SB1893 Engrossed LRB095 14451 KBJ 40356 b

1     AN ACT concerning regulation.
 
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 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
17 benefits 3 years or more after the effective date of this
18 amendatory Act of the 95th General Assembly per covered
19 individual. The maximum limit under this subsection shall not
20 be altered by the Board, and no actuarial equivalent benefit
21 may be substituted by the Board. Any person who otherwise would
22 qualify for coverage under the Plan, but is excluded because he
23 or she is eligible for Medicare, shall be eligible for any

 

 

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1 separate Medicare supplement policy or policies which the Board
2 may offer.
3     b. Outline of benefits. Covered expenses shall be limited
4 to the usual and customary charge, including negotiated fees,
5 in the locality for the following services and articles when
6 prescribed by a physician and determined by the Plan to be
7 medically necessary for the following areas of services,
8 subject to such separate deductibles, co-payments, exclusions,
9 and other limitations on benefits as the Board shall establish
10 and approve, and the other provisions of this Section:
11         (1) Hospital services, except that any services
12     provided by a hospital that is located more than 75 miles
13     outside the State of Illinois shall be covered only for a
14     maximum of 45 days in any calendar year. With respect to
15     covered expenses incurred during any calendar year ending
16     on or after December 31, 1999, inpatient hospitalization of
17     an eligible person for the treatment of mental illness at a
18     hospital located within the State of Illinois shall be
19     subject to the same terms and conditions as for any other
20     illness.
21         (2) Professional services for the diagnosis or
22     treatment of injuries, illnesses or conditions, other than
23     dental and mental and nervous disorders as described in
24     paragraph (17), which are rendered by a physician, or by
25     other licensed professionals at the physician's direction.
26     This includes reconstruction of the breast on which a

 

 

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1     mastectomy was performed; surgery and reconstruction of
2     the other breast to produce a symmetrical appearance; and
3     prostheses and treatment of physical complications at all
4     stages of the mastectomy, including lymphedemas.
5         (2.5) Professional services provided by a physician to
6     children under the age of 16 years for physical
7     examinations and age appropriate immunizations ordered by
8     a physician licensed to practice medicine in all its
9     branches.
10         (3) (Blank).
11         (4) Outpatient prescription drugs that by law require a
12     prescription written by a physician licensed to practice
13     medicine in all its branches subject to such separate
14     deductible, copayment, and other limitations or
15     restrictions as the Board shall approve, including the use
16     of a prescription drug card or any other program, or both.
17         (5) Skilled nursing services of a licensed skilled
18     nursing facility for not more than 120 days during a policy
19     year.
20         (6) Services of a home health agency in accord with a
21     home health care plan, up to a maximum of 270 visits per
22     year.
23         (7) Services of a licensed hospice for not more than
24     180 days during a policy year.
25         (8) Use of radium or other radioactive materials.
26         (9) Oxygen.

 

 

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1         (10) Anesthetics.
2         (11) Orthoses and prostheses other than dental.
3         (12) Rental or purchase in accordance with Board
4     policies or procedures of durable medical equipment, other
5     than eyeglasses or hearing aids, for which there is no
6     personal use in the absence of the condition for which it
7     is prescribed.
8         (13) Diagnostic x-rays and laboratory tests.
9         (14) Oral surgery (i) for excision of partially or
10     completely unerupted impacted teeth when not performed in
11     connection with the routine extraction or repair of teeth;
12     (ii) for excision of tumors or cysts of the jaws, cheeks,
13     lips, tongue, and roof and floor of the mouth; (iii)
14     required for correction of cleft lip and palate and other
15     craniofacial and maxillofacial birth defects; or (iv) for
16     treatment of injuries to natural teeth or a fractured jaw
17     due to an accident.
18         (15) Physical, speech, and functional occupational
19     therapy as medically necessary and provided by appropriate
20     licensed professionals.
21         (16) Emergency and other medically necessary
22     transportation provided by a licensed ambulance service to
23     the nearest health care facility qualified to treat a
24     covered illness, injury, or condition, subject to the
25     provisions of the Emergency Medical Systems (EMS) Act.
26         (17) Outpatient services for diagnosis and treatment

