HB3462 EngrossedLRB097 10590 RPM 50951 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Comprehensive Health Insurance Plan Act is
5amended by changing Section 8 as follows:
 
6    (215 ILCS 105/8)  (from Ch. 73, par. 1308)
7    Sec. 8. Minimum benefits.
8    a. Availability. The Plan shall offer in a periodically
9renewable policy major medical expense coverage to every
10eligible person who is not eligible for Medicare. Major medical
11expense coverage offered by the Plan shall pay an eligible
12person's covered expenses, subject to limit on the deductible
13and coinsurance payments authorized under paragraph (4) of
14subsection d of this Section, up to a lifetime benefit limit of
15$5,000,000. The maximum limit under this subsection shall not
16be altered by the Board, and no actuarial equivalent benefit
17may be substituted by the Board. Any person who otherwise would
18qualify for coverage under the Plan, but is excluded because he
19or she is eligible for Medicare, shall be eligible for any
20separate Medicare supplement policy or policies which the Board
21may offer.
22    b. Outline of benefits. Covered expenses shall be limited
23to the usual and customary charge, including negotiated fees,

 

 

HB3462 Engrossed- 2 -LRB097 10590 RPM 50951 b

1in the locality for the following services and articles when
2prescribed by a physician and determined by the Plan to be
3medically necessary for the following areas of services,
4subject to such separate deductibles, co-payments, exclusions,
5and other limitations on benefits as the Board shall establish
6and approve, and the other provisions of this Section:
7        (1) Hospital services, except that any services
8    provided by a hospital that is located more than 75 miles
9    outside the State of Illinois shall be covered only for a
10    maximum of 45 days in any calendar year. With respect to
11    covered expenses incurred during any calendar year ending
12    on or after December 31, 1999, inpatient hospitalization of
13    an eligible person for the treatment of mental illness at a
14    hospital located within the State of Illinois shall be
15    subject to the same terms and conditions as for any other
16    illness.
17        (2) Professional services for the diagnosis or
18    treatment of injuries, illnesses or conditions, other than
19    dental and mental and nervous disorders as described in
20    paragraph (17), which are rendered by a physician, or by
21    other licensed professionals at the physician's direction.
22    This includes reconstruction of the breast on which a
23    mastectomy was performed; surgery and reconstruction of
24    the other breast to produce a symmetrical appearance; and
25    prostheses and treatment of physical complications at all
26    stages of the mastectomy, including lymphedemas.

 

 

HB3462 Engrossed- 3 -LRB097 10590 RPM 50951 b

1        (2.5) Professional services provided by a physician to
2    children under the age of 16 years for physical
3    examinations and age appropriate immunizations ordered by
4    a physician licensed to practice medicine in all its
5    branches.
6        (3) (Blank).
7        (4) Outpatient prescription drugs that by law require a
8    prescription written by a physician licensed to practice
9    medicine in all its branches subject to such separate
10    deductible, copayment, and other limitations or
11    restrictions as the Board shall approve, including the use
12    of a prescription drug card or any other program, or both.
13        (5) Skilled nursing services of a licensed skilled
14    nursing facility for not more than 120 days during a policy
15    year.
16        (6) Services of a home health agency in accord with a
17    home health care plan, up to a maximum of 270 visits per
18    year.
19        (7) Services of a licensed hospice for not more than
20    180 days during a policy year.
21        (8) Use of radium or other radioactive materials.
22        (9) Oxygen.
23        (10) Anesthetics.
24        (11) Orthoses and prostheses other than dental.
25        (12) Rental or purchase in accordance with Board
26    policies or procedures of durable medical equipment, other

 

 

HB3462 Engrossed- 4 -LRB097 10590 RPM 50951 b

1    than eyeglasses or hearing aids, for which there is no
2    personal use in the absence of the condition for which it
3    is prescribed.
4        (13) Diagnostic x-rays and laboratory tests.
5        (14) Oral surgery (i) for excision of partially or
6    completely unerupted impacted teeth when not performed in
7    connection with the routine extraction or repair of teeth;
8    (ii) for excision of tumors or cysts of the jaws, cheeks,
9    lips, tongue, and roof and floor of the mouth; (iii)
10    required for correction of cleft lip and palate and other
11    craniofacial and maxillofacial birth defects; or (iv) for
12    treatment of injuries to natural teeth or a fractured jaw
13    due to an accident.
14        (15) Physical, speech, and functional occupational
15    therapy as medically necessary and provided by appropriate
16    licensed professionals.
17        (16) Emergency and other medically necessary
18    transportation provided by a licensed ambulance service to
19    the nearest health care facility qualified to treat a
20    covered illness, injury, or condition, subject to the
21    provisions of the Emergency Medical Systems (EMS) Act.
22        (17) Outpatient services for diagnosis and treatment
23    of mental and nervous disorders provided that a covered
24    person shall be required to make a copayment not to exceed
25    50% and that the Plan's payment shall not exceed such
26    amounts as are established by the Board.

