[ Search ] [ Legislation ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ Engrossed ] | [ Enrolled ] |
91_HB4433sam001
LRB9110326JSsbam
1 AMENDMENT TO HOUSE BILL 4433
2 AMENDMENT NO. . Amend House Bill 4433 on page 1 by
3 replacing lines 1 and 2 with the following:
4 "AN ACT concerning insurance coverage for certain medical
5 conditions."; and
6 on page 1 by replacing line 6 with the following:
7 "is amended by changing Sections 2, 7, 8, and 11 as follows:
8 (215 ILCS 105/2) (from Ch. 73, par. 1302)
9 Sec. 2. Definitions. As used in this Act, unless the
10 context otherwise requires:
11 "Plan administrator" means the insurer or third party
12 administrator designated under Section 5 of this Act.
13 "Benefits plan" means the coverage to be offered by the
14 Plan to eligible persons and federally eligible individuals
15 pursuant to this Act.
16 "Board" means the Illinois Comprehensive Health Insurance
17 Board.
18 "Church plan" has the same meaning given that term in the
19 federal Health Insurance Portability and Accountability Act
20 of 1996.
21 "Continuation coverage" means continuation of coverage
22 under a group health plan or other health insurance coverage
-2- LRB9110326JSsbam
1 for former employees or dependents of former employees that
2 would otherwise have terminated under the terms of that
3 coverage pursuant to any continuation provisions under
4 federal or State law, including the Consolidated Omnibus
5 Budget Reconciliation Act of 1985 (COBRA), as amended,
6 Sections 367.2 and 367e of the Illinois Insurance Code, or
7 any other similar requirement in another State.
8 "Covered person" means a person who is and continues to
9 remain eligible for Plan coverage and is covered under one of
10 the benefit plans offered by the Plan.
11 "Creditable coverage" means, with respect to a federally
12 eligible individual, coverage of the individual under any of
13 the following:
14 (A) A group health plan.
15 (B) Health insurance coverage (including group
16 health insurance coverage).
17 (C) Medicare.
18 (D) Medical assistance.
19 (E) Chapter 55 of title 10, United States Code.
20 (F) A medical care program of the Indian Health
21 Service or of a tribal organization.
22 (G) A state health benefits risk pool.
23 (H) A health plan offered under Chapter 89 of title
24 5, United States Code.
25 (I) A public health plan (as defined in regulations
26 consistent with Section 104 of the Health Care
27 Portability and Accountability Act of 1996 that may be
28 promulgated by the Secretary of the U.S. Department of
29 Health and Human Services).
30 (J) A health benefit plan under Section 5(e) of the
31 Peace Corps Act (22 U.S.C. 2504(e)).
32 (K) Any other qualifying coverage required by the
33 federal Health Insurance Portability and Accountability
34 Act of 1996, as it may be amended, or regulations under
-3- LRB9110326JSsbam
1 that Act.
2 "Creditable coverage" does not include coverage
3 consisting solely of coverage of excepted benefits (as
4 defined in Section 2791(c) of title XXVII of the Public
5 Health Service Act (42 U.S.C. 300 gg-91) nor does it include
6 any period of coverage under any of items (A) through (K)
7 that occurred before a break of more than 63 days during all
8 of which the individual was not covered under any of items
9 (A) through (K) above. Any period that an individual is in a
10 waiting period for any coverage under a group health plan (or
11 for group health insurance coverage) or is in an affiliation
12 period under the terms of health insurance coverage offered
13 by a health maintenance organization shall not be taken into
14 account in determining if there has been a break of more than
15 63 days in any credible coverage.
16 "Department" means the Illinois Department of Insurance.
17 "Dependent" means an Illinois resident: who is a spouse;
18 or who is claimed as a dependent by the principal insured for
19 purposes of filing a federal income tax return and resides in
20 the principal insured's household, and is a resident
21 unmarried child under the age of 19 years; or who is an
22 unmarried child who also is a full-time student under the age
23 of 23 years and who is financially dependent upon the
24 principal insured; or who is a child of any age and who is
25 disabled and financially dependent upon the principal
26 insured.
27 "Direct Illinois premiums" means, for Illinois business,
28 an insurer's direct premium income for the kinds of business
29 described in clause (b) of Class 1 or clause (a) of Class 2
30 of Section 4 of the Illinois Insurance Code, and direct
31 premium income of a health maintenance organization or a
32 voluntary health services plan, except it shall not include
33 credit health insurance as defined in Article IX 1/2 of the
34 Illinois Insurance Code.
-4- LRB9110326JSsbam
1 "Director" means the Director of the Illinois Department
2 of Insurance.
