State of Illinois
90th General Assembly
Legislation

   [ Search ]   [ Legislation ]   [ Bill Summary ]
[ Home ]   [ Back ]   [ Bottom ]


[ Introduced ]

90_HB0673eng

      215 ILCS 5/122-1          from Ch. 73, par. 734-1
      215 ILCS 5/1003           from Ch. 73, par. 1065.703
      215 ILCS 105/8            from Ch. 73, par. 1308
          Amends  the  Illinois  Insurance  Code.   Provides   that
      persons  who  provide  coverage  for naprapathic services are
      subject to the jurisdiction of the Department  of  Insurance.
      Includes  a  naprapath  within the scope of the term "medical
      professional" under the  Insurance  Information  and  Privacy
      Protection  Article  of  the  Code.  Amends the Comprehensive
      Health Insurance Plan Act.  Includes coverage for naprapathic
      services under the minimum benefits available under that Act.
                                                     LRB9003688JSgc
HB0673 Engrossed                               LRB9003688JSgc
 1        AN ACT concerning naprapathic  services,  amending  named
 2    Acts.
 3        Be  it  enacted  by  the People of the State of Illinois,
 4    represented in the General Assembly:
 5        Section 5.  The Illinois Insurance  Code  is  amended  by
 6    changing Sections 122-1 and 1003 as follows:
 7        (215 ILCS 5/122-1) (from Ch. 73, par. 734-1)
 8        Sec.  122-1.  The authority and jurisdiction of Insurance
 9    Department.  Notwithstanding any other provision of law,  and
10    except  as  provided herein, any person or other entity which
11    provides  coverage  in  this  State  for  medical,  surgical,
12    chiropractic,   naprapathic,   physical    therapy,    speech
13    pathology,  audiology,  professional  mental  health, dental,
14    hospital, ophthalmologic,  or  optometric  expenses,  whether
15    such   coverage   is  by  direct-payment,  reimbursement,  or
16    otherwise,  shall  be  presumed  to   be   subject   to   the
17    jurisdiction  of  the  Department  unless the person or other
18    entity shows that while providing such coverage it is subject
19    to the jurisdiction of another  agency  of  this  state,  any
20    subdivision of this state, or the Federal Government, or is a
21    plan  of  self-insurance  or  other  employee welfare benefit
22    program of an individual employer or labor union  established
23    or  maintained  under  or pursuant to a collective bargaining
24    agreement or other arrangement which provides for health care
25    services solely  for  its  employees  or  members  and  their
26    dependents.
27    (Source: P.A. 86-753.)
28        (215 ILCS 5/1003) (from Ch. 73, par. 1065.703)
29        Sec.  1003.   Definitions.   As used in this Article: (A)
30    "Adverse underwriting decision" means:
HB0673 Engrossed            -2-                LRB9003688JSgc
 1        (1)  any  of  the  following  actions  with  respect   to
 2    insurance  transactions involving insurance coverage which is
 3    individually underwritten:
 4        (a)  a declination of insurance coverage,
 5        (b)  a termination of insurance coverage,
 6        (c)  failure of an agent to apply for insurance  coverage
 7    with   a  specific  insurance  institution  which  the  agent
 8    represents and which is requested by an applicant,
 9        (d)  in the case of  a  property  or  casualty  insurance
10    coverage:
11        (i) placement  by  an insurance institution or agent of a
12    risk  with  a  residual  market  mechanism,  an  unauthorized
13    insurer or an  insurance  institution  which  specializes  in
14    substandard risks, or
15        (ii) the  charging  of  a  higher  rate  on  the basis of
16    information which differs from that which  the  applicant  or
17    policyholder furnished, or
18        (e)  in  the case of life, health or disability insurance
19    coverage, an offer to insure at higher than standard rates.
20        (2)  Notwithstanding paragraph (1) above,  the  following
21    actions   shall   not   be  considered  adverse  underwriting
22    decisions but the insurance institution or agent  responsible
23    for their occurrence shall nevertheless provide the applicant
24    or policyholder with the specific reason or reasons for their
25    occurrence:
26        (a)  the  termination  of  an individual policy form on a
27    class or statewide basis,
28        (b)  a declination of insurance coverage  solely  because
29    such coverage is not available on a class or statewide basis,
30    or
31        (c)  the rescission of a policy.
32        (B)  "Affiliate"  or  "affiliated"  means  a  person that
33    directly, or indirectly through one or  more  intermediaries,
34    controls,  is  controlled  by or is under common control with
HB0673 Engrossed            -3-                LRB9003688JSgc
 1    another person.
 2        (C)  "Agent"  means  an  individual,  firm,  partnership,
 3    association  or  corporation   who   is   involved   in   the
 4    solicitation,  negotiation  or binding of coverages for or on
 5    applications or policies of insurance, covering  property  or
 6    risks  located  in  this  State.   For  the  purposes of this
 7    Article, both "Insurance Agent" and  "Insurance  Broker",  as
 8    defined in Section 490, shall be considered an agent.
 9        (D)  "Applicant"  means  any person who seeks to contract
10    for insurance coverage other  than  a  person  seeking  group
11    insurance that is not individually underwritten.
