HB0197 Enrolled LRB094 05352 LJB 35397 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Comprehensive Health Insurance Plan Act is
5 amended by changing Section 7 as follows:
 
6     (215 ILCS 105/7)  (from Ch. 73, par. 1307)
7     Sec. 7. Eligibility.
8     a. Except as provided in subsection (e) of this Section or
9 in Section 15 of this Act, any person who is either a citizen
10 of the United States or an alien lawfully admitted for
11 permanent residence and who has been for a period of at least
12 180 days and continues to be a resident of this State shall be
13 eligible for Plan coverage under this Section if evidence is
14 provided of:
15         (1) A notice of rejection or refusal to issue
16     substantially similar individual health insurance coverage
17     for health reasons by a health insurance issuer; or
18         (2) A refusal by a health insurance issuer to issue
19     individual health insurance coverage except at a rate
20     exceeding the applicable Plan rate for which the person is
21     responsible.
22     A rejection or refusal by a group health plan or health
23 insurance issuer offering only stop-loss or excess of loss
24 insurance or contracts, agreements, or other arrangements for
25 reinsurance coverage with respect to the applicant shall not be
26 sufficient evidence under this subsection.
27     b. The board shall promulgate a list of medical or health
28 conditions for which a person who is either a citizen of the
29 United States or an alien lawfully admitted for permanent
30 residence and a resident of this State would be eligible for
31 Plan coverage without applying for health insurance coverage
32 pursuant to subsection a. of this Section. Persons who can

 

 

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1 demonstrate the existence or history of any medical or health
2 conditions on the list promulgated by the board shall not be
3 required to provide the evidence specified in subsection a. of
4 this Section. The list shall be effective on the first day of
5 the operation of the Plan and may be amended from time to time
6 as appropriate.
7     c. Family members of the same household who each are
8 covered persons are eligible for optional family coverage under
9 the Plan.
10     d. For persons qualifying for coverage in accordance with
11 Section 7 of this Act, the board shall, if it determines that
12 such appropriations as are made pursuant to Section 12 of this
13 Act are insufficient to allow the board to accept all of the
14 eligible persons which it projects will apply for enrollment
15 under the Plan, limit or close enrollment to ensure that the
16 Plan is not over-subscribed and that it has sufficient
17 resources to meet its obligations to existing enrollees. The
18 board shall not limit or close enrollment for federally
19 eligible individuals.
20     e. A person shall not be eligible for coverage under the
21 Plan if:
22         (1) He or she has or obtains other coverage under a
23     group health plan or health insurance coverage
24     substantially similar to or better than a Plan policy as an
25     insured or covered dependent or would be eligible to have
26     that coverage if he or she elected to obtain it. Persons
27     otherwise eligible for Plan coverage may, however, solely
28     for the purpose of having coverage for a pre-existing
29     condition, maintain other coverage only while satisfying
30     any pre-existing condition waiting period under a Plan
31     policy or a subsequent replacement policy of a Plan policy.
32         (1.1) His or her prior coverage under a group health
33     plan or health insurance coverage, provided or arranged by
34     an employer of more than 10 employees was discontinued for
35     any reason without the entire group or plan being
36     discontinued and not replaced, provided he or she remains

 

 

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1     an employee, or dependent thereof, of the same employer.
2         (2) He or she is a recipient of or is approved to
3     receive medical assistance, except that a person may
4     continue to receive medical assistance through the medical
5     assistance no grant program, but only while satisfying the
6     requirements for a preexisting condition under Section 8,
7     subsection f. of this Act. Payment of premiums pursuant to
8     this Act shall be allocable to the person's spenddown for
9     purposes of the medical assistance no grant program, but
10     that person shall not be eligible for any Plan benefits
11     while that person remains eligible for medical assistance.
12     If the person continues to receive or be approved to
13     receive medical assistance through the medical assistance
14     no grant program at or after the time that requirements for
15     a preexisting condition are satisfied, the person shall not
16     be eligible for coverage under the Plan. In that
17     circumstance, coverage under the plan shall terminate as of
18     the expiration of the preexisting condition limitation
19     period. Under all other circumstances, coverage under the
20     Plan shall automatically terminate as of the effective date
21     of any medical assistance.
22         (3) Except as provided in Section 15, the person has
23     previously participated in the Plan and voluntarily
24     terminated Plan coverage, unless 12 months have elapsed
25     since the person's latest voluntary termination of
26     coverage.
27         (4) The person fails to pay the required premium under
28     the covered person's terms of enrollment and
29     participation, in which event the liability of the Plan
30     shall be limited to benefits incurred under the Plan for
31     the time period for which premiums had been paid and the
32     covered person remained eligible for Plan coverage.
33         (5) The Plan has paid a total of $1,000,000 in benefits
34     on behalf of the covered person.
35         (6) The person is a resident of a public institution.
36         (7) The person's premium is paid for or reimbursed

 

 

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1     under any government sponsored program or by any government
2     agency or health care provider, except as an otherwise
3     qualifying full-time employee, or dependent of such
4     employee, of a government agency or health care provider
5     or, except when a person's premium is paid by the U.S.
6     Treasury Department pursuant to the federal Trade Act of
7     2002.
8         (8) The person has or later receives other benefits or
9     funds from any settlement, judgement, or award resulting
10     from any accident or injury, regardless of the date of the
11     accident or injury, or any other circumstances creating a
12     legal liability for damages due that person by a third
13     party, whether the settlement, judgment, or award is in the
14     form of a contract, agreement, or trust on behalf of a
15     minor or otherwise and whether the settlement, judgment, or
16     award is payable to the person, his or her dependent,
17     estate, personal representative, or guardian in a lump sum
18     or over time, so long as there continues to be benefits or
19     assets remaining from those sources in an amount in excess
20     of $300,000 $100,000.
21         (9) Within the 5 years prior to the date a person's
22     Plan application is received by the Board, the person's
23     coverage under any health care benefit program as defined
24     in 18 U.S.C. 24, including any public or private plan or
25     contract under which any medical benefit, item, or service
26     is provided, was terminated as a result of any act or
27     practice that constitutes fraud under State or federal law
28     or as a result of an intentional misrepresentation of
29     material fact; or if that person knowingly and willfully
30     obtained or attempted to obtain, or fraudulently aided or
31     attempted to aid any other person in obtaining, any
32     coverage or benefits under the Plan to which that person
33     was not entitled.
34     f. The board or the administrator shall require
35 verification of residency and may require any additional
36 information or documentation, or statements under oath, when

 

 

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1 necessary to determine residency upon initial application and
2 for the entire term of the policy.
3     g. Coverage shall cease (i) on the date a person is no
4 longer a resident of Illinois, (ii) on the date a person
5 requests coverage to end, (iii) upon the death of the covered
6 person, (iv) on the date State law requires cancellation of the
7 policy, or (v) at the Plan's option, 30 days after the Plan
8 makes any inquiry concerning a person's eligibility or place of
9 residence to which the person does not reply.
10     h. Except under the conditions set forth in subsection g of
11 this Section, the coverage of any person who ceases to meet the
12 eligibility requirements of this Section shall be terminated at
13 the end of the current policy period for which the necessary
14 premiums have been paid.
15 (Source: P.A. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03.)