093_HB0707enr
HB0707 Enrolled LRB093 05485 MKM 05576 b
1 AN ACT concerning the Comprehensive Health Insurance
2 Plan.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. If and only if House Bill 3298 of the 93rd
6 General Assembly becomes law, the Comprehensive Health
7 Insurance Plan Act is amended by changing Sections 2, 4, 7,
8 and 15 as follows:
9 (215 ILCS 105/2) (from Ch. 73, par. 1302)
10 Sec. 2. Definitions. As used in this Act, unless the
11 context otherwise requires:
12 "Plan administrator" means the insurer or third party
13 administrator designated under Section 5 of this Act.
14 "Benefits plan" means the coverage to be offered by the
15 Plan to eligible persons and federally eligible individuals
16 pursuant to this Act.
17 "Board" means the Illinois Comprehensive Health Insurance
18 Board.
19 "Church plan" has the same meaning given that term in the
20 federal Health Insurance Portability and Accountability Act
21 of 1996.
22 "Continuation coverage" means continuation of coverage
23 under a group health plan or other health insurance coverage
24 for former employees or dependents of former employees that
25 would otherwise have terminated under the terms of that
26 coverage pursuant to any continuation provisions under
27 federal or State law, including the Consolidated Omnibus
28 Budget Reconciliation Act of 1985 (COBRA), as amended,
29 Sections 367.2 and 367e of the Illinois Insurance Code, or
30 any other similar requirement in another State.
31 "Covered person" means a person who is and continues to
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1 remain eligible for Plan coverage and is covered under one of
2 the benefit plans offered by the Plan.
3 "Creditable coverage" means, with respect to a federally
4 eligible individual, coverage of the individual under any of
5 the following:
6 (A) A group health plan.
7 (B) Health insurance coverage (including group
8 health insurance coverage).
9 (C) Medicare.
10 (D) Medical assistance.
11 (E) Chapter 55 of title 10, United States Code.
12 (F) A medical care program of the Indian Health
13 Service or of a tribal organization.
14 (G) A state health benefits risk pool.
15 (H) A health plan offered under Chapter 89 of title
16 5, United States Code.
17 (I) A public health plan (as defined in regulations
18 consistent with Section 104 of the Health Care
19 Portability and Accountability Act of 1996 that may be
20 promulgated by the Secretary of the U.S. Department of
21 Health and Human Services).
22 (J) A health benefit plan under Section 5(e) of the
23 Peace Corps Act (22 U.S.C. 2504(e)).
24 (K) Any other qualifying coverage required by the
25 federal Health Insurance Portability and Accountability
26 Act of 1996, as it may be amended, or regulations under
27 that Act.
28 "Creditable coverage" does not include coverage
29 consisting solely of coverage of excepted benefits, as
30 defined in Section 2791(c) of title XXVII of the Public
31 Health Service Act (42 U.S.C. 300 gg-91), nor does it include
32 any period of coverage under any of items (A) through (K)
33 that occurred before a break of more than 90 days or, if
34 after September 30, 2003, the individual has either been
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1 certified as an eligible person pursuant to the federal Trade
2 Adjustment Act of 2002 or initially been paid a benefit by
3 the Pension Benefit Guaranty Corporation, a break of more
4 than 63 days during all of which the individual was not
5 covered under any of items (A) through (K) above.
6 For an individual who between December 1, 2002 and
7 September 30, 2003 has either (1) been certified as eligible
8 pursuant to the federal Trade Act of 2002, (2) initially been
9 paid a benefit by the Pension Benefit Guaranty Corporation,
10 or (3) as of December 1, 2002, been receiving benefits from
11 the Pension Benefit Guaranty Corporation and who has
12 qualified health insurance, as defined by the federal Trade
13 Act of 2002, "creditable coverage" includes any period of
14 coverage aggregating 3 or more months under any of items (A)
15 through (K), irrespective of the length of a break during all
16 of which the individual was not covered under any of items
17 (A) through (K).
