorporate under the provisions of this Act a health services plan corporation for the purpose of establishing and operating a voluntary health services plan. Such corporation shall be subject to regulation and supervision by the Director as hereinafter provided, but shall not be subject to the laws of this state with respect to insurance corporations except as provided in this Act.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/5) (from Ch. 32, par. 599)
    Sec. 5. The business and affairs of a health services plan corporation shall be managed by a board of trustees, which shall have the power to adopt, and to amend from time to time, by‑laws governing the conduct of the corporation's business. The board of trustees shall consist of not less than seven persons, all of whom shall have the same general qualifications as the incorporators, and at least 30% of whom shall, in addition, be physicians or dentists, licensed in Illinois to practice medicine in all of its branches or dentistry, respectively; provided, however, that if in computing the required number of physicians or dentists on the board of trustees, the amount of 30% does not coincide with a whole number, but lies between whole numbers, the smaller whole number shall be controlling as to the number of physicians or dentists. The original board of trustees shall be appointed by the incorporators. Trustees shall serve for a term of three years, except that as to the original appointed board, not more than one‑third of the members thereof shall be appointed for three years, not more than one‑third thereof for two years and the balance thereof for one year. As the terms of the members of the board of trustees expire, they shall be replaced, from time to time, by election by the health services plan subscribers who are members of the health services plan corporation. If the corporation furnishes medical services to the plan's subscribers and beneficiaries and these services are rendered by physicians licensed in Illinois to practice medicine in all of its branches, the board of trustees shall appoint a Medical Director who shall be a physician licensed in Illinois to practice medicine in all of its branches. The Medical Director may participate in all deliberations of the board of trustees but shall not vote in any decisions or determinations made by the board of trustees. The Medical Director, under the board of trustees, shall have complete charge of and responsibility for the medical and medically related scientific aspects of the business of the corporation.
(Source: P.A. 81‑1203.)

    (215 ILCS 165/6) (from Ch. 32, par. 600)
    Sec. 6. A health services plan corporation may, in the discretion of its board of trustees, through its by‑laws, limit or define the classes of persons who shall be eligible to become subscribers or beneficiaries, limit and define the benefits which it will furnish, and may divide such benefits as it undertakes to furnish into classes or kinds.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/7) (from Ch. 32, par. 601)
    Sec. 7. Every physician licensed in Illinois to practice medicine in all of its branches, every podiatrist licensed to practice podiatric medicine in Illinois, and every dentist and dental surgeon licensed to practice in Illinois may be eligible to render medical, podiatric or dental services respectively, upon such terms and conditions as may be mutually acceptable to such physician, podiatrist, dentist or dental surgeon and to the health services plan corporation involved. Such a corporation shall impose no restrictions on the physicians, podiatrists, dentists or dental surgeons who treat its subscribers as to methods of diagnosis or treatment. The private physician‑patient relationship shall be maintained, and subscribers shall at all times have free choice of any physician, podiatrist, dentist or dental surgeon who is rendering service on behalf of the corporation. All of the records, charts, files and other data of a health services plan corporation pertaining to the condition of health of its subscribers and beneficiaries shall be and remain confidential, and no disclosure of the contents thereof shall be made by the corporation to any person, except upon the prior written authorization of the particular subscriber or beneficiary concerned.
(Source: P.A. 81‑1456.)

