Illinois General Assembly - Full Text of HB1559
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Full Text of HB1559  97th General Assembly




State of Illinois
2011 and 2012


Introduced 2/15/2011, by Rep. Robyn Gabel


215 ILCS 105/1.1  from Ch. 73, par. 1301.1
215 ILCS 105/2  from Ch. 73, par. 1302
215 ILCS 105/4  from Ch. 73, par. 1304
215 ILCS 105/7  from Ch. 73, par. 1307
215 ILCS 105/12  from Ch. 73, par. 1312

    Amends the Comprehensive Health Insurance Plan Act. Deletes language that provides that the State may subsidize the cost of health insurance coverage offered by the Comprehensive Health Insurance Plan. Makes changes to the definition of "dependent". In the provisions concerning powers and authority of the board and eligibility, changes references of "appropriated funds" to "assessments". Deletes language that provides that any deficit incurred or expected to be incurred on behalf of eligible persons who qualify for plan coverage shall be recouped by an appropriation made by the General Assembly. Makes other changes. Effective immediately.

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HB1559LRB097 08646 RPM 48775 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 Sections 1.1, 2, 4, 7, and 12 as follows:
6    (215 ILCS 105/1.1)  (from Ch. 73, par. 1301.1)
7    Sec. 1.1. The General Assembly hereby makes the following
8findings and declarations:
9    (a) The Comprehensive Health Insurance Plan is established
10as a State program that is intended to provide an alternate
11market for health insurance for certain uninsurable Illinois
12residents, and further is intended to provide an acceptable
13alternative mechanism as described in the federal Health
14Insurance Portability and Accountability Act of 1996 for
15providing portable and accessible individual health insurance
16coverage for federally eligible individuals as defined in this
18    (b) The State of Illinois may subsidize the cost of health
19insurance coverage offered by the Plan. However, since the
20State has only a limited amount of resources, the General
21Assembly declares that it intends for this program to provide
22portable and accessible individual health insurance coverage
23for every federally eligible individual who qualifies for



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1coverage in accordance with Section 15 of this Act, but does
2not intend for every eligible person who qualifies for Plan
3coverage in accordance with Section 7 of this Act to be
4guaranteed a right to be issued a policy under this Plan as a
5matter of entitlement.
6    (c) The Comprehensive Health Insurance Plan Board shall
7operate the Plan in a manner so that the estimated cost of the
8program during any fiscal year will not exceed the total income
9it expects to receive from policy premiums, investment income,
10assessments, or fees collected or received by the Board and
11other funds which are made available from appropriations for
12the Plan by the General Assembly for that fiscal year.
13(Source: P.A. 90-30, eff. 7-1-97.)
14    (215 ILCS 105/2)  (from Ch. 73, par. 1302)
15    Sec. 2. Definitions. As used in this Act, unless the
16context otherwise requires:
17    "Plan administrator" means the insurer or third party
18administrator designated under Section 5 of this Act.
19    "Benefits plan" means the coverage to be offered by the
20Plan to eligible persons and federally eligible individuals
21pursuant to this Act.
22    "Board" means the Illinois Comprehensive Health Insurance
24    "Church plan" has the same meaning given that term in the
25federal Health Insurance Portability and Accountability Act of



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2    "Continuation coverage" means continuation of coverage
3under a group health plan or other health insurance coverage
4for former employees or dependents of former employees that
5would otherwise have terminated under the terms of that
6coverage pursuant to any continuation provisions under federal
7or State law, including the Consolidated Omnibus Budget
8Reconciliation Act of 1985 (COBRA), as amended, Sections 367.2,
9367e, and 367e.1 of the Illinois Insurance Code, or any other
10similar requirement in another State.
11    "Covered person" means a person who is and continues to
12remain eligible for Plan coverage and is covered under one of
13the benefit plans offered by the Plan.
14    "Creditable coverage" means, with respect to a federally
15eligible individual, coverage of the individual under any of
16the following:
17        (A) A group health plan.
18        (B) Health insurance coverage (including group health
19    insurance coverage).
20        (C) Medicare.
21        (D) Medical assistance.
22        (E) Chapter 55 of title 10, United States Code.
23        (F) A medical care program of the Indian Health Service
24    or of a tribal organization.
25        (G) A state health benefits risk pool.
26        (H) A health plan offered under Chapter 89 of title 5,



