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91st General Assembly
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Public Act 91-0735

HB4433 Enrolled                                LRB9110326JSsb

    AN ACT concerning insurance coverage for certain  medical
conditions.

    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 2, 7, 8, and 11 as follows:

    (215 ILCS 105/2) (from Ch. 73, par. 1302)
    Sec.  2.   Definitions.   As used in this Act, unless the
context otherwise requires:
    "Plan administrator" means the  insurer  or  third  party
administrator designated under Section 5 of this Act.
    "Benefits  plan"  means the coverage to be offered by the
Plan to eligible persons and federally  eligible  individuals
pursuant to this Act.
    "Board" means the Illinois Comprehensive Health Insurance
Board.
    "Church plan" has the same meaning given that term in the
federal  Health  Insurance Portability and Accountability Act
of 1996.
    "Continuation coverage" means  continuation  of  coverage
under  a group health plan or other health insurance coverage
for former employees or dependents of former  employees  that
would  otherwise  have  terminated  under  the  terms of that
coverage  pursuant  to  any  continuation  provisions   under
federal  or  State  law,  including  the Consolidated Omnibus
Budget  Reconciliation  Act  of  1985  (COBRA),  as  amended,
Sections 367.2 and 367e of the Illinois  Insurance  Code,  or
any other similar requirement in another State.
    "Covered  person"  means a person who is and continues to
remain eligible for Plan coverage and is covered under one of
the benefit plans offered by the Plan.
    "Creditable coverage" means, with respect to a  federally
eligible  individual, coverage of the individual under any of
the following:
         (A)  A group health plan.
         (B)  Health  insurance  coverage  (including   group
    health insurance coverage).
         (C)  Medicare.
         (D)  Medical assistance.
         (E)  Chapter 55 of title 10, United States Code.
         (F)  A  medical  care  program  of the Indian Health
    Service or of a tribal organization.
         (G)  A state health benefits risk pool.
         (H)  A health plan offered under Chapter 89 of title
    5, United States Code.
         (I)  A public health plan (as defined in regulations
    consistent  with  Section  104   of   the   Health   Care
    Portability  and  Accountability  Act of 1996 that may be
    promulgated by the Secretary of the  U.S.  Department  of
    Health and Human Services).
         (J)  A health benefit plan under Section 5(e) of the
    Peace Corps Act (22 U.S.C. 2504(e)).
         (K)  Any  other  qualifying coverage required by the
    federal Health Insurance Portability  and  Accountability
    Act  of  1996, as it may be amended, or regulations under
    that Act.
    "Creditable   coverage"   does   not   include   coverage
consisting  solely  of  coverage  of  excepted  benefits  (as
defined in Section 2791(c)  of  title  XXVII  of  the  Public
Health  Service Act (42 U.S.C. 300 gg-91) nor does it include
any period of coverage under any of  items  (A)  through  (K)
that  occurred before a break of more than 63 days during all
of which the individual was not covered under  any  of  items
(A) through (K) above.  Any period that an individual is in a
waiting period for any coverage under a group health plan (or
for  group health insurance coverage) or is in an affiliation
period under the terms of health insurance  coverage  offered
by  a health maintenance organization shall not be taken into
account in determining if there has been a break of more than
63 days in any credible coverage.
    "Department" means the Illinois Department of Insurance.
    "Dependent" means an Illinois resident: who is a  spouse;
or who is claimed as a dependent by the principal insured for
purposes of filing a federal income tax return and resides in
the   principal   insured's  household,  and  is  a  resident
unmarried child under the age of  19  years;  or  who  is  an
unmarried child who also is a full-time student under the age
of  23  years  and  who  is  financially  dependent  upon the
principal insured; or who is a child of any age  and  who  is
disabled   and   financially  dependent  upon  the  principal
insured.
    "Direct Illinois premiums" means, for Illinois  business,
an  insurer's direct premium income for the kinds of business
described in clause (b) of Class 1 or clause (a) of  Class  2
of  Section  4  of  the  Illinois  Insurance Code, and direct
premium income of a  health  maintenance  organization  or  a
voluntary  health  services plan, except it shall not include
credit health insurance as defined in Article IX 1/2  of  the
Illinois Insurance Code.
    "Director"  means the Director of the Illinois Department
of Insurance.
    "Eligible person" means a  resident  of  this  State  who
