Illinois Compiled Statutes
215 ILCS 5/ - Illinois Insurance Code.
Article XXXI 1/4 - Third Party Administrators

(215 ILCS 5/Art. XXXI.25 heading)

 
(215 ILCS 5/511.100) (from Ch. 73, par. 1065.58-100)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.100.
Purpose.
The purpose of this Article is to recognize and
provide reasonable public supervision and licensing of persons who provide
administrative services in connection with insurance or alternatives to
insurance.

(Source: P.A. 84-887.)
 
(215 ILCS 5/511.101) (from Ch. 73, par. 1065.58-101)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.101. Definitions. For the purpose of this Article:
(a) "Administrator" means any person who on behalf of a plan sponsor or
insurer receives or collects charges, contributions or premiums for, or
adjusts or settles claims on residents of this State in connection with
any type of life or accident or health benefit provided through or as an
alternative to insurance within the scope of Class 1(a), 1(b) or 2(a) of
Section 4 of this Code, other than any of the following:
(b) "Covered Individual" means any individual eligible for life or accident
or health benefits under a plan.
(c) "Contributions" means any money charged a covered individual, plan
sponsor or other entity to fund the self-insured portion of any plan in
accordance with written provisions of the plan or contracts of insurance.
Contributions shall include administrative fees charged to a covered
individual. Administrative fee means any compensation paid by a covered
individual for services performed by the administrator.
(d) "Premiums" means any money charged a covered individual, plan sponsor
or other entity to provide life or accident or health insurance under a
plan. The term premium shall include amounts paid by or charged to a covered
individual plan sponsor or other entity for stop loss or excess insurance.
(e) "Charges" means any compensation paid by a plan sponsor or insurer
for services performed by the administrator.
(f) "Administrator Trust Fund", hereinafter referred to as "ATF", means
a special fiduciary account established and maintained by an administrator
pursuant to Section 511.112 in which contributions and premiums are deposited.
(g) "Claims Administration Services Account", hereinafter referred to
as "CASA", means a special fiduciary account established and maintained
by an administrator pursuant to Section 511.112 of this Code from which
claims and claims adjustment expenses are disbursed.
(h) "Plan Sponsor" means any person other than an insurer, who establishes
or maintains a plan covering residents of this State, including but not
limited to plans established or maintained by 2 or more employers or
jointly by one or more employers and one or more employee organizations,
the association, committee, joint board of trustees, or other similar group
of representatives of the parties who establish or maintain the plan.
Provided, however, that "Plan Sponsor" shall not include:
No plan sponsor covered in whole by provisions of the Employee Retirement
Income Security Act of 1974 (ERISA) shall be covered by any of the
provisions of this Act to the extent that such provisions are inconsistent
with or in conflict with any provisions of ERISA as now or hereafter amended.
(i) "Financial Institution" means any federal or state chartered bank
or savings and loan institution which is insured by the Federal Deposit
Insurance Corporation (FDIC) or the Federal Savings and Loan Insurance
Corporation (FSLIC).
(j) "Plan" means any plan, fund or program established or maintained by
a plan sponsor or insurer to the extent that such plan, fund or program
was established or is maintained to provide through insurance or alternatives
to insurance any type of life or accident or health benefit within the scope
of Class 1(a), 1(b) or 2(a) of Section 4 of the Illinois Insurance Code.
(k) "Insurer" means any person who transacts insurance or health care
service business authorized under the laws of this State.
(l) "Quasi-resident" means a nonresident licensee who produces 50% or
more of his contributions and premium volume during a calendar year from
residents of this State.

(Source: P.A. 101-108, eff. 1-1-20.)
 
(215 ILCS 5/511.102) (from Ch. 73, par. 1065.58-102)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.102.
License required.
(a) No person may act as or hold
himself out to be an administrator after July 1, 1986 unless duly licensed
in accordance with this Article. An administrator doing business in this
State on July 1, 1986 shall apply for a license within 90 days thereafter.
(b) In addition to any other penalty set forth in this Article, any person
violating subsection (a) above is guilty of a Class A misdemeanor.

