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92_HB0745 LRB9205282JSpc 1 AN ACT concerning the comprehensive health insurance 2 plan. 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 2 as follows: 7 (215 ILCS 105/2) (from Ch. 73, par. 1302) 8 Sec. 2. Definitions.
As usedIn 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. -2- LRB9205282JSpc 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 -3- LRB9205282JSpc 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 -4- LRB9205282JSpc 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 -5- LRB9205282JSpc 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. -6- LRB9205282JSpc 1 "Health insurance issuer" means an insurance company, 2 insurance service, or insurance organization (including a 3 health maintenance organization and a voluntary health 4 services plan) that is authorized to transact health 5 insurance business in this State. Such term does not include 6 a group health plan. 7 "Health Maintenance Organization" means an organization 8 as defined in the Health Maintenance Organization Act. 9 "Hospice" means a program as defined in and licensed 10 under the Hospice Program Licensing Act. 11 "Hospital" means a duly licensed institution as defined 12 in the Hospital Licensing Act, an institution that meets all 13 comparable conditions and requirements in effect in the state 14 in which it is located, or the University of Illinois 15 Hospital as defined in the University of Illinois Hospital 16 Act. 17 "Individual health insurance coverage" means health 18 insurance coverage offered to individuals in the individual 19 market, but does not include short-term, limited-duration 20 insurance. 21 "Insured" means any individual resident of this State who 22 is eligible to receive benefits from any insurer (including 23 health insurance coverage offered in connection with a group 24 health plan) or health insurance issuer as defined in this 25 Section. 26 "Insurer" means any insurance company authorized to 27 transact health insurance business in this State and any 28 corporation that provides medical services and is organized 29 under the Voluntary Health Services Plans Act or the Health 30 Maintenance Organization Act. 31 "Medical assistance" means the State medical assistance 32 or medical assistance no grant (MANG) programs provided under 33 Title XIX of the Social Security Act and Articles V (Medical 34 Assistance) and VI (General Assistance) of the Illinois -7- LRB9205282JSpc 1 Public Aid Code (or any successor program) or under any 2 similar program of health care benefits in a state other than 3 Illinois. 4 "Medically necessary" means that a service, drug, or 5 supply is necessary and appropriate for the diagnosis or 6 treatment of an illness or injury in accord with generally 7 accepted standards of medical practice at the time the 8 service, drug, or supply is provided. When specifically 9 applied to a confinement it further means that the diagnosis 10 or treatment of the covered person's medical symptoms or 11 condition cannot be safely provided to that person as an 12 outpatient. A service, drug, or supply shall not be medically 13 necessary if it: (i) is investigational, experimental, or for 14 research purposes; or (ii) is provided solely for the 15 convenience of the patient, the patient's family, physician, 16 hospital, or any other provider; or (iii) exceeds in scope, 17 duration, or intensity that level of care that is needed to 18 provide safe, adequate, and appropriate diagnosis or 19 treatment; or (iv) could have been omitted without adversely 20 affecting the covered person's condition or the quality of 21 medical care; or (v) involves the use of a medical device, 22 drug, or substance not formally approved by the United States 23 Food and Drug Administration. 24 "Medical care" means the ordinary and usual professional 25 services rendered by a physician or other specified provider 26 during a professional visit for treatment of an illness or 27 injury. 28 "Medicare" means coverage under both Part A and Part B of 29 Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395, 30 et seq. 31 "Minimum premium plan" means an arrangement whereby a 32 specified amount of health care claims is self-funded, but 33 the insurance company assumes the risk that claims will 34 exceed that amount. -8- LRB9205282JSpc 1 "Participating transplant center" means a hospital 2 designated by the Board as a preferred or exclusive provider 3 of services for one or more specified human organ or tissue 4 transplants for which the hospital has signed an agreement 5 with the Board to accept a transplant payment allowance for 6 all expenses related to the transplant during a transplant 7 benefit period. 8 "Physician" means a person licensed to practice medicine 9 pursuant to the Medical Practice Act of 1987. 10 "Plan" means the Comprehensive Health Insurance Plan 11 established by this Act. 12 "Plan of operation" means the plan of operation of the 13 Plan, including articles, bylaws and operating rules, adopted 14 by the board pursuant to this Act. 15 "Provider" means any hospital, skilled nursing facility, 16 hospice, home health agency, physician, registered pharmacist 17 acting within the scope of that registration, or any other 18 person or entity licensed in Illinois to furnish medical 19 care. 20 "Qualified high risk pool" has the same meaning given 21 that term in the federal Health Insurance Portability and 22 Accountability Act of 1996. 23 "Resident" means a person who is and continues to be 24 legally domiciled and physically residing on a permanent and 25 full-time basis in a place of permanent habitation in this 26 State that remains that person's principal residence and from 27 which that person is absent only for temporary or transitory 28 purpose. 29 "Skilled nursing facility" means a facility or that 30 portion of a facility that is licensed by the Illinois 31 Department of Public Health under the Nursing Home Care Act 32 or a comparable licensing authority in another state to 33 provide skilled nursing care. 34 "Stop-loss coverage" means an arrangement whereby an -9- LRB9205282JSpc 1 insurer insures against the risk that any one claim will 2 exceed a specific dollar amount or that the entire loss of a 3 self-insurance plan will exceed a specific amount. 4 "Third party administrator" means an administrator as 5 defined in Section 511.101 of the Illinois Insurance Code who 6 is licensed under Article XXXI 1/4 of that Code. 7 (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99; 8 91-735, eff. 6-2-00.)
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