qualifies for Plan coverage under Section 7 of this Act.
    "Employee" means a resident of this State who is employed
by an employer or has entered into the employment of or works
under  contract  or  service  of  an  employer  including the
officers, managers and employees of subsidiary or  affiliated
corporations  and  the  individual  proprietors, partners and
employees  of  affiliated  individuals  and  firms  when  the
business of the subsidiary or affiliated corporations,  firms
or  individuals  is  controlled  by a common employer through
stock ownership, contract, or otherwise.
    "Employer"    means    any    individual,    partnership,
association, corporation, business trust, or  any  person  or
group  of  persons  acting  directly  or  indirectly  in  the
interest of an employer in relation to an employee, for which
one or more persons is gainfully employed.
    "Family" coverage means the coverage provided by the Plan
for the covered person and his or her eligible dependents who
also are covered persons.
    "Federally   eligible  individual"  means  an  individual
resident of this State:
         (1)(A)  for whom,  as  of  the  date  on  which  the
    individual  seeks  Plan coverage under Section 15 of this
    Act, the aggregate of the periods of creditable  coverage
    is  18  or  more  months, and (B) whose most recent prior
    creditable coverage  was  under  group  health  insurance
    coverage  offered  by  a health insurance issuer, a group
    health plan, a governmental plan, or a  church  plan  (or
    health  insurance coverage offered in connection with any
    such plans) or any other type of creditable coverage that
    may  be  required  by  the   federal   Health   Insurance
    Portability  and Accountability Act of 1996, as it may be
    amended, or the regulations under that Act;
         (2)  who is not eligible for coverage  under  (A)  a
    group  health  plan, (B) part A or part B of Medicare, or
    (C) medical assistance, and does not  have  other  health
    insurance coverage;
         (3)  with  respect  to whom the most recent coverage
    within the coverage period described in paragraph  (1)(A)
    of this definition was not terminated based upon a factor
    relating to nonpayment of premiums or fraud;
         (4)  if  the  individual had been offered the option
    of  continuation  coverage  under  a  COBRA  continuation
    provision or under a similar State program,  who  elected
    such coverage; and
         (5)  who,    if    the   individual   elected   such
    continuation coverage, has  exhausted  such  continuation
    coverage under such provision or program.
    "Group  health  insurance  coverage" means, in connection
with a group health plan, health insurance  coverage  offered
in connection with that plan.
    "Group  health plan" has the same meaning given that term
in   the   federal   Health   Insurance    Portability    and
Accountability Act of 1996.
    "Governmental  plan" has the same meaning given that term
in   the   federal   Health   Insurance    Portability    and
Accountability Act of 1996.
    "Health  insurance coverage" means benefits consisting of
medical  care  (provided  directly,  through   insurance   or
reimbursement,  or otherwise and including items and services
paid for as medical care)  under  any  hospital  and  medical
expense-incurred policy, certificate, or contract provided by
an  insurer,  non-profit  health  care service plan contract,
health maintenance organization or other subscriber contract,
or any other health care plan or arrangement that pays for or
furnishes  medical  or  health  care  services   whether   by
insurance  or otherwise.  Health insurance coverage shall not
include  short  term,  accident  only,   disability   income,
hospital  confinement or fixed indemnity, dental only, vision
only, limited benefit, or credit insurance,  coverage  issued
as a supplement to liability insurance, insurance arising out
of   a  workers'  compensation  or  similar  law,  automobile
medical-payment insurance, or insurance under which  benefits
are  payable  with  or  without  regard to fault and which is
statutorily  required  to  be  contained  in  any   liability
insurance policy or equivalent self-insurance.
    "Health  insurance coverage" means benefits consisting of
medical  care  (provided  directly,  through   insurance   or
reimbursement,  or otherwise and including items and services
paid for as medical  care)  under  any  hospital  or  medical
service  policy  or  certificate, hospital or medical service
plan contract, or health  maintenance  organization  contract
offered by a health insurance issuer.
    "Health  insurance  issuer"  means  an insurance company,
insurance service, or  insurance  organization  (including  a
health   maintenance  organization  and  a  voluntary  health
services  plan)  that  is  authorized  to   transact   health
