State of Illinois
91st General Assembly
Legislation

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[ Introduced ][ Enrolled ][ Senate Amendment 001 ]

91_HB4433eng

 
HB4433 Engrossed                               LRB9110326JSsb

 1        AN ACT to amend the Comprehensive Health  Insurance  Plan
 2    Act by changing Section 8.

 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 Section 8 as follows:

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

33        Section 99.  Effective date.  This Act takes effect  upon
 
HB4433 Engrossed            -14-               LRB9110326JSsb
 1    becoming law.

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