[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ Engrossed ] | [ Enrolled ] |
90_HB0705sam001
LRB9002464JSgcam01
1 AMENDMENT TO HOUSE BILL 705
2 AMENDMENT NO. . Amend House Bill 705 by replacing
3 the title with the following:
4 "AN ACT regarding health insurance for children."; and
5 by replacing everything after the enacting clause with the
6 following:
7 "Section 1. Short title. This Act may be cited as the
8 Children's Health Insurance Program Act.
9 Section 5. Legislative intent. The General Assembly
10 finds that, for the economic and social benefit of all
11 citizens of the State, it is important to enable low-income
12 children of this State, to the extent funding permits, to
13 access health benefits coverage, especially preventive health
14 care. The General Assembly recognizes that assistance to
15 help families purchase health benefits for low income
16 children must be provided in a fair and equitable fashion and
17 must treat all children at the same income level in a similar
18 fashion. The State of Illinois should help low-income
19 families transition from a health care system where
20 government partners with families to provide health benefits
21 to low-income children to a system where families with higher
-2- LRB9002464JSgcam01
1 incomes eventually transition into private or employer based
2 health plans. This Act is not intended to create an
3 entitlement.
4 Section 10. Definitions. As used in this Act:
5 "Benchmarking" means health benefits coverage as defined
6 in Section 2103 of the Social Security Act.
7 "Child" means a person under the age of 19.
8 "Department" means the Department of Public Aid.
9 "Medical assistance" means health care benefits provided
10 under Article V of the Illinois Public Aid Code.
11 "Medical visit" means a hospital, dental, physician,
12 optical, or other health care visit where services are
13 provided pursuant to this Act.
14 "Program" means the Children's Health Insurance Program,
15 which includes subsidizing the cost of privately sponsored
16 health insurance and purchasing or providing health care
17 benefits for eligible children.
18 "Resident" means a person who meets the residency
19 requirements as defined in Section 5-3 of the Illinois Public
20 Aid Code.
21 Section 15. Operation of the Program. There is hereby
22 created a Children's Health Insurance Program. The Program
23 shall operate subject to appropriation and shall be
24 administered by the Department of Public Aid. The Department
25 shall have the powers and authority granted to the Department
26 under the Illinois Public Aid Code. The Department may
27 contract with a Third Party Administrator or other entities
28 to administer and oversee any portion of this Program.
29 Section 20. Eligibility.
30 (a) To be eligible for this Program, a person must be a
31 person who has a child eligible under this Act and who is
-3- LRB9002464JSgcam01
1 eligible under a waiver of federal requirements pursuant to
2 an application made pursuant to subdivision (a)(1) of Section
3 40 of this Act or who is a child who:
4 (1) is a child who is not eligible for medical
5 assistance;
6 (2) is a child whose annual household income, as
7 determined by the Department, is above 133% of the
8 federal poverty level and at or below 185% of the federal
9 poverty level;
10 (3) is a resident of the State of Illinois; and
11 (4) is a child who is either a United States
12 citizen or included in one of the following categories of
13 non-citizens:
14 (A) unmarried dependent children of either a
15 United States Veteran honorably discharged or a
16 person on active military duty;
17 (B) refugees under Section 207 of the
18 Immigration and Nationality Act;
19 (C) asylees under Section 208 of the
20 Immigration and Nationality Act;
21 (D) persons for whom deportation has been
22 withheld under Section 243(h) of the Immigration
23 and Nationality Act;
24 (E) persons granted conditional entry under
25 Section 203(a)(7) of the Immigration and Nationality
26 Act as in effect prior to April 1, 1980;
27 (F) persons lawfully admitted for permanent
28 residence under the Immigration and Nationality Act;
29 and
30 (G) parolees, for at least one year, under
31 Section 212(d)(5) of the Immigration and Nationality
32 Act.
33 Those children who are in the categories set forth in
34 subdivisions (4)(F) and (4)(G) of this subsection, who enter
-4- LRB9002464JSgcam01
1 the United States on or after August 22, 1996, shall not be
2 eligible for 5 years beginning on the date the child entered
3 the United States.