 

 

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1     of mental and nervous disorders provided that a covered
2     person shall be required to make a copayment not to exceed
3     50% and that the Plan's payment shall not exceed such
4     amounts as are established by the Board.
5         (18) Human organ or tissue transplants specified by the
6     Board that are performed at a hospital designated by the
7     Board as a participating transplant center for that
8     specific organ or tissue transplant.
9         (19) Naprapathic services, as appropriate, provided by
10     a licensed naprapathic practitioner.
11         (20) Acupuncture therapy as medically necessary and as
12 provided by appropriately licensed professionals.
13     c. Exclusions. Covered expenses of the Plan shall not
14 include the following:
15         (1) Any charge for treatment for cosmetic purposes
16     other than for reconstructive surgery when the service is
17     incidental to or follows surgery resulting from injury,
18     sickness or other diseases of the involved part or surgery
19     for the repair or treatment of a congenital bodily defect
20     to restore normal bodily functions.
21         (2) Any charge for care that is primarily for rest,
22     custodial, educational, or domiciliary purposes.
23         (3) Any charge for services in a private room to the
24     extent it is in excess of the institution's charge for its
25     most common semiprivate room, unless a private room is
26     prescribed as medically necessary by a physician.

 

 

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1         (4) That part of any charge for room and board or for
2     services rendered or articles prescribed by a physician,
3     dentist, or other health care personnel that exceeds the
4     reasonable and customary charge in the locality or for any
5     services or supplies not medically necessary for the
6     diagnosed injury or illness.
7         (5) Any charge for services or articles the provision
8     of which is not within the scope of licensure of the
9     institution or individual providing the services or
10     articles.
11         (6) Any expense incurred prior to the effective date of
12     coverage by the Plan for the person on whose behalf the
13     expense is incurred.
14         (7) Dental care, dental surgery, dental treatment, any
15     other dental procedure involving the teeth or
16     periodontium, or any dental appliances, including crowns,
17     bridges, implants, or partial or complete dentures, except
18     as specifically provided in paragraph (14) of subsection b
19     of this Section.
20         (8) Eyeglasses, contact lenses, hearing aids or their
21     fitting.
22         (9) Illness or injury due to acts of war.
23         (10) Services of blood donors and any fee for failure
24     to replace the first 3 pints of blood provided to a covered
25     person each policy year.
26         (11) Personal supplies or services provided by a

 

 

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1     hospital or nursing home, or any other nonmedical or
2     nonprescribed supply or service.
3         (12) Routine maternity charges for a pregnancy, except
4     where added as optional coverage with payment of an
5     additional premium for pregnancy resulting from conception
6     occurring after the effective date of the optional
7     coverage.
8         (13) (Blank).
9         (14) Any expense or charge for services, drugs, or
10     supplies that are: (i) not provided in accord with
11     generally accepted standards of current medical practice;
12     (ii) for procedures, treatments, equipment, transplants,
13     or implants, any of which are investigational,
14     experimental, or for research purposes; (iii)
15     investigative and not proven safe and effective; or (iv)
16     for, or resulting from, a gender transformation operation.
17         (15) Any expense or charge for routine physical
18     examinations or tests except as provided in item (2.5) of
19     subsection b of this Section.
20         (16) Any expense for which a charge is not made in the
21     absence of insurance or for which there is no legal
22     obligation on the part of the patient to pay.
23         (17) Any expense incurred for benefits provided under
24     the laws of the United States and this State, including
25     Medicare, Medicaid, and other medical assistance, maternal
26     and child health services and any other program that is

 

 

