093_HB3622

 
                                     LRB093 07142 JLS 07297 b

 1        AN ACT relating to insurance.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 5.  The Comprehensive Health Insurance  Plan  Act
 5    is amended by changing Sections 7 and 8 as follows:

 6        (215 ILCS 105/7) (from Ch. 73, par. 1307)
 7        Sec. 7.  Eligibility.
 8        a.  Except  as provided in subsection (e) of this Section
 9    or in Section 15 of this Act, any  person  who  is  either  a
10    citizen  of  the  United States or an alien lawfully admitted
11    for permanent residence and who has been for a period  of  at
12    least  180  days and continues to be a resident of this State
13    shall be eligible for Plan coverage  under  this  Section  if
14    evidence is provided of:
15             (1)  A  notice  of  rejection  or  refusal  to issue
16        substantially   similar   individual   health   insurance
17        coverage for health reasons by a health insurance issuer;
18        or
19             (2)  A refusal by a health insurance issuer to issue
20        individual health insurance coverage  except  at  a  rate
21        exceeding  the  applicable Plan rate for which the person
22        is responsible.
23        A rejection or refusal by a group health plan  or  health
24    insurance  issuer  offering  only stop-loss or excess of loss
25    insurance or contracts, agreements, or other arrangements for
26    reinsurance coverage with respect to the applicant shall  not
27    be sufficient evidence under this subsection.
28        b.  The  board  shall  promulgate  a  list  of medical or
29    health conditions for which a person who is either a  citizen
30    of  the  United  States  or  an  alien  lawfully admitted for
31    permanent residence and a resident of  this  State  would  be
 
                            -2-      LRB093 07142 JLS 07297 b
 1    eligible  for  Plan  coverage  without  applying  for  health
 2    insurance coverage pursuant to subsection a. of this Section.
 3    Persons  who  can demonstrate the existence or history of any
 4    medical or health conditions on the list promulgated  by  the
 5    board shall not be required to provide the evidence specified
 6    in  subsection  a.  of  this  Section.   The  list  shall  be
 7    effective  on  the first day of the operation of the Plan and
 8    may be amended from time to time as appropriate.
 9        c.  Family members of the same  household  who  each  are
10    covered  persons  are  eligible  for optional family coverage
11    under the Plan.
12        d.  For persons qualifying  for  coverage  in  accordance
13    with Section 7 of this Act, the board shall, if it determines
14    that  such  appropriations as are made pursuant to Section 12
15    of this Act are insufficient to allow the board to accept all
16    of the eligible persons which  it  projects  will  apply  for
17    enrollment  under  the  Plan,  limit  or  close enrollment to
18    ensure that the Plan is not over-subscribed and that  it  has
19    sufficient  resources  to  meet  its  obligations to existing
20    enrollees.  The board shall not limit or close enrollment for
21    federally eligible individuals.
22        e.  A person shall not be eligible for coverage under the
23    Plan if:
24             (1)  He or she has or obtains other coverage under a
25        group  health   plan   or   health   insurance   coverage
26        substantially  similar to or better than a Plan policy as
27        an insured or covered dependent or would be  eligible  to
28        have  that  coverage  if  he or she elected to obtain it.
29        Persons  otherwise  eligible  for  Plan   coverage   may,
30        however,  solely for the purpose of having coverage for a
31        pre-existing  condition,  maintain  other  coverage  only
32        while  satisfying  any  pre-existing  condition   waiting
33        period  under  a  Plan policy or a subsequent replacement
34        policy of a Plan policy.
 