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1    United States Code.
2        (I) A public health plan (as defined in regulations
3    consistent with Section 104 of the Health Care Portability
4    and Accountability Act of 1996 that may be promulgated by
5    the Secretary of the U.S. Department of Health and Human
6    Services).
7        (J) A health benefit plan under Section 5(e) of the
8    Peace Corps Act (22 U.S.C. 2504(e)).
9        (K) Any other qualifying coverage required by the
10    federal Health Insurance Portability and Accountability
11    Act of 1996, as it may be amended, or regulations under
12    that Act.
13    "Creditable coverage" does not include coverage consisting
14solely of coverage of excepted benefits, as defined in Section
152791(c) of title XXVII of the Public Health Service Act (42
16U.S.C. 300 gg-91), nor does it include any period of coverage
17under any of items (A) through (K) that occurred before a break
18of more than 90 days or, if the individual has been certified
19as eligible pursuant to the federal Trade Act of 2002, a break
20of more than 63 days during all of which the individual was not
21covered under any of items (A) through (K) above.
22    Any period that an individual is in a waiting period for
23any coverage under a group health plan (or for group health
24insurance coverage) or is in an affiliation period under the
25terms of health insurance coverage offered by a health
26maintenance organization shall not be taken into account in



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1determining if there has been a break of more than 90 days in
2any creditable coverage.
3    "Department" means the Illinois Department of Insurance.
4    "Dependent" means an Illinois resident: who is a spouse; or
5who is an claimed as a dependent by the principal insured for
6purposes of filing a federal income tax return and resides in
7the principal insured's household, and is a resident unmarried
8child under the age of 26 19 years; or who is an unmarried
9child who also is a full-time student under the age of 23 years
10and who is financially dependent upon the principal insured; or
11who is an unmarried child under the age of 30 years if the
12child (i) is an Illinois resident, (ii) served as a member of
13the active or reserve components of any of the branches of the
14Armed Forces of the United States, and (iii) has received a
15release or discharge other than a dishonorable discharge; or
16who is a child of any age and who is disabled and financially
17dependent upon the principal insured.
18    "Direct Illinois premiums" means, for Illinois business,
19an insurer's direct premium income for the kinds of business
20described in clause (b) of Class 1 or clause (a) of Class 2 of
21Section 4 of the Illinois Insurance Code, and direct premium
22income of a health maintenance organization or a voluntary
23health services plan, except it shall not include credit health
24insurance as defined in Article IX 1/2 of the Illinois
25Insurance Code.
26    "Director" means the Director of the Illinois Department of



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2    "Effective date of medical assistance" means the date that
3eligibility for medical assistance for a person is approved by
4the Department of Human Services or the Department of
5Healthcare and Family Services, except when the Department of
6Human Services or the Department of Healthcare and Family
7Services determines eligibility retroactively. In such
8circumstances, the effective date of the medical assistance is
9the date the Department of Human Services or the Department of
10Healthcare and Family Services determines the person to be
11eligible for medical assistance.
12    "Eligible person" means a resident of this State who
13qualifies for Plan coverage under Section 7 of this Act.
14    "Employee" means a resident of this State who is employed
15by an employer or has entered into the employment of or works
16under contract or service of an employer including the
17officers, managers and employees of subsidiary or affiliated
18corporations and the individual proprietors, partners and
19employees of affiliated individuals and firms when the business
20of the subsidiary or affiliated corporations, firms or
21individuals is controlled by a common employer through stock
22ownership, contract, or otherwise.
23    "Employer" means any individual, partnership, association,
24corporation, business trust, or any person or group of persons
25acting directly or indirectly in the interest of an employer in
26relation to an employee, for which one or more persons is



