Rep. Karen May

Filed: 1/12/2009

 

 


 

 


 
09500SB0243ham001 LRB095 04622 RPM 53985 a

1
AMENDMENT TO SENATE BILL 243

2     AMENDMENT NO. ______. Amend Senate Bill 243 by replacing
3 everything after the enacting clause with the following:
 
4     "Section 5. The Comprehensive Health Insurance Plan Act is
5 amended by changing Section 8 as follows:
 
6     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
7     Sec. 8. Minimum benefits.
8     a. Availability. The Plan shall offer in an annually
9 renewable policy major medical expense coverage to every
10 eligible person who is not eligible for Medicare. Major medical
11 expense coverage offered by the Plan shall pay an eligible
12 person's covered expenses, subject to limit on the deductible
13 and coinsurance payments authorized under paragraph (4) of
14 subsection d of this Section, up to a lifetime benefit limit of
15 $2,000,000 until 3 years after the effective date of this
16 amendatory Act of the 95th General Assembly, and $1,500,000 in

 

 

09500SB0243ham001 - 2 - LRB095 04622 RPM 53985 a

1 benefits 3 years or more after the effective date of this
2 amendatory Act of the 95th General Assembly per covered
3 individual. The maximum limit under this subsection shall not
4 be altered by the Board, and no actuarial equivalent benefit
5 may be substituted by the Board. Any person who otherwise would
6 qualify for coverage under the Plan, but is excluded because he
7 or she is eligible for Medicare, shall be eligible for any
8 separate Medicare supplement policy or policies which the Board
9 may offer.
10     b. Outline of benefits. Covered expenses shall be limited
11 to the usual and customary charge, including negotiated fees,
12 in the locality for the following services and articles when
13 prescribed by a physician and determined by the Plan to be
14 medically necessary for the following areas of services,
15 subject to such separate deductibles, co-payments, exclusions,
16 and other limitations on benefits as the Board shall establish
17 and approve, and the other provisions of this Section:
18         (1) Hospital services, except that any services
19     provided by a hospital that is located more than 75 miles
20     outside the State of Illinois shall be covered only for a
21     maximum of 45 days in any calendar year. With respect to
22     covered expenses incurred during any calendar year ending
23     on or after December 31, 1999, inpatient hospitalization of
24     an eligible person for the treatment of mental illness at a
25     hospital located within the State of Illinois shall be
26     subject to the same terms and conditions as for any other

 

 

09500SB0243ham001 - 3 - LRB095 04622 RPM 53985 a

1     illness.
2         (2) Professional services for the diagnosis or
3     treatment of injuries, illnesses or conditions, other than
4     dental and mental and nervous disorders as described in
5     paragraph (17), which are rendered by a physician, or by
6     other licensed professionals at the physician's direction.
7     This includes reconstruction of the breast on which a
8     mastectomy was performed; surgery and reconstruction of
9     the other breast to produce a symmetrical appearance; and
10     prostheses and treatment of physical complications at all
11     stages of the mastectomy, including lymphedemas.
12         (2.5) Professional services provided by a physician to
13     children under the age of 16 years for physical
14     examinations and age appropriate immunizations ordered by
15     a physician licensed to practice medicine in all its
16     branches.
17         (3) (Blank).
18         (4) Outpatient prescription drugs that by law require a
19     prescription written by a physician licensed to practice
20     medicine in all its branches subject to such separate
21     deductible, copayment, and other limitations or
22     restrictions as the Board shall approve, including the use
23     of a prescription drug card or any other program, or both.
24         (5) Skilled nursing services of a licensed skilled
25     nursing facility for not more than 120 days during a policy
26     year.

 

 

09500SB0243ham001 - 4 - LRB095 04622 RPM 53985 a

1         (6) Services of a home health agency in accord with a
2     home health care plan, up to a maximum of 270 visits per
3     year.
4         (7) Services of a licensed hospice for not more than
5     180 days during a policy year.
6         (8) Use of radium or other radioactive materials.
7         (9) Oxygen.
8         (10) Anesthetics.
9         (11) Orthoses and prostheses other than dental.
10         (12) Rental or purchase in accordance with Board
11     policies or procedures of durable medical equipment, other
12     than eyeglasses or hearing aids, for which there is no
13     personal use in the absence of the condition for which it
14     is prescribed.
15         (13) Diagnostic x-rays and laboratory tests.
16         (14) Oral surgery (i) for excision of partially or
17     completely unerupted impacted teeth when not performed in
18     connection with the routine extraction or repair of teeth;
19     (ii) for excision of tumors or cysts of the jaws, cheeks,
20     lips, tongue, and roof and floor of the mouth; (iii)
21     required for correction of cleft lip and palate and other
22     craniofacial and maxillofacial birth defects; or (iv) for
23     treatment of injuries to natural teeth or a fractured jaw
24     due to an accident.
25         (15) Physical, speech, and functional occupational
26     therapy as medically necessary and provided by appropriate