                            -3-      LRB093 07142 JLS 07297 b
 1             (1.1)  His or  her  prior  coverage  under  a  group
 2        health  plan  or  health  insurance coverage, provided or
 3        arranged by an employer of more  than  10  employees  was
 4        discontinued  for  any reason without the entire group or
 5        plan being discontinued and not replaced, provided he  or
 6        she  remains  an  employee,  or dependent thereof, of the
 7        same employer.
 8             (2)  He or she is a recipient of or is  approved  to
 9        receive  medical  assistance,  except  that  a person may
10        continue  to  receive  medical  assistance  through   the
11        medical  assistance  no  grant  program,  but  only while
12        satisfying the requirements for a  preexisting  condition
13        under  Section  8, subsection f. of this Act.  Payment of
14        premiums pursuant to this Act shall be allocable  to  the
15        person's spenddown for purposes of the medical assistance
16        no  grant  program, but that person shall not be eligible
17        for any Plan benefits while that person remains  eligible
18        for  medical  assistance.   If  the  person  continues to
19        receive or be  approved  to  receive  medical  assistance
20        through  the  medical  assistance  no grant program at or
21        after  the  time  that  requirements  for  a  preexisting
22        condition are satisfied, the person shall not be eligible
23        for  coverage  under  the  Plan.  In  that  circumstance,
24        coverage  under  the  plan  shall  terminate  as  of  the
25        expiration  of  the  preexisting   condition   limitation
26        period.   Under  all  other circumstances, coverage under
27        the  Plan  shall  automatically  terminate  as   of   the
28        effective date of any medical assistance.
29             (3)  Except  as  provided  in Section 15, the person
30        has previously participated in the Plan  and  voluntarily
31        terminated  Plan  coverage, unless 12 months have elapsed
32        since  the  person's  latest  voluntary  termination   of
33        coverage.
34             (4)  The  person  fails  to pay the required premium
 
                            -4-      LRB093 07142 JLS 07297 b
 1        under  the  covered  person's  terms  of  enrollment  and
 2        participation, in which event the liability of  the  Plan
 3        shall  be limited to benefits incurred under the Plan for
 4        the time period for which premiums had been paid and  the
 5        covered person remained eligible for Plan coverage.
 6             (5)  The   Plan  has  paid  a  total  of  $2,000,000
 7        $1,000,000 in benefits on behalf of the covered person.
 8             (6)  The  person  is  a   resident   of   a   public
 9        institution.
10             (7)  The  person's premium is paid for or reimbursed
11        under  any  government  sponsored  program  or   by   any
12        government  agency  or health care provider, except as an
13        otherwise qualifying full-time employee, or dependent  of
14        such  employee,  of  a  government  agency or health care
15        provider.
16             (8)  The person has or later receives other benefits
17        or  funds  from  any  settlement,  judgement,  or   award
18        resulting  from any accident or injury, regardless of the
19        date  of  the  accident   or   injury,   or   any   other
20        circumstances  creating a legal liability for damages due
21        that person by a third  party,  whether  the  settlement,
22        judgment,  or  award  is  in  the  form  of  a  contract,
23        agreement, or trust on behalf of a minor or otherwise and
24        whether  the settlement, judgment, or award is payable to
25        the  person,  his  or  her  dependent,  estate,  personal
26        representative, or guardian in a lump sum or  over  time,
27        so  long  as  there  continues  to  be benefits or assets
28        remaining from those sources in an amount  in  excess  of
29        $100,000.
30             (9)  Within the 5 years prior to the date a person's
31        Plan  application  is received by the Board, the person's
32        coverage under any health care benefit program as defined
33        in 18 U.S.C. 24, including any public or private plan  or
34        contract  under  which  any  medical  benefit,  item,  or
 
                            -5-      LRB093 07142 JLS 07297 b
 1        service  is  provided,  was terminated as a result of any
 2        act or practice that constitutes  fraud  under  State  or
 3        federal   law   or   as   a   result  of  an  intentional
 4        misrepresentation of material fact;  or  if  that  person
 5        knowingly  and willfully obtained or attempted to obtain,
 6        or fraudulently aided  or  attempted  to  aid  any  other
 7        person  in  obtaining, any coverage or benefits under the
 8        Plan to which that person was not entitled.
 9        f.  The  board  or  the   administrator   shall   require
10    verification  of  residency  and  may  require any additional
11    information or documentation, or statements under oath,  when
12    necessary to determine residency upon initial application and
13    for the entire term of the policy.
14        g.  Coverage  shall  cease (i) on the date a person is no
15    longer a resident of Illinois, (ii)  on  the  date  a  person
16    requests coverage to end, (iii) upon the death of the covered
17    person,  (iv)  on the date State law requires cancellation of
18    the policy, or (v) at the Plan's option, 30  days  after  the
19    Plan  makes  any inquiry concerning a person's eligibility or
20    place of residence to which the person does not reply.
21        h.  Except under the conditions set forth in subsection g
22    of this Section, the coverage of any  person  who  ceases  to
23    meet  the  eligibility  requirements of this Section shall be
24    terminated at the end of the current policy period for  which
25    the necessary premiums have been paid.
26    (Source: P.A.  90-30,  eff.  7-1-97;  91-639,  eff.  8-20-99;
27    91-735, eff. 6-2-00.)