(Source: P.A. 84-887.)
 
(215 ILCS 5/511.103) (from Ch. 73, par. 1065.58-103)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.103.
Application.
The applicant for a license shall file
with the Director an application upon a form prescribed by the Director,
which shall include or have attached the following:
(Source: P.A. 93-32, eff. 7-1-03.)
 
(215 ILCS 5/511.104) (from Ch. 73, par. 1065.58-104)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.104.
Bond requirements for administrators.
(a) Every applicant
for an administrator's license shall file with the application and shall
thereafter maintain in force while so licensed, a fidelity bond in favor
of the people of the State of Illinois executed by a surety company and
payable to any party injured under the terms of the bond. The bond shall
be continuous in form and in one of the following amounts:
Such bond is required of an administrator who maintains or should maintain
funds in a fiduciary capacity as set forth in Section 511.112 of this Code
unless the administrator is contracted with the insurer as an
administrator and if the plan is fully insured by the insurer on whose
behalf the funds are held.
(b) Such bond shall remain in force and effect until the surety is
released from liability by the Director or until the bond is cancelled by
the surety. The surety may cancel the bond and be released from further
liability thereunder upon 30 days' written notice in advance to the
Director. Such cancellation shall not affect any liability incurred or
accrued thereunder before the termination of the 30-day period. Upon
receipt of any notice of cancellation, the Director shall immediately notify
the licensee.
(c) The license required by Section 511.102 shall automatically
terminate if the bond required by this Section is not in force. Within 30
days thereafter, the administrator shall return the license to the Director
for cancellation.

(Source: P.A. 84-1431.)
 
(215 ILCS 5/511.105) (from Ch. 73, par. 1065.58-105)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.105.
License.
(a) The Director shall cause a license to be
issued to each applicant that has demonstrated to the Director's satisfaction
compliance with the requirements of this Article.
(b) Each administrator license shall remain in effect as long as the holder
of the license maintains in force and effect the bond required by Section
511.104 and pays the annual fee of $200 prior to the anniversary
date of
the license, unless the license is revoked or suspended pursuant to Section
511.107.
(c) Each license shall contain the name, business address and
identification number of the licensee, the date the license was issued and
any other information the Director considers proper.

(Source: P.A. 93-32, eff. 7-1-03.)
 
(215 ILCS 5/511.106) (from Ch. 73, par. 1065.58-106)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.106.
Administrator requirements.
(a) Each administrator shall
identify to the Director any ownership interest or affiliation of any kind
with any plan sponsor or insurer responsible directly or through reinsurance
for providing benefits to any plan for which it provides services as an administrator.
(b) An administrator shall provide services as an administrator pursuant
to a written agreement. The written agreement shall be between the administrator
and the plan sponsor or insurer and shall be retained as part of the official
records of the administrator for the duration of said agreement and for
5 years thereafter.
(c) An administrator shall maintain in its principal office for the duration
of the written agreement with any plan sponsor or insurer and for 5 years
thereafter adequate books and records of all transactions involving a plan
sponsor or insurer and covered individuals or beneficiaries. Such books and
records shall be maintained in accordance with generally accepted standards
of business recordkeeping. An administrator is not required to maintain
copies of books and records if such originals are returned to the plan sponsor
or insurer prior to the end of such 5 year period. The administrator shall
maintain evidence of the return of the originals for the balance of the 5 year period.
(d) The administrator shall file with the Director the names and addresses
of the insurers and plan sponsors with whom the administrator has written
agreements. If an insurer or plan sponsor does not assume or bear the risk,
the administrator must disclose the name and address of the ultimate risk
bearer. This filing requirement shall apply to the initial application
for an administrator's license and the renewal of such license.
(e) An administrator shall use only advertising pertaining to the plan which
has been approved in advance by the plan sponsor or insurer.
(f) Upon receipt of instructions from the plan sponsor or insurer, an
administrator shall deliver promptly to covered individuals or beneficiaries
all policies, certificate booklets, termination notices or other written communications.
(g) An administrator shall not receive compensation from a plan sponsor
or insurer which is contingent upon the loss ratio of the plan. This subsection
shall not, however, prevent the administrator from engaging in cost containment
activities with a plan sponsor or insurer.
(h) An administrator shall not receive from any plan sponsor, insurer,
covered individual or beneficiary under a plan any compensation or other
payments except as expressly set forth in the written agreement between
the administrator and the plan sponsor or insurer.
(i) Upon request of the Director, an administrator shall make available
for examination, either in the City of Springfield or at the licensee's
principal place of business, all basic organizational documents including
but not limited to articles of incorporation, articles of association, partnership
agreement, trade name certificate, trust agreement, shareholder agreement
and other applicable documents and all amendments thereto, bylaws, rules
and regulations or similar documents regulating the conduct of its internal affairs.