12        (E)  "Director" means the Director of Insurance.
13        (F)  "Consumer  report"  means any written, oral or other
14    communication of information bearing on  a  natural  person's
15    credit   worthiness,   credit   standing,   credit  capacity,
16    character, general reputation,  personal  characteristics  or
17    mode  of  living  which  is  used  or  expected to be used in
18    connection with an insurance transaction.
19        (G) "Consumer reporting agency" means any person who:
20        (1) regularly engages,  in  whole  or  in  part,  in  the
21    practice  of  assembling  or preparing consumer reports for a
22    monetary fee,
23        (2) obtains information primarily from sources other than
24    insurance institutions, and
25        (3) furnishes consumer reports to other persons.
26        (H)  "Control", including the terms  "controlled  by"  or
27    "under  common control with", means the possession, direct or
28    indirect, of the power to direct or cause  the  direction  of
29    the  management and policies of a person, whether through the
30    ownership of voting securities,  by  contract  other  than  a
31    commercial  contract  for goods or nonmanagement services, or
32    otherwise, unless the power is  the  result  of  an  official
33    position with or corporate office held by the person.
34        (I)  "Declination  of insurance coverage" means a denial,
HB0673 Engrossed            -4-                LRB9003688JSgc
 1    in whole or in part, by an insurance institution or agent  of
 2    requested insurance coverage.
 3        (J)  "Individual" means any natural person who:
 4        (1)  in  the case of property or casualty insurance, is a
 5    past, present or proposed named insured or certificateholder;
 6        (2)  in the case of life, health or disability insurance,
 7    is  a  past,  present  or  proposed  principal   insured   or
 8    certificateholder;
 9        (3)  is a past, present or proposed policyowner;
10        (4)  is a past or present applicant;
11        (5)  is a past or present claimant; or
12        (6)  derived,  derives or is proposed to derive insurance
13    coverage under an insurance policy or certificate subject  to
14    this Article.
15        (K)  "Institutional   source"   means   any   person   or
16    governmental   entity  that  provides  information  about  an
17    individual   to   an   agent,   insurance   institution    or
18    insurance-support organization, other than:
19        (1)  an agent,
20        (2)  the   individual   who   is   the   subject  of  the
21    information, or
22        (3)  a natural  person  acting  in  a  personal  capacity
23    rather than in a business or professional capacity.
24        (L)  "Insurance   institution"   means  any  corporation,
25    association, partnership, reciprocal exchange, inter-insurer,
26    Lloyd's insurer, fraternal benefit society  or  other  person
27    engaged  in  the  business  of  insurance, health maintenance
28    organizations  as  defined  in  Section  2  of  the   "Health
29    Maintenance  Organization  Act",  medical  service  plans  as
30    defined  in  Section  2  of  "The  Medical Service Plan Act",
31    hospital service corporation under "The Nonprofit Health Care
32    Service Plan Act", voluntary health services plans as defined
33    in Section 2 of "The Voluntary Health  Services  Plans  Act",
34    vision  service  plans as defined in Section 2 of "The Vision
HB0673 Engrossed            -5-                LRB9003688JSgc
 1    Service Plan Act", dental service plans as defined in Section
 2    4 of  "The  Dental  Service  Plan  Act",  and  pharmaceutical
 3    service  plans as defined in Section 4 of "The Pharmaceutical
 4    Service Plan Act".  "Insurance institution" shall not include
 5    agents or insurance-support organizations.
 6        (M)  "Insurance-support  organization"  means:  (1)   any
 7    person  who  regularly  engages,  in whole or in part, in the
 8    practice  of  assembling  or  collecting  information   about
 9    natural  persons  for  the  primary  purpose of providing the
10    information  to  an  insurance  institution  or   agent   for
11    insurance transactions, including:
12        (a)  the  furnishing of consumer reports or investigative
13    consumer reports to an insurance institution or agent for use
14    in connection with an insurance transaction, or
15        (b)  the  collection   of   personal   information   from
16    insurance  institutions,  agents  or  other insurance-support
17    organizations for the  purpose  of  detecting  or  preventing
18    fraud,  material  misrepresentation or material nondisclosure
19    in connection with insurance underwriting or insurance  claim
20    activity.
21        (2) Notwithstanding  paragraph  (1)  above, the following
22    persons   shall   not   be   considered    "insurance-support
23    organizations"   for   purposes   of  this  Article:  agents,
24    government institutions, insurance institutions, medical care
25    institutions and medical professionals.
26        (N)  "Insurance  transaction"   means   any   transaction
27    involving   insurance   primarily  for  personal,  family  or
28    household needs rather than business  or  professional  needs
29    which entails:
30        (1)  the determination of an individual's eligibility for
31    an insurance coverage, benefit or payment, or
32        (2)  the  servicing  of an insurance application, policy,
33    contract or certificate.
