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90_HB0705enr
215 ILCS 5/356t new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 130/3009 from Ch. 73, par. 1503-9
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code, Health Maintenance
Organization Act, Limited Health Service Organization Act,
and Voluntary Health Services Plans Act. Provides that
health benefit coverage under those Acts must include
coverage for child health supervision services for children
under the age of 6. Child health supervision services
provide for a periodic review of a child's physical and
emotional status by a physician or under a physician's
supervision. Defines terms. Effective immediately.
LRB9002464JScc
HB0705 Enrolled LRB9002464JScc
1 AN ACT regarding health insurance for children.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Children's Health Insurance Program Act.
6 Section 5. Legislative intent. The General Assembly
7 finds that, for the economic and social benefit of all
8 citizens of the State, it is important to enable low-income
9 children of this State, to the extent funding permits, to
10 access health benefits coverage, especially preventive health
11 care. The General Assembly recognizes that assistance to
12 help families purchase health benefits for low-income
13 children must be provided in a fair and equitable fashion and
14 must treat all children at the same income level in a similar
15 fashion. The State of Illinois should help low-income
16 families transition from a health care system where
17 government partners with families to provide health benefits
18 to low-income children to a system where families with higher
19 incomes eventually transition into private or employer based
20 health plans. This Act is not intended to create an
21 entitlement.
22 Section 10. Definitions. As used in this Act:
23 "Benchmarking" means health benefits coverage as defined
24 in Section 2103 of the Social Security Act.
25 "Child" means a person under the age of 19.
26 "Department" means the Department of Public Aid.
27 "Medical assistance" means health care benefits provided
28 under Article V of the Illinois Public Aid Code.
29 "Medical visit" means a hospital, dental, physician,
30 optical, or other health care visit where services are
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1 provided pursuant to this Act.
2 "Program" means the Children's Health Insurance Program,
3 which includes subsidizing the cost of privately sponsored
4 health insurance and purchasing or providing health care
5 benefits for eligible children.
6 "Resident" means a person who meets the residency
7 requirements as defined in Section 5-3 of the Illinois Public
8 Aid Code.
9 Section 15. Operation of the Program. There is hereby
10 created a Children's Health Insurance Program. The Program
11 shall operate subject to appropriation and shall be
12 administered by the Department of Public Aid. The Department
13 shall have the powers and authority granted to the Department
14 under the Illinois Public Aid Code. The Department may
15 contract with a Third Party Administrator or other entities
16 to administer and oversee any portion of this Program.
17 Section 20. Eligibility.
18 (a) To be eligible for this Program, a person must be a
19 person who has a child eligible under this Act and who is
20 eligible under a waiver of federal requirements pursuant to
21 an application made pursuant to subdivision (a)(1) of Section
22 40 of this Act or who is a child who:
23 (1) is a child who is not eligible for medical
24 assistance;
25 (2) is a child whose annual household income, as
26 determined by the Department, is above 133% of the
27 federal poverty level and at or below 185% of the federal
28 poverty level;
29 (3) is a resident of the State of Illinois; and
30 (4) is a child who is either a United States
31 citizen or included in one of the following categories of
32 non-citizens:
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1 (A) unmarried dependent children of either a
2 United States Veteran honorably discharged or a
3 person on active military duty;
4 (B) refugees under Section 207 of the
5 Immigration and Nationality Act;
6 (C) asylees under Section 208 of the
7 Immigration and Nationality Act;
8 (D) persons for whom deportation has been
9 withheld under Section 243(h) of the Immigration
10 and Nationality Act;
11 (E) persons granted conditional entry under
12 Section 203(a)(7) of the Immigration and Nationality
13 Act as in effect prior to April 1, 1980;
14 (F) persons lawfully admitted for permanent
15 residence under the Immigration and Nationality Act;
16 and
17 (G) parolees, for at least one year, under
18 Section 212(d)(5) of the Immigration and Nationality
19 Act.
20 Those children who are in the categories set forth in
21 subdivisions (4)(F) and (4)(G) of this subsection, who enter
22 the United States on or after August 22, 1996, shall not be
23 eligible for 5 years beginning on the date the child entered
24 the United States.
