State of Illinois
92nd General Assembly

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 1        AN ACT  concerning  the  comprehensive  health  insurance
 2    plan.

 3        Be  it  enacted  by  the People of the State of Illinois,
 4    represented in the General Assembly:

 5        Section 5.  The Comprehensive Health Insurance  Plan  Act
 6    is amended by changing Section 2 as follows:

 7        (215 ILCS 105/2) (from Ch. 73, par. 1302)
 8        Sec.  2.  Definitions.   As  used In this Act, unless the
 9    context otherwise requires:
10        "Plan administrator" means the  insurer  or  third  party
11    administrator designated under Section 5 of this Act.
12        "Benefits  plan"  means the coverage to be offered by the
13    Plan to eligible persons and federally  eligible  individuals
14    pursuant to this Act.
15        "Board" means the Illinois Comprehensive Health Insurance
16    Board.
17        "Church plan" has the same meaning given that term in the
18    federal  Health  Insurance Portability and Accountability Act
19    of 1996.
20        "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
24    coverage  pursuant  to  any  continuation  provisions   under
25    federal  or  State  law,  including  the Consolidated Omnibus
26    Budget  Reconciliation  Act  of  1985  (COBRA),  as  amended,
27    Sections 367.2 and 367e of the Illinois  Insurance  Code,  or
28    any other similar requirement in another State.
29        "Covered  person"  means a person who is and continues to
30    remain eligible for Plan coverage and is covered under one of
31    the benefit plans offered by the Plan.
                            -2-                LRB9205282JSpc
 1        "Creditable coverage" means, with respect to a  federally
 2    eligible  individual, coverage of the individual under any of
 3    the following:
 4             (A)  A group health plan.
 5             (B)  Health  insurance  coverage  (including   group
 6        health insurance coverage).
 7             (C)  Medicare.
 8             (D)  Medical assistance.
 9             (E)  Chapter 55 of title 10, United States Code.
10             (F)  A  medical  care  program  of the Indian Health
11        Service or of a tribal organization.
12             (G)  A state health benefits risk pool.
13             (H)  A health plan offered under Chapter 89 of title
14        5, United States Code.
15             (I)  A public health plan (as defined in regulations
16        consistent  with  Section  104   of   the   Health   Care
17        Portability  and  Accountability  Act of 1996 that may be
18        promulgated by the Secretary of the  U.S.  Department  of
19        Health and Human Services).
20             (J)  A health benefit plan under Section 5(e) of the
21        Peace Corps Act (22 U.S.C. 2504(e)).
22             (K)  Any  other  qualifying coverage required by the
23        federal Health Insurance Portability  and  Accountability
24        Act  of  1996, as it may be amended, or regulations under
25        that Act.
26        "Creditable   coverage"   does   not   include   coverage
27    consisting  solely  of  coverage  of  excepted  benefits  (as
28    defined in Section 2791(c)  of  title  XXVII  of  the  Public
29    Health  Service Act (42 U.S.C. 300 gg-91) nor does it include
30    any period of coverage under any of  items  (A)  through  (K)
31    that  occurred before a break of more than 63 days during all
32    of which the individual was not covered under  any  of  items
33    (A) through (K) above.  Any period that an individual is in a
34    waiting period for any coverage under a group health plan (or
                            -3-                LRB9205282JSpc
 1    for  group health insurance coverage) or is in an affiliation
 2    period under the terms of health insurance  coverage  offered
 3    by  a health maintenance organization shall not be taken into
 4    account in determining if there has been a break of more than
 5    63 days in any credible coverage.
 6        "Department" means the Illinois Department of Insurance.
 7        "Dependent" means an Illinois resident: who is a  spouse;
 8    or who is claimed as a dependent by the principal insured for
 9    purposes of filing a federal income tax return and resides in
10    the   principal   insured's  household,  and  is  a  resident
11    unmarried child under the age of  19  years;  or  who  is  an
12    unmarried child who also is a full-time student under the age
13    of  23  years  and  who  is  financially  dependent  upon the
14    principal insured; or who is a child of any age  and  who  is
15    disabled   and   financially  dependent  upon  the  principal
16    insured.
17        "Direct Illinois premiums" means, for Illinois  business,
18    an  insurer's direct premium income for the kinds of business
19    described in clause (b) of Class 1 or clause (a) of  Class  2
20    of  Section  4  of  the  Illinois  Insurance Code, and direct
21    premium income of a  health  maintenance  organization  or  a
22    voluntary  health  services plan, except it shall not include
23    credit health insurance as defined in Article IX 1/2  of  the
24    Illinois Insurance Code.
25        "Director"  means the Director of the Illinois Department
26    of Insurance.
27        "Eligible person" means a  resident  of  this  State  who
28    qualifies for Plan coverage under Section 7 of this Act.
29        "Employee" means a resident of this State who is employed
30    by an employer or has entered into the employment of or works
31    under  contract  or  service  of  an  employer  including the
32    officers, managers and employees of subsidiary or  affiliated
