State of Illinois
91st General Assembly

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[ Introduced ][ Engrossed ][ Senate Amendment 001 ]


HB4433 Enrolled                                LRB9110326JSsb

 1        AN ACT concerning insurance coverage for certain  medical
 2    conditions.

 3        Be  it  enacted  by  the People of the State of Illinois,
 4    represented in the General Assembly:

 5        Section 5.  The Comprehensive Health Insurance  Plan  Act
 6    is amended by changing Sections 2, 7, 8, and 11 as follows:

 7        (215 ILCS 105/2) (from Ch. 73, par. 1302)
 8        Sec.  2.   Definitions.   As used in this Act, unless the
 9    context otherwise requires:
10        "Plan administrator" means the  insurer  or  third  party
11    administrator designated under Section 5 of this Act.
12        "Benefits  plan"  means the coverage to be offered by the
13    Plan to eligible persons and federally  eligible  individuals
14    pursuant to this Act.
15        "Board" means the Illinois Comprehensive Health Insurance
16    Board.
17        "Church plan" has the same meaning given that term in the
18    federal  Health  Insurance Portability and Accountability Act
19    of 1996.
20        "Continuation coverage" means  continuation  of  coverage
21    under  a group health plan or other health insurance coverage
22    for former employees or dependents of former  employees  that
23    would  otherwise  have  terminated  under  the  terms of that
24    coverage  pursuant  to  any  continuation  provisions   under
25    federal  or  State  law,  including  the Consolidated Omnibus
26    Budget  Reconciliation  Act  of  1985  (COBRA),  as  amended,
27    Sections 367.2 and 367e of the Illinois  Insurance  Code,  or
28    any other similar requirement in another State.
29        "Covered  person"  means a person who is and continues to
30    remain eligible for Plan coverage and is covered under one of
31    the benefit plans offered by the Plan.
HB4433 Enrolled            -2-                 LRB9110326JSsb
 1        "Creditable coverage" means, with respect to a  federally
 2    eligible  individual, coverage of the individual under any of
 3    the following:
 4             (A)  A group health plan.
 5             (B)  Health  insurance  coverage  (including   group
 6        health insurance coverage).
 7             (C)  Medicare.
 8             (D)  Medical assistance.
 9             (E)  Chapter 55 of title 10, United States Code.
10             (F)  A  medical  care  program  of the Indian Health
11        Service or of a tribal organization.
12             (G)  A state health benefits risk pool.
13             (H)  A health plan offered under Chapter 89 of title
14        5, United States Code.
15             (I)  A public health plan (as defined in regulations
16        consistent  with  Section  104   of   the   Health   Care
17        Portability  and  Accountability  Act of 1996 that may be
18        promulgated by the Secretary of the  U.S.  Department  of
19        Health and Human Services).
20             (J)  A health benefit plan under Section 5(e) of the
21        Peace Corps Act (22 U.S.C. 2504(e)).
22             (K)  Any  other  qualifying coverage required by the
23        federal Health Insurance Portability  and  Accountability
24        Act  of  1996, as it may be amended, or regulations under
25        that Act.
26        "Creditable   coverage"   does   not   include   coverage
27    consisting  solely  of  coverage  of  excepted  benefits  (as
28    defined in Section 2791(c)  of  title  XXVII  of  the  Public
29    Health  Service Act (42 U.S.C. 300 gg-91) nor does it include
30    any period of coverage under any of  items  (A)  through  (K)
31    that  occurred before a break of more than 63 days during all
32    of which the individual was not covered under  any  of  items
33    (A) through (K) above.  Any period that an individual is in a
34    waiting period for any coverage under a group health plan (or
HB4433 Enrolled            -3-                 LRB9110326JSsb
 1    for  group health insurance coverage) or is in an affiliation
 2    period under the terms of health insurance  coverage  offered
 3    by  a health maintenance organization shall not be taken into
 4    account in determining if there has been a break of more than
 5    63 days in any credible coverage.
 6        "Department" means the Illinois Department of Insurance.
 7        "Dependent" means an Illinois resident: who is a  spouse;
 8    or who is claimed as a dependent by the principal insured for
 9    purposes of filing a federal income tax return and resides in
10    the   principal   insured's  household,  and  is  a  resident
11    unmarried child under the age of  19  years;  or  who  is  an
12    unmarried child who also is a full-time student under the age
13    of  23  years  and  who  is  financially  dependent  upon the
14    principal insured; or who is a child of any age  and  who  is
15    disabled   and   financially  dependent  upon  the  principal
16    insured.
17        "Direct Illinois premiums" means, for Illinois  business,
18    an  insurer's direct premium income for the kinds of business
19    described in clause (b) of Class 1 or clause (a) of  Class  2
20    of  Section  4  of  the  Illinois  Insurance Code, and direct
21    premium income of a  health  maintenance  organization  or  a
22    voluntary  health  services plan, except it shall not include
23    credit health insurance as defined in Article IX 1/2  of  the
24    Illinois Insurance Code.
25        "Director"  means the Director of the Illinois Department
26    of Insurance.
27        "Eligible person" means a  resident  of  this  State  who
28    qualifies for Plan coverage under Section 7 of this Act.
29        "Employee" means a resident of this State who is employed
30    by an employer or has entered into the employment of or works
31    under  contract  or  service  of  an  employer  including the
32    officers, managers and employees of subsidiary or  affiliated
33    corporations  and  the  individual  proprietors, partners and
34    employees  of  affiliated  individuals  and  firms  when  the
HB4433 Enrolled            -4-                 LRB9110326JSsb
 1    business of the subsidiary or affiliated corporations,  firms
 2    or  individuals  is  controlled  by a common employer through
 3    stock ownership, contract, or otherwise.
 4        "Employer"    means    any    individual,    partnership,
 5    association, corporation, business trust, or  any  person  or
 6    group  of  persons  acting  directly  or  indirectly  in  the
 7    interest of an employer in relation to an employee, for which
 8    one or more persons is gainfully employed.
 9        "Family" coverage means the coverage provided by the Plan
10    for the covered person and his or her eligible dependents who
11    also are covered persons.