    (215 ILCS 165/8) (from Ch. 32, par. 602)
    Sec. 8. Except as otherwise provided by Section 3 of this Act, no person shall offer to the public any voluntary health service plan or otherwise engage in the business of a health service plan corporation without having first received a charter from the Director. No charter under this Act shall be approved by the Director for any organization seeking to provide medical or hospital services unless the organization files a concomitant application for a certificate of authority, and is approved by the Director, as a health maintenance organization pursuant to the requirements of the Health Maintenance Organization Act. Application therefor shall be made to the Director upon forms prescribed by him and shall include the following information:
    (a) The names, places of residence, occupations, and qualifications of the incorporators;
    (b) The location of the corporation's registered office, and the name and address of its registered agent;
    (c) A detailed financial statement, including the amount of original capital to be contributed to the corporation before it shall commence doing business, as well as the name of each contributor, and the amount by him contributed and the terms of such contribution;
    (d) A copy of the by‑laws to be adopted by the board of trustees upon the issuance of a charter;
    (e) Specimen copies of all subscription certificates which it is proposed the corporation shall issue to subscribers, which certificates shall set forth in detail the rates to be charged subscribers and the nature and extent of the services which the subscriber or other beneficiary shall be entitled to receive;
    (f) A detailed statement as to the health services plan or plans which the corporation proposes to offer, including the rates to be charged, the benefits to be provided and the names of the counties in which it is proposed the corporation shall have authority to engage in business;
    (g) A copy of the proposed charter under which the corporation intends to operate.
    (h) Specimen copies of all agreements to be entered into between the corporation and hospitals, physicians, dentists, pharmacists and nurses, which agreements shall set forth in detail the terms and conditions upon which each shall be obliged to render service to subscribers of the corporations.
    After consideration of the statements and documents submitted to him and such additional investigation as he deems necessary, the Director shall issue a charter to the applicant corporation if he finds:
    (1) The corporation has complied with the requirements of this Act,
    (2) The subscription certificates to be offered by the corporation and its methods of operation would not work a fraud on the subscriber,
    (3) The rates to be charged and the benefits to be provided are fair and reasonable to both the subscriber and to the corporation,
    (4) The amount of money actually available for original capital is sufficient to carry all acquisition costs and operating expenses for a reasonable period of time from the issuance of the charter and is not less than the minimum requirements set forth in subsection (5) of Section 8 of this Act.
    (5) The amounts contributed as original capital of the corporation shall aggregate not less than $100,000 at the start of business.
    (6) Adequate and reasonable reserves are provided to insure the contracts; and
    (7) The corporation has contracts or agreements with hospitals, physicians, dentists, pharmacists, nurses and dental hygienists sufficient in number to carry out the terms of the contracts to be issued to these subscribers.
    Amendments to a charter shall be made by application to the Director in the same manner as on original application.
(Source: P.A. 85‑1246.)

    (215 ILCS 165/9) (from Ch. 32, par. 603)
    Sec. 9. After the issuance of a charter, the Director as he deems in the public interest may authorize or require a health services plan corporation to charge rates or to utilize soliciting methods different from those on which the charter was based, provided that such contracts and practices are in compliance with provisions of this Act and are not violative of other laws of this State.
    The Director may revoke or amend, after reasonable notice and hearing, any charter, certificates, order, authority or consent made by him to a health services plan corporation on having found (1) that the further solicitation of subscribers or further continuance of the practices in question will work a fraud on subscribers, or (2) that the rates charged or the benefits provided are not fair and reasonable to both the subscriber and the corporation.
(Source: Laws 1951, p. 569.)

    (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, 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, 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. 95‑189, eff. 8‑16‑07; 95‑331, eff. 8‑21‑07; 95‑422, eff. 8‑24‑07; 95‑520, eff. 8‑28‑07; 95‑876, eff. 8‑21‑08; 95‑958, eff. 6‑1‑09; 95‑978, eff. 1‑1‑09; 95‑1005, eff. 12‑12‑08; 95‑1045, eff. 3‑27‑09; 95‑1049, eff. 1‑1‑10; 96‑328, eff. 8‑11‑09; 96‑833, eff. 6‑1‑10; 96‑1000, eff. 7‑2‑10.)

    (215 ILCS 165/11) (from Ch. 32, par. 605)
    Sec. 11. Examination of corporations. The Director shall have with respect to health services plan corporations the powers of examination conferred upon him relative to insurance companies by Sections 132 through 132.7 of the Illinois Insurance Code. The cost of any examination shall be paid by the corporation examined.
(Source: P.A. 89‑97, eff. 7‑7‑95.)

    (215 ILCS 165/12) (from Ch. 32, par. 606)
    Sec. 12. All rates or formula base for experience rate subscriber contracts shall be submitted to the Director prior to use. The Director may disapprove rates or formula base for rates for specific reason and must do so within 45 days of receipt of supporting information or rates will be deemed approved.
(Source: P.A. 81‑1203.)

    (215 ILCS 165/13) (from Ch. 32, par. 607)
    Sec. 13. No subscription certificate shall be issued by any health services plan corporation until the form thereof has been filed with and approved by the Director, together with all applications, riders and endorsements for use in connection with the issuance or renewal thereof. It shall be the duty of the Director of Insurance to withhold approval of any contract form filed with him if it violates any provisions of this Act, or if it violates or is contrary to any provisions of Sections 143, 355, and 355a of the "Illinois Insurance Code", approved June 29, 1937, as amended, which are not inconsistent or in conflict with provisions of this Act.
(Source: P.A. 79‑681.)