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1gainfully employed.
2    "Family" coverage means the coverage provided by the Plan
3for the covered person and his or her eligible dependents who
4also are covered persons.
5    "Federally eligible individual" means an individual
6resident of this State:
7        (1)(A) for whom, as of the date on which the individual
8    seeks Plan coverage under Section 15 of this Act, the
9    aggregate of the periods of creditable coverage is 18 or
10    more months or, if the individual has been certified as
11    eligible pursuant to the federal Trade Act of 2002, 3 or
12    more months, and (B) whose most recent prior creditable
13    coverage was under group health insurance coverage offered
14    by a health insurance issuer, a group health plan, a
15    governmental plan, or a church plan (or health insurance
16    coverage offered in connection with any such plans) or any
17    other type of creditable coverage that may be required by
18    the federal Health Insurance Portability and
19    Accountability Act of 1996, as it may be amended, or the
20    regulations under that Act;
21        (2) who is not eligible for coverage under (A) a group
22    health plan (other than an individual who has been
23    certified as eligible pursuant to the federal Trade Act of
24    2002), (B) part A or part B of Medicare due to age (other
25    than an individual who has been certified as eligible
26    pursuant to the federal Trade Act of 2002), or (C) medical



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1    assistance, and does not have other health insurance
2    coverage (other than an individual who has been certified
3    as eligible pursuant to the federal Trade Act of 2002);
4        (3) with respect to whom (other than an individual who
5    has been certified as eligible pursuant to the federal
6    Trade Act of 2002) the most recent coverage within the
7    coverage period described in paragraph (1)(A) of this
8    definition was not terminated based upon a factor relating
9    to nonpayment of premiums or fraud;
10        (4) if the individual (other than an individual who has
11    been certified as eligible pursuant to the federal Trade
12    Act of 2002) had been offered the option of continuation
13    coverage under a COBRA continuation provision or under a
14    similar State program, who elected such coverage; and
15        (5) who, if the individual elected such continuation
16    coverage, has exhausted such continuation coverage under
17    such provision or program.
18    However, an individual who has been certified as eligible
19pursuant to the federal Trade Act of 2002 shall not be required
20to elect continuation coverage under a COBRA continuation
21provision or under a similar state program.
22    "Group health insurance coverage" means, in connection
23with a group health plan, health insurance coverage offered in
24connection with that plan.
25    "Group health plan" has the same meaning given that term in
26the federal Health Insurance Portability and Accountability



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1Act of 1996.
2    "Governmental plan" has the same meaning given that term in
3the federal Health Insurance Portability and Accountability
4Act of 1996.
5    "Health insurance coverage" means benefits consisting of
6medical care (provided directly, through insurance or
7reimbursement, or otherwise and including items and services
8paid for as medical care) under any hospital and medical
9expense-incurred policy, certificate, or contract provided by
10an insurer, non-profit health care service plan contract,
11health maintenance organization or other subscriber contract,
12or any other health care plan or arrangement that pays for or
13furnishes medical or health care services whether by insurance
14or otherwise. Health insurance coverage shall not include short
15term, accident only, disability income, hospital confinement
16or fixed indemnity, dental only, vision only, limited benefit,
17or credit insurance, coverage issued as a supplement to
18liability insurance, insurance arising out of a workers'
19compensation or similar law, automobile medical-payment
20insurance, or insurance under which benefits are payable with
21or without regard to fault and which is statutorily required to
22be contained in any liability insurance policy or equivalent
24    "Health insurance issuer" means an insurance company,
25insurance service, or insurance organization (including a
26health maintenance organization and a voluntary health



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1services plan) that is authorized to transact health insurance
2business in this State. Such term does not include a group
3health plan.
4    "Health Maintenance Organization" means an organization as
5defined in the Health Maintenance Organization Act.
6    "Hospice" means a program as defined in and licensed under
7the Hospice Program Licensing Act.
8    "Hospital" means a duly licensed institution as defined in
9the Hospital Licensing Act, an institution that meets all
10comparable conditions and requirements in effect in the state
11in which it is located, or the University of Illinois Hospital
12as defined in the University of Illinois Hospital Act.
13    "Individual health insurance coverage" means health
14insurance coverage offered to individuals in the individual
15market, but does not include short-term, limited-duration
17    "Insured" means any individual resident of this State who
18is eligible to receive benefits from any insurer (including
19health insurance coverage offered in connection with a group
20health plan) or health insurance issuer as defined in this
22    "Insurer" means any insurance company authorized to
23transact health insurance business in this State and any
24corporation that provides medical services and is organized
25under the Voluntary Health Services Plans Act or the Health
26Maintenance Organization Act.