 

 

09500SB0243ham001 - 5 - LRB095 04622 RPM 53985 a

1     licensed professionals.
2         (16) Emergency and other medically necessary
3     transportation provided by a licensed ambulance service to
4     the nearest health care facility qualified to treat a
5     covered illness, injury, or condition, subject to the
6     provisions of the Emergency Medical Systems (EMS) Act.
7         (17) Outpatient services for diagnosis and treatment
8     of mental and nervous disorders provided that a covered
9     person shall be required to make a copayment not to exceed
10     50% and that the Plan's payment shall not exceed such
11     amounts as are established by the Board.
12         (18) Human organ or tissue transplants specified by the
13     Board that are performed at a hospital designated by the
14     Board as a participating transplant center for that
15     specific organ or tissue transplant.
16         (19) Naprapathic services, as appropriate, provided by
17     a licensed naprapathic practitioner.
18         (20) Coverage for benefits as required under Sections
19     356g, 356u, 356x, and 356z.4 of the Illinois Insurance
20     Code.
21     Rulemaking authority to implement this amendatory Act of
22 the 95th General Assembly, if any, is conditioned on the rules
23 being adopted in accordance with all provisions of the Illinois
24 Administrative Procedure Act and all rules and procedures of
25 the Joint Committee on Administrative Rules; any purported rule
26 not so adopted, for whatever reason, is unauthorized.

 

 

09500SB0243ham001 - 6 - LRB095 04622 RPM 53985 a

1     c. Exclusions. Covered expenses of the Plan shall not
2 include the following:
3         (1) Any charge for treatment for cosmetic purposes
4     other than for reconstructive surgery when the service is
5     incidental to or follows surgery resulting from injury,
6     sickness or other diseases of the involved part or surgery
7     for the repair or treatment of a congenital bodily defect
8     to restore normal bodily functions.
9         (2) Any charge for care that is primarily for rest,
10     custodial, educational, or domiciliary purposes.
11         (3) Any charge for services in a private room to the
12     extent it is in excess of the institution's charge for its
13     most common semiprivate room, unless a private room is
14     prescribed as medically necessary by a physician.
15         (4) That part of any charge for room and board or for
16     services rendered or articles prescribed by a physician,
17     dentist, or other health care personnel that exceeds the
18     reasonable and customary charge in the locality or for any
19     services or supplies not medically necessary for the
20     diagnosed injury or illness.
21         (5) Any charge for services or articles the provision
22     of which is not within the scope of licensure of the
23     institution or individual providing the services or
24     articles.
25         (6) Any expense incurred prior to the effective date of
26     coverage by the Plan for the person on whose behalf the

 

 

09500SB0243ham001 - 7 - LRB095 04622 RPM 53985 a

1     expense is incurred.
2         (7) Dental care, dental surgery, dental treatment, any
3     other dental procedure involving the teeth or
4     periodontium, or any dental appliances, including crowns,
5     bridges, implants, or partial or complete dentures, except
6     as specifically provided in paragraph (14) of subsection b
7     of this Section.
8         (8) Eyeglasses, contact lenses, hearing aids or their
9     fitting.
10         (9) Illness or injury due to acts of war.
11         (10) Services of blood donors and any fee for failure
12     to replace the first 3 pints of blood provided to a covered
13     person each policy year.
14         (11) Personal supplies or services provided by a
15     hospital or nursing home, or any other nonmedical or
16     nonprescribed supply or service.
17         (12) Routine maternity charges for a pregnancy, except
18     where added as optional coverage with payment of an
19     additional premium for pregnancy resulting from conception
20     occurring after the effective date of the optional
21     coverage.
22         (13) (Blank).
23         (14) Any expense or charge for services, drugs, or
24     supplies that are: (i) not provided in accord with
25     generally accepted standards of current medical practice;
26     (ii) for procedures, treatments, equipment, transplants,

 

 