3 "Eligible person" means a resident of this State who
4 qualifies for Plan coverage under Section 7 of this Act.
5 "Employee" means a resident of this State who is employed
6 by an employer or has entered into the employment of or works
7 under contract or service of an employer including the
8 officers, managers and employees of subsidiary or affiliated
9 corporations and the individual proprietors, partners and
10 employees of affiliated individuals and firms when the
11 business of the subsidiary or affiliated corporations, firms
12 or individuals is controlled by a common employer through
13 stock ownership, contract, or otherwise.
14 "Employer" means any individual, partnership,
15 association, corporation, business trust, or any person or
16 group of persons acting directly or indirectly in the
17 interest of an employer in relation to an employee, for which
18 one or more persons is gainfully employed.
19 "Family" coverage means the coverage provided by the Plan
20 for the covered person and his or her eligible dependents who
21 also are covered persons.
22 "Federally eligible individual" means an individual
23 resident of this State:
24 (1)(A) for whom, as of the date on which the
25 individual seeks Plan coverage under Section 15 of this
26 Act, the aggregate of the periods of creditable coverage
27 is 18 or more months, and (B) whose most recent prior
28 creditable coverage was under group health insurance
29 coverage offered by a health insurance issuer, a group
30 health plan, a governmental plan, or a church plan (or
31 health insurance coverage offered in connection with any
32 such plans) or any other type of creditable coverage that
33 may be required by the federal Health Insurance
34 Portability and Accountability Act of 1996, as it may be
-5- LRB9110326JSsbam
1 amended, or the regulations under that Act;
2 (2) who is not eligible for coverage under (A) a
3 group health plan, (B) part A or part B of Medicare, or
4 (C) medical assistance, and does not have other health
5 insurance coverage;
6 (3) with respect to whom the most recent coverage
7 within the coverage period described in paragraph (1)(A)
8 of this definition was not terminated based upon a factor
9 relating to nonpayment of premiums or fraud;
10 (4) if the individual had been offered the option
11 of continuation coverage under a COBRA continuation
12 provision or under a similar State program, who elected
13 such coverage; and
14 (5) who, if the individual elected such
15 continuation coverage, has exhausted such continuation
16 coverage under such provision or program.
17 "Group health insurance coverage" means, in connection
18 with a group health plan, health insurance coverage offered
19 in connection with that plan.
20 "Group health plan" has the same meaning given that term
21 in the federal Health Insurance Portability and
22 Accountability Act of 1996.
23 "Governmental plan" has the same meaning given that term
24 in the federal Health Insurance Portability and
25 Accountability Act of 1996.
26 "Health insurance coverage" means benefits consisting of
27 medical care (provided directly, through insurance or
28 reimbursement, or otherwise and including items and services
29 paid for as medical care) under any hospital and medical
30 expense-incurred policy, certificate, or contract provided by
31 an insurer, non-profit health care service plan contract,
32 health maintenance organization or other subscriber contract,
33 or any other health care plan or arrangement that pays for or
34 furnishes medical or health care services whether by
-6- LRB9110326JSsbam
1 insurance or otherwise. Health insurance coverage shall not
2 include short term, accident only, disability income,
3 hospital confinement or fixed indemnity, dental only, vision
4 only, limited benefit, or credit insurance, coverage issued
5 as a supplement to liability insurance, insurance arising out
6 of a workers' compensation or similar law, automobile
7 medical-payment insurance, or insurance under which benefits
8 are payable with or without regard to fault and which is
9 statutorily required to be contained in any liability
10 insurance policy or equivalent self-insurance.
11 "Health insurance coverage" means benefits consisting of
12 medical care (provided directly, through insurance or
13 reimbursement, or otherwise and including items and services
14 paid for as medical care) under any hospital or medical
15 service policy or certificate, hospital or medical service
16 plan contract, or health maintenance organization contract
17 offered by a health insurance issuer.
18 "Health insurance issuer" means an insurance company,
19 insurance service, or insurance organization (including a
20 health maintenance organization and a voluntary health
21 services plan) that is authorized to transact health
22 insurance business in this State. Such term does not include
23 a group health plan.
24 "Health Maintenance Organization" means an organization
25 as defined in the Health Maintenance Organization Act.
26 "Hospice" means a program as defined in and licensed
27 under the Hospice Program Licensing Act.
28 "Hospital" means a duly licensed institution as defined
29 in the Hospital Licensing Act, an institution that meets all
30 comparable conditions and requirements in effect in the state
31 in which it is located, or the University of Illinois
32 Hospital as defined in the University of Illinois Hospital
33 Act.
34 "Individual health insurance coverage" means health
-7- LRB9110326JSsbam
1 insurance coverage offered to individuals in the individual
2 market, but does not include short-term, limited-duration
3 insurance.