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1    "Medical assistance" means the State medical assistance or
2medical assistance no grant (MANG) programs provided under
3Title XIX of the Social Security Act and Articles V (Medical
4Assistance) and VI (General Assistance) of the Illinois Public
5Aid Code (or any successor program) or under any similar
6program of health care benefits in a state other than Illinois.
7    "Medically necessary" means that a service, drug, or supply
8is necessary and appropriate for the diagnosis or treatment of
9an illness or injury in accord with generally accepted
10standards of medical practice at the time the service, drug, or
11supply is provided. When specifically applied to a confinement
12it further means that the diagnosis or treatment of the covered
13person's medical symptoms or condition cannot be safely
14provided to that person as an outpatient. A service, drug, or
15supply shall not be medically necessary if it: (i) is
16investigational, experimental, or for research purposes; or
17(ii) is provided solely for the convenience of the patient, the
18patient's family, physician, hospital, or any other provider;
19or (iii) exceeds in scope, duration, or intensity that level of
20care that is needed to provide safe, adequate, and appropriate
21diagnosis or treatment; or (iv) could have been omitted without
22adversely affecting the covered person's condition or the
23quality of medical care; or (v) involves the use of a medical
24device, drug, or substance not formally approved by the United
25States Food and Drug Administration.
26    "Medical care" means the ordinary and usual professional



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1services rendered by a physician or other specified provider
2during a professional visit for treatment of an illness or
4    "Medicare" means coverage under both Part A and Part B of
5Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395, et
7    "Minimum premium plan" means an arrangement whereby a
8specified amount of health care claims is self-funded, but the
9insurance company assumes the risk that claims will exceed that
11    "Participating transplant center" means a hospital
12designated by the Board as a preferred or exclusive provider of
13services for one or more specified human organ or tissue
14transplants for which the hospital has signed an agreement with
15the Board to accept a transplant payment allowance for all
16expenses related to the transplant during a transplant benefit
18    "Physician" means a person licensed to practice medicine
19pursuant to the Medical Practice Act of 1987.
20    "Plan" means the Comprehensive Health Insurance Plan
21established by this Act.
22    "Plan of operation" means the plan of operation of the
23Plan, including articles, bylaws and operating rules, adopted
24by the board pursuant to this Act.
25    "Provider" means any hospital, skilled nursing facility,
26hospice, home health agency, physician, registered pharmacist



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1acting within the scope of that registration, or any other
2person or entity licensed in Illinois to furnish medical care.
3    "Qualified high risk pool" has the same meaning given that
4term in the federal Health Insurance Portability and
5Accountability Act of 1996.
6    "Resident" means a person who is and continues to be
7legally domiciled and physically residing on a permanent and
8full-time basis in a place of permanent habitation in this
9State that remains that person's principal residence and from
10which that person is absent only for temporary or transitory
12    "Skilled nursing facility" means a facility or that portion
13of a facility that is licensed by the Illinois Department of
14Public Health under the Nursing Home Care Act or a comparable
15licensing authority in another state to provide skilled nursing
17    "Stop-loss coverage" means an arrangement whereby an
18insurer insures against the risk that any one claim will exceed
19a specific dollar amount or that the entire loss of a
20self-insurance plan will exceed a specific amount.
21    "Third party administrator" means an administrator as
22defined in Section 511.101 of the Illinois Insurance Code who
23is licensed under Article XXXI 1/4 of that Code.
24(Source: P.A. 95-965, eff. 9-23-08.)
25    (215 ILCS 105/4)  (from Ch. 73, par. 1304)



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1    Sec. 4. Powers and authority of the board. The board shall
2have the general powers and authority granted under the laws of
3this State to insurance companies licensed to transact health
4and accident insurance and in addition thereto, the specific
5authority to:
6    a. Enter into contracts as are necessary or proper to carry
7out the provisions and purposes of this Act, including the
8authority, with the approval of the Director, to enter into
9contracts with similar plans of other states for the joint
10performance of common administrative functions, or with
11persons or other organizations for the performance of
12administrative functions including, without limitation,
13utilization review and quality assurance programs, or with
14health maintenance organizations or preferred provider
15organizations for the provision of health care services.
16    b. Sue or be sued, including taking any legal actions
17necessary or proper.
18    c. Take such legal action as necessary to:
19        (1) avoid the payment of improper claims against the
20    plan or the coverage provided by or through the plan;
21        (2) to recover any amounts erroneously or improperly
22    paid by the plan;
23        (3) to recover any amounts paid by the plan as a result
24    of a mistake of fact or law; or
25        (4) to recover or collect any other amounts, including
26    assessments, that are due or owed the Plan or have been



