State of Illinois
92nd General Assembly
Legislation

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92_HB5606

 
                                               LRB9213627JSpc

 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 8 as follows:

 7        (215 ILCS 105/8) (from Ch. 73, par. 1308)
 8        Sec. 8.  Minimum benefits.
 9        a.  Availability.  The  Plan  shall  offer in an annually
10    renewable policy major  medical  expense  coverage  to  every
11    eligible  person  who  is  not  eligible for Medicare.  Major
12    medical expense coverage offered by the  Plan  shall  pay  an
13    eligible  person's  covered expenses, subject to limit on the
14    deductible  and   coinsurance   payments   authorized   under
15    paragraph  (4)  of  subsection  d  of  this  Section, up to a
16    lifetime benefit limit of $1,000,000 per covered  individual.
17    The  maximum limit under this subsection shall not be altered
18    by the Board, and no  actuarial  equivalent  benefit  may  be
19    substituted  by  the  Board.  Any  person who otherwise would
20    qualify for coverage under the Plan, but is excluded  because
21    he or she is eligible for Medicare, shall be eligible for any
22    separate  Medicare  supplement  policy  or policies which the
23    Board may offer.
24        b.  Outline  of  benefits.   Covered  expenses  shall  be
25    limited  to  the  usual  and  customary   charge,   including
26    negotiated  fees,  in the locality for the following services
27    and articles when prescribed by a physician and determined by
28    the Plan to be medically necessary for the following areas of
29    services, subject to such separate deductibles,  co-payments,
30    exclusions,  and  other limitations on benefits  as the Board
31    shall establish and approve, and the other provisions of this
 
                            -2-                LRB9213627JSpc
 1    Section:
 2             (1)  Hospital services,  except  that  any  services
 3        provided by a hospital that is located more than 75 miles
 4        outside the State of Illinois shall be covered only for a
 5        maximum of 45 days in any calendar year.  With respect to
 6        covered expenses incurred during any calendar year ending
 7        on  or after December 31, 1999, inpatient hospitalization
 8        of an eligible person for the treatment of mental illness
 9        at a hospital located within the State of Illinois  shall
10        be  subject  to  the same terms and conditions as for any
11        other illness.
12             (2)  Professional  services  for  the  diagnosis  or
13        treatment of injuries,  illnesses  or  conditions,  other
14        than dental and mental and nervous disorders as described
15        in  paragraph (17), which are rendered by a physician, or
16        by  other  licensed  professionals  at  the   physician's
17        direction.  This includes reconstruction of the breast on
18        which   a   mastectomy   was   performed;   surgery   and
19        reconstruction  of  the  other  breast   to   produce   a
20        symmetrical  appearance;  and prostheses and treatment of
21        physical complications at all stages of  the  mastectomy,
22        including lymphedemas.
23             (2.5)  Professional services provided by a physician
24        to  children  under  the  age  of  16  years for physical
25        examinations and age appropriate immunizations ordered by
26        a physician licensed to  practice  medicine  in  all  its
27        branches.
28             (3)  (Blank).
29             (4)  Outpatient   prescription  drugs  that  by  law
30        require a prescription written by a physician licensed to
31        practice medicine in all its  branches  subject  to  such
32        separate  deductible, copayment, and other limitations or
33        restrictions as the Board shall  approve,  including  the
34        use  of a prescription drug card or any other program, or
 
