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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Comprehensive Health Insurance Plan Act is
5amended by changing Section 2 as follows:
 
6    (215 ILCS 105/2)  (from Ch. 73, par. 1302)
7    Sec. 2. Definitions. As used in this Act, unless the
8context otherwise requires:
9    "Plan administrator" means the insurer or third party
10administrator designated under Section 5 of this Act.
11    "Benefits plan" means the coverage to be offered by the
12Plan to eligible persons and federally eligible individuals
13pursuant to this Act.
14    "Board" means the Illinois Comprehensive Health Insurance
15Board.
16    "Church plan" has the same meaning given that term in the
17federal Health Insurance Portability and Accountability Act of
181996.
19    "Continuation coverage" means continuation of coverage
20under a group health plan or other health insurance coverage
21for former employees or dependents of former employees that
22would otherwise have terminated under the terms of that
23coverage pursuant to any continuation provisions under federal

 

 

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1or State law, including the Consolidated Omnibus Budget
2Reconciliation Act of 1985 (COBRA), as amended, Sections 367.2,
3367e, and 367e.1 of the Illinois Insurance Code, or any other
4similar requirement in another State.
5    "Covered person" means a person who is and continues to
6remain eligible for Plan coverage and is covered under one of
7the benefit plans offered by the Plan.
8    "Creditable coverage" means, with respect to a federally
9eligible individual, coverage of the individual under any of
10the following:
11        (A) A group health plan.
12        (B) Health insurance coverage (including group health
13    insurance coverage).
14        (C) Medicare.
15        (D) Medical assistance.
16        (E) Chapter 55 of title 10, United States Code.
17        (F) A medical care program of the Indian Health Service
18    or of a tribal organization.
19        (G) A state health benefits risk pool.
20        (H) A health plan offered under Chapter 89 of title 5,
21    United States Code.
22        (I) A public health plan (as defined in regulations
23    consistent with Section 104 of the Health Care Portability
24    and Accountability Act of 1996 that may be promulgated by
25    the Secretary of the U.S. Department of Health and Human
26    Services).

 

 

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1        (J) A health benefit plan under Section 5(e) of the
2    Peace Corps Act (22 U.S.C. 2504(e)).
3        (K) Any other qualifying coverage required by the
4    federal Health Insurance Portability and Accountability
5    Act of 1996, as it may be amended, or regulations under
6    that Act.
7    "Creditable coverage" does not include coverage consisting
8solely of coverage of excepted benefits, as defined in Section
92791(c) of title XXVII of the Public Health Service Act (42
10U.S.C. 300 gg-91), nor does it include any period of coverage
11under any of items (A) through (K) that occurred before a break
12of more than 90 days or, if the individual has been certified
13as eligible pursuant to the federal Trade Act of 2002, a break
14of more than 63 days during all of which the individual was not
15covered under any of items (A) through (K) above.
16    Any period that an individual is in a waiting period for
17any coverage under a group health plan (or for group health
18insurance coverage) or is in an affiliation period under the
19terms of health insurance coverage offered by a health
20maintenance organization shall not be taken into account in
21determining if there has been a break of more than 90 days in
22any creditable coverage.
23    "Department" means the Illinois Department of Insurance.
24    "Dependent" means an Illinois resident: who is a spouse; or
25who is claimed as a dependent by the principal insured for
26purposes of filing a federal income tax return and resides in

 

 

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1the principal insured's household, and is a resident unmarried
2child under the age of 19 years; or who is an unmarried child
3who also is a full-time student under the age of 23 years and
4who is financially dependent upon the principal insured; or who
5is a child of any age and who is disabled and financially
6dependent upon the principal insured.
7    "Direct Illinois premiums" means, for Illinois business,
8an insurer's direct premium income for the kinds of business
9described in clause (b) of Class 1 or clause (a) of Class 2 of
10Section 4 of the Illinois Insurance Code, and direct premium
11income of a health maintenance organization or a voluntary
12health services plan, except it shall not include credit health
13insurance as defined in Article IX 1/2 of the Illinois
14Insurance Code.
15    "Director" means the Director of the Illinois Department of
16Insurance.
17    "Effective date of medical assistance" means the date that
18eligibility for medical assistance for a person is approved by
19the Department of Human Services or the Department of
20Healthcare and Family Services, except when the Department of
21Human Services or the Department of Healthcare and Family
22Services determines eligibility retroactively. In such
23circumstances, the effective date of the medical assistance is
24the date the Department of Human Services or the Department of
25Healthcare and Family Services determines the person to be
26eligible for medical assistance. As it pertains to Medicare,

 

 