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1    billed on its or the Plan's behalf.
2    d. Establish appropriate rates, rate schedules, rate
3adjustments, expense allowances, agents' referral fees, claim
4reserves, and formulas and any other actuarial function
5appropriate to the operation of the plan. Rates and rate
6schedules may be adjusted for appropriate risk factors such as
7age and area variation in claim costs and shall take into
8consideration appropriate risk factors in accordance with
9established actuarial and underwriting practices.
10    e. Issue policies of insurance in accordance with the
11requirements of this Act.
12    f. Appoint appropriate legal, actuarial and other
13committees as necessary to provide technical assistance in the
14operation of the plan, policy and other contract design, and
15any other function within the authority of the plan.
16    g. Borrow money to effect the purposes of the Illinois
17Comprehensive Health Insurance Plan. Any notes or other
18evidence of indebtedness of the plan not in default shall be
19legal investments for insurers and may be carried as admitted
21    h. Establish rules, conditions and procedures for
22reinsuring risks under this Act.
23    i. Employ and fix the compensation of employees. Such
24employees may be paid on a warrant issued by the State
25Treasurer pursuant to a payroll voucher certified by the Board
26and drawn by the Comptroller against appropriations or trust



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1funds held by the State Treasurer.
2    j. Enter into intergovernmental cooperation agreements
3with other agencies or entities of State government for the
4purpose of sharing the cost of providing health care services
5that are otherwise authorized by this Act for children who are
6both plan participants and eligible for financial assistance
7from the Division of Specialized Care for Children of the
8University of Illinois.
9    k. Establish conditions and procedures under which the plan
10may, if funds permit, discount or subsidize premium rates that
11are paid directly by senior citizens, as defined by the Board,
12and other plan participants, who are retired or unemployed and
13meet other qualifications.
14    l. Establish and maintain the Plan Fund authorized in
15Section 3 of this Act, which shall be divided into separate
16accounts, as follows:
17        (1) accounts to fund the administrative, claim, and
18    other expenses of the Plan associated with eligible persons
19    who qualify for Plan coverage under Section 7 of this Act,
20    which shall consist of:
21            (A) premiums paid on behalf of covered persons;
22            (B) assessments appropriated funds and other
23        revenues collected or received by the Board;
24            (C) reserves for future losses maintained by the
25        Board; and
26            (D) interest earnings from investment of the funds



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1        in the Plan Fund or any of its accounts other than the
2        funds in the account established under item 2 of this
3        subsection;
4        (2) an account, to be denominated the federally
5    eligible individuals account, to fund the administrative,
6    claim, and other expenses of the Plan associated with
7    federally eligible individuals who qualify for Plan
8    coverage under Section 15 of this Act, which shall consist
9    of:
10            (A) premiums paid on behalf of covered persons;
11            (B) assessments and other revenues collected or
12        received by the Board;
13            (C) reserves for future losses maintained by the
14        Board; and
15            (D) interest earnings from investment of the
16        federally eligible individuals account funds; and
17            (E) grants provided pursuant to the federal Trade
18        Act of 2002; and
19        (3) such other accounts as may be appropriate.
20    m. Charge and collect assessments paid by insurers pursuant
21to Section 12 of this Act and recover any assessments for, on
22behalf of, or against those insurers.
23(Source: P.A. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03.)
24    (215 ILCS 105/7)  (from Ch. 73, par. 1307)
25    Sec. 7. Eligibility.