4 (b) A child who is determined to be eligible for
5 assistance shall remain eligible for 12 months, provided the
6 child maintains his or her residence in the State, has not
7 yet attained 19 years of age, and is not excluded pursuant to
8 subsection (c). Eligibility shall be re-determined by the
9 Department at least annually.
10 (c) A child shall not be eligible for coverage under
11 this Program if:
12 (1) the premium required pursuant to Section 30 of
13 this Act has not been paid. If the required premiums are
14 not paid the liability of the Program shall be limited to
15 benefits incurred under the Program for the time period
16 for which premiums had been paid. If the required
17 monthly premium is not paid, the child shall be
18 ineligible for re-enrollment for a minimum period of 3
19 months. Re-enrollment shall be completed prior to the
20 next covered medical visit and the first month's required
21 premium shall be paid in advance of the next covered
22 medical visit. The Department shall promulgate rules
23 regarding grace periods, notice requirements, and hearing
24 procedures pursuant to this subsection;
25 (2) the child is an inmate of a public institution
26 or a patient in an institution for mental diseases; or
27 (3) the child is a member of a family that is
28 eligible for health benefits covered under the State of
29 Illinois health benefits plan on the basis of a member's
30 employment with a public agency.
31 Section 25. Health benefits for children.
32 (a) The Department shall, subject to appropriation,
33 provide health benefits coverage to eligible children by:
-5- LRB9002464JSgcam01
1 (1) Subsidizing the cost of privately sponsored
2 health insurance, including employer based health
3 insurance, to assist families to take advantage of
4 available privately sponsored health insurance for their
5 eligible children; and
6 (2) Purchasing or providing health care benefits
7 for eligible children. The health benefits provided
8 under this subdivision (a)(2) shall, subject to
9 appropriation and without regard to any applicable cost
10 sharing under Section 30, be identical to the benefits
11 provided for children under the State's approved plan
12 under Title XIX of the Social Security Act. Providers
13 under this subdivision (a)(2) shall be subject to
14 approval by the Department to provide health care under
15 the Illinois Public Aid Code and shall be reimbursed at
16 the same rate as providers under the State's approved
17 plan under Title XIX of the Social Security Act. In
18 addition, providers may retain copayments when determined
19 appropriate by the Department.
20 (b) The subsidization provided pursuant to subdivision
21 (a)(1) shall be credited to the family of the eligible child.
22 (c) The Department is prohibited from denying coverage
23 to a child who is enrolled in a privately sponsored health
24 insurance plan pursuant to subdivision (a)(1) because the
25 plan does not meet federal benchmarking standards or cost
26 sharing and contribution requirements. To be eligible for
27 inclusion in the Program, the plan shall contain
28 comprehensive major medical coverage which shall consist of
29 physician and hospital inpatient services. The Department is
30 prohibited from denying coverage to a child who is enrolled
31 in a privately sponsored health insurance plan pursuant to
32 subdivision (a)(1) because the plan offers benefits in
33 addition to physician and hospital inpatient services.
34 (d) The total dollar amount of subsidizing coverage per
-6- LRB9002464JSgcam01
1 child per month pursuant to subdivision (a)(1) shall be equal
2 to the average dollar payments, less premiums incurred, per
3 child per month pursuant to subdivision (a)(2). The
4 Department shall set this amount prospectively based upon the
5 prior fiscal year's experience adjusted for incurred but not
6 reported claims and estimated increases or decreases in the
7 cost of medical care. Payments obligated before July 1,
8 1999, will be computed using State Fiscal Year 1996 payments
9 for children eligible for Medical Assistance and income
10 assistance under the Aid to Families with Dependent Children
11 Program, with appropriate adjustments for cost and
12 utilization changes through January 1, 1999. The Department
13 is prohibited from providing a subsidy pursuant to
14 subdivision (a)(1) that is more than the individual's monthly
15 portion of the premium.
16 (e) An eligible child may obtain immediate coverage
17 under this Program only once during a medical visit. If
18 coverage lapses, re-enrollment shall be completed in advance
19 of the next covered medical visit and the first month's
20 required premium shall be paid in advance of any covered
21 medical visit.
22 (f) In order to accelerate and facilitate the
23 development of networks to deliver services to children in
24 areas outside counties with populations in excess of
25 3,000,000, in the event less than 25% of the eligible
26 children in a county or contiguous counties has enrolled with
27 a Health Maintenance Organization pursuant to Section 5-11 of
28 the Illinois Public Aid Code, the Department may develop and
29 implement demonstration projects to create alternative
30 networks designed to enhance enrollment and participation in
31 the program. The Department shall prescribe by rule the
32 criteria, standards, and procedures for effecting
33 demonstration projects under this Section.