(Source: P.A. 84-887.)
 
(215 ILCS 5/511.107) (from Ch. 73, par. 1065.58-107)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.107.
License suspension, revocation or denial.
(a) Any license
issued under this Article may be suspended or revoked, after notice to the
licensee and an opportunity for hearing, and any application for a license
may be denied, after notice and an opportunity for hearing, if the Director
finds that the licensee or applicant:
(b) Denial of an application or suspension or revocation of a license,
pursuant to this Section shall be by written order sent to the applicant
or licensee by certified or registered mail at the address specified in
the records of the Department. The written order shall state the grounds,
charges or conduct on which denial, suspension or revocation is based.
The applicant or licensee may in writing request a hearing within 30 days
from the date of mailing. Upon receipt of a written request, the Director
shall issue an order setting (i) a specific time for the hearing, which
may not be less than 20 nor more than 30 days after receipt of the request
and (ii) a specific place for the hearing, which may be in either the City
of Springfield or in the county in Illinois where the applicant's or licensee's
principal place of business is located. If no written request is received
by the Director, such order shall be final upon the expiration of said 30 days.
(c) Upon revocation of a license, the licensee or other person having
possession or custody of such license shall deliver it to the Director
in person or by mail within 30 days of such revocation.
(d) Any administrator whose license is revoked or whose application is
denied pursuant to this Section shall be ineligible to reapply for any license
for 2 years. A suspension pursuant to this Section may be for a period
of up to 2 years.

(Source: P.A. 84-887.)
 
(215 ILCS 5/511.108) (from Ch. 73, par. 1065.58-108)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.108. Felony convictions. Any administrator and any individual
listed on the application as required by Section 511.103, who is convicted
of a felony shall report such conviction to the Director within 30 days
of the entry date of the judgment. Within that 30-day
period, the administrator
shall also provide the Director with a copy of the judgment, the probation
or commitment order and any other relevant documents.

(Source: P.A. 96-328, eff. 8-11-09.)
 