09500SB0243ham001 - 8 - LRB095 04622 RPM 53985 a

1     or implants, any of which are investigational,
2     experimental, or for research purposes; (iii)
3     investigative and not proven safe and effective; or (iv)
4     for, or resulting from, a gender transformation operation.
5         (15) Any expense or charge for routine physical
6     examinations or tests except as provided in items item
7     (2.5) and (20) of subsection b of this Section.
8         (16) Any expense for which a charge is not made in the
9     absence of insurance or for which there is no legal
10     obligation on the part of the patient to pay.
11         (17) Any expense incurred for benefits provided under
12     the laws of the United States and this State, including
13     Medicare, Medicaid, and other medical assistance, maternal
14     and child health services and any other program that is
15     administered or funded by the Department of Human Services,
16     Department of Healthcare and Family Services, or
17     Department of Public Health, military service-connected
18     disability payments, medical services provided for members
19     of the armed forces and their dependents or employees of
20     the armed forces of the United States, and medical services
21     financed on behalf of all citizens by the United States.
22         (18) Any expense or charge for in vitro fertilization,
23     artificial insemination, or any other artificial means
24     used to cause pregnancy.
25         (19) (Blank). Any expense or charge for oral
26     contraceptives used for birth control or any other

 

 

09500SB0243ham001 - 9 - LRB095 04622 RPM 53985 a

1     temporary birth control measures.
2         (20) Any expense or charge for sterilization or
3     sterilization reversals.
4         (21) Any expense or charge for weight loss programs,
5     exercise equipment, or treatment of obesity, except when
6     certified by a physician as morbid obesity (at least 2
7     times normal body weight).
8         (22) Any expense or charge for acupuncture treatment
9     unless used as an anesthetic agent for a covered surgery.
10         (23) Any expense or charge for or related to organ or
11     tissue transplants other than those performed at a hospital
12     with a Board approved organ transplant program that has
13     been designated by the Board as a preferred or exclusive
14     provider organization for that specific organ or tissue
15     transplant.
16         (24) Any expense or charge for procedures, treatments,
17     equipment, or services that are provided in special
18     settings for research purposes or in a controlled
19     environment, are being studied for safety, efficiency, and
20     effectiveness, and are awaiting endorsement by the
21     appropriate national medical speciality college for
22     general use within the medical community.
23     d. Deductibles and coinsurance.
24     The Plan coverage defined in Section 6 shall provide for a
25 choice of deductibles per individual as authorized by the
26 Board. If 2 individual members of the same family household,

 

 

09500SB0243ham001 - 10 - LRB095 04622 RPM 53985 a

1 who are both covered persons under the Plan, satisfy the same
2 applicable deductibles, no other member of that family who is
3 also a covered person under the Plan shall be required to meet
4 any deductibles for the balance of that calendar year. The
5 deductibles must be applied first to the authorized amount of
6 covered expenses incurred by the covered person. A mandatory
7 coinsurance requirement shall be imposed at the rate authorized
8 by the Board in excess of the mandatory deductible, the
9 coinsurance in the aggregate not to exceed such amounts as are
10 authorized by the Board per annum. At its discretion the Board
11 may, however, offer catastrophic coverages or other policies
12 that provide for larger deductibles with or without coinsurance
13 requirements. The deductibles and coinsurance factors may be
14 adjusted annually according to the Medical Component of the
15 Consumer Price Index.
16     e. Scope of coverage.
17         (1) In approving any of the benefit plans to be offered
18     by the Plan, the Board shall establish such benefit levels,
19     deductibles, coinsurance factors, exclusions, and
20     limitations as it may deem appropriate and that it believes
21     to be generally reflective of and commensurate with health
22     insurance coverage that is provided in the individual
23     market in this State.
24         (2) The benefit plans approved by the Board may also
25     provide for and employ various cost containment measures
26     and other requirements including, but not limited to,

 

 

09500SB0243ham001 - 11 - LRB095 04622 RPM 53985 a

1     preadmission certification, prior approval, second
2     surgical opinions, concurrent utilization review programs,
3     individual case management, preferred provider
4     organizations, health maintenance organizations, and other
5     cost effective arrangements for paying for covered
6     expenses.
7     f. Preexisting conditions.
8         (1) Except for federally eligible individuals
9     qualifying for Plan coverage under Section 15 of this Act
10     or eligible persons who qualify for the waiver authorized
11     in paragraph (3) of this subsection, plan coverage shall
12     exclude charges or expenses incurred during the first 6
13     months following the effective date of coverage as to any
14     condition for which medical advice, care or treatment was
15     recommended or received during the 6 month period
16     immediately preceding the effective date of coverage.
17         (2) (Blank).
18         (3) Waiver: The preexisting condition exclusions as
19     set forth in paragraph (1) of this subsection shall be
20     waived to the extent to which the eligible person (a) has
21     satisfied similar exclusions under any prior individual
22     health insurance policy that was involuntarily terminated
23     because of the insolvency of the issuer of the policy and
24     (b) has applied for Plan coverage within 90 days following
25     the involuntary termination of that individual health
26     insurance coverage.