-7- LRB9002464JSgcam01
1 Section 30. Cost sharing.
2 (a) Children enrolled in a health benefits program
3 pursuant to subdivision (a)(2) of Section 25 shall be subject
4 to the following cost sharing requirements:
5 (1) There shall be no co-payment required for
6 well-baby or well-child care, including age-appropriate
7 immunizations as required under federal law.
8 (2) Health insurance premiums for children in
9 families whose household income is at or above 150% of
10 the federal poverty level shall be payable monthly,
11 subject to rules promulgated by the Department for grace
12 periods and advance payments, and shall be as follows:
13 (A) $15 per month for one child.
14 (B) $25 per month for 2 children.
15 (C) $30 per month for 3 or more children.
16 (3) Co-payments for children in families whose
17 income is below 150% of the federal poverty level, at a
18 minimum and to the extent permitted under federal law,
19 shall be $2 for all medical visits and prescriptions
20 provided under this Act.
21 (4) Co-payments for children in families whose
22 income is at or above 150% of the federal poverty level,
23 at a minimum and to the extent permitted under federal
24 law shall be as follows:
25 (A) $5 for medical visits.
26 (B) $3 for generic prescriptions and $5 for
27 brand name prescriptions.
28 (C) $25 for emergency room use for a
29 non-emergency situation as defined by the Department
30 by rule.
31 (5) The maximum amount of out-of-pocket expenses
32 for co-payments shall be $100 per family per year.
33 (b) Individuals enrolled in a privately sponsored health
34 insurance plan pursuant to subdivision (a)(1) of Section 25
-8- LRB9002464JSgcam01
1 shall be subject to the cost sharing provisions as stated in
2 the privately sponsored health insurance plan.
3 Section 35. Funding.
4 (a) This Program is not an entitlement and shall not be
5 construed to create an entitlement. Eligibility for the
6 Program is subject to appropriation of funds by the State and
7 federal governments. Subdivision (a)(2) of Section 25 shall
8 operate and be funded only if subdivision (a)(1) of Section
9 25 is operational and funded. The estimated net State share
10 of appropriated funds for subdivision (a)(2) of Section 25
11 shall be equal to the estimated net State share of
12 appropriated funds for subdivision (a)(1) of Section 25.
13 (b) Any requirement imposed under this Act and any
14 implementation of this Act by the Department shall cease in
15 the event (1) continued receipt of federal funds for
16 implementation of this Act requires an amendment to this Act,
17 or (2) federal funds for implementation of the Act are not
18 otherwise available.
19 (c) Payments under this Act shall be appropriated from
20 the General Revenue Fund.
21 (d) Benefits under this Act shall be available only as
22 long as the intergovernmental agreements made pursuant to
23 Section 12-4.7 and Article XV of the Illinois Public Aid Code
24 and entered into between the Department and the Cook County
25 Board of Commissioners continue to exist.
26 Section 40. Waivers.
27 (a) The Department shall request any necessary waivers
28 of federal requirements in order to allow receipt of federal
29 funding for:
30 (1) the coverage of families with eligible children
31 under this Act; and
32 (2) for the coverage of children who would
-9- LRB9002464JSgcam01
1 otherwise be eligible under this Act, but who have health
2 insurance.
3 (b) The failure of the responsible federal agency to
4 approve a waiver for children who would otherwise be eligible
5 under this Act but who have health insurance shall not
6 prevent the implementation of any Section of this Act
7 provided that there are sufficient appropriated funds.
8 Section 45. Study.
9 (a) The Department shall conduct a study which includes,
10 but is not limited to, the following:
11 (1) Establishes estimates, broken down by regions
12 of the State, of the number of children with health
13 insurance coverage and without health insurance coverage;
14 the number of children who are eligible for Medicaid, and
15 of that number, the number who are enrolled in Medicaid;
16 the number of children with access to dependent coverage
17 through an employer, and of that number, the number who
18 are enrolled in dependent coverage through an employer.
19 (2) Ascertains, for the population of children
20 potentially eligible for coverage under any component of
21 the Program, the extent of access to dependent coverage,
22 how many children are enrolled in dependent coverage, the
23 comprehensiveness of dependent coverage benefit packages
24 available, and the amount of cost sharing currently paid
25 by the employees.
