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LRB095 19723 KBJ 46088 b |
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| AN ACT concerning regulation.
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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 1. Short title. This Act may be cited as the |
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| Hospital Uninsured Patient Discount Act. |
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| Section 5. Definitions. As used in this Act: |
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| "Cost to charge ratio" means the ratio of a hospital's |
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| costs to its charges taken from its most recently filed |
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| Medicare cost report (CMS 2552-96 Worksheet C, Part I, PPS |
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| Inpatient Ratios). |
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| "Critical Access Hospital" means a hospital that is |
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| designated as such under the federal Medicare Rural Hospital |
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| Flexibility Program. |
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| "Family income" means the sum of a family's annual earnings |
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| and cash benefits from all sources before taxes, less payments |
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| made for child support. |
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| "Federal poverty income guidelines" means the poverty |
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| guidelines updated periodically in the Federal Register by the |
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| United States Department of Health and Human Services under |
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| authority of 42 U.S.C. 9902(2). |
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| "Health care services" means any medically necessary |
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| inpatient or outpatient hospital service, including |
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| pharmaceuticals or supplies provided by a hospital to a |
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LRB095 19723 KBJ 46088 b |
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| patient. |
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| "Hospital" means any facility or institution required to be |
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| licensed pursuant to the Hospital Licensing Act or operated |
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| under the University of Illinois Hospital Act. |
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| "Illinois resident" means a person who lives in Illinois |
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| and who intends to remain living in Illinois indefinitely. |
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| Relocation to Illinois for the sole purpose of receiving health |
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| care benefits does not satisfy the residency requirement under |
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| this Act. |
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| "Medically necessary" means any inpatient or outpatient |
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| hospital service, including pharmaceuticals or supplies |
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| provided by a hospital to a patient, covered under Title XVIII |
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| of the federal Social Security Act for beneficiaries with the |
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| same clinical presentation as the uninsured patient. A |
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| "medically necessary" service does not include any of the |
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| following: |
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| (1) Non-medical services such as social and vocational |
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| services. |
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| (2) Elective cosmetic surgery, but not plastic surgery |
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| designed to correct disfigurement caused by injury, |
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| illness, or congenital defect or deformity. |
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| "Rural hospital" means a hospital that is located outside a |
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| metropolitan statistical area. |
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| "Uninsured discount" means a hospital's charges multiplied |
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| by the uninsured discount factor. |
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| "Uninsured discount factor" means 1.0 less the product of a |
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LRB095 19723 KBJ 46088 b |
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| hospital's cost to charge ratio multiplied by 1.35. |
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| "Uninsured patient" means an Illinois resident who is a |
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| patient of a hospital and is not covered under a policy of |
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| health insurance and is not a beneficiary under a public or |
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| private health insurance, health benefit, or other health |
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| coverage program, including high deductible health insurance |
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| plans, workers' compensation, accident liability insurance, or |
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| other third party liability. |
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| Section 10. Uninsured patient discounts. |
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| (a) Eligibility. |
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| (1) A hospital, other than a rural hospital or Critical |
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| Access Hospital, shall provide a discount from its charges |
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| to any uninsured patient who applies for a discount and has |
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| family income of not more than 600% of the federal poverty |
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| income guidelines for all medically necessary health care |
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| services exceeding $300 in any one inpatient admission or |
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| outpatient encounter. |
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| (2) A rural hospital or Critical Access Hospital shall |
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| provide a discount from its charges to any uninsured |
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| patient who applies for a discount and has annual family |
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| income of not more than 300% of the federal poverty income |
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| guidelines for all medically necessary health care |
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| services exceeding $300 in any one inpatient admission or |
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| outpatient encounter. |
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| (b) Discount. For all health care services exceeding $300 |
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LRB095 19723 KBJ 46088 b |
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| in any one inpatient admission or outpatient encounter, a |
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| hospital shall not collect from an uninsured patient, deemed |
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| eligible under subsection (a), more than its charges less the |
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| amount of the uninsured discount. |