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1the effective date is 24 months after the entitlement date as
2approved by the Social Security Administration, except when
3eligibility is made retroactive to a prior date. In such
4circumstances, the effective date of Medicare is the date on
5the Notice of Award letter issued by the Social Security
6Administration.
7    "Eligible person" means a resident of this State who
8qualifies for Plan coverage under Section 7 of this Act.
9    "Employee" means a resident of this State who is employed
10by an employer or has entered into the employment of or works
11under contract or service of an employer including the
12officers, managers and employees of subsidiary or affiliated
13corporations and the individual proprietors, partners and
14employees of affiliated individuals and firms when the business
15of the subsidiary or affiliated corporations, firms or
16individuals is controlled by a common employer through stock
17ownership, contract, or otherwise.
18    "Employer" means any individual, partnership, association,
19corporation, business trust, or any person or group of persons
20acting directly or indirectly in the interest of an employer in
21relation to an employee, for which one or more persons is
22gainfully employed.
23    "Family" coverage means the coverage provided by the Plan
24for the covered person and his or her eligible dependents who
25also are covered persons.
26    "Federally eligible individual" means an individual

 

 

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1resident of this State:
2        (1)(A) for whom, as of the date on which the individual
3    seeks Plan coverage under Section 15 of this Act, the
4    aggregate of the periods of creditable coverage is 18 or
5    more months or, if the individual has been certified as
6    eligible pursuant to the federal Trade Act of 2002, 3 or
7    more months, and (B) whose most recent prior creditable
8    coverage was under group health insurance coverage offered
9    by a health insurance issuer, a group health plan, a
10    governmental plan, or a church plan (or health insurance
11    coverage offered in connection with any such plans) or any
12    other type of creditable coverage that may be required by
13    the federal Health Insurance Portability and
14    Accountability Act of 1996, as it may be amended, or the
15    regulations under that Act;
16        (2) who is not eligible for coverage under (A) a group
17    health plan (other than an individual who has been
18    certified as eligible pursuant to the federal Trade Act of
19    2002), (B) part A or part B of Medicare due to age (other
20    than an individual who has been certified as eligible
21    pursuant to the federal Trade Act of 2002), or (C) medical
22    assistance, and does not have other health insurance
23    coverage (other than an individual who has been certified
24    as eligible pursuant to the federal Trade Act of 2002);
25        (3) with respect to whom (other than an individual who
26    has been certified as eligible pursuant to the federal

 

 

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1    Trade Act of 2002) the most recent coverage within the
2    coverage period described in paragraph (1)(A) of this
3    definition was not terminated based upon a factor relating
4    to nonpayment of premiums or fraud;
5        (4) if the individual (other than an individual who has
6    been certified as eligible pursuant to the federal Trade
7    Act of 2002) had been offered the option of continuation
8    coverage under a COBRA continuation provision or under a
9    similar State program, who elected such coverage; and
10        (5) who, if the individual elected such continuation
11    coverage, has exhausted such continuation coverage under
12    such provision or program.
13    However, an individual who has been certified as eligible
14pursuant to the federal Trade Act of 2002 shall not be required
15to elect continuation coverage under a COBRA continuation
16provision or under a similar state program.
17    "Group health insurance coverage" means, in connection
18with a group health plan, health insurance coverage offered in
19connection with that plan.
20    "Group health plan" has the same meaning given that term in
21the federal Health Insurance Portability and Accountability
22Act of 1996.
23    "Governmental plan" has the same meaning given that term in
24the federal Health Insurance Portability and Accountability
25Act of 1996.
26    "Health insurance coverage" means benefits consisting of

 

 

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1medical care (provided directly, through insurance or
2reimbursement, or otherwise and including items and services
3paid for as medical care) under any hospital and medical
4expense-incurred policy, certificate, or contract provided by
5an insurer, non-profit health care service plan contract,
6health maintenance organization or other subscriber contract,
7or any other health care plan or arrangement that pays for or
8furnishes medical or health care services whether by insurance
9or otherwise. Health insurance coverage shall not include short
10term, accident only, disability income, hospital confinement
11or fixed indemnity, dental only, vision only, limited benefit,
12or credit insurance, coverage issued as a supplement to
13liability insurance, insurance arising out of a workers'
14compensation or similar law, automobile medical-payment
15insurance, or insurance under which benefits are payable with
16or without regard to fault and which is statutorily required to
17be contained in any liability insurance policy or equivalent
18self-insurance.
19    "Health insurance issuer" means an insurance company,
20insurance service, or insurance organization (including a
21health maintenance organization and a voluntary health
22services plan) that is authorized to transact health insurance
23business in this State. Such term does not include a group
24health plan.
25    "Health Maintenance Organization" means an organization as
26defined in the Health Maintenance Organization Act.