26 (b) The Department shall submit the preliminary results
27 of the study to the Governor and the General Assembly by
28 December 1, 1998 and shall submit the final results to the
29 Governor and the General Assembly by May 1, 1999.
30 Section 50. Program evaluation. The Department shall
31 conduct 2 evaluations of the effectiveness of the program
32 implemented under this Act. The first evaluation shall be
-10- LRB9002464JSgcam01
1 for the first 6 full months of implementation, and the
2 evaluation shall be completed within 90 days after that
3 period. The second evaluation shall be for the first 12 full
4 months of implementation and shall be completed within 90
5 days after that period.
6 Section 55. Contracts with non-governmental bodies. All
7 contracts with non-governmental bodies that are determined by
8 the Department to be necessary for the implementation of this
9 Section are deemed to be purchase of care as defined in the
10 Illinois Procurement Code.
11 Section 60. Emergency rulemaking. Prior to June 30,
12 1999, the Department may adopt rules necessary to establish
13 and implement this Section through the use of emergency
14 rulemaking in accordance with Section 5-45 of the Illinois
15 Administrative Procedure Act. For purposes of that Act, the
16 General Assembly finds that the adoption of rules to
17 implement this Section is deemed an emergency and necessary
18 for the public interest, safety, and welfare.
19 Section 96. Inseverability. The provisions of this Act
20 are mutually dependent and inseverable. If any provision or
21 its application to any person or circumstance is held
22 invalid, then this entire Act is invalid.
23 Section 97. Repealer. This Act is repealed on June 30,
24 2001.
25 Section 98. The Illinois Health Insurance Portability
26 and Accountability Act is amended by changing Section 20 as
27 follows:
28 (215 ILCS 97/20)
-11- LRB9002464JSgcam01
1 Sec. 20. Increased portability through limitation on
2 preexisting condition exclusions.
3 (A) Limitation of preexisting condition exclusion
4 period; crediting for periods of previous coverage. Subject
5 to subsection (D), a group health plan, and a health
6 insurance issuer offering group health insurance coverage,
7 may, with respect to a participant or beneficiary, impose a
8 preexisting condition exclusion only if:
9 (1) the exclusion relates to a condition (whether
10 physical or mental), regardless of the cause of the
11 condition, for which medical advice, diagnosis, care, or
12 treatment was recommended or received within the 6-month
13 period ending on the enrollment date;
14 (2) the exclusion extends for a period of not more
15 than 12 months (or 18 months in the case of a late
16 enrollee) after the enrollment date; and
17 (3) the period of any such preexisting condition
18 exclusion is reduced by the aggregate of the periods of
19 creditable coverage (if any, as defined in subsection
20 (C)(1)) applicable to the participant or beneficiary as
21 of the enrollment date.
22 (B) Preexisting condition exclusion. A group health
23 plan, and health insurance issuer offering group health
24 insurance coverage, may not impose any preexisting condition
25 exclusion relating to pregnancy as a preexisting condition.
26 Genetic information shall not be treated as a condition
27 described in subsection (A)(1) in the absence of a diagnosis
28 of the condition related to such information.
29 (C) Rules relating to crediting previous coverage.
30 (1) Creditable coverage defined. For purposes of
31 this Act, the term "creditable coverage" means, with
32 respect to an individual, coverage of the individual
33 under any of the following:
34 (a) A group health plan.
-12- LRB9002464JSgcam01
1 (b) Health insurance coverage.
2 (c) Part A or part B of title XVIII of the
3 Social Security Act.
4 (d) Title XIX of the Social Security Act,
5 other than coverage consisting solely of benefits
6 under Section 1928.
7 (e) Chapter 55 of title 10, United States
8 Code.
9 (f) A medical care program of the Indian
10 Health Service or of a tribal organization.
11 (g) A State health benefits risk pool.
12 (h) A health plan offered under chapter 89 of
13 title 5, United States Code.
14 (i) A public health plan (as defined in
15 regulations).
16 (j) A health benefit plan under Section 5(e)
17 of the Peace Corps Act (22 U.S.C. 2504(e)).
18 (k) Title XXI of the federal Social Security
19 Act, State Children's Health Insurance Program.
20 Such term does not include coverage consisting
21 solely of coverage of excepted benefits.
22 (2) Excepted benefits. For purposes of this Act,
23 the term "excepted benefits" means benefits under one or
24 more of the following:
25 (a) Benefits not subject to requirements:
26 (i) Coverage only for accident, or
27 disability income insurance, or any combination
28 thereof.
