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Public Act 91-0639
HB2166 Enrolled LRB9102918JSpc
AN ACT to amend the Comprehensive Health Insurance Plan
Act by changing Sections 7 and 8 and repealing Section 8.5.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Comprehensive Health Insurance Plan Act
is amended by changing Sections 7 and 8 as follows:
(215 ILCS 105/7) (from Ch. 73, par. 1307)
Sec. 7. Eligibility.
a. Except as provided in subsection (e) of this Section
or in Section 15 of this Act, any individual person who is
either a citizen of the United States or an alien lawfully
admitted for permanent residence and continues to be a
resident of this State shall be eligible for Plan coverage if
evidence is provided of:
(1) A notice of rejection or refusal to issue
substantially similar individual health insurance
coverage for health reasons by a health insurance issuer;
or
(2) A refusal by a health insurance issuer to issue
individual health insurance coverage except at a rate
exceeding the applicable Plan rate for which the person
is responsible.
A rejection or refusal by a group health plan or health
insurance issuer offering only stop-loss or excess of loss
insurance or contracts, agreements, or other arrangements for
reinsurance coverage with respect to the applicant shall not
be sufficient evidence under this subsection.
b. The board shall promulgate a list of medical or
health conditions for which a person who is either a citizen
of the United States or an alien lawfully admitted for
permanent residence and a resident of this State would be
eligible for Plan coverage without applying for health
insurance coverage pursuant to subsection a. of this Section.
Persons who can demonstrate the existence or history of any
medical or health conditions on the list promulgated by the
board shall not be required to provide the evidence specified
in subsection a. of this Section. The list shall be
effective on the first day of the operation of the Plan and
may be amended from time to time as appropriate.
c. Family members of the same household who each are
covered persons are eligible for optional family coverage
under the Plan.
d. For persons qualifying for coverage in accordance
with Section 7 of this Act, the board shall, if it determines
that such appropriations as are made pursuant to Section 12
of this Act are insufficient to allow the board to accept all
of the eligible persons which it projects will apply for
enrollment under the Plan, limit or close enrollment to
ensure that the Plan is not over-subscribed and that it has
sufficient resources to meet its obligations to existing
enrollees. The board shall not limit or close enrollment for
federally eligible individuals.
e. A person shall not be eligible for coverage under the
Plan if:
(1) He or she has or obtains other coverage under a
group health plan or health insurance coverage
substantially similar to or better than a Plan policy as
an insured or covered dependent or would be eligible to
have that coverage if he or she elected to obtain it.
Persons otherwise eligible for Plan coverage may,
however, solely for the purpose of having coverage for a
pre-existing condition, maintain other coverage only
while satisfying any pre-existing condition waiting
period under a Plan policy or a subsequent replacement
policy of a Plan policy.
(1.1) His or her prior coverage under a group
health plan or health insurance coverage, provided or
arranged by an employer of more than 10 employees was
discontinued for any reason without the entire group or
plan being discontinued and not replaced, provided he or
she remains an employee, or dependent thereof, of the
same employer.
(2) He or she is a recipient of or is approved to
receive medical assistance, except that a person may
continue to receive medical assistance through the
medical assistance no grant program, but only while
satisfying the requirements for a preexisting condition
under Section 8, subsection f. of this Act. Payment of
premiums pursuant to this Act shall be allocable to the
person's spenddown for purposes of the medical assistance
no grant program, but that person shall not be eligible
for any Plan benefits while that person remains eligible
for medical assistance. If the person continues to
receive or be approved to receive medical assistance
through the medical assistance no grant program at or
after the time that requirements for a preexisting
condition are satisfied, the person shall not be eligible
for coverage under the Plan. In that circumstance,
coverage under the plan shall terminate as of the
expiration of the preexisting condition limitation
period. Under all other circumstances, coverage under
the Plan shall automatically terminate as of the
effective date of any medical assistance.
(3) Except as provided in Section 15, the person
has previously participated in the Plan and voluntarily
terminated Plan coverage, unless 12 months have elapsed
since the person's latest voluntary termination of
coverage.
(4) The person fails to pay the required premium
under the covered person's terms of enrollment and
participation, in which event the liability of the Plan
shall be limited to benefits incurred under the Plan for
the time period for which premiums had been paid and the
covered person remained eligible for Plan coverage.