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| (c) Maximum Collectible Amount. |
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| (1) The maximum amount that may be collected in a 12 |
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| month period for health care services provided by the |
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| hospital from a patient determined by that hospital to be |
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| eligible under subsection (a) is 25% of the patient's |
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| family income, and is subject to the patient's continued |
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| eligibility under this Act. |
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| (2) The 12 month period to which the maximum amount |
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| applies shall begin on the first date, after the effective |
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| date of this Act, an uninsured patient receives health care |
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| services that are determined to be eligible for the |
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| uninsured discount at that hospital. |
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| (3) To be eligible to have this maximum amount applied |
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| to subsequent charges, the uninsured patient shall inform |
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| the hospital in subsequent inpatient admissions or |
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| outpatient encounters that the patient has previously |
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| received health care services from that hospital and was |
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| determined to be entitled to the uninsured discount. |
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| (4) Hospitals may adopt policies to exclude an |
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| uninsured patient from the application of subdivision |
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| (c)(1) when the patient owns assets having a value in |
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| excess of 600% of the federal poverty level for hospitals |
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LRB095 19723 KBJ 46088 b |
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| in a metropolitan statistical area or owns assets having a |
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| value in excess of 300% of the federal poverty level for |
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| Critical Access Hospitals or hospitals outside a |
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| metropolitan statistical area, not counting the following |
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| assets: the uninsured patient's primary residence; |
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| personal property exempt from judgment under Section |
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| 12-1001 of the Code of Civil Procedure; or any amounts held |
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| in a pension or retirement plan, provided, however, that |
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| distributions and payments from pension or retirement |
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| plans may be included as income for the purposes of this |
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| Act. |
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| (d) Each hospital bill, invoice, or other summary of |
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| charges to an uninsured patient shall include with it, or on |
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| it, a prominent statement that an uninsured patient who meets |
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| certain income requirements may qualify for an uninsured |
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| discount and information regarding how an uninsured patient may |
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| apply for consideration under the hospital's financial |
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| assistance policy. |
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| Section 15. Patient responsibility. |
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| (a) Hospitals may make the availability of a discount and |
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| the maximum collectible amount under this Act contingent upon |
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| the uninsured patient first applying for coverage under public |
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| programs, such as Medicare, Medicaid, AllKids, the State |
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| Children's Health Insurance Program, or any other program, if |
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| there is a reasonable basis to believe that the uninsured |
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LRB095 19723 KBJ 46088 b |
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| patient may be eligible for such program. |
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| (b) Hospitals shall permit an uninsured patient to apply |
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| for a discount within 60 days of the date of discharge or date |
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| of service. |
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| (1) Income verification. Hospitals may require an |
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| uninsured patient who is requesting an uninsured discount |
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| to provide documentation of family income. Acceptable |
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| family income documentation shall include any one of the |
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| following: |
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| (A) a copy of the most recent tax return; |
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| (B) a copy of the most recent W-2 form and 1099 |
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| forms; |
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| (C) copies of the 2 most recent pay stubs; |
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| (D) written income verification from an employer |
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| if paid in cash; or |
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| (E) one other reasonable form of third party income |
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| verification
deemed acceptable to the hospital. |
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| (2) Asset verification. Hospitals may require an |
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| uninsured patient who is requesting an uninsured discount |
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| to certify the existence of assets owned by the patient and |
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| to provide documentation of the value of such assets. |
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| Acceptable documentation may include statements from |
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| financial institutions or some other third party |
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| verification of an asset's value. If no third party |
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| verification exists, then the patient shall certify as to |
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| the estimated value of the asset. |
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LRB095 19723 KBJ 46088 b |
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| (3) Illinois resident verification. Hospitals may |
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| require an uninsured patient who is requesting an uninsured |
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| discount to verify Illinois residency. Acceptable |
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| verification of Illinois residency shall include any one of |
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| the following: |
