Full Text of SB2380 95th General Assembly
SB2380enr 95TH GENERAL ASSEMBLY
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| AN ACT concerning regulation.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 1. Short title. This Act may be cited as the | 5 |
| Hospital Uninsured Patient Discount Act. | 6 |
| Section 5. Definitions. As used in this Act: | 7 |
| "Cost to charge ratio" means the ratio of a hospital's | 8 |
| costs to its charges taken from its most recently filed | 9 |
| Medicare cost report (CMS 2552-96 Worksheet C, Part I, PPS | 10 |
| Inpatient Ratios). | 11 |
| "Critical Access Hospital" means a hospital that is | 12 |
| designated as such under the federal Medicare Rural Hospital | 13 |
| Flexibility Program. | 14 |
| "Family income" means the sum of a family's annual earnings | 15 |
| and cash benefits from all sources before taxes, less payments | 16 |
| made for child support. | 17 |
| "Federal poverty income guidelines" means the poverty | 18 |
| guidelines updated periodically in the Federal Register by the | 19 |
| United States Department of Health and Human Services under | 20 |
| authority of 42 U.S.C. 9902(2). | 21 |
| "Health care services" means any medically necessary | 22 |
| inpatient or outpatient hospital service, including | 23 |
| pharmaceuticals or supplies provided by a hospital to a |
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| patient. | 2 |
| "Hospital" means any facility or institution required to be | 3 |
| licensed pursuant to the Hospital Licensing Act or operated | 4 |
| under the University of Illinois Hospital Act. | 5 |
| "Illinois resident" means a person who lives in Illinois | 6 |
| and who intends to remain living in Illinois indefinitely. | 7 |
| Relocation to Illinois for the sole purpose of receiving health | 8 |
| care benefits does not satisfy the residency requirement under | 9 |
| this Act. | 10 |
| "Medically necessary" means any inpatient or outpatient | 11 |
| hospital service, including pharmaceuticals or supplies | 12 |
| provided by a hospital to a patient, covered under Title XVIII | 13 |
| of the federal Social Security Act for beneficiaries with the | 14 |
| same clinical presentation as the uninsured patient. A | 15 |
| "medically necessary" service does not include any of the | 16 |
| following: | 17 |
| (1) Non-medical services such as social and vocational | 18 |
| services. | 19 |
| (2) Elective cosmetic surgery, but not plastic surgery | 20 |
| designed to correct disfigurement caused by injury, | 21 |
| illness, or congenital defect or deformity. | 22 |
| "Rural hospital" means a hospital that is located outside a | 23 |
| metropolitan statistical area. | 24 |
| "Uninsured discount" means a hospital's charges multiplied | 25 |
| by the uninsured discount factor. | 26 |
| "Uninsured discount factor" means 1.0 less the product of a |
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| hospital's cost to charge ratio multiplied by 1.35. | 2 |
| "Uninsured patient" means an Illinois resident who is a | 3 |
| patient of a hospital and is not covered under a policy of | 4 |
| health insurance and is not a beneficiary under a public or | 5 |
| private health insurance, health benefit, or other health | 6 |
| coverage program, including high deductible health insurance | 7 |
| plans, workers' compensation, accident liability insurance, or | 8 |
| other third party liability. | 9 |
| Section 10. Uninsured patient discounts. | 10 |
| (a) Eligibility. | 11 |
| (1) A hospital, other than a rural hospital or Critical | 12 |
| Access Hospital, shall provide a discount from its charges | 13 |
| to any uninsured patient who applies for a discount and has | 14 |
| family income of not more than 600% of the federal poverty | 15 |
| income guidelines for all medically necessary health care | 16 |
| services exceeding $300 in any one inpatient admission or | 17 |
| outpatient encounter. | 18 |
| (2) A rural hospital or Critical Access Hospital shall | 19 |
| provide a discount from its charges to any uninsured | 20 |
| patient who applies for a discount and has annual family | 21 |
| income of not more than 300% of the federal poverty income | 22 |
| guidelines for all medically necessary health care | 23 |
| services exceeding $300 in any one inpatient admission or | 24 |
| outpatient encounter. | 25 |
| (b) Discount. For all health care services exceeding $300 |
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| in any one inpatient admission or outpatient encounter, a | 2 |
| hospital shall not collect from an uninsured patient, deemed | 3 |
