Full Text of SB0475 94th General Assembly
SB0475eng 94TH GENERAL ASSEMBLY
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 5. The Comprehensive Health Insurance Plan Act is | 5 |
| amended by changing Sections 4, 7, and 15 as follows:
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| (215 ILCS 105/4) (from Ch. 73, par. 1304)
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| Sec. 4. Powers and authority of the board. The board shall | 8 |
| have the
general powers and authority granted under the laws of | 9 |
| this State to
insurance companies licensed to transact health | 10 |
| and accident insurance and
in addition thereto, the specific | 11 |
| authority to:
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| a. Enter into contracts as are necessary or proper to carry | 13 |
| out the
provisions and purposes of this Act, including the | 14 |
| authority, with the
approval of the Director, to enter into | 15 |
| contracts with similar plans of
other states for the joint | 16 |
| performance of common administrative functions,
or with | 17 |
| persons or other organizations for the performance of
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| administrative functions including, without limitation, | 19 |
| utilization review
and quality assurance programs, or with | 20 |
| health maintenance organizations or
preferred provider | 21 |
| organizations for the provision of health care services.
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| b. Sue or be sued, including taking any legal actions | 23 |
| necessary or
proper.
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| c. Take such legal action as necessary to:
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| (1) avoid the payment of improper
claims against the | 26 |
| plan or the coverage provided by or through the plan;
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| (2) to recover any amounts erroneously or improperly | 28 |
| paid by the plan;
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| (3) to recover any amounts paid by the plan as a result | 30 |
| of a mistake of
fact or law; or
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| (4) to recover or collect any other amounts, including | 32 |
| assessments, that
are due or owed the Plan or have been |
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| billed on its or the Plan's behalf.
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| d. Establish appropriate rates, rate schedules, rate | 3 |
| adjustments,
expense allowances, agents' referral fees, claim | 4 |
| reserves, and formulas and
any other actuarial function | 5 |
| appropriate to the operation of the plan.
Rates and rate | 6 |
| schedules may be adjusted for appropriate risk factors
such as | 7 |
| age and area variation in claim costs and shall take into
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| consideration appropriate risk factors in accordance with | 9 |
| established
actuarial and underwriting practices.
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| e. Issue policies of insurance in accordance with the | 11 |
| requirements of
this Act.
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| f. Appoint appropriate legal, actuarial and other | 13 |
| committees as
necessary to provide technical assistance in the | 14 |
| operation of the plan,
policy and other contract design, and | 15 |
| any other function within
the authority of the plan.
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| g. Borrow money to effect the purposes of the Illinois | 17 |
| Comprehensive
Health Insurance Plan. Any notes or other | 18 |
| evidence of indebtedness of the
plan not in default shall be | 19 |
| legal investments for insurers and may be
carried as admitted | 20 |
| assets.
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| h. Establish rules, conditions and procedures for | 22 |
| reinsuring risks
under this Act.
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| i. Employ and fix the compensation of employees. Such | 24 |
| employees
may be
paid on a warrant issued by the State | 25 |
| Treasurer pursuant to a payroll
voucher certified by the Board | 26 |
| and drawn by the Comptroller against
appropriations or trust | 27 |
| funds held by the State Treasurer.
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| j. Enter into intergovernmental cooperation agreements | 29 |
| with other agencies
or entities of State government for the | 30 |
| purpose of sharing the cost of
providing health care services | 31 |
| that are otherwise authorized by this Act for
children who are | 32 |
| both plan participants and eligible for financial assistance
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| from the Division of Specialized Care for Children of the | 34 |
| University of
Illinois.
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| k. Establish conditions and procedures under which the plan | 36 |
| may, if funds
permit, discount or subsidize premium rates that |
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| are paid directly by senior
citizens, as defined by the Board, | 2 |
| by unemployed or retired coal miners who are federally eligible | 3 |
| and whose employer-provided health insurance coverage was | 4 |
| terminated on September 28, 2004, and by other
plan | 5 |
| participants, who are retired or unemployed and meet other
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| qualifications.