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1     administered or funded by the Department of Human Services,
2     Department of Healthcare and Family Services, or
3     Department of Public Health, military service-connected
4     disability payments, medical services provided for members
5     of the armed forces and their dependents or employees of
6     the armed forces of the United States, and medical services
7     financed on behalf of all citizens by the United States.
8         (18) Any expense or charge for in vitro fertilization,
9     artificial insemination, or any other artificial means
10     used to cause pregnancy.
11         (19) Any expense or charge for oral contraceptives used
12     for birth control or any other temporary birth control
13     measures.
14         (20) Any expense or charge for sterilization or
15     sterilization reversals.
16         (21) Any expense or charge for weight loss programs,
17     exercise equipment, or treatment of obesity, except when
18     certified by a physician as morbid obesity (at least 2
19     times normal body weight).
20         (22) (Blank). Any expense or charge for acupuncture
21     treatment unless used as an anesthetic agent for a covered
22     surgery.
23         (23) Any expense or charge for or related to organ or
24     tissue transplants other than those performed at a hospital
25     with a Board approved organ transplant program that has
26     been designated by the Board as a preferred or exclusive

 

 

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1     provider organization for that specific organ or tissue
2     transplant.
3         (24) Any expense or charge for procedures, treatments,
4     equipment, or services that are provided in special
5     settings for research purposes or in a controlled
6     environment, are being studied for safety, efficiency, and
7     effectiveness, and are awaiting endorsement by the
8     appropriate national medical speciality college for
9     general use within the medical community.
10     d. Deductibles and coinsurance.
11     The Plan coverage defined in Section 6 shall provide for a
12 choice of deductibles per individual as authorized by the
13 Board. If 2 individual members of the same family household,
14 who are both covered persons under the Plan, satisfy the same
15 applicable deductibles, no other member of that family who is
16 also a covered person under the Plan shall be required to meet
17 any deductibles for the balance of that calendar year. The
18 deductibles must be applied first to the authorized amount of
19 covered expenses incurred by the covered person. A mandatory
20 coinsurance requirement shall be imposed at the rate authorized
21 by the Board in excess of the mandatory deductible, the
22 coinsurance in the aggregate not to exceed such amounts as are
23 authorized by the Board per annum. At its discretion the Board
24 may, however, offer catastrophic coverages or other policies
25 that provide for larger deductibles with or without coinsurance
26 requirements. The deductibles and coinsurance factors may be

 

 

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1 adjusted annually according to the Medical Component of the
2 Consumer Price Index.
3     e. Scope of coverage.
4         (1) In approving any of the benefit plans to be offered
5     by the Plan, the Board shall establish such benefit levels,
6     deductibles, coinsurance factors, exclusions, and
7     limitations as it may deem appropriate and that it believes
8     to be generally reflective of and commensurate with health
9     insurance coverage that is provided in the individual
10     market in this State.
11         (2) The benefit plans approved by the Board may also
12     provide for and employ various cost containment measures
13     and other requirements including, but not limited to,
14     preadmission certification, prior approval, second
15     surgical opinions, concurrent utilization review programs,
16     individual case management, preferred provider
17     organizations, health maintenance organizations, and other
18     cost effective arrangements for paying for covered
19     expenses.
20     f. Preexisting conditions.
21         (1) Except for federally eligible individuals
22     qualifying for Plan coverage under Section 15 of this Act
23     or eligible persons who qualify for the waiver authorized
24     in paragraph (3) of this subsection, plan coverage shall
25     exclude charges or expenses incurred during the first 6
26     months following the effective date of coverage as to any

 

 

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1     condition for which medical advice, care or treatment was
2     recommended or received during the 6 month period
3     immediately preceding the effective date of coverage.
4         (2) (Blank).
5         (3) Waiver: The preexisting condition exclusions as
6     set forth in paragraph (1) of this subsection shall be
7     waived to the extent to which the eligible person (a) has
8     satisfied similar exclusions under any prior individual
9     health insurance policy that was involuntarily terminated
10     because of the insolvency of the issuer of the policy and
11     (b) has applied for Plan coverage within 90 days following
12     the involuntary termination of that individual health
13     insurance coverage.
14     g. Other sources primary; nonduplication of benefits.
15         (1) The Plan shall be the last payor of benefits
16     whenever any other benefit or source of third party payment
17     is available. Subject to the provisions of subsection e of
18     Section 7, benefits otherwise payable under Plan coverage
19     shall be reduced by all amounts paid or payable by Medicare
20     or any other government program or through any health
21     insurance coverage or group health plan, whether by
22     insurance, reimbursement, or otherwise, or through any
23     third party liability, settlement, judgment, or award,
24     regardless of the date of the settlement, judgment, or
25     award, whether the settlement, judgment, or award is in the
26     form of a contract, agreement, or trust on behalf of a