4 "Insured" means any individual resident of this State who
5 is eligible to receive benefits from any insurer (including
6 health insurance coverage offered in connection with a group
7 health plan) or health insurance issuer as defined in this
8 Section.
9 "Insurer" means any insurance company authorized to
10 transact health insurance business in this State and any
11 corporation that provides medical services and is organized
12 under the Voluntary Health Services Plans Act or the Health
13 Maintenance Organization Act.
14 "Medical assistance" means the State medical assistance
15 or medical assistance no grant (MANG) programs provided under
16 Title XIX of the Social Security Act and Articles V (Medical
17 Assistance) and VI (General Assistance) of the Illinois
18 Public Aid Code (or any successor program) or under any
19 similar program of health care benefits in a state other than
20 Illinois.
21 "Medically necessary" means that a service, drug, or
22 supply is necessary and appropriate for the diagnosis or
23 treatment of an illness or injury in accord with generally
24 accepted standards of medical practice at the time the
25 service, drug, or supply is provided. When specifically
26 applied to a confinement it further means that the diagnosis
27 or treatment of the covered person's medical symptoms or
28 condition cannot be safely provided to that person as an
29 outpatient. A service, drug, or supply shall not be medically
30 necessary if it: (i) is investigational, experimental, or for
31 research purposes; or (ii) is provided solely for the
32 convenience of the patient, the patient's family, physician,
33 hospital, or any other provider; or (iii) exceeds in scope,
34 duration, or intensity that level of care that is needed to
-8- LRB9110326JSsbam
1 provide safe, adequate, and appropriate diagnosis or
2 treatment; or (iv) could have been omitted without adversely
3 affecting the covered person's condition or the quality of
4 medical care; or (v) involves the use of a medical device,
5 drug, or substance not formally approved by the United States
6 Food and Drug Administration.
7 "Medical care" means the ordinary and usual professional
8 services rendered by a physician or other specified provider
9 during a professional visit for treatment of an illness or
10 injury.
11 "Medicare" means coverage under both Part A and Part B of
12 Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395,
13 et seq.
14 "Minimum premium plan" means an arrangement whereby a
15 specified amount of health care claims is self-funded, but
16 the insurance company assumes the risk that claims will
17 exceed that amount.
18 "Participating transplant center" means a hospital
19 designated by the Board as a preferred or exclusive provider
20 of services for one or more specified human organ or tissue
21 transplants for which the hospital has signed an agreement
22 with the Board to accept a transplant payment allowance for
23 all expenses related to the transplant during a transplant
24 benefit period.
25 "Physician" means a person licensed to practice medicine
26 pursuant to the Medical Practice Act of 1987.
27 "Plan" means the Comprehensive Health Insurance Plan
28 established by this Act.
29 "Plan of operation" means the plan of operation of the
30 Plan, including articles, bylaws and operating rules, adopted
31 by the board pursuant to this Act.
32 "Provider" means any hospital, skilled nursing facility,
33 hospice, home health agency, physician, registered pharmacist
34 acting within the scope of that registration, or any other
-9- LRB9110326JSsbam
1 person or entity licensed in Illinois to furnish medical
2 care.
3 "Qualified high risk pool" has the same meaning given
4 that term in the federal Health Insurance Portability and
5 Accountability Act of 1996.
6 "Resident eligible person" means a person who is and
7 continues to be has been legally domiciled and physically
8 residing on a permanent and full-time basis in a place of
9 permanent habitation in this State that remains that person's
10 principal residence and from which that person is absent only
11 for temporary or transitory purpose for a period of at least
12 180 days and continues to be domiciled in this State.
13 "Skilled nursing facility" means a facility or that
14 portion of a facility that is licensed by the Illinois
15 Department of Public Health under the Nursing Home Care Act
16 or a comparable licensing authority in another state to
17 provide skilled nursing care.
18 "Stop-loss coverage" means an arrangement whereby an
19 insurer insures against the risk that any one claim will
20 exceed a specific dollar amount or that the entire loss of a
21 self-insurance plan will exceed a specific amount.
22 "Third party administrator" means an administrator as
23 defined in Section 511.101 of the Illinois Insurance Code who
24 is licensed under Article XXXI 1/4 of that Code.
25 (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99.)