(5) The Plan has paid a total of $1,000,000 in
benefits on behalf of the covered person.
(6) The person is a resident of a public
institution.
(7) The person's premium is paid for or reimbursed
under any government sponsored program or by any
government agency or health care provider, except as an
otherwise qualifying full-time employee, or dependent of
such employee, of a government agency or health care
provider.
(8) The person has or later receives other benefits
or funds from any settlement, judgement, or award
resulting from any accident or injury, regardless of the
date of the accident or injury, or any other
circumstances creating a legal liability for damages due
that person by a third party, whether the settlement,
judgment, or award is in the form of a contract,
agreement, or trust on behalf of a minor or otherwise and
whether the settlement, judgment, or award is payable to
the person, his or her dependent, estate, personal
representative, or guardian in a lump sum or over time,
so long as there continues to be benefits or assets
remaining from those sources in an amount in excess of
$100,000.
(9) Within the 5 years prior to the date a person's
Plan application is received by the Board, the person's
coverage under any health care benefit program as defined
in 18 U.S.C. 24, including any public or private plan or
contract under which any medical benefit, item, or
service is provided, was terminated as a result of any
act or practice that constitutes fraud under State or
federal law or as a result of an intentional
misrepresentation of material fact; or if that person
knowingly and willfully obtained or attempted to obtain,
or fraudulently aided or attempted to aid any other
person in obtaining, any coverage or benefits under the
Plan to which that person was not entitled.
f. The board or the administrator shall require
verification of residency and may require any additional
information or documentation, or statements under oath, when
necessary to determine residency upon initial application and
for the entire term of the policy.
g. Coverage shall cease (i) on the date a person is no
longer a resident of Illinois, (ii) on the date a person
requests coverage to end, (iii) upon the death of the covered
person, (iv) on the date State law requires cancellation of
the policy, or (v) at the Plan's option, 30 days after the
Plan makes any inquiry concerning a person's eligibility or
place of residence to which the person does not reply.
h. Except under the conditions set forth in subsection g
of this Section, the coverage of any person who ceases to
meet the eligibility requirements of this Section shall be
terminated at the end of the current policy period for which
the necessary premiums have been paid.
(Source: P.A. 89-486, eff. 6-21-96; 90-30, eff. 7-1-97.)
(215 ILCS 105/8) (from Ch. 73, par. 1308)
Sec. 8. Minimum benefits.
a. Availability. The Plan shall offer in an annually
renewable policy major medical expense coverage to every
eligible person who is not eligible for Medicare. Major
medical expense coverage offered by the Plan shall pay an
eligible person's covered expenses, subject to limit on the
deductible and coinsurance payments authorized under
paragraph (4) of subsection d of this Section, up to a
lifetime benefit limit of $1,000,000 per covered individual.
The maximum limit under this subsection shall not be altered
by the Board, and no actuarial equivalent benefit may be
substituted by the Board. Any person who otherwise would
qualify for coverage under the Plan, but is excluded because
he or she is eligible for Medicare, shall be eligible for any
separate Medicare supplement policy or policies which the
Board may offer.
b. Outline of benefits. Covered expenses shall be
limited to the usual and customary charge, including
negotiated fees, in the locality for the following services
and articles when prescribed by a physician and determined by
the Plan to be medically necessary for the following areas of
services, subject to such separate deductibles, co-payments,
exclusions, and other limitations on benefits as the Board
shall establish and approve, and the other provisions of this
Section:
(1) Hospital services, except that any services
provided by a hospital that is located more than 75 miles
outside the State of Illinois shall be covered only for a
maximum of 45 days in any calendar year. With respect to
covered expenses incurred during any calendar year ending
on or after December 31, 1999, inpatient hospitalization
of an eligible person for the treatment of mental illness
at a hospital located within the State of Illinois shall
be subject to the same terms and conditions as for any
other illness.
(2) Professional services for the diagnosis or
treatment of injuries, illnesses or conditions, other
than dental and mental and nervous disorders as described
in paragraph (17), which are rendered by a physician, or
by other licensed professionals at the physician's
direction.