| eligible under subsection (a), more than its charges less the | 4 |
| amount of the uninsured discount. | 5 |
| (c) Maximum Collectible Amount. | 6 |
| (1) The maximum amount that may be collected in a 12 | 7 |
| month period for health care services provided by the | 8 |
| hospital from a patient determined by that hospital to be | 9 |
| eligible under subsection (a) is 25% of the patient's | 10 |
| family income, and is subject to the patient's continued | 11 |
| eligibility under this Act. | 12 |
| (2) The 12 month period to which the maximum amount | 13 |
| applies shall begin on the first date, after the effective | 14 |
| date of this Act, an uninsured patient receives health care | 15 |
| services that are determined to be eligible for the | 16 |
| uninsured discount at that hospital. | 17 |
| (3) To be eligible to have this maximum amount applied | 18 |
| to subsequent charges, the uninsured patient shall inform | 19 |
| the hospital in subsequent inpatient admissions or | 20 |
| outpatient encounters that the patient has previously | 21 |
| received health care services from that hospital and was | 22 |
| determined to be entitled to the uninsured discount. | 23 |
| (4) Hospitals may adopt policies to exclude an | 24 |
| uninsured patient from the application of subdivision | 25 |
| (c)(1) when the patient owns assets having a value in | 26 |
| excess of 600% of the federal poverty level for hospitals |
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| in a metropolitan statistical area or owns assets having a | 2 |
| value in excess of 300% of the federal poverty level for | 3 |
| Critical Access Hospitals or hospitals outside a | 4 |
| metropolitan statistical area, not counting the following | 5 |
| assets: the uninsured patient's primary residence; | 6 |
| personal property exempt from judgment under Section | 7 |
| 12-1001 of the Code of Civil Procedure; or any amounts held | 8 |
| in a pension or retirement plan, provided, however, that | 9 |
| distributions and payments from pension or retirement | 10 |
| plans may be included as income for the purposes of this | 11 |
| Act. | 12 |
| (d) Each hospital bill, invoice, or other summary of | 13 |
| charges to an uninsured patient shall include with it, or on | 14 |
| it, a prominent statement that an uninsured patient who meets | 15 |
| certain income requirements may qualify for an uninsured | 16 |
| discount and information regarding how an uninsured patient may | 17 |
| apply for consideration under the hospital's financial | 18 |
| assistance policy. | 19 |
| Section 15. Patient responsibility. | 20 |
| (a) Hospitals may make the availability of a discount and | 21 |
| the maximum collectible amount under this Act contingent upon | 22 |
| the uninsured patient first applying for coverage under public | 23 |
| programs, such as Medicare, Medicaid, AllKids, the State | 24 |
| Children's Health Insurance Program, or any other program, if | 25 |
| there is a reasonable basis to believe that the uninsured |
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| patient may be eligible for such program. | 2 |
| (b) Hospitals shall permit an uninsured patient to apply | 3 |
| for a discount within 60 days of the date of discharge or date | 4 |
| of service. | 5 |
| (1) Income verification. Hospitals may require an | 6 |
| uninsured patient who is requesting an uninsured discount | 7 |
| to provide documentation of family income. Acceptable | 8 |
| family income documentation shall include any one of the | 9 |
| following: | 10 |
| (A) a copy of the most recent tax return; | 11 |
| (B) a copy of the most recent W-2 form and 1099 | 12 |
| forms; | 13 |
| (C) copies of the 2 most recent pay stubs; | 14 |
| (D) written income verification from an employer | 15 |
| if paid in cash; or | 16 |
| (E) one other reasonable form of third party income | 17 |
| verification
deemed acceptable to the hospital. | 18 |
| (2) Asset verification. Hospitals may require an | 19 |
| uninsured patient who is requesting an uninsured discount | 20 |
| to certify the existence of assets owned by the patient and | 21 |
| to provide documentation of the value of such assets. | 22 |
| Acceptable documentation may include statements from | 23 |
| financial institutions or some other third party | 24 |
| verification of an asset's value. If no third party | 25 |
| verification exists, then the patient shall certify as to | 26 |
| the estimated value of the asset. |
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| (3) Illinois resident verification. Hospitals may | 2 |