18 Any period that an individual is in a waiting period for
19 any coverage under a group health plan (or for group health
20 insurance coverage) or is in an affiliation period under the
21 terms of health insurance coverage offered by a health
22 maintenance organization shall not be taken into account in
23 determining if there has been a break of more than 90 days in
24 any creditable coverage.
25 "Department" means the Illinois Department of Insurance.
26 "Dependent" means an Illinois resident: who is a spouse;
27 or who is claimed as a dependent by the principal insured for
28 purposes of filing a federal income tax return and resides in
29 the principal insured's household, and is a resident
30 unmarried child under the age of 19 years; or who is an
31 unmarried child who also is a full-time student under the age
32 of 23 years and who is financially dependent upon the
33 principal insured; or who is a child of any age and who is
34 disabled and financially dependent upon the principal
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1 insured.
2 "Direct Illinois premiums" means, for Illinois business,
3 an insurer's direct premium income for the kinds of business
4 described in clause (b) of Class 1 or clause (a) of Class 2
5 of Section 4 of the Illinois Insurance Code, and direct
6 premium income of a health maintenance organization or a
7 voluntary health services plan, except it shall not include
8 credit health insurance as defined in Article IX 1/2 of the
9 Illinois Insurance Code.
10 "Director" means the Director of the Illinois Department
11 of Insurance.
12 "Eligible person" means a resident of this State who
13 qualifies for Plan coverage under Section 7 of this Act.
14 "Employee" means a resident of this State who is employed
15 by an employer or has entered into the employment of or works
16 under contract or service of an employer including the
17 officers, managers and employees of subsidiary or affiliated
18 corporations and the individual proprietors, partners and
19 employees of affiliated individuals and firms when the
20 business of the subsidiary or affiliated corporations, firms
21 or individuals is controlled by a common employer through
22 stock ownership, contract, or otherwise.
23 "Employer" means any individual, partnership,
24 association, corporation, business trust, or any person or
25 group of persons acting directly or indirectly in the
26 interest of an employer in relation to an employee, for which
27 one or more persons is gainfully employed.
28 "Family" coverage means the coverage provided by the Plan
29 for the covered person and his or her eligible dependents who
30 also are covered persons.
31 "Federally eligible individual" means an individual
32 resident of this State:
33 (1)(A) for whom, as of the date on which the
34 individual seeks Plan coverage under Section 15 of this
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1 Act, the aggregate of the periods of creditable coverage
2 is 18 or more months or, if the individual has either (i)
3 been certified as an eligible person pursuant to the
4 federal Trade Adjustment Act of 2002, (ii) initially been
5 paid a benefit by the Pension Benefit Guaranty
6 Corporation, or (iii) as of December 1, 2002, been
7 receiving benefits from the Pension Benefit Guaranty
8 Corporation and has qualified health insurance, as
9 defined by the federal Trade Act of 2002, 3 or more
10 months, and (B) whose most recent prior creditable
11 coverage was under group health insurance coverage
12 offered by a health insurance issuer, a group health
13 plan, a governmental plan, or a church plan (or health
14 insurance coverage offered in connection with any such
15 plans) or any other type of creditable coverage that may
16 be required by the federal Health Insurance Portability
17 and Accountability Act of 1996, as it may be amended, or
18 the regulations under that Act;
19 (2) who is not eligible for coverage under (A) a
20 group health plan, (B) part A or part B of Medicare due
21 to age, or (C) medical assistance, and does not have
22 other health insurance coverage;
23 (3) with respect to whom the most recent coverage
24 within the coverage period described in paragraph (1)(A)
25 of this definition was not terminated based upon a factor
26 relating to nonpayment of premiums or fraud;
27 (4) if the individual (, other than an individual
28 who has either (A) been certified as an eligible person
29 pursuant to the federal Trade Adjustment Act of 2002, (B)
30 initially been paid a benefit by the Pension Benefit
31 Guaranty Corporation, or (C) as of December 1, 2002, been
32 receiving benefits from the Pension Benefit Guaranty
33 Corporation and who has qualified health insurance, as
34 defined by the federal Trade Act of 2002), had been
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1 offered the option of continuation coverage under a COBRA
2 continuation provision or under a similar State program,
3 who elected such coverage; and
4 (5) who, if the individual elected such
5 continuation coverage, has exhausted such continuation
6 coverage under such provision or program.