26 (215 ILCS 105/7) (from Ch. 73, par. 1307)
27 Sec. 7. Eligibility.
28 a. Except as provided in subsection (e) of this Section
29 or in Section 15 of this Act, any individual person who is
30 either a citizen of the United States or an alien lawfully
31 admitted for permanent residence and who has been for a
32 period of at least 180 days and continues to be a resident of
33 this State shall be eligible for Plan coverage under this
-10- LRB9110326JSsbam
1 Section if evidence is provided of:
2 (1) A notice of rejection or refusal to issue
3 substantially similar individual health insurance
4 coverage for health reasons by a health insurance issuer;
5 or
6 (2) A refusal by a health insurance issuer to issue
7 individual health insurance coverage except at a rate
8 exceeding the applicable Plan rate for which the person
9 is responsible.
10 A rejection or refusal by a group health plan or health
11 insurance issuer offering only stop-loss or excess of loss
12 insurance or contracts, agreements, or other arrangements for
13 reinsurance coverage with respect to the applicant shall not
14 be sufficient evidence under this subsection.
15 b. The board shall promulgate a list of medical or
16 health conditions for which a person who is either a citizen
17 of the United States or an alien lawfully admitted for
18 permanent residence and a resident of this State would be
19 eligible for Plan coverage without applying for health
20 insurance coverage pursuant to subsection a. of this Section.
21 Persons who can demonstrate the existence or history of any
22 medical or health conditions on the list promulgated by the
23 board shall not be required to provide the evidence specified
24 in subsection a. of this Section. The list shall be
25 effective on the first day of the operation of the Plan and
26 may be amended from time to time as appropriate.
27 c. Family members of the same household who each are
28 covered persons are eligible for optional family coverage
29 under the Plan.
30 d. For persons qualifying for coverage in accordance
31 with Section 7 of this Act, the board shall, if it determines
32 that such appropriations as are made pursuant to Section 12
33 of this Act are insufficient to allow the board to accept all
34 of the eligible persons which it projects will apply for
-11- LRB9110326JSsbam
1 enrollment under the Plan, limit or close enrollment to
2 ensure that the Plan is not over-subscribed and that it has
3 sufficient resources to meet its obligations to existing
4 enrollees. The board shall not limit or close enrollment for
5 federally eligible individuals.
6 e. A person shall not be eligible for coverage under the
7 Plan if:
8 (1) He or she has or obtains other coverage under a
9 group health plan or health insurance coverage
10 substantially similar to or better than a Plan policy as
11 an insured or covered dependent or would be eligible to
12 have that coverage if he or she elected to obtain it.
13 Persons otherwise eligible for Plan coverage may,
14 however, solely for the purpose of having coverage for a
15 pre-existing condition, maintain other coverage only
16 while satisfying any pre-existing condition waiting
17 period under a Plan policy or a subsequent replacement
18 policy of a Plan policy.
19 (1.1) His or her prior coverage under a group
20 health plan or health insurance coverage, provided or
21 arranged by an employer of more than 10 employees was
22 discontinued for any reason without the entire group or
23 plan being discontinued and not replaced, provided he or
24 she remains an employee, or dependent thereof, of the
25 same employer.
26 (2) He or she is a recipient of or is approved to
27 receive medical assistance, except that a person may
28 continue to receive medical assistance through the
29 medical assistance no grant program, but only while
30 satisfying the requirements for a preexisting condition
31 under Section 8, subsection f. of this Act. Payment of
32 premiums pursuant to this Act shall be allocable to the
33 person's spenddown for purposes of the medical assistance
34 no grant program, but that person shall not be eligible
-12- LRB9110326JSsbam
1 for any Plan benefits while that person remains eligible
2 for medical assistance. If the person continues to
3 receive or be approved to receive medical assistance
4 through the medical assistance no grant program at or
5 after the time that requirements for a preexisting
6 condition are satisfied, the person shall not be eligible
7 for coverage under the Plan. In that circumstance,
8 coverage under the plan shall terminate as of the
9 expiration of the preexisting condition limitation
10 period. Under all other circumstances, coverage under
11 the Plan shall automatically terminate as of the
12 effective date of any medical assistance.
13 (3) Except as provided in Section 15, the person
14 has previously participated in the Plan and voluntarily
15 terminated Plan coverage, unless 12 months have elapsed
16 since the person's latest voluntary termination of
17 coverage.
18 (4) The person fails to pay the required premium
19 under the covered person's terms of enrollment and
20 participation, in which event the liability of the Plan
21 shall be limited to benefits incurred under the Plan for
22 the time period for which premiums had been paid and the
23 covered person remained eligible for Plan coverage.
24 (5) The Plan has paid a total of $1,000,000 in
25 benefits on behalf of the covered person.
26 (6) The person is a resident of a public
27 institution.