                            -3-                LRB9213627JSpc
 1        both.
 2             (5)  Skilled nursing services of a licensed  skilled
 3        nursing  facility  for  not  more  than 120 days during a
 4        policy year.
 5             (6)  Services of a home health agency in accord with
 6        a home health care plan, up to a maximum  of  270  visits
 7        per year.
 8             (7)  Services  of  a  licensed  hospice for not more
 9        than 180 days during a policy year.
10             (8)  Use of radium or other radioactive materials.
11             (9)  Oxygen.
12             (10)  Anesthetics.
13             (11)  Orthoses and prostheses other than dental.
14             (12)  Rental or purchase in  accordance  with  Board
15        policies  or  procedures  of  durable  medical equipment,
16        other than eyeglasses or hearing aids, for which there is
17        no personal use in the absence of the condition for which
18        it is prescribed.
19             (13)  Diagnostic x-rays and laboratory tests.
20             (14)  Oral surgery (i) for excision of partially  or
21        completely unerupted impacted teeth when not performed in
22        connection  with  the  routine  extraction  or  repair of
23        teeth; (ii) for excision of tumors or cysts of the  jaws,
24        cheeks,  lips,  tongue,  and roof and floor of the mouth;
25        (iii) required for correction of cleft lip and palate and
26        other craniofacial and maxillofacial  birth  defects;  or
27        (iv)  for  treatment  of  injuries  to natural teeth or a
28        fractured jaw due to an accident.
29             (15)  Physical, speech, and functional  occupational
30        therapy   as   medically   necessary   and   provided  by
31        appropriate licensed professionals.
32             (16)  Emergency  and   other   medically   necessary
33        transportation  provided  by a licensed ambulance service
34        to the nearest health care facility qualified to treat  a
 
                            -4-                LRB9213627JSpc
 1        covered  illness,  injury,  or  condition, subject to the
 2        provisions of the Emergency Medical Systems (EMS) Act.
 3             (17)  Outpatient   services   for   diagnosis    and
 4        treatment of mental and nervous disorders provided that a
 5        covered  person shall be required to make a copayment not
 6        to exceed 50% and  that  the  Plan's  payment  shall  not
 7        exceed such amounts as are established by the Board.
 8             (18)  Human organ or tissue transplants specified by
 9        the  Board that are performed at a hospital designated by
10        the Board as a participating transplant center  for  that
11        specific organ or tissue transplant.
12             (19)  Naprapathic services, as appropriate, provided
13        by a licensed naprapathic practitioner.
14        c.  Exclusions.   Covered  expenses of the Plan shall not
15    include the following:
16             (1)  Any charge for treatment for cosmetic  purposes
17        other than for reconstructive surgery when the service is
18        incidental  to  or follows surgery resulting from injury,
19        sickness or  other  diseases  of  the  involved  part  or
20        surgery  for  the  repair  or  treatment  of a congenital
21        bodily defect to restore normal bodily functions.
22             (2)  Any charge for care that is primarily for rest,
23        custodial, educational, or domiciliary purposes.
24             (3)  Any charge for services in a  private  room  to
25        the  extent  it  is in excess of the institution's charge
26        for its most common semiprivate room,  unless  a  private
27        room is prescribed as medically necessary by a physician.
28             (4)  That  part  of any charge for room and board or
29        for  services  rendered  or  articles  prescribed  by   a
30        physician,  dentist,  or other health care personnel that
31        exceeds  the  reasonable  and  customary  charge  in  the
32        locality or for any services or  supplies  not  medically
33        necessary for the diagnosed injury or illness.
34             (5)  Any   charge   for  services  or  articles  the
 
                            -5-                LRB9213627JSpc
 1        provision of which is not within the scope  of  licensure
 2        of  the  institution or individual providing the services
 3        or articles.
 4             (6)  Any expense incurred  prior  to  the  effective
 5        date  of  coverage  by  the  Plan for the person on whose
 6        behalf the expense is incurred.
 7             (7)  Dental care, dental surgery, dental  treatment,
 8        any   other  dental  procedure  involving  the  teeth  or
 9        periodontium, or any dental appliances, including crowns,
10        bridges,  implants,  or  partial  or  complete  dentures,
11        except as specifically  provided  in  paragraph  (14)  of
12        subsection b of this Section.
13             (8)  Eyeglasses,  contact  lenses,  hearing  aids or
14        their fitting.
15             (9)  Illness or injury due to acts of war.
16             (10)  Services of  blood  donors  and  any  fee  for
17        failure to replace the first 3 pints of blood provided to
18        a covered  person each policy year.
19             (11)  Personal  supplies  or  services provided by a
20        hospital or nursing home,  or  any  other  nonmedical  or
21        nonprescribed supply or service.
22             (12)  Routine  maternity  charges  for  a pregnancy,
23        except where added as optional coverage with  payment  of
24        an   additional  premium  for  pregnancy  resulting  from
25        conception occurring after  the  effective  date  of  the
26        optional coverage.
27             (13)  (Blank).
28             (14)  Any  expense or charge for services, drugs, or
29        supplies that  are:  (i)  not  provided  in  accord  with
30        generally accepted standards of current medical practice;
31        (ii)  for procedures, treatments, equipment, transplants,
32        or  implants,   any   of   which   are   investigational,
33        experimental,    or    for   research   purposes;   (iii)
34        investigative and not proven safe and effective; or  (iv)
 
