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| [ Introduced ] | [ Engrossed ] | [ Senate Amendment 001 ] |
91_HB4433enr 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 of2medical care (provided directly, through insurance or3reimbursement, or otherwise and including items and services4paid for as medical care) under any hospital or medical5service policy or certificate, hospital or medical service6plan contract, or health maintenance organization contract7offered 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 "Residenteligible person" means a person who is and 31 continues to behas beenlegally 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 purposefor a period of at least2180 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, anyindividualperson 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 isrequired for correction of cleft lip and 17 palate and other craniofacial and maxillofacial birth 18 defects; or (iv) for treatment ofto treatinjuries to 19 natural teeth or a fractured jaw due to an accidentthat20occurred 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 16if: (a) the condition had manifested itself within the 617month period immediately preceding the effective date of18coverage in such a manner as would cause an ordinarily19prudent person to seek diagnosis, care or treatment; or20(b)medical advice, care or treatment was recommended or 21 received duringwithinthe 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.