7 An individual who has either been certified as an
8 eligible person pursuant to the federal Trade Adjustment Act
9 of 2002 or initially been paid a benefit by the Pension
10 Benefit Guaranty Corporation shall not be required to elect
11 continuation coverage under a COBRA continuation provision or
12 under a similar state program.
13 "Group health insurance coverage" means, in connection
14 with a group health plan, health insurance coverage offered
15 in connection with that plan.
16 "Group health plan" has the same meaning given that term
17 in the federal Health Insurance Portability and
18 Accountability Act of 1996.
19 "Governmental plan" has the same meaning given that term
20 in the federal Health Insurance Portability and
21 Accountability Act of 1996.
22 "Health insurance coverage" means benefits consisting of
23 medical care (provided directly, through insurance or
24 reimbursement, or otherwise and including items and services
25 paid for as medical care) under any hospital and medical
26 expense-incurred policy, certificate, or contract provided by
27 an insurer, non-profit health care service plan contract,
28 health maintenance organization or other subscriber contract,
29 or any other health care plan or arrangement that pays for or
30 furnishes medical or health care services whether by
31 insurance or otherwise. Health insurance coverage shall not
32 include short term, accident only, disability income,
33 hospital confinement or fixed indemnity, dental only, vision
34 only, limited benefit, or credit insurance, coverage issued
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1 as a supplement to liability insurance, insurance arising out
2 of a workers' compensation or similar law, automobile
3 medical-payment insurance, or insurance under which benefits
4 are payable with or without regard to fault and which is
5 statutorily required to be contained in any liability
6 insurance policy or equivalent self-insurance.
7 "Health insurance issuer" means an insurance company,
8 insurance service, or insurance organization (including a
9 health maintenance organization and a voluntary health
10 services plan) that is authorized to transact health
11 insurance business in this State. Such term does not include
12 a group health plan.
13 "Health Maintenance Organization" means an organization
14 as defined in the Health Maintenance Organization Act.
15 "Hospice" means a program as defined in and licensed
16 under the Hospice Program Licensing Act.
17 "Hospital" means a duly licensed institution as defined
18 in the Hospital Licensing Act, an institution that meets all
19 comparable conditions and requirements in effect in the state
20 in which it is located, or the University of Illinois
21 Hospital as defined in the University of Illinois Hospital
22 Act.
23 "Individual health insurance coverage" means health
24 insurance coverage offered to individuals in the individual
25 market, but does not include short-term, limited-duration
26 insurance.
27 "Insured" means any individual resident of this State who
28 is eligible to receive benefits from any insurer (including
29 health insurance coverage offered in connection with a group
30 health plan) or health insurance issuer as defined in this
31 Section.
32 "Insurer" means any insurance company authorized to
33 transact health insurance business in this State and any
34 corporation that provides medical services and is organized
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1 under the Voluntary Health Services Plans Act or the Health
2 Maintenance Organization Act.
3 "Medical assistance" means the State medical assistance
4 or medical assistance no grant (MANG) programs provided under
5 Title XIX of the Social Security Act and Articles V (Medical
6 Assistance) and VI (General Assistance) of the Illinois
7 Public Aid Code (or any successor program) or under any
8 similar program of health care benefits in a state other than
9 Illinois.
10 "Medically necessary" means that a service, drug, or
11 supply is necessary and appropriate for the diagnosis or
12 treatment of an illness or injury in accord with generally
13 accepted standards of medical practice at the time the
14 service, drug, or supply is provided. When specifically
15 applied to a confinement it further means that the diagnosis
16 or treatment of the covered person's medical symptoms or
17 condition cannot be safely provided to that person as an
18 outpatient. A service, drug, or supply shall not be medically
19 necessary if it: (i) is investigational, experimental, or for
20 research purposes; or (ii) is provided solely for the
21 convenience of the patient, the patient's family, physician,
22 hospital, or any other provider; or (iii) exceeds in scope,
23 duration, or intensity that level of care that is needed to
24 provide safe, adequate, and appropriate diagnosis or
25 treatment; or (iv) could have been omitted without adversely
26 affecting the covered person's condition or the quality of
27 medical care; or (v) involves the use of a medical device,
28 drug, or substance not formally approved by the United States
29 Food and Drug Administration.
30 "Medical care" means the ordinary and usual professional
31 services rendered by a physician or other specified provider
32 during a professional visit for treatment of an illness or
33 injury.