34        (O)  "Investigative consumer  report"  means  a  consumer
HB0673 Engrossed            -6-                LRB9003688JSgc
 1    report  or  portion  thereof  in  which  information  about a
 2    natural  person's  character,  general  reputation,  personal
 3    characteristics  or  mode  of  living  is  obtained   through
 4    personal  interviews  with  the  person's neighbors, friends,
 5    associates, acquaintances or others who  may  have  knowledge
 6    concerning such items of information.
 7        (P)  "Medical-care  institution"  means  any  facility or
 8    institution that is licensed to provide health care  services
 9    to  natural persons, including but not limited to: hospitals,
10    skilled nursing  facilities,  home-health  agencies,  medical
11    clinics,  rehabilitation  agencies and public-health agencies
12    and health-maintenance organizations.
13        (Q)  "Medical professional" means any person licensed  or
14    certified    to  provide  health  care  services  to  natural
15    persons,  including but not limited to, a physician, dentist,
16    nurse,  optometrist,  chiropractor,  naprapath,   pharmacist,
17    physical   or   occupational  therapist,  psychiatric  social
18    worker, speech  therapist,  clinical  dietitian  or  clinical
19    psychologist.
20        (R)  "Medical-record    information"    means    personal
21    information which:
22        (1)  relates   to  an  individual's  physical  or  mental
23    condition, medical history or medical treatment, and
24        (2)  is  obtained  from   a   medical   professional   or
25    medical-care  institution,  from  the individual, or from the
26    individual's spouse, parent or legal guardian.
27        (S)  "Person"  means  any  natural  person,  corporation,
28    association, partnership or other legal entity.
29        (T)  "Personal  information"   means   any   individually
30    identifiable  information  gathered  in  connection  with  an
31    insurance  transaction from which judgments can be made about
32    an  individual's  character,  habits,  avocations,  finances,
33    occupation, general reputation, credit, health or  any  other
34    personal characteristics.  "Personal information" includes an
HB0673 Engrossed            -7-                LRB9003688JSgc
 1    individual's    name    and   address   and   "medical-record
 2    information" but does not include "privileged information".
 3        (U)  "Policyholder" means any person who:
 4        (1)  in the  case  of  individual  property  or  casualty
 5    insurance, is a present named insured;
 6        (2)  in the case of individual life, health or disability
 7    insurance, is a present policyowner; or
 8        (3)  in the case of group insurance which is individually
 9    underwritten, is a present group certificateholder.
10        (V)  "Pretext  interview"  means  an  interview whereby a
11    person, in an attempt to obtain information about  a  natural
12    person, performs one or more of the following acts:
13        (1)  pretends to be someone he or she is not,
14        (2)  pretends  to  represent a person he or she is not in
15    fact representing,
16        (3)  misrepresents the true purpose of the interview, or
17        (4)  refuses to identify himself or herself upon request.
18        (W)  "Privileged  information"  means  any   individually
19    identifiable  information  that:  (1)  relates to a claim for
20    insurance  benefits  or  a  civil  or   criminal   proceeding
21    involving  an  individual, and (2) is collected in connection
22    with or in reasonable anticipation of a claim  for  insurance
23    benefits   or  civil  or  criminal  proceeding  involving  an
24    individual; provided, however, information otherwise  meeting
25    the  requirements  of  this  subsection shall nevertheless be
26    considered "personal information" under this Article if it is
27    disclosed in violation of Section 1014 of this Article.
28        (X)  "Residual market mechanism"  means  an  association,
29    organization  or  other entity described in Article XXXIII of
30    this Act, or Section 7-501 of "The Illinois Vehicle Code".
31        (Y)  "Termination of insurance coverage" or  "termination
32    of  an  insurance  policy"  means  either  a  cancellation or
33    nonrenewal of an insurance policy, in whole or in  part,  for
34    any  reason  other  than  the  failure  to  pay  a premium as
HB0673 Engrossed            -8-                LRB9003688JSgc
 1    required by the policy.
 2        (Z) "Unauthorized insurer" means an insurance institution
 3    that has not been granted a certificate of authority  by  the
 4    Director to transact the business of insurance in this State.
 5    (Source: P.A. 82-108.)
 6        Section  10.  The Comprehensive Health Insurance Plan Act
 7    is amended by changing Section 8 as follows:
 8        (215 ILCS 105/8) (from Ch. 73, par. 1308)
 9        Sec. 8.  Minimum benefits.
10        a.  Availability. The Plan shall  offer  in  an  annually
11    renewable  policy  major  medical  expense  coverage to every
12    eligible person who is  not  eligible  for  Medicare.   Major
13    medical  expense  coverage  offered  by the Plan shall pay an
14    eligible person's covered expenses, subject to limit  on  the
15    deductible   and   coinsurance   payments   authorized  under
16    paragraph (4) of subsection  d  of  this  Section,  up  to  a
17    lifetime  benefit  limit  of $500,000 per covered individual.
18    The maximum limit under this subsection shall not be  altered
19    by  the  Board,  and  no  actuarial equivalent benefit may be
20    substituted by the Board.  Any  person  who  otherwise  would
21    qualify  for coverage under the Plan, but is excluded because
22    he or she is eligible for Medicare, shall be eligible for any
23    separate Medicare  supplement  policy  which  the  Board  may
24    offer.