25 (b) A child who is determined to be eligible for
26 assistance shall remain eligible for 12 months, provided the
27 child maintains his or her residence in the State, has not
28 yet attained 19 years of age, and is not excluded pursuant to
29 subsection (c). Eligibility shall be re-determined by the
30 Department at least annually.
31 (c) A child shall not be eligible for coverage under
32 this Program if:
33 (1) the premium required pursuant to Section 30 of
34 this Act has not been paid. If the required premiums are
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1 not paid the liability of the Program shall be limited to
2 benefits incurred under the Program for the time period
3 for which premiums had been paid. If the required
4 monthly premium is not paid, the child shall be
5 ineligible for re-enrollment for a minimum period of 3
6 months. Re-enrollment shall be completed prior to the
7 next covered medical visit and the first month's required
8 premium shall be paid in advance of the next covered
9 medical visit. The Department shall promulgate rules
10 regarding grace periods, notice requirements, and hearing
11 procedures pursuant to this subsection;
12 (2) the child is an inmate of a public institution
13 or a patient in an institution for mental diseases; or
14 (3) the child is a member of a family that is
15 eligible for health benefits covered under the State of
16 Illinois health benefits plan on the basis of a member's
17 employment with a public agency.
18 Section 25. Health benefits for children.
19 (a) The Department shall, subject to appropriation,
20 provide health benefits coverage to eligible children by:
21 (1) Subsidizing the cost of privately sponsored
22 health insurance, including employer based health
23 insurance, to assist families to take advantage of
24 available privately sponsored health insurance for their
25 eligible children; and
26 (2) Purchasing or providing health care benefits
27 for eligible children. The health benefits provided
28 under this subdivision (a)(2) shall, subject to
29 appropriation and without regard to any applicable cost
30 sharing under Section 30, be identical to the benefits
31 provided for children under the State's approved plan
32 under Title XIX of the Social Security Act. Providers
33 under this subdivision (a)(2) shall be subject to
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1 approval by the Department to provide health care under
2 the Illinois Public Aid Code and shall be reimbursed at
3 the same rate as providers under the State's approved
4 plan under Title XIX of the Social Security Act. In
5 addition, providers may retain co-payments when
6 determined appropriate by the Department.
7 (b) The subsidization provided pursuant to subdivision
8 (a)(1) shall be credited to the family of the eligible child.
9 (c) The Department is prohibited from denying coverage
10 to a child who is enrolled in a privately sponsored health
11 insurance plan pursuant to subdivision (a)(1) because the
12 plan does not meet federal benchmarking standards or cost
13 sharing and contribution requirements. To be eligible for
14 inclusion in the Program, the plan shall contain
15 comprehensive major medical coverage which shall consist of
16 physician and hospital inpatient services. The Department is
17 prohibited from denying coverage to a child who is enrolled
18 in a privately sponsored health insurance plan pursuant to
19 subdivision (a)(1) because the plan offers benefits in
20 addition to physician and hospital inpatient services.
21 (d) The total dollar amount of subsidizing coverage per
22 child per month pursuant to subdivision (a)(1) shall be equal
23 to the average dollar payments, less premiums incurred, per
24 child per month pursuant to subdivision (a)(2). The
25 Department shall set this amount prospectively based upon the
26 prior fiscal year's experience adjusted for incurred but not
27 reported claims and estimated increases or decreases in the
28 cost of medical care. Payments obligated before July 1,
29 1999, will be computed using State Fiscal Year 1996 payments
30 for children eligible for Medical Assistance and income
31 assistance under the Aid to Families with Dependent Children
32 Program, with appropriate adjustments for cost and
33 utilization changes through January 1, 1999. The Department
34 is prohibited from providing a subsidy pursuant to
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1 subdivision (a)(1) that is more than the individual's monthly
2 portion of the premium.
3 (e) An eligible child may obtain immediate coverage
4 under this Program only once during a medical visit. If
5 coverage lapses, re-enrollment shall be completed in advance
6 of the next covered medical visit and the first month's
7 required premium shall be paid in advance of any covered
8 medical visit.
9 (f) In order to accelerate and facilitate the
10 development of networks to deliver services to children in
11 areas outside counties with populations in excess of
12 3,000,000, in the event less than 25% of the eligible
13 children in a county or contiguous counties has enrolled with
14 a Health Maintenance Organization pursuant to Section 5-11 of
15 the Illinois Public Aid Code, the Department may develop and
16 implement demonstration projects to create alternative
17 networks designed to enhance enrollment and participation in
18 the program. The Department shall prescribe by rule the
19 criteria, standards, and procedures for effecting
20 demonstration projects under this Section.