 

 

09500SB0243ham001 - 12 - LRB095 04622 RPM 53985 a

1     g. Other sources primary; nonduplication of benefits.
2         (1) The Plan shall be the last payor of benefits
3     whenever any other benefit or source of third party payment
4     is available. Subject to the provisions of subsection e of
5     Section 7, benefits otherwise payable under Plan coverage
6     shall be reduced by all amounts paid or payable by Medicare
7     or any other government program or through any health
8     insurance coverage or group health plan, whether by
9     insurance, reimbursement, or otherwise, or through any
10     third party liability, settlement, judgment, or award,
11     regardless of the date of the settlement, judgment, or
12     award, whether the settlement, judgment, or award is in the
13     form of a contract, agreement, or trust on behalf of a
14     minor or otherwise and whether the settlement, judgment, or
15     award is payable to the covered person, his or her
16     dependent, estate, personal representative, or guardian in
17     a lump sum or over time, and by all hospital or medical
18     expense benefits paid or payable under any worker's
19     compensation coverage, automobile medical payment, or
20     liability insurance, whether provided on the basis of fault
21     or nonfault, and by any hospital or medical benefits paid
22     or payable under or provided pursuant to any State or
23     federal law or program.
24         (2) The Plan shall have a cause of action against any
25     covered person or any other person or entity for the
26     recovery of any amount paid to the extent the amount was

 

 

09500SB0243ham001 - 13 - LRB095 04622 RPM 53985 a

1     for treatment, services, or supplies not covered in this
2     Section or in excess of benefits as set forth in this
3     Section.
4         (3) Whenever benefits are due from the Plan because of
5     sickness or an injury to a covered person resulting from a
6     third party's wrongful act or negligence and the covered
7     person has recovered or may recover damages from a third
8     party or its insurer, the Plan shall have the right to
9     reduce benefits or to refuse to pay benefits that otherwise
10     may be payable by the amount of damages that the covered
11     person has recovered or may recover regardless of the date
12     of the sickness or injury or the date of any settlement,
13     judgment, or award resulting from that sickness or injury.
14         During the pendency of any action or claim that is
15     brought by or on behalf of a covered person against a third
16     party or its insurer, any benefits that would otherwise be
17     payable except for the provisions of this paragraph (3)
18     shall be paid if payment by or for the third party has not
19     yet been made and the covered person or, if incapable, that
20     person's legal representative agrees in writing to pay back
21     promptly the benefits paid as a result of the sickness or
22     injury to the extent of any future payments made by or for
23     the third party for the sickness or injury. This agreement
24     is to apply whether or not liability for the payments is
25     established or admitted by the third party or whether those
26     payments are itemized.

 

 

09500SB0243ham001 - 14 - LRB095 04622 RPM 53985 a

1         Any amounts due the plan to repay benefits may be
2     deducted from other benefits payable by the Plan after
3     payments by or for the third party are made.
4         (4) Benefits due from the Plan may be reduced or
5     refused as an offset against any amount otherwise
6     recoverable under this Section.
7     h. Right of subrogation; recoveries.
8         (1) Whenever the Plan has paid benefits because of
9     sickness or an injury to any covered person resulting from
10     a third party's wrongful act or negligence, or for which an
11     insurer is liable in accordance with the provisions of any
12     policy of insurance, and the covered person has recovered
13     or may recover damages from a third party that is liable
14     for the damages, the Plan shall have the right to recover
15     the benefits it paid from any amounts that the covered
16     person has received or may receive regardless of the date
17     of the sickness or injury or the date of any settlement,
18     judgment, or award resulting from that sickness or injury.
19     The Plan shall be subrogated to any right of recovery the
20     covered person may have under the terms of any private or
21     public health care coverage or liability coverage,
22     including coverage under the Workers' Compensation Act or
23     the Workers' Occupational Diseases Act, without the
24     necessity of assignment of claim or other authorization to
25     secure the right of recovery. To enforce its subrogation
26     right, the Plan may (i) intervene or join in an action or

 

 