34 "Medicare" means coverage under both Part A and Part B of
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1 Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395,
2 et seq.
3 "Minimum premium plan" means an arrangement whereby a
4 specified amount of health care claims is self-funded, but
5 the insurance company assumes the risk that claims will
6 exceed that amount.
7 "Participating transplant center" means a hospital
8 designated by the Board as a preferred or exclusive provider
9 of services for one or more specified human organ or tissue
10 transplants for which the hospital has signed an agreement
11 with the Board to accept a transplant payment allowance for
12 all expenses related to the transplant during a transplant
13 benefit period.
14 "Physician" means a person licensed to practice medicine
15 pursuant to the Medical Practice Act of 1987.
16 "Plan" means the Comprehensive Health Insurance Plan
17 established by this Act.
18 "Plan of operation" means the plan of operation of the
19 Plan, including articles, bylaws and operating rules, adopted
20 by the board pursuant to this Act.
21 "Provider" means any hospital, skilled nursing facility,
22 hospice, home health agency, physician, registered pharmacist
23 acting within the scope of that registration, or any other
24 person or entity licensed in Illinois to furnish medical
25 care.
26 "Qualified high risk pool" has the same meaning given
27 that term in the federal Health Insurance Portability and
28 Accountability Act of 1996.
29 "Resident" means a person who is and continues to be
30 legally domiciled and physically residing on a permanent and
31 full-time basis in a place of permanent habitation in this
32 State that remains that person's principal residence and from
33 which that person is absent only for temporary or transitory
34 purpose.
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1 "Skilled nursing facility" means a facility or that
2 portion of a facility that is licensed by the Illinois
3 Department of Public Health under the Nursing Home Care Act
4 or a comparable licensing authority in another state to
5 provide skilled nursing care.
6 "Stop-loss coverage" means an arrangement whereby an
7 insurer insures against the risk that any one claim will
8 exceed 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. 91-357, eff. 7-29-99; 91-735, eff. 6-2-00;
14 92-153, eff. 7-25-01; 93HB3298enr.)
15 (215 ILCS 105/4) (from Ch. 73, par. 1304)
16 Sec. 4. Powers and authority of the board. The board
17 shall have the general powers and authority granted under the
18 laws of this State to insurance companies licensed to
19 transact health and accident insurance and in addition
20 thereto, the specific authority to:
21 a. Enter into contracts as are necessary or proper to
22 carry out the provisions and purposes of this Act, including
23 the authority, with the approval of the Director, to enter
24 into contracts with similar plans of other states for the
25 joint performance of common administrative functions, or with
26 persons or other organizations for the performance of
27 administrative functions including, without limitation,
28 utilization review and quality assurance programs, or with
29 health maintenance organizations or preferred provider
30 organizations for the provision of health care services.
31 b. Sue or be sued, including taking any legal actions
32 necessary or proper.
33 c. Take such legal action as necessary to:
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1 (1) avoid the payment of improper claims against
2 the plan or the coverage provided by or through the plan;
3 (2) to recover any amounts erroneously or
4 improperly paid by the plan;
5 (3) to recover any amounts paid by the plan as a
6 result of a mistake of fact or law; or
7 (4) to recover or collect any other amounts,
8 including assessments, that are due or owed the Plan or
9 have been billed on its or the Plan's behalf.