(2.5) Professional services provided by a physician
to children under the age of 16 years for physical
examinations and age appropriate immunizations ordered by
a physician licensed to practice medicine in all its
branches.
(3) (Blank).
(4) Outpatient prescription drugs that by law
require requiring a physician's prescription written by a
physician licensed to practice medicine in all its
branches subject to such separate deductible, copayment,
and other limitations or restrictions as the Board shall
approve, including the use of a prescription drug card or
any other program, or both.
(5) Skilled nursing services of a licensed skilled
nursing facility for not more than 120 days during a
policy year.
(6) Services of a home health agency in accord with
a home health care plan, up to a maximum of 270 visits
per year.
(7) Services of a licensed hospice for not more
than 180 days during a policy year.
(8) Use of radium or other radioactive materials.
(9) Oxygen.
(10) Anesthetics.
(11) Orthoses and prostheses other than dental.
(12) Rental or purchase in accordance with Board
policies or procedures of durable medical equipment,
other than eyeglasses or hearing aids, for which there is
no personal use in the absence of the condition for which
it is prescribed.
(13) Diagnostic x-rays and laboratory tests.
(14) Oral surgery for excision of partially or
completely unerupted impacted teeth or the gums and
tissues of the mouth, when not performed in connection
with the routine extraction or repair of teeth, that is
required to treat and oral surgery and procedures,
including orthodontics and prosthetics necessary for
craniofacial or maxillofacial conditions and to correct
congenital defects or injuries to natural teeth or a
fractured jaw due to an accident that occurred while a
covered person.
(15) Physical, speech, and functional occupational
therapy as medically necessary and provided by
appropriate licensed professionals.
(16) Emergency and other medically necessary
transportation provided by a licensed ambulance service
to the nearest health care facility qualified to treat a
covered illness, injury, or condition, subject to the
provisions of the Emergency Medical Systems (EMS) Act.
(17) Outpatient services for diagnosis and
treatment of mental and nervous disorders provided that a
covered person shall be required to make a copayment not
to exceed 50% and that the Plan's payment shall not
exceed such amounts as are established by the Board.
(18) Human organ or tissue transplants specified by
the Board that are performed at a hospital designated by
the Board as a participating transplant center for that
specific organ or tissue transplant.
(19) Naprapathic services, as appropriate, provided
by a licensed naprapathic practitioner.
c. Exclusions. Covered expenses of the Plan shall not
include the following:
(1) Any charge for treatment for cosmetic purposes
other than for reconstructive surgery when the service is
incidental to or follows surgery resulting from injury,
sickness or other diseases of the involved part or
surgery for the repair or treatment of a congenital
bodily defect to restore normal bodily functions.
(2) Any charge for care that is primarily for rest,
custodial, educational, or domiciliary purposes.
(3) Any charge for services in a private room to
the extent it is in excess of the institution's charge
for its most common semiprivate room, unless a private
room is prescribed as medically necessary by a physician.
(4) That part of any charge for room and board or
for services rendered or articles prescribed by a
physician, dentist, or other health care personnel that
exceeds the reasonable and customary charge in the
locality or for any services or supplies not medically
necessary for the diagnosed injury or illness.
(5) Any charge for services or articles the
provision of which is not within the scope of licensure
of the institution or individual providing the services
or articles.
(6) Any expense incurred prior to the effective
date of coverage by the Plan for the person on whose
behalf the expense is incurred.
(7) Dental care, dental surgery, dental treatment
or dental appliances, except as provided in paragraph
(14) of subsection b of this Section.
(8) Eyeglasses, contact lenses, hearing aids or
their fitting.
(9) Illness or injury due to acts of war.
(10) Services of blood donors and any fee for
failure to replace the first 3 pints of blood provided to
a covered person each policy year.
(11) Personal supplies or services provided by a
hospital or nursing home, or any other nonmedical or
nonprescribed supply or service.
(12) Routine maternity charges for a pregnancy,
except where added as optional coverage with payment of
an additional premium for pregnancy resulting from
conception occurring after the effective date of the
optional coverage.
(13) (Blank).
(14) Any expense or charge for services, drugs, or
supplies that are: (i) not provided in accord with
generally accepted standards of current medical practice;
(ii) for procedures, treatments, equipment, transplants,
or implants, any of which are investigational,
experimental, or for research purposes; (iii)
investigative and not proven safe and effective; or (iv)
for, or resulting from, a gender transformation
operation.