                            -6-                LRB9213627JSpc
 1        for,   or   resulting   from,   a  gender  transformation
 2        operation.
 3             (15)  Any expense or  charge  for  routine  physical
 4        examinations or tests except as provided in item (2.5) of
 5        subsection b of this Section.
 6             (16)  Any  expense for which a charge is not made in
 7        the absence of insurance or for which there is  no  legal
 8        obligation on the part of the patient to pay.
 9             (17)  Any  expense  incurred  for  benefits provided
10        under the laws of  the  United  States  and  this  State,
11        including   Medicare,   Medicaid,   and   other   medical
12        assistance,  maternal  and  child health services and any
13        other program that  is  administered  or  funded  by  the
14        Department  of  Human Services, Department of Public Aid,
15        or    Department    of    Public     Health,     military
16        service-connected  disability  payments, medical services
17        provided for  members  of  the  armed  forces  and  their
18        dependents or employees of the armed forces of the United
19        States,  and  medical  services financed on behalf of all
20        citizens by the United States.
21             (18)  Any   expense   or   charge   for   in   vitro
22        fertilization,  artificial  insemination,  or  any  other
23        artificial means used to cause pregnancy.
24             (19)  Any expense or charge for oral  contraceptives
25        used  for  birth  control  or  any  other temporary birth
26        control measures.
27             (20)  Any expense or  charge  for  sterilization  or
28        sterilization reversals.
29             (21)  Any   expense   or   charge  for  weight  loss
30        programs, exercise equipment, or  treatment  of  obesity,
31        except  when  certified  by a physician as morbid obesity
32        (at least 2 times normal body weight).
33             (22)  Any  expense   or   charge   for   acupuncture
34        treatment  unless  used  as  an  anesthetic  agent  for a
 
                            -7-                LRB9213627JSpc
 1        covered surgery.
 2             (23)  Any expense or charge for or related to  organ
 3        or  tissue  transplants  other  than those performed at a
 4        hospital with a Board approved organ  transplant  program
 5        that  has  been designated by the Board as a preferred or
 6        exclusive provider organization for that  specific  organ
 7        or tissue transplant.
 8             (24)  Any   expense   or   charge   for  procedures,
 9        treatments, equipment, or services that are  provided  in
10        special settings for research purposes or in a controlled
11        environment,  are  being  studied for safety, efficiency,
12        and effectiveness, and are awaiting  endorsement  by  the
13        appropriate   national  medical  speciality  college  for
14        general use within the medical community.
15        d.  Deductibles and coinsurance.
16        The Plan coverage defined in Section 6 shall provide  for
17    a  choice  of deductibles per individual as authorized by the
18    Board.  If 2 individual members of the same family household,
19    who are both covered persons under the Plan, satisfy the same
20    applicable deductibles, no other member of that family who is
21    also a covered person under the Plan  shall  be  required  to
22    meet  any  deductibles for the balance of that calendar year.
23    The deductibles must  be  applied  first  to  the  authorized
24    amount of covered expenses incurred by the covered person.  A
25    mandatory  coinsurance  requirement  shall  be imposed at the
26    rate authorized by the  Board  in  excess  of  the  mandatory
27    deductible,  the  coinsurance  in the aggregate not to exceed
28    such amounts as are authorized by the Board  per  annum.   At
29    its  discretion  the  Board  may, however, offer catastrophic
30    coverages  or  other  policies  that   provide   for   larger
31    deductibles  with  or  without coinsurance requirements.  The
32    deductibles and coinsurance factors may be adjusted  annually
33    according  to  the  Medical  Component  of the Consumer Price
34    Index.
 