09500SB0243ham001 - 15 - LRB095 04622 RPM 53985 a

1     proceeding brought by the covered person or his personal
2     representative, including his guardian, conservator,
3     estate, dependents, or survivors, against any third party
4     or the third party's insurer that may be liable or (ii)
5     institute and prosecute legal proceedings against any
6     third party or the third party's insurer that may be liable
7     for the sickness or injury in an appropriate court either
8     in the name of the Plan or in the name of the covered
9     person or his personal representative, including his
10     guardian, conservator, estate, dependents, or survivors.
11         (2) If any action or claim is brought by or on behalf
12     of a covered person against a third party or the third
13     party's insurer, the covered person or his personal
14     representative, including his guardian, conservator,
15     estate, dependents, or survivors, shall notify the Plan by
16     personal service or registered mail of the action or claim
17     and of the name of the court in which the action or claim
18     is brought, filing proof thereof in the action or claim.
19     The Plan may, at any time thereafter, join in the action or
20     claim upon its motion so that all orders of court after
21     hearing and judgment shall be made for its protection. No
22     release or settlement of a claim for damages and no
23     satisfaction of judgment in the action shall be valid
24     without the written consent of the Plan to the extent of
25     its interest in the settlement or judgment and of the
26     covered person or his personal representative.

 

 

09500SB0243ham001 - 16 - LRB095 04622 RPM 53985 a

1         (3) In the event that the covered person or his
2     personal representative fails to institute a proceeding
3     against any appropriate third party before the fifth month
4     before the action would be barred, the Plan may, in its own
5     name or in the name of the covered person or personal
6     representative, commence a proceeding against any
7     appropriate third party for the recovery of damages on
8     account of any sickness, injury, or death to the covered
9     person. The covered person shall cooperate in doing what is
10     reasonably necessary to assist the Plan in any recovery and
11     shall not take any action that would prejudice the Plan's
12     right to recovery. The Plan shall pay to the covered person
13     or his personal representative all sums collected from any
14     third party by judgment or otherwise in excess of amounts
15     paid in benefits under the Plan and amounts paid or to be
16     paid as costs, attorneys fees, and reasonable expenses
17     incurred by the Plan in making the collection or enforcing
18     the judgment.
19         (4) In the event that a covered person or his personal
20     representative, including his guardian, conservator,
21     estate, dependents, or survivors, recovers damages from a
22     third party for sickness or injury caused to the covered
23     person, the covered person or the personal representative
24     shall pay to the Plan from the damages recovered the amount
25     of benefits paid or to be paid on behalf of the covered
26     person.

 

 

09500SB0243ham001 - 17 - LRB095 04622 RPM 53985 a

1         (5) When the action or claim is brought by the covered
2     person alone and the covered person incurs a personal
3     liability to pay attorney's fees and costs of litigation,
4     the Plan's claim for reimbursement of the benefits provided
5     to the covered person shall be the full amount of benefits
6     paid to or on behalf of the covered person under this Act
7     less a pro rata share that represents the Plan's reasonable
8     share of attorney's fees paid by the covered person and
9     that portion of the cost of litigation expenses determined
10     by multiplying by the ratio of the full amount of the
11     expenditures to the full amount of the judgement, award, or
12     settlement.
13         (6) In the event of judgment or award in a suit or
14     claim against a third party or insurer, the court shall
15     first order paid from any judgement or award the reasonable
16     litigation expenses incurred in preparation and
17     prosecution of the action or claim, together with
18     reasonable attorney's fees. After payment of those
19     expenses and attorney's fees, the court shall apply out of
20     the balance of the judgment or award an amount sufficient
21     to reimburse the Plan the full amount of benefits paid on
22     behalf of the covered person under this Act, provided the
23     court may reduce and apportion the Plan's portion of the
24     judgement proportionate to the recovery of the covered
25     person. The burden of producing evidence sufficient to
26     support the exercise by the court of its discretion to

 

 

09500SB0243ham001 - 18 - LRB095 04622 RPM 53985 a

1     reduce the amount of a proven charge sought to be enforced
2     against the recovery shall rest with the party seeking the
3     reduction. The court may consider the nature and extent of
4     the injury, economic and non-economic loss, settlement
5     offers, comparative negligence as it applies to the case at
6     hand, hospital costs, physician costs, and all other
7     appropriate costs. The Plan shall pay its pro rata share of
8     the attorney fees based on the Plan's recovery as it
9     compares to the total judgment. Any reimbursement rights of
10     the Plan shall take priority over all other liens and
11     charges existing under the laws of this State with the
12     exception of any attorney liens filed under the Attorneys
13     Lien Act.
14         (7) The Plan may compromise or settle and release any
15     claim for benefits provided under this Act or waive any
16     claims for benefits, in whole or in part, for the
17     convenience of the Plan or if the Plan determines that
18     collection would result in undue hardship upon the covered
19     person.
20 (Source: P.A. 94-737, eff. 5-3-06; 95-547, eff. 8-29-07.)".