28        (215 ILCS 105/8) (from Ch. 73, par. 1308)
29        Sec. 8.  Minimum benefits.
30        a.  Availability.  The  Plan  shall  offer in an annually
31    renewable policy major  medical  expense  coverage  to  every
32    eligible  person  who  is  not  eligible for Medicare.  Major
33    medical expense coverage offered by the  Plan  shall  pay  an
 
                            -6-      LRB093 07142 JLS 07297 b
 1    eligible  person's  covered expenses, subject to limit on the
 2    deductible  and   coinsurance   payments   authorized   under
 3    paragraph  (4)  of  subsection  d  of  this  Section, up to a
 4    lifetime benefit limit of $2,000,000 $1,000,000  per  covered
 5    individual.   The  maximum  limit under this subsection shall
 6    not be altered by the  Board,  and  no  actuarial  equivalent
 7    benefit  may  be  substituted  by  the  Board. Any person who
 8    otherwise would qualify for coverage under the Plan,  but  is
 9    excluded because he or she is eligible for Medicare, shall be
10    eligible  for  any  separate  Medicare  supplement  policy or
11    policies which the Board may offer.
12        b.  Outline  of  benefits.   Covered  expenses  shall  be
13    limited  to  the  usual  and  customary   charge,   including
14    negotiated  fees,  in the locality for the following services
15    and articles when prescribed by a physician and determined by
16    the Plan to be medically necessary for the following areas of
17    services, subject to such separate deductibles,  co-payments,
18    exclusions,  and  other limitations on benefits  as the Board
19    shall establish and approve, and the other provisions of this
20    Section:
21             (1)  Hospital services,  except  that  any  services
22        provided by a hospital that is located more than 75 miles
23        outside the State of Illinois shall be covered only for a
24        maximum of 45 days in any calendar year.  With respect to
25        covered expenses incurred during any calendar year ending
26        on  or after December 31, 1999, inpatient hospitalization
27        of an eligible person for the treatment of mental illness
28        at a hospital located within the State of Illinois  shall
29        be  subject  to  the same terms and conditions as for any
30        other illness.
31             (2)  Professional  services  for  the  diagnosis  or
32        treatment of injuries,  illnesses  or  conditions,  other
33        than dental and mental and nervous disorders as described
34        in  paragraph (17), which are rendered by a physician, or
 
                            -7-      LRB093 07142 JLS 07297 b
 1        by  other  licensed  professionals  at  the   physician's
 2        direction.  This includes reconstruction of the breast on
 3        which   a   mastectomy   was   performed;   surgery   and
 4        reconstruction  of  the  other  breast   to   produce   a
 5        symmetrical  appearance;  and prostheses and treatment of
 6        physical complications at all stages of  the  mastectomy,
 7        including lymphedemas.
 8             (2.5)  Professional services provided by a physician
 9        to  children  under  the  age  of  16  years for physical
10        examinations and age appropriate immunizations ordered by
11        a physician licensed to  practice  medicine  in  all  its
12        branches.
13             (3)  (Blank).
14             (4)  Outpatient   prescription  drugs  that  by  law
15        require a prescription written by a physician licensed to
16        practice medicine in all its  branches  subject  to  such
17        separate  deductible, copayment, and other limitations or
18        restrictions as the Board shall  approve,  including  the
19        use  of a prescription drug card or any other program, or
20        both.
21             (5)  Skilled nursing services of a licensed  skilled
22        nursing  facility  for  not  more  than 120 days during a
23        policy year.
24             (6)  Services of a home health agency in accord with
25        a home health care plan, up to a maximum  of  270  visits
26        per year.
27             (7)  Services  of  a  licensed  hospice for not more
28        than 180 days during a policy year.
29             (8)  Use of radium or other radioactive materials.
30             (9)  Oxygen.
31             (10)  Anesthetics.
32             (11)  Orthoses and prostheses other than dental.
33             (12)  Rental or purchase in  accordance  with  Board
34        policies  or  procedures  of  durable  medical equipment,
 