29 (ii) Coverage issued as a supplement to
30 liability insurance.
31 (iii) Liability insurance, including
32 general liability insurance and automobile
33 liability insurance.
34 (iv) Workers' compensation or similar
-13- LRB9002464JSgcam01
1 insurance.
2 (v) Automobile medical payment insurance.
3 (vi) Credit-only insurance.
4 (vii) Coverage for on-site medical
5 clinics.
6 (viii) Other similar insurance coverage,
7 specified in regulations, under which benefits
8 for medical care are secondary or incidental to
9 other insurance benefits.
10 (b) Benefits not subject to requirements if
11 offered separately:
12 (i) Limited scope dental or vision
13 benefits.
14 (ii) Benefits for long-term care, nursing
15 home care, home health care, community-based
16 care, or any combination thereof.
17 (iii) Such other similar, limited
18 benefits as are specified in rules.
19 (c) Benefits not subject to requirements if
20 offered, as independent, noncoordinated benefits:
21 (i) Coverage only for a specified disease
22 or illness.
23 (ii) Hospital indemnity or other fixed
24 indemnity insurance.
25 (d) Benefits not subject to requirements if
26 offered as separate insurance policy. Medicare
27 supplemental health insurance (as defined under
28 Section 1882(g)(1) of the Social Security Act),
29 coverage supplemental to the coverage provided under
30 chapter 55 of title 10, United States Code, and
31 similar supplemental coverage provided to coverage
32 under a group health plan.
33 (3) Not counting periods before significant breaks
34 in coverage.
-14- LRB9002464JSgcam01
1 (a) In general. A period of creditable
2 coverage shall not be counted, with respect to
3 enrollment of an individual under a group health
4 plan, if, after such period and before the
5 enrollment date, there was a 63- day period during
6 all of which the individual was not covered under
7 any creditable coverage.
8 (b) Waiting period not treated as a break in
9 coverage. For purposes of subparagraph (a) and
10 subsection (D)(3), any period that an individual is
11 in a waiting period for any coverage under a group
12 health plan (or for group health insurance coverage)
13 or is in an affiliation period (as defined in
14 subsection (G)(2)) shall not be taken into account
15 in determining the continuous period under
16 subparagraph (a).
17 (4) Method of crediting coverage.
18 (a) Standard method. Except as otherwise
19 provided under subparagraph (b), for purposes of
20 applying subsection (A)(3), a group health plan, and
21 a health insurance issuer offering group health
22 insurance coverage, shall count a period of
23 creditable coverage without regard to the specific
24 benefits covered during the period.
25 (b) Election of alternative method. A group
26 health plan, or a health insurance issuer offering
27 group health insurance, may elect to apply
28 subsection (A)(3) based on coverage of benefits
29 within each of several classes or categories of
30 benefits specified in regulations rather than as
31 provided under subparagraph (a). Such election
32 shall be made on a uniform basis for all
33 participants and beneficiaries. Under such election
34 a group health plan or issuer shall count a period
-15- LRB9002464JSgcam01
1 of creditable coverage with respect to any class or
2 category of benefits if any level of benefits is
3 covered within such class or category.
4 (c) Plan notice. In the case of an election
5 with respect to a group health plan under
6 subparagraph (b) (whether or not health insurance
7 coverage is provided in connection with such plan),
8 the plan shall:
9 (i) prominently state in any disclosure
10 statements concerning the plan, and state to
11 each enrollee at the time of enrollment under
12 the plan, that the plan has made such election;
13 and
14 (ii) include in such statements a
15 description of the effect of this election.
16 (d) Issuer notice. In the case of an election
17 under subparagraph (b) with respect to health
18 insurance coverage offered by an issuer in the small
19 or large group market, the issuer:
20 (i) shall prominently state in any
21 disclosure statements concerning the coverage,
22 and to each employer at the time of the offer
23 or sale of the coverage, that the issuer has
24 made such election; and
25 (ii) shall include in such statements a
26 description of the effect of such election.
27 (5) Establishment of period. Periods of creditable
28 coverage with respect to an individual shall be
29 established through presentation or certifications
30 described in subsection (E) or in such other manner as
31 may be specified in regulations.
32 (D) Exceptions:
33 (1) Exclusion not applicable to certain newborns.