(15) Any expense or charge for routine physical
examinations or tests except as provided in item (2.5) of
subsection b of this Section.
(16) Any expense for which a charge is not made in
the absence of insurance or for which there is no legal
obligation on the part of the patient to pay.
(17) Any expense incurred for benefits provided
under the laws of the United States and this State,
including Medicare, and Medicaid, and other medical
assistance, maternal and child health services and any
other program that is administered or funded by the
Department of Human Services, Department of Public Aid,
or Department of Public Health, military
service-connected disability payments, medical services
provided for members of the armed forces and their
dependents or employees of the armed forces of the United
States, and medical services financed on behalf of all
citizens by the United States.
(18) Any expense or charge for in vitro
fertilization, artificial insemination, or any other
artificial means used to cause pregnancy.
(19) Any expense or charge for oral contraceptives
used for birth control or any other temporary birth
control measures.
(20) Any expense or charge for sterilization or
sterilization reversals.
(21) Any expense or charge for weight loss
programs, exercise equipment, or treatment of obesity,
except when certified by a physician as morbid obesity
(at least 2 times normal body weight).
(22) Any expense or charge for acupuncture
treatment unless used as an anesthetic agent for a
covered surgery.
(23) Any expense or charge for or related to organ
or tissue transplants other than those performed at a
hospital with a Board approved organ transplant program
that has been designated by the Board as a preferred or
exclusive provider organization for that specific organ
or tissue transplant.
(24) Any expense or charge for procedures,
treatments, equipment, or services that are provided in
special settings for research purposes or in a controlled
environment, are being studied for safety, efficiency,
and effectiveness, and are awaiting endorsement by the
appropriate national medical speciality college for
general use within the medical community.
d. Deductibles and coinsurance.
The Plan coverage defined in Section 6 shall provide for
a choice of deductibles per individual as authorized by the
Board. If 2 individual members of the same family household,
who are both covered persons under the Plan, satisfy the same
applicable deductibles, no other member of that family who is
also a covered person under the Plan shall be required to
meet any deductibles for the balance of that calendar year.
The deductibles must be applied first to the authorized
amount of covered expenses incurred by the covered person. A
mandatory coinsurance requirement shall be imposed at the
rate authorized by the Board in excess of the mandatory
deductible, the coinsurance in the aggregate not to exceed
such amounts as are authorized by the Board per annum. At
its discretion the Board may, however, offer catastrophic
coverages or other policies that provide for larger
deductibles with or without coinsurance requirements. The
deductibles and coinsurance factors may be adjusted annually
according to the Medical Component of the Consumer Price
Index.
e. Scope of coverage.
(1) In approving any of the benefit plans to be offered
by the Plan, the Board shall establish such benefit levels,
deductibles, coinsurance factors, exclusions, and limitations
as it may deem appropriate and that it believes to be
generally reflective of and commensurate with health
insurance coverage that is provided in the individual market
in this State.
(2) The benefit plans approved by the Board may also
provide for and employ various cost containment measures and
other requirements including, but not limited to,
preadmission certification, prior approval, second surgical
opinions, concurrent utilization review programs, individual
case management, preferred provider organizations, health
maintenance organizations, and other cost effective
arrangements for paying for covered expenses.
f. Preexisting conditions.
(1) Except for federally eligible individuals
qualifying for Plan coverage under Section 15 of this Act
or eligible persons who qualify for and elect to purchase
the waiver authorized in paragraph (3) of this
subsection, plan coverage shall exclude charges or
expenses incurred during the first 6 months following the
effective date of coverage as to any condition if: (a)
the condition had manifested itself within the 6 month
period immediately preceding the effective date of
coverage in such a manner as would cause an ordinarily
prudent person to seek diagnosis, care or treatment; or
(b) medical advice, care or treatment was recommended or
received within the 6 month period immediately preceding
the effective date of coverage.
(2) (Blank).