insurance business in this State.  Such term does not include
a group health plan.
    "Health  Maintenance  Organization" means an organization
as defined in the Health Maintenance Organization Act.
    "Hospice" means a program  as  defined  in  and  licensed
under the Hospice Program Licensing Act.
    "Hospital"  means  a duly licensed institution as defined
in the Hospital Licensing Act, an institution that meets  all
comparable conditions and requirements in effect in the state
in  which  it  is  located,  or  the  University  of Illinois
Hospital as defined in the University  of  Illinois  Hospital
Act.
    "Individual   health  insurance  coverage"  means  health
insurance coverage offered to individuals in  the  individual
market,  but  does  not  include short-term, limited-duration
insurance.
    "Insured" means any individual resident of this State who
is eligible to receive benefits from any  insurer  (including
health  insurance coverage offered in connection with a group
health plan) or health insurance issuer as  defined  in  this
Section.
    "Insurer"  means  any  insurance  company  authorized  to
transact  health  insurance  business  in  this State and any
corporation that provides medical services and  is  organized
under  the  Voluntary Health Services Plans Act or the Health
Maintenance Organization Act.
    "Medical assistance" means the State  medical  assistance
or medical assistance no grant (MANG) programs provided under
Title  XIX of the Social Security Act and Articles V (Medical
Assistance) and  VI  (General  Assistance)  of  the  Illinois
Public  Aid  Code  (or  any  successor  program) or under any
similar program of health care benefits in a state other than
Illinois.
    "Medically necessary" means  that  a  service,  drug,  or
supply  is  necessary  and  appropriate  for the diagnosis or
treatment of an illness or injury in  accord  with  generally
accepted  standards  of  medical  practice  at  the  time the
service, drug,  or  supply  is  provided.  When  specifically
applied  to a confinement it further means that the diagnosis
or treatment of the  covered  person's  medical  symptoms  or
condition  cannot  be  safely  provided  to that person as an
outpatient. A service, drug, or supply shall not be medically
necessary if it: (i) is investigational, experimental, or for
research  purposes;  or  (ii)  is  provided  solely  for  the
convenience of the patient, the patient's family,  physician,
hospital,  or  any other provider; or (iii) exceeds in scope,
duration, or intensity that level of care that is  needed  to
provide   safe,   adequate,   and  appropriate  diagnosis  or
treatment; or (iv) could have been omitted without  adversely
affecting  the  covered  person's condition or the quality of
medical care; or (v) involves the use of  a  medical  device,
drug, or substance not formally approved by the United States
Food and Drug Administration.
    "Medical  care" means the ordinary and usual professional
services rendered by a physician or other specified  provider
during  a  professional  visit for treatment of an illness or
injury.
    "Medicare" means coverage under both Part A and Part B of
Title XVIII of the Social Security Act, 42 U.S.C. Sec.  1395,
et seq.
    "Minimum  premium  plan"  means  an arrangement whereby a
specified amount of health care claims  is  self-funded,  but
the  insurance  company  assumes  the  risk  that claims will
exceed that amount.
    "Participating  transplant  center"  means   a   hospital
designated  by the Board as a preferred or exclusive provider
of services for one or more specified human organ  or  tissue
transplants  for  which  the hospital has signed an agreement
with the Board to accept a transplant payment  allowance  for
all  expenses  related  to the transplant during a transplant
benefit period.
    "Physician" means a person licensed to practice  medicine
pursuant to the Medical Practice Act of 1987.
    "Plan"  means  the  Comprehensive  Health  Insurance Plan
established by this Act.
    "Plan of operation" means the plan of  operation  of  the
Plan, including articles, bylaws and operating rules, adopted
by the board pursuant to this Act.
    "Provider"  means any hospital, skilled nursing facility,
hospice, home health agency, physician, registered pharmacist
acting within the scope of that registration,  or  any  other
person  or  entity  licensed  in  Illinois to furnish medical
care.
    "Qualified high risk pool" has  the  same  meaning  given
that  term  in  the  federal Health Insurance Portability and
Accountability Act of 1996.
    "Resident eligible person" means  a  person  who  is  and
continues  to  be  has  been legally domiciled and physically
residing on a permanent and full-time basis  in  a  place  of
permanent habitation in this State that remains that person's
principal residence and from which that person is absent only