10 d. Establish appropriate rates, rate schedules, rate
11 adjustments, expense allowances, agents' referral fees, claim
12 reserves, and formulas and any other actuarial function
13 appropriate to the operation of the plan. Rates and rate
14 schedules may be adjusted for appropriate risk factors such
15 as age and area variation in claim costs and shall take into
16 consideration appropriate risk factors in accordance with
17 established actuarial and underwriting practices.
18 e. Issue policies of insurance in accordance with the
19 requirements of this Act.
20 f. Appoint appropriate legal, actuarial and other
21 committees as necessary to provide technical assistance in
22 the operation of the plan, policy and other contract design,
23 and any other function within the authority of the plan.
24 g. Borrow money to effect the purposes of the Illinois
25 Comprehensive Health Insurance Plan. Any notes or other
26 evidence of indebtedness of the plan not in default shall be
27 legal investments for insurers and may be carried as admitted
28 assets.
29 h. Establish rules, conditions and procedures for
30 reinsuring risks under this Act.
31 i. Employ and fix the compensation of employees. Such
32 employees may be paid on a warrant issued by the State
33 Treasurer pursuant to a payroll voucher certified by the
34 Board and drawn by the Comptroller against appropriations or
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1 trust funds held by the State Treasurer.
2 j. Enter into intergovernmental cooperation agreements
3 with other agencies or entities of State government for the
4 purpose of sharing the cost of providing health care services
5 that are otherwise authorized by this Act for children who
6 are both plan participants and eligible for financial
7 assistance from the Division of Specialized Care for Children
8 of the University of Illinois.
9 k. Establish conditions and procedures under which the
10 plan may, if funds permit, discount or subsidize premium
11 rates that are paid directly by senior citizens, as defined
12 by the Board, and other plan participants, who are retired or
13 unemployed and meet other qualifications.
14 l. Establish and maintain the Plan Fund authorized in
15 Section 3 of this Act, which shall be divided into separate
16 accounts, as follows:
17 (1) accounts to fund the administrative, claim, and
18 other expenses of the Plan associated with eligible
19 persons who qualify for Plan coverage under Section 7 of
20 this Act, which shall consist of:
21 (A) premiums paid on behalf of covered
22 persons;
23 (B) appropriated funds and other revenues
24 collected or received by the Board;
25 (C) reserves for future losses maintained by
26 the Board; and
27 (D) interest earnings from investment of the
28 funds in the Plan Fund or any of its accounts other
29 than the funds in the account established under item
30 2 of this subsection;
31 (2) an account, to be denominated the federally
32 eligible individuals account, to fund the administrative,
33 claim, and other expenses of the Plan associated with
34 federally eligible individuals who qualify for Plan
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1 coverage under Section 15 of this Act, which shall
2 consist of:
3 (A) premiums paid on behalf of covered
4 persons;
5 (B) assessments and other revenues collected
6 or received by the Board;
7 (C) reserves for future losses maintained by
8 the Board; and
9 (D) interest earnings from investment of the
10 federally eligible individuals account funds; and
11 (E) grants provided pursuant to the federal
12 Trade Adjustment Act of 2002; and
13 (3) such other accounts as may be appropriate.
14 m. Charge and collect assessments paid by insurers
15 pursuant to Section 12 of this Act and recover any
16 assessments for, on behalf of, or against those insurers.
17 (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99;
18 93HB3298enr.)
19 (215 ILCS 105/7) (from Ch. 73, par. 1307)
20 Sec. 7. Eligibility.
21 a. Except as provided in subsection (e) of this Section
22 or in Section 15 of this Act, any person who is either a
23 citizen of the United States or an alien lawfully admitted
24 for permanent residence and who has been for a period of at
25 least 180 days and continues to be a resident of this State
26 shall be eligible for Plan coverage under this Section if
27 evidence is provided of:
28 (1) A notice of rejection or refusal to issue
29 substantially similar individual health insurance
30 coverage for health reasons by a health insurance issuer;
31 or
32 (2) A refusal by a health insurance issuer to issue
33 individual health insurance coverage except at a rate
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1 exceeding the applicable Plan rate for which the person
2 is responsible.