25        b.  Covered  expenses.  Covered expenses shall be limited
26    to the reasonable and customary charge, including  negotiated
27    fees, in the locality for the following services and articles
28    when  medically necessary and prescribed by a person licensed
29    and practicing within the scope of his or her  profession  as
30    authorized by State law:
31             (1)  Hospital  room and board and any other hospital
32        services, except that inpatient hospitalization  for  the
HB0673 Engrossed            -9-                LRB9003688JSgc
 1        treatment of mental and emotional disorders shall only be
 2        covered for a maximum of 45 days in a calendar year.
 3             (2)  Professional  services  for  the  diagnosis  or
 4        treatment  of  injuries,  illnesses  or conditions, other
 5        than  dental,  or  outpatient  mental  as  described   in
 6        paragraph  (17),  which  are  rendered  by a physician or
 7        chiropractor, or by other licensed professionals  at  the
 8        physician's or chiropractor's direction.
 9             (3)  If  surgery  has  been  recommended,  a  second
10        opinion  may be required. The charge for a second opinion
11        as to whether the surgery is required  will  be  paid  in
12        full   without   regard   to   deductible  or  co-payment
13        requirements.  If the second  opinion  differs  from  the
14        first,  the  charge for a third opinion, if desired, will
15        also be paid in full  without  regard  to  deductible  or
16        co-payment   requirements.   Regardless  of  whether  the
17        second opinion or third  opinion  confirms  the  original
18        recommendation,  it  is the patient's decision whether to
19        undergo surgery.
20             (4)  Drugs requiring a physician's or other  legally
21        authorized prescription.
22             (5)  Skilled  nursing  care  provided  in  a skilled
23        nursing facility for not more than 120 days in a calendar
24        year, provided  the  service  commences  within  14  days
25        following a confinement of at least 3 consecutive days in
26        a hospital for the same condition.
27             (6)  Services of a home health agency in accord with
28        a  home  health  care plan, up to a maximum of 270 visits
29        per year.
30             (7)  Services of a licensed  hospice  for  not  more
31        than 180 days during a policy year.
32             (8)  Use of radium or other radioactive materials.
33             (9)  Oxygen.
34             (10)  Anesthetics.
HB0673 Engrossed            -10-               LRB9003688JSgc
 1             (11)  Orthoses and prostheses other than dental.
 2             (12)  Rental  or  purchase  in accordance with Board
 3        policies or  procedures  of  durable  medical  equipment,
 4        other than eyeglasses or hearing aids, for which there is
 5        no personal use in the absence of the condition for which
 6        it is prescribed.
 7             (13)  Diagnostic x-rays and laboratory tests.
 8             (14)  Oral  surgery  for  excision  of  partially or
 9        completely unerupted  impacted  teeth  or  the  gums  and
10        tissues  of  the  mouth, when not performed in connection
11        with the routine extraction or repair of teeth, and  oral
12        surgery   and   procedures,  including  orthodontics  and
13        prosthetics necessary for craniofacial  or  maxillofacial
14        conditions  and to correct congenital defects or injuries
15        due to accident.
16             (15)  Physical, speech, and functional  occupational
17        therapy   as   medically   necessary   and   provided  by
18        appropriate licensed professionals.
19             (16)  Transportation   provided   by   a    licensed
20        ambulance  service  to  the  nearest health care facility
21        qualified to treat  the  illness,  injury  or  condition,
22        subject  to  the  provisions  of  the  Emergency  Medical
23        Systems (EMS) Act.
24             (17)  The  first  50  professional outpatient visits
25        for diagnosis  and  treatment  of  mental  and  emotional
26        disorders  rendered  during  the year, up to a maximum of
27        $80 per visit.
28             (18)  Human organ or tissue transplants specified by
29        the Board that are performed at a hospital designated  by
30        the  Board  as a participating transplant center for that
31        specific organ or tissue transplant.
32             (19)  Naprapathic services, as appropriate, provided
33        by a licensed naprapathic practitioner.
34        c.  Exclusion.  Covered expenses of the  Plan  shall  not
HB0673 Engrossed            -11-               LRB9003688JSgc
 1    include the following:
 2             (1)  Any  charge for treatment for cosmetic purposes
 3        other than for reconstructive surgery when the service is
 4        incidental to or follows surgery resulting  from  injury,
 5        sickness  or  other  diseases  of  the  involved  part or
 6        surgery for the  repair  or  treatment  of  a  congenital
 7        bodily defect to restore normal bodily functions.
 8             (2)  Any charge for care that is primarily for rest,
 9        custodial, educational, or domiciliary purposes.
10             (3)  Any  charge  for  services in a private room to
11        the extent it is in excess of  the  institution's  charge
12        for  its  most  common semiprivate room, unless a private
13        room is prescribed as medically necessary by a physician.
14             (4)  That part of any charge for room and  board  or
15        for   services  rendered  or  articles  prescribed  by  a
16        physician, dentist, or other health care  personnel  that
17        exceeds  the  reasonable  and  customary  charge  in  the
18        locality  or  for  any services or supplies not medically
19        necessary for the diagnosed injury or illness.
