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Public Act 91-0735
HB4433 Enrolled LRB9110326JSsb
AN ACT concerning insurance coverage for certain medical
conditions.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Comprehensive Health Insurance Plan Act
is amended by changing Sections 2, 7, 8, and 11 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 and 367e 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 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
63 days in any credible 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.
"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, 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, (B) part A or part B of Medicare, or
(C) medical assistance, and does not have other health
insurance coverage;
(3) with respect to whom 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 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.
"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 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 or medical
service policy or certificate, hospital or medical service
plan contract, or health maintenance organization contract
offered by a health insurance issuer.
"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 eligible person" means a person who is and
continues to be has been 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 for a period of at least
180 days and continues to be domiciled in this State.
"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. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99.)
(215 ILCS 105/7) (from Ch. 73, par. 1307)
Sec. 7. Eligibility.
a. Except as provided in subsection (e) of this Section
or in Section 15 of this Act, any individual person who is
either a citizen of the United States or an alien lawfully
admitted for permanent residence and who has been for a
period of at least 180 days and continues to be a resident of
this State shall be eligible for Plan coverage under this
Section if evidence is provided of:
(1) A notice of rejection or refusal to issue
substantially similar individual health insurance
coverage for health reasons by a health insurance issuer;
or
(2) A refusal by a health insurance issuer to issue
individual health insurance coverage except at a rate
exceeding the applicable Plan rate for which the person
is responsible.
A rejection or refusal by a group health plan or health
insurance issuer offering only stop-loss or excess of loss
insurance or contracts, agreements, or other arrangements for
reinsurance coverage with respect to the applicant shall not
be sufficient evidence under this subsection.
b. The board shall promulgate a list of medical or
health conditions for which a person who is either a citizen
of the United States or an alien lawfully admitted for
permanent residence and a resident of this State would be
eligible for Plan coverage without applying for health
insurance coverage pursuant to subsection a. of this Section.
Persons who can demonstrate the existence or history of any
medical or health conditions on the list promulgated by the
board shall not be required to provide the evidence specified
in subsection a. of this Section. The list shall be
effective on the first day of the operation of the Plan and
may be amended from time to time as appropriate.
c. Family members of the same household who each are
covered persons are eligible for optional family coverage
under the Plan.
d. For persons qualifying for coverage in accordance
with Section 7 of this Act, the board shall, if it determines
that such appropriations as are made pursuant to Section 12
of this Act are insufficient to allow the board to accept all
of the eligible persons which it projects will apply for
enrollment under the Plan, limit or close enrollment to
ensure that the Plan is not over-subscribed and that it has
sufficient resources to meet its obligations to existing
enrollees. The board shall not limit or close enrollment for
federally eligible individuals.
e. A person shall not be eligible for coverage under the
Plan if:
(1) He or she has or obtains other coverage under a
group health plan or health insurance coverage
substantially similar to or better than a Plan policy as
an insured or covered dependent or would be eligible to
have that coverage if he or she elected to obtain it.
Persons otherwise eligible for Plan coverage may,
however, solely for the purpose of having coverage for a
pre-existing condition, maintain other coverage only
while satisfying any pre-existing condition waiting
period under a Plan policy or a subsequent replacement
policy of a Plan policy.
(1.1) His or her prior coverage under a group
health plan or health insurance coverage, provided or
arranged by an employer of more than 10 employees was
discontinued for any reason without the entire group or
plan being discontinued and not replaced, provided he or
she remains an employee, or dependent thereof, of the
same employer.
(2) He or she is a recipient of or is approved to
receive medical assistance, except that a person may
continue to receive medical assistance through the
medical assistance no grant program, but only while
satisfying the requirements for a preexisting condition
under Section 8, subsection f. of this Act. Payment of
premiums pursuant to this Act shall be allocable to the
person's spenddown for purposes of the medical assistance
no grant program, but that person shall not be eligible
for any Plan benefits while that person remains eligible
for medical assistance. If the person continues to
receive or be approved to receive medical assistance
through the medical assistance no grant program at or
after the time that requirements for a preexisting
condition are satisfied, the person shall not be eligible
for coverage under the Plan. In that circumstance,
coverage under the plan shall terminate as of the
expiration of the preexisting condition limitation
period. Under all other circumstances, coverage under
the Plan shall automatically terminate as of the
effective date of any medical assistance.