(215 ILCS 5/511.109) (from Ch. 73, par. 1065.58-109)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.109.
Examination.
(a) The Director or his designee may examine
any applicant for or holder of an administrator's license.
(b) Any administrator being examined shall provide to the Director or
his designee convenient and free access, at all reasonable hours at their
offices, to all books, records, documents and other papers relating to such
administrator's business affairs.
(c) The Director or his designee may administer oaths and thereafter examine
any individual about the business of the administrator.
(d) The examiners designated by the Director pursuant to this Section
may make reports to the Director. Any report alleging substantive violations
of this Article, any applicable provisions of the Illinois Insurance Code,
or any applicable Part of Title 50 of the Illinois Administrative Code shall
be in writing and be based upon facts obtained by the examiners. The report
shall be verified by the examiners.
(e) If a report is made, the Director shall either deliver a duplicate
thereof to the administrator being examined or send such duplicate by certified
or registered mail to the administrator's address specified in the records
of the Department. The Director shall afford the administrator an opportunity
to request a hearing to object to the report. The administrator may request
a hearing within 30 days after receipt of the duplicate of the examination
report by giving the Director written notice of such request together with
written objections to the report. Any hearing shall be conducted in accordance
with Sections 402 and 403 of this Code. The right to hearing is waived
if the delivery of the report is refused or the report is otherwise
undeliverable or the administrator does not timely request a hearing.
After the hearing or upon expiration of the time period during which an
administrator may request a hearing, if the examination reveals that the
administrator is operating in violation of any applicable provision of the
Illinois Insurance Code, any applicable Part of Title 50 of the Illinois
Administrative Code or prior order, the Director, in the written order, may
require the administrator to take any action the Director considers
necessary or appropriate in accordance with the report or examination
hearing. If the Director issues an order, it shall be issued within 90
days after the report is filed, or if there is a hearing, within 90 days
after the conclusion of the hearing. The order is subject to review under
the Administrative Review Law.

(Source: P.A. 84-887.)
 
(215 ILCS 5/511.110) (from Ch. 73, par. 1065.58-110)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.110.
Administrative fine.
(a) If the Director finds that one
or more grounds exist for the revocation or suspension of a license issued
under this Article, the Director may, in lieu of or in addition to such
suspension or revocation, impose a fine upon the administrator.
(b) With respect to any knowing and wilful violation of a lawful order
of the Director, any applicable portion of the Illinois Insurance Code or
Part of Title 50 of the Illinois Administrative Code, or a provision of
this Article, the Director may impose a fine upon the administrator in an
amount not to exceed $10,000 for each such violation. In no
event shall
such fine exceed an aggregate amount of $50,000 for all knowing
and wilful
violations arising out of the same action.

(Source: P.A. 93-32, eff. 7-1-03.)
 
(215 ILCS 5/511.111) (from Ch. 73, par. 1065.58-111)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.111. Insurance Producer Administration Fund. All fees and fines
paid to and collected by the Director under this Article shall be paid promptly
after receipt thereof, together with a detailed statement of such fees,
into a special fund in the State Treasury to be known as the Insurance Producer
Administration Fund. The monies deposited into the Insurance Producer
Administration Fund shall be used only for payment of the expenses of the
Department and shall be appropriated as otherwise provided by law for the
payment of such expenses. Moneys in the Insurance Producer Administration Fund may be transferred to the Professions Indirect Cost Fund, as authorized under Section 2105-300 of the Department of Professional Regulation Law of the Civil Administrative Code of Illinois.

(Source: P.A. 98-463, eff. 8-16-13.)
 