28 (7) The person's premium is paid for or reimbursed
29 under any government sponsored program or by any
30 government agency or health care provider, except as an
31 otherwise qualifying full-time employee, or dependent of
32 such employee, of a government agency or health care
33 provider.
34 (8) The person has or later receives other benefits
-13- LRB9110326JSsbam
1 or funds from any settlement, judgement, or award
2 resulting from any accident or injury, regardless of the
3 date of the accident or injury, or any other
4 circumstances creating a legal liability for damages due
5 that person by a third party, whether the settlement,
6 judgment, or award is in the form of a contract,
7 agreement, or trust on behalf of a minor or otherwise and
8 whether the settlement, judgment, or award is payable to
9 the person, his or her dependent, estate, personal
10 representative, or guardian in a lump sum or over time,
11 so long as there continues to be benefits or assets
12 remaining from those sources in an amount in excess of
13 $100,000.
14 (9) Within the 5 years prior to the date a person's
15 Plan application is received by the Board, the person's
16 coverage under any health care benefit program as defined
17 in 18 U.S.C. 24, including any public or private plan or
18 contract under which any medical benefit, item, or
19 service is provided, was terminated as a result of any
20 act or practice that constitutes fraud under State or
21 federal law or as a result of an intentional
22 misrepresentation of material fact; or if that person
23 knowingly and willfully obtained or attempted to obtain,
24 or fraudulently aided or attempted to aid any other
25 person in obtaining, any coverage or benefits under the
26 Plan to which that person was not entitled.
27 f. The board or the administrator shall require
28 verification of residency and may require any additional
29 information or documentation, or statements under oath, when
30 necessary to determine residency upon initial application and
31 for the entire term of the policy.
32 g. Coverage shall cease (i) on the date a person is no
33 longer a resident of Illinois, (ii) on the date a person
34 requests coverage to end, (iii) upon the death of the covered
-14- LRB9110326JSsbam
1 person, (iv) on the date State law requires cancellation of
2 the policy, or (v) at the Plan's option, 30 days after the
3 Plan makes any inquiry concerning a person's eligibility or
4 place of residence to which the person does not reply.
5 h. Except under the conditions set forth in subsection g
6 of this Section, the coverage of any person who ceases to
7 meet the eligibility requirements of this Section shall be
8 terminated at the end of the current policy period for which
9 the necessary premiums have been paid.
10 (Source: P.A. 90-30, eff. 7-1-97; 91-639, eff. 8-20-99.)";
11 and
12 on page 2 by replacing line 17 with the following:
13 "direction. This includes reconstruction of the breast on
14 which a mastectomy was performed; surgery and reconstruction
15 of the other breast to produce a symmetrical appearance; and
16 prostheses and treatment of physical complications at all
17 stages of the mastectomy, including lymphedemas."; and
18 on page 3 by replacing lines 15 through 19 with the
19 following:
20 "(14) Oral surgery (i) for excision of partially or
21 completely unerupted impacted teeth, when not performed
22 in connection with the routine extraction or repair of
23 teeth; (ii) for excision of tumors or cysts of the jaws,
24 cheeks, lips, tongue, and roof and floor of the mouth;
25 (iii), that is required for correction of cleft lip and
26 palate and other craniofacial and maxillofacial birth
27 defects; or (iv) for treatment of to treat injuries to
28 natural teeth or a fractured jaw due to an accident that
29 occurred while a covered person."; and
30 on page 4 by replacing lines 32 and 33 with the following:
31 "(7) Dental care, dental surgery, dental treatment,
32 any other dental procedure involving the teeth or
33 periodontium, or any dental appliances, including crowns,
-15- LRB9110326JSsbam
1 bridges, implants, or partial or complete dentures,
2 except as specifically provided in paragraph"; and
3 on page 8, line 28, by changing "or" to "coverage or"; and
4 on page 13 by inserting immediately below line 32 the
5 following:
6 "(215 ILCS 105/11) (from Ch. 73, par. 1311)
7 Sec. 11. Plan notice. On and after the date the
8 Illinois Comprehensive Health Insurance Plan becomes
9 operational as provided in this Act, every insurer licensed
10 to issue, and which issues for delivery, policies of accident
11 and health insurance in this State shall include a notice of
12 the existence of the Illinois Comprehensive Health Insurance
13 Plan in any rejection of any application for individual
14 health insurance coverage as defined in this Act for reasons
15 of the health of the applicant or any other person proposed
16 for insurance in such application. Such notice shall be in
17 substantially the form and content prescribed by the
18 Director.
19 (Source: P.A. 85-702.)".