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1    a. Except as provided in subsection (e) of this Section or
2in Section 15 of this Act, any person who is either a citizen
3of the United States or an alien lawfully admitted for
4permanent residence and who has been for a period of at least
5180 days and continues to be a resident of this State shall be
6eligible for Plan coverage under this Section if evidence is
7provided of:
8        (1) A notice of rejection or refusal to issue
9    substantially similar individual health insurance coverage
10    for health reasons by a health insurance issuer; or
11        (2) A refusal by a health insurance issuer to issue
12    individual health insurance coverage except at a rate
13    exceeding the applicable Plan rate for which the person is
14    responsible.
15    A rejection or refusal by a group health plan or health
16insurance issuer offering only stop-loss or excess of loss
17insurance or contracts, agreements, or other arrangements for
18reinsurance coverage with respect to the applicant shall not be
19sufficient evidence under this subsection.
20    b. The board shall promulgate a list of medical or health
21conditions for which a person who is either a citizen of the
22United States or an alien lawfully admitted for permanent
23residence and a resident of this State would be eligible for
24Plan coverage without applying for health insurance coverage
25pursuant to subsection a. of this Section. Persons who can
26demonstrate the existence or history of any medical or health



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1conditions on the list promulgated by the board shall not be
2required to provide the evidence specified in subsection a. of
3this Section. The list shall be effective on the first day of
4the operation of the Plan and may be amended from time to time
5as appropriate.
6    c. Family members of the same household who each are
7covered persons are eligible for optional family coverage under
8the Plan.
9    d. For persons qualifying for coverage in accordance with
10Section 7 of this Act, the board shall, if it determines that
11such assessments appropriations as are made pursuant to Section
1212 of this Act are insufficient to allow the board to accept
13all of the eligible persons which it projects will apply for
14enrollment under the Plan, limit or close enrollment to ensure
15that the Plan is not over-subscribed and that it has sufficient
16resources to meet its obligations to existing enrollees. The
17board shall not limit or close enrollment for federally
18eligible individuals.
19    e. A person shall not be eligible for coverage under the
20Plan if:
21        (1) He or she has or obtains other coverage under a
22    group health plan or health insurance coverage
23    substantially similar to or better than a Plan policy as an
24    insured or covered dependent or would be eligible to have
25    that coverage if he or she elected to obtain it. Persons
26    otherwise eligible for Plan coverage may, however, solely



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1    for the purpose of having coverage for a pre-existing
2    condition, maintain other coverage only while satisfying
3    any pre-existing condition waiting period under a Plan
4    policy or a subsequent replacement policy of a Plan policy.
5        (1.1) His or her prior coverage under a group health
6    plan or health insurance coverage, provided or arranged by
7    an employer of more than 10 employees was discontinued for
8    any reason without the entire group or plan being
9    discontinued and not replaced, provided he or she remains
10    an employee, or dependent thereof, of the same employer.
11        (2) He or she is a recipient of or is approved to
12    receive medical assistance, except that a person may
13    continue to receive medical assistance through the medical
14    assistance no grant program, but only while satisfying the
15    requirements for a preexisting condition under Section 8,
16    subsection f. of this Act. Payment of premiums pursuant to
17    this Act shall be allocable to the person's spenddown for
18    purposes of the medical assistance no grant program, but
19    that person shall not be eligible for any Plan benefits
20    while that person remains eligible for medical assistance.
21    If the person continues to receive or be approved to
22    receive medical assistance through the medical assistance
23    no grant program at or after the time that requirements for
24    a preexisting condition are satisfied, the person shall not
25    be eligible for coverage under the Plan. In that
26    circumstance, coverage under the plan shall terminate as of



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1    the expiration of the preexisting condition limitation
2    period. Under all other circumstances, coverage under the
3    Plan shall automatically terminate as of the effective date
4    of any medical assistance.
5        (3) Except as provided in Section 15, the person has
6    previously participated in the Plan and voluntarily
7    terminated Plan coverage, unless 12 months have elapsed
8    since the person's latest voluntary termination of
9    coverage.
10        (4) The person fails to pay the required premium under
11    the covered person's terms of enrollment and
12    participation, in which event the liability of the Plan
13    shall be limited to benefits incurred under the Plan for
14    the time period for which premiums had been paid and the
15    covered person remained eligible for Plan coverage.
16        (5) The Plan has paid a total of $5,000,000 in benefits
17    on behalf of the covered person.
18        (6) The person is a resident of a public institution.
19        (7) The person's premium is paid for or reimbursed
20    under any government sponsored program or by any government
21    agency or health care provider, except as an otherwise
22    qualifying full-time employee, or dependent of such
23    employee, of a government agency or health care provider
24    or, except when a person's premium is paid by the U.S.
25    Treasury Department pursuant to the federal Trade Act of
26    2002.