                            -8-      LRB093 07142 JLS 07297 b
 1        other than eyeglasses or hearing aids, for which there is
 2        no personal use in the absence of the condition for which
 3        it is prescribed.
 4             (13)  Diagnostic x-rays and laboratory tests.
 5             (14)  Oral surgery (i) for excision of partially  or
 6        completely unerupted impacted teeth when not performed in
 7        connection  with  the  routine  extraction  or  repair of
 8        teeth; (ii) for excision of tumors or cysts of the  jaws,
 9        cheeks,  lips,  tongue,  and roof and floor of the mouth;
10        (iii) required for correction of cleft lip and palate and
11        other craniofacial and maxillofacial  birth  defects;  or
12        (iv)  for  treatment  of  injuries  to natural teeth or a
13        fractured jaw due to an accident.
14             (15)  Physical, speech, and functional  occupational
15        therapy   as   medically   necessary   and   provided  by
16        appropriate licensed professionals.
17             (16)  Emergency  and   other   medically   necessary
18        transportation  provided  by a licensed ambulance service
19        to the nearest health care facility qualified to treat  a
20        covered  illness,  injury,  or  condition, subject to the
21        provisions of the Emergency Medical Systems (EMS) Act.
22             (17)  Outpatient   services   for   diagnosis    and
23        treatment of mental and nervous disorders provided that a
24        covered  person shall be required to make a copayment not
25        to exceed 50% and  that  the  Plan's  payment  shall  not
26        exceed such amounts as are established by the Board.
27             (18)  Human organ or tissue transplants specified by
28        the  Board that are performed at a hospital designated by
29        the Board as a participating transplant center  for  that
30        specific organ or tissue transplant.
31             (19)  Naprapathic services, as appropriate, provided
32        by a licensed naprapathic practitioner.
33        c.  Exclusions.   Covered  expenses of the Plan shall not
34    include the following:
 
                            -9-      LRB093 07142 JLS 07297 b
 1             (1)  Any charge for treatment for cosmetic  purposes
 2        other than for reconstructive surgery when the service is
 3        incidental  to  or follows surgery resulting from injury,
 4        sickness or  other  diseases  of  the  involved  part  or
 5        surgery  for  the  repair  or  treatment  of a congenital
 6        bodily defect to restore normal bodily functions.
 7             (2)  Any charge for care that is primarily for rest,
 8        custodial, educational, or domiciliary purposes.
 9             (3)  Any charge for services in a  private  room  to
10        the  extent  it  is in excess of the institution's charge
11        for its most common semiprivate room,  unless  a  private
12        room is prescribed as medically necessary by a physician.
13             (4)  That  part  of any charge for room and board or
14        for  services  rendered  or  articles  prescribed  by   a
15        physician,  dentist,  or other health care personnel that
16        exceeds  the  reasonable  and  customary  charge  in  the
17        locality or for any services or  supplies  not  medically
18        necessary for the diagnosed injury or illness.
19             (5)  Any   charge   for  services  or  articles  the
20        provision of which is not within the scope  of  licensure
21        of  the  institution or individual providing the services
22        or articles.
23             (6)  Any expense incurred  prior  to  the  effective
24        date  of  coverage  by  the  Plan for the person on whose
25        behalf the expense is incurred.
26             (7)  Dental care, dental surgery, dental  treatment,
27        any   other  dental  procedure  involving  the  teeth  or
28        periodontium, or any dental appliances, including crowns,
29        bridges,  implants,  or  partial  or  complete  dentures,
30        except as specifically  provided  in  paragraph  (14)  of
31        subsection b of this Section.
32             (8)  Eyeglasses,  contact  lenses,  hearing  aids or
33        their fitting.
34             (9)  Illness or injury due to acts of war.
 
