State of Illinois
92nd General Assembly
Legislation

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[ Introduced ][ Enrolled ][ House Amendment 001 ]


92_HB3004eng

 
HB3004 Engrossed                               LRB9200745JSpc

 1        AN ACT to amend the Comprehensive Health  Insurance  Plan
 2    Act by changing Sections 2 and 15.

 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 Sections 2 and 15 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.
 
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 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 90 63 days during
32    all of which the individual was  not  covered  under  any  of
33    items  (A)  through (K) above.  Any period that an individual
34    is in a waiting period for any coverage under a group  health
 
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 1    plan  (or  for  group  health insurance coverage) or is in an
 2    affiliation  period  under  the  terms  of  health  insurance
 3    coverage offered by a health maintenance  organization  shall
 4    not  be taken into account in determining if there has been a
 5    break of more than 90 63  days  in  any  creditable  credible
 6    coverage.
 7        "Department" means the Illinois Department of Insurance.
 8        "Dependent"  means an Illinois resident: who is a spouse;
 9    or who is claimed as a dependent by the principal insured for
10    purposes of filing a federal income tax return and resides in
11    the  principal  insured's  household,  and  is   a   resident
12    unmarried  child  under  the  age  of  19 years; or who is an
13    unmarried child who also is a full-time student under the age
14    of 23  years  and  who  is  financially  dependent  upon  the
15    principal  insured;  or  who is a child of any age and who is
16    disabled  and  financially  dependent  upon   the   principal
17    insured.
18        "Direct  Illinois premiums" means, for Illinois business,
19    an insurer's direct premium income for the kinds of  business
20    described  in  clause (b) of Class 1 or clause (a) of Class 2
21    of Section 4 of  the  Illinois  Insurance  Code,  and  direct
22    premium  income  of  a  health  maintenance organization or a
23    voluntary health services plan, except it shall  not  include
24    credit  health  insurance as defined in Article IX 1/2 of the
25    Illinois Insurance Code.
26        "Director" means the Director of the Illinois  Department
27    of Insurance.
28        "Eligible  person"  means  a  resident  of this State who
29    qualifies for Plan coverage under Section 7 of this Act.
30        "Employee" means a resident of this State who is employed
31    by an employer or has entered into the employment of or works
32    under contract  or  service  of  an  employer  including  the
33    officers,  managers and employees of subsidiary or affiliated
34    corporations and the  individual  proprietors,  partners  and
 
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 1    employees  of  affiliated  individuals  and  firms  when  the
 2    business  of the subsidiary or affiliated corporations, firms
 3    or individuals is controlled by  a  common  employer  through
 4    stock ownership, contract, or otherwise.
 5        "Employer"    means    any    individual,    partnership,
 6    association,  corporation,  business  trust, or any person or
 7    group  of  persons  acting  directly  or  indirectly  in  the
 8    interest of an employer in relation to an employee, for which
 9    one or more persons is gainfully employed.
10        "Family" coverage means the coverage provided by the Plan
11    for the covered person and his or her eligible dependents who
12    also are covered persons.
13        "Federally  eligible  individual"  means  an   individual
14    resident of this State:
15             (1)(A)  for  whom,  as  of  the  date  on  which the
16        individual seeks Plan coverage under Section 15  of  this
17        Act,  the aggregate of the periods of creditable coverage
18        is 18 or more months, and (B)  whose  most  recent  prior
19        creditable  coverage  was  under  group  health insurance
20        coverage offered by a health insurance  issuer,  a  group
21        health  plan,  a  governmental plan, or a church plan (or
22        health insurance coverage offered in connection with  any
23        such plans) or any other type of creditable coverage that
24        may   be   required   by  the  federal  Health  Insurance
25        Portability and Accountability Act of 1996, as it may  be
26        amended, or the regulations under that Act;
27             (2)  who  is  not  eligible for coverage under (A) a
28        group health plan, (B) part A or part B of  Medicare  due
29        to  age,  or  (C)  medical  assistance, and does not have
30        other health insurance coverage;
31             (3)  with respect to whom the most  recent  coverage
32        within  the coverage period described in paragraph (1)(A)
33        of this definition was not terminated based upon a factor
34        relating to nonpayment of premiums or fraud;
 