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1        (8) The person has or later receives other benefits or
2    funds from any settlement, judgement, or award resulting
3    from any accident or injury, regardless of the date of the
4    accident or injury, or any other circumstances creating a
5    legal liability for damages due that person by a third
6    party, whether the settlement, judgment, or award is in the
7    form of a contract, agreement, or trust on behalf of a
8    minor or otherwise and whether the settlement, judgment, or
9    award is payable to the person, his or her dependent,
10    estate, personal representative, or guardian in a lump sum
11    or over time, so long as there continues to be benefits or
12    assets remaining from those sources in an amount in excess
13    of $300,000.
14        (9) Within the 5 years prior to the date a person's
15    Plan application is received by the Board, the person's
16    coverage under any health care benefit program as defined
17    in 18 U.S.C. 24, including any public or private plan or
18    contract under which any medical benefit, item, or service
19    is provided, was terminated as a result of any act or
20    practice that constitutes fraud under State or federal law
21    or as a result of an intentional misrepresentation of
22    material fact; or if that person knowingly and willfully
23    obtained or attempted to obtain, or fraudulently aided or
24    attempted to aid any other person in obtaining, any
25    coverage or benefits under the Plan to which that person
26    was not entitled.



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1    f. The board or the administrator shall require
2verification of residency and may require any additional
3information or documentation, or statements under oath, when
4necessary to determine residency upon initial application and
5for the entire term of the policy.
6    g. Coverage shall cease (i) on the date a person is no
7longer a resident of Illinois, (ii) on the date a person
8requests coverage to end, (iii) upon the death of the covered
9person, (iv) on the date State law requires cancellation of the
10policy, or (v) at the Plan's option, 30 days after the Plan
11makes any inquiry concerning a person's eligibility or place of
12residence to which the person does not reply.
13    h. Except under the conditions set forth in subsection g of
14this Section, the coverage of any person who ceases to meet the
15eligibility requirements of this Section shall be terminated at
16the end of the current policy period for which the necessary
17premiums have been paid.
18(Source: P.A. 95-547, eff. 8-29-07; 96-938, eff. 6-24-10.)
19    (215 ILCS 105/12)  (from Ch. 73, par. 1312)
20    Sec. 12. Deficit or surplus.
21    a. If premiums or other receipts by the Board exceed the
22amount required for the operation of the Plan, including actual
23losses and administrative expenses of the Plan, the Board shall
24direct that the excess be held at interest, in a bank
25designated by the Board, or used to offset future losses or to



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1reduce Plan premiums. In this subsection, the term "future
2losses" includes reserves for incurred but not reported claims.
3    b. (Blank). Any deficit incurred or expected to be incurred
4on behalf of eligible persons who qualify for plan coverage
5under Section 7 of this Act shall be recouped by an
6appropriation made by the General Assembly.
7    c. For the purposes of this Section, a deficit shall be
8incurred when anticipated losses and incurred but not reported
9claims expenses exceed anticipated income from earned premiums
10net of administrative expenses.
11    d. Any deficit incurred or expected to be incurred on
12behalf of covered persons federally eligible individuals who
13qualify for Plan coverage under Section 7 or Section 15 of this
14Act shall be recouped by an assessment of all insurers made in
15accordance with the provisions of this Section. The Board shall
16within 90 days of the effective date of this amendatory Act of
171997 and within the first quarter of each fiscal year
18thereafter assess all insurers for the anticipated deficit in
19accordance with the provisions of this Section. The board may
20also make additional assessments no more than 4 times a year to
21fund unanticipated deficits, implementation expenses, and cash
22flow needs.
23    e. An insurer's assessment shall be determined by
24multiplying the total assessment, as determined in subsection
25d. of this Section, by a fraction, the numerator of which
26equals that insurer's direct Illinois premiums during the