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| l. Establish and maintain the Plan Fund authorized in
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| Section 3 of this Act, which shall be divided into separate | 9 |
| accounts, as
follows:
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| (1) accounts to fund the administrative, claim, and | 11 |
| other expenses of the
Plan associated with eligible persons | 12 |
| who qualify for Plan coverage under
Section 7 of this Act, | 13 |
| which shall consist of:
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| (A) premiums paid on behalf of covered persons;
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| (B) appropriated funds and other revenues | 16 |
| collected or received by the
Board;
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| (C) reserves for future losses maintained by the | 18 |
| Board; and
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| (D) interest earnings from investment of the funds | 20 |
| in the Plan
Fund or any of its accounts other than the | 21 |
| funds in the account established
under item 2 of this | 22 |
| subsection;
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| (2) an account, to be denominated the federally | 24 |
| eligible individuals
account, to fund the administrative, | 25 |
| claim, and other expenses of the Plan
associated with | 26 |
| federally eligible individuals who qualify for Plan | 27 |
| coverage
under Section 15 of this Act, which shall consist | 28 |
| of:
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| (A) premiums paid on behalf of covered persons;
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| (B) assessments and other revenues collected or | 31 |
| received by the Board;
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| (C) reserves for future losses maintained by the | 33 |
| Board; and
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| (D) interest earnings from investment of the | 35 |
| federally eligible
individuals account funds; and
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| (E) grants provided pursuant to the federal Trade |
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| Act of
2002; and
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| (3) such other accounts as may be appropriate.
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| m. Charge and collect assessments paid by insurers pursuant | 4 |
| to
Section 12 of this Act and recover any assessments for, on | 5 |
| behalf of, or
against those insurers. | 6 |
| n. Accept funds appropriated by law for the sole purpose | 7 |
| of, in accordance with subsection k of this Section, | 8 |
| discounting or subsidizing premium rates paid directly by | 9 |
| unemployed or retired coal miners who are federally eligible | 10 |
| individuals and whose employer-provided health insurance | 11 |
| coverage was terminated on September 28, 2004.
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| (Source: P.A. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03.)
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| (215 ILCS 105/7) (from Ch. 73, par. 1307)
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| Sec. 7. Eligibility.
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| a. Except as provided in subsection (e) of this Section or | 16 |
| in Section
15 of this Act, any person who is either a citizen | 17 |
| of the United States or an
alien lawfully admitted for | 18 |
| permanent residence and who has been for a period
of at least | 19 |
| 180 days and continues to be a resident of this State shall be
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| eligible for Plan coverage under this Section if evidence is | 21 |
| provided of:
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| (1) A notice of rejection or refusal to issue | 23 |
| substantially
similar individual health insurance coverage | 24 |
| for health reasons by a
health insurance issuer; or
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| (2) A refusal by a health insurance issuer to issue | 26 |
| individual
health insurance coverage except at a rate | 27 |
| exceeding the
applicable Plan rate for which the person is | 28 |
| responsible.
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| A rejection or refusal by a group health plan or health | 30 |
| insurance issuer
offering only
stop-loss or excess of loss | 31 |
| insurance or contracts,
agreements, or other arrangements for | 32 |
| reinsurance coverage with respect
to the applicant shall not be | 33 |
| sufficient evidence under this subsection.
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| b. The board shall promulgate a list of medical or health | 35 |
| conditions for
which a person who is either a citizen of the |
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| United States or an
alien lawfully admitted for permanent | 2 |
| residence and a resident of this State
would be eligible for | 3 |
| Plan coverage without applying for
health insurance coverage | 4 |
| pursuant to subsection a. of this Section.
Persons who
can | 5 |
| demonstrate the existence or history of any medical or health
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| conditions on the list promulgated by the board shall not be | 7 |
| required to
provide the evidence specified in subsection a. of | 8 |
| this Section. The list
shall be effective
on the first day of | 9 |
| the operation of the Plan and may be amended from time
to time | 10 |
| as appropriate.
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| c. Family members of the same household who each are | 12 |
| covered
persons are
eligible for optional family coverage under | 13 |
| the Plan.