 

 

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1     minor or otherwise and whether the settlement, judgment, or
2     award is payable to the covered person, his or her
3     dependent, estate, personal representative, or guardian in
4     a lump sum or over time, and by all hospital or medical
5     expense benefits paid or payable under any worker's
6     compensation coverage, automobile medical payment, or
7     liability insurance, whether provided on the basis of fault
8     or nonfault, and by any hospital or medical benefits paid
9     or payable under or provided pursuant to any State or
10     federal law or program.
11         (2) The Plan shall have a cause of action against any
12     covered person or any other person or entity for the
13     recovery of any amount paid to the extent the amount was
14     for treatment, services, or supplies not covered in this
15     Section or in excess of benefits as set forth in this
16     Section.
17         (3) Whenever benefits are due from the Plan because of
18     sickness or an injury to a covered person resulting from a
19     third party's wrongful act or negligence and the covered
20     person has recovered or may recover damages from a third
21     party or its insurer, the Plan shall have the right to
22     reduce benefits or to refuse to pay benefits that otherwise
23     may be payable by the amount of damages that the covered
24     person has recovered or may recover regardless of the date
25     of the sickness or injury or the date of any settlement,
26     judgment, or award resulting from that sickness or injury.

 

 

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1         During the pendency of any action or claim that is
2     brought by or on behalf of a covered person against a third
3     party or its insurer, any benefits that would otherwise be
4     payable except for the provisions of this paragraph (3)
5     shall be paid if payment by or for the third party has not
6     yet been made and the covered person or, if incapable, that
7     person's legal representative agrees in writing to pay back
8     promptly the benefits paid as a result of the sickness or
9     injury to the extent of any future payments made by or for
10     the third party for the sickness or injury. This agreement
11     is to apply whether or not liability for the payments is
12     established or admitted by the third party or whether those
13     payments are itemized.
14         Any amounts due the plan to repay benefits may be
15     deducted from other benefits payable by the Plan after
16     payments by or for the third party are made.
17         (4) Benefits due from the Plan may be reduced or
18     refused as an offset against any amount otherwise
19     recoverable under this Section.
20     h. Right of subrogation; recoveries.
21         (1) Whenever the Plan has paid benefits because of
22     sickness or an injury to any covered person resulting from
23     a third party's wrongful act or negligence, or for which an
24     insurer is liable in accordance with the provisions of any
25     policy of insurance, and the covered person has recovered
26     or may recover damages from a third party that is liable

 

 

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1     for the damages, the Plan shall have the right to recover
2     the benefits it paid from any amounts that the covered
3     person has received or may receive regardless of the date
4     of the sickness or injury or the date of any settlement,
5     judgment, or award resulting from that sickness or injury.
6     The Plan shall be subrogated to any right of recovery the
7     covered person may have under the terms of any private or
8     public health care coverage or liability coverage,
9     including coverage under the Workers' Compensation Act or
10     the Workers' Occupational Diseases Act, without the
11     necessity of assignment of claim or other authorization to
12     secure the right of recovery. To enforce its subrogation
13     right, the Plan may (i) intervene or join in an action or
14     proceeding brought by the covered person or his personal
15     representative, including his guardian, conservator,
16     estate, dependents, or survivors, against any third party
17     or the third party's insurer that may be liable or (ii)
18     institute and prosecute legal proceedings against any
19     third party or the third party's insurer that may be liable
20     for the sickness or injury in an appropriate court either
21     in the name of the Plan or in the name of the covered
22     person or his personal representative, including his
23     guardian, conservator, estate, dependents, or survivors.
24         (2) If any action or claim is brought by or on behalf
25     of a covered person against a third party or the third
26     party's insurer, the covered person or his personal

