|
A rejection or refusal by a group health plan or health |
insurance issuer
offering only
stop-loss or excess of loss |
insurance or contracts,
agreements, or other arrangements for |
reinsurance coverage with respect
to the applicant shall not be |
sufficient evidence under this subsection. |
b. The board shall promulgate a list of medical or health |
conditions for
which a person who is either a citizen of the |
United States or an
alien lawfully admitted for permanent |
residence and a resident of this State
would be eligible for |
Plan coverage without applying for
health insurance coverage |
pursuant to subsection a. of this Section.
Persons who
can |
demonstrate the existence or history of any medical or health
|
conditions on the list promulgated by the board shall not be |
required to
provide the evidence specified in subsection a. of |
this Section. The list
shall be effective
on the first day of |
the operation of the Plan and may be amended from time
to time |
as appropriate. |
c. Family members of the same household who each are |
covered
persons are
eligible for optional family coverage under |
the Plan. |
d. For persons qualifying for coverage in accordance with |
Section 7 of
this Act, the board shall, if it determines that |
such appropriations as are
made pursuant to Section 12 of this |
Act are insufficient to allow the board
to accept all of the |
eligible persons which it projects will apply for
enrollment |
under the Plan, limit or close enrollment to ensure that the
|
|
Plan is not over-subscribed and that it has sufficient |
resources to meet
its obligations to existing enrollees. The |
board shall not limit or close
enrollment for federally |
eligible individuals. |
e. A person shall not be eligible for coverage under the |
Plan if: |
(1) He or she has or obtains other coverage under a |
group health plan
or health insurance coverage
|
substantially similar to or better than a Plan policy as an |
insured or
covered dependent or would be eligible to have |
that coverage if he or she
elected to obtain it. Persons |
otherwise eligible for Plan coverage may,
however, solely |
for the purpose of having coverage for a pre-existing
|
condition, maintain other coverage only while satisfying |
any pre-existing
condition waiting period under a Plan |
policy or a subsequent replacement
policy of a Plan policy. |
(1.1) His or her prior coverage under a group health |
plan or health
insurance coverage, provided or arranged by |
an employer of more than 10 employees was discontinued
for |
any reason without the entire group or plan being |
discontinued and not
replaced, provided he or she remains |
an employee, or dependent thereof, of the
same employer. |
(2) He or she is a recipient of or is approved to |
receive medical
assistance, except that a person may |
continue to receive medical
assistance through the medical |
assistance no grant program, but only
while satisfying the |
|
requirements for a preexisting condition under
Section 8, |
subsection f. of this Act. Payment of premiums pursuant to |
this
Act shall be allocable to the person's spenddown for |
purposes of the
medical assistance no grant program, but |
that person shall not be
eligible for any Plan benefits |
while that person remains eligible for
medical assistance. |
If the person continues to receive
or be approved to |
receive medical assistance through the medical
assistance |
no grant program at or after the time that requirements for |
a
preexisting condition are satisfied, the person shall not |
be eligible for
coverage under the Plan. In that |
circumstance, coverage under the plan
shall terminate as of |
the expiration of the preexisting condition
limitation |
period. Under all other circumstances, coverage under the |
Plan
shall automatically terminate as of the effective date |
of any medical
assistance. |
(3) Except as provided in Section 15, the person has |
previously
participated in the Plan and voluntarily
|
terminated Plan coverage, unless 12 months have elapsed
|
since the person's
latest voluntary termination of |
coverage. |
(4) The person fails to pay the required premium under |
the covered
person's
terms of enrollment and |
participation, in which event the liability of the
Plan |
shall be limited to benefits incurred under the Plan for |
the time
period for which premiums had been paid and the |
|
covered person remained
eligible for Plan coverage. |
(5) The Plan has paid a total of
$5,000,000
in benefits
|
on behalf of the covered person. |
(6) The person is a resident of a public institution. |
(7) The person's premium is paid for or reimbursed |
under any
government sponsored program or by any government |
agency or health
care provider, except as an otherwise |
qualifying full-time employee, or
dependent of such |
employee, of a government agency or health care provider
|
or, except when a person's premium is paid by the U.S. |
Treasury Department
pursuant to the federal Trade Act of |
2002. |
(8) The person has or later receives other benefits or |
funds from
any settlement, judgement, or award resulting |
from any accident or injury,
regardless of the date of the |
accident or injury, or any other
circumstances creating a |
legal liability for damages due that person by a
third |
party, whether the settlement, judgment, or award is in the |
form of a
contract, agreement, or trust on behalf of a |
minor or otherwise and whether
the settlement, judgment, or |
award is payable to the person, his or her
dependent, |
estate, personal representative, or guardian in a lump sum |
or
over time, so long as there continues to be benefits or |
assets remaining
from those sources in an amount in excess |
of $300,000. |
(9) Within the 5 years prior to the date a person's |
|
Plan application is
received by the Board, the person's |
coverage under any health care benefit
program as defined |
in 18 U.S.C. 24, including any public or private plan or
|
contract under which any
medical benefit, item, or service |
is provided, was terminated as a result of
any act or |
practice that constitutes fraud under State or federal law |
or as a
result of an intentional misrepresentation of |
material fact; or if that person
knowingly and willfully |
obtained or attempted to obtain, or fraudulently aided
or |
attempted to aid any other person in obtaining, any |
coverage or benefits
under the Plan to which that person |
was not entitled. |
f. The board or the administrator shall require |
verification of
residency and may require any additional |
information or documentation, or
statements under oath, when |
necessary to determine residency upon initial
application and |
for the entire term of the policy. |
g. Coverage shall cease (i) on the date a person is no |
longer a
resident of Illinois, (ii) on the date a person |
requests coverage to end,
(iii) upon the death of the covered |
person, (iv) on the date State law
requires cancellation of the |
policy, or (v) at the Plan's option, 30 days
after the Plan |
makes any inquiry concerning a person's eligibility or place
of |
residence to which the person does not reply. |
h. Except under the conditions set forth in subsection g of |
this
Section, the coverage of any person who ceases to meet the
|