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1preceding calendar year and the denominator of which equals the
2total of all insurers' direct Illinois premiums. The Board may
3exempt those insurers whose share as determined under this
4subsection would be so minimal as to not exceed the estimated
5cost of levying the assessment.
6    f. The Board shall charge and collect from each insurer the
7amounts determined to be due under this Section. The assessment
8shall be billed by Board invoice based upon the insurer's
9direct Illinois premium income as shown in its annual statement
10for the preceding calendar year as filed with the Director. The
11invoice shall be due upon receipt and must be paid no later
12than 30 days after receipt by the insurer.
13    g. When an insurer fails to pay the full amount of any
14assessment of $100 or more due under this Section there shall
15be added to the amount due as a penalty the greater of $50 or an
16amount equal to 5% of the deficiency for each month or part of
17a month that the deficiency remains unpaid.
18    h. Amounts collected under this Section shall be paid to
19the Board for deposit into the Plan Fund authorized by Section
203 of this Act.
21    i. An insurer may petition the Director for an abatement or
22deferment of all or part of an assessment imposed by the Board.
23The Director may abate or defer, in whole or in part, the
24assessment if, in the opinion of the Director, payment of the
25assessment would endanger the ability of the insurer to fulfill
26its contractual obligations. In the event an assessment against



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1an insurer is abated or deferred in whole or in part, the
2amount by which the assessment is abated or deferred shall be
3assessed against the other insurers in a manner consistent with
4the basis for assessments set forth in this subsection. The
5insurer receiving a deferment shall remain liable to the plan
6for the deficiency for 4 years.
7    j. The board shall establish procedures for appeal by any
8insurer subject to assessment pursuant to this Section. Such
9procedures shall require that:
10        (1) Any insurer that wishes to appeal all or any part
11    of an assessment made pursuant to this Section shall first
12    pay the amount of the assessment as set forth in the
13    invoice provided by the board within the time provided in
14    subsection f. of this Section. The board shall hold such
15    payments in a separate interest-bearing account. The
16    payments shall be accompanied by a statement in writing
17    that the payment is made under appeal. The statement shall
18    specify the grounds for the appeal. The insurer may be
19    represented in its appeal by counsel or other
20    representative of its choosing.
21        (2) Within 90 days following the payment of an
22    assessment under appeal by any insurer, the board shall
23    notify the insurer or representative designated by the
24    insurer in writing of its determination with respect to the
25    appeal and the basis or bases for that determination unless
26    the Board notifies the insurer that a reasonable amount of



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1    additional time is required to resolve the issues raised by
2    the appeal.
3        (3) The board shall refer to the Director any question
4    concerning the amount of direct Illinois premium income as
5    shown in an insurer's annual statement for the preceding
6    calendar year on file with the Director on the invoice date
7    of the assessment. Unless additional time is required to
8    resolve the question, the Director shall within 60 days
9    report to the board in writing his determination respecting
10    the amount of direct Illinois premium income on file on the
11    invoice date of the assessment.
12        (4) In the event the board determines that the insurer
13    is entitled to a refund, the refund shall be paid within 30
14    days following the date upon which the board makes its
15    determination, together with the accrued interest.
16    Interest on any refund due an insurer shall be paid at the
17    rate actually earned by the Board on the separate account.
18        (5) The amount of any such refund shall then be
19    assessed against all insurers in a manner consistent with
20    the basis for assessment as otherwise authorized by this
21    Section.
22        (6) The board's determination with respect to any
23    appeal received pursuant to this subsection shall be a
24    final administrative decision as defined in Section 3-101
25    of the Code of Civil Procedure. The provisions of the
26    Administrative Review Law shall apply to and govern all



HB1559- 28 -LRB097 08646 RPM 48775 b

1    proceedings for the judicial review of final
2    administrative decisions of the board.
3        (7) If an insurer fails to appeal an assessment in
4    accordance with the provisions of this subsection, the
5    insurer shall be deemed to have waived its right of appeal.
6    The provisions of this subsection apply to all assessments
7made in any calendar year ending on or after December 31, 1997.
8(Source: P.A. 90-30, eff. 7-1-97; 90-567, eff. 1-23-98.)
9    Section 99. Effective date. This Act takes effect upon
10becoming law.