34 Subject to paragraph (3), a group health plan, and a
-16- LRB9002464JSgcam01
1 health insurance issuer offering group health insurance
2 coverage, may not impose any preexisting condition
3 exclusion in the case of an individual who, as of the
4 last day of the 30-day period beginning with the date of
5 birth, is covered under creditable coverage.
6 (2) Exclusion not applicable to certain adopted
7 children. Subject to paragraph (3), a group health plan,
8 and a health insurance issuer offering group health
9 insurance coverage, may not impose any preexisting
10 condition exclusion in the case of a child who is adopted
11 or placed for adoption before attaining 18 years of age
12 and who, as of the last day of the 30-day period
13 beginning on the date of the adoption or placement for
14 adoption, is covered under creditable coverage.
15 The previous sentence shall not apply to coverage
16 before the date of such adoption or placement for
17 adoption.
18 (3) Loss if break in coverage. Paragraphs (1) and
19 (2) shall no longer apply to an individual after the end
20 of the first 63-day period during all of which the
21 individual was not covered under any creditable coverage.
22 (E) Certifications and disclosure of coverage.
23 (1) Requirement for Certification of Period of
24 Creditable Coverage.
25 (a) A group health plan, and a health
26 insurance issuer offering group health insurance
27 coverage, shall provide the certification described
28 in subparagraph (b):
29 (i) at the time an individual ceases to
30 be covered under the plan or otherwise becomes
31 covered under a COBRA continuation provision;
32 (ii) in the case of an individual
33 becoming covered under such a provision, at the
34 time the individual ceases to be covered under
-17- LRB9002464JSgcam01
1 such provision; and
2 (iii) on the request on behalf of an
3 individual made not later than 24 months after
4 the date of cessation of the coverage described
5 in clause (i) or (ii), whichever is later.
6 The certification under clause (i) may be provided,
7 to the extent practicable, at a time consistent with
8 notices required under any applicable COBRA
9 continuation provision.
10 (b) The certification described in this
11 subparagraph is a written certification of:
12 (i) the period of creditable coverage of
13 the individual under such plan and the coverage
14 (if any) under such COBRA continuation
15 provision; and
16 (ii) the waiting period (if any) (and
17 affiliation period, if applicable) imposed with
18 respect to the individual for any coverage
19 under such plan.
20 (c) To the extent that medical care under a
21 group health plan consists of group health insurance
22 coverage, the plan is deemed to have satisfied the
23 certification requirement under this paragraph if
24 the health insurance issuer offering the coverage
25 provides for such certification in accordance with
26 this paragraph.
27 (2) Disclosure of information on previous benefits.
28 In the case of an election described in subsection
29 (C)(4)(b) by a group health plan or health insurance
30 issuer, if the plan or issuer enrolls an individual for
31 coverage under the plan and the individual provides a
32 certification of coverage of the individual under
33 paragraph (1):
34 (a) upon request of such plan or issuer, the
-18- LRB9002464JSgcam01
1 entity which issued the certification provided by
2 the individual shall promptly disclose to such
3 requesting plan or issuer information on coverage of
4 classes and categories of health benefits available
5 under such entity's plan or coverage; and
6 (b) such entity may charge the requesting plan
7 or issuer for the reasonable cost of disclosing such
8 information.
9 (3) Rules. The Department shall establish rules to
10 prevent an entity's failure to provide information under
11 paragraph (1) or (2) with respect to previous coverage of
12 an individual from adversely affecting any subsequent
13 coverage of the individual under another group health
14 plan or health insurance coverage.
15 (4) Treatment of certain plans as group health plan
16 for notice provision. A program under which creditable
17 coverage described in subparagraph (c), (d), (e), or (f)
18 of Section 20(C)(1) is provided shall be treated as a
19 group health plan for purposes of this Section.
20 (F) Special enrollment periods.
21 (1) Individuals losing other coverage. A group
22 health plan, and a health insurance issuer offering group
23 health insurance coverage in connection with a group
24 health plan, shall permit an employee who is eligible,
25 but not enrolled, for coverage under the terms of the
26 plan (or a dependent of such an employee if the dependent
27 is eligible, but not enrolled, for coverage under such
28 terms) to enroll for coverage under the terms of the plan
29 if each of the following conditions is met:
30 (a) The employee or dependent was covered
31 under a group health plan or had health insurance
32 coverage at the time coverage was previously offered
33 to the employee or dependent.
