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Public Act 92-0153
HB3004 Enrolled LRB9200745JSpc
AN ACT to amend the Comprehensive Health Insurance Plan
Act by changing Sections 2 and 15.
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 and 15 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 90 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 63 days in any creditable 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 due
to age, 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 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. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99;
91-735, eff. 6-2-00.)
(215 ILCS 105/15)
Sec. 15. Alternative portable coverage for federally
eligible individuals.
(a) Notwithstanding the requirements of subsection a. of
Section 7, any federally eligible individual for whom a Plan
application, and such enclosures and supporting documentation
as the Board may require, is received by the Board within 90
63 days after the termination of prior creditable coverage
shall qualify to enroll in the Plan under the portability
provisions of this Section.
(b) Any federally eligible individual seeking Plan
coverage under this Section must submit with his or her
application evidence, including acceptable written
certification of previous creditable coverage, that will
establish to the Board's satisfaction, that he or she meets
all of the requirements to be a federally eligible individual
and is currently and permanently residing in this State (as
of the date his or her application was received by the
Board).
(c) A period of creditable coverage shall not be
counted, with respect to qualifying an applicant for Plan
coverage as a federally eligible individual under this
Section, if after such period and before the application for
Plan coverage was received by the Board, there was at least a
90 63 day period during all of which the individual was not
covered under any creditable coverage.
(d) Any federally eligible individual who the Board
determines qualifies for Plan coverage under this Section
shall be offered his or her choice of enrolling in one of
alternative portability health benefit plans which the Board
is authorized under this Section to establish for these
federally eligible individuals and their dependents.
(e) The Board shall offer a choice of health care
coverages consistent with major medical coverage under the
alternative health benefit plans authorized by this Section
to every federally eligible individual. The coverages to be
offered under the plans, the schedule of benefits,
deductibles, co-payments, exclusions, and other limitations
shall be approved by the Board. One optional form of
coverage shall be comparable to comprehensive health
insurance coverage offered in the individual market in this
State or a standard option of coverage available under the
group or individual health insurance laws of the State. The
standard benefit plan that is authorized by Section 8 of this
Act may be used for this purpose. The Board may also offer a
preferred provider option and such other options as the Board
determines may be appropriate for these federally eligible
individuals who qualify for Plan coverage pursuant to this
Section.
(f) Notwithstanding the requirements of subsection f. of
Section 8, any plan coverage that is issued to federally
eligible individuals who qualify for the Plan pursuant to the
portability provisions of this Section shall not be subject
to any preexisting conditions exclusion, waiting period, or
other similar limitation on coverage.
(g) Federally eligible individuals who qualify and
enroll in the Plan pursuant to this Section shall be required
to pay such premium rates as the Board shall establish and
approve in accordance with the requirements of Section 7.1 of
this Act.
(h) A federally eligible individual who qualifies and
enrolls in the Plan pursuant to this Section must satisfy on
an ongoing basis all of the other eligibility requirements of
this Act to the extent not inconsistent with the federal
Health Insurance Portability and Accountability Act of 1996
in order to maintain continued eligibility for coverage under
the Plan.
(Source: P.A. 90-30, eff. 7-1-97.)
Section 99. Effective date. This Act takes effect upon
becoming law.
Passed in the General Assembly May 10, 2001.
Approved July 25, 2001.
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