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| (A) any of the documents listed in paragraph (1); |
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| (B) a valid state-issued identification card; |
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| (C) a recent residential utility bill; |
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| (D) a lease agreement; |
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| (E) a vehicle registration card; |
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| (F) a voter registration card; |
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| (G) mail addressed to the uninsured patient at an |
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| Illinois address from a government or other credible |
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| source; |
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| (H) a statement from a family member of the |
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| uninsured patient who resides at the same address and |
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| presents verification of residency; or |
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| (I) a letter from a homeless shelter, transitional |
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| house or other similar facility verifying that the |
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| uninsured patient resides at the facility. |
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| (c) Hospital obligations toward an individual uninsured |
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| patient under this Act shall cease if that patient unreasonably |
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| fails or refuses to provide the hospital with information or |
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| documentation requested under subsection (b) or to apply for |
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| coverage under public programs when requested under subsection |
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| (a) within 30 days of the hospital's request. |
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LRB095 19723 KBJ 46088 b |
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| (d) In order for a hospital to determine the 12 month |
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| maximum amount that can be collected from a patient deemed |
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| eligible under Section 10, an uninsured patient shall inform |
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| the hospital in subsequent inpatient admissions or outpatient |
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| encounters that the patient has previously received health care |
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| services from that hospital and was determined to be entitled |
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| to the uninsured discount. |
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| (e) Hospitals may require patients to certify that all of |
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| the information provided in the application is true. The |
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| application may state that if any of the information is untrue, |
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| any discount granted to the patient is forfeited and the |
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| patient is responsible for payment of the hospital's full |
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| charges. |
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| Section 20. Exemptions and limitations. |
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| (a) Hospitals that do not charge for their services are |
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| exempt from the provisions of this Act. |
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| (b) Nothing in this Act shall be used by any private or |
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| public health care insurer or plan as a basis for reducing its |
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| payment or reimbursement rates or policies with any hospital. |
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| Notwithstanding any other provisions of law, discounts |
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| authorized under this Act shall not be used by any private or |
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| public health care insurer or plan, regulatory agency, |
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| arbitrator, court, or other third party to determine a |
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| hospital's usual and customary charges for any health care |
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| service. |
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LRB095 19723 KBJ 46088 b |
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| (c) Nothing in this Act shall be construed to require a |
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| hospital to provide an uninsured patient with a particular type |
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| of health care service or other service. |
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| (d) Nothing in this Act shall be deemed to reduce or |
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| infringe upon the rights and obligations of hospitals and |
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| patients under the Fair Patient Billing Act. |
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| (e) The obligations of hospitals under this Act shall take |
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| effect for health care services provided on or after the first |
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| day of the month that begins 90 days after the effective date |
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| of this Act or 90 days after the initial adoption of rules |
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| authorized under subsection (a) of Section 25, whichever occurs |
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| later. |
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| Section 25. Enforcement. |
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| (a) The Attorney General is responsible for administering |
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| and ensuring compliance with this Act, including the |
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| development of any rules necessary for the implementation and |
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| enforcement of this Act. |
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| (b) The Attorney General shall develop and implement a |
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| process for receiving and handling complaints from individuals |
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| or hospitals regarding possible violations of this Act. |
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| (c) The Attorney General may conduct any investigation |
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| deemed necessary regarding possible violations of this Act by |
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| any hospital including, without limitation, the issuance of |
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| subpoenas to: |
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| (1) require the hospital to file a statement or report |
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LRB095 19723 KBJ 46088 b |
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| or answer interrogatories in writing as to all information |
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| relevant to the alleged violations; |
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| (2) examine under oath any person who possesses |
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| knowledge or information directly related to the alleged |
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| violations; and |
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| (3) examine any record, book, document, account, or |