12        "Federally   eligible  individual"  means  an  individual
13    resident of this State:
14             (1)(A)  for whom,  as  of  the  date  on  which  the
15        individual  seeks  Plan coverage under Section 15 of this
16        Act, the aggregate of the periods of creditable  coverage
17        is  18  or  more  months, and (B) whose most recent prior
18        creditable coverage  was  under  group  health  insurance
19        coverage  offered  by  a health insurance issuer, a group
20        health plan, a governmental plan, or a  church  plan  (or
21        health  insurance coverage offered in connection with any
22        such plans) or any other type of creditable coverage that
23        may  be  required  by  the   federal   Health   Insurance
24        Portability  and Accountability Act of 1996, as it may be
25        amended, or the regulations under that Act;
26             (2)  who is not eligible for coverage  under  (A)  a
27        group  health  plan, (B) part A or part B of Medicare, or
28        (C) medical assistance, and does not  have  other  health
29        insurance coverage;
30             (3)  with  respect  to whom the most recent coverage
31        within the coverage period described in paragraph  (1)(A)
32        of this definition was not terminated based upon a factor
33        relating to nonpayment of premiums or fraud;
34             (4)  if  the  individual had been offered the option
HB4433 Enrolled            -5-                 LRB9110326JSsb
 1        of  continuation  coverage  under  a  COBRA  continuation
 2        provision or under a similar State program,  who  elected
 3        such coverage; and
 4             (5)  who,    if    the   individual   elected   such
 5        continuation coverage, has  exhausted  such  continuation
 6        coverage under such provision or program.
 7        "Group  health  insurance  coverage" means, in connection
 8    with a group health plan, health insurance  coverage  offered
 9    in connection with that plan.
10        "Group  health plan" has the same meaning given that term
11    in   the   federal   Health   Insurance    Portability    and
12    Accountability Act of 1996.
13        "Governmental  plan" has the same meaning given that term
14    in   the   federal   Health   Insurance    Portability    and
15    Accountability Act of 1996.
16        "Health  insurance coverage" means benefits consisting of
17    medical  care  (provided  directly,  through   insurance   or
18    reimbursement,  or otherwise and including items and services
19    paid for as medical care)  under  any  hospital  and  medical
20    expense-incurred policy, certificate, or contract provided by
21    an  insurer,  non-profit  health  care service plan contract,
22    health maintenance organization or other subscriber contract,
23    or any other health care plan or arrangement that pays for or
24    furnishes  medical  or  health  care  services   whether   by
25    insurance  or otherwise.  Health insurance coverage shall not
26    include  short  term,  accident  only,   disability   income,
27    hospital  confinement or fixed indemnity, dental only, vision
28    only, limited benefit, or credit insurance,  coverage  issued
29    as a supplement to liability insurance, insurance arising out
30    of   a  workers'  compensation  or  similar  law,  automobile
31    medical-payment insurance, or insurance under which  benefits
32    are  payable  with  or  without  regard to fault and which is
33    statutorily  required  to  be  contained  in  any   liability
34    insurance policy or equivalent self-insurance.
HB4433 Enrolled            -6-                 LRB9110326JSsb
 1        "Health  insurance coverage" means benefits consisting of
 2    medical  care  (provided  directly,  through   insurance   or
 3    reimbursement,  or otherwise and including items and services
 4    paid for as medical  care)  under  any  hospital  or  medical
 5    service  policy  or  certificate, hospital or medical service
 6    plan contract, or health  maintenance  organization  contract
 7    offered by a health insurance issuer.
 8        "Health  insurance  issuer"  means  an insurance company,
 9    insurance service, or  insurance  organization  (including  a
10    health   maintenance  organization  and  a  voluntary  health
11    services  plan)  that  is  authorized  to   transact   health
12    insurance business in this State.  Such term does not include
13    a group health plan.
14        "Health  Maintenance  Organization" means an organization
15    as defined in the Health Maintenance Organization Act.
16        "Hospice" means a program  as  defined  in  and  licensed
17    under the Hospice Program Licensing Act.
18        "Hospital"  means  a duly licensed institution as defined
19    in the Hospital Licensing Act, an institution that meets  all
20    comparable conditions and requirements in effect in the state
21    in  which  it  is  located,  or  the  University  of Illinois
22    Hospital as defined in the University  of  Illinois  Hospital
23    Act.
24        "Individual   health  insurance  coverage"  means  health
25    insurance coverage offered to individuals in  the  individual
26    market,  but  does  not  include short-term, limited-duration
27    insurance.
28        "Insured" means any individual resident of this State who
29    is eligible to receive benefits from any  insurer  (including
30    health  insurance coverage offered in connection with a group
31    health plan) or health insurance issuer as  defined  in  this
32    Section.
33        "Insurer"  means  any  insurance  company  authorized  to
34    transact  health  insurance  business  in  this State and any
HB4433 Enrolled            -7-                 LRB9110326JSsb
 1    corporation that provides medical services and  is  organized
 2    under  the  Voluntary Health Services Plans Act or the Health
 3    Maintenance Organization Act.
 4        "Medical assistance" means the State  medical  assistance
 5    or medical assistance no grant (MANG) programs provided under
 6    Title  XIX of the Social Security Act and Articles V (Medical
 7    Assistance) and  VI  (General  Assistance)  of  the  Illinois
 8    Public  Aid  Code  (or  any  successor  program) or under any
 9    similar program of health care benefits in a state other than
10    Illinois.
11        "Medically necessary" means  that  a  service,  drug,  or
12    supply  is  necessary  and  appropriate  for the diagnosis or
13    treatment of an illness or injury in  accord  with  generally
14    accepted  standards  of  medical  practice  at  the  time the
15    service, drug,  or  supply  is  provided.  When  specifically
16    applied  to a confinement it further means that the diagnosis
17    or treatment of the  covered  person's  medical  symptoms  or
18    condition  cannot  be  safely  provided  to that person as an
19    outpatient. A service, drug, or supply shall not be medically
20    necessary if it: (i) is investigational, experimental, or for
21    research  purposes;  or  (ii)  is  provided  solely  for  the
22    convenience of the patient, the patient's family,  physician,
23    hospital,  or  any other provider; or (iii) exceeds in scope,
24    duration, or intensity that level of care that is  needed  to
25    provide   safe,   adequate,   and  appropriate  diagnosis  or
26    treatment; or (iv) could have been omitted without  adversely
27    affecting  the  covered  person's condition or the quality of
28    medical care; or (v) involves the use of  a  medical  device,
29    drug, or substance not formally approved by the United States
30    Food and Drug Administration.
31        "Medical  care" means the ordinary and usual professional
32    services rendered by a physician or other specified  provider
33    during  a  professional  visit for treatment of an illness or
34    injury.