                            -10-     LRB093 07142 JLS 07297 b
 1             (10)  Services of  blood  donors  and  any  fee  for
 2        failure to replace the first 3 pints of blood provided to
 3        a covered  person each policy year.
 4             (11)  Personal  supplies  or  services provided by a
 5        hospital or nursing home,  or  any  other  nonmedical  or
 6        nonprescribed supply or service.
 7             (12)  Routine  maternity  charges  for  a pregnancy,
 8        except where added as optional coverage with  payment  of
 9        an   additional  premium  for  pregnancy  resulting  from
10        conception occurring after  the  effective  date  of  the
11        optional coverage.
12             (13)  (Blank).
13             (14)  Any  expense or charge for services, drugs, or
14        supplies that  are:  (i)  not  provided  in  accord  with
15        generally accepted standards of current medical practice;
16        (ii)  for procedures, treatments, equipment, transplants,
17        or  implants,   any   of   which   are   investigational,
18        experimental,    or    for   research   purposes;   (iii)
19        investigative and not proven safe and effective; or  (iv)
20        for,   or   resulting   from,   a  gender  transformation
21        operation.
22             (15)  Any expense or  charge  for  routine  physical
23        examinations or tests except as provided in item (2.5) of
24        subsection b of this Section.
25             (16)  Any  expense for which a charge is not made in
26        the absence of insurance or for which there is  no  legal
27        obligation on the part of the patient to pay.
28             (17)  Any  expense  incurred  for  benefits provided
29        under the laws of  the  United  States  and  this  State,
30        including   Medicare,   Medicaid,   and   other   medical
31        assistance,  maternal  and  child health services and any
32        other program that  is  administered  or  funded  by  the
33        Department  of  Human Services, Department of Public Aid,
34        or    Department    of    Public     Health,     military
 
                            -11-     LRB093 07142 JLS 07297 b
 1        service-connected  disability  payments, medical services
 2        provided for  members  of  the  armed  forces  and  their
 3        dependents or employees of the armed forces of the United
 4        States,  and  medical  services financed on behalf of all
 5        citizens by the United States.
 6             (18)  Any   expense   or   charge   for   in   vitro
 7        fertilization,  artificial  insemination,  or  any  other
 8        artificial means used to cause pregnancy.
 9             (19)  Any expense or charge for oral  contraceptives
10        used  for  birth  control  or  any  other temporary birth
11        control measures.
12             (20)  Any expense or  charge  for  sterilization  or
13        sterilization reversals.
14             (21)  Any   expense   or   charge  for  weight  loss
15        programs, exercise equipment, or  treatment  of  obesity,
16        except  when  certified  by a physician as morbid obesity
17        (at least 2 times normal body weight).
18             (22)  Any  expense   or   charge   for   acupuncture
19        treatment  unless  used  as  an  anesthetic  agent  for a
20        covered surgery.
21             (23)  Any expense or charge for or related to  organ
22        or  tissue  transplants  other  than those performed at a
23        hospital with a Board approved organ  transplant  program
24        that  has  been designated by the Board as a preferred or
25        exclusive provider organization for that  specific  organ
26        or tissue transplant.
27             (24)  Any   expense   or   charge   for  procedures,
28        treatments, equipment, or services that are  provided  in
29        special settings for research purposes or in a controlled
30        environment,  are  being  studied for safety, efficiency,
31        and effectiveness, and are awaiting  endorsement  by  the
32        appropriate   national  medical  speciality  college  for
33        general use within the medical community.
34        d.  Deductibles and coinsurance.
 