21 Section 30. Cost sharing.
22 (a) Children enrolled in a health benefits program
23 pursuant to subdivision (a)(2) of Section 25 shall be subject
24 to the following cost sharing requirements:
25 (1) There shall be no co-payment required for
26 well-baby or well-child care, including age-appropriate
27 immunizations as required under federal law.
28 (2) Health insurance premiums for children in
29 families whose household income is at or above 150% of
30 the federal poverty level shall be payable monthly,
31 subject to rules promulgated by the Department for grace
32 periods and advance payments, and shall be as follows:
33 (A) $15 per month for one child.
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1 (B) $25 per month for 2 children.
2 (C) $30 per month for 3 or more children.
3 (3) Co-payments for children in families whose
4 income is below 150% of the federal poverty level, at a
5 minimum and to the extent permitted under federal law,
6 shall be $2 for all medical visits and prescriptions
7 provided under this Act.
8 (4) Co-payments for children in families whose
9 income is at or above 150% of the federal poverty level,
10 at a minimum and to the extent permitted under federal
11 law shall be as follows:
12 (A) $5 for medical visits.
13 (B) $3 for generic prescriptions and $5 for
14 brand name prescriptions.
15 (C) $25 for emergency room use for a
16 non-emergency situation as defined by the Department
17 by rule.
18 (5) The maximum amount of out-of-pocket expenses
19 for co-payments shall be $100 per family per year.
20 (b) Individuals enrolled in a privately sponsored health
21 insurance plan pursuant to subdivision (a)(1) of Section 25
22 shall be subject to the cost sharing provisions as stated in
23 the privately sponsored health insurance plan.
24 Section 35. Funding.
25 (a) This Program is not an entitlement and shall not be
26 construed to create an entitlement. Eligibility for the
27 Program is subject to appropriation of funds by the State and
28 federal governments. Subdivision (a)(2) of Section 25 shall
29 operate and be funded only if subdivision (a)(1) of Section
30 25 is operational and funded. The estimated net State share
31 of appropriated funds for subdivision (a)(2) of Section 25
32 shall be equal to the estimated net State share of
33 appropriated funds for subdivision (a)(1) of Section 25.
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1 (b) Any requirement imposed under this Act and any
2 implementation of this Act by the Department shall cease in
3 the event (1) continued receipt of federal funds for
4 implementation of this Act requires an amendment to this Act,
5 or (2) federal funds for implementation of the Act are not
6 otherwise available.
7 (c) Payments under this Act shall be appropriated from
8 the General Revenue Fund.
9 (d) Benefits under this Act shall be available only as
10 long as the intergovernmental agreements made pursuant to
11 Section 12-4.7 and Article XV of the Illinois Public Aid Code
12 and entered into between the Department and the Cook County
13 Board of Commissioners continue to exist.
14 Section 40. Waivers.
15 (a) The Department shall request any necessary waivers
16 of federal requirements in order to allow receipt of federal
17 funding for:
18 (1) the coverage of families with eligible children
19 under this Act; and
20 (2) for the coverage of children who would
21 otherwise be eligible under this Act, but who have health
22 insurance.
23 (b) The failure of the responsible federal agency to
24 approve a waiver for children who would otherwise be eligible
25 under this Act but who have health insurance shall not
26 prevent the implementation of any Section of this Act
27 provided that there are sufficient appropriated funds.
28 Section 45. Study.
29 (a) The Department shall conduct a study which includes,
30 but is not limited to, the following:
31 (1) Establishes estimates, broken down by regions
32 of the State, of the number of children with health
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1 insurance coverage and without health insurance coverage;
2 the number of children who are eligible for Medicaid, and
3 of that number, the number who are enrolled in Medicaid;
4 the number of children with access to dependent coverage
5 through an employer, and of that number, the number who
6 are enrolled in dependent coverage through an employer.
7 (2) Ascertains, for the population of children
8 potentially eligible for coverage under any component of
9 the Program, the extent of access to dependent coverage,
10 how many children are enrolled in dependent coverage, the
11 comprehensiveness of dependent coverage benefit packages
12 available, and the amount of cost sharing currently paid
13 by the employees.
