|
or State law,
including the Consolidated Omnibus Budget |
Reconciliation Act of 1985 (COBRA),
as amended, Sections 367.2, |
367e, and 367e.1 of the Illinois Insurance Code, or
any
other |
similar requirement in another State.
|
"Covered person" means a person who is and continues to |
remain eligible for
Plan coverage and is covered under one of |
the benefit plans offered by the
Plan.
|
"Creditable coverage" means, with respect to a federally |
eligible
individual, coverage of the individual under any of |
the following:
|
(A) A group health plan.
|
(B) Health insurance coverage (including group health |
insurance coverage).
|
(C) Medicare.
|
(D) Medical assistance.
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(E) Chapter 55 of title 10, United States Code.
|
(F) A medical care program of the Indian Health Service |
or of a tribal
organization.
|
(G) A state health benefits risk pool.
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(H) A health plan offered under Chapter 89 of title 5, |
United States Code.
|
(I) A public health plan (as defined in regulations |
consistent with
Section
104 of the Health Care Portability |
and Accountability Act of 1996 that may be
promulgated by |
the Secretary of the U.S. Department of Health and Human
|
Services).
|
|
(J) A health benefit plan under Section 5(e) of the |
Peace Corps Act (22
U.S.C. 2504(e)).
|
(K) Any other qualifying coverage required by the |
federal Health Insurance
Portability and Accountability |
Act of 1996, as it may be amended, or
regulations under |
that
Act.
|
"Creditable coverage" does not include coverage consisting |
solely of coverage
of excepted benefits, as defined in Section |
2791(c) of title XXVII of
the
Public Health Service Act (42 |
U.S.C. 300 gg-91), nor does it include any
period
of coverage |
under any of items (A) through (K) that occurred before a break |
of
more than 90 days or, if the individual has
been certified |
as eligible pursuant to the federal Trade Act
of 2002, a
break |
of more than 63 days during all of which the individual was not |
covered
under any of items (A) through (K) above.
|
Any period that an individual is in a waiting period for
|
any coverage under a group health plan (or for group health |
insurance
coverage) or is in an affiliation period under the |
terms of health insurance
coverage offered by a health |
maintenance organization shall not be taken into
account in |
determining if there has been a break of more than 90
days in |
any
creditable coverage.
|
"Department" means the Illinois Department of Insurance.
|
"Dependent" means an Illinois resident: who is a spouse; or |
who is claimed
as a dependent by the principal insured for |
purposes of filing a federal income
tax return and resides in |
|
the principal insured's household, and is a resident
unmarried |
child under the age of 19 years; or who is an unmarried child |
who
also is a full-time student under the age of 23 years and |
who is financially
dependent upon the principal insured; or who |
is a child of any age and who is
disabled and financially |
dependent upon the
principal insured.
|
"Direct Illinois premiums" means, for Illinois business, |
an insurer's direct
premium income for the kinds of business |
described in clause (b) of Class 1 or
clause (a) of Class 2 of |
Section 4 of the Illinois Insurance Code, and direct
premium |
income of a health maintenance organization or a voluntary |
health
services plan, except it shall not include credit health |
insurance as defined
in Article IX 1/2 of the Illinois |
Insurance Code.
|
"Director" means the Director of the Illinois Department of |
Insurance.
|
"Effective date of medical assistance" means the date that |
eligibility for medical assistance for a person is approved by |
the Department of Human Services or the Department of |
Healthcare and Family Services, except when the Department of |
Human Services or the Department of Healthcare and Family |
Services determines eligibility retroactively. In such |
circumstances, the effective date of the medical assistance is |
the date the Department of Human Services or the Department of |
Healthcare and Family Services determines the person to be |
eligible for medical assistance. As it pertains to Medicare, |
|
the effective date is 24 months after the entitlement date as |
approved by the Social Security Administration, except when |
eligibility is made retroactive to a prior date. In such |
circumstances, the effective date of Medicare is the date on |
the Notice of Award letter issued by the Social Security |
Administration. |
"Eligible person" means a resident of this State who |
qualifies
for Plan coverage under Section 7 of this Act.
|
"Employee" means a resident of this State who is employed |
by an employer
or has entered into
the employment of or works |
under contract or service of an employer
including the |
officers, managers and employees of subsidiary or affiliated
|
corporations and the individual proprietors, partners and |
employees of
affiliated individuals and firms when the business |
of the subsidiary or
affiliated corporations, firms or |
individuals is controlled by a common
employer through stock |
ownership, contract, or otherwise.