HB4433 Enrolled            -8-                 LRB9110326JSsb
 1        "Medicare" means coverage under both Part A and Part B of
 2    Title XVIII of the Social Security Act, 42 U.S.C. Sec.  1395,
 3    et seq.
 4        "Minimum  premium  plan"  means  an arrangement whereby a
 5    specified amount of health care claims  is  self-funded,  but
 6    the  insurance  company  assumes  the  risk  that claims will
 7    exceed that amount.
 8        "Participating  transplant  center"  means   a   hospital
 9    designated  by the Board as a preferred or exclusive provider
10    of services for one or more specified human organ  or  tissue
11    transplants  for  which  the hospital has signed an agreement
12    with the Board to accept a transplant payment  allowance  for
13    all  expenses  related  to the transplant during a transplant
14    benefit period.
15        "Physician" means a person licensed to practice  medicine
16    pursuant to the Medical Practice Act of 1987.
17        "Plan"  means  the  Comprehensive  Health  Insurance Plan
18    established by this Act.
19        "Plan of operation" means the plan of  operation  of  the
20    Plan, including articles, bylaws and operating rules, adopted
21    by the board pursuant to this Act.
22        "Provider"  means any hospital, skilled nursing facility,
23    hospice, home health agency, physician, registered pharmacist
24    acting within the scope of that registration,  or  any  other
25    person  or  entity  licensed  in  Illinois to furnish medical
26    care.
27        "Qualified high risk pool" has  the  same  meaning  given
28    that  term  in  the  federal Health Insurance Portability and
29    Accountability Act of 1996.
30        "Resident eligible person" means  a  person  who  is  and
31    continues  to  be  has  been legally domiciled and physically
32    residing on a permanent and full-time basis  in  a  place  of
33    permanent habitation in this State that remains that person's
34    principal residence and from which that person is absent only
HB4433 Enrolled            -9-                 LRB9110326JSsb
 1    for  temporary or transitory purpose for a period of at least
 2    180 days and continues to be domiciled in this State.
 3        "Skilled nursing  facility"  means  a  facility  or  that
 4    portion  of  a  facility  that  is  licensed  by the Illinois
 5    Department of Public Health under the Nursing Home  Care  Act
 6    or  a  comparable  licensing  authority  in  another state to
 7    provide skilled nursing care.
 8        "Stop-loss coverage"  means  an  arrangement  whereby  an
 9    insurer  insures  against  the  risk  that any one claim will
10    exceed a specific dollar amount or that the entire loss of  a
11    self-insurance plan will exceed a specific amount.
12        "Third  party  administrator"  means  an administrator as
13    defined in Section 511.101 of the Illinois Insurance Code who
14    is licensed under Article XXXI 1/4 of that Code.
15    (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99.)

16        (215 ILCS 105/7) (from Ch. 73, par. 1307)
17        Sec. 7.  Eligibility.
18        a.  Except as provided in subsection (e) of this  Section
19    or  in  Section  15 of this Act, any individual person who is
20    either a citizen of the United States or  an  alien  lawfully
21    admitted  for  permanent  residence  and  who  has been for a
22    period of at least 180 days and continues to be a resident of
23    this State shall be eligible for  Plan  coverage  under  this
24    Section if evidence is provided of:
25             (1)  A  notice  of  rejection  or  refusal  to issue
26        substantially   similar   individual   health   insurance
27        coverage for health reasons by a health insurance issuer;
28        or
29             (2)  A refusal by a health insurance issuer to issue
30        individual health insurance coverage  except  at  a  rate
31        exceeding  the  applicable Plan rate for which the person
32        is responsible.
33        A rejection or refusal by a group health plan  or  health
HB4433 Enrolled            -10-                LRB9110326JSsb
 1    insurance  issuer  offering  only stop-loss or excess of loss
 2    insurance or contracts, agreements, or other arrangements for
 3    reinsurance coverage with respect to the applicant shall  not
 4    be sufficient evidence under this subsection.
 5        b.  The  board  shall  promulgate  a  list  of medical or
 6    health conditions for which a person who is either a  citizen
 7    of  the  United  States  or  an  alien  lawfully admitted for
 8    permanent residence and a resident of  this  State  would  be
 9    eligible  for  Plan  coverage  without  applying  for  health
10    insurance coverage pursuant to subsection a. of this Section.
11    Persons  who  can demonstrate the existence or history of any
12    medical or health conditions on the list promulgated  by  the
13    board shall not be required to provide the evidence specified
14    in  subsection  a.  of  this  Section.   The  list  shall  be
15    effective  on  the first day of the operation of the Plan and
16    may be amended from time to time as appropriate.
17        c.  Family members of the same  household  who  each  are
18    covered  persons  are  eligible  for optional family coverage
19    under the Plan.
20        d.  For persons qualifying  for  coverage  in  accordance
21    with Section 7 of this Act, the board shall, if it determines
22    that  such  appropriations as are made pursuant to Section 12
23    of this Act are insufficient to allow the board to accept all
24    of the eligible persons which  it  projects  will  apply  for
25    enrollment  under  the  Plan,  limit  or  close enrollment to
26    ensure that the Plan is not over-subscribed and that  it  has
27    sufficient  resources  to  meet  its  obligations to existing
28    enrollees.  The board shall not limit or close enrollment for
29    federally eligible individuals.
30        e.  A person shall not be eligible for coverage under the
31    Plan if:
32             (1)  He or she has or obtains other coverage under a
33        group  health   plan   or   health   insurance   coverage
34        substantially  similar to or better than a Plan policy as
HB4433 Enrolled            -11-                LRB9110326JSsb
 1        an insured or covered dependent or would be  eligible  to
 2        have  that  coverage  if  he or she elected to obtain it.