    (215 ILCS 165/14) (from Ch. 32, par. 608)
    Sec. 14. Every subscription certificate issued by a health services plan corporation shall provide for the rendering of health services as therein specified for a period of 12 months from the date of issuance of the subscription certificate subject to compliance with the by‑laws and rules and regulations of the corporation by the subscriber. Any such certificate may provide that it shall ordinarily be renewed from year to year unless there has been one month's written notice of termination either by the subscriber or by the corporation. During the first contract year the provisions of the contract may provide that the coverage by the contract may be deferred for not more than two months from date of issue of the contract and may exclude treatment for illness or other conditions requiring service existing at the time of executing the contract.
(Source: Laws 1951, p. 569.)

    (215 ILCS 165/15) (from Ch. 32, par. 609)
    Sec. 15.
    Every contract entered into by a health services plan corporation and a subscriber shall be in writing and a certificate stating the terms and conditions thereof shall be furnished the subscriber. No such subscription certificate shall be issued unless it contains the following provisions:
    (a) A statement of the nature of the health services to be provided and the period during which the certificate shall be effective; and if there are any types of services to be excepted, a detailed statement of such exceptions printed as hereinafter specified;
    (b) A statement of the terms or conditions, if any, upon which the certificate may be cancelled or otherwise terminated at the option of either party;
    (c) A statement that the subscription certificate constitutes the entire contract between the corporation and the subscriber and includes any endorsements attached;
    (d) A statement that no statement by the subscriber in his application for a certificate shall void the contract or be used in any legal proceeding thereunder, unless such application or an exact copy thereof is included in or attached to the certificate, and that no agent or representative of such corporation other than an officer or officers designated in the certificate, are authorized to change the contract or waive any of its provisions;
    (e) A statement that if the subscriber defaults in making any payment under the certificate, the subsequent acceptance of a payment by the corporation or by one of its duly authorized agents shall reinstate the certificate, but with respect to sickness and injury may cover only such sickness or injury as may be first manifested more than a specified number of days, not exceeding ten, after the date of such acceptance;
    (f) A statement of the period of grace which will be allowed the subscriber for making any payment due under the contract. Such period shall not be less than ten days;
    (g) A statement that indemnity in the form of cash will not be paid to any subscriber except in reimbursement for payments made by the subscriber to a physician, dentist or dental surgeon for which the subscriber had received express authorization by the corporation and for which the corporation was liable at the time of such payment.
    (h) Every voluntary health services plan and each subscription certificate issued by a health services plan corporation and providing coverage for hospital treatment shall provide coverage for treatment of alcoholism in a hospital licensed under the Hospital Licensing Act approved July 1, 1953 as amended or an approved public or private alcoholism treatment facility meeting the standards prescribed in Section 9 (1) of the Uniform Alcoholism and Intoxication Treatment Act enacted by the 78th General Assembly and approved under Section 9 (3) of the Uniform Alcoholism and Intoxication Treatment Act enacted by the 78th General Assembly.
(Source: P. A. 78‑767.)

    (215 ILCS 165/15.1) (from Ch. 32, par. 609.1)
    Sec. 15.1.
    No contract issued by a voluntary health services plan shall contain any exception or exclusion from coverage which would preclude the payment of expenses incurred for the processing and administration of blood and its components.
(Source: P. A. 77‑2724.)

    (215 ILCS 165/15.2) (from Ch. 32, par. 609.2)
    Sec. 15.2.
    No claim shall be denied, under a contract issued or renewed by a voluntary health services plan after the effective date of this Amendatory Act, for treatment or services for mental illness rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P. A. 78‑708.)

    (215 ILCS 165/15.3) (from Ch. 32, par. 609.3)
    Sec. 15.3. (1) No service plan contract of a health service plan corporation which in addition to covering the subscriber, also covers members of the subscriber's immediate family, shall contain any disclaimer, waiver, or other limitation of coverage relative to the health service benefits for or insurability of newborn infants of the subscriber from and after the moment of birth.
    (2) Each such contract shall contain a provision stating that the health service benefits applicable for children shall be granted immediately with respect to a newly born child from the moment of birth. The coverage for newly born children shall include coverage of illness, injury, congenital defects, birth abnormalities and premature birth.
    (3) If payment of a specific subscription fee is required to provide coverage for a child, the contract may require that notification of birth of a newly born child must be furnished to the corporation within 31 days after the date of birth in order to have the coverage continue beyond such 31 day period and may require payment of the appropriate fee.
    (4) The requirements of this Section shall apply to all contracts delivered, issued for delivery, renewed, or amended on or after the sixtieth day following the effective date of this Section.
(Source: P.A. 79‑74.)