| require an uninsured patient who is requesting an uninsured | 3 |
| discount to verify Illinois residency. Acceptable | 4 |
| verification of Illinois residency shall include any one of | 5 |
| the following: | 6 |
| (A) any of the documents listed in paragraph (1); | 7 |
| (B) a valid state-issued identification card; | 8 |
| (C) a recent residential utility bill; | 9 |
| (D) a lease agreement; | 10 |
| (E) a vehicle registration card; | 11 |
| (F) a voter registration card; | 12 |
| (G) mail addressed to the uninsured patient at an | 13 |
| Illinois address from a government or other credible | 14 |
| source; | 15 |
| (H) a statement from a family member of the | 16 |
| uninsured patient who resides at the same address and | 17 |
| presents verification of residency; or | 18 |
| (I) a letter from a homeless shelter, transitional | 19 |
| house or other similar facility verifying that the | 20 |
| uninsured patient resides at the facility. | 21 |
| (c) Hospital obligations toward an individual uninsured | 22 |
| patient under this Act shall cease if that patient unreasonably | 23 |
| fails or refuses to provide the hospital with information or | 24 |
| documentation requested under subsection (b) or to apply for | 25 |
| coverage under public programs when requested under subsection | 26 |
| (a) within 30 days of the hospital's request. |
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| (d) In order for a hospital to determine the 12 month | 2 |
| maximum amount that can be collected from a patient deemed | 3 |
| eligible under Section 10, an uninsured patient shall inform | 4 |
| the hospital in subsequent inpatient admissions or outpatient | 5 |
| encounters that the patient has previously received health care | 6 |
| services from that hospital and was determined to be entitled | 7 |
| to the uninsured discount. | 8 |
| (e) Hospitals may require patients to certify that all of | 9 |
| the information provided in the application is true. The | 10 |
| application may state that if any of the information is untrue, | 11 |
| any discount granted to the patient is forfeited and the | 12 |
| patient is responsible for payment of the hospital's full | 13 |
| charges. | 14 |
| Section 20. Exemptions and limitations. | 15 |
| (a) Hospitals that do not charge for their services are | 16 |
| exempt from the provisions of this Act. | 17 |
| (b) Nothing in this Act shall be used by any private or | 18 |
| public health care insurer or plan as a basis for reducing its | 19 |
| payment or reimbursement rates or policies with any hospital. | 20 |
| Notwithstanding any other provisions of law, discounts | 21 |
| authorized under this Act shall not be used by any private or | 22 |
| public health care insurer or plan, regulatory agency, | 23 |
| arbitrator, court, or other third party to determine a | 24 |
| hospital's usual and customary charges for any health care | 25 |
| service. |
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| (c) Nothing in this Act shall be construed to require a | 2 |
| hospital to provide an uninsured patient with a particular type | 3 |
| of health care service or other service. | 4 |
| (d) Nothing in this Act shall be deemed to reduce or | 5 |
| infringe upon the rights and obligations of hospitals and | 6 |
| patients under the Fair Patient Billing Act. | 7 |
| (e) The obligations of hospitals under this Act shall take | 8 |
| effect for health care services provided on or after the first | 9 |
| day of the month that begins 90 days after the effective date | 10 |
| of this Act or 90 days after the initial adoption of rules | 11 |
| authorized under subsection (a) of Section 25, whichever occurs | 12 |
| later. | 13 |
| Section 25. Enforcement. | 14 |
| (a) The Attorney General is responsible for administering | 15 |
| and ensuring compliance with this Act, including the | 16 |
| development of any rules necessary for the implementation and | 17 |
| enforcement of this Act. | 18 |
| (b) The Attorney General shall develop and implement a | 19 |
| process for receiving and handling complaints from individuals | 20 |
| or hospitals regarding possible violations of this Act. | 21 |
| (c) The Attorney General may conduct any investigation | 22 |
| deemed necessary regarding possible violations of this Act by | 23 |
| any hospital including, without limitation, the issuance of | 24 |
| subpoenas to: | 25 |
| (1) require the hospital to file a statement or report |
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| or answer interrogatories in writing as to all information | 2 |