(3) (Blank) Waiver: The preexisting condition
exclusions as set forth in paragraph (1) of this
subsection shall be waived to the extent to which the
eligible person: (a) has satisfied similar exclusions
under any prior health insurance coverage or group health
plan that was involuntarily terminated; (b) is ineligible
for any continuation coverage that would continue or
provide substantially similar coverage following that
termination; and (c) has applied for Plan coverage not
later than 30 days following the involuntary termination.
No policy or plan shall be deemed to have been
involuntarily terminated if the master policyholder or
other controlling party elected to change insurance
coverage from one health insurance issuer or group health
plan to another even if that decision resulted in a
discontinuation of coverage for any individual under the
plan, either totally or for any medical condition. For
each eligible person who qualifies for and elects this
waiver, there shall be added to each payment of premium,
on a prorated basis, a surcharge of up to 10% of the
otherwise applicable annual premium for as long as that
individual's coverage under the Plan remains in effect or
60 months, whichever is less.
g. Other sources primary; nonduplication of benefits.
(1) The Plan shall be the last payor of benefits
whenever any other benefit or source of third party
payment is available. Subject to the provisions of
subsection e of Section 7, benefits otherwise payable
under Plan coverage shall be reduced by all amounts paid
or payable by Medicare or any other government program or
through any health insurance or group health plan,
whether by insurance, reimbursement, or otherwise, or
through any third party liability, settlement, judgment,
or award, regardless of the date of the settlement,
judgment, or award, whether the settlement, judgment, or
award is in the form of a contract, agreement, or trust
on behalf of a minor or otherwise and whether the
settlement, judgment, or award is payable to the covered
person, his or her dependent, estate, personal
representative, or guardian in a lump sum or over time,
and by all hospital or medical expense benefits paid or
payable under any worker's compensation coverage,
automobile medical payment, or liability insurance,
whether provided on the basis of fault or nonfault, and
by any hospital or medical benefits paid or payable under
or provided pursuant to any State or federal law or
program.
(2) The Plan shall have a cause of action against
any covered person or any other person or entity for the
recovery of any amount paid to the extent the amount was
for treatment, services, or supplies not covered in this
Section or in excess of benefits as set forth in this
Section.
(3) Whenever benefits are due from the Plan because
of sickness or an injury to a covered person resulting
from a third party's wrongful act or negligence and the
covered person has recovered or may recover damages from
a third party or its insurer, the Plan shall have the
right to reduce benefits or to refuse to pay benefits
that otherwise may be payable by the amount of damages
that the covered person has recovered or may recover
regardless of the date of the sickness or injury or the
date of any settlement, judgment, or award resulting from
that sickness or injury.
During the pendency of any action or claim that is
brought by or on behalf of a covered person against a
third party or its insurer, any benefits that would
otherwise be payable except for the provisions of this
paragraph (3) shall be paid if payment by or for the
third party has not yet been made and the covered person
or, if incapable, that person's legal representative
agrees in writing to pay back promptly the benefits paid
as a result of the sickness or injury to the extent of
any future payments made by or for the third party for
the sickness or injury. This agreement is to apply
whether or not liability for the payments is established
or admitted by the third party or whether those payments
are itemized.
Any amounts due the plan to repay benefits may be
deducted from other benefits payable by the Plan after
payments by or for the third party are made.
(4) Benefits due from the Plan may be reduced or
refused as an offset against any amount otherwise
recoverable under this Section.
h. Right of subrogation; recoveries.
(1) Whenever the Plan has paid benefits because of
sickness or an injury to any covered person resulting
from a third party's wrongful act or negligence, or for
which an insurer is liable in accordance with the
provisions of any policy of insurance, and the covered
person has recovered or may recover damages from a third
party that is liable for the damages, the Plan shall have
the right to recover the benefits it paid from any
amounts that the covered person has received or may
receive regardless of the date of the sickness or injury
or the date of any settlement, judgment, or award
resulting from that sickness or injury. The Plan shall
be subrogated to any right of recovery the covered person
may have under the terms of any private or public health
care coverage or liability coverage, including coverage
under the Workers' Compensation Act or the Workers'
Occupational Diseases Act, without the necessity of
assignment of claim or other authorization to secure the
right of recovery. To enforce its subrogation right, the
Plan may (i) intervene or join in an action or proceeding
brought by the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, against any third party
or the third party's insurer that may be liable or (ii)
institute and prosecute legal proceedings against any
third party or the third party's insurer that may be
liable for the sickness or injury in an appropriate court
either in the name of the Plan or in the name of the
covered person or his personal representative, including
his guardian, conservator, estate, dependents, or
survivors.