 3        Persons  otherwise  eligible  for  Plan   coverage   may,
 4        however,  solely for the purpose of having coverage for a
 5        pre-existing  condition,  maintain  other  coverage  only
 6        while  satisfying  any  pre-existing  condition   waiting
 7        period  under  a  Plan policy or a subsequent replacement
 8        policy of a Plan policy.
 9             (1.1)  His or  her  prior  coverage  under  a  group
10        health  plan  or  health  insurance coverage, provided or
11        arranged by an employer of more  than  10  employees  was
12        discontinued  for  any reason without the entire group or
13        plan being discontinued and not replaced, provided he  or
14        she  remains  an  employee,  or dependent thereof, of the
15        same employer.
16             (2)  He or she is a recipient of or is  approved  to
17        receive  medical  assistance,  except  that  a person may
18        continue  to  receive  medical  assistance  through   the
19        medical  assistance  no  grant  program,  but  only while
20        satisfying the requirements for a  preexisting  condition
21        under  Section  8, subsection f. of this Act.  Payment of
22        premiums pursuant to this Act shall be allocable  to  the
23        person's spenddown for purposes of the medical assistance
24        no  grant  program, but that person shall not be eligible
25        for any Plan benefits while that person remains  eligible
26        for  medical  assistance.   If  the  person  continues to
27        receive or be  approved  to  receive  medical  assistance
28        through  the  medical  assistance  no grant program at or
29        after  the  time  that  requirements  for  a  preexisting
30        condition are satisfied, the person shall not be eligible
31        for  coverage  under  the  Plan.  In  that  circumstance,
32        coverage  under  the  plan  shall  terminate  as  of  the
33        expiration  of  the  preexisting   condition   limitation
34        period.   Under  all  other circumstances, coverage under
HB4433 Enrolled            -12-                LRB9110326JSsb
 1        the  Plan  shall  automatically  terminate  as   of   the
 2        effective date of any medical assistance.
 3             (3)  Except  as  provided  in Section 15, the person
 4        has previously participated in the Plan  and  voluntarily
 5        terminated  Plan  coverage, unless 12 months have elapsed
 6        since  the  person's  latest  voluntary  termination   of
 7        coverage.
 8             (4)  The  person  fails  to pay the required premium
 9        under  the  covered  person's  terms  of  enrollment  and
10        participation, in which event the liability of  the  Plan
11        shall  be limited to benefits incurred under the Plan for
12        the time period for which premiums had been paid and  the
13        covered person remained eligible for Plan coverage.
14             (5)  The  Plan  has  paid  a  total of $1,000,000 in
15        benefits on behalf of the covered person.
16             (6)  The  person  is  a   resident   of   a   public
17        institution.
18             (7)  The  person's premium is paid for or reimbursed
19        under  any  government  sponsored  program  or   by   any
20        government  agency  or health care provider, except as an
21        otherwise qualifying full-time employee, or dependent  of
22        such  employee,  of  a  government  agency or health care
23        provider.
24             (8)  The person has or later receives other benefits
25        or  funds  from  any  settlement,  judgement,  or   award
26        resulting  from any accident or injury, regardless of the
27        date  of  the  accident   or   injury,   or   any   other
28        circumstances  creating a legal liability for damages due
29        that person by a third  party,  whether  the  settlement,
30        judgment,  or  award  is  in  the  form  of  a  contract,
31        agreement, or trust on behalf of a minor or otherwise and
32        whether  the settlement, judgment, or award is payable to
33        the  person,  his  or  her  dependent,  estate,  personal
34        representative, or guardian in a lump sum or  over  time,
HB4433 Enrolled            -13-                LRB9110326JSsb
 1        so  long  as  there  continues  to  be benefits or assets
 2        remaining from those sources in an amount  in  excess  of
 3        $100,000.
 4             (9)  Within the 5 years prior to the date a person's
 5        Plan  application  is received by the Board, the person's
 6        coverage under any health care benefit program as defined
 7        in 18 U.S.C. 24, including any public or private plan  or
 8        contract  under  which  any  medical  benefit,  item,  or
 9        service  is  provided,  was terminated as a result of any
10        act or practice that constitutes  fraud  under  State  or
11        federal   law   or   as   a   result  of  an  intentional
12        misrepresentation of material fact;  or  if  that  person
13        knowingly  and willfully obtained or attempted to obtain,
14        or fraudulently aided  or  attempted  to  aid  any  other
15        person  in  obtaining, any coverage or benefits under the
16        Plan to which that person was not entitled.
17        f.  The  board  or  the   administrator   shall   require
18    verification  of  residency  and  may  require any additional
19    information or documentation, or statements under oath,  when
20    necessary to determine residency upon initial application and
21    for the entire term of the policy.
22        g.  Coverage  shall  cease (i) on the date a person is no
23    longer a resident of Illinois, (ii)  on  the  date  a  person
24    requests coverage to end, (iii) upon the death of the covered
25    person,  (iv)  on the date State law requires cancellation of
26    the policy, or (v) at the Plan's option, 30  days  after  the
27    Plan  makes  any inquiry concerning a person's eligibility or
28    place of residence to which the person does not reply.
29        h.  Except under the conditions set forth in subsection g
30    of this Section, the coverage of any  person  who  ceases  to
31    meet  the  eligibility  requirements of this Section shall be
32    terminated at the end of the current policy period for  which
33    the necessary premiums have been paid.
34    (Source: P.A. 90-30, eff. 7-1-97; 91-639, eff. 8-20-99.)
HB4433 Enrolled            -14-                LRB9110326JSsb
 1        (215 ILCS 105/8) (from Ch. 73, par. 1308)
 2        Sec. 8.  Minimum benefits.
 3        a.  Availability.  The  Plan  shall  offer in an annually
 4    renewable policy major  medical  expense  coverage  to  every
 5    eligible  person  who  is  not  eligible for Medicare.  Major
 6    medical expense coverage offered by the  Plan  shall  pay  an
 7    eligible  person's  covered expenses, subject to limit on the
 8    deductible  and   coinsurance   payments   authorized   under
 9    paragraph  (4)  of  subsection  d  of  this  Section, up to a
10    lifetime benefit limit of $1,000,000 per covered  individual.
