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1     AN ACT concerning 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 is
5 amended by changing Sections 4, 7, and 15 as follows:
 
6     (215 ILCS 105/4)  (from Ch. 73, par. 1304)
7     Sec. 4. Powers and authority of the board. The board shall
8 have the general powers and authority granted under the laws of
9 this State to insurance companies licensed to transact health
10 and accident insurance and in addition thereto, the specific
11 authority to:
12     a. Enter into contracts as are necessary or proper to carry
13 out the provisions and purposes of this Act, including the
14 authority, with the approval of the Director, to enter into
15 contracts with similar plans of other states for the joint
16 performance of common administrative functions, or with
17 persons or other organizations for the performance of
18 administrative functions including, without limitation,
19 utilization review and quality assurance programs, or with
20 health maintenance organizations or preferred provider
21 organizations for the provision of health care services.
22     b. Sue or be sued, including taking any legal actions
23 necessary or proper.
24     c. Take such legal action as necessary to:
25         (1) avoid the payment of improper claims against the
26     plan or the coverage provided by or through the plan;
27         (2) to recover any amounts erroneously or improperly
28     paid by the plan;
29         (3) to recover any amounts paid by the plan as a result
30     of a mistake of fact or law; or
31         (4) to recover or collect any other amounts, including
32     assessments, that are due or owed the Plan or have been

 

 

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1     billed on its or the Plan's behalf.
2     d. Establish appropriate rates, rate schedules, rate
3 adjustments, expense allowances, agents' referral fees, claim
4 reserves, and formulas and any other actuarial function
5 appropriate to the operation of the plan. Rates and rate
6 schedules may be adjusted for appropriate risk factors such as
7 age and area variation in claim costs and shall take into
8 consideration appropriate risk factors in accordance with
9 established actuarial and underwriting practices.
10     e. Issue policies of insurance in accordance with the
11 requirements of this Act.
12     f. Appoint appropriate legal, actuarial and other
13 committees as necessary to provide technical assistance in the
14 operation of the plan, policy and other contract design, and
15 any other function within the authority of the plan.
16     g. Borrow money to effect the purposes of the Illinois
17 Comprehensive Health Insurance Plan. Any notes or other
18 evidence of indebtedness of the plan not in default shall be
19 legal investments for insurers and may be carried as admitted
20 assets.
21     h. Establish rules, conditions and procedures for
22 reinsuring risks under this Act.
23     i. Employ and fix the compensation of employees. Such
24 employees may be paid on a warrant issued by the State
25 Treasurer pursuant to a payroll voucher certified by the Board
26 and drawn by the Comptroller against appropriations or trust
27 funds held by the State Treasurer.
28     j. Enter into intergovernmental cooperation agreements
29 with other agencies or entities of State government for the
30 purpose of sharing the cost of providing health care services
31 that are otherwise authorized by this Act for children who are
32 both plan participants and eligible for financial assistance
33 from the Division of Specialized Care for Children of the
34 University of Illinois.
35     k. Establish conditions and procedures under which the plan
36 may, if funds permit, discount or subsidize premium rates that

 

 

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1 are paid directly by senior citizens, as defined by the Board,
2 by unemployed or retired coal miners who are federally eligible
3 and whose employer-provided health insurance coverage was
4 terminated on September 28, 2004, and by other plan
5 participants, who are retired or unemployed and meet other
6 qualifications.
7     l. Establish and maintain the Plan Fund authorized in
8 Section 3 of this Act, which shall be divided into separate
9 accounts, as follows:
10         (1) accounts to fund the administrative, claim, and
11     other expenses of the Plan associated with eligible persons
12     who qualify for Plan coverage under Section 7 of this Act,
13     which shall consist of:
14             (A) premiums paid on behalf of covered persons;
15             (B) appropriated funds and other revenues
16         collected or received by the Board;
17             (C) reserves for future losses maintained by the
18         Board; and
19             (D) interest earnings from investment of the funds
20         in the Plan Fund or any of its accounts other than the
21         funds in the account established under item 2 of this
22         subsection;
23         (2) an account, to be denominated the federally
24     eligible individuals account, to fund the administrative,
25     claim, and other expenses of the Plan associated with
26     federally eligible individuals who qualify for Plan
27     coverage under Section 15 of this Act, which shall consist
28     of:
29             (A) premiums paid on behalf of covered persons;
30             (B) assessments and other revenues collected or
31         received by the Board;
32             (C) reserves for future losses maintained by the
33         Board; and
34             (D) interest earnings from investment of the
35         federally eligible individuals account funds; and
36             (E) grants provided pursuant to the federal Trade