(3) Except as provided in Section 15, the person
has previously participated in the Plan and voluntarily
terminated Plan coverage, unless 12 months have elapsed
since the person's latest voluntary termination of
coverage.
(4) The person fails to pay the required premium
under the covered person's terms of enrollment and
participation, in which event the liability of the Plan
shall be limited to benefits incurred under the Plan for
the time period for which premiums had been paid and the
covered person remained eligible for Plan coverage.
(5) The Plan has paid a total of $1,000,000 in
benefits on behalf of the covered person.
(6) The person is a resident of a public
institution.
(7) The person's premium is paid for or reimbursed
under any government sponsored program or by any
government agency or health care provider, except as an
otherwise qualifying full-time employee, or dependent of
such employee, of a government agency or health care
provider.
(8) The person has or later receives other benefits
or funds from any settlement, judgement, or award
resulting from any accident or injury, regardless of the
date of the accident or injury, or any other
circumstances creating a legal liability for damages due
that person by a third party, whether the settlement,
judgment, or award is in the form of a contract,
agreement, or trust on behalf of a minor or otherwise and
whether the settlement, judgment, or award is payable to
the person, his or her dependent, estate, personal
representative, or guardian in a lump sum or over time,
so long as there continues to be benefits or assets
remaining from those sources in an amount in excess of
$100,000.
(9) Within the 5 years prior to the date a person's
Plan application is received by the Board, the person's
coverage under any health care benefit program as defined
in 18 U.S.C. 24, including any public or private plan or
contract under which any medical benefit, item, or
service is provided, was terminated as a result of any
act or practice that constitutes fraud under State or
federal law or as a result of an intentional
misrepresentation of material fact; or if that person
knowingly and willfully obtained or attempted to obtain,
or fraudulently aided or attempted to aid any other
person in obtaining, any coverage or benefits under the
Plan to which that person was not entitled.
f. The board or the administrator shall require
verification of residency and may require any additional
information or documentation, or statements under oath, when
necessary to determine residency upon initial application and
for the entire term of the policy.
g. Coverage shall cease (i) on the date a person is no
longer a resident of Illinois, (ii) on the date a person
requests coverage to end, (iii) upon the death of the covered
person, (iv) on the date State law requires cancellation of
the policy, or (v) at the Plan's option, 30 days after the
Plan makes any inquiry concerning a person's eligibility or
place of residence to which the person does not reply.
h. Except under the conditions set forth in subsection g
of this Section, the coverage of any person who ceases to
meet the eligibility requirements of this Section shall be
terminated at the end of the current policy period for which
the necessary premiums have been paid.
(Source: P.A. 90-30, eff. 7-1-97; 91-639, eff. 8-20-99.)
(215 ILCS 105/8) (from Ch. 73, par. 1308)
Sec. 8. Minimum benefits.
a. Availability. The Plan shall offer in an annually
renewable policy major medical expense coverage to every
eligible person who is not eligible for Medicare. Major
medical expense coverage offered by the Plan shall pay an
eligible person's covered expenses, subject to limit on the
deductible and coinsurance payments authorized under
paragraph (4) of subsection d of this Section, up to a
lifetime benefit limit of $1,000,000 per covered individual.
The maximum limit under this subsection shall not be altered
by the Board, and no actuarial equivalent benefit may be
substituted by the Board. Any person who otherwise would
qualify for coverage under the Plan, but is excluded because
he or she is eligible for Medicare, shall be eligible for any
separate Medicare supplement policy or policies which the
Board may offer.
b. Outline of benefits. Covered expenses shall be
limited to the usual and customary charge, including
negotiated fees, in the locality for the following services
and articles when prescribed by a physician and determined by
the Plan to be medically necessary for the following areas of
services, subject to such separate deductibles, co-payments,
exclusions, and other limitations on benefits as the Board
shall establish and approve, and the other provisions of this
Section:
(1) Hospital services, except that any services
provided by a hospital that is located more than 75 miles
outside the State of Illinois shall be covered only for a
maximum of 45 days in any calendar year. With respect to
covered expenses incurred during any calendar year ending
on or after December 31, 1999, inpatient hospitalization
of an eligible person for the treatment of mental illness
at a hospital located within the State of Illinois shall
be subject to the same terms and conditions as for any
other illness.