                            -12-     LRB093 07142 JLS 07297 b
 1        The Plan coverage defined in Section 6 shall provide  for
 2    a  choice  of deductibles per individual as authorized by the
 3    Board.  If 2 individual members of the same family household,
 4    who are both covered persons under the Plan, satisfy the same
 5    applicable deductibles, no other member of that family who is
 6    also a covered person under the Plan  shall  be  required  to
 7    meet  any  deductibles for the balance of that calendar year.
 8    The deductibles must  be  applied  first  to  the  authorized
 9    amount of covered expenses incurred by the covered person.  A
10    mandatory  coinsurance  requirement  shall  be imposed at the
11    rate authorized by the  Board  in  excess  of  the  mandatory
12    deductible,  the  coinsurance  in the aggregate not to exceed
13    such amounts as are authorized by the Board  per  annum.   At
14    its  discretion  the  Board  may, however, offer catastrophic
15    coverages  or  other  policies  that   provide   for   larger
16    deductibles  with  or  without coinsurance requirements.  The
17    deductibles and coinsurance factors may be adjusted  annually
18    according  to  the  Medical  Component  of the Consumer Price
19    Index.
20        e.  Scope of coverage.
21             (1)  In approving any of the  benefit  plans  to  be
22        offered  by  the  Plan,  the  Board  shall establish such
23        benefit   levels,   deductibles,   coinsurance   factors,
24        exclusions, and limitations as it  may  deem  appropriate
25        and  that  it  believes to be generally reflective of and
26        commensurate  with  health  insurance  coverage  that  is
27        provided in the individual market in this State.
28             (2)  The benefit plans approved  by  the  Board  may
29        also  provide  for  and  employ  various cost containment
30        measures  and  other  requirements  including,  but   not
31        limited  to,  preadmission certification, prior approval,
32        second surgical opinions, concurrent  utilization  review
33        programs,  individual case management, preferred provider
34        organizations,  health  maintenance  organizations,   and
 
                            -13-     LRB093 07142 JLS 07297 b
 1        other  cost effective arrangements for paying for covered
 2        expenses.
 3        f.  Preexisting conditions.
 4             (1)  Except  for  federally   eligible   individuals
 5        qualifying for Plan coverage under Section 15 of this Act
 6        or eligible persons who qualify for the waiver authorized
 7        in  paragraph (3) of this subsection, plan coverage shall
 8        exclude charges or expenses incurred during the  first  6
 9        months following the effective date of coverage as to any
10        condition for which medical advice, care or treatment was
11        recommended   or  received  during  the  6  month  period
12        immediately preceding the effective date of coverage.
13             (2)  (Blank).
14             (3)  Waiver: The preexisting condition exclusions as
15        set forth in paragraph (1) of this  subsection  shall  be
16        waived to the extent to which the eligible person (a) has
17        satisfied  similar  exclusions under any prior individual
18        health insurance policy that was involuntarily terminated
19        because of the insolvency of the issuer of the policy and
20        (b)  has  applied  for  Plan  coverage  within  90   days
21        following  the involuntary termination of that individual
22        health insurance coverage.
23        g.  Other sources primary;  nonduplication of benefits.
24             (1)  The Plan shall be the last  payor  of  benefits
25        whenever  any  other  benefit  or  source  of third party
26        payment is  available.   Subject  to  the  provisions  of
27        subsection  e  of  Section  7, benefits otherwise payable
28        under Plan coverage shall be reduced by all amounts  paid
29        or payable by Medicare or any other government program or
30        through  any  health  insurance  coverage or group health
31        plan, whether by insurance, reimbursement, or  otherwise,
32        or   through   any  third  party  liability,  settlement,
33        judgment,  or  award,  regardless  of  the  date  of  the
34        settlement, judgment, or award, whether  the  settlement,
 
                            -14-     LRB093 07142 JLS 07297 b
 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  covered  person,  his  or  her  dependent,   estate,
 5        personal  representative,  or  guardian  in a lump sum or
 6        over  time,  and  by  all  hospital  or  medical  expense
 7        benefits paid or payable under any worker's  compensation
 8        coverage,   automobile   medical  payment,  or  liability
 9        insurance, whether provided on  the  basis  of  fault  or
10        nonfault, and by any hospital or medical benefits paid or
11        payable  under  or  provided  pursuant  to  any  State or
12        federal law or program.
13             (2)  The Plan shall have a cause of  action  against
14        any  covered person or any other person or entity for the
15        recovery of any amount paid to the extent the amount  was
16        for  treatment, services, or supplies not covered in this
17        Section or in excess of benefits as  set  forth  in  this
18        Section.
19             (3)  Whenever benefits are due from the Plan because
20        of  sickness  or  an injury to a covered person resulting
21        from a third party's wrongful act or negligence  and  the
22        covered  person has recovered or may recover damages from
23        a third party or its insurer, the  Plan  shall  have  the
24        right  to  reduce  benefits  or to refuse to pay benefits
25        that otherwise may be payable by the  amount  of  damages
26        that  the  covered  person  has  recovered or may recover
27        regardless of the date of the sickness or injury  or  the
28        date of any settlement, judgment, or award resulting from
29        that sickness or injury.
30             During  the  pendency of any action or claim that is
31        brought by or on behalf of a  covered  person  against  a
32        third  party  or  its  insurer,  any  benefits that would
33        otherwise be payable except for the  provisions  of  this
34        paragraph  (3)  shall  be  paid  if payment by or for the
 