| relevant to the alleged violations; | 3 |
| (2) examine under oath any person who possesses | 4 |
| knowledge or information directly related to the alleged | 5 |
| violations; and | 6 |
| (3) examine any record, book, document, account, or | 7 |
| paper necessary to investigate the alleged violation. | 8 |
| (d) If the Attorney General determines that there is a | 9 |
| reason to believe that any hospital has violated this Act, the | 10 |
| Attorney General may bring an action in the name of the People | 11 |
| of the State against the hospital to obtain temporary, | 12 |
| preliminary, or permanent injunctive relief for any act, | 13 |
| policy, or practice by the hospital that violates this Act. | 14 |
| Before bringing such an action, the Attorney General may permit | 15 |
| the hospital to submit a Correction Plan for the Attorney | 16 |
| General's approval. | 17 |
| (e) This Section applies if: | 18 |
| (1) A court orders a party to make payments to the | 19 |
| Attorney General and the payments are to be used for the | 20 |
| operations of the Office of the Attorney General; or | 21 |
| (2) A party agrees in a Correction Plan under this Act | 22 |
| to make payments to the Attorney General for the operations | 23 |
| of the Office of the Attorney General. | 24 |
| (f) Moneys paid under any of the conditions described in | 25 |
| subsection (e) shall be deposited into the Attorney General | 26 |
| Court Ordered and Voluntary Compliance Payment Projects Fund. |
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| Moneys in the Fund shall be used, subject to appropriation, for | 2 |
| the performance of any function, pertaining to the exercise of | 3 |
| the duties, to the Attorney General including, but not limited | 4 |
| to, enforcement of any law of this State and conducting public | 5 |
| education programs; however, any moneys in the Fund that are | 6 |
| required by the court to be used for a particular purpose shall | 7 |
| be used for that purpose.
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| (g) The Attorney General may seek the assessment of a civil | 9 |
| monetary penalty not to exceed $500 per violation in any action | 10 |
| filed under this Act where a hospital, by pattern or practice, | 11 |
| knowingly violates Section 10 of this Act. | 12 |
| (h) In the event a court grants a final order of relief | 13 |
| against any hospital for a violation of this Act, the Attorney | 14 |
| General may, after all appeal rights have been exhausted, refer | 15 |
| the hospital to the Illinois Department of Public Health for | 16 |
| possible adverse licensure action under the Hospital Licensing | 17 |
| Act. | 18 |
| (i) Each hospital shall file Worksheet C Part I from its | 19 |
| most recently filed Medicare Cost Report with the Attorney | 20 |
| General within 60 days after the effective date of this Act and | 21 |
| thereafter shall file each subsequent Worksheet C Part I with | 22 |
| the Attorney General within 30 days of filing its Medicare Cost | 23 |
| Report with the hospital's fiscal intermediary. | 24 |
| Section 30. Home rule. A home rule unit may not regulate | 25 |
| hospitals in a manner inconsistent with the provisions of this |
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| Act. This Section is a limitation under subsection (i) of | 2 |
| Section 6 of Article VII of the Illinois Constitution on the | 3 |
| concurrent exercise by home rule units of powers and functions | 4 |
| exercised by the State. | 5 |
| Section 90. The Comprehensive Health Insurance Plan Act is | 6 |
| amended by changing Section 2 as follows: | 7 |
| (215 ILCS 105/2) (from Ch. 73, par. 1302)
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| Sec. 2. Definitions. As used in this Act, unless the | 9 |
| context otherwise
requires:
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| "Plan administrator" means the insurer or third party
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| administrator designated under Section 5 of this Act.
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| "Benefits plan" means the coverage to be offered by the | 13 |
| Plan to
eligible persons and federally eligible individuals | 14 |
| pursuant to this Act.
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| "Board" means the Illinois Comprehensive Health Insurance | 16 |
| Board.
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| "Church plan" has the same meaning given that term in the | 18 |
| federal Health
Insurance Portability and Accountability Act of | 19 |
| 1996.