 

 

HB3462 Engrossed- 5 -LRB097 10590 RPM 50951 b

1        (18) Human organ or tissue transplants specified by the
2    Board that are performed at a hospital designated by the
3    Board as a participating transplant center for that
4    specific organ or tissue transplant.
5        (19) Naprapathic services, as appropriate, provided by
6    a licensed naprapathic practitioner.
7    c. Exclusions. Covered expenses of the Plan shall not
8include the following:
9        (1) Any charge for treatment for cosmetic purposes
10    other than for reconstructive surgery when the service is
11    incidental to or follows surgery resulting from injury,
12    sickness or other diseases of the involved part or surgery
13    for the repair or treatment of a congenital bodily defect
14    to restore normal bodily functions.
15        (2) Any charge for care that is primarily for rest,
16    custodial, educational, or domiciliary purposes.
17        (3) Any charge for services in a private room to the
18    extent it is in excess of the institution's charge for its
19    most common semiprivate room, unless a private room is
20    prescribed as medically necessary by a physician.
21        (4) That part of any charge for room and board or for
22    services rendered or articles prescribed by a physician,
23    dentist, or other health care personnel that exceeds the
24    reasonable and customary charge in the locality or for any
25    services or supplies not medically necessary for the
26    diagnosed injury or illness.

 

 

HB3462 Engrossed- 6 -LRB097 10590 RPM 50951 b

1        (5) Any charge for services or articles the provision
2    of which is not within the scope of licensure of the
3    institution or individual providing the services or
4    articles.
5        (6) Any expense incurred prior to the effective date of
6    coverage by the Plan for the person on whose behalf the
7    expense is incurred.
8        (7) Dental care, dental surgery, dental treatment, any
9    other dental procedure involving the teeth or
10    periodontium, or any dental appliances, including crowns,
11    bridges, implants, or partial or complete dentures, except
12    as specifically provided in paragraph (14) of subsection b
13    of this Section.
14        (8) Eyeglasses, contact lenses, hearing aids or their
15    fitting.
16        (9) Illness or injury due to acts of war.
17        (10) Services of blood donors and any fee for failure
18    to replace the first 3 pints of blood provided to a covered
19    person each policy year.
20        (11) Personal supplies or services provided by a
21    hospital or nursing home, or any other nonmedical or
22    nonprescribed supply or service.
23        (12) Routine maternity charges for a pregnancy, except
24    where added as optional coverage with payment of an
25    additional premium for pregnancy resulting from conception
26    occurring after the effective date of the optional

 

 

HB3462 Engrossed- 7 -LRB097 10590 RPM 50951 b

1    coverage.
2        (13) (Blank).
3        (14) Any expense or charge for services, drugs, or
4    supplies that are: (i) not provided in accord with
5    generally accepted standards of current medical practice;
6    (ii) for procedures, treatments, equipment, transplants,
7    or implants, any of which are investigational,
8    experimental, or for research purposes; (iii)
9    investigative and not proven safe and effective; or (iv)
10    for, or resulting from, a gender transformation operation.
11        (15) (Blank) Any expense or charge for routine physical
12    examinations or tests except as provided in item (2.5) of
13    subsection b of this Section.
14        (16) Any expense for which a charge is not made in the
15    absence of insurance or for which there is no legal
16    obligation on the part of the patient to pay.
17        (17) Any expense incurred for benefits provided under
18    the laws of the United States and this State, including
19    Medicare, Medicaid, and other medical assistance, maternal
20    and child health services and any other program that is
21    administered or funded by the Department of Human Services,
22    Department of Healthcare and Family Services, or
23    Department of Public Health, military service-connected
24    disability payments, medical services provided for members
25    of the armed forces and their dependents or employees of
26    the armed forces of the United States, and medical services

 

 