|
"Employer" means any individual, partnership, association, |
corporation,
business trust, or any person or group of persons |
acting directly or indirectly
in the interest of an employer in |
relation to an employee, for which one or
more
persons is |
gainfully employed.
|
"Family" coverage means the coverage provided by the Plan |
for the
covered person and his or her eligible dependents who |
also are
covered persons.
|
"Federally eligible individual" means an individual |
|
resident of this State:
|
(1)(A) for whom, as of the date on which the individual |
seeks Plan
coverage
under Section 15 of this Act, the |
aggregate of the periods of creditable
coverage is 18 or |
more months or, if the individual has been
certified as
|
eligible pursuant to the federal Trade Act of 2002,
3 or |
more
months, and (B) whose most recent prior creditable
|
coverage was under group health insurance coverage offered |
by a health
insurance issuer, a group health plan, a |
governmental plan, or a church plan
(or
health insurance |
coverage offered in connection with any such plans) or any
|
other type of creditable coverage that may be required by |
the federal Health
Insurance Portability
and |
Accountability Act of 1996, as it may be amended, or the |
regulations
under that Act;
|
(2) who
is not eligible for coverage under
(A) a group |
health plan
(other than an individual who has been |
certified as eligible
pursuant to the federal Trade Act of |
2002), (B)
part
A or part B of Medicare due to age
(other |
than an individual who has been certified as eligible
|
pursuant to the federal Trade Act of 2002), or (C) medical |
assistance, and
does not
have other
health insurance |
coverage (other than an individual who has been certified |
as
eligible pursuant to the federal Trade Act of 2002);
|
(3) with respect to whom (other than an individual who |
has been
certified as eligible pursuant to the federal |
|
Trade Act of 2002) the most
recent coverage within the |
coverage
period
described in paragraph (1)(A) of this |
definition was not terminated
based upon a factor relating |
to nonpayment of premiums or fraud;
|
(4) if the individual (other than an individual who has
|
been certified
as eligible pursuant to the federal Trade |
Act
of 2002)
had been offered the option of continuation
|
coverage
under a COBRA continuation provision or under a |
similar State program, who
elected such coverage; and
|
(5) who, if the individual elected such continuation |
coverage, has
exhausted
such continuation coverage under |
such provision or program.
|
However, an individual who has been certified as
eligible
|
pursuant to the
federal Trade Act of 2002
shall not be required |
to elect
continuation
coverage under a COBRA continuation |
provision or under a similar state
program.
|
"Group health insurance coverage" means, in connection |
with a group health
plan, health insurance coverage offered in |
connection with that plan.
|
"Group health plan" has the same meaning given that term in |
the federal
Health
Insurance Portability and Accountability |
Act of 1996.
|
"Governmental plan" has the same meaning given that term in |
the federal
Health
Insurance Portability and Accountability |
Act of 1996.
|
"Health insurance coverage" means benefits consisting of |
|
medical care
(provided directly, through insurance or |
reimbursement, or otherwise and
including items and services |
paid for as medical care) under any hospital and
medical |
expense-incurred policy,
certificate, or
contract provided by |
an insurer, non-profit health care service plan
contract, |
health maintenance organization or other subscriber contract, |
or
any other health care plan or arrangement that pays for or |
furnishes
medical or health care services whether by
insurance |
or otherwise. Health insurance coverage shall not include short
|
term,
accident only,
disability income, hospital confinement |
or fixed indemnity, dental only,
vision only, limited benefit, |
or credit
insurance, coverage issued as a supplement to |
liability insurance,
insurance arising out of a workers' |
compensation or similar law, automobile
medical-payment |
insurance, or insurance under which benefits are payable
with |
or without regard to fault and which is statutorily required to |
be
contained in any liability insurance policy or equivalent |
self-insurance.
|
"Health insurance issuer" means an insurance company, |
insurance service,
or insurance organization (including a |
health maintenance organization and a
voluntary health |
services plan) that is authorized to transact health
insurance
|
business in this State. Such term does not include a group |
health plan.
|
"Health Maintenance Organization" means an organization as
|
defined in the Health Maintenance Organization Act.
|
|
"Hospice" means a program as defined in and licensed under |
the
Hospice Program Licensing Act.
|
"Hospital" means a duly licensed institution as defined in |
the
Hospital Licensing Act,
an institution that meets all |
comparable conditions and requirements in
effect in the state |
in which it is located, or the University of Illinois
Hospital |
as defined in the University of Illinois Hospital Act.