(2) Professional services for the diagnosis or
treatment of injuries, illnesses or conditions, other
than dental and mental and nervous disorders as described
in paragraph (17), which are rendered by a physician, or
by other licensed professionals at the physician's
direction. This includes reconstruction of the breast on
which a mastectomy was performed; surgery and
reconstruction of the other breast to produce a
symmetrical appearance; and prostheses and treatment of
physical complications at all stages of the mastectomy,
including lymphedemas.
(2.5) Professional services provided by a physician
to children under the age of 16 years for physical
examinations and age appropriate immunizations ordered by
a physician licensed to practice medicine in all its
branches.
(3) (Blank).
(4) Outpatient prescription drugs that by law
require a prescription written by a physician licensed to
practice medicine in all its branches subject to such
separate deductible, copayment, and other limitations or
restrictions as the Board shall approve, including the
use of a prescription drug card or any other program, or
both.
(5) Skilled nursing services of a licensed skilled
nursing facility for not more than 120 days during a
policy year.
(6) Services of a home health agency in accord with
a home health care plan, up to a maximum of 270 visits
per year.
(7) Services of a licensed hospice for not more
than 180 days during a policy year.
(8) Use of radium or other radioactive materials.
(9) Oxygen.
(10) Anesthetics.
(11) Orthoses and prostheses other than dental.
(12) Rental or purchase in accordance with Board
policies or procedures of durable medical equipment,
other than eyeglasses or hearing aids, for which there is
no personal use in the absence of the condition for which
it is prescribed.
(13) Diagnostic x-rays and laboratory tests.
(14) Oral surgery (i) for excision of partially or
completely unerupted impacted teeth, when not performed
in connection with the routine extraction or repair of
teeth; (ii) for excision of tumors or cysts of the jaws,
cheeks, lips, tongue, and roof and floor of the mouth;
(iii), that is required for correction of cleft lip and
palate and other craniofacial and maxillofacial birth
defects; or (iv) for treatment of to treat injuries to
natural teeth or a fractured jaw due to an accident that
occurred while a covered person.
(15) Physical, speech, and functional occupational
therapy as medically necessary and provided by
appropriate licensed professionals.
(16) Emergency and other medically necessary
transportation provided by a licensed ambulance service
to the nearest health care facility qualified to treat a
covered illness, injury, or condition, subject to the
provisions of the Emergency Medical Systems (EMS) Act.
(17) Outpatient services for diagnosis and
treatment of mental and nervous disorders provided that a
covered person shall be required to make a copayment not
to exceed 50% and that the Plan's payment shall not
exceed such amounts as are established by the Board.
(18) Human organ or tissue transplants specified by
the Board that are performed at a hospital designated by
the Board as a participating transplant center for that
specific organ or tissue transplant.
(19) Naprapathic services, as appropriate, provided
by a licensed naprapathic practitioner.
c. Exclusions. Covered expenses of the Plan shall not
include the following:
(1) Any charge for treatment for cosmetic purposes
other than for reconstructive surgery when the service is
incidental to or follows surgery resulting from injury,
sickness or other diseases of the involved part or
surgery for the repair or treatment of a congenital
bodily defect to restore normal bodily functions.
(2) Any charge for care that is primarily for rest,
custodial, educational, or domiciliary purposes.
(3) Any charge for services in a private room to
the extent it is in excess of the institution's charge
for its most common semiprivate room, unless a private
room is prescribed as medically necessary by a physician.
(4) That part of any charge for room and board or
for services rendered or articles prescribed by a
physician, dentist, or other health care personnel that
exceeds the reasonable and customary charge in the
locality or for any services or supplies not medically
necessary for the diagnosed injury or illness.
(5) Any charge for services or articles the
provision of which is not within the scope of licensure
of the institution or individual providing the services
or articles.
(6) Any expense incurred prior to the effective
date of coverage by the Plan for the person on whose
behalf the expense is incurred.
(7) Dental care, dental surgery, dental treatment,
any other dental procedure involving the teeth or
periodontium, or any dental appliances, including crowns,
bridges, implants, or partial or complete dentures,
except as specifically provided in paragraph (14) of
subsection b of this Section.