HB3462 Engrossed- 8 -LRB097 10590 RPM 50951 b

1    financed on behalf of all citizens by the United States.
2        (18) Any expense or charge for in vitro fertilization,
3    artificial insemination, or any other artificial means
4    used to cause pregnancy.
5        (19) Any expense or charge for oral contraceptives used
6    for birth control or any other temporary birth control
7    measures.
8        (20) Any expense or charge for sterilization or
9    sterilization reversals.
10        (21) Any expense or charge for weight loss programs,
11    exercise equipment, or treatment of obesity, except when
12    certified by a physician as morbid obesity (at least 2
13    times normal body weight).
14        (22) Any expense or charge for acupuncture treatment
15    unless used as an anesthetic agent for a covered surgery.
16        (23) Any expense or charge for or related to organ or
17    tissue transplants other than those performed at a hospital
18    with a Board approved organ transplant program that has
19    been designated by the Board as a preferred or exclusive
20    provider organization for that specific organ or tissue
21    transplant.
22        (24) Any expense or charge for procedures, treatments,
23    equipment, or services that are provided in special
24    settings for research purposes or in a controlled
25    environment, are being studied for safety, efficiency, and
26    effectiveness, and are awaiting endorsement by the

 

 

HB3462 Engrossed- 9 -LRB097 10590 RPM 50951 b

1    appropriate national medical speciality college for
2    general use within the medical community.
3    d. Deductibles and coinsurance.
4    The Plan coverage defined in Section 6 shall provide for a
5choice of deductibles per individual as authorized by the
6Board. If 2 individual members of the same family household,
7who are both covered persons under the Plan, satisfy the same
8applicable deductibles, no other member of that family who is
9also a covered person under the Plan shall be required to meet
10any deductibles for the balance of that calendar year. The
11deductibles must be applied first to the authorized amount of
12covered expenses incurred by the covered person. A mandatory
13coinsurance requirement shall be imposed at the rate authorized
14by the Board in excess of the mandatory deductible, the
15coinsurance in the aggregate not to exceed such amounts as are
16authorized by the Board per annum. At its discretion the Board
17may, however, offer catastrophic coverages or other policies
18that provide for larger deductibles with or without coinsurance
19requirements. The deductibles and coinsurance factors may be
20adjusted annually according to the Medical Component of the
21Consumer Price Index.
22    e. Scope of coverage.
23        (1) In approving any of the benefit plans to be offered
24    by the Plan, the Board shall establish such benefit levels,
25    deductibles, coinsurance factors, exclusions, and
26    limitations as it may deem appropriate and that it believes

 

 

HB3462 Engrossed- 10 -LRB097 10590 RPM 50951 b

1    to be generally reflective of and commensurate with health
2    insurance coverage that is provided in the individual
3    market in this State.
4        (2) The benefit plans approved by the Board may also
5    provide for and employ various cost containment measures
6    and other requirements including, but not limited to,
7    preadmission certification, prior approval, second
8    surgical opinions, concurrent utilization review programs,
9    individual case management, preferred provider
10    organizations, health maintenance organizations, and other
11    cost effective arrangements for paying for covered
12    expenses.
13    f. Preexisting conditions.
14        (1) Except for federally eligible individuals
15    qualifying for Plan coverage under Section 15 of this Act
16    or eligible persons who qualify for the waiver authorized
17    in paragraph (3) of this subsection, plan coverage shall
18    exclude charges or expenses incurred during the first 6
19    months following the effective date of coverage as to any
20    condition for which medical advice, care or treatment was
21    recommended or received during the 6 month period
22    immediately preceding the effective date of coverage.
23        (2) (Blank).
24        (3) Waiver: The preexisting condition exclusions as
25    set forth in paragraph (1) of this subsection shall be
26    waived to the extent to which the eligible person (a) has

 

 

HB3462 Engrossed- 11 -LRB097 10590 RPM 50951 b

1    satisfied similar exclusions under any prior individual
2    health insurance policy that was involuntarily terminated
3    because of the insolvency of the issuer of the policy and
4    (b) has applied for Plan coverage within 90 days following
5    the involuntary termination of that individual health
6    insurance coverage.
7        (4) Waiver: The preexisting condition exclusions as
8    set forth in paragraph (1) of this subsection shall be
9    waived to the extent to which the eligible person (a) has
10    satisfied the exclusion under prior Comprehensive Health
11    Insurance Plan coverage that was involuntarily terminated
12    because of meeting a lower lifetime benefit limit and (b)
13    has reapplied for Plan coverage within 90 days following an
14    increase in the lifetime benefit limit set forth in Section
15    8 of this Act.
16    g. Other sources primary; nonduplication of benefits.
17        (1) The Plan shall be the last payor of benefits
18    whenever any other benefit or source of third party payment
19    is available. Subject to the provisions of subsection e of
20    Section 7, benefits otherwise payable under Plan coverage
21    shall be reduced by all amounts paid or payable by Medicare
22    or any other government program or through any health
23    insurance coverage or group health plan, whether by
24    insurance, reimbursement, or otherwise, or through any
25    third party liability, settlement, judgment, or award,
26    regardless of the date of the settlement, judgment, or