14 (b) The Department shall submit the preliminary results
15 of the study to the Governor and the General Assembly by
16 December 1, 1998 and shall submit the final results to the
17 Governor and the General Assembly by May 1, 1999.
18 Section 50. Program evaluation. The Department shall
19 conduct 2 evaluations of the effectiveness of the program
20 implemented under this Act. The first evaluation shall be
21 for the first 6 full months of implementation, and the
22 evaluation shall be completed within 90 days after that
23 period. The second evaluation shall be for the first 12 full
24 months of implementation and shall be completed within 90
25 days after that period.
26 Section 55. Contracts with non-governmental bodies. All
27 contracts with non-governmental bodies that are determined by
28 the Department to be necessary for the implementation of this
29 Section are deemed to be purchase of care as defined in the
30 Illinois Procurement Code.
31 Section 60. Emergency rulemaking. Prior to June 30,
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1 1999, the Department may adopt rules necessary to establish
2 and implement this Section through the use of emergency
3 rulemaking in accordance with Section 5-45 of the Illinois
4 Administrative Procedure Act. For purposes of that Act, the
5 General Assembly finds that the adoption of rules to
6 implement this Section is deemed an emergency and necessary
7 for the public interest, safety, and welfare.
8 Section 96. Inseverability. The provisions of this Act
9 are mutually dependent and inseverable. If any provision or
10 its application to any person or circumstance is held
11 invalid, then this entire Act is invalid.
12 Section 97. Repealer. This Act is repealed on June 30,
13 2001.
14 Section 98. The Illinois Health Insurance Portability
15 and Accountability Act is amended by changing Section 20 as
16 follows:
17 (215 ILCS 97/20)
18 Sec. 20. Increased portability through limitation on
19 preexisting condition exclusions.
20 (A) Limitation of preexisting condition exclusion
21 period; crediting for periods of previous coverage. Subject
22 to subsection (D), a group health plan, and a health
23 insurance issuer offering group health insurance coverage,
24 may, with respect to a participant or beneficiary, impose a
25 preexisting condition exclusion only if:
26 (1) the exclusion relates to a condition (whether
27 physical or mental), regardless of the cause of the
28 condition, for which medical advice, diagnosis, care, or
29 treatment was recommended or received within the 6-month
30 period ending on the enrollment date;
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1 (2) the exclusion extends for a period of not more
2 than 12 months (or 18 months in the case of a late
3 enrollee) after the enrollment date; and
4 (3) the period of any such preexisting condition
5 exclusion is reduced by the aggregate of the periods of
6 creditable coverage (if any, as defined in subsection
7 (C)(1)) applicable to the participant or beneficiary as
8 of the enrollment date.
9 (B) Preexisting condition exclusion. A group health
10 plan, and health insurance issuer offering group health
11 insurance coverage, may not impose any preexisting condition
12 exclusion relating to pregnancy as a preexisting condition.
13 Genetic information shall not be treated as a condition
14 described in subsection (A)(1) in the absence of a diagnosis
15 of the condition related to such information.
16 (C) Rules relating to crediting previous coverage.
17 (1) Creditable coverage defined. For purposes of
18 this Act, the term "creditable coverage" means, with
19 respect to an individual, coverage of the individual
20 under any of the following:
21 (a) A group health plan.
22 (b) Health insurance coverage.
23 (c) Part A or part B of title XVIII of the
24 Social Security Act.
25 (d) Title XIX of the Social Security Act,
26 other than coverage consisting solely of benefits
27 under Section 1928.
28 (e) Chapter 55 of title 10, United States
29 Code.
30 (f) A medical care program of the Indian
31 Health Service or of a tribal organization.
32 (g) A State health benefits risk pool.
33 (h) A health plan offered under chapter 89 of
34 title 5, United States Code.
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1 (i) A public health plan (as defined in
2 regulations).
3 (j) A health benefit plan under Section 5(e)
4 of the Peace Corps Act (22 U.S.C. 2504(e)).
5 (k) Title XXI of the federal Social Security
6 Act, State Children's Health Insurance Program.
7 Such term does not include coverage consisting
8 solely of coverage of excepted benefits.