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| d. For persons qualifying for coverage in accordance with | 15 |
| Section 7 of
this Act, the board shall, if it determines that | 16 |
| such appropriations as are
made pursuant to Section 12 of this | 17 |
| Act are insufficient to allow the board
to accept all of the | 18 |
| eligible persons which it projects will apply for
enrollment | 19 |
| under the Plan, limit or close enrollment to ensure that the
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| Plan is not over-subscribed and that it has sufficient | 21 |
| resources to meet
its obligations to existing enrollees. The | 22 |
| board shall not limit or close
enrollment for federally | 23 |
| eligible individuals.
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| e. A person shall not be eligible for coverage under the | 25 |
| Plan if:
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| (1) He or she has or obtains other coverage under a | 27 |
| group health plan
or health insurance coverage
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| substantially similar to or better than a Plan policy as an | 29 |
| insured or
covered dependent or would be eligible to have | 30 |
| that coverage if he or she
elected to obtain it. Persons | 31 |
| otherwise eligible for Plan coverage may,
however, solely | 32 |
| for the purpose of having coverage for a pre-existing
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| condition, maintain other coverage only while satisfying | 34 |
| any pre-existing
condition waiting period under a Plan | 35 |
| policy or a subsequent replacement
policy of a Plan policy.
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| (1.1) His or her prior coverage under a group health |
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| plan or health
insurance coverage, provided or arranged by | 2 |
| an employer of more than 10 employees was discontinued
for | 3 |
| any reason without the entire group or plan being | 4 |
| discontinued and not
replaced, provided he or she remains | 5 |
| an employee, or dependent thereof, of the
same employer.
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| (2) He or she is a recipient of or is approved to | 7 |
| receive medical
assistance, except that a person may | 8 |
| continue to receive medical
assistance through the medical | 9 |
| assistance no grant program, but only
while satisfying the | 10 |
| requirements for a preexisting condition under
Section 8, | 11 |
| subsection f. of this Act. Payment of premiums pursuant to | 12 |
| this
Act shall be allocable to the person's spenddown for | 13 |
| purposes of the
medical assistance no grant program, but | 14 |
| that person shall not be
eligible for any Plan benefits | 15 |
| while that person remains eligible for
medical assistance. | 16 |
| If the person continues to receive
or be approved to | 17 |
| receive medical assistance through the medical
assistance | 18 |
| no grant program at or after the time that requirements for | 19 |
| a
preexisting condition are satisfied, the person shall not | 20 |
| be eligible for
coverage under the Plan. In that | 21 |
| circumstance, coverage under the plan
shall terminate as of | 22 |
| the expiration of the preexisting condition
limitation | 23 |
| period. Under all other circumstances, coverage under the | 24 |
| Plan
shall automatically terminate as of the effective date | 25 |
| of any medical
assistance.
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| (3) Except as provided in Section 15, the person has | 27 |
| previously
participated in the Plan and voluntarily
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| terminated Plan coverage, unless 12 months have elapsed
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| since the person's
latest voluntary termination of | 30 |
| coverage.
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| (4) The person fails to pay the required premium under | 32 |
| the covered
person's
terms of enrollment and | 33 |
| participation, in which event the liability of the
Plan | 34 |
| shall be limited to benefits incurred under the Plan for | 35 |
| the time
period for which premiums had been paid and the | 36 |
| covered person remained
eligible for Plan coverage.
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| (5) The Plan has paid a total of $1,000,000 in benefits
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| on behalf of the covered person.
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| (6) The person is a resident of a public institution.
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| (7) The person's premium is paid for or reimbursed | 5 |
| under any
government sponsored program or by any government | 6 |
| agency or health
care provider, except as an otherwise | 7 |
| qualifying full-time employee, or
dependent of such | 8 |
| employee, of a government agency or health care provider ,
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| or , except when a person's premium is paid by the U.S. | 10 |
| Treasury Department
pursuant to the federal Trade Act of | 11 |
| 2002 , or except when the premium rate of an unemployed or | 12 |
| retired coal miner who is a federally eligible individual | 13 |
| whose employer-provided health insurance coverage was | 14 |
| terminated on September 28, 2004 is discounted or | 15 |
| subsidized with funds appropriated by law .