11    The  maximum limit under this subsection shall not be altered
12    by the Board, and no  actuarial  equivalent  benefit  may  be
13    substituted  by  the  Board.  Any  person who otherwise would
14    qualify for coverage under the Plan, but is excluded  because
15    he or she is eligible for Medicare, shall be eligible for any
16    separate  Medicare  supplement  policy  or policies which the
17    Board may offer.
18        b.  Outline  of  benefits.   Covered  expenses  shall  be
19    limited  to  the  usual  and  customary   charge,   including
20    negotiated  fees,  in the locality for the following services
21    and articles when prescribed by a physician and determined by
22    the Plan to be medically necessary for the following areas of
23    services, subject to such separate deductibles,  co-payments,
24    exclusions,  and  other limitations on benefits  as the Board
25    shall establish and approve, and the other provisions of this
26    Section:
27             (1)  Hospital services,  except  that  any  services
28        provided by a hospital that is located more than 75 miles
29        outside the State of Illinois shall be covered only for a
30        maximum of 45 days in any calendar year.  With respect to
31        covered expenses incurred during any calendar year ending
32        on  or after December 31, 1999, inpatient hospitalization
33        of an eligible person for the treatment of mental illness
34        at a hospital located within the State of Illinois  shall
HB4433 Enrolled            -15-                LRB9110326JSsb
 1        be  subject  to  the same terms and conditions as for any
 2        other illness.
 3             (2)  Professional  services  for  the  diagnosis  or
 4        treatment of injuries,  illnesses  or  conditions,  other
 5        than dental and mental and nervous disorders as described
 6        in  paragraph (17), which are rendered by a physician, or
 7        by  other  licensed  professionals  at  the   physician's
 8        direction.  This includes reconstruction of the breast on
 9        which   a   mastectomy   was   performed;   surgery   and
10        reconstruction  of  the  other  breast   to   produce   a
11        symmetrical  appearance;  and prostheses and treatment of
12        physical complications at all stages of  the  mastectomy,
13        including lymphedemas.
14             (2.5)  Professional services provided by a physician
15        to  children  under  the  age  of  16  years for physical
16        examinations and age appropriate immunizations ordered by
17        a physician licensed to  practice  medicine  in  all  its
18        branches.
19             (3)  (Blank).
20             (4)  Outpatient   prescription  drugs  that  by  law
21        require a prescription written by a physician licensed to
22        practice medicine in all its  branches  subject  to  such
23        separate  deductible, copayment, and other limitations or
24        restrictions as the Board shall  approve,  including  the
25        use  of a prescription drug card or any other program, or
26        both.
27             (5)  Skilled nursing services of a licensed  skilled
28        nursing  facility  for  not  more  than 120 days during a
29        policy year.
30             (6)  Services of a home health agency in accord with
31        a home health care plan, up to a maximum  of  270  visits
32        per year.
33             (7)  Services  of  a  licensed  hospice for not more
34        than 180 days during a policy year.
HB4433 Enrolled            -16-                LRB9110326JSsb
 1             (8)  Use of radium or other radioactive materials.
 2             (9)  Oxygen.
 3             (10)  Anesthetics.
 4             (11)  Orthoses and prostheses other than dental.
 5             (12)  Rental or purchase in  accordance  with  Board
 6        policies  or  procedures  of  durable  medical equipment,
 7        other than eyeglasses or hearing aids, for which there is
 8        no personal use in the absence of the condition for which
 9        it is prescribed.
10             (13)  Diagnostic x-rays and laboratory tests.
11             (14)  Oral surgery (i) for excision of partially  or
12        completely  unerupted  impacted teeth, when not performed
13        in connection with the routine extraction  or  repair  of
14        teeth;  (ii) for excision of tumors or cysts of the jaws,
15        cheeks, lips, tongue, and roof and floor  of  the  mouth;
16        (iii),  that  is required for correction of cleft lip and
17        palate and other  craniofacial  and  maxillofacial  birth
18        defects;  or  (iv)  for treatment of to treat injuries to
19        natural teeth or a fractured jaw due to an accident  that
20        occurred while a covered person.
21             (15)  Physical,  speech, and functional occupational
22        therapy  as   medically   necessary   and   provided   by
23        appropriate licensed professionals.
24             (16)  Emergency   and   other   medically  necessary
25        transportation provided by a licensed  ambulance  service
26        to  the nearest health care facility qualified to treat a
27        covered illness, injury, or  condition,  subject  to  the
28        provisions of the Emergency Medical Systems (EMS) Act.
29             (17)  Outpatient    services   for   diagnosis   and
30        treatment of mental and nervous disorders provided that a
31        covered person shall be required to make a copayment  not
32        to  exceed  50%  and  that  the  Plan's payment shall not
33        exceed such amounts as are established by the Board.
34             (18)  Human organ or tissue transplants specified by
HB4433 Enrolled            -17-                LRB9110326JSsb
 1        the Board that are performed at a hospital designated  by
 2        the  Board  as a participating transplant center for that
 3        specific organ or tissue transplant.
 4             (19)  Naprapathic services, as appropriate, provided
 5        by a licensed naprapathic practitioner.
 6        c.  Exclusions.  Covered expenses of the Plan  shall  not
 7    include the following:
 8             (1)  Any  charge for treatment for cosmetic purposes
 9        other than for reconstructive surgery when the service is
10        incidental to or follows surgery resulting  from  injury,
11        sickness  or  other  diseases  of  the  involved  part or
12        surgery for the  repair  or  treatment  of  a  congenital
13        bodily defect to restore normal bodily functions.
14             (2)  Any charge for care that is primarily for rest,
15        custodial, educational, or domiciliary purposes.
16             (3)  Any  charge  for  services in a private room to
17        the extent it is in excess of  the  institution's  charge
18        for  its  most  common semiprivate room, unless a private
19        room is prescribed as medically necessary by a physician.