 

 

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1         Act of 2002; and
2         (3) such other accounts as may be appropriate.
3     m. Charge and collect assessments paid by insurers pursuant
4 to Section 12 of this Act and recover any assessments for, on
5 behalf of, or against those insurers.
6     n. Accept funds appropriated by law for the sole purpose
7 of, in accordance with subsection k of this Section,
8 discounting or subsidizing premium rates paid directly by
9 unemployed or retired coal miners who are federally eligible
10 individuals and whose employer-provided health insurance
11 coverage was terminated on September 28, 2004.
12 (Source: P.A. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03.)
 
13     (215 ILCS 105/7)  (from Ch. 73, par. 1307)
14     Sec. 7. Eligibility.
15     a. Except as provided in subsection (e) of this Section or
16 in Section 15 of this Act, any person who is either a citizen
17 of the United States or an alien lawfully admitted for
18 permanent residence and who has been for a period of at least
19 180 days and continues to be a resident of this State shall be
20 eligible for Plan coverage under this Section if evidence is
21 provided of:
22         (1) A notice of rejection or refusal to issue
23     substantially similar individual health insurance coverage
24     for health reasons by a health insurance issuer; or
25         (2) A refusal by a health insurance issuer to issue
26     individual health insurance coverage except at a rate
27     exceeding the applicable Plan rate for which the person is
28     responsible.
29     A rejection or refusal by a group health plan or health
30 insurance issuer offering only stop-loss or excess of loss
31 insurance or contracts, agreements, or other arrangements for
32 reinsurance coverage with respect to the applicant shall not be
33 sufficient evidence under this subsection.
34     b. The board shall promulgate a list of medical or health
35 conditions for which a person who is either a citizen of the

 

 

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1 United States or an alien lawfully admitted for permanent
2 residence and a resident of this State would be eligible for
3 Plan coverage without applying for health insurance coverage
4 pursuant to subsection a. of this Section. Persons who can
5 demonstrate the existence or history of any medical or health
6 conditions on the list promulgated by the board shall not be
7 required to provide the evidence specified in subsection a. of
8 this Section. The list shall be effective on the first day of
9 the operation of the Plan and may be amended from time to time
10 as appropriate.
11     c. Family members of the same household who each are
12 covered persons are eligible for optional family coverage under
13 the Plan.
14     d. For persons qualifying for coverage in accordance with
15 Section 7 of this Act, the board shall, if it determines that
16 such appropriations as are made pursuant to Section 12 of this
17 Act are insufficient to allow the board to accept all of the
18 eligible persons which it projects will apply for enrollment
19 under the Plan, limit or close enrollment to ensure that the
20 Plan is not over-subscribed and that it has sufficient
21 resources to meet its obligations to existing enrollees. The
22 board shall not limit or close enrollment for federally
23 eligible individuals.
24     e. A person shall not be eligible for coverage under the
25 Plan if:
26         (1) He or she has or obtains other coverage under a
27     group health plan or health insurance coverage
28     substantially similar to or better than a Plan policy as an
29     insured or covered dependent or would be eligible to have
30     that coverage if he or she elected to obtain it. Persons
31     otherwise eligible for Plan coverage may, however, solely
32     for the purpose of having coverage for a pre-existing
33     condition, maintain other coverage only while satisfying
34     any pre-existing condition waiting period under a Plan
35     policy or a subsequent replacement policy of a Plan policy.
36         (1.1) His or her prior coverage under a group health

 

 