9 (2) Excepted benefits. For purposes of this Act,
10 the term "excepted benefits" means benefits under one or
11 more of the following:
12 (a) Benefits not subject to requirements:
13 (i) Coverage only for accident, or
14 disability income insurance, or any combination
15 thereof.
16 (ii) Coverage issued as a supplement to
17 liability insurance.
18 (iii) Liability insurance, including
19 general liability insurance and automobile
20 liability insurance.
21 (iv) Workers' compensation or similar
22 insurance.
23 (v) Automobile medical payment insurance.
24 (vi) Credit-only insurance.
25 (vii) Coverage for on-site medical
26 clinics.
27 (viii) Other similar insurance coverage,
28 specified in regulations, under which benefits
29 for medical care are secondary or incidental to
30 other insurance benefits.
31 (b) Benefits not subject to requirements if
32 offered separately:
33 (i) Limited scope dental or vision
34 benefits.
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1 (ii) Benefits for long-term care, nursing
2 home care, home health care, community-based
3 care, or any combination thereof.
4 (iii) Such other similar, limited
5 benefits as are specified in rules.
6 (c) Benefits not subject to requirements if
7 offered, as independent, noncoordinated benefits:
8 (i) Coverage only for a specified disease
9 or illness.
10 (ii) Hospital indemnity or other fixed
11 indemnity insurance.
12 (d) Benefits not subject to requirements if
13 offered as separate insurance policy. Medicare
14 supplemental health insurance (as defined under
15 Section 1882(g)(1) of the Social Security Act),
16 coverage supplemental to the coverage provided under
17 chapter 55 of title 10, United States Code, and
18 similar supplemental coverage provided to coverage
19 under a group health plan.
20 (3) Not counting periods before significant breaks
21 in coverage.
22 (a) In general. A period of creditable
23 coverage shall not be counted, with respect to
24 enrollment of an individual under a group health
25 plan, if, after such period and before the
26 enrollment date, there was a 63- day period during
27 all of which the individual was not covered under
28 any creditable coverage.
29 (b) Waiting period not treated as a break in
30 coverage. For purposes of subparagraph (a) and
31 subsection (D)(3), any period that an individual is
32 in a waiting period for any coverage under a group
33 health plan (or for group health insurance coverage)
34 or is in an affiliation period (as defined in
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1 subsection (G)(2)) shall not be taken into account
2 in determining the continuous period under
3 subparagraph (a).
4 (4) Method of crediting coverage.
5 (a) Standard method. Except as otherwise
6 provided under subparagraph (b), for purposes of
7 applying subsection (A)(3), a group health plan, and
8 a health insurance issuer offering group health
9 insurance coverage, shall count a period of
10 creditable coverage without regard to the specific
11 benefits covered during the period.
12 (b) Election of alternative method. A group
13 health plan, or a health insurance issuer offering
14 group health insurance, may elect to apply
15 subsection (A)(3) based on coverage of benefits
16 within each of several classes or categories of
17 benefits specified in regulations rather than as
18 provided under subparagraph (a). Such election
19 shall be made on a uniform basis for all
20 participants and beneficiaries. Under such election
21 a group health plan or issuer shall count a period
22 of creditable coverage with respect to any class or
23 category of benefits if any level of benefits is
24 covered within such class or category.
25 (c) Plan notice. In the case of an election
26 with respect to a group health plan under
27 subparagraph (b) (whether or not health insurance
28 coverage is provided in connection with such plan),
29 the plan shall:
30 (i) prominently state in any disclosure
31 statements concerning the plan, and state to
32 each enrollee at the time of enrollment under
33 the plan, that the plan has made such election;
34 and
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1 (ii) include in such statements a
2 description of the effect of this election.
3 (d) Issuer notice. In the case of an election
4 under subparagraph (b) with respect to health
5 insurance coverage offered by an issuer in the small
6 or large group market, the issuer:
7 (i) shall prominently state in any
8 disclosure statements concerning the coverage,
9 and to each employer at the time of the offer
10 or sale of the coverage, that the issuer has
11 made such election; and
12 (ii) shall include in such statements a
13 description of the effect of such election.
14 (5) Establishment of period. Periods of creditable
15 coverage with respect to an individual shall be
16 established through presentation or certifications
17 described in subsection (E) or in such other manner as
18 may be specified in regulations.
19 (D) Exceptions:
20 (1) Exclusion not applicable to certain newborns.