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| paper necessary to investigate the alleged violation. |
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| (d) If the Attorney General determines that there is a |
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| reason to believe that any hospital has violated this Act, the |
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| Attorney General may bring an action in the name of the People |
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| of the State against the hospital to obtain temporary, |
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| preliminary, or permanent injunctive relief for any act, |
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| policy, or practice by the hospital that violates this Act. |
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| Before bringing such an action, the Attorney General may permit |
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| the hospital to submit a Correction Plan for the Attorney |
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| General's approval. |
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| (e) This Section applies if: |
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| (1) A court orders a party to make payments to the |
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| Attorney General and the payments are to be used for the |
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| operations of the Office of the Attorney General; or |
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| (2) A party agrees in a Correction Plan under this Act |
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| to make payments to the Attorney General for the operations |
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| of the Office of the Attorney General. |
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| (f) Moneys paid under any of the conditions described in |
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| subsection (e) shall be deposited into the Attorney General |
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| Court Ordered and Voluntary Compliance Payment Projects Fund. |
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| Moneys in the Fund shall be used, subject to appropriation, for |
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| the performance of any function, pertaining to the exercise of |
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| the duties, to the Attorney General including, but not limited |
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| to, enforcement of any law of this State and conducting public |
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| education programs; however, any moneys in the Fund that are |
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| required by the court to be used for a particular purpose shall |
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| be used for that purpose.
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| (g) The Attorney General may seek the assessment of a civil |
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| monetary penalty not to exceed $500 per violation in any action |
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| filed under this Act where a hospital, by pattern or practice, |
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| knowingly violates Section 10 of this Act. |
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| (h) In the event a court grants a final order of relief |
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| against any hospital for a violation of this Act, the Attorney |
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| General may, after all appeal rights have been exhausted, refer |
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| the hospital to the Illinois Department of Public Health for |
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| possible adverse licensure action under the Hospital Licensing |
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| Act. |
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| (i) Each hospital shall file Worksheet C Part I from its |
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| most recently filed Medicare Cost Report with the Attorney |
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| General within 60 days after the effective date of this Act and |
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| thereafter shall file each subsequent Worksheet C Part I with |
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| the Attorney General within 30 days of filing its Medicare Cost |
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| Report with the hospital's fiscal intermediary. |
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| Section 30. Home rule. A home rule unit may not regulate |
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| hospitals in a manner inconsistent with the provisions of this |
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LRB095 19723 KBJ 46088 b |
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| Act. This Section is a limitation under subsection (i) of |
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| Section 6 of Article VII of the Illinois Constitution on the |
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| concurrent exercise by home rule units of powers and functions |
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| exercised by the State. |
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| Section 90. The Comprehensive Health Insurance Plan Act is |
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| amended by changing Section 2 as follows: |
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| (215 ILCS 105/2) (from Ch. 73, par. 1302)
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| Sec. 2. Definitions. As used in this Act, unless the |
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| context otherwise
requires:
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| "Plan administrator" means the insurer or third party
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| administrator designated under Section 5 of this Act.
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| "Benefits plan" means the coverage to be offered by the |
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| Plan to
eligible persons and federally eligible individuals |
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| pursuant to this Act.
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| "Board" means the Illinois Comprehensive Health Insurance |
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| Board.
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| "Church plan" has the same meaning given that term in the |
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| federal Health
Insurance Portability and Accountability Act of |
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| 1996.
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| "Continuation coverage" means continuation of coverage |
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| under a group health
plan or other health insurance coverage |
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| for former employees or dependents of
former employees that |
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| would otherwise have terminated under the terms of that
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| coverage pursuant to any continuation provisions under federal |
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LRB095 19723 KBJ 46088 b |
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| or State law,
including the Consolidated Omnibus Budget |
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| Reconciliation Act of 1985 (COBRA),
as amended, Sections 367.2, |
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| 367e, and 367e.1 of the Illinois Insurance Code, or
any
other |
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| similar requirement in another State.
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| "Covered person" means a person who is and continues to |
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| remain eligible for
Plan coverage and is covered under one of |
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| the benefit plans offered by the
Plan.