3 A rejection or refusal by a group health plan or health
4 insurance issuer offering only stop-loss or excess of loss
5 insurance or contracts, agreements, or other arrangements for
6 reinsurance coverage with respect to the applicant shall not
7 be sufficient evidence under this subsection.
8 b. The board shall promulgate a list of medical or
9 health conditions for which a person who is either a citizen
10 of the United States or an alien lawfully admitted for
11 permanent residence and a resident of this State would be
12 eligible for Plan coverage without applying for health
13 insurance coverage pursuant to subsection a. of this Section.
14 Persons who can demonstrate the existence or history of any
15 medical or health conditions on the list promulgated by the
16 board shall not be required to provide the evidence specified
17 in subsection a. of this Section. The list shall be
18 effective on the first day of the operation of the Plan and
19 may be amended from time to time as appropriate.
20 c. Family members of the same household who each are
21 covered persons are eligible for optional family coverage
22 under the Plan.
23 d. For persons qualifying for coverage in accordance
24 with Section 7 of this Act, the board shall, if it determines
25 that such appropriations as are made pursuant to Section 12
26 of this Act are insufficient to allow the board to accept all
27 of the eligible persons which it projects will apply for
28 enrollment under the Plan, limit or close enrollment to
29 ensure that the Plan is not over-subscribed and that it has
30 sufficient resources to meet its obligations to existing
31 enrollees. The board shall not limit or close enrollment for
32 federally eligible individuals.
33 e. A person shall not be eligible for coverage under the
34 Plan if:
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1 (1) He or she has or obtains other coverage under a
2 group health plan or health insurance coverage
3 substantially similar to or better than a Plan policy as
4 an insured or covered dependent or would be eligible to
5 have that coverage if he or she elected to obtain it.
6 Persons otherwise eligible for Plan coverage may,
7 however, solely for the purpose of having coverage for a
8 pre-existing condition, maintain other coverage only
9 while satisfying any pre-existing condition waiting
10 period under a Plan policy or a subsequent replacement
11 policy of a Plan policy.
12 (1.1) His or her prior coverage under a group
13 health plan or health insurance coverage, provided or
14 arranged by an employer of more than 10 employees was
15 discontinued for any reason without the entire group or
16 plan being discontinued and not replaced, provided he or
17 she remains an employee, or dependent thereof, of the
18 same employer.
19 (2) He or she is a recipient of or is approved to
20 receive medical assistance, except that a person may
21 continue to receive medical assistance through the
22 medical assistance no grant program, but only while
23 satisfying the requirements for a preexisting condition
24 under Section 8, subsection f. of this Act. Payment of
25 premiums pursuant to this Act shall be allocable to the
26 person's spenddown for purposes of the medical assistance
27 no grant program, but that person shall not be eligible
28 for any Plan benefits while that person remains eligible
29 for medical assistance. If the person continues to
30 receive or be approved to receive medical assistance
31 through the medical assistance no grant program at or
32 after the time that requirements for a preexisting
33 condition are satisfied, the person shall not be eligible
34 for coverage under the Plan. In that circumstance,
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1 coverage under the plan shall terminate as of the
2 expiration of the preexisting condition limitation
3 period. Under all other circumstances, coverage under
4 the Plan shall automatically terminate as of the
5 effective date of any medical assistance.
6 (3) Except as provided in Section 15, the person
7 has previously participated in the Plan and voluntarily
8 terminated Plan coverage, unless 12 months have elapsed
9 since the person's latest voluntary termination of
10 coverage.
11 (4) The person fails to pay the required premium
12 under the covered person's terms of enrollment and
13 participation, in which event the liability of the Plan
14 shall be limited to benefits incurred under the Plan for
15 the time period for which premiums had been paid and the
16 covered person remained eligible for Plan coverage.
17 (5) The Plan has paid a total of $1,000,000 in
18 benefits on behalf of the covered person.
19 (6) The person is a resident of a public
20 institution.