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| (8) The person has or later receives other benefits or | 17 |
| funds from
any settlement, judgement, or award resulting | 18 |
| from any accident or injury,
regardless of the date of the | 19 |
| accident or injury, or any other
circumstances creating a | 20 |
| legal liability for damages due that person by a
third | 21 |
| party, whether the settlement, judgment, or award is in the | 22 |
| form of a
contract, agreement, or trust on behalf of a | 23 |
| minor or otherwise and whether
the settlement, judgment, or | 24 |
| award is payable to the person, his or her
dependent, | 25 |
| estate, personal representative, or guardian in a lump sum | 26 |
| or
over time, so long as there continues to be benefits or | 27 |
| assets remaining
from those sources in an amount in excess | 28 |
| of $100,000.
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| (9) Within the 5 years prior to the date a person's | 30 |
| Plan application is
received by the Board, the person's | 31 |
| coverage under any health care benefit
program as defined | 32 |
| in 18 U.S.C. 24, including any public or private plan or
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| contract under which any
medical benefit, item, or service | 34 |
| is provided, was terminated as a result of
any act or | 35 |
| practice that constitutes fraud under State or federal law | 36 |
| or as a
result of an intentional misrepresentation of |
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| material fact; or if that person
knowingly and willfully | 2 |
| obtained or attempted to obtain, or fraudulently aided
or | 3 |
| attempted to aid any other person in obtaining, any | 4 |
| coverage or benefits
under the Plan to which that person | 5 |
| was not entitled.
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| f. The board or the administrator shall require | 7 |
| verification of
residency and may require any additional | 8 |
| information or documentation, or
statements under oath, when | 9 |
| necessary to determine residency upon initial
application and | 10 |
| for the entire term of the policy.
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| g. Coverage shall cease (i) on the date a person is no | 12 |
| longer a
resident of Illinois, (ii) on the date a person | 13 |
| requests coverage to end,
(iii) upon the death of the covered | 14 |
| person, (iv) on the date State law
requires cancellation of the | 15 |
| policy, or (v) at the Plan's option, 30 days
after the Plan | 16 |
| makes any inquiry concerning a person's eligibility or place
of | 17 |
| residence to which the person does not reply.
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| h. Except under the conditions set forth in subsection g of | 19 |
| this
Section, the coverage of any person who ceases to meet the
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| eligibility requirements of this Section shall be terminated at | 21 |
| the end of
the current policy period for which the necessary | 22 |
| premiums have been paid.
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| (Source: P.A. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03.)
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| (215 ILCS 105/15)
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| Sec. 15. Alternative portable coverage for federally | 26 |
| eligible individuals.
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| (a) Notwithstanding the requirements of subsection a. of | 28 |
| Section 7 and
except as otherwise provided in this Section, any
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| federally eligible individual for whom a Plan
application, and | 30 |
| such enclosures and supporting documentation as the Board may
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| require, is received by the Board within 90 days after the
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| termination of prior
creditable coverage shall qualify to | 33 |
| enroll in the Plan under the
portability provisions of this | 34 |
| Section.
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| A federally eligible person who has
been certified as |
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| eligible pursuant to the federal Trade
Act of 2002
and whose | 2 |
| Plan application and enclosures and supporting
documentation | 3 |
| as the Board may require is received by the Board within 63 | 4 |
| days
after the termination of previous creditable coverage | 5 |
| shall qualify to enroll
in the Plan under the portability | 6 |
| provisions of this Section.
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| (b) Any federally eligible individual seeking Plan | 8 |
| coverage under this
Section must submit with his or her | 9 |
| application evidence, including acceptable
written | 10 |
| certification of previous creditable coverage, that will | 11 |
| establish to
the Board's satisfaction, that he or she meets all | 12 |
| of the requirements to be a
federally eligible individual and | 13 |
| is currently and
permanently residing in this State (as of the | 14 |
| date his or her application was
received by the Board).