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| "Continuation coverage" means continuation of coverage | 21 |
| under a group health
plan or other health insurance coverage | 22 |
| for former employees or dependents of
former employees that | 23 |
| would otherwise have terminated under the terms of that
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| coverage pursuant to any continuation provisions under federal |
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| or State law,
including the Consolidated Omnibus Budget | 2 |
| Reconciliation Act of 1985 (COBRA),
as amended, Sections 367.2, | 3 |
| 367e, and 367e.1 of the Illinois Insurance Code, or
any
other | 4 |
| similar requirement in another State.
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| "Covered person" means a person who is and continues to | 6 |
| remain eligible for
Plan coverage and is covered under one of | 7 |
| the benefit plans offered by the
Plan.
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| "Creditable coverage" means, with respect to a federally | 9 |
| eligible
individual, coverage of the individual under any of | 10 |
| the following:
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| (A) A group health plan.
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| (B) Health insurance coverage (including group health | 13 |
| insurance coverage).
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| (C) Medicare.
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| (D) Medical assistance.
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| (E) Chapter 55 of title 10, United States Code.
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| (F) A medical care program of the Indian Health Service | 18 |
| or of a tribal
organization.
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| (G) A state health benefits risk pool.
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| (H) A health plan offered under Chapter 89 of title 5, | 21 |
| United States Code.
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| (I) A public health plan (as defined in regulations | 23 |
| consistent with
Section
104 of the Health Care Portability | 24 |
| and Accountability Act of 1996 that may be
promulgated by | 25 |
| the Secretary of the U.S. Department of Health and Human
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| Services).
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| (J) A health benefit plan under Section 5(e) of the | 2 |
| Peace Corps Act (22
U.S.C. 2504(e)).
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| (K) Any other qualifying coverage required by the | 4 |
| federal Health Insurance
Portability and Accountability | 5 |
| Act of 1996, as it may be amended, or
regulations under | 6 |
| that
Act.
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| "Creditable coverage" does not include coverage consisting | 8 |
| solely of coverage
of excepted benefits, as defined in Section | 9 |
| 2791(c) of title XXVII of
the
Public Health Service Act (42 | 10 |
| U.S.C. 300 gg-91), nor does it include any
period
of coverage | 11 |
| under any of items (A) through (K) that occurred before a break | 12 |
| of
more than 90 days or, if the individual has
been certified | 13 |
| as eligible pursuant to the federal Trade Act
of 2002, a
break | 14 |
| of more than 63 days during all of which the individual was not | 15 |
| covered
under any of items (A) through (K) above.
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| Any period that an individual is in a waiting period for
| 17 |
| any coverage under a group health plan (or for group health | 18 |
| insurance
coverage) or is in an affiliation period under the | 19 |
| terms of health insurance
coverage offered by a health | 20 |
| maintenance organization shall not be taken into
account in | 21 |
| determining if there has been a break of more than 90
days in | 22 |
| any
creditable coverage.
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| "Department" means the Illinois Department of Insurance.
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| "Dependent" means an Illinois resident: who is a spouse; or | 25 |
| who is claimed
as a dependent by the principal insured for | 26 |
| purposes of filing a federal income
tax return and resides in |
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| the principal insured's household, and is a resident
unmarried | 2 |
| child under the age of 19 years; or who is an unmarried child | 3 |
| who
also is a full-time student under the age of 23 years and | 4 |
| who is financially
dependent upon the principal insured; or who | 5 |
| is a child of any age and who is
disabled and financially | 6 |
| dependent upon the
principal insured.
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| "Direct Illinois premiums" means, for Illinois business, | 8 |
| an insurer's direct
premium income for the kinds of business | 9 |
| described in clause (b) of Class 1 or
clause (a) of Class 2 of | 10 |
| Section 4 of the Illinois Insurance Code, and direct
premium | 11 |
| income of a health maintenance organization or a voluntary | 12 |
| health
services plan, except it shall not include credit health | 13 |
| insurance as defined
in Article IX 1/2 of the Illinois | 14 |
| Insurance Code.