21 (7) The person's premium is paid for or reimbursed
22 under any government sponsored program or by any
23 government agency or health care provider, except as an
24 otherwise qualifying full-time employee, or dependent of
25 such employee, of a government agency or health care
26 provider or, except when a person's premium is paid by
27 the U.S. Treasury Department pursuant to the federal
28 Trade Adjustment Act of 2002.
29 (8) The person has or later receives other benefits
30 or funds from any settlement, judgement, or award
31 resulting from any accident or injury, regardless of the
32 date of the accident or injury, or any other
33 circumstances creating a legal liability for damages due
34 that person by a third party, whether the settlement,
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1 judgment, or award is in the form of a contract,
2 agreement, or trust on behalf of a minor or otherwise and
3 whether the settlement, judgment, or award is payable to
4 the person, his or her dependent, estate, personal
5 representative, or guardian in a lump sum or over time,
6 so long as there continues to be benefits or assets
7 remaining from those sources in an amount in excess of
8 $100,000.
9 (9) Within the 5 years prior to the date a person's
10 Plan application is received by the Board, the person's
11 coverage under any health care benefit program as defined
12 in 18 U.S.C. 24, including any public or private plan or
13 contract under which any medical benefit, item, or
14 service is provided, was terminated as a result of any
15 act or practice that constitutes fraud under State or
16 federal law or as a result of an intentional
17 misrepresentation of material fact; or if that person
18 knowingly and willfully obtained or attempted to obtain,
19 or fraudulently aided or attempted to aid any other
20 person in obtaining, any coverage or benefits under the
21 Plan to which that person was not entitled.
22 f. The board or the administrator shall require
23 verification of residency and may require any additional
24 information or documentation, or statements under oath, when
25 necessary to determine residency upon initial application and
26 for the entire term of the policy.
27 g. Coverage shall cease (i) on the date a person is no
28 longer a resident of Illinois, (ii) on the date a person
29 requests coverage to end, (iii) upon the death of the covered
30 person, (iv) on the date State law requires cancellation of
31 the policy, or (v) at the Plan's option, 30 days after the
32 Plan makes any inquiry concerning a person's eligibility or
33 place of residence to which the person does not reply.
34 h. Except under the conditions set forth in subsection g
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1 of this Section, the coverage of any person who ceases to
2 meet the eligibility requirements of this Section shall be
3 terminated at the end of the current policy period for which
4 the necessary premiums have been paid.
5 (Source: P.A. 90-30, eff. 7-1-97; 91-639, eff. 8-20-99;
6 91-735, eff. 6-2-00; 93HB3298enr.)
7 (215 ILCS 105/15)
8 Sec. 15. Alternative portable coverage for federally
9 eligible individuals.
10 (a) Notwithstanding the requirements of subsection a. of
11 Section 7 and except as otherwise provided in this Section,
12 any federally eligible individual for whom a Plan
13 application, and such enclosures and supporting documentation
14 as the Board may require, is received by the Board within 90
15 days after the termination of prior creditable coverage shall
16 qualify to enroll in the Plan under the portability
17 provisions of this Section.
18 A federally eligible person who between December 1, 2002
19 and September 30, 2003 has either (1) been certified as
20 eligible pursuant to the federal Trade Act of 2002, (2)
21 initially been paid a benefit by the Pension Benefit Guaranty
22 Corporation, or (3) as of December 1, 2002, been receiving
23 benefits from the Pension Benefit Guaranty Corporation, who
24 has qualified health insurance, as defined by the federal
25 Trade Act of 2002, and whose Plan application and enclosures
26 and supporting documentation, as the Board may require, is
27 received by the Board after the termination of previous
28 creditable coverage shall qualify to enroll in the Plan under
29 the portability provisions of this Section.
30 A federally eligible person who, after September 30,
31 2003, has either been certified as an eligible person
32 pursuant to the federal Trade Adjustment Act of 2002 or
33 initially been paid a benefit by the Pension Benefit Guaranty
HB0707 Enrolled -19- LRB093 05485 MKM 05576 b
1 Corporation and whose Plan application and enclosures and
2 supporting documentation as the Board may require is received
3 by the Board within 63 days after the termination of previous
4 creditable coverage shall qualify to enroll in the Plan under
5 the portability provisions of this Section.
