Public Act 097-0346
 
HB3405 EnrolledLRB097 05453 RPM 45511 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Comprehensive Health Insurance Plan Act is
amended by changing Section 2 as follows:
 
    (215 ILCS 105/2)  (from Ch. 73, par. 1302)
    Sec. 2. Definitions. As used in this Act, unless the
context otherwise requires:
    "Plan administrator" means the insurer or third party
administrator designated under Section 5 of this Act.
    "Benefits plan" means the coverage to be offered by the
Plan to eligible persons and federally eligible individuals
pursuant to this Act.
    "Board" means the Illinois Comprehensive Health Insurance
Board.
    "Church plan" has the same meaning given that term in the
federal Health Insurance Portability and Accountability Act of
1996.
    "Continuation coverage" means continuation of coverage
under a group health plan or other health insurance coverage
for former employees or dependents of former employees that
would otherwise have terminated under the terms of that
coverage pursuant to any continuation provisions under federal
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.
        (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.
        (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.