                            -8-                LRB9213627JSpc
 1        e.  Scope of coverage.
 2             (1)  In approving any of the  benefit  plans  to  be
 3        offered  by  the  Plan,  the  Board  shall establish such
 4        benefit   levels,   deductibles,   coinsurance   factors,
 5        exclusions, and limitations as it  may  deem  appropriate
 6        and  that  it  believes to be generally reflective of and
 7        commensurate  with  health  insurance  coverage  that  is
 8        provided in the individual market in this State.
 9             (2)  The benefit plans approved  by  the  Board  may
10        also  provide  for  and  employ  various cost containment
11        measures  and  other  requirements  including,  but   not
12        limited  to,  preadmission certification, prior approval,
13        second surgical opinions, concurrent  utilization  review
14        programs,  individual case management, preferred provider
15        organizations,  health  maintenance  organizations,   and
16        other  cost effective arrangements for paying for covered
17        expenses.
18        f.  Preexisting conditions.
19             (1)  Except  for  federally   eligible   individuals
20        qualifying for Plan coverage under Section 15 of this Act
21        or eligible persons who qualify for the waiver authorized
22        in  paragraph (3) of this subsection, plan coverage shall
23        exclude charges or expenses incurred during the  first  6
24        months following the effective date of coverage as to any
25        condition for which medical advice, care or treatment was
26        recommended   or  received  during  the  6  month  period
27        immediately preceding the effective date of coverage.
28             (2)  (Blank).
29             (3)  Waiver: The preexisting condition exclusions as
30        set forth in paragraph (1) of this  subsection  shall  be
31        waived to the extent to which the eligible person (a) has
32        satisfied  similar  exclusions under any prior individual
33        health insurance policy that was involuntarily terminated
34        because of the insolvency of the issuer of the policy and
 
                            -9-                LRB9213627JSpc
 1        (b) has applied for  Plan  coverage  within  90  63  days
 2        following  the involuntary termination of that individual
 3        health insurance coverage.
 4        g.  Other sources primary;  nonduplication of benefits.
 5             (1)  The Plan shall be the last  payor  of  benefits
 6        whenever  any  other  benefit  or  source  of third party
 7        payment is  available.   Subject  to  the  provisions  of
 8        subsection  e  of  Section  7, benefits otherwise payable
 9        under Plan coverage shall be reduced by all amounts  paid
10        or payable by Medicare or any other government program or
11        through  any  health  insurance  coverage or group health
12        plan, whether by insurance, reimbursement, or  otherwise,
13        or   through   any  third  party  liability,  settlement,
14        judgment,  or  award,  regardless  of  the  date  of  the
15        settlement, judgment, or award, whether  the  settlement,
16        judgment,  or  award  is  in  the  form  of  a  contract,
17        agreement, or trust on behalf of a minor or otherwise and
18        whether  the settlement, judgment, or award is payable to
19        the  covered  person,  his  or  her  dependent,   estate,
20        personal  representative,  or  guardian  in a lump sum or
21        over  time,  and  by  all  hospital  or  medical  expense
22        benefits paid or payable under any worker's  compensation
23        coverage,   automobile   medical  payment,  or  liability
24        insurance, whether provided on  the  basis  of  fault  or
25        nonfault, and by any hospital or medical benefits paid or
26        payable  under  or  provided  pursuant  to  any  State or
27        federal law or program.
28             (2)  The Plan shall have a cause of  action  against
29        any  covered person or any other person or entity for the
30        recovery of any amount paid to the extent the amount  was
31        for  treatment, services, or supplies not covered in this
32        Section or in excess of benefits as  set  forth  in  this
33        Section.
34             (3)  Whenever benefits are due from the Plan because
 