21 Subject to paragraph (3), a group health plan, and a
22 health insurance issuer offering group health insurance
23 coverage, may not impose any preexisting condition
24 exclusion in the case of an individual who, as of the
25 last day of the 30-day period beginning with the date of
26 birth, is covered under creditable coverage.
27 (2) Exclusion not applicable to certain adopted
28 children. Subject to paragraph (3), a group health plan,
29 and a health insurance issuer offering group health
30 insurance coverage, may not impose any preexisting
31 condition exclusion in the case of a child who is adopted
32 or placed for adoption before attaining 18 years of age
33 and who, as of the last day of the 30-day period
34 beginning on the date of the adoption or placement for
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1 adoption, is covered under creditable coverage.
2 The previous sentence shall not apply to coverage
3 before the date of such adoption or placement for
4 adoption.
5 (3) Loss if break in coverage. Paragraphs (1) and
6 (2) shall no longer apply to an individual after the end
7 of the first 63-day period during all of which the
8 individual was not covered under any creditable coverage.
9 (E) Certifications and disclosure of coverage.
10 (1) Requirement for Certification of Period of
11 Creditable Coverage.
12 (a) A group health plan, and a health
13 insurance issuer offering group health insurance
14 coverage, shall provide the certification described
15 in subparagraph (b):
16 (i) at the time an individual ceases to
17 be covered under the plan or otherwise becomes
18 covered under a COBRA continuation provision;
19 (ii) in the case of an individual
20 becoming covered under such a provision, at the
21 time the individual ceases to be covered under
22 such provision; and
23 (iii) on the request on behalf of an
24 individual made not later than 24 months after
25 the date of cessation of the coverage described
26 in clause (i) or (ii), whichever is later.
27 The certification under clause (i) may be provided,
28 to the extent practicable, at a time consistent with
29 notices required under any applicable COBRA
30 continuation provision.
31 (b) The certification described in this
32 subparagraph is a written certification of:
33 (i) the period of creditable coverage of
34 the individual under such plan and the coverage
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1 (if any) under such COBRA continuation
2 provision; and
3 (ii) the waiting period (if any) (and
4 affiliation period, if applicable) imposed with
5 respect to the individual for any coverage
6 under such plan.
7 (c) To the extent that medical care under a
8 group health plan consists of group health insurance
9 coverage, the plan is deemed to have satisfied the
10 certification requirement under this paragraph if
11 the health insurance issuer offering the coverage
12 provides for such certification in accordance with
13 this paragraph.
14 (2) Disclosure of information on previous benefits.
15 In the case of an election described in subsection
16 (C)(4)(b) by a group health plan or health insurance
17 issuer, if the plan or issuer enrolls an individual for
18 coverage under the plan and the individual provides a
19 certification of coverage of the individual under
20 paragraph (1):
21 (a) upon request of such plan or issuer, the
22 entity which issued the certification provided by
23 the individual shall promptly disclose to such
24 requesting plan or issuer information on coverage of
25 classes and categories of health benefits available
26 under such entity's plan or coverage; and
27 (b) such entity may charge the requesting plan
28 or issuer for the reasonable cost of disclosing such
29 information.
30 (3) Rules. The Department shall establish rules to
31 prevent an entity's failure to provide information under
32 paragraph (1) or (2) with respect to previous coverage of
33 an individual from adversely affecting any subsequent
34 coverage of the individual under another group health
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1 plan or health insurance coverage.
2 (4) Treatment of certain plans as group health plan
3 for notice provision. A program under which creditable
4 coverage described in subparagraph (c), (d), (e), or (f)
5 of Section 20(C)(1) is provided shall be treated as a
6 group health plan for purposes of this Section.
7 (F) Special enrollment periods.
8 (1) Individuals losing other coverage. A group
9 health plan, and a health insurance issuer offering group
10 health insurance coverage in connection with a group
11 health plan, shall permit an employee who is eligible,
12 but not enrolled, for coverage under the terms of the
13 plan (or a dependent of such an employee if the dependent
14 is eligible, but not enrolled, for coverage under such
15 terms) to enroll for coverage under the terms of the plan
16 if each of the following conditions is met:
17 (a) The employee or dependent was covered
18 under a group health plan or had health insurance
19 coverage at the time coverage was previously offered
20 to the employee or dependent.