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 1             (4)  if the individual had been offered  the  option
 2        of  continuation  coverage  under  a  COBRA  continuation
 3        provision  or  under a similar State program, who elected
 4        such coverage; and
 5             (5)  who,   if   the   individual    elected    such
 6        continuation  coverage,  has  exhausted such continuation
 7        coverage under such provision or program.
 8        "Group health insurance coverage"  means,  in  connection
 9    with  a  group health plan, health insurance coverage offered
10    in connection with that plan.
11        "Group health plan" has the same meaning given that  term
12    in    the    federal   Health   Insurance   Portability   and
13    Accountability Act of 1996.
14        "Governmental plan" has the same meaning given that  term
15    in    the    federal   Health   Insurance   Portability   and
16    Accountability Act of 1996.
17        "Health insurance coverage" means benefits consisting  of
18    medical   care   (provided  directly,  through  insurance  or
19    reimbursement, or otherwise and including items and  services
20    paid  for  as  medical  care)  under any hospital and medical
21    expense-incurred policy, certificate, or contract provided by
22    an insurer, non-profit health  care  service  plan  contract,
23    health maintenance organization or other subscriber contract,
24    or any other health care plan or arrangement that pays for or
25    furnishes   medical   or  health  care  services  whether  by
26    insurance or otherwise.  Health insurance coverage shall  not
27    include   short   term,  accident  only,  disability  income,
28    hospital confinement or fixed indemnity, dental only,  vision
29    only,  limited  benefit, or credit insurance, coverage issued
30    as a supplement to liability insurance, insurance arising out
31    of  a  workers'  compensation  or  similar  law,   automobile
32    medical-payment  insurance, or insurance under which benefits
33    are payable with or without regard  to  fault  and  which  is
34    statutorily   required  to  be  contained  in  any  liability
 
HB3004 Engrossed            -6-                LRB9200745JSpc
 1    insurance policy or equivalent self-insurance.
 2        "Health insurance issuer"  means  an  insurance  company,
 3    insurance  service,  or  insurance  organization (including a
 4    health  maintenance  organization  and  a  voluntary   health
 5    services   plan)   that  is  authorized  to  transact  health
 6    insurance business in this State.  Such term does not include
 7    a group health plan.
 8        "Health Maintenance Organization" means  an  organization
 9    as defined in the Health Maintenance Organization Act.
10        "Hospice"  means  a  program  as  defined in and licensed
11    under the Hospice Program Licensing Act.
12        "Hospital" means a duly licensed institution  as  defined
13    in  the Hospital Licensing Act, an institution that meets all
14    comparable conditions and requirements in effect in the state
15    in which  it  is  located,  or  the  University  of  Illinois
16    Hospital  as  defined  in the University of Illinois Hospital
17    Act.
18        "Individual  health  insurance  coverage"  means   health
19    insurance  coverage  offered to individuals in the individual
20    market, but does  not  include  short-term,  limited-duration
21    insurance.
22        "Insured" means any individual resident of this State who
23    is  eligible  to receive benefits from any insurer (including
24    health insurance coverage offered in connection with a  group
25    health  plan)  or  health insurance issuer as defined in this
26    Section.
27        "Insurer"  means  any  insurance  company  authorized  to
28    transact health insurance business  in  this  State  and  any
29    corporation  that  provides medical services and is organized
30    under the Voluntary Health Services Plans Act or  the  Health
31    Maintenance Organization Act.
32        "Medical  assistance"  means the State medical assistance
33    or medical assistance no grant (MANG) programs provided under
34    Title XIX of the Social Security Act and Articles V  (Medical
 