                            -10-               LRB9213627JSpc
 1        of  sickness  or  an injury to a covered person resulting
 2        from a third party's wrongful act or negligence  and  the
 3        covered  person has recovered or may recover damages from
 4        a third party or its insurer, the  Plan  shall  have  the
 5        right  to  reduce  benefits  or to refuse to pay benefits
 6        that otherwise may be payable by the  amount  of  damages
 7        that  the  covered  person  has  recovered or may recover
 8        regardless of the date of the sickness or injury  or  the
 9        date of any settlement, judgment, or award resulting from
10        that sickness or injury.
11             During  the  pendency of any action or claim that is
12        brought by or on behalf of a  covered  person  against  a
13        third  party  or  its  insurer,  any  benefits that would
14        otherwise be payable except for the  provisions  of  this
15        paragraph  (3)  shall  be  paid  if payment by or for the
16        third party has not yet been made and the covered  person
17        or,  if  incapable,  that  person's  legal representative
18        agrees in writing to pay back promptly the benefits  paid
19        as  a  result  of the sickness or injury to the extent of
20        any future payments made by or for the  third  party  for
21        the  sickness  or  injury.   This  agreement  is to apply
22        whether or not liability for the payments is  established
23        or  admitted by the third party or whether those payments
24        are itemized.
25             Any amounts due the plan to repay  benefits  may  be
26        deducted  from  other  benefits payable by the Plan after
27        payments by or for the third party are made.
28             (4)  Benefits due from the Plan may  be  reduced  or
29        refused   as  an  offset  against  any  amount  otherwise
30        recoverable under this Section.
31        h.  Right of subrogation; recoveries.
32             (1)  Whenever the Plan has paid benefits because  of
33        sickness  or  an  injury  to any covered person resulting
34        from a third party's wrongful act or negligence,  or  for
 
                            -11-               LRB9213627JSpc
 1        which  an  insurer  is  liable  in  accordance  with  the
 2        provisions  of  any  policy of insurance, and the covered
 3        person has recovered or may recover damages from a  third
 4        party that is liable for the damages, the Plan shall have
 5        the  right  to  recover  the  benefits  it  paid from any
 6        amounts that the  covered  person  has  received  or  may
 7        receive  regardless of the date of the sickness or injury
 8        or  the  date  of  any  settlement,  judgment,  or  award
 9        resulting from that sickness or injury.  The  Plan  shall
10        be subrogated to any right of recovery the covered person
11        may  have under the terms of any private or public health
12        care coverage or liability coverage,  including  coverage
13        under  the  Workers'  Compensation  Act  or  the Workers'
14        Occupational  Diseases  Act,  without  the  necessity  of
15        assignment of claim or other authorization to secure  the
16        right of recovery.  To enforce its subrogation right, the
17        Plan may (i) intervene or join in an action or proceeding
18        brought   by   the   covered   person   or  his  personal
19        representative,  including  his  guardian,   conservator,
20        estate, dependents, or survivors, against any third party
21        or  the  third party's insurer that may be liable or (ii)
22        institute and prosecute  legal  proceedings  against  any
23        third  party  or  the  third  party's insurer that may be
24        liable for the sickness or injury in an appropriate court
25        either in the name of the Plan or  in  the  name  of  the
26        covered  person or his personal representative, including
27        his  guardian,  conservator,   estate,   dependents,   or
28        survivors.
29             (2)  If  any  action  or  claim  is brought by or on
30        behalf of a covered person against a third party  or  the
31        third party's insurer, the covered person or his personal
32        representative,   including  his  guardian,  conservator,
33        estate, dependents, or survivors, shall notify  the  Plan
34        by  personal  service or registered mail of the action or
 