6 (b) Any federally eligible individual seeking Plan
7 coverage under this Section must submit with his or her
8 application evidence, including acceptable written
9 certification of previous creditable coverage, that will
10 establish to the Board's satisfaction, that he or she meets
11 all of the requirements to be a federally eligible individual
12 and is currently and permanently residing in this State (as
13 of the date his or her application was received by the
14 Board).
15 (c) Except as otherwise provided in this Section, a
16 period of creditable coverage shall not be counted, with
17 respect to qualifying an applicant for Plan coverage as a
18 federally eligible individual under this Section, if after
19 such period and before the application for Plan coverage was
20 received by the Board, there was at least a 90 day period
21 during all of which the individual was not covered under any
22 creditable coverage.
23 For a federally eligible person who between December 1,
24 2002 and September 30, 2003 has either (1) been certified as
25 eligible pursuant to the federal Trade Act of 2002, (2)
26 initially been paid a benefit by the Pension Benefit Guaranty
27 Corporation, or (3) as of December 1, 2002, been receiving
28 benefits from the Pension Benefit Guaranty Corporation and
29 who has qualified health insurance, as defined by the federal
30 Trade Act of 2002, a period of creditable coverage shall be
31 counted, with respect to qualifying an applicant for Plan
32 coverage as a federally eligible individual under this
33 Section, when the application for Plan coverage was received
34 by the Board.
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1 For a federally eligible person who, after September 30,
2 2003, has either been certified as an eligible person
3 pursuant to the federal Trade Adjustment Act of 2002 or
4 initially been paid a benefit by the Pension Benefit Guaranty
5 Corporation, a period of creditable coverage shall not be
6 counted, with respect to qualifying an applicant for Plan
7 coverage as a federally eligible individual under this
8 Section, if after such period and before the application for
9 Plan coverage was received by the Board, there was at least a
10 63 day period during all of which the individual was not
11 covered under any creditable coverage.
12 (d) Any federally eligible individual who the Board
13 determines qualifies for Plan coverage under this Section
14 shall be offered his or her choice of enrolling in one of
15 alternative portability health benefit plans which the Board
16 is authorized under this Section to establish for these
17 federally eligible individuals and their dependents.
18 (e) The Board shall offer a choice of health care
19 coverages consistent with major medical coverage under the
20 alternative health benefit plans authorized by this Section
21 to every federally eligible individual. The coverages to be
22 offered under the plans, the schedule of benefits,
23 deductibles, co-payments, exclusions, and other limitations
24 shall be approved by the Board. One optional form of
25 coverage shall be comparable to comprehensive health
26 insurance coverage offered in the individual market in this
27 State or a standard option of coverage available under the
28 group or individual health insurance laws of the State. The
29 standard benefit plan that is authorized by Section 8 of this
30 Act may be used for this purpose. The Board may also offer a
31 preferred provider option and such other options as the Board
32 determines may be appropriate for these federally eligible
33 individuals who qualify for Plan coverage pursuant to this
34 Section.
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1 (f) Notwithstanding the requirements of subsection f. of
2 Section 8, any plan coverage that is issued to federally
3 eligible individuals who qualify for the Plan pursuant to the
4 portability provisions of this Section shall not be subject
5 to any preexisting conditions exclusion, waiting period, or
6 other similar limitation on coverage.
7 (g) Federally eligible individuals who qualify and
8 enroll in the Plan pursuant to this Section shall be required
9 to pay such premium rates as the Board shall establish and
10 approve in accordance with the requirements of Section 7.1 of
11 this Act.
12 (h) A federally eligible individual who qualifies and
13 enrolls in the Plan pursuant to this Section must satisfy on
14 an ongoing basis all of the other eligibility requirements of
15 this Act to the extent not inconsistent with the federal
16 Health Insurance Portability and Accountability Act of 1996
17 in order to maintain continued eligibility for coverage under
18 the Plan.
19 (Source: P.A. 92-153, eff. 7-25-01; 93HB3298enr.)
20 Section 99. Effective date. This Act takes effect upon
21 becoming law.