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| "Creditable coverage" means, with respect to a federally |
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| eligible
individual, coverage of the individual under any of |
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| the following:
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| (A) A group health plan.
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| (B) Health insurance coverage (including group health |
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| insurance coverage).
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| (C) Medicare.
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| (D) Medical assistance.
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| (E) Chapter 55 of title 10, United States Code.
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| (F) A medical care program of the Indian Health Service |
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| or of a tribal
organization.
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| (G) A state health benefits risk pool.
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| (H) A health plan offered under Chapter 89 of title 5, |
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| United States Code.
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| (I) A public health plan (as defined in regulations |
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| consistent with
Section
104 of the Health Care Portability |
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| and Accountability Act of 1996 that may be
promulgated by |
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| the Secretary of the U.S. Department of Health and Human
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| Services).
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LRB095 19723 KBJ 46088 b |
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| (J) A health benefit plan under Section 5(e) of the |
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| Peace Corps Act (22
U.S.C. 2504(e)).
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| (K) Any other qualifying coverage required by the |
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| federal Health Insurance
Portability and Accountability |
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| Act of 1996, as it may be amended, or
regulations under |
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| that
Act.
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| "Creditable coverage" does not include coverage consisting |
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| solely of coverage
of excepted benefits, as defined in Section |
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| 2791(c) of title XXVII of
the
Public Health Service Act (42 |
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| U.S.C. 300 gg-91), nor does it include any
period
of coverage |
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| under any of items (A) through (K) that occurred before a break |
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| of
more than 90 days or, if the individual has
been certified |
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| as eligible pursuant to the federal Trade Act
of 2002, a
break |
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| of more than 63 days during all of which the individual was not |
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| covered
under any of items (A) through (K) above.
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| Any period that an individual is in a waiting period for
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| any coverage under a group health plan (or for group health |
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| insurance
coverage) or is in an affiliation period under the |
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| terms of health insurance
coverage offered by a health |
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| maintenance organization shall not be taken into
account in |
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| determining if there has been a break of more than 90
days in |
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| any
creditable coverage.
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| "Department" means the Illinois Department of Insurance.
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| "Dependent" means an Illinois resident: who is a spouse; or |
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| who is claimed
as a dependent by the principal insured for |
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| purposes of filing a federal income
tax return and resides in |
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| the principal insured's household, and is a resident
unmarried |
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| child under the age of 19 years; or who is an unmarried child |
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| who
also is a full-time student under the age of 23 years and |
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| who is financially
dependent upon the principal insured; or who |
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| is a child of any age and who is
disabled and financially |
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| dependent upon the
principal insured.
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| "Direct Illinois premiums" means, for Illinois business, |
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| an insurer's direct
premium income for the kinds of business |
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| described in clause (b) of Class 1 or
clause (a) of Class 2 of |
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| Section 4 of the Illinois Insurance Code, and direct
premium |
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| income of a health maintenance organization or a voluntary |
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| health
services plan, except it shall not include credit health |
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| insurance as defined
in Article IX 1/2 of the Illinois |
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| Insurance Code.
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| "Director" means the Director of the Illinois Department of |
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| Insurance.
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| "Effective date of medical assistance" means the date that |
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| eligibility for medical assistance for a person is approved by |
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| the Department of Human Services or the Department of |
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| Healthcare and Family Services, except when the Department of |
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| Human Services or the Department of Healthcare and Family |
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| Services determines eligibility retroactively. In such |
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| circumstances, the effective date of the medical assistance is |
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| the date the Department of Human Services or the Department of |
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| Healthcare and Family Services determines the person to be |
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| eligible for medical assistance. |
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| "Eligible person" means a resident of this State who |
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| qualifies
for Plan coverage under Section 7 of this Act.