HB3004 Engrossed            -7-                LRB9200745JSpc
 1    Assistance)  and  VI  (General  Assistance)  of  the Illinois
 2    Public Aid Code (or  any  successor  program)  or  under  any
 3    similar program of health care benefits in a state other than
 4    Illinois.
 5        "Medically  necessary"  means  that  a  service, drug, or
 6    supply is necessary and  appropriate  for  the  diagnosis  or
 7    treatment  of  an  illness or injury in accord with generally
 8    accepted standards  of  medical  practice  at  the  time  the
 9    service,  drug,  or  supply  is  provided.  When specifically
10    applied to a confinement it further means that the  diagnosis
11    or  treatment  of  the  covered  person's medical symptoms or
12    condition cannot be safely provided  to  that  person  as  an
13    outpatient. A service, drug, or supply shall not be medically
14    necessary if it: (i) is investigational, experimental, or for
15    research  purposes;  or  (ii)  is  provided  solely  for  the
16    convenience  of the patient, the patient's family, physician,
17    hospital, or any other provider; or (iii) exceeds  in  scope,
18    duration,  or  intensity that level of care that is needed to
19    provide  safe,  adequate,  and   appropriate   diagnosis   or
20    treatment;  or (iv) could have been omitted without adversely
21    affecting the covered person's condition or  the  quality  of
22    medical  care;  or  (v) involves the use of a medical device,
23    drug, or substance not formally approved by the United States
24    Food and Drug Administration.
25        "Medical care" means the ordinary and usual  professional
26    services  rendered by a physician or other specified provider
27    during a professional visit for treatment of  an  illness  or
28    injury.
29        "Medicare" means coverage under both Part A and Part B of
30    Title  XVIII of the Social Security Act, 42 U.S.C. Sec. 1395,
31    et seq.
32        "Minimum premium plan" means  an  arrangement  whereby  a
33    specified  amount  of  health care claims is self-funded, but
34    the insurance company  assumes  the  risk  that  claims  will
 
HB3004 Engrossed            -8-                LRB9200745JSpc
 1    exceed that amount.
 2        "Participating   transplant   center"  means  a  hospital
 3    designated by the Board as a preferred or exclusive  provider
 4    of  services  for one or more specified human organ or tissue
 5    transplants for which the hospital has  signed  an  agreement
 6    with  the  Board to accept a transplant payment allowance for
 7    all expenses related to the transplant  during  a  transplant
 8    benefit period.
 9        "Physician"  means a person licensed to practice medicine
10    pursuant to the Medical Practice Act of 1987.
11        "Plan" means  the  Comprehensive  Health  Insurance  Plan
12    established by this Act.
13        "Plan  of  operation"  means the plan of operation of the
14    Plan, including articles, bylaws and operating rules, adopted
15    by the board pursuant to this Act.
16        "Provider" means any hospital, skilled nursing  facility,
17    hospice, home health agency, physician, registered pharmacist
18    acting  within  the  scope of that registration, or any other
19    person or entity licensed  in  Illinois  to  furnish  medical
20    care.
21        "Qualified  high  risk  pool"  has the same meaning given
22    that term in the federal  Health  Insurance  Portability  and
23    Accountability Act of 1996.
24        "Resident"  means  a  person  who  is and continues to be
25    legally domiciled and physically residing on a permanent  and
26    full-time  basis  in  a place of permanent habitation in this
27    State that remains that person's principal residence and from
28    which that person is absent only for temporary or  transitory
29    purpose.
30        "Skilled  nursing  facility"  means  a  facility  or that
31    portion of a  facility  that  is  licensed  by  the  Illinois
32    Department  of  Public Health under the Nursing Home Care Act
33    or a comparable  licensing  authority  in  another  state  to
34    provide skilled nursing care.
 
HB3004 Engrossed            -9-                LRB9200745JSpc
 1        "Stop-loss  coverage"  means  an  arrangement  whereby an
 2    insurer insures against the risk  that  any  one  claim  will
 3    exceed  a specific dollar amount or that the entire loss of a
 4    self-insurance plan will exceed a specific amount.
 5        "Third party administrator"  means  an  administrator  as
 6    defined in Section 511.101 of the Illinois Insurance Code who
 7    is licensed under Article XXXI 1/4 of that Code.
 8    (Source:  P.A.  90-30,  eff.  7-1-97;  91-357,  eff. 7-29-99;
 9    91-735, eff. 6-2-00.)