                            -12-               LRB9213627JSpc
 1        claim and of the name of the court in which the action or
 2        claim is brought, filing proof thereof in the  action  or
 3        claim.  The Plan may, at any time thereafter, join in the
 4        action  or  claim  upon  its motion so that all orders of
 5        court after hearing and judgment shall be  made  for  its
 6        protection.   No  release  or  settlement  of a claim for
 7        damages and no satisfaction of  judgment  in  the  action
 8        shall be valid without the written consent of the Plan to
 9        the  extent of its interest in the settlement or judgment
10        and of the covered person or his personal representative.
11             (3)  In the event that the  covered  person  or  his
12        personal  representative  fails to institute a proceeding
13        against any appropriate  third  party  before  the  fifth
14        month before the action would be barred, the Plan may, in
15        its  own  name  or  in  the name of the covered person or
16        personal representative, commence  a  proceeding  against
17        any  appropriate  third party for the recovery of damages
18        on account of any  sickness,  injury,  or  death  to  the
19        covered  person.   The  covered person shall cooperate in
20        doing what is reasonably necessary to assist the Plan  in
21        any  recovery  and  shall  not take any action that would
22        prejudice the Plan's right to recovery.  The  Plan  shall
23        pay  to the covered person or his personal representative
24        all sums collected from any third party  by  judgment  or
25        otherwise in excess of amounts paid in benefits under the
26        Plan  and  amounts paid or to be paid as costs, attorneys
27        fees, and reasonable expenses incurred  by  the  Plan  in
28        making the collection or enforcing the judgment.
29             (4)  In  the  event  that  a  covered  person or his
30        personal   representative,   including   his    guardian,
31        conservator,  estate,  dependents, or survivors, recovers
32        damages from a third party for sickness or injury  caused
33        to the covered person, the covered person or the personal
34        representative  shall  pay  to  the Plan from the damages
 
                            -13-               LRB9213627JSpc
 1        recovered the amount of benefits paid or to  be  paid  on
 2        behalf of the covered person.
 3             (5)  When  the  action  or  claim  is brought by the
 4        covered person alone and  the  covered  person  incurs  a
 5        personal  liability  to  pay attorney's fees and costs of
 6        litigation, the Plan's claim  for  reimbursement  of  the
 7        benefits provided to the covered person shall be the full
 8        amount  of  benefits  paid to or on behalf of the covered
 9        person  under  this  Act  less  a  pro  rata  share  that
10        represents the Plan's reasonable share of attorney's fees
11        paid by the covered person and that portion of  the  cost
12        of  litigation  expenses determined by multiplying by the
13        ratio of the full amount of the expenditures to the  full
14        amount of the judgement, award, or settlement.
15             (6)  In  the event of judgment or award in a suit or
16        claim against a third party or insurer, the  court  shall
17        first   order  paid  from  any  judgement  or  award  the
18        reasonable litigation expenses  incurred  in  preparation
19        and  prosecution  of  the  action or claim, together with
20        reasonable  attorney's  fees.   After  payment  of  those
21        expenses and attorney's fees, the court shall  apply  out
22        of  the  balance  of  the  judgment  or  award  an amount
23        sufficient to reimburse  the  Plan  the  full  amount  of
24        benefits  paid on behalf of the covered person under this
25        Act, provided the court  may  reduce  and  apportion  the
26        Plan's  portion  of  the  judgement  proportionate to the
27        recovery of the covered person.  The burden of  producing
28        evidence  sufficient to support the exercise by the court
29        of its discretion to reduce the amount of a proven charge
30        sought to be enforced against  the  recovery  shall  rest
31        with  the  party  seeking  the  reduction.  The court may
32        consider the nature and extent of  the  injury,  economic
33        and  non-economic  loss,  settlement  offers, comparative
34        negligence as it applies to the case  at  hand,  hospital
 
                            -14-               LRB9213627JSpc
 1        costs, physician costs, and all other appropriate costs.
 2        The  Plan  shall  pay  its pro rata share of the attorney
 3        fees based on the Plan's recovery as it compares  to  the
 4        total  judgment.   Any  reimbursement  rights of the Plan
 5        shall take priority over  all  other  liens  and  charges
 6        existing  under the laws of this State with the exception
 7        of any attorney liens filed under the Attorneys Lien Act.
 8             (7)  The Plan may compromise or settle  and  release
 9        any  claim  for benefits provided under this Act or waive
10        any claims for benefits, in whole or  in  part,  for  the
11        convenience  of  the  Plan or if the Plan determines that
12        collection  would  result  in  undue  hardship  upon  the
13        covered person.
14    (Source: P.A. 91-639,  eff.  8-20-99;  91-735,  eff.  6-2-00;
15    92-2, eff. 5-1-01.)

16        Section  99.  Effective date.  This Act takes effect upon
17    becoming law.

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