 

 

HB3462 Engrossed- 12 -LRB097 10590 RPM 50951 b

1    award, whether the settlement, judgment, or award is in the
2    form of a contract, agreement, or trust on behalf of a
3    minor or otherwise and whether the settlement, judgment, or
4    award is payable to the covered person, his or her
5    dependent, estate, personal representative, or guardian in
6    a lump sum or over time, and by all hospital or medical
7    expense benefits paid or payable under any worker's
8    compensation coverage, automobile medical payment, or
9    liability insurance, whether provided on the basis of fault
10    or nonfault, and by any hospital or medical benefits paid
11    or payable under or provided pursuant to any State or
12    federal law or program.
13        (2) The Plan shall have a cause of action against any
14    covered person or any other person or entity for the
15    recovery of any amount paid to the extent the amount was
16    for treatment, services, or supplies not covered in this
17    Section or in excess of benefits as set forth in this
18    Section.
19        (3) Whenever benefits are due from the Plan because of
20    sickness or an injury to a covered person resulting from a
21    third party's wrongful act or negligence and the covered
22    person has recovered or may recover damages from a third
23    party or its insurer, the Plan shall have the right to
24    reduce benefits or to refuse to pay benefits that otherwise
25    may be payable by the amount of damages that the covered
26    person has recovered or may recover regardless of the date

 

 

HB3462 Engrossed- 13 -LRB097 10590 RPM 50951 b

1    of the sickness or injury or the date of any settlement,
2    judgment, or award resulting from that sickness or injury.
3        During the pendency of any action or claim that is
4    brought by or on behalf of a covered person against a third
5    party or its insurer, any benefits that would otherwise be
6    payable except for the provisions of this paragraph (3)
7    shall be paid if payment by or for the third party has not
8    yet been made and the covered person or, if incapable, that
9    person's legal representative agrees in writing to pay back
10    promptly the benefits paid as a result of the sickness or
11    injury to the extent of any future payments made by or for
12    the third party for the sickness or injury. This agreement
13    is to apply whether or not liability for the payments is
14    established or admitted by the third party or whether those
15    payments are itemized.
16        Any amounts due the plan to repay benefits may be
17    deducted from other benefits payable by the Plan after
18    payments by or for the third party are made.
19        (4) Benefits due from the Plan may be reduced or
20    refused as an offset against any amount otherwise
21    recoverable under this Section.
22    h. Right of subrogation; recoveries.
23        (1) Whenever the Plan has paid benefits because of
24    sickness or an injury to any covered person resulting from
25    a third party's wrongful act or negligence, or for which an
26    insurer is liable in accordance with the provisions of any

 

 

HB3462 Engrossed- 14 -LRB097 10590 RPM 50951 b

1    policy of insurance, and the covered person has recovered
2    or may recover damages from a third party that is liable
3    for the damages, the Plan shall have the right to recover
4    the benefits it paid from any amounts that the covered
5    person has received or may receive regardless of the date
6    of the sickness or injury or the date of any settlement,
7    judgment, or award resulting from that sickness or injury.
8    The Plan shall be subrogated to any right of recovery the
9    covered person may have under the terms of any private or
10    public health care coverage or liability coverage,
11    including coverage under the Workers' Compensation Act or
12    the Workers' Occupational Diseases Act, without the
13    necessity of assignment of claim or other authorization to
14    secure the right of recovery. To enforce its subrogation
15    right, the Plan may (i) intervene or join in an action or
16    proceeding brought by the covered person or his personal
17    representative, including his guardian, conservator,
18    estate, dependents, or survivors, against any third party
19    or the third party's insurer that may be liable or (ii)
20    institute and prosecute legal proceedings against any
21    third party or the third party's insurer that may be liable
22    for the sickness or injury in an appropriate court either
23    in the name of the Plan or in the name of the covered
24    person or his personal representative, including his
25    guardian, conservator, estate, dependents, or survivors.
26        (2) If any action or claim is brought by or on behalf

 

 