21 (b) The employee stated in writing at such
22 time that coverage under a group health plan or
23 health insurance coverage was the reason for
24 declining enrollment, but only if the plan sponsor
25 or issuer (if applicable) required such a statement
26 at such time and provided the employee with notice
27 of such requirement (and the consequences of such
28 requirement) at such time.
29 (c) The employee's or dependent's coverage
30 described in subparagraph (a):
31 (i) was under a COBRA continuation
32 provision and the coverage under such provision
33 was exhausted; or
34 (ii) was not under such a provision and
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1 either the coverage was terminated as a result
2 of loss of eligibility for the coverage
3 (including as a result of legal separation,
4 divorce, death, termination of employment, or
5 reduction in the number of hours of employment)
6 or employer contributions towards such coverage
7 were terminated.
8 (d) Under the terms of the plan, the employee
9 requests such enrollment not later than 30 days
10 after the date of exhaustion of coverage described
11 in subparagraph (c)(i) or termination of coverage or
12 employer contributions described in subparagraph
13 (c)(ii).
14 (2) For dependent beneficiaries.
15 (a) In general. If:
16 (i) a group health plan makes coverage
17 available with respect to a dependent of an
18 individual,
19 (ii) the individual is a participant
20 under the plan (or has met any waiting period
21 applicable to becoming a participant under the
22 plan and is eligible to be enrolled under the
23 plan but for a failure to enroll during a
24 previous enrollment period), and
25 (iii) a person becomes such a dependent
26 of the individual through marriage, birth, or
27 adoption or placement for adoption,
28 then the group health plan shall provide for a
29 dependent special enrollment period described in
30 subparagraph (b) during which the person (or, if not
31 otherwise enrolled, the individual) may be enrolled
32 under the plan as a dependent of the individual, and
33 in the case of the birth or adoption of a child, the
34 spouse of the individual may be enrolled as a
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1 dependent of the individual if such spouse is
2 otherwise eligible for coverage.
3 (b) Dependent special enrollment period. A
4 dependent special enrollment period under this
5 subparagraph shall be a period of not less than 30
6 days and shall begin on the later of:
7 (i) the date dependent coverage is made
8 available; or
9 (ii) the date of the marriage, birth, or
10 adoption or placement for adoption (as the case
11 may be) described in subparagraph (a)(iii).
12 (c) No waiting period. If an individual seeks
13 to enroll a dependent during the first 30 days of
14 such a dependent special enrollment period, the
15 coverage of the dependent shall become effective:
16 (i) in the case of marriage, not later
17 than the first day of the first month beginning
18 after the date the completed request for
19 enrollment is received;
20 (ii) in the case of a dependent's birth,
21 as of the date of such birth; or
22 (iii) in the case of a dependent's
23 adoption or placement for adoption, the date of
24 such adoption or placement for adoption.
25 (G) Use of affiliation period by HMOs as alternative to
26 preexisting condition exclusion.
27 (1) In general. A health maintenance organization
28 which offers health insurance coverage in connection with
29 a group health plan and which does not impose any
30 pre-existing condition exclusion allowed under subsection
31 (A) with respect to any particular coverage option may
32 impose an affiliation period for such coverage option,
33 but only if:
34 (a) such period is applied uniformly without
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1 regard to any health status-related factors; and
2 (b) such period does not exceed 2 months (or 3
3 months in the case of a late enrollee).
4 (2) Affiliation period.
5 (a) Defined. For purposes of this Act, the
6 term "affiliation period" means a period which,
7 under the terms of the health insurance coverage
8 offered by the health maintenance organization, must
9 expire before the health insurance coverage becomes
10 effective. The organization is not required to
11 provide health care services or benefits during such
12 period and no premium shall be charged to the
13 participant or beneficiary for any coverage during
14 the period.
15 (b) Beginning. Such period shall begin on the
16 enrollment date.
17 (c) Runs concurrently with waiting periods.
18 An affiliation period under a plan shall run
19 concurrently with any waiting period under the plan.
20 (3) Alternative methods. A health maintenance
21 organization described in paragraph (1) may use
22 alternative methods, from those described in such
23 paragraph, to address adverse selection as approved by
24 the Department.
25 (Source: P.A. 90-30, eff. 7-1-97.)
26 Section 99. Effective Date. This Act takes effect upon
27 becoming law.