33    corporations  and  the  individual  proprietors, partners and
34    employees  of  affiliated  individuals  and  firms  when  the
                            -4-                LRB9205282JSpc
 1    business of the subsidiary or affiliated corporations,  firms
 2    or  individuals  is  controlled  by a common employer through
 3    stock ownership, contract, or otherwise.
 4        "Employer"    means    any    individual,    partnership,
 5    association, corporation, business trust, or  any  person  or
 6    group  of  persons  acting  directly  or  indirectly  in  the
 7    interest of an employer in relation to an employee, for which
 8    one or more persons is gainfully employed.
 9        "Family" coverage means the coverage provided by the Plan
10    for the covered person and his or her eligible dependents who
11    also are covered persons.
12        "Federally   eligible  individual"  means  an  individual
13    resident of this State:
14             (1)(A)  for whom,  as  of  the  date  on  which  the
15        individual  seeks  Plan coverage under Section 15 of this
16        Act, the aggregate of the periods of creditable  coverage
17        is  18  or  more  months, and (B) whose most recent prior
18        creditable coverage  was  under  group  health  insurance
19        coverage  offered  by  a health insurance issuer, a group
20        health plan, a governmental plan, or a  church  plan  (or
21        health  insurance coverage offered in connection with any
22        such plans) or any other type of creditable coverage that
23        may  be  required  by  the   federal   Health   Insurance
24        Portability  and Accountability Act of 1996, as it may be
25        amended, or the regulations under that Act;
26             (2)  who is not eligible for coverage  under  (A)  a
27        group  health  plan, (B) part A or part B of Medicare, or
28        (C) medical assistance, and does not  have  other  health
29        insurance coverage;
30             (3)  with  respect  to whom the most recent coverage
31        within the coverage period described in paragraph  (1)(A)
32        of this definition was not terminated based upon a factor
33        relating to nonpayment of premiums or fraud;
34             (4)  if  the  individual had been offered the option
                            -5-                LRB9205282JSpc
 1        of  continuation  coverage  under  a  COBRA  continuation
 2        provision or under a similar State program,  who  elected
 3        such coverage; and
 4             (5)  who,    if    the   individual   elected   such
 5        continuation coverage, has  exhausted  such  continuation
 6        coverage under such provision or program.
 7        "Group  health  insurance  coverage" means, in connection
 8    with a group health plan, health insurance  coverage  offered
 9    in connection with that plan.
10        "Group  health plan" has the same meaning given that term
11    in   the   federal   Health   Insurance    Portability    and
12    Accountability Act of 1996.
13        "Governmental  plan" has the same meaning given that term
14    in   the   federal   Health   Insurance    Portability    and
15    Accountability Act of 1996.
16        "Health  insurance coverage" means benefits consisting of
17    medical  care  (provided  directly,  through   insurance   or
18    reimbursement,  or otherwise and including items and services
19    paid for as medical care)  under  any  hospital  and  medical
20    expense-incurred policy, certificate, or contract provided by
21    an  insurer,  non-profit  health  care service plan contract,
22    health maintenance organization or other subscriber contract,
23    or any other health care plan or arrangement that pays for or
24    furnishes  medical  or  health  care  services   whether   by
25    insurance  or otherwise.  Health insurance coverage shall not
26    include  short  term,  accident  only,   disability   income,
27    hospital  confinement or fixed indemnity, dental only, vision
28    only, limited benefit, or credit insurance,  coverage  issued
29    as a supplement to liability insurance, insurance arising out
30    of   a  workers'  compensation  or  similar  law,  automobile
31    medical-payment insurance, or insurance under which  benefits
32    are  payable  with  or  without  regard to fault and which is
33    statutorily  required  to  be  contained  in  any   liability
34    insurance policy or equivalent self-insurance.
                            -6-                LRB9205282JSpc
 1        "Health  insurance  issuer"  means  an insurance company,
 2    insurance service, or  insurance  organization  (including  a
 3    health   maintenance  organization  and  a  voluntary  health
 4    services  plan)  that  is  authorized  to   transact   health
 5    insurance business in this State.  Such term does not include
 6    a group health plan.
 7        "Health  Maintenance  Organization" means an organization
 8    as defined in the Health Maintenance Organization Act.
 9        "Hospice" means a program  as  defined  in  and  licensed
10    under the Hospice Program Licensing Act.
11        "Hospital"  means  a duly licensed institution as defined
12    in the Hospital Licensing Act, an institution that meets  all
13    comparable conditions and requirements in effect in the state
14    in  which  it  is  located,  or  the  University  of Illinois
15    Hospital as defined in the University  of  Illinois  Hospital
16    Act.
17        "Individual   health  insurance  coverage"  means  health
18    insurance coverage offered to individuals in  the  individual