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1     plan or health insurance coverage, provided or arranged by
2     an employer of more than 10 employees was discontinued for
3     any reason without the entire group or plan being
4     discontinued and not replaced, provided he or she remains
5     an employee, or dependent thereof, of the same employer.
6         (2) He or she is a recipient of or is approved to
7     receive medical assistance, except that a person may
8     continue to receive medical assistance through the medical
9     assistance no grant program, but only while satisfying the
10     requirements for a preexisting condition under Section 8,
11     subsection f. of this Act. Payment of premiums pursuant to
12     this Act shall be allocable to the person's spenddown for
13     purposes of the medical assistance no grant program, but
14     that person shall not be eligible for any Plan benefits
15     while that person remains eligible for medical assistance.
16     If the person continues to receive or be approved to
17     receive medical assistance through the medical assistance
18     no grant program at or after the time that requirements for
19     a preexisting condition are satisfied, the person shall not
20     be eligible for coverage under the Plan. In that
21     circumstance, coverage under the plan shall terminate as of
22     the expiration of the preexisting condition limitation
23     period. Under all other circumstances, coverage under the
24     Plan shall automatically terminate as of the effective date
25     of any medical assistance.
26         (3) Except as provided in Section 15, the person has
27     previously participated in the Plan and voluntarily
28     terminated Plan coverage, unless 12 months have elapsed
29     since the person's latest voluntary termination of
30     coverage.
31         (4) The person fails to pay the required premium under
32     the covered person's terms of enrollment and
33     participation, in which event the liability of the Plan
34     shall be limited to benefits incurred under the Plan for
35     the time period for which premiums had been paid and the
36     covered person remained eligible for Plan coverage.

 

 

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1         (5) The Plan has paid a total of $1,000,000 in benefits
2     on behalf of the covered person.
3         (6) The person is a resident of a public institution.
4         (7) The person's premium is paid for or reimbursed
5     under any government sponsored program or by any government
6     agency or health care provider, except as an otherwise
7     qualifying full-time employee, or dependent of such
8     employee, of a government agency or health care provider,
9     or, except when a person's premium is paid by the U.S.
10     Treasury Department pursuant to the federal Trade Act of
11     2002, or except when the premium rate of an unemployed or
12     retired coal miner who is a federally eligible individual
13     whose employer-provided health insurance coverage was
14     terminated on September 28, 2004 is discounted or
15     subsidized with funds appropriated by law.
16         (8) The person has or later receives other benefits or
17     funds from any settlement, judgement, or award resulting
18     from any accident or injury, regardless of the date of the
19     accident or injury, or any other circumstances creating a
20     legal liability for damages due that person by a third
21     party, whether the settlement, judgment, or award is in the
22     form of a contract, agreement, or trust on behalf of a
23     minor or otherwise and whether the settlement, judgment, or
24     award is payable to the person, his or her dependent,
25     estate, personal representative, or guardian in a lump sum
26     or over time, so long as there continues to be benefits or
27     assets remaining from those sources in an amount in excess
28     of $100,000.
29         (9) Within the 5 years prior to the date a person's
30     Plan application is received by the Board, the person's
31     coverage under any health care benefit program as defined
32     in 18 U.S.C. 24, including any public or private plan or
33     contract under which any medical benefit, item, or service
34     is provided, was terminated as a result of any act or
35     practice that constitutes fraud under State or federal law
36     or as a result of an intentional misrepresentation of

 

 

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1     material fact; or if that person knowingly and willfully
2     obtained or attempted to obtain, or fraudulently aided or
3     attempted to aid any other person in obtaining, any
4     coverage or benefits under the Plan to which that person
5     was not entitled.
6     f. The board or the administrator shall require
7 verification of residency and may require any additional
8 information or documentation, or statements under oath, when
9 necessary to determine residency upon initial application and
10 for the entire term of the policy.
11     g. Coverage shall cease (i) on the date a person is no
12 longer a resident of Illinois, (ii) on the date a person
13 requests coverage to end, (iii) upon the death of the covered
14 person, (iv) on the date State law requires cancellation of the
15 policy, or (v) at the Plan's option, 30 days after the Plan
16 makes any inquiry concerning a person's eligibility or place of
17 residence to which the person does not reply.
18     h. Except under the conditions set forth in subsection g of
19 this Section, the coverage of any person who ceases to meet the
20 eligibility requirements of this Section shall be terminated at
21 the end of the current policy period for which the necessary
22 premiums have been paid.
23 (Source: P.A. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03.)
 
