Public Act 095-0965
 
SB2380 Enrolled LRB095 19723 KBJ 46088 b

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