19    market,  but  does  not  include short-term, limited-duration
20    insurance.
21        "Insured" means any individual resident of this State who
22    is eligible to receive benefits from any  insurer  (including
23    health  insurance coverage offered in connection with a group
24    health plan) or health insurance issuer as  defined  in  this
25    Section.
26        "Insurer"  means  any  insurance  company  authorized  to
27    transact  health  insurance  business  in  this State and any
28    corporation that provides medical services and  is  organized
29    under  the  Voluntary Health Services Plans Act or the Health
30    Maintenance Organization Act.
31        "Medical assistance" means the State  medical  assistance
32    or medical assistance no grant (MANG) programs provided under
33    Title  XIX of the Social Security Act and Articles V (Medical
34    Assistance) and  VI  (General  Assistance)  of  the  Illinois
                            -7-                LRB9205282JSpc
 1    Public  Aid  Code  (or  any  successor  program) or under any
 2    similar program of health care benefits in a state other than
 3    Illinois.
 4        "Medically necessary" means  that  a  service,  drug,  or
 5    supply  is  necessary  and  appropriate  for the diagnosis or
 6    treatment of an illness or injury in  accord  with  generally
 7    accepted  standards  of  medical  practice  at  the  time the
 8    service, drug,  or  supply  is  provided.  When  specifically
 9    applied  to a confinement it further means that the diagnosis
10    or treatment of the  covered  person's  medical  symptoms  or
11    condition  cannot  be  safely  provided  to that person as an
12    outpatient. A service, drug, or supply shall not be medically
13    necessary if it: (i) is investigational, experimental, or for
14    research  purposes;  or  (ii)  is  provided  solely  for  the
15    convenience of the patient, the patient's family,  physician,
16    hospital,  or  any other provider; or (iii) exceeds in scope,
17    duration, or intensity that level of care that is  needed  to
18    provide   safe,   adequate,   and  appropriate  diagnosis  or
19    treatment; or (iv) could have been omitted without  adversely
20    affecting  the  covered  person's condition or the quality of
21    medical care; or (v) involves the use of  a  medical  device,
22    drug, or substance not formally approved by the United States
23    Food and Drug Administration.
24        "Medical  care" means the ordinary and usual professional
25    services rendered by a physician or other specified  provider
26    during  a  professional  visit for treatment of an illness or
27    injury.
28        "Medicare" means coverage under both Part A and Part B of
29    Title XVIII of the Social Security Act, 42 U.S.C. Sec.  1395,
30    et seq.
31        "Minimum  premium  plan"  means  an arrangement whereby a
32    specified amount of health care claims  is  self-funded,  but
33    the  insurance  company  assumes  the  risk  that claims will
34    exceed that amount.
                            -8-                LRB9205282JSpc
 1        "Participating  transplant  center"  means   a   hospital
 2    designated  by the Board as a preferred or exclusive provider
 3    of services for one or more specified human organ  or  tissue
 4    transplants  for  which  the hospital has signed an agreement
 5    with the Board to accept a transplant payment  allowance  for
 6    all  expenses  related  to the transplant during a transplant
 7    benefit period.
 8        "Physician" means a person licensed to practice  medicine
 9    pursuant to the Medical Practice Act of 1987.
10        "Plan"  means  the  Comprehensive  Health  Insurance Plan
11    established by this Act.
12        "Plan of operation" means the plan of  operation  of  the
13    Plan, including articles, bylaws and operating rules, adopted
14    by the board pursuant to this Act.
15        "Provider"  means any hospital, skilled nursing facility,
16    hospice, home health agency, physician, registered pharmacist
17    acting within the scope of that registration,  or  any  other
18    person  or  entity  licensed  in  Illinois to furnish medical
19    care.
20        "Qualified high risk pool" has  the  same  meaning  given
21    that  term  in  the  federal Health Insurance Portability and
22    Accountability Act of 1996.
23        "Resident" means a person who  is  and  continues  to  be
24    legally  domiciled and physically residing on a permanent and
25    full-time basis in a place of permanent  habitation  in  this
26    State that remains that person's principal residence and from
27    which  that person is absent only for temporary or transitory
28    purpose.
29        "Skilled nursing  facility"  means  a  facility  or  that
30    portion  of  a  facility  that  is  licensed  by the Illinois
31    Department of Public Health under the Nursing Home  Care  Act
32    or  a  comparable  licensing  authority  in  another state to
33    provide skilled nursing care.
34        "Stop-loss coverage"  means  an  arrangement  whereby  an
                            -9-                LRB9205282JSpc
 1    insurer  insures  against  the  risk  that any one claim will
 2    exceed a specific dollar amount or that the entire loss of  a
 3    self-insurance plan will exceed a specific amount.
 4        "Third  party  administrator"  means  an administrator as
 5    defined in Section 511.101 of the Illinois Insurance Code who
 6    is licensed under Article XXXI 1/4 of that Code.
 7    (Source: P.A.  90-30,  eff.  7-1-97;  91-357,  eff.  7-29-99;
 8    91-735, eff. 6-2-00.)

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