(8) Eyeglasses, contact lenses, hearing aids or
their fitting.
(9) Illness or injury due to acts of war.
(10) Services of blood donors and any fee for
failure to replace the first 3 pints of blood provided to
a covered person each policy year.
(11) Personal supplies or services provided by a
hospital or nursing home, or any other nonmedical or
nonprescribed supply or service.
(12) Routine maternity charges for a pregnancy,
except where added as optional coverage with payment of
an additional premium for pregnancy resulting from
conception occurring after the effective date of the
optional coverage.
(13) (Blank).
(14) Any expense or charge for services, drugs, or
supplies that are: (i) not provided in accord with
generally accepted standards of current medical practice;
(ii) for procedures, treatments, equipment, transplants,
or implants, any of which are investigational,
experimental, or for research purposes; (iii)
investigative and not proven safe and effective; or (iv)
for, or resulting from, a gender transformation
operation.
(15) Any expense or charge for routine physical
examinations or tests except as provided in item (2.5) of
subsection b of this Section.
(16) Any expense for which a charge is not made in
the absence of insurance or for which there is no legal
obligation on the part of the patient to pay.
(17) Any expense incurred for benefits provided
under the laws of the United States and this State,
including Medicare, Medicaid, and other medical
assistance, maternal and child health services and any
other program that is administered or funded by the
Department of Human Services, Department of Public Aid,
or Department of Public Health, military
service-connected disability payments, medical services
provided for members of the armed forces and their
dependents or employees of the armed forces of the United
States, and medical services financed on behalf of all
citizens by the United States.
(18) Any expense or charge for in vitro
fertilization, artificial insemination, or any other
artificial means used to cause pregnancy.
(19) Any expense or charge for oral contraceptives
used for birth control or any other temporary birth
control measures.
(20) Any expense or charge for sterilization or
sterilization reversals.
(21) Any expense or charge for weight loss
programs, exercise equipment, or treatment of obesity,
except when certified by a physician as morbid obesity
(at least 2 times normal body weight).
(22) Any expense or charge for acupuncture
treatment unless used as an anesthetic agent for a
covered surgery.
(23) Any expense or charge for or related to organ
or tissue transplants other than those performed at a
hospital with a Board approved organ transplant program
that has been designated by the Board as a preferred or
exclusive provider organization for that specific organ
or tissue transplant.
(24) Any expense or charge for procedures,
treatments, equipment, or services that are provided in
special settings for research purposes or in a controlled
environment, are being studied for safety, efficiency,
and effectiveness, and are awaiting endorsement by the
appropriate national medical speciality college for
general use within the medical community.
d. Deductibles and coinsurance.
The Plan coverage defined in Section 6 shall provide for
a choice of deductibles per individual as authorized by the
Board. If 2 individual members of the same family household,
who are both covered persons under the Plan, satisfy the same
applicable deductibles, no other member of that family who is
also a covered person under the Plan shall be required to
meet any deductibles for the balance of that calendar year.
The deductibles must be applied first to the authorized
amount of covered expenses incurred by the covered person. A
mandatory coinsurance requirement shall be imposed at the
rate authorized by the Board in excess of the mandatory
deductible, the coinsurance in the aggregate not to exceed
such amounts as are authorized by the Board per annum. At
its discretion the Board may, however, offer catastrophic
coverages or other policies that provide for larger
deductibles with or without coinsurance requirements. The
deductibles and coinsurance factors may be adjusted annually
according to the Medical Component of the Consumer Price
Index.
e. Scope of coverage.
(1) In approving any of the benefit plans to be
offered by the Plan, the Board shall establish such
benefit levels, deductibles, coinsurance factors,
exclusions, and limitations as it may deem appropriate
and that it believes to be generally reflective of and
commensurate with health insurance coverage that is
provided in the individual market in this State.
(2) The benefit plans approved by the Board may
also provide for and employ various cost containment
measures and other requirements including, but not
limited to, preadmission certification, prior approval,
second surgical opinions, concurrent utilization review
programs, individual case management, preferred provider
organizations, health maintenance organizations, and
other cost effective arrangements for paying for covered
expenses.
f. Preexisting conditions.