(215 ILCS 5/511.112) (from Ch. 73, par. 1065.58-112)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.112.
Fiduciary accounts and duties.
(a) Administrators shall
hold in a fiduciary capacity all contributions and premiums received or
collected on behalf of a plan sponsor or insurer. Such funds shall not be
used as general operating funds of the administrator. All contributions
and premiums received or collected by the administrator from residents of
this State, which the Administrator holds more than 15 days or deposits
into an account which is not under the control of the plan sponsor or insurer,
shall be placed in a special fiduciary account, which account shall
be designated an "Administrator
Trust Fund Account" ("ATF"). All resident and quasi-resident licensees
required to maintain an ATF pursuant to this Section shall maintain such
ATF with one or more financial institutions located within the State of
Illinois and subject to jurisdiction of the Illinois courts. Funds
belonging to 2 or more plans may be
held in the same ATF, provided the administrator's records clearly indicate
the funds belonging to each plan. Checks drawn on the ATF shall indicate
on their face that they are drawn on the ATF of the administrator.
(b) The administrator may make the following disbursements from the ATF:
(c) For each plan where an ATF is required, the balance in the ATF shall
at all times be the amount deposited plus accrued interest, if any, less
authorized disbursements. If the balance at the financial institution with
respect to the ATF is less than the amount deposited plus accrued interest,
if any, less authorized disbursements, the administrator shall be deemed
to have misappropriated fiduciary funds and to have acted in a financially
irresponsible manner.
(d) If the ATF is interest bearing or income producing, the full nature
of the account must first be disclosed to the plan sponsors or insurers
on whose behalf the funds are or will be held. The administrator
must secure written consent and authorization from the plan sponsors or
insurers for the investment of the money and disposition of the interest
or earnings. No investment shall be made which assumes any risk other than
the risk that the obligor shall not pay the principal when due.
The use of specialized techniques or strategies which incur additional
risks to generate higher returns or to extend maturities is not permitted.
Such techniques would include, but not be limited to, the following: Use
of financial futures or options, buying on margins and pledging of ATF balances.
(e) Administrators may place ATF funds in interest bearing or income
producing investments and retain the interest or income thereon, providing
the administrator obtains the prior written authorization of the plan
sponsors or insurers on whose behalf the funds are to be held. In addition
to savings and checking accounts, an administrator may invest in the following:
(f) The administrator shall hold in a fiduciary capacity all moneys which
the administrator receives to pay claims and claim adjustment expenses.
All resident and quasi-resident licensees shall
place all such money for claims and claim adjustment
expenses for residents of this State, whether received from a plan sponsor
or insurer or from the ATF of the administrator, in a special fiduciary
account in a financial institution located in this State. The account shall
be designated a "Claims Administration Service Account" ("CASA"). Funds
belonging to 2 or more plans may be held in the same CASA, provided the
administrator's records clearly indicate the funds belonging to each plan.
Checks drawn on the CASA shall indicate on their face that they are drawn
on the CASA of the administrator.
(g) No deposit shall be made into a CASA and no disbursement shall be
made from a CASA except for claims and claims adjustment expenses. For
each plan where a CASA is required, the balance in the CASA shall at all
times be the amount deposited less claims and claims adjustment expenses paid.
If the CASA balance is less than such amount, the administrator shall be
deemed to have misappropriated fiduciary funds and to have acted in a
financially irresponsible manner.
(h)(1) Administrators shall maintain detailed books and records which
reflect all transactions involving the receipt and disbursement of:
(2) The detailed preparation, journalizing and posting of such books and
records must be maintained on a timely basis and all journal entries for
receipts and disbursements shall be supported by evidential matter, which
must be referenced in the journal entry so that it may be traced for
verification. Administrators shall prepare and maintain monthly financial
institution account reconciliations of any ATF and CASA established by the
administrator. The minimum detail required shall be as follows:
(i) Failure to maintain accurately and timely the books and records required
above shall be deemed untrustworthy, hazardous or injurious to participants
in the plan or the public and financially irresponsible.
(j) This Section shall not apply to nonresident administrators who are
subject to substantially similar requirements in their state of domicile.

(Source: P.A. 84-1431.)
 
(215 ILCS 5/511.113) (from Ch. 73, par. 1065.58-113)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.113.
Unauthorized Activities.
Nothing in this Article shall
be construed to permit any person or entity to receive, or collect charges,
contributions or premiums for, or adjust or settle claims in connection with
any type of life or accident or health benefit unless such person or entity
is authorized through the insurance laws of a state or the ERISA of 1974, 29
USC par. 1001 et seq. as amended, to provide such benefits.

(Source: P.A. 84-887.)
 
(215 ILCS 5/511.114)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.114.
Drug formulary; notice.
All administrators must comply
with
Section 155.37 of this Code.

(Source: P.A. 92-440, eff. 8-17-01.)
 
(215 ILCS 5/511.118)
(Section scheduled to be repealed on January 1, 2027)
Sec. 511.118.
Managed Care Reform and Patient Rights Act.
All
administrators are
subject to the provisions of Sections 55 and 85 of the Managed Care
Reform and Patient Rights Act.

(Source: P.A. 91-617, eff. 1-1-00.)

Structure Illinois Compiled Statutes