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| "Employee" means a resident of this State who is employed |
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| by an employer
or has entered into
the employment of or works |
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| under contract or service of an employer
including the |
6 |
| officers, managers and employees of subsidiary or affiliated
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| corporations and the individual proprietors, partners and |
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| employees of
affiliated individuals and firms when the business |
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| of the subsidiary or
affiliated corporations, firms or |
10 |
| individuals is controlled by a common
employer through stock |
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| ownership, contract, or otherwise.
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| "Employer" means any individual, partnership, association, |
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| corporation,
business trust, or any person or group of persons |
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| acting directly or indirectly
in the interest of an employer in |
15 |
| relation to an employee, for which one or
more
persons is |
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| gainfully employed.
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| "Family" coverage means the coverage provided by the Plan |
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| for the
covered person and his or her eligible dependents who |
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| also are
covered persons.
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| "Federally eligible individual" means an individual |
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| resident of this State:
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| (1)(A) for whom, as of the date on which the individual |
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| seeks Plan
coverage
under Section 15 of this Act, the |
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| aggregate of the periods of creditable
coverage is 18 or |
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| more months or, if the individual has been
certified as
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| eligible pursuant to the federal Trade Act of 2002,
3 or |
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LRB095 19723 KBJ 46088 b |
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1 |
| more
months, and (B) whose most recent prior creditable
|
2 |
| coverage was under group health insurance coverage offered |
3 |
| by a health
insurance issuer, a group health plan, a |
4 |
| governmental plan, or a church plan
(or
health insurance |
5 |
| coverage offered in connection with any such plans) or any
|
6 |
| other type of creditable coverage that may be required by |
7 |
| the federal Health
Insurance Portability
and |
8 |
| Accountability Act of 1996, as it may be amended, or the |
9 |
| regulations
under that Act;
|
10 |
| (2) who
is not eligible for coverage under
(A) a group |
11 |
| health plan
(other than an individual who has been |
12 |
| certified as eligible
pursuant to the federal Trade Act of |
13 |
| 2002), (B)
part
A or part B of Medicare due to age
(other |
14 |
| than an individual who has been certified as eligible
|
15 |
| pursuant to the federal Trade Act of 2002), or (C) medical |
16 |
| assistance, and
does not
have other
health insurance |
17 |
| coverage (other than an individual who has been certified |
18 |
| as
eligible pursuant to the federal Trade Act of 2002);
|
19 |
| (3) with respect to whom (other than an individual who |
20 |
| has been
certified as eligible pursuant to the federal |
21 |
| Trade Act of 2002) the most
recent coverage within the |
22 |
| coverage
period
described in paragraph (1)(A) of this |
23 |
| definition was not terminated
based upon a factor relating |
24 |
| to nonpayment of premiums or fraud;
|
25 |
| (4) if the individual (other than an individual who has
|
26 |
| been certified
as eligible pursuant to the federal Trade |
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
|
1 |
| Act
of 2002)
had been offered the option of continuation
|
2 |
| coverage
under a COBRA continuation provision or under a |
3 |
| similar State program, who
elected such coverage; and
|
4 |
| (5) who, if the individual elected such continuation |
5 |
| coverage, has
exhausted
such continuation coverage under |
6 |
| such provision or program.
|
7 |
| However, an individual who has been certified as
eligible
|
8 |
| pursuant to the
federal Trade Act of 2002
shall not be required |
9 |
| to elect
continuation
coverage under a COBRA continuation |
10 |
| provision or under a similar state
program.
|
11 |
| "Group health insurance coverage" means, in connection |
12 |
| with a group health
plan, health insurance coverage offered in |
13 |
| connection with that plan.
|
14 |
| "Group health plan" has the same meaning given that term in |
15 |
| the federal
Health
Insurance Portability and Accountability |
16 |
| Act of 1996.
|
17 |
| "Governmental plan" has the same meaning given that term in |
18 |
| the federal
Health
Insurance Portability and Accountability |
19 |
| Act of 1996.