                            -15-     LRB093 07142 JLS 07297 b
 1        third party has not yet been made and the covered  person
 2        or,  if  incapable,  that  person's  legal representative
 3        agrees in writing to pay back promptly the benefits  paid
 4        as  a  result  of the sickness or injury to the extent of
 5        any future payments made by or for the  third  party  for
 6        the  sickness  or  injury.   This  agreement  is to apply
 7        whether or not liability for the payments is  established
 8        or  admitted by the third party or whether those payments
 9        are itemized.
10             Any amounts due the plan to repay  benefits  may  be
11        deducted  from  other  benefits payable by the Plan after
12        payments by or for the third party are made.
13             (4)  Benefits due from the Plan may  be  reduced  or
14        refused   as  an  offset  against  any  amount  otherwise
15        recoverable under this Section.
16        h.  Right of subrogation; recoveries.
17             (1)  Whenever the Plan has paid benefits because  of
18        sickness  or  an  injury  to any covered person resulting
19        from a third party's wrongful act or negligence,  or  for
20        which  an  insurer  is  liable  in  accordance  with  the
21        provisions  of  any  policy of insurance, and the covered
22        person has recovered or may recover damages from a  third
23        party that is liable for the damages, the Plan shall have
24        the  right  to  recover  the  benefits  it  paid from any
25        amounts that the  covered  person  has  received  or  may
26        receive  regardless of the date of the sickness or injury
27        or  the  date  of  any  settlement,  judgment,  or  award
28        resulting from that sickness or injury.  The  Plan  shall
29        be subrogated to any right of recovery the covered person
30        may  have under the terms of any private or public health
31        care coverage or liability coverage,  including  coverage
32        under  the  Workers'  Compensation  Act  or  the Workers'
33        Occupational  Diseases  Act,  without  the  necessity  of
34        assignment of claim or other authorization to secure  the
 
                            -16-     LRB093 07142 JLS 07297 b
 1        right of recovery.  To enforce its subrogation right, the
 2        Plan may (i) intervene or join in an action or proceeding
 3        brought   by   the   covered   person   or  his  personal
 4        representative,  including  his  guardian,   conservator,
 5        estate, dependents, or survivors, against any third party
 6        or  the  third party's insurer that may be liable or (ii)
 7        institute and prosecute  legal  proceedings  against  any
 8        third  party  or  the  third  party's insurer that may be
 9        liable for the sickness or injury in an appropriate court
10        either in the name of the Plan or  in  the  name  of  the
11        covered  person or his personal representative, including
12        his  guardian,  conservator,   estate,   dependents,   or
13        survivors.
14             (2)  If  any  action  or  claim  is brought by or on
15        behalf of a covered person against a third party  or  the
16        third party's insurer, the covered person or his personal
17        representative,   including  his  guardian,  conservator,
18        estate, dependents, or survivors, shall notify  the  Plan
19        by  personal  service or registered mail of the action or
20        claim and of the name of the court in which the action or
21        claim is brought, filing proof thereof in the  action  or
22        claim.  The Plan may, at any time thereafter, join in the
23        action  or  claim  upon  its motion so that all orders of
24        court after hearing and judgment shall be  made  for  its
25        protection.   No  release  or  settlement  of a claim for
26        damages and no satisfaction of  judgment  in  the  action
27        shall be valid without the written consent of the Plan to
28        the  extent of its interest in the settlement or judgment
29        and of the covered person or his personal representative.
30             (3)  In the event that the  covered  person  or  his
31        personal  representative  fails to institute a proceeding
32        against any appropriate  third  party  before  the  fifth
33        month before the action would be barred, the Plan may, in
34        its  own  name  or  in  the name of the covered person or
 