for  temporary or transitory purpose for a period of at least
180 days and continues to be domiciled in this State.
    "Skilled nursing  facility"  means  a  facility  or  that
portion  of  a  facility  that  is  licensed  by the Illinois
Department of Public Health under the Nursing Home  Care  Act
or  a  comparable  licensing  authority  in  another state to
provide skilled nursing care.
    "Stop-loss coverage"  means  an  arrangement  whereby  an
insurer  insures  against  the  risk  that any one claim will
exceed a specific dollar amount or that the entire loss of  a
self-insurance plan will exceed a specific amount.
    "Third  party  administrator"  means  an administrator as
defined in Section 511.101 of the Illinois Insurance Code who
is licensed under Article XXXI 1/4 of that Code.
(Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99.)

    (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  who  has been for a
period of at least 180 days and continues to be a resident of
this State shall be eligible for  Plan  coverage  under  this
Section 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. 90-30, eff. 7-1-97; 91-639, eff. 8-20-99.)
    (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.  This includes reconstruction of the breast on
    which   a   mastectomy   was   performed;   surgery   and
    reconstruction  of  the  other  breast   to   produce   a
    symmetrical  appearance;  and prostheses and treatment of
    physical complications at all stages of  the  mastectomy,
    including lymphedemas.
         (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 a 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 (i) for excision of partially  or
    completely  unerupted  impacted teeth, when not performed
    in connection with the routine extraction  or  repair  of
    teeth;  (ii) for excision of tumors or cysts of the jaws,
    cheeks, lips, tongue, and roof and floor  of  the  mouth;
    (iii),  that  is required for correction of cleft lip and
    palate and other  craniofacial  and  maxillofacial  birth
    defects;  or  (iv)  for treatment of to treat 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,
    any  other  dental  procedure  involving  the  teeth   or
    periodontium, or any dental appliances, including crowns,
    bridges,  implants,  or  partial  or  complete  dentures,
    except  as  specifically  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,   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,  plan  coverage  shall  exclude  charges or expenses
    incurred  during  the  first  6  months   following   the
    effective  date of coverage as to any condition for which
    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  during  within  the  6 month period immediately
    preceding the effective date of coverage.
         (2)  (Blank).
         (3)  (Blank).
    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  coverage 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. 90-7, eff. 6-10-97; 90-30, eff. 7-1-97; 90-655,
eff. 7-30-98; 91-639, eff. 8-20-99.)

    (215 ILCS 105/11) (from Ch. 73, par. 1311)
    Sec. 11.   Plan  notice.   On  and  after  the  date  the
Illinois   Comprehensive   Health   Insurance   Plan  becomes
operational as provided in this Act, every  insurer  licensed
to issue, and which issues for delivery, policies of accident
and  health insurance in this State shall include a notice of
the existence of the Illinois Comprehensive Health  Insurance
Plan  in  any  rejection  of  any  application for individual
health insurance coverage as defined in this Act  for reasons
of the health of the applicant or any other  person  proposed
for  insurance  in such application.  Such notice shall be in
substantially  the  form  and  content  prescribed   by   the
Director.
(Source: P.A. 85-702.)

    Section  99.  Effective date.  This Act takes effect upon
becoming law.

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