|
20 |
| "Health insurance coverage" means benefits consisting of |
21 |
| medical care
(provided directly, through insurance or |
22 |
| reimbursement, or otherwise and
including items and services |
23 |
| paid for as medical care) under any hospital and
medical |
24 |
| expense-incurred policy,
certificate, or
contract provided by |
25 |
| an insurer, non-profit health care service plan
contract, |
26 |
| health maintenance organization or other subscriber contract, |
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
|
1 |
| or
any other health care plan or arrangement that pays for or |
2 |
| furnishes
medical or health care services whether by
insurance |
3 |
| or otherwise. Health insurance coverage shall not include short
|
4 |
| term,
accident only,
disability income, hospital confinement |
5 |
| or fixed indemnity, dental only,
vision only, limited benefit, |
6 |
| or credit
insurance, coverage issued as a supplement to |
7 |
| liability insurance,
insurance arising out of a workers' |
8 |
| compensation or similar law, automobile
medical-payment |
9 |
| insurance, or insurance under which benefits are payable
with |
10 |
| or without regard to fault and which is statutorily required to |
11 |
| be
contained in any liability insurance policy or equivalent |
12 |
| self-insurance.
|
13 |
| "Health insurance issuer" means an insurance company, |
14 |
| insurance service,
or insurance organization (including a |
15 |
| health maintenance organization and a
voluntary health |
16 |
| services plan) that is authorized to transact health
insurance
|
17 |
| business in this State. Such term does not include a group |
18 |
| health plan.
|
19 |
| "Health Maintenance Organization" means an organization as
|
20 |
| defined in the Health Maintenance Organization Act.
|
21 |
| "Hospice" means a program as defined in and licensed under |
22 |
| the
Hospice Program Licensing Act.
|
23 |
| "Hospital" means a duly licensed institution as defined in |
24 |
| the
Hospital Licensing Act,
an institution that meets all |
25 |
| comparable conditions and requirements in
effect in the state |
26 |
| in which it is located, or the University of Illinois
Hospital |
|
|
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SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
|
1 |
| as defined in the University of Illinois Hospital Act.
|
2 |
| "Individual health insurance coverage" means health |
3 |
| insurance coverage
offered to individuals in the individual |
4 |
| market, but does not include
short-term, limited-duration |
5 |
| insurance.
|
6 |
| "Insured" means any individual resident of this State who |
7 |
| is
eligible to receive benefits from any insurer (including |
8 |
| health insurance
coverage offered in connection with a group |
9 |
| health plan) or health
insurance issuer as
defined in this |
10 |
| Section.
|
11 |
| "Insurer" means any insurance company authorized to |
12 |
| transact health
insurance business in this State and any |
13 |
| corporation that provides medical
services and is organized |
14 |
| under the Voluntary Health Services Plans Act or
the Health |
15 |
| Maintenance Organization
Act.
|
16 |
| "Medical assistance" means the State medical assistance or |
17 |
| medical
assistance no grant (MANG) programs provided under
|
18 |
| Title XIX of the Social Security Act and
Articles V (Medical |
19 |
| Assistance) and VI (General Assistance) of the Illinois
Public |
20 |
| Aid Code (or any successor program) or under any
similar |
21 |
| program of health care benefits in a state other than Illinois.
|
22 |
| "Medically necessary" means that a service, drug, or supply |
23 |
| is
necessary and appropriate for the diagnosis or treatment of |
24 |
| an illness or
injury in accord with generally accepted |
25 |
| standards of medical practice at
the time the service, drug, or |
26 |
| supply is provided. When specifically
applied to a confinement |
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
|
1 |
| it further means that the diagnosis or treatment
of the covered |
2 |
| person's medical symptoms or condition cannot be
safely
|
3 |
| provided to that person as an outpatient. A service, drug, or |
4 |
| supply shall
not be medically necessary if it: (i) is |
5 |
| investigational, experimental, or
for research purposes; or |
6 |
| (ii) is provided solely for the convenience of
the patient, the |
7 |
| patient's family, physician, hospital, or any other
provider; |
8 |
| or (iii) exceeds in scope, duration, or intensity that level of
|
9 |
| care that is needed to provide safe, adequate, and appropriate |
10 |
| diagnosis or
treatment; or (iv) could have been omitted without |
11 |
| adversely affecting the
covered person's condition or the |
12 |
| quality of medical care; or
(v) involves
the use of a medical |
13 |
| device, drug, or substance not formally approved by
the United |
14 |
| States Food and Drug Administration.