10        (215 ILCS 105/15)
11        Sec. 15.  Alternative  portable  coverage  for  federally
12    eligible individuals.
13        (a)  Notwithstanding the requirements of subsection a. of
14    Section  7, any federally eligible individual for whom a Plan
15    application, and such enclosures and supporting documentation
16    as the Board may require, is received by the Board within  90
17    63  days  after  the termination of prior creditable coverage
18    shall qualify to enroll in the  Plan  under  the  portability
19    provisions of this Section.
20        (b)  Any   federally  eligible  individual  seeking  Plan
21    coverage under this Section  must  submit  with  his  or  her
22    application    evidence,    including    acceptable   written
23    certification of  previous  creditable  coverage,  that  will
24    establish  to  the Board's satisfaction, that he or she meets
25    all of the requirements to be a federally eligible individual
26    and is currently and permanently residing in this  State  (as
27    of  the  date  his  or  her  application  was received by the
28    Board).
29        (c)  A  period  of  creditable  coverage  shall  not   be
30    counted,  with  respect  to  qualifying an applicant for Plan
31    coverage  as  a  federally  eligible  individual  under  this
32    Section, if after such period and before the application  for
33    Plan coverage was received by the Board, there was at least a
 
HB3004 Engrossed            -10-               LRB9200745JSpc
 1    90  63  day period during all of which the individual was not
 2    covered under any creditable coverage.
 3        (d)  Any federally  eligible  individual  who  the  Board
 4    determines  qualifies  for  Plan  coverage under this Section
 5    shall be offered his or her choice of  enrolling  in  one  of
 6    alternative  portability health benefit plans which the Board
 7    is authorized under  this  Section  to  establish  for  these
 8    federally eligible individuals and their dependents.
 9        (e)  The  Board  shall  offer  a  choice  of  health care
10    coverages consistent with major medical  coverage  under  the
11    alternative  health  benefit plans authorized by this Section
12    to every federally eligible individual. The coverages  to  be
13    offered   under   the   plans,   the  schedule  of  benefits,
14    deductibles, co-payments, exclusions, and  other  limitations
15    shall  be  approved  by  the  Board.   One  optional  form of
16    coverage  shall  be  comparable   to   comprehensive   health
17    insurance  coverage  offered in the individual market in this
18    State or a standard option of coverage  available  under  the
19    group  or individual health insurance laws of the State.  The
20    standard benefit plan that is authorized by Section 8 of this
21    Act may be used for this purpose.  The Board may also offer a
22    preferred provider option and such other options as the Board
23    determines may be appropriate for  these  federally  eligible
24    individuals  who  qualify  for Plan coverage pursuant to this
25    Section.
26        (f)  Notwithstanding the requirements of subsection f. of
27    Section 8, any plan coverage  that  is  issued  to  federally
28    eligible individuals who qualify for the Plan pursuant to the
29    portability  provisions  of this Section shall not be subject
30    to any preexisting conditions exclusion, waiting  period,  or
31    other similar limitation on coverage.
32        (g)  Federally   eligible  individuals  who  qualify  and
33    enroll in the Plan pursuant to this Section shall be required
34    to pay such premium rates as the Board  shall  establish  and
 
HB3004 Engrossed            -11-               LRB9200745JSpc
 1    approve in accordance with the requirements of Section 7.1 of
 2    this Act.
 3        (h)  A  federally  eligible  individual who qualifies and
 4    enrolls in the Plan pursuant to this Section must satisfy  on
 5    an ongoing basis all of the other eligibility requirements of
 6    this  Act  to  the  extent  not inconsistent with the federal
 7    Health Insurance Portability and Accountability Act  of  1996
 8    in order to maintain continued eligibility for coverage under
 9    the Plan.
10    (Source: P.A. 90-30, eff. 7-1-97.)

11        Section  99.  Effective date.  This Act takes effect upon
12    becoming law.

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