(1) Except for federally eligible individuals
qualifying for Plan coverage under Section 15 of this
Act, plan coverage shall exclude charges or expenses
incurred during the first 6 months following the
effective date of coverage as to any condition for which
if: (a) the condition had manifested itself within the 6
month period immediately preceding the effective date of
coverage in such a manner as would cause an ordinarily
prudent person to seek diagnosis, care or treatment; or
(b) medical advice, care or treatment was recommended or
received during within the 6 month period immediately
preceding the effective date of coverage.
(2) (Blank).
(3) (Blank).
g. Other sources primary; nonduplication of benefits.
(1) The Plan shall be the last payor of benefits
whenever any other benefit or source of third party
payment is available. Subject to the provisions of
subsection e of Section 7, benefits otherwise payable
under Plan coverage shall be reduced by all amounts paid
or payable by Medicare or any other government program or
through any health insurance coverage or group health
plan, whether by insurance, reimbursement, or otherwise,
or through any third party liability, settlement,
judgment, or award, regardless of the date of the
settlement, judgment, or award, whether the settlement,
judgment, or award is in the form of a contract,
agreement, or trust on behalf of a minor or otherwise and
whether the settlement, judgment, or award is payable to
the covered person, his or her dependent, estate,
personal representative, or guardian in a lump sum or
over time, and by all hospital or medical expense
benefits paid or payable under any worker's compensation
coverage, automobile medical payment, or liability
insurance, whether provided on the basis of fault or
nonfault, and by any hospital or medical benefits paid or
payable under or provided pursuant to any State or
federal law or program.
(2) The Plan shall have a cause of action against
any covered person or any other person or entity for the
recovery of any amount paid to the extent the amount was
for treatment, services, or supplies not covered in this
Section or in excess of benefits as set forth in this
Section.
(3) Whenever benefits are due from the Plan because
of sickness or an injury to a covered person resulting
from a third party's wrongful act or negligence and the
covered person has recovered or may recover damages from
a third party or its insurer, the Plan shall have the
right to reduce benefits or to refuse to pay benefits
that otherwise may be payable by the amount of damages
that the covered person has recovered or may recover
regardless of the date of the sickness or injury or the
date of any settlement, judgment, or award resulting from
that sickness or injury.
During the pendency of any action or claim that is
brought by or on behalf of a covered person against a
third party or its insurer, any benefits that would
otherwise be payable except for the provisions of this
paragraph (3) shall be paid if payment by or for the
third party has not yet been made and the covered person
or, if incapable, that person's legal representative
agrees in writing to pay back promptly the benefits paid
as a result of the sickness or injury to the extent of
any future payments made by or for the third party for
the sickness or injury. This agreement is to apply
whether or not liability for the payments is established
or admitted by the third party or whether those payments
are itemized.
Any amounts due the plan to repay benefits may be
deducted from other benefits payable by the Plan after
payments by or for the third party are made.
(4) Benefits due from the Plan may be reduced or
refused as an offset against any amount otherwise
recoverable under this Section.
h. Right of subrogation; recoveries.
(1) Whenever the Plan has paid benefits because of
sickness or an injury to any covered person resulting
from a third party's wrongful act or negligence, or for
which an insurer is liable in accordance with the
provisions of any policy of insurance, and the covered
person has recovered or may recover damages from a third
party that is liable for the damages, the Plan shall have
the right to recover the benefits it paid from any
amounts that the covered person has received or may
receive regardless of the date of the sickness or injury
or the date of any settlement, judgment, or award
resulting from that sickness or injury. The Plan shall
be subrogated to any right of recovery the covered person
may have under the terms of any private or public health
care coverage or liability coverage, including coverage
under the Workers' Compensation Act or the Workers'
Occupational Diseases Act, without the necessity of
assignment of claim or other authorization to secure the
right of recovery. To enforce its subrogation right, the
Plan may (i) intervene or join in an action or proceeding
brought by the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, against any third party
or the third party's insurer that may be liable or (ii)
institute and prosecute legal proceedings against any
third party or the third party's insurer that may be
liable for the sickness or injury in an appropriate court
either in the name of the Plan or in the name of the
covered person or his personal representative, including
his guardian, conservator, estate, dependents, or
survivors.