(2) If any action or claim is brought by or on
behalf of a covered person against a third party or the
third party's insurer, the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, shall notify the Plan
by personal service or registered mail of the action or
claim and of the name of the court in which the action or
claim is brought, filing proof thereof in the action or
claim. The Plan may, at any time thereafter, join in the
action or claim upon its motion so that all orders of
court after hearing and judgment shall be made for its
protection. No release or settlement of a claim for
damages and no satisfaction of judgment in the action
shall be valid without the written consent of the Plan to
the extent of its interest in the settlement or judgment
and of the covered person or his personal representative.
(3) In the event that the covered person or his
personal representative fails to institute a proceeding
against any appropriate third party before the fifth
month before the action would be barred, the Plan may, in
its own name or in the name of the covered person or
personal representative, commence a proceeding against
any appropriate third party for the recovery of damages
on account of any sickness, injury, or death to the
covered person. The covered person shall cooperate in
doing what is reasonably necessary to assist the Plan in
any recovery and shall not take any action that would
prejudice the Plan's right to recovery. The Plan shall
pay to the covered person or his personal representative
all sums collected from any third party by judgment or
otherwise in excess of amounts paid in benefits under the
Plan and amounts paid or to be paid as costs, attorneys
fees, and reasonable expenses incurred by the Plan in
making the collection or enforcing the judgment.
(4) In the event that a covered person or his
personal representative, including his guardian,
conservator, estate, dependents, or survivors, recovers
damages from a third party for sickness or injury caused
to the covered person, the covered person or the personal
representative shall pay to the Plan from the damages
recovered the amount of benefits paid or to be paid on
behalf of the covered person.
(5) When the action or claim is brought by the
covered person alone and the covered person incurs a
personal liability to pay attorney's fees and costs of
litigation, the Plan's claim for reimbursement of the
benefits provided to the covered person shall be the full
amount of benefits paid to or on behalf of the covered
person under this Act less a pro rata share that
represents the Plan's reasonable share of attorney's fees
paid by the covered person and that portion of the cost
of litigation expenses determined by multiplying by the
ratio of the full amount of the expenditures to the full
amount of the judgement, award, or settlement.
(6) In the event of judgment or award in a suit or
claim against a third party or insurer, the court shall
first order paid from any judgement or award the
reasonable litigation expenses incurred in preparation
and prosecution of the action or claim, together with
reasonable attorney's fees. After payment of those
expenses and attorney's fees, the court shall apply out
of the balance of the judgment or award an amount
sufficient to reimburse the Plan the full amount of
benefits paid on behalf of the covered person under this
Act, provided the court may reduce and apportion the
Plan's portion of the judgement proportionate to the
recovery of the covered person. The burden of producing
evidence sufficient to support the exercise by the court
of its discretion to reduce the amount of a proven charge
sought to be enforced against the recovery shall rest
with the party seeking the reduction. The court may
consider the nature and extent of the injury, economic
and non-economic loss, settlement offers, comparative
negligence as it applies to the case at hand, hospital
costs, physician costs, and all other appropriate costs.
The Plan shall pay its pro rata share of the attorney
fees based on the Plan's recovery as it compares to the
total judgment. Any reimbursement rights of the Plan
shall take priority over all other liens and charges
existing under the laws of this State with the exception
of any attorney liens filed under the Attorneys Lien Act.
(7) The Plan may compromise or settle and release
any claim for benefits provided under this Act or waive
any claims for benefits, in whole or in part, for the
convenience of the Plan or if the Plan determines that
collection would result in undue hardship upon the
covered person.
(Source: P.A. 89-486, eff. 6-21-96; 90-7, eff. 6-10-97;
90-30, eff. 7-1-97; 90-655, eff. 7-30-98.)
(215 ILCS 105/8.5 rep.)
Section 10. The Comprehensive Health Insurance Plan Act
is amended by repealing Section 8.5.
Section 99. Effective date. This Act takes effect upon
becoming law.
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