20             (5)  Any  charge  for  services  or   articles   the
21        provision  of  which is not within the scope of licensure
22        of the institution or individual providing  the  services
23        or articles.
24             (6)  Any  expense  incurred  prior  to the effective
25        date of coverage by the Plan  for  the  person  on  whose
26        behalf the expense is incurred.
27             (7)  Dental  care,  dental surgery, dental treatment
28        or dental appliances, except  as  provided  in  paragraph
29        (14) of subsection b of this Section.
30             (8)  Eyeglasses,  contact  lenses,  hearing  aids or
31        their fitting.
32             (9)  Illness or injury due to (A) war or any acts of
33        war; (B) commission of, or attempt to commit,  a  felony;
34        or  (C)  aviation  activities, except when traveling as a
HB0673 Engrossed            -12-               LRB9003688JSgc
 1        fare-paying passenger on a commercial airline.
 2             (10)  Services of  blood  donors  and  any  fee  for
 3        failure  to  replace blood provided to an eligible person
 4        each policy year.
 5             (11)  Personal supplies or services  provided  by  a
 6        hospital  or  nursing  home,  or  any other nonmedical or
 7        nonprescribed supply or service.
 8             (12)  Routine maternity  charges  for  a  pregnancy,
 9        except  where  added as optional coverage with payment of
10        an  additional  premium  for  pregnancy  resulting   from
11        conception  occurring  after  the  effective  date of the
12        optional coverage.
13             (13)  Expenses of  obtaining  an  abortion,  induced
14        miscarriage  or  induced  premature  birth unless, in the
15        opinion of a physician, those  procedures  are  necessary
16        for  the  preservation  of life of the woman seeking such
17        treatment, or except an induced premature birth  intended
18        to  produce  a  live  viable  child  and the procedure is
19        necessary for the health of the mother or unborn child.
20             (14)  Any expense or charge for services, drugs,  or
21        supplies  that  are:  (i)  not  provided  in  accord with
22        generally accepted standards of current medical practice;
23        (ii) for procedures, treatments, equipment,  transplants,
24        or   implants,   any   of   which   are  investigational,
25        experimental,   or   for   research    purposes;    (iii)
26        investigative  and not proven safe and effective; or (iv)
27        for,  or  resulting   from,   a   gender   transformation
28        operation.
29             (15)  Any  expense  or  charge  for routine physical
30        examinations or tests.
31             (16)  Any expense for which a charge is not made  in
32        the  absence  of insurance or for which there is no legal
33        obligation on the part of the patient to pay.
34             (17)  Any expense  incurred  for  benefits  provided
HB0673 Engrossed            -13-               LRB9003688JSgc
 1        under  the  laws  of  the  United  States and this State,
 2        including  Medicare  and  Medicaid  and   other   medical
 3        assistance,    military    service-connected   disability
 4        payments, medical services provided for  members  of  the
 5        armed  forces  and  their  dependents or employees of the
 6        armed forces of the United States, and  medical  services
 7        financed on behalf of all citizens by the United States.
 8             (18)  Any   expense   or   charge   for   in   vitro
 9        fertilization,  artificial  insemination,  or  any  other
10        artificial means used to cause pregnancy.
11             (19)  Any  expense or charge for oral contraceptives
12        used for birth  control  or  any  other  temporary  birth
13        control measures.
14             (20)  Any  expense  or  charge  for sterilization or
15        sterilization reversals.
16             (21)  Any  expense  or  charge   for   weight   loss
17        programs,  exercise  equipment,  or treatment of obesity,
18        except when certified by a physician  as  morbid  obesity
19        (at least 2 times normal body weight).
20             (22)  Any   expense   or   charge   for  acupuncture
21        treatment unless  used  as  an  anesthetic  agent  for  a
22        covered surgery.
23             (23)  Any  expense or charge for or related to organ
24        or tissue transplants other than  those  performed  at  a
25        hospital  with  a Board approved organ transplant program
26        that has been designated by the Board as a  preferred  or
27        exclusive  provider  organization for that specific organ
28        or tissue.
29             (24)  Any  expense   or   charge   for   procedures,
30        treatments,  equipment,  or services that are provided in
31        special settings for research purposes or in a controlled
32        environment, are being studied  for  safety,  efficiency,
33        and  effectiveness,  and  are awaiting endorsement by the
34        appropriate  national  medical  speciality  college   for
HB0673 Engrossed            -14-               LRB9003688JSgc
 1        general use within the medical community.
 2        d.  Premiums, deductibles, and coinsurance.
 3             (1)  Premiums  charged  for  coverage  issued by the
 4        Plan may not be unreasonable in relation to the  benefits
 5        provided, the risk experience and the reasonable expenses
 6        of providing the coverage.
 7             (2)  Separate  schedules  of  premium rates based on
 8        sex,  age  and  geographical  location  shall  apply  for
 9        individual risks.