20             (4)  That part of any charge for room and  board  or
21        for   services  rendered  or  articles  prescribed  by  a
22        physician, dentist, or other health care  personnel  that
23        exceeds  the  reasonable  and  customary  charge  in  the
24        locality  or  for  any services or supplies not medically
25        necessary for the diagnosed injury or illness.
26             (5)  Any  charge  for  services  or   articles   the
27        provision  of  which is not within the scope of licensure
28        of the institution or individual providing  the  services
29        or articles.
30             (6)  Any  expense  incurred  prior  to the effective
31        date of coverage by the Plan  for  the  person  on  whose
32        behalf the expense is incurred.
33             (7)  Dental  care, dental surgery, dental treatment,
34        any  other  dental  procedure  involving  the  teeth   or
HB4433 Enrolled            -18-                LRB9110326JSsb
 1        periodontium, or any dental appliances, including crowns,
 2        bridges,  implants,  or  partial  or  complete  dentures,
 3        except  as  specifically  provided  in  paragraph (14) of
 4        subsection b of this Section.
 5             (8)  Eyeglasses, contact  lenses,  hearing  aids  or
 6        their fitting.
 7             (9)  Illness or injury due to acts of war.
 8             (10)  Services  of  blood  donors  and  any  fee for
 9        failure to replace the first 3 pints of blood provided to
10        a covered  person each policy year.
11             (11)  Personal supplies or services  provided  by  a
12        hospital  or  nursing  home,  or  any other nonmedical or
13        nonprescribed supply or service.
14             (12)  Routine maternity  charges  for  a  pregnancy,
15        except  where  added as optional coverage with payment of
16        an  additional  premium  for  pregnancy  resulting   from
17        conception  occurring  after  the  effective  date of the
18        optional coverage.
19             (13)  (Blank).
20             (14)  Any expense or charge for services, drugs,  or
21        supplies  that  are:  (i)  not  provided  in  accord with
22        generally accepted standards of current medical practice;
23        (ii) for procedures, treatments, equipment,  transplants,
24        or   implants,   any   of   which   are  investigational,
25        experimental,   or   for   research    purposes;    (iii)
26        investigative  and not proven safe and effective; or (iv)
27        for,  or  resulting   from,   a   gender   transformation
28        operation.
29             (15)  Any  expense  or  charge  for routine physical
30        examinations or tests except as provided in item (2.5) of
31        subsection b of this Section.
32             (16)  Any expense for which a charge is not made  in
33        the  absence  of insurance or for which there is no legal
34        obligation on the part of the patient to pay.
HB4433 Enrolled            -19-                LRB9110326JSsb
 1             (17)  Any expense  incurred  for  benefits  provided
 2        under  the  laws  of  the  United  States and this State,
 3        including   Medicare,   Medicaid,   and   other   medical
 4        assistance, maternal and child health  services  and  any
 5        other  program  that  is  administered  or  funded by the
 6        Department of Human Services, Department of  Public  Aid,
 7        or     Department     of    Public    Health,    military
 8        service-connected disability payments,  medical  services
 9        provided  for  members  of  the  armed  forces  and their
10        dependents or employees of the armed forces of the United
11        States, and medical services financed on  behalf  of  all
12        citizens by the United States.
13             (18)  Any   expense   or   charge   for   in   vitro
14        fertilization,  artificial  insemination,  or  any  other
15        artificial means used to cause pregnancy.
16             (19)  Any  expense or charge for oral contraceptives
17        used for birth  control  or  any  other  temporary  birth
18        control measures.
19             (20)  Any  expense  or  charge  for sterilization or
20        sterilization reversals.
21             (21)  Any  expense  or  charge   for   weight   loss
22        programs,  exercise  equipment,  or treatment of obesity,
23        except when certified by a physician  as  morbid  obesity
24        (at least 2 times normal body weight).
25             (22)  Any   expense   or   charge   for  acupuncture
26        treatment unless  used  as  an  anesthetic  agent  for  a
27        covered surgery.
28             (23)  Any  expense or charge for or related to organ
29        or tissue transplants other than  those  performed  at  a
30        hospital  with  a Board approved organ transplant program
31        that has been designated by the Board as a  preferred  or
32        exclusive  provider  organization for that specific organ
33        or tissue transplant.
34             (24)  Any  expense   or   charge   for   procedures,
HB4433 Enrolled            -20-                LRB9110326JSsb
 1        treatments,  equipment,  or services that are provided in
 2        special settings for research purposes or in a controlled
 3        environment, are being studied  for  safety,  efficiency,
 4        and  effectiveness,  and  are awaiting endorsement by the
 5        appropriate  national  medical  speciality  college   for
 6        general use within the medical community.
 7        d.  Deductibles and coinsurance.
 8        The  Plan coverage defined in Section 6 shall provide for
 9    a choice of deductibles per individual as authorized  by  the
10    Board.  If 2 individual members of the same family household,
11    who are both covered persons under the Plan, satisfy the same
12    applicable deductibles, no other member of that family who is
13    also  a  covered  person  under the Plan shall be required to
14    meet any deductibles for the balance of that  calendar  year.
15    The  deductibles  must  be  applied  first  to the authorized
16    amount of covered expenses incurred by the covered person.  A
17    mandatory coinsurance requirement shall  be  imposed  at  the
18    rate  authorized  by  the  Board  in  excess of the mandatory
19    deductible, the coinsurance in the aggregate  not  to  exceed
20    such  amounts  as  are authorized by the Board per annum.  At
21    its discretion the Board  may,  however,  offer  catastrophic
22    coverages   or   other   policies  that  provide  for  larger
23    deductibles with or without  coinsurance  requirements.   The
24    deductibles  and coinsurance factors may be adjusted annually
25    according to the Medical  Component  of  the  Consumer  Price
26    Index.
27        e.  Scope of coverage.
28             (1)  In  approving  any  of  the benefit plans to be
29        offered by the  Plan,  the  Board  shall  establish  such
30        benefit   levels,   deductibles,   coinsurance   factors,
31        exclusions,  and  limitations  as it may deem appropriate
32        and that it believes to be generally  reflective  of  and
33        commensurate  with  health  insurance  coverage  that  is
34        provided in the individual market in this State.