24     (215 ILCS 105/15)
25     Sec. 15. Alternative portable coverage for federally
26 eligible individuals.
27     (a) Notwithstanding the requirements of subsection a. of
28 Section 7 and except as otherwise provided in this Section, any
29 federally eligible individual for whom a Plan application, and
30 such enclosures and supporting documentation as the Board may
31 require, is received by the Board within 90 days after the
32 termination of prior creditable coverage shall qualify to
33 enroll in the Plan under the portability provisions of this
34 Section.
35     A federally eligible person who has been certified as

 

 

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1 eligible pursuant to the federal Trade Act of 2002 and whose
2 Plan application and enclosures and supporting documentation
3 as the Board may require is received by the Board within 63
4 days after the termination of previous creditable coverage
5 shall qualify to enroll in the Plan under the portability
6 provisions of this Section.
7     (b) Any federally eligible individual seeking Plan
8 coverage under this Section must submit with his or her
9 application evidence, including acceptable written
10 certification of previous creditable coverage, that will
11 establish to the Board's satisfaction, that he or she meets all
12 of the requirements to be a federally eligible individual and
13 is currently and permanently residing in this State (as of the
14 date his or her application was received by the Board).
15     (c) Except as otherwise provided in this Section, a period
16 of creditable coverage shall not be counted, with respect to
17 qualifying an applicant for Plan coverage as a federally
18 eligible individual under this Section, if after such period
19 and before the application for Plan coverage was received by
20 the Board, there was at least a 90 day period during all of
21 which the individual was not covered under any creditable
22 coverage.
23     For a federally eligible person who has been certified as
24 eligible pursuant to the federal Trade Act of 2002, a period of
25 creditable coverage shall not be counted, with respect to
26 qualifying an applicant for Plan coverage as a federally
27 eligible individual under this Section, if after such period
28 and before the application for Plan coverage was received by
29 the Board, there was at least a 63 day period during all of
30 which the individual was not covered under any creditable
31 coverage.
32     (d) Any federally eligible individual who the Board
33 determines qualifies for Plan coverage under this Section shall
34 be offered his or her choice of enrolling in one of alternative
35 portability health benefit plans which the Board is authorized
36 under this Section to establish for these federally eligible

 

 

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1 individuals and their dependents.
2     (e) The Board shall offer a choice of health care coverages
3 consistent with major medical coverage under the alternative
4 health benefit plans authorized by this Section to every
5 federally eligible individual. The coverages to be offered
6 under the plans, the schedule of benefits, deductibles,
7 co-payments, exclusions, and other limitations shall be
8 approved by the Board. One optional form of coverage shall be
9 comparable to comprehensive health insurance coverage offered
10 in the individual market in this State or a standard option of
11 coverage available under the group or individual health
12 insurance laws of the State. The standard benefit plan that is
13 authorized by Section 8 of this Act may be used for this
14 purpose. The Board may also offer a preferred provider option
15 and such other options as the Board determines may be
16 appropriate for these federally eligible individuals who
17 qualify for Plan coverage pursuant to this Section.
18     (f) Notwithstanding the requirements of subsection f. of
19 Section 8, any plan coverage that is issued to federally
20 eligible individuals who qualify for the Plan pursuant to the
21 portability provisions of this Section shall not be subject to
22 any preexisting conditions exclusion, waiting period, or other
23 similar limitation on coverage.
24     (g) Federally eligible individuals who qualify and enroll
25 in the Plan pursuant to this Section shall be required to pay
26 such premium rates as the Board shall establish and approve in
27 accordance with the requirements of Section 7.1 of this Act.
28 Federally eligible individuals who qualify and enroll in the
29 Plan and are unemployed or retired coal miners whose
30 employer-provided health insurance coverage was terminated on
31 September 28, 2004 shall be required to pay the discounted or
32 subsidized premium rates that the Board has established and
33 approved in accordance with subsection k of Section 4 of this
34 Act.
35     (h) A federally eligible individual who qualifies and
36 enrolls in the Plan pursuant to this Section must satisfy on an

 

 

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1 ongoing basis all of the other eligibility requirements of this
2 Act to the extent not inconsistent with the federal Health
3 Insurance Portability and Accountability Act of 1996 in order
4 to maintain continued eligibility for coverage under the Plan.
5 (Source: P.A. 92-153, eff. 7-25-01; 93-33, eff. 6-23-03; 93-34,
6 eff. 6-23-03; 93-622, eff. 12-18-03.)
 
7     Section 99. Effective date. This Act takes effect upon
8 becoming law.