10             (3)  The Plan may provide for separate premium rates
11        for optional family coverage for the  spouse  or  one  or
12        more  dependents  of  any  person  eligible to be insured
13        under the Plan who is also the oldest adult member of the
14        family and remains continuously enrolled in the  Plan  as
15        the  primary enrollee. The rates shall be such percentage
16        of the applicable individual Plan rate as the  Board,  in
17        accordance  with  appropriate actuarial principles, shall
18        establish for each spouse or dependent.
19             (4)  The Board shall determine, in  accordance  with
20        appropriate  actuarial principles, the average rates that
21        individual standard risks in this State are charged by at
22        least 5 of the largest  insurers  providing  coverage  to
23        residents  of  Illinois  that is substantially similar to
24        the Plan coverage. In the event at least  5  insurers  do
25        not offer substantially similar coverage, the rates shall
26        be  established using reasonable actuarial techniques and
27        shall reflect anticipated  claims  experience,  expenses,
28        and  other appropriate risk factors relating to the Plan.
29        Rates for  Plan  coverage  shall  be  135%  of  rates  so
30        established  as applicable for individual standard risks;
31        provided,  however,  if  after   determining   that   the
32        appropriations  made  pursuant  to Section 12 of this Act
33        are insufficient to ensure that  total  income  from  all
34        sources will equal or exceed the total incurred costs and
HB0673 Engrossed            -15-               LRB9003688JSgc
 1        expenses  for  the current number of enrollees, the board
 2        shall raise premium rates above this 135% standard to the
 3        level it deems necessary to ensure the financial solvency
 4        of the Plan for enrollees already in the Plan. All  rates
 5        and  rate  schedules  shall be submitted to the board for
 6        approval.
 7             (5)  The Plan coverage defined in  Section  6  shall
 8        provide  for a choice of deductibles as authorized by the
 9        Board per individual per annum.  If 2 individual  members
10        of  a  family satisfy the same applicable deductibles, no
11        other member of that family who is eligible for  coverage
12        under  the Plan shall be required to meet any deductibles
13        for the balance of that calendar year.   The  deductibles
14        must be applied first to the authorized amount of covered
15        expenses  incurred  by  the  covered person.  A mandatory
16        coinsurance requirement shall  be  imposed  at  the  rate
17        authorized  by  the  Board  in  excess  of  the mandatory
18        deductible, the  coinsurance  in  the  aggregate  not  to
19        exceed  such  amounts  as are authorized by the Board per
20        annum.  At its discretion the Board may,  however,  offer
21        catastrophic coverages or other policies that provide for
22        larger    deductibles   with   or   without   coinsurance
23        requirements.  The deductibles  and  coinsurance  factors
24        may   be  adjusted  annually  according  to  the  Medical
25        Component of the Consumer Price Index.
26             (6)  The  Plan  may  provide  for  and  employ  cost
27        containment measures and requirements including, but  not
28        limited  to,  preadmission certification, second surgical
29        opinion,   concurrent   utilization   review    programs,
30        individual    case    management,    preferred   provider
31        organizations, and other cost effective arrangements  for
32        paying for covered expenses.
33        e.  Scope  of coverage.  Except as provided in subsection
34    c of this Section, if the covered expenses  incurred  by  the
HB0673 Engrossed            -16-               LRB9003688JSgc
 1    eligible  person  exceed  the  deductible  for  major medical
 2    expense coverage in a calendar year, the Plan  shall  pay  at
 3    least  80% of any additional covered expenses incurred by the
 4    person during the calendar year.
 5        f.  Preexisting conditions.
 6             (1)  Six months: Plan coverage shall exclude charges
 7        or expenses incurred during the first 6 months  following
 8        the  effective  date  of coverage as to any condition if:
 9        (a) the condition had  manifested  itself  within  the  6
10        month  period immediately preceding the effective date of
11        coverage in such a manner as would  cause  an  ordinarily
12        prudent  person  to seek diagnosis, care or treatment; or
13        (b) medical advice, care or treatment was recommended  or
14        received  within the 6 month period immediately preceding
15        the effective date of coverage.
16             (2)  (Blank).
17             (3)  Waiver: The preexisting condition exclusions as
18        set forth in paragraph (1) of this  subsection  shall  be
19        waived  to  the  extent to which the eligible person: (a)
20        has satisfied similar exclusions under any  prior  health
21        insurance   policy   or   plan   that  was  involuntarily
22        terminated; (b) is ineligible  for  any  continuation  or
23        conversion   rights   that   would  continue  or  provide
24        substantially    similar    coverage    following    that
25        termination; and (c) has applied for  Plan  coverage  not
26        later than 30 days following the involuntary termination.
27        No   policy   or  plan  shall  be  deemed  to  have  been
28        involuntarily terminated if the  master  policyholder  or
29        other  controlling  party  elected  to  change  insurance
30        coverage from one company or plan to another even if that
31        decision  resulted  in  a discontinuation of coverage for
32        any individual under the plan, either totally or for  any
33        medical condition. For each eligible person who qualifies
34        for  and elects this waiver, there shall be added to each
HB0673 Engrossed            -17-               LRB9003688JSgc
 1        payment of premium, on a prorated basis, a  surcharge  of
 2        up  to 10% of the otherwise applicable annual premium for
 3        as long as that  individual's  coverage  under  the  Plan
 4        remains in effect or 60 months, whichever is less.