 

 

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1     representative, including his guardian, conservator,
2     estate, dependents, or survivors, shall notify the Plan by
3     personal service or registered mail of the action or claim
4     and of the name of the court in which the action or claim
5     is brought, filing proof thereof in the action or claim.
6     The Plan may, at any time thereafter, join in the action or
7     claim upon its motion so that all orders of court after
8     hearing and judgment shall be made for its protection. No
9     release or settlement of a claim for damages and no
10     satisfaction of judgment in the action shall be valid
11     without the written consent of the Plan to the extent of
12     its interest in the settlement or judgment and of the
13     covered person or his personal representative.
14         (3) In the event that the covered person or his
15     personal representative fails to institute a proceeding
16     against any appropriate third party before the fifth month
17     before the action would be barred, the Plan may, in its own
18     name or in the name of the covered person or personal
19     representative, commence a proceeding against any
20     appropriate third party for the recovery of damages on
21     account of any sickness, injury, or death to the covered
22     person. The covered person shall cooperate in doing what is
23     reasonably necessary to assist the Plan in any recovery and
24     shall not take any action that would prejudice the Plan's
25     right to recovery. The Plan shall pay to the covered person
26     or his personal representative all sums collected from any

 

 

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1     third party by judgment or otherwise in excess of amounts
2     paid in benefits under the Plan and amounts paid or to be
3     paid as costs, attorneys fees, and reasonable expenses
4     incurred by the Plan in making the collection or enforcing
5     the judgment.
6         (4) In the event that a covered person or his personal
7     representative, including his guardian, conservator,
8     estate, dependents, or survivors, recovers damages from a
9     third party for sickness or injury caused to the covered
10     person, the covered person or the personal representative
11     shall pay to the Plan from the damages recovered the amount
12     of benefits paid or to be paid on behalf of the covered
13     person.
14         (5) When the action or claim is brought by the covered
15     person alone and the covered person incurs a personal
16     liability to pay attorney's fees and costs of litigation,
17     the Plan's claim for reimbursement of the benefits provided
18     to the covered person shall be the full amount of benefits
19     paid to or on behalf of the covered person under this Act
20     less a pro rata share that represents the Plan's reasonable
21     share of attorney's fees paid by the covered person and
22     that portion of the cost of litigation expenses determined
23     by multiplying by the ratio of the full amount of the
24     expenditures to the full amount of the judgement, award, or
25     settlement.
26         (6) In the event of judgment or award in a suit or

 

 

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1     claim against a third party or insurer, the court shall
2     first order paid from any judgement or award the reasonable
3     litigation expenses incurred in preparation and
4     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 of
7     the balance of the judgment or award an amount sufficient
8     to reimburse the Plan the full amount of benefits paid on
9     behalf of the covered person under this Act, provided the
10     court may reduce and apportion the Plan's portion of the
11     judgement proportionate to the recovery of the covered
12     person. The burden of producing evidence sufficient to
13     support the exercise by the court of its discretion to
14     reduce the amount of a proven charge sought to be enforced
15     against the recovery shall rest with the party seeking the
16     reduction. The court may consider the nature and extent of
17     the injury, economic and non-economic loss, settlement
18     offers, comparative negligence as it applies to the case at
19     hand, hospital costs, physician costs, and all other
20     appropriate costs. The Plan shall pay its pro rata share of
21     the attorney fees based on the Plan's recovery as it
22     compares to the total judgment. Any reimbursement rights of
23     the Plan shall take priority over all other liens and
24     charges existing under the laws of this State with the
25     exception of any attorney liens filed under the Attorneys
26     Lien Act.

 

 

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1         (7) The Plan may compromise or settle and release any
2     claim for benefits provided under this Act or waive any
3     claims for benefits, in whole or in part, for the
4     convenience of the Plan or if the Plan determines that
5     collection would result in undue hardship upon the covered
6     person.
7 (Source: P.A. 94-737, eff. 5-3-06; 95-547, eff. 8-29-07.)
 
8     Section 99. Effective date. This Act takes effect upon
9 becoming law.