HB3462 Engrossed- 15 -LRB097 10590 RPM 50951 b

1    of a covered person against a third party or the third
2    party's insurer, the covered person or his personal
3    representative, including his guardian, conservator,
4    estate, dependents, or survivors, shall notify the Plan by
5    personal service or registered mail of the action or claim
6    and of the name of the court in which the action or claim
7    is brought, filing proof thereof in the action or claim.
8    The Plan may, at any time thereafter, join in the action or
9    claim upon its motion so that all orders of court after
10    hearing and judgment shall be made for its protection. No
11    release or settlement of a claim for damages and no
12    satisfaction of judgment in the action shall be valid
13    without the written consent of the Plan to the extent of
14    its interest in the settlement or judgment and of the
15    covered person or his personal representative.
16        (3) In the event that the covered person or his
17    personal representative fails to institute a proceeding
18    against any appropriate third party before the fifth month
19    before the action would be barred, the Plan may, in its own
20    name or in the name of the covered person or personal
21    representative, commence a proceeding against any
22    appropriate third party for the recovery of damages on
23    account of any sickness, injury, or death to the covered
24    person. The covered person shall cooperate in doing what is
25    reasonably necessary to assist the Plan in any recovery and
26    shall not take any action that would prejudice the Plan's

 

 

HB3462 Engrossed- 16 -LRB097 10590 RPM 50951 b

1    right to recovery. The Plan shall pay to the covered person
2    or his personal representative all sums collected from any
3    third party by judgment or otherwise in excess of amounts
4    paid in benefits under the Plan and amounts paid or to be
5    paid as costs, attorneys fees, and reasonable expenses
6    incurred by the Plan in making the collection or enforcing
7    the judgment.
8        (4) In the event that a covered person or his personal
9    representative, including his guardian, conservator,
10    estate, dependents, or survivors, recovers damages from a
11    third party for sickness or injury caused to the covered
12    person, the covered person or the personal representative
13    shall pay to the Plan from the damages recovered the amount
14    of benefits paid or to be paid on behalf of the covered
15    person.
16        (5) When the action or claim is brought by the covered
17    person alone and the covered person incurs a personal
18    liability to pay attorney's fees and costs of litigation,
19    the Plan's claim for reimbursement of the benefits provided
20    to the covered person shall be the full amount of benefits
21    paid to or on behalf of the covered person under this Act
22    less a pro rata share that represents the Plan's reasonable
23    share of attorney's fees paid by the covered person and
24    that portion of the cost of litigation expenses determined
25    by multiplying by the ratio of the full amount of the
26    expenditures to the full amount of the judgement, award, or

 

 

HB3462 Engrossed- 17 -LRB097 10590 RPM 50951 b

1    settlement.
2        (6) In the event of judgment or award in a suit or
3    claim against a third party or insurer, the court shall
4    first order paid from any judgement or award the reasonable
5    litigation expenses incurred in preparation and
6    prosecution of the action or claim, together with
7    reasonable attorney's fees. After payment of those
8    expenses and attorney's fees, the court shall apply out of
9    the balance of the judgment or award an amount sufficient
10    to reimburse the Plan the full amount of benefits paid on
11    behalf of the covered person under this Act, provided the
12    court may reduce and apportion the Plan's portion of the
13    judgement proportionate to the recovery of the covered
14    person. The burden of producing evidence sufficient to
15    support the exercise by the court of its discretion to
16    reduce the amount of a proven charge sought to be enforced
17    against the recovery shall rest with the party seeking the
18    reduction. The court may consider the nature and extent of
19    the injury, economic and non-economic loss, settlement
20    offers, comparative negligence as it applies to the case at
21    hand, hospital costs, physician costs, and all other
22    appropriate costs. The Plan shall pay its pro rata share of
23    the attorney fees based on the Plan's recovery as it
24    compares to the total judgment. Any reimbursement rights of
25    the Plan shall take priority over all other liens and
26    charges existing under the laws of this State with the

 

 

HB3462 Engrossed- 18 -LRB097 10590 RPM 50951 b

1    exception of any attorney liens filed under the Attorneys
2    Lien Act.
3        (7) The Plan may compromise or settle and release any
4    claim for benefits provided under this Act or waive any
5    claims for benefits, in whole or in part, for the
6    convenience of the Plan or if the Plan determines that
7    collection would result in undue hardship upon the covered
8    person.
9(Source: P.A. 95-547, eff. 8-29-07; 96-791, eff. 9-25-09;
1096-938, eff. 6-24-10.)