|
15 |
| "Medical care" means the ordinary and usual professional |
16 |
| services rendered
by a physician or other specified provider |
17 |
| during a professional visit for
treatment of an illness or |
18 |
| injury.
|
19 |
| "Medicare" means coverage under both Part A and Part B of |
20 |
| Title XVIII of
the Social Security
Act, 42 U.S.C. Sec. 1395, et |
21 |
| seq.
|
22 |
| "Minimum premium plan" means an arrangement whereby a |
23 |
| specified
amount of health care claims is self-funded, but the |
24 |
| insurance company
assumes the risk that claims will exceed that |
25 |
| amount.
|
26 |
| "Participating transplant center" means a hospital |
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
|
1 |
| designated by the
Board as a preferred or exclusive provider of |
2 |
| services for one or more
specified human organ or tissue |
3 |
| transplants for which the hospital has
signed an agreement with |
4 |
| the Board to accept a transplant payment allowance
for all |
5 |
| expenses related to the transplant during a transplant benefit |
6 |
| period.
|
7 |
| "Physician" means a person licensed to practice medicine |
8 |
| pursuant to
the Medical Practice Act of 1987.
|
9 |
| "Plan" means the Comprehensive Health Insurance Plan
|
10 |
| established by this Act.
|
11 |
| "Plan of operation" means the plan of operation of the
|
12 |
| Plan, including articles, bylaws and operating rules, adopted |
13 |
| by the board
pursuant to this Act.
|
14 |
| "Provider" means any hospital, skilled nursing facility, |
15 |
| hospice, home
health agency, physician, registered pharmacist |
16 |
| acting within the scope of that
registration, or any other |
17 |
| person or entity licensed in Illinois to furnish
medical care.
|
18 |
| "Qualified high risk pool" has the same meaning given that |
19 |
| term in the
federal Health
Insurance Portability and |
20 |
| Accountability Act of 1996.
|
21 |
| "Resident" means a person who is and continues to be |
22 |
| legally domiciled
and physically residing on a permanent and |
23 |
| full-time basis in a
place of permanent habitation
in this |
24 |
| State
that remains that person's principal residence and from |
25 |
| which that person is
absent only for temporary or transitory |
26 |
| purpose.
|
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
|
1 |
| "Skilled nursing facility" means a facility or that portion |
2 |
| of a facility
that is licensed by the Illinois Department of |
3 |
| Public Health under the
Nursing Home Care Act or a comparable |
4 |
| licensing authority in another state
to provide skilled nursing |
5 |
| care.
|
6 |
| "Stop-loss coverage" means an arrangement whereby an |
7 |
| insurer
insures against the risk that any one claim will exceed |
8 |
| a specific dollar
amount or that the entire loss of a |
9 |
| self-insurance plan will exceed
a specific amount.
|
10 |
| "Third party administrator" means an administrator as |
11 |
| defined in
Section 511.101 of the Illinois Insurance Code who |
12 |
| is licensed under
Article XXXI 1/4 of that Code.
|
13 |
| (Source: P.A. 92-153, eff. 7-25-01; 93-33, eff. 6-23-03; 93-34, |
14 |
| eff. 6-23-03; 93-477, eff. 8-8-03; 93-622, eff. 12-18-03.)
|
15 |
| Section 99. Effective date. This Act takes effect upon |
16 |
| becoming law, except that Sections 1 through 30 take effect 90 |
17 |
| days after becoming law.
|