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| "Director" means the Director of the Illinois Department of | 16 |
| Insurance.
| 17 |
| "Effective date of medical assistance" means the date that | 18 |
| eligibility for medical assistance for a person is approved by | 19 |
| the Department of Human Services or the Department of | 20 |
| Healthcare and Family Services, except when the Department of | 21 |
| Human Services or the Department of Healthcare and Family | 22 |
| Services determines eligibility retroactively. In such | 23 |
| circumstances, the effective date of the medical assistance is | 24 |
| the date the Department of Human Services or the Department of | 25 |
| Healthcare and Family Services determines the person to be | 26 |
| eligible for medical assistance. |
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| "Eligible person" means a resident of this State who | 2 |
| qualifies
for Plan coverage under Section 7 of this Act.
| 3 |
| "Employee" means a resident of this State who is employed | 4 |
| by an employer
or has entered into
the employment of or works | 5 |
| under contract or service of an employer
including the | 6 |
| officers, managers and employees of subsidiary or affiliated
| 7 |
| corporations and the individual proprietors, partners and | 8 |
| employees of
affiliated individuals and firms when the business | 9 |
| of the subsidiary or
affiliated corporations, firms or | 10 |
| individuals is controlled by a common
employer through stock | 11 |
| ownership, contract, or otherwise.
| 12 |
| "Employer" means any individual, partnership, association, | 13 |
| corporation,
business trust, or any person or group of persons | 14 |
| acting directly or indirectly
in the interest of an employer in | 15 |
| relation to an employee, for which one or
more
persons is | 16 |
| gainfully employed.
| 17 |
| "Family" coverage means the coverage provided by the Plan | 18 |
| for the
covered person and his or her eligible dependents who | 19 |
| also are
covered persons.
| 20 |
| "Federally eligible individual" means an individual | 21 |
| resident of this State:
| 22 |
| (1)(A) for whom, as of the date on which the individual | 23 |
| seeks Plan
coverage
under Section 15 of this Act, the | 24 |
| aggregate of the periods of creditable
coverage is 18 or | 25 |
| more months or, if the individual has been
certified as
| 26 |
| eligible pursuant to the federal Trade Act of 2002,
3 or |
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| more
months, and (B) whose most recent prior creditable
| 2 |
| coverage was under group health insurance coverage offered | 3 |
| by a health
insurance issuer, a group health plan, a | 4 |
| governmental plan, or a church plan
(or
health insurance | 5 |
| coverage offered in connection with any such plans) or any
| 6 |
| other type of creditable coverage that may be required by | 7 |
| the federal Health
Insurance Portability
and | 8 |
| Accountability Act of 1996, as it may be amended, or the | 9 |
| regulations
under that Act;
| 10 |
| (2) who
is not eligible for coverage under
(A) a group | 11 |
| health plan
(other than an individual who has been | 12 |
| certified as eligible
pursuant to the federal Trade Act of | 13 |
| 2002), (B)
part
A or part B of Medicare due to age
(other | 14 |
| than an individual who has been certified as eligible
| 15 |
| pursuant to the federal Trade Act of 2002), or (C) medical | 16 |
| assistance, and
does not
have other
health insurance | 17 |
| coverage (other than an individual who has been certified | 18 |
| as
eligible pursuant to the federal Trade Act of 2002);
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| (3) with respect to whom (other than an individual who | 20 |
| has been
certified as eligible pursuant to the federal | 21 |
| Trade Act of 2002) the most
recent coverage within the | 22 |
| coverage
period
described in paragraph (1)(A) of this | 23 |
| definition was not terminated
based upon a factor relating | 24 |
| to nonpayment of premiums or fraud;
| 25 |
| (4) if the individual (other than an individual who has
| 26 |
| been certified
as eligible pursuant to the federal Trade |
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| Act
of 2002)
had been offered the option of continuation
| 2 |
| coverage
under a COBRA continuation provision or under a | 3 |
| similar State program, who
elected such coverage; and
| 4 |
| (5) who, if the individual elected such continuation | 5 |
| coverage, has
exhausted
such continuation coverage under | 6 |
| such provision or program.
| 7 |
| However, an individual who has been certified as
eligible
| 8 |
| pursuant to the
federal Trade Act of 2002
shall not be required | 9 |
| to elect
continuation
coverage under a COBRA continuation | 10 |
| provision or under a similar state
program.
| 11 |
| "Group health insurance coverage" means, in connection | 12 |
| with a group health
plan, health insurance coverage offered in | 13 |
| connection with that plan.