|
"Individual health insurance coverage" means health |
insurance coverage
offered to individuals in the individual |
market, but does not include
short-term, limited-duration |
insurance.
|
"Insured" means any individual resident of this State who |
is
eligible to receive benefits from any insurer (including |
health insurance
coverage offered in connection with a group |
health plan) or health
insurance issuer as
defined in this |
Section.
|
"Insurer" means any insurance company authorized to |
transact health
insurance business in this State and any |
corporation that provides medical
services and is organized |
under the Voluntary Health Services Plans Act or
the Health |
Maintenance Organization
Act.
|
"Medical assistance" means the State medical assistance or |
medical
assistance no grant (MANG) programs provided under
|
Title XIX of the Social Security Act and
Articles V (Medical |
Assistance) and VI (General Assistance) of the Illinois
Public |
Aid Code (or any successor program) or under any
similar |
|
program of health care benefits in a state other than Illinois.
|
"Medically necessary" means that a service, drug, or supply |
is
necessary and appropriate for the diagnosis or treatment of |
an illness or
injury in accord with generally accepted |
standards of medical practice at
the time the service, drug, or |
supply is provided. When specifically
applied to a confinement |
it further means that the diagnosis or treatment
of the covered |
person's medical symptoms or condition cannot be
safely
|
provided to that person as an outpatient. A service, drug, or |
supply shall
not be medically necessary if it: (i) is |
investigational, experimental, or
for research purposes; or |
(ii) is provided solely for the convenience of
the patient, the |
patient's family, physician, hospital, or any other
provider; |
or (iii) exceeds in scope, duration, or intensity that level of
|
care that is needed to provide safe, adequate, and appropriate |
diagnosis or
treatment; or (iv) could have been omitted without |
adversely affecting the
covered person's condition or the |
quality of medical care; or
(v) involves
the use of a medical |
device, drug, or substance not formally approved by
the United |
States Food and Drug Administration.
|
"Medical care" means the ordinary and usual professional |
services rendered
by a physician or other specified provider |
during a professional visit for
treatment of an illness or |
injury.
|
"Medicare" means coverage under both Part A and Part B of |
Title XVIII of
the Social Security
Act, 42 U.S.C. Sec. 1395, et |
|
seq.
|
"Minimum premium plan" means an arrangement whereby a |
specified
amount of health care claims is self-funded, but the |
insurance company
assumes the risk that claims will exceed that |
amount.
|
"Participating transplant center" means a hospital |
designated by the
Board as a preferred or exclusive provider of |
services for one or more
specified human organ or tissue |
transplants for which the hospital has
signed an agreement with |
the Board to accept a transplant payment allowance
for all |
expenses related to the transplant during a transplant benefit |
period.
|
"Physician" means a person licensed to practice medicine |
pursuant to
the Medical Practice Act of 1987.
|
"Plan" means the Comprehensive Health Insurance Plan
|
established by this Act.
|
"Plan of operation" means the plan of operation of the
|
Plan, including articles, bylaws and operating rules, adopted |
by the board
pursuant to this Act.
|
"Provider" means any hospital, skilled nursing facility, |
hospice, home
health agency, physician, registered pharmacist |
acting within the scope of that
registration, or any other |
person or entity licensed in Illinois to furnish
medical care.
|
"Qualified high risk pool" has the same meaning given that |
term in the
federal Health
Insurance Portability and |
Accountability Act of 1996.
|
|
"Resident" means a person who is and continues to be |
legally domiciled
and physically residing on a permanent and |
full-time basis in a
place of permanent habitation
in this |
State
that remains that person's principal residence and from |
which that person is
absent only for temporary or transitory |
purpose.
|
"Skilled nursing facility" means a facility or that portion |
of a facility
that is licensed by the Illinois Department of |
Public Health under the
Nursing Home Care Act or a comparable |
licensing authority in another state
to provide skilled nursing |
care.
|
"Stop-loss coverage" means an arrangement whereby an |
insurer
insures against the risk that any one claim will exceed |
a specific dollar
amount or that the entire loss of a |
self-insurance plan will exceed
a specific amount.
|
"Third party administrator" means an administrator as |
defined in
Section 511.101 of the Illinois Insurance Code who |
is licensed under
Article XXXI 1/4 of that Code.
|
(Source: P.A. 95-965, eff. 9-23-08.)
|
Section 99. Effective date. This Act takes effect upon |
becoming law.
|