                            -17-     LRB093 07142 JLS 07297 b
 1        personal representative, commence  a  proceeding  against
 2        any  appropriate  third party for the recovery of damages
 3        on account of any  sickness,  injury,  or  death  to  the
 4        covered  person.   The  covered person shall cooperate in
 5        doing what is reasonably necessary to assist the Plan  in
 6        any  recovery  and  shall  not take any action that would
 7        prejudice the Plan's right to recovery.  The  Plan  shall
 8        pay  to the covered person or his personal representative
 9        all sums collected from any third party  by  judgment  or
10        otherwise in excess of amounts paid in benefits under the
11        Plan  and  amounts paid or to be paid as costs, attorneys
12        fees, and reasonable expenses incurred  by  the  Plan  in
13        making the collection or enforcing the judgment.
14             (4)  In  the  event  that  a  covered  person or his
15        personal   representative,   including   his    guardian,
16        conservator,  estate,  dependents, or survivors, recovers
17        damages from a third party for sickness or injury  caused
18        to the covered person, the covered person or the personal
19        representative  shall  pay  to  the Plan from the damages
20        recovered the amount of benefits paid or to  be  paid  on
21        behalf of the covered person.
22             (5)  When  the  action  or  claim  is brought by the
23        covered person alone and  the  covered  person  incurs  a
24        personal  liability  to  pay attorney's fees and costs of
25        litigation, the Plan's claim  for  reimbursement  of  the
26        benefits provided to the covered person shall be the full
27        amount  of  benefits  paid to or on behalf of the covered
28        person  under  this  Act  less  a  pro  rata  share  that
29        represents the Plan's reasonable share of attorney's fees
30        paid by the covered person and that portion of  the  cost
31        of  litigation  expenses determined by multiplying by the
32        ratio of the full amount of the expenditures to the  full
33        amount of the judgement, award, or settlement.
34             (6)  In  the event of judgment or award in a suit or
 
                            -18-     LRB093 07142 JLS 07297 b
 1        claim against a third party or insurer, the  court  shall
 2        first   order  paid  from  any  judgement  or  award  the
 3        reasonable litigation expenses  incurred  in  preparation
 4        and  prosecution  of  the  action or claim, together with
 5        reasonable  attorney's  fees.   After  payment  of  those
 6        expenses and attorney's fees, the court shall  apply  out
 7        of  the  balance  of  the  judgment  or  award  an amount
 8        sufficient to reimburse  the  Plan  the  full  amount  of
 9        benefits  paid on behalf of the covered person under this
10        Act, provided the court  may  reduce  and  apportion  the
11        Plan's  portion  of  the  judgement  proportionate to the
12        recovery of the covered person.  The burden of  producing
13        evidence  sufficient to support the exercise by the court
14        of its discretion to reduce the amount of a proven charge
15        sought to be enforced against  the  recovery  shall  rest
16        with  the  party  seeking  the  reduction.  The court may
17        consider the nature and extent of  the  injury,  economic
18        and  non-economic  loss,  settlement  offers, comparative
19        negligence as it applies to the case  at  hand,  hospital
20        costs, physician costs, and all other appropriate costs.
21        The  Plan  shall  pay  its pro rata share of the attorney
22        fees based on the Plan's recovery as it compares  to  the
23        total  judgment.   Any  reimbursement  rights of the Plan
24        shall take priority over  all  other  liens  and  charges
25        existing  under the laws of this State with the exception
26        of any attorney liens filed under the Attorneys Lien Act.
27             (7)  The Plan may compromise or settle  and  release
28        any  claim  for benefits provided under this Act or waive
29        any claims for benefits, in whole or  in  part,  for  the
30        convenience  of  the  Plan or if the Plan determines that
31        collection  would  result  in  undue  hardship  upon  the
32        covered person.
33    (Source: P.A. 91-639,  eff.  8-20-99;  91-735,  eff.  6-2-00;
34    92-2, eff. 5-1-01; 92-630, eff. 7-11-02.)