HB4433 Enrolled            -21-                LRB9110326JSsb
 1             (2)  The  benefit  plans  approved  by the Board may
 2        also provide for  and  employ  various  cost  containment
 3        measures   and  other  requirements  including,  but  not
 4        limited to, preadmission certification,  prior  approval,
 5        second  surgical  opinions, concurrent utilization review
 6        programs, individual case management, preferred  provider
 7        organizations,   health  maintenance  organizations,  and
 8        other cost effective arrangements for paying for  covered
 9        expenses.
10        f.  Preexisting conditions.
11             (1)  Except   for   federally  eligible  individuals
12        qualifying for Plan coverage under  Section  15  of  this
13        Act,  plan  coverage  shall  exclude  charges or expenses
14        incurred  during  the  first  6  months   following   the
15        effective  date of coverage as to any condition for which
16        if: (a) the condition had manifested itself within the  6
17        month  period immediately preceding the effective date of
18        coverage in such a manner as would  cause  an  ordinarily
19        prudent  person  to seek diagnosis, care or treatment; or
20        (b) medical advice, care or treatment was recommended  or
21        received  during  within  the  6 month period immediately
22        preceding the effective date of coverage.
23             (2)  (Blank).
24             (3)  (Blank).
25        g.  Other sources primary;  nonduplication of benefits.
26             (1)  The Plan shall be the last  payor  of  benefits
27        whenever  any  other  benefit  or  source  of third party
28        payment is  available.   Subject  to  the  provisions  of
29        subsection  e  of  Section  7, benefits otherwise payable
30        under Plan coverage shall be reduced by all amounts  paid
31        or payable by Medicare or any other government program or
32        through  any  health  insurance  coverage or group health
33        plan, whether by insurance, reimbursement, or  otherwise,
34        or   through   any  third  party  liability,  settlement,
HB4433 Enrolled            -22-                LRB9110326JSsb
 1        judgment,  or  award,  regardless  of  the  date  of  the
 2        settlement, judgment, or award, whether  the  settlement,
 3        judgment,  or  award  is  in  the  form  of  a  contract,
 4        agreement, or trust on behalf of a minor or otherwise and
 5        whether  the settlement, judgment, or award is payable to
 6        the  covered  person,  his  or  her  dependent,   estate,
 7        personal  representative,  or  guardian  in a lump sum or
 8        over  time,  and  by  all  hospital  or  medical  expense
 9        benefits paid or payable under any worker's  compensation
10        coverage,   automobile   medical  payment,  or  liability
11        insurance, whether provided on  the  basis  of  fault  or
12        nonfault, and by any hospital or medical benefits paid or
13        payable  under  or  provided  pursuant  to  any  State or
14        federal law or program.
15             (2)  The Plan shall have a cause of  action  against
16        any  covered person or any other person or entity for the
17        recovery of any amount paid to the extent the amount  was
18        for  treatment, services, or supplies not covered in this
19        Section or in excess of benefits as  set  forth  in  this
20        Section.
21             (3)  Whenever benefits are due from the Plan because
22        of  sickness  or  an injury to a covered person resulting
23        from a third party's wrongful act or negligence  and  the
24        covered  person has recovered or may recover damages from
25        a third party or its insurer, the  Plan  shall  have  the
26        right  to  reduce  benefits  or to refuse to pay benefits
27        that otherwise may be payable by the  amount  of  damages
28        that  the  covered  person  has  recovered or may recover
29        regardless of the date of the sickness or injury  or  the
30        date of any settlement, judgment, or award resulting from
31        that sickness or injury.
32             During  the  pendency of any action or claim that is
33        brought by or on behalf of a  covered  person  against  a
34        third  party  or  its  insurer,  any  benefits that would
HB4433 Enrolled            -23-                LRB9110326JSsb
 1        otherwise be payable except for the  provisions  of  this
 2        paragraph  (3)  shall  be  paid  if payment by or for the
 3        third party has not yet been made and the covered  person
 4        or,  if  incapable,  that  person's  legal representative
 5        agrees in writing to pay back promptly the benefits  paid
 6        as  a  result  of the sickness or injury to the extent of
 7        any future payments made by or for the  third  party  for
 8        the  sickness  or  injury.   This  agreement  is to apply
 9        whether or not liability for the payments is  established
10        or  admitted by the third party or whether those payments
11        are itemized.
12             Any amounts due the plan to repay  benefits  may  be
13        deducted  from  other  benefits payable by the Plan after
14        payments by or for the third party are made.
15             (4)  Benefits due from the Plan may  be  reduced  or
16        refused   as  an  offset  against  any  amount  otherwise
17        recoverable under this Section.
18        h.  Right of subrogation; recoveries.
19             (1)  Whenever the Plan has paid benefits because  of
20        sickness  or  an  injury  to any covered person resulting
21        from a third party's wrongful act or negligence,  or  for
22        which  an  insurer  is  liable  in  accordance  with  the
23        provisions  of  any  policy of insurance, and the covered
24        person has recovered or may recover damages from a  third
25        party that is liable for the damages, the Plan shall have
26        the  right  to  recover  the  benefits  it  paid from any
27        amounts that the  covered  person  has  received  or  may
28        receive  regardless of the date of the sickness or injury
29        or  the  date  of  any  settlement,  judgment,  or  award
30        resulting from that sickness or injury.  The  Plan  shall
31        be subrogated to any right of recovery the covered person
32        may  have under the terms of any private or public health
33        care coverage or liability coverage,  including  coverage
34        under  the  Workers'  Compensation  Act  or  the Workers'
HB4433 Enrolled            -24-                LRB9110326JSsb
 1        Occupational  Diseases  Act,  without  the  necessity  of
 2        assignment of claim or other authorization to secure  the
 3        right of recovery.  To enforce its subrogation right, the
 4        Plan may (i) intervene or join in an action or proceeding
 5        brought   by   the   covered   person   or  his  personal
 6        representative,  including  his  guardian,   conservator,
 7        estate, dependents, or survivors, against any third party
 8        or  the  third party's insurer that may be liable or (ii)
 9        institute and prosecute  legal  proceedings  against  any
10        third  party  or  the  third  party's insurer that may be
11        liable for the sickness or injury in an appropriate court
12        either in the name of the Plan or  in  the  name  of  the
13        covered  person or his personal representative, including
14        his  guardian,  conservator,   estate,   dependents,   or
15        survivors.