| 14 |
| "Group health plan" has the same meaning given that term in | 15 |
| the federal
Health
Insurance Portability and Accountability | 16 |
| Act of 1996.
| 17 |
| "Governmental plan" has the same meaning given that term in | 18 |
| the federal
Health
Insurance Portability and Accountability | 19 |
| Act of 1996.
| 20 |
| "Health insurance coverage" means benefits consisting of | 21 |
| medical care
(provided directly, through insurance or | 22 |
| reimbursement, or otherwise and
including items and services | 23 |
| paid for as medical care) under any hospital and
medical | 24 |
| expense-incurred policy,
certificate, or
contract provided by | 25 |
| an insurer, non-profit health care service plan
contract, | 26 |
| health maintenance organization or other subscriber contract, |
|
|
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LRB095 19723 KBJ 46088 b |
|
| 1 |
| or
any other health care plan or arrangement that pays for or | 2 |
| furnishes
medical or health care services whether by
insurance | 3 |
| or otherwise. Health insurance coverage shall not include short
| 4 |
| term,
accident only,
disability income, hospital confinement | 5 |
| or fixed indemnity, dental only,
vision only, limited benefit, | 6 |
| or credit
insurance, coverage issued as a supplement to | 7 |
| liability insurance,
insurance arising out of a workers' | 8 |
| compensation or similar law, automobile
medical-payment | 9 |
| insurance, or insurance under which benefits are payable
with | 10 |
| or without regard to fault and which is statutorily required to | 11 |
| be
contained in any liability insurance policy or equivalent | 12 |
| self-insurance.
| 13 |
| "Health insurance issuer" means an insurance company, | 14 |
| insurance service,
or insurance organization (including a | 15 |
| health maintenance organization and a
voluntary health | 16 |
| services plan) that is authorized to transact health
insurance
| 17 |
| business in this State. Such term does not include a group | 18 |
| health plan.
| 19 |
| "Health Maintenance Organization" means an organization as
| 20 |
| defined in the Health Maintenance Organization Act.
| 21 |
| "Hospice" means a program as defined in and licensed under | 22 |
| the
Hospice Program Licensing Act.
| 23 |
| "Hospital" means a duly licensed institution as defined in | 24 |
| the
Hospital Licensing Act,
an institution that meets all | 25 |
| comparable conditions and requirements in
effect in the state | 26 |
| in which it is located, or the University of Illinois
Hospital |
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
| 1 |
| as defined in the University of Illinois Hospital Act.
| 2 |
| "Individual health insurance coverage" means health | 3 |
| insurance coverage
offered to individuals in the individual | 4 |
| market, but does not include
short-term, limited-duration | 5 |
| insurance.
| 6 |
| "Insured" means any individual resident of this State who | 7 |
| is
eligible to receive benefits from any insurer (including | 8 |
| health insurance
coverage offered in connection with a group | 9 |
| health plan) or health
insurance issuer as
defined in this | 10 |
| Section.
| 11 |
| "Insurer" means any insurance company authorized to | 12 |
| transact health
insurance business in this State and any | 13 |
| corporation that provides medical
services and is organized | 14 |
| under the Voluntary Health Services Plans Act or
the Health | 15 |
| Maintenance Organization
Act.
| 16 |
| "Medical assistance" means the State medical assistance or | 17 |
| medical
assistance no grant (MANG) programs provided under
| 18 |
| Title XIX of the Social Security Act and
Articles V (Medical | 19 |
| Assistance) and VI (General Assistance) of the Illinois
Public | 20 |
| Aid Code (or any successor program) or under any
similar | 21 |
| program of health care benefits in a state other than Illinois.