    (215 ILCS 165/15.4) (from Ch. 32, par. 609.4)
    Sec. 15.4. (1) No service plan contract of a health service plan corporation which in addition to covering the subscriber, also covers the subscriber's spouse shall contain a provision for termination of coverage for a spouse covered under the service plan contract solely as a result of a break in the marital relationship except by reason of an entry of a valid judgment of dissolution of marriage between the parties.
    (2) Every such service plan contract, other than a contract whose continuance is contingent upon continued employment or membership, which contains a provision for termination of coverage of the spouse upon dissolution of marriage shall contain a provision to the effect that upon the entry of a valid judgment of dissolution of marriage between the covered parties the spouse whose marriage was dissolved shall be entitled to have issued to her or him, without evidence of insurability, and upon application made to the corporation within 60 days following the entry of such judgment, upon the payment of the appropriate subscription fee, an individual service plan contract. Such contract shall provide the coverage then being issued by the corporation which is most nearly similar to, but not greater than, such terminated coverage. Any and all probationary or waiting periods set forth in the conversion contract shall be considered as being met to the extent coverage was in force under the prior contract.
    (3) The requirements of this Section shall apply to all contracts delivered, issued for delivery, renewed, or amended on or after the 60th day following the effective date of this Section.
(Source: P.A. 81‑230.)

    (215 ILCS 165/15.5) (from Ch. 32, par. 609.5)
    Sec. 15.5. Conversion Privilege‑Group Type Contracts.
    (1) Every service plan contract of a health service plan corporation which provides that the continued coverage of a beneficiary is contingent upon the continued employment or membership of the subscriber with a particular employer, union, or association shall further provide for the right of said person to make application for an individual service plan contract under the circumstances and in accordance with the requirements set forth in Sections 367e and 367e.1 of the "Illinois Insurance Code". The application of Sections 367e and 367e.1 of the Code shall not be construed in such a manner as to require a health service plan corporation to furnish a service or kind of benefit not customarily provided by such corporation and which is inconsistent with the provision of this Act.
    (2) The requirements of this Section shall apply to all such contracts delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this Section.
(Source: P.A. 93‑477, eff. 1‑1‑04.)

    (215 ILCS 165/15.6‑1) (from Ch. 32, par. 609.6‑1)
    Sec. 15.6‑1. Continuance privilege ‑ Group type contacts. (1) Every service plan contract of a health service plan corporation which provides that the continued coverage of a beneficiary is contingent upon the continued employment of the subscriber with a particular employer shall further provide for the continuance of such contract in accordance with the requirements set forth in Section 367.2 of the "Illinois Insurance Code", approved June 29, 1937, as amended.
    (2) The requirements of this Section shall apply to all such contracts delivered, issued for delivery, renewed or amended on or after the effective date of this amendatory Act of 1985.
(Source: P.A. 84‑556.)

    (215 ILCS 165/15.7) (from Ch. 32, par. 609.7)
    Sec. 15.7. No claim shall be denied, under a contract issued or renewed by a voluntary health services plan after the effective day of this amendatory Act, for treatment or services for rehabilitation following either a physical or mental illness, rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P.A. 79‑303; 79‑1454.)

    (215 ILCS 165/15.8) (from Ch. 32, par. 609.8)
    Sec. 15.8. Sexual assault or abuse victims.
    (1) Policies, contracts or subscription certificates issued by a health services plan corporation, which provide benefits for hospital or medical expenses based upon the actual expenses incurred, shall to the full extent of coverage provided for any other emergency or accident care, provide for the payment of actual expenses incurred, without offset or reduction for benefit deductibles or co‑insurance amounts, in the examination and testing of a victim of an offense defined in Sections 12‑13 through 12‑16 of the Criminal Code of 1961, as now or hereafter amended, or attempt to commit such offense, to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense.
    (2) For purposes of enabling the recovery of State Funds, any health services plan corporation subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its insureds or subscribers entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay, hospital or medical expenses for which a health care service corporation is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section.
    (3) Whenever the Department of Public Health finds that it has paid all or part of any hospital or medical expenses which a health services plan corporation is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such corporation provided that the Department of Public Health has notified the corporation of its claims before the corporation has paid such benefits to its subscribers or in behalf of its subscribers.
(Source: P.A. 89‑187, eff. 7‑19‑95.)

    (215 ILCS 165/15.9) (from Ch. 32, par. 609.9)
    Sec. 15.9. Coverage of services for mental illness. To the extent not inconsistent with this Act every Health Service Corporation shall be subject to the provisions of Section 370c of the "Illinois Insurance Code", approved June 29, 1937, as amended.
(Source: P.A. 81‑1509.)


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