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| (c) Except as otherwise provided in this Section, a period | 16 |
| of creditable
coverage shall not be counted, with respect to
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| qualifying an applicant for Plan coverage as a federally | 18 |
| eligible individual
under this Section, if after such period | 19 |
| and before the application for Plan
coverage was received by | 20 |
| the Board, there was at least a 90 day
period during
all of | 21 |
| which the individual was not covered under any creditable | 22 |
| coverage.
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| For a federally eligible person who has
been certified as | 24 |
| eligible
pursuant to the federal Trade Act of 2002, a period of | 25 |
| creditable
coverage shall not be counted, with respect to | 26 |
| qualifying an applicant for Plan
coverage as a federally | 27 |
| eligible individual under this Section, if after such
period | 28 |
| and before the application for Plan coverage was received by | 29 |
| the Board,
there was at
least a 63 day period during all of | 30 |
| which the individual was not covered under
any creditable | 31 |
| coverage.
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| (d) Any federally eligible individual who the Board | 33 |
| determines qualifies for
Plan coverage under this Section shall | 34 |
| be offered his or her choice of
enrolling in one of alternative | 35 |
| portability health benefit plans which the
Board
is authorized | 36 |
| under this Section to establish for these federally eligible
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| individuals
and their dependents.
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| (e) The Board shall offer a choice of health care coverages | 3 |
| consistent with
major medical coverage under the alternative | 4 |
| health benefit plans authorized by
this Section to every | 5 |
| federally eligible individual.
The coverages to be offered | 6 |
| under the plans, the schedule of
benefits, deductibles, | 7 |
| co-payments, exclusions, and other limitations shall be
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| approved by the Board. One optional form of coverage shall be | 9 |
| comparable to
comprehensive health insurance coverage offered | 10 |
| in the individual market in
this State or a standard option of | 11 |
| coverage available under the group or
individual health | 12 |
| insurance laws of the State. The standard benefit plan that
is
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| authorized by Section 8 of this Act may be used for this | 14 |
| purpose. The Board
may also offer a preferred provider option | 15 |
| and such other options as the Board
determines may be | 16 |
| appropriate for these federally eligible individuals who
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| qualify for Plan coverage pursuant to this Section.
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| (f) Notwithstanding the requirements of subsection f. of | 19 |
| Section 8, any
plan coverage
that is issued to federally | 20 |
| eligible individuals who qualify for the Plan
pursuant
to the | 21 |
| portability provisions of this Section shall not be subject to | 22 |
| any
preexisting conditions exclusion, waiting period, or other | 23 |
| similar limitation
on coverage.
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| (g) Federally eligible individuals who qualify and enroll | 25 |
| in the Plan
pursuant
to this Section shall be required to pay | 26 |
| such premium rates as the Board shall
establish and approve in | 27 |
| accordance with the requirements of Section 7.1 of
this Act. | 28 |
| Federally eligible individuals who qualify and enroll in the | 29 |
| Plan and are unemployed or retired coal miners whose | 30 |
| employer-provided health insurance coverage was terminated on | 31 |
| September 28, 2004 shall be required to pay the discounted or | 32 |
| subsidized premium rates that the Board has established and | 33 |
| approved in accordance with subsection k of Section 4 of this | 34 |
| Act.
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| (h) A federally eligible individual who qualifies and | 36 |
| enrolls in the Plan
pursuant to this Section must satisfy on an |
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| ongoing basis all of the other
eligibility requirements of this | 2 |
| Act to the extent not inconsistent with the
federal Health | 3 |
| Insurance Portability and Accountability Act of 1996 in order | 4 |
| to
maintain continued eligibility
for coverage under the Plan.
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| (Source: P.A. 92-153, eff. 7-25-01; 93-33, eff. 6-23-03; 93-34, | 6 |
| eff. 6-23-03; 93-622, eff. 12-18-03.)
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| Section 99. Effective date. This Act takes effect upon | 8 |
| becoming law.
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