16             (2)  If  any  action  or  claim  is brought by or on
17        behalf of a covered person against a third party  or  the
18        third party's insurer, the covered person or his personal
19        representative,   including  his  guardian,  conservator,
20        estate, dependents, or survivors, shall notify  the  Plan
21        by  personal  service or registered mail of the action or
22        claim and of the name of the court in which the action or
23        claim is brought, filing proof thereof in the  action  or
24        claim.  The Plan may, at any time thereafter, join in the
25        action  or  claim  upon  its motion so that all orders of
26        court after hearing and judgment shall be  made  for  its
27        protection.   No  release  or  settlement  of a claim for
28        damages and no satisfaction of  judgment  in  the  action
29        shall be valid without the written consent of the Plan to
30        the  extent of its interest in the settlement or judgment
31        and of the covered person or his personal representative.
32             (3)  In the event that the  covered  person  or  his
33        personal  representative  fails to institute a proceeding
34        against any appropriate  third  party  before  the  fifth
HB4433 Enrolled            -25-                LRB9110326JSsb
 1        month before the action would be barred, the Plan may, in
 2        its  own  name  or  in  the name of the covered person or
 3        personal representative, commence  a  proceeding  against
 4        any  appropriate  third party for the recovery of damages
 5        on account of any  sickness,  injury,  or  death  to  the
 6        covered  person.   The  covered person shall cooperate in
 7        doing what is reasonably necessary to assist the Plan  in
 8        any  recovery  and  shall  not take any action that would
 9        prejudice the Plan's right to recovery.  The  Plan  shall
10        pay  to the covered person or his personal representative
11        all sums collected from any third party  by  judgment  or
12        otherwise in excess of amounts paid in benefits under the
13        Plan  and  amounts paid or to be paid as costs, attorneys
14        fees, and reasonable expenses incurred  by  the  Plan  in
15        making the collection or enforcing the judgment.
16             (4)  In  the  event  that  a  covered  person or his
17        personal   representative,   including   his    guardian,
18        conservator,  estate,  dependents, or survivors, recovers
19        damages from a third party for sickness or injury  caused
20        to the covered person, the covered person or the personal
21        representative  shall  pay  to  the Plan from the damages
22        recovered the amount of benefits paid or to  be  paid  on
23        behalf of the covered person.
24             (5)  When  the  action  or  claim  is brought by the
25        covered person alone and  the  covered  person  incurs  a
26        personal  liability  to  pay attorney's fees and costs of
27        litigation, the Plan's claim  for  reimbursement  of  the
28        benefits provided to the covered person shall be the full
29        amount  of  benefits  paid to or on behalf of the covered
30        person  under  this  Act  less  a  pro  rata  share  that
31        represents the Plan's reasonable share of attorney's fees
32        paid by the covered person and that portion of  the  cost
33        of  litigation  expenses determined by multiplying by the
34        ratio of the full amount of the expenditures to the  full
HB4433 Enrolled            -26-                LRB9110326JSsb
 1        amount of the judgement, award, or settlement.
 2             (6)  In  the event of judgment or award in a suit or
 3        claim against a third party or insurer, the  court  shall
 4        first   order  paid  from  any  judgement  or  award  the
 5        reasonable litigation expenses  incurred  in  preparation
 6        and  prosecution  of  the  action or claim, together with
 7        reasonable  attorney's  fees.   After  payment  of  those
 8        expenses and attorney's fees, the court shall  apply  out
 9        of  the  balance  of  the  judgment  or  award  an amount
10        sufficient to reimburse  the  Plan  the  full  amount  of
11        benefits  paid on behalf of the covered person under this
12        Act, provided the court  may  reduce  and  apportion  the
13        Plan's  portion  of  the  judgement  proportionate to the
14        recovery of the covered person.  The burden of  producing
15        evidence  sufficient to support the exercise by the court
16        of its discretion to reduce the amount of a proven charge
17        sought to be enforced against  the  recovery  shall  rest
18        with  the  party  seeking  the  reduction.  The court may
19        consider the nature and extent of  the  injury,  economic
20        and  non-economic  loss,  settlement  offers, comparative
21        negligence as it applies to the case  at  hand,  hospital
22        costs, physician costs, and all other appropriate costs.
23        The  Plan  shall  pay  its pro rata share of the attorney
24        fees based on the Plan's recovery as it compares  to  the
25        total  judgment.   Any  reimbursement  rights of the Plan
26        shall take priority over  all  other  liens  and  charges
27        existing  under the laws of this State with the exception
28        of any attorney liens filed under the Attorneys Lien Act.
29             (7)  The Plan may compromise or settle  and  release
30        any  claim  for benefits provided under this Act or waive
31        any claims for benefits, in whole or  in  part,  for  the
32        convenience  of  the  Plan or if the Plan determines that
33        collection  would  result  in  undue  hardship  upon  the
34        covered person.
HB4433 Enrolled            -27-                LRB9110326JSsb
 1    (Source: P.A. 90-7, eff. 6-10-97; 90-30, eff. 7-1-97; 90-655,
 2    eff. 7-30-98; 91-639, eff. 8-20-99.)

 3        (215 ILCS 105/11) (from Ch. 73, par. 1311)
 4        Sec. 11.   Plan  notice.   On  and  after  the  date  the
 5    Illinois   Comprehensive   Health   Insurance   Plan  becomes
 6    operational as provided in this Act, every  insurer  licensed
 7    to issue, and which issues for delivery, policies of accident
 8    and  health insurance in this State shall include a notice of
 9    the existence of the Illinois Comprehensive Health  Insurance
10    Plan  in  any  rejection  of  any  application for individual
11    health insurance coverage as defined in this Act  for reasons
12    of the health of the applicant or any other  person  proposed
13    for  insurance  in such application.  Such notice shall be in
14    substantially  the  form  and  content  prescribed   by   the
15    Director.
16    (Source: P.A. 85-702.)

17        Section  99.  Effective date.  This Act takes effect upon
18    becoming law.

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