 5        g.  Other sources primary;  nonduplication of benefits.
 6             (1)  The  Plan  shall  be the last payor of benefits
 7        whenever any other  benefit  or  source  of  third  party
 8        payment  is  available.   Subject  to  the  provisions of
 9        subsection e of Section  7,  benefits  otherwise  payable
10        under  Plan coverage shall be reduced by all amounts paid
11        or payable by Medicare or any other government program or
12        through any health  insurance  or  other  health  benefit
13        plan,  whether insured or otherwise, or through any third
14        party  liability,   settlement,   judgment,   or   award,
15        regardless  of  the  date of the settlement, judgment, or
16        award, whether the settlement, judgment, or award  is  in
17        the  form of a contract, agreement, or trust on behalf of
18        a  minor  or  otherwise  and  whether   the   settlement,
19        judgment,  or award is payable to the covered person, his
20        or her dependent,  estate,  personal  representative,  or
21        guardian  in a lump sum or over time, and by all hospital
22        or medical expense benefits paid  or  payable  under  any
23        worker's   compensation   coverage,   automobile  medical
24        payment, or liability insurance, whether provided on  the
25        basis  of  fault  or  nonfault,  and  by  any hospital or
26        medical  benefits  paid  or  payable  under  or  provided
27        pursuant to any State or federal law or program.
28             (2)  The Plan shall have a cause of  action  against
29        any  covered person or any other person or entity for the
30        recovery of any amount paid to the extent the amount  was
31        for  treatment, services, or supplies not covered in this
32        Section or in excess of benefits as  set  forth  in  this
33        Section.
34             (3)  Whenever benefits are due from the Plan because
HB0673 Engrossed            -18-               LRB9003688JSgc
 1        of  sickness  or  an injury to a covered person resulting
 2        from a third party's wrongful act or negligence  and  the
 3        covered  person has recovered or may recover damages from
 4        a third party or its insurer, the  Plan  shall  have  the
 5        right  to  reduce  benefits  or to refuse to pay benefits
 6        that otherwise may be payable by the  amount  of  damages
 7        that  the  covered  person  has  recovered or may recover
 8        regardless of the date of the sickness or injury  or  the
 9        date of any settlement, judgment, or award resulting from
10        that sickness or injury.
11             During  the  pendency of any action or claim that is
12        brought by or on behalf of a  covered  person  against  a
13        third  party  or  its  insurer,  any  benefits that would
14        otherwise be payable except for the  provisions  of  this
15        paragraph  (3)  shall  be  paid  if payment by or for the
16        third party has not yet been made and the covered  person
17        or,  if  incapable,  that  person's  legal representative
18        agrees in writing to pay back promptly the benefits  paid
19        as  a  result  of the sickness or injury to the extent of
20        any future payments made by or for the  third  party  for
21        the  sickness  or  injury.   This  agreement  is to apply
22        whether or not liability for the payments is  established
23        or  admitted by the third party or whether those payments
24        are itemized.
25             Any amounts due the plan to repay  benefits  may  be
26        deducted  from  other  benefits payable by the Plan after
27        payments by or for the third party are made.
28             (4)  Benefits due from the Plan may  be  reduced  or
29        refused   as  an  offset  against  any  amount  otherwise
30        recoverable under this Section.
31        h.  Right of subrogation; recoveries.
32             (1)  Whenever the Plan has paid benefits because  of
33        sickness  or  an  injury  to any covered person resulting
34        from a third party's wrongful act or negligence,  or  for
HB0673 Engrossed            -19-               LRB9003688JSgc
 1        which  an  insurer  is  liable  in  accordance  with  the
 2        provisions  of  any  policy of insurance, and the covered
 3        person has recovered or may recover damages from a  third
 4        party that is liable for the damages, the Plan shall have
 5        the  right  to  recover  the  benefits  it  paid from any
 6        amounts that the  covered  person  has  received  or  may
 7        receive  regardless of the date of the sickness or injury
 8        or  the  date  of  any  settlement,  judgment,  or  award
 9        resulting from that sickness or injury.  The  Plan  shall
10        be subrogated to any right of recovery the covered person
11        may  have under the terms of any private or public health
12        care coverage or liability coverage,  including  coverage
13        under  the  Workers'  Compensation  Act  or  the Workers'
14        Occupational  Diseases  Act,  without  the  necessity  of
15        assignment of claim or other authorization to secure  the
16        right of recovery.  To enforce its subrogation right, the
17        Plan may (i) intervene or join in an action or proceeding
18        brought   by   the   covered   person   or  his  personal
19        representative,  including  his  guardian,   conservator,
20        estate, dependents, or survivors, against any third party
21        or  the  third party's insurer that may be liable or (ii)
22        institute and prosecute  legal  proceedings  against  any
23        third  party  or  the  third  party's insurer that may be
24        liable for the sickness or injury in an appropriate court
25        either in the name of the Plan or  in  the  name  of  the
26        covered  person or his personal representative, including
27        his  guardian,  conservator,   estate,   dependents,   or
28        survivors.
