Illinois § 355.7

§ 355.7.

Medical loss ratio report and premium rebate. (a) A health insurance issuer offering group or individual health insurance coverage, including a grandfathered health plan, shall, with respect to each plan year, submit to the Director a report concerning the ratio of the incurred loss or incurred claims plus the loss adjustment expense or change in contract reserves to earned premiums. The report shall include the percentage of total premium revenue, after accounting for collections or receipts for risk adjustment and risk corridors and payments of reinsurance, that such coverage expends: (1) on reimbursement for clinical services provided to enrollees under such coverage; (2) for activities that improve health care quality; and (3) on all other non-claims costs, including an explanation of the nature of such costs, and excluding federal and State taxes and licensing or regulatory fees. (b) A health insurance issuer shall comply with subsection (a) by filing with the Director a copy of the report submitted to the United States Department of Health and Human Services under 42 U.S.C. 300gg-18, which must comply with federal regulations promulgated thereunder. The Department shall make the reports received under this Section available to the public on its website. (c) If 42 U.S.C. 300gg-18 or the federal regulations promulgated thereunder are amended after January 15, 2025 to repeal the reporting or rebate requirements, reduce the amount or types of information required to be reported, or adopt a calculation method that reduces the amount of rebates in this State, a health insurance issuer shall file a supplemental report with the Director or make supplemental rebate payments, as applicable, for group or individual health insurance coverage regulated by this State to ensure that the same total information is filed with the Director and the same total rebates are remitted to enrollees as before the federal repeal, reduction, or recalculation took effect. (d) Notwithstanding any other provision of this Section, under no circumstances may the costs described in paragraphs (1) and (2) of subsection (a) include: (1) executive compensation beyond base salary; (2) entity surplus or accumulated profit; or (3) costs attendant with an application for lifestyle management, weight loss, or wellness when the application falls outside the scope of 45 CFR 158.140 through 158.160. (e) This Section does not apply with respect to any policy of excepted benefits as defined under 42 U.S.C. 300gg-91. (f) Notwithstanding anything in this Section to the contrary, this Section does not apply to policies issued or delivered in this State that provide medical assistance under the Illinois Public Aid Code or the Children's Health Insurance Program Act. (Source: P.A. 104-28, eff. 1-1-26.)