34 (b) The employee stated in writing at such
-19- LRB9002464JSgcam01
1 time that coverage under a group health plan or
2 health insurance coverage was the reason for
3 declining enrollment, but only if the plan sponsor
4 or issuer (if applicable) required such a statement
5 at such time and provided the employee with notice
6 of such requirement (and the consequences of such
7 requirement) at such time.
8 (c) The employee's or dependent's coverage
9 described in subparagraph (a):
10 (i) was under a COBRA continuation
11 provision and the coverage under such provision
12 was exhausted; or
13 (ii) was not under such a provision and
14 either the coverage was terminated as a result
15 of loss of eligibility for the coverage
16 (including as a result of legal separation,
17 divorce, death, termination of employment, or
18 reduction in the number of hours of employment)
19 or employer contributions towards such coverage
20 were terminated.
21 (d) Under the terms of the plan, the employee
22 requests such enrollment not later than 30 days
23 after the date of exhaustion of coverage described
24 in subparagraph (c)(i) or termination of coverage or
25 employer contributions described in subparagraph
26 (c)(ii).
27 (2) For dependent beneficiaries.
28 (a) In general. If:
29 (i) a group health plan makes coverage
30 available with respect to a dependent of an
31 individual,
32 (ii) the individual is a participant
33 under the plan (or has met any waiting period
34 applicable to becoming a participant under the
-20- LRB9002464JSgcam01
1 plan and is eligible to be enrolled under the
2 plan but for a failure to enroll during a
3 previous enrollment period), and
4 (iii) a person becomes such a dependent
5 of the individual through marriage, birth, or
6 adoption or placement for adoption,
7 then the group health plan shall provide for a
8 dependent special enrollment period described in
9 subparagraph (b) during which the person (or, if not
10 otherwise enrolled, the individual) may be enrolled
11 under the plan as a dependent of the individual, and
12 in the case of the birth or adoption of a child, the
13 spouse of the individual may be enrolled as a
14 dependent of the individual if such spouse is
15 otherwise eligible for coverage.
16 (b) Dependent special enrollment period. A
17 dependent special enrollment period under this
18 subparagraph shall be a period of not less than 30
19 days and shall begin on the later of:
20 (i) the date dependent coverage is made
21 available; or
22 (ii) the date of the marriage, birth, or
23 adoption or placement for adoption (as the case
24 may be) described in subparagraph (a)(iii).
25 (c) No waiting period. If an individual seeks
26 to enroll a dependent during the first 30 days of
27 such a dependent special enrollment period, the
28 coverage of the dependent shall become effective:
29 (i) in the case of marriage, not later
30 than the first day of the first month beginning
31 after the date the completed request for
32 enrollment is received;
33 (ii) in the case of a dependent's birth,
34 as of the date of such birth; or
-21- LRB9002464JSgcam01
1 (iii) in the case of a dependent's
2 adoption or placement for adoption, the date of
3 such adoption or placement for adoption.
4 (G) Use of affiliation period by HMOs as alternative to
5 preexisting condition exclusion.
6 (1) In general. A health maintenance organization
7 which offers health insurance coverage in connection with
8 a group health plan and which does not impose any
9 pre-existing condition exclusion allowed under subsection
10 (A) with respect to any particular coverage option may
11 impose an affiliation period for such coverage option,
12 but only if:
13 (a) such period is applied uniformly without
14 regard to any health status-related factors; and
15 (b) such period does not exceed 2 months (or 3
16 months in the case of a late enrollee).
17 (2) Affiliation period.
18 (a) Defined. For purposes of this Act, the
19 term "affiliation period" means a period which,
20 under the terms of the health insurance coverage
21 offered by the health maintenance organization, must
22 expire before the health insurance coverage becomes
23 effective. The organization is not required to
24 provide health care services or benefits during such
25 period and no premium shall be charged to the
26 participant or beneficiary for any coverage during
27 the period.
28 (b) Beginning. Such period shall begin on the
29 enrollment date.
30 (c) Runs concurrently with waiting periods.
31 An affiliation period under a plan shall run
32 concurrently with any waiting period under the plan.
33 (3) Alternative methods. A health maintenance
34 organization described in paragraph (1) may use
-22- LRB9002464JSgcam01
1 alternative methods, from those described in such
2 paragraph, to address adverse selection as approved by
3 the Department.
4 (Source: P.A. 90-30, eff. 7-1-97.)
5 Section 99. Effective Date. This Act takes effect upon
6 becoming law.".