 

 

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1    "Hospice" means a program as defined in and licensed under
2the Hospice Program Licensing Act.
3    "Hospital" means a duly licensed institution as defined in
4the Hospital Licensing Act, an institution that meets all
5comparable conditions and requirements in effect in the state
6in which it is located, or the University of Illinois Hospital
7as defined in the University of Illinois Hospital Act.
8    "Individual health insurance coverage" means health
9insurance coverage offered to individuals in the individual
10market, but does not include short-term, limited-duration
11insurance.
12    "Insured" means any individual resident of this State who
13is eligible to receive benefits from any insurer (including
14health insurance coverage offered in connection with a group
15health plan) or health insurance issuer as defined in this
16Section.
17    "Insurer" means any insurance company authorized to
18transact health insurance business in this State and any
19corporation that provides medical services and is organized
20under the Voluntary Health Services Plans Act or the Health
21Maintenance Organization Act.
22    "Medical assistance" means the State medical assistance or
23medical assistance no grant (MANG) programs provided under
24Title XIX of the Social Security Act and Articles V (Medical
25Assistance) and VI (General Assistance) of the Illinois Public
26Aid Code (or any successor program) or under any similar

 

 

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1program of health care benefits in a state other than Illinois.
2    "Medically necessary" means that a service, drug, or supply
3is necessary and appropriate for the diagnosis or treatment of
4an illness or injury in accord with generally accepted
5standards of medical practice at the time the service, drug, or
6supply is provided. When specifically applied to a confinement
7it further means that the diagnosis or treatment of the covered
8person's medical symptoms or condition cannot be safely
9provided to that person as an outpatient. A service, drug, or
10supply shall not be medically necessary if it: (i) is
11investigational, experimental, or for research purposes; or
12(ii) is provided solely for the convenience of the patient, the
13patient's family, physician, hospital, or any other provider;
14or (iii) exceeds in scope, duration, or intensity that level of
15care that is needed to provide safe, adequate, and appropriate
16diagnosis or treatment; or (iv) could have been omitted without
17adversely affecting the covered person's condition or the
18quality of medical care; or (v) involves the use of a medical
19device, drug, or substance not formally approved by the United
20States Food and Drug Administration.
21    "Medical care" means the ordinary and usual professional
22services rendered by a physician or other specified provider
23during a professional visit for treatment of an illness or
24injury.
25    "Medicare" means coverage under both Part A and Part B of
26Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395, et

 

 

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1seq.
2    "Minimum premium plan" means an arrangement whereby a
3specified amount of health care claims is self-funded, but the
4insurance company assumes the risk that claims will exceed that
5amount.
6    "Participating transplant center" means a hospital
7designated by the Board as a preferred or exclusive provider of
8services for one or more specified human organ or tissue
9transplants for which the hospital has signed an agreement with
10the Board to accept a transplant payment allowance for all
11expenses related to the transplant during a transplant benefit
12period.
13    "Physician" means a person licensed to practice medicine
14pursuant to the Medical Practice Act of 1987.
15    "Plan" means the Comprehensive Health Insurance Plan
16established by this Act.
17    "Plan of operation" means the plan of operation of the
18Plan, including articles, bylaws and operating rules, adopted
19by the board pursuant to this Act.
20    "Provider" means any hospital, skilled nursing facility,
21hospice, home health agency, physician, registered pharmacist
22acting within the scope of that registration, or any other
23person or entity licensed in Illinois to furnish medical care.
24    "Qualified high risk pool" has the same meaning given that
25term in the federal Health Insurance Portability and
26Accountability Act of 1996.

 

 

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1    "Resident" means a person who is and continues to be
2legally domiciled and physically residing on a permanent and
3full-time basis in a place of permanent habitation in this
4State that remains that person's principal residence and from
5which that person is absent only for temporary or transitory
6purpose.
7    "Skilled nursing facility" means a facility or that portion
8of a facility that is licensed by the Illinois Department of
9Public Health under the Nursing Home Care Act or a comparable
10licensing authority in another state to provide skilled nursing
11care.
12    "Stop-loss coverage" means an arrangement whereby an
13insurer insures against the risk that any one claim will exceed
14a specific dollar amount or that the entire loss of a
15self-insurance plan will exceed a specific amount.
16    "Third party administrator" means an administrator as
17defined in Section 511.101 of the Illinois Insurance Code who
18is licensed under Article XXXI 1/4 of that Code.
19(Source: P.A. 95-965, eff. 9-23-08.)
 
20    Section 99. Effective date. This Act takes effect upon
21becoming law.