| 22 |
| "Medically necessary" means that a service, drug, or supply | 23 |
| is
necessary and appropriate for the diagnosis or treatment of | 24 |
| an illness or
injury in accord with generally accepted | 25 |
| standards of medical practice at
the time the service, drug, or | 26 |
| supply is provided. When specifically
applied to a confinement |
|
|
|
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LRB095 19723 KBJ 46088 b |
|
| 1 |
| it further means that the diagnosis or treatment
of the covered | 2 |
| person's medical symptoms or condition cannot be
safely
| 3 |
| provided to that person as an outpatient. A service, drug, or | 4 |
| supply shall
not be medically necessary if it: (i) is | 5 |
| investigational, experimental, or
for research purposes; or | 6 |
| (ii) is provided solely for the convenience of
the patient, the | 7 |
| patient's family, physician, hospital, or any other
provider; | 8 |
| or (iii) exceeds in scope, duration, or intensity that level of
| 9 |
| care that is needed to provide safe, adequate, and appropriate | 10 |
| diagnosis or
treatment; or (iv) could have been omitted without | 11 |
| adversely affecting the
covered person's condition or the | 12 |
| quality of medical care; or
(v) involves
the use of a medical | 13 |
| device, drug, or substance not formally approved by
the United | 14 |
| States Food and Drug Administration.
| 15 |
| "Medical care" means the ordinary and usual professional | 16 |
| services rendered
by a physician or other specified provider | 17 |
| during a professional visit for
treatment of an illness or | 18 |
| injury.
| 19 |
| "Medicare" means coverage under both Part A and Part B of | 20 |
| Title XVIII of
the Social Security
Act, 42 U.S.C. Sec. 1395, et | 21 |
| seq.
| 22 |
| "Minimum premium plan" means an arrangement whereby a | 23 |
| specified
amount of health care claims is self-funded, but the | 24 |
| insurance company
assumes the risk that claims will exceed that | 25 |
| amount.
| 26 |
| "Participating transplant center" means a hospital |
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
| 1 |
| designated by the
Board as a preferred or exclusive provider of | 2 |
| services for one or more
specified human organ or tissue | 3 |
| transplants for which the hospital has
signed an agreement with | 4 |
| the Board to accept a transplant payment allowance
for all | 5 |
| expenses related to the transplant during a transplant benefit | 6 |
| period.
| 7 |
| "Physician" means a person licensed to practice medicine | 8 |
| pursuant to
the Medical Practice Act of 1987.
| 9 |
| "Plan" means the Comprehensive Health Insurance Plan
| 10 |
| established by this Act.
| 11 |
| "Plan of operation" means the plan of operation of the
| 12 |
| Plan, including articles, bylaws and operating rules, adopted | 13 |
| by the board
pursuant to this Act.
| 14 |
| "Provider" means any hospital, skilled nursing facility, | 15 |
| hospice, home
health agency, physician, registered pharmacist | 16 |
| acting within the scope of that
registration, or any other | 17 |
| person or entity licensed in Illinois to furnish
medical care.
| 18 |
| "Qualified high risk pool" has the same meaning given that | 19 |
| term in the
federal Health
Insurance Portability and | 20 |
| Accountability Act of 1996.
| 21 |
| "Resident" means a person who is and continues to be | 22 |
| legally domiciled
and physically residing on a permanent and | 23 |
| full-time basis in a
place of permanent habitation
in this | 24 |
| State
that remains that person's principal residence and from | 25 |
| which that person is
absent only for temporary or transitory | 26 |
| purpose.
|
|
|
|
SB2380 Enrolled |
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LRB095 19723 KBJ 46088 b |
|
| 1 |
| "Skilled nursing facility" means a facility or that portion | 2 |
| of a facility
that is licensed by the Illinois Department of | 3 |
| Public Health under the
Nursing Home Care Act or a comparable | 4 |
| licensing authority in another state
to provide skilled nursing | 5 |
| care.
| 6 |
| "Stop-loss coverage" means an arrangement whereby an | 7 |
| insurer
insures against the risk that any one claim will exceed | 8 |
| a specific dollar
amount or that the entire loss of a | 9 |
| self-insurance plan will exceed
a specific amount.
| 10 |
| "Third party administrator" means an administrator as | 11 |
| defined in
Section 511.101 of the Illinois Insurance Code who | 12 |
| is licensed under
Article XXXI 1/4 of that Code.
| 13 |
| (Source: P.A. 92-153, eff. 7-25-01; 93-33, eff. 6-23-03; 93-34, | 14 |
| eff. 6-23-03; 93-477, eff. 8-8-03; 93-622, eff. 12-18-03.)
| 15 |
| Section 99. Effective date. This Act takes effect upon | 16 |
| becoming law, except that Sections 1 through 30 take effect 90 | 17 |
| days after becoming law.
|
|