29             (2)  If  any  action  or  claim  is brought by or on
30        behalf of a covered person against a third party  or  the
31        third party's insurer, the covered person or his personal
32        representative,   including  his  guardian,  conservator,
33        estate, dependents, or survivors, shall notify  the  Plan
34        by  personal  service or registered mail of the action or
HB0673 Engrossed            -20-               LRB9003688JSgc
 1        claim and of the name of the court in which the action or
 2        claim is brought, filing proof thereof in the  action  or
 3        claim.  The Plan may, at any time thereafter, join in the
 4        action  or  claim  upon  its motion so that all orders of
 5        court after hearing and judgment shall be  made  for  its
 6        protection.   No  release  or  settlement  of a claim for
 7        damages and no satisfaction of  judgment  in  the  action
 8        shall be valid without the written consent of the Plan to
 9        the  extent of its interest in the settlement or judgment
10        and of the covered person or his personal representative.
11             (3)  In the event that the  covered  person  or  his
12        personal  representative  fails to institute a proceeding
13        against any appropriate  third  party  before  the  fifth
14        month before the action would be barred, the Plan may, in
15        its  own  name  or  in  the name of the covered person or
16        personal representative, commence  a  proceeding  against
17        any  appropriate  third party for the recovery of damages
18        on account of any  sickness,  injury,  or  death  to  the
19        covered  person.   The  covered person shall cooperate in
20        doing what is reasonably necessary to assist the Plan  in
21        any  recovery  and  shall  not take any action that would
22        prejudice the Plan's right to recovery.  The  Plan  shall
23        pay  to the covered person or his personal representative
24        all sums collected from any third party  by  judgment  or
25        otherwise in excess of amounts paid in benefits under the
26        Plan  and  amounts paid or to be paid as costs, attorneys
27        fees, and reasonable expenses incurred  by  the  Plan  in
28        making the collection or enforcing the judgment.
29             (4)  In  the  event  that  a  covered  person or his
30        personal   representative,   including   his    guardian,
31        conservator,  estate,  dependents, or survivors, recovers
32        damages from a third party for sickness or injury  caused
33        to the covered person, the covered person or the personal
34        representative  shall  pay  to  the Plan from the damages
HB0673 Engrossed            -21-               LRB9003688JSgc
 1        recovered the amount of benefits paid or to  be  paid  on
 2        behalf of the covered person.
 3             (5)  When  the  action  or  claim  is brought by the
 4        covered person alone and  the  covered  person  incurs  a
 5        personal  liability  to  pay attorney's fees and costs of
 6        litigation, the Plan's claim  for  reimbursement  of  the
 7        benefits provided to the covered person shall be the full
 8        amount  of  benefits  paid to or on behalf of the covered
 9        person  under  this  Act  less  a  pro  rata  share  that
10        represents the Plan's reasonable share of attorney's fees
11        paid by the covered person and that portion of  the  cost
12        of  litigation  expenses determined by multiplying by the
13        ratio of the full amount of the expenditures to the  full
14        amount of the judgement, award, or settlement.
15             (6)  In  the event of judgment or award in a suit or
16        claim against a third party or insurer, the  court  shall
17        first   order  paid  from  any  judgement  or  award  the
18        reasonable litigation expenses  incurred  in  preparation
19        and  prosecution  of  the  action or claim, together with
20        reasonable  attorney's  fees.   After  payment  of  those
21        expenses and attorney's fees, the court shall  apply  out
22        of  the  balance  of  the  judgment  or  award  an amount
23        sufficient to reimburse  the  Plan  the  full  amount  of
24        benefits  paid on behalf of the covered person under this
25        Act, provided the court  may  reduce  and  apportion  the
26        Plan's  portion  of  the  judgement  proportionate to the
27        recovery of the covered person.  The burden of  producing
28        evidence  sufficient to support the exercise by the court
29        of its discretion to reduce the amount of a proven charge
30        sought to be enforced against  the  recovery  shall  rest
31        with  the  party  seeking  the  reduction.  The court may
32        consider the nature and extent of  the  injury,  economic
33        and  non-economic  loss,  settlement  offers, comparative
34        negligence as it applies to the case  at  hand,  hospital
HB0673 Engrossed            -22-               LRB9003688JSgc
 1        costs,  physician costs, and all other appropriate costs.
 2        The Plan shall pay its pro rata  share  of  the  attorney
 3        fees  based  on the Plan's recovery as it compares to the
 4        total judgment.  Any reimbursement  rights  of  the  Plan
 5        shall  take  priority  over  all  other liens and charges
 6        existing under the laws of this State with the  exception
 7        of any attorney liens filed under the Attorneys Lien Act.
 8             (7)  The  Plan  may compromise or settle and release
 9        any claim for benefits provided under this Act  or  waive
10        any  claims  for  benefits,  in whole or in part, for the
11        convenience of the Plan or if the  Plan  determines  that
12        collection  would  result  in  undue  hardship  upon  the
13        covered person.
14    (Source: P.A. 89-486, eff. 6-21-96.)

[ Top ]