(2) If any action or claim is brought by or on
behalf of a covered person against a third party or the
third party's insurer, the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, shall notify the Plan
by personal service or registered mail of the action or
claim and of the name of the court in which the action or
claim is brought, filing proof thereof in the action or
claim. The Plan may, at any time thereafter, join in the
action or claim upon its motion so that all orders of
court after hearing and judgment shall be made for its
protection. No release or settlement of a claim for
damages and no satisfaction of judgment in the action
shall be valid without the written consent of the Plan to
the extent of its interest in the settlement or judgment
and of the covered person or his personal representative.
(3) In the event that the covered person or his
personal representative fails to institute a proceeding
against any appropriate third party before the fifth
month before the action would be barred, the Plan may, in
its own name or in the name of the covered person or
personal representative, commence a proceeding against
any appropriate third party for the recovery of damages
on account of any sickness, injury, or death to the
covered person. The covered person shall cooperate in
doing what is reasonably necessary to assist the Plan in
any recovery and shall not take any action that would
prejudice the Plan's right to recovery. The Plan shall
pay to the covered person or his personal representative
all sums collected from any third party by judgment or
otherwise in excess of amounts paid in benefits under the
Plan and amounts paid or to be paid as costs, attorneys
fees, and reasonable expenses incurred by the Plan in
making the collection or enforcing the judgment.
(4) In the event that a covered person or his
personal representative, including his guardian,
conservator, estate, dependents, or survivors, recovers
damages from a third party for sickness or injury caused
to the covered person, the covered person or the personal
representative shall pay to the Plan from the damages
recovered the amount of benefits paid or to be paid on
behalf of the covered person.
(5) When the action or claim is brought by the
covered person alone and the covered person incurs a
personal liability to pay attorney's fees and costs of
litigation, the Plan's claim for reimbursement of the
benefits provided to the covered person shall be the full
amount of benefits paid to or on behalf of the covered
person under this Act less a pro rata share that
represents the Plan's reasonable share of attorney's fees
paid by the covered person and that portion of the cost
of litigation expenses determined by multiplying by the
ratio of the full amount of the expenditures to the full
amount of the judgement, award, or settlement.
(6) In the event of judgment or award in a suit or
claim against a third party or insurer, the court shall
first order paid from any judgement or award the
reasonable litigation expenses incurred in preparation
and prosecution of the action or claim, together with
reasonable attorney's fees. After payment of those
expenses and attorney's fees, the court shall apply out
of the balance of the judgment or award an amount
sufficient to reimburse the Plan the full amount of
benefits paid on behalf of the covered person under this
Act, provided the court may reduce and apportion the
Plan's portion of the judgement proportionate to the
recovery of the covered person. The burden of producing
evidence sufficient to support the exercise by the court
of its discretion to reduce the amount of a proven charge
sought to be enforced against the recovery shall rest
with the party seeking the reduction. The court may
consider the nature and extent of the injury, economic
and non-economic loss, settlement offers, comparative
negligence as it applies to the case at hand, hospital
costs, physician costs, and all other appropriate costs.
The Plan shall pay its pro rata share of the attorney
fees based on the Plan's recovery as it compares to the
total judgment. Any reimbursement rights of the Plan
shall take priority over all other liens and charges
existing under the laws of this State with the exception
of any attorney liens filed under the Attorneys Lien Act.
(7) The Plan may compromise or settle and release
any claim for benefits provided under this Act or waive
any claims for benefits, in whole or in part, for the
convenience of the Plan or if the Plan determines that
collection would result in undue hardship upon the
covered person.
(Source: P.A. 90-7, eff. 6-10-97; 90-30, eff. 7-1-97; 90-655,
eff. 7-30-98; 91-639, eff. 8-20-99.)
(215 ILCS 105/11) (from Ch. 73, par. 1311)
Sec. 11. Plan notice. On and after the date the
Illinois Comprehensive Health Insurance Plan becomes
operational as provided in this Act, every insurer licensed
to issue, and which issues for delivery, policies of accident
and health insurance in this State shall include a notice of
the existence of the Illinois Comprehensive Health Insurance
Plan in any rejection of any application for individual
health insurance coverage as defined in this Act for reasons
of the health of the applicant or any other person proposed
for insurance in such application. Such notice shall be in
substantially the form and content prescribed by the
Director.
(Source: P.A. 85-702.)
Section 99. Effective date. This Act takes effect upon
becoming law.
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