HB5648 Engrossed LRB095 19208 KBJ 45459 b

1     AN ACT concerning regulation.
 
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 2 as follows:
 
6     (215 ILCS 105/2)  (from Ch. 73, par. 1302)
7     Sec. 2. Definitions. As used in this Act, unless the
8 context otherwise requires:
9     "Plan administrator" means the insurer or third party
10 administrator designated under Section 5 of this Act.
11     "Benefits plan" means the coverage to be offered by the
12 Plan to eligible persons and federally eligible individuals
13 pursuant to this Act.
14     "Board" means the Illinois Comprehensive Health Insurance
15 Board.
16     "Church plan" has the same meaning given that term in the
17 federal Health Insurance Portability and Accountability Act of
18 1996.
19     "Continuation coverage" means continuation of coverage
20 under a group health plan or other health insurance coverage
21 for former employees or dependents of former employees that
22 would otherwise have terminated under the terms of that
23 coverage pursuant to any continuation provisions under federal

 

 

HB5648 Engrossed - 2 - LRB095 19208 KBJ 45459 b

1 or State law, including the Consolidated Omnibus Budget
2 Reconciliation Act of 1985 (COBRA), as amended, Sections 367.2,
3 367e, and 367e.1 of the Illinois Insurance Code, or any other
4 similar requirement in another State.
5     "Covered person" means a person who is and continues to
6 remain eligible for Plan coverage and is covered under one of
7 the benefit plans offered by the Plan.
8     "Creditable coverage" means, with respect to a federally
9 eligible individual, coverage of the individual under any of
10 the 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).

 

 

HB5648 Engrossed - 3 - LRB095 19208 KBJ 45459 b

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
8 solely of coverage of excepted benefits, as defined in Section
9 2791(c) of title XXVII of the Public Health Service Act (42
10 U.S.C. 300 gg-91), nor does it include any period of coverage
11 under any of items (A) through (K) that occurred before a break
12 of more than 90 days or, if the individual has been certified
13 as eligible pursuant to the federal Trade Act of 2002, a break
14 of more than 63 days during all of which the individual was not
15 covered under any of items (A) through (K) above.
16     Any period that an individual is in a waiting period for
17 any coverage under a group health plan (or for group health
18 insurance coverage) or is in an affiliation period under the
19 terms of health insurance coverage offered by a health
20 maintenance organization shall not be taken into account in
21 determining if there has been a break of more than 90 days in
22 any creditable coverage.
23     "Department" means the Illinois Department of Insurance.
24     "Dependent" means an Illinois resident: who is a spouse; or
25 who is claimed as a dependent by the principal insured for
26 purposes of filing a federal income tax return and resides in

 

 

HB5648 Engrossed - 4 - LRB095 19208 KBJ 45459 b

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

 

 

HB5648 Engrossed - 5 - LRB095 19208 KBJ 45459 b

1 by an employer or has entered into the employment of or works
2 under contract or service of an employer including the
3 officers, managers and employees of subsidiary or affiliated
4 corporations and the individual proprietors, partners and
5 employees of affiliated individuals and firms when the business
6 of the subsidiary or affiliated corporations, firms or
7 individuals is controlled by a common employer through stock
8 ownership, contract, or otherwise.
9     "Employer" means any individual, partnership, association,
10 corporation, business trust, or any person or group of persons
11 acting directly or indirectly in the interest of an employer in
12 relation to an employee, for which one or more persons is
13 gainfully employed.
14     "Family" coverage means the coverage provided by the Plan
15 for the covered person and his or her eligible dependents who
16 also are covered persons.
17     "Federally eligible individual" means an individual
18 resident of this State:
19         (1)(A) for whom, as of the date on which the individual
20     seeks Plan coverage under Section 15 of this Act, the
21     aggregate of the periods of creditable coverage is 18 or
22     more months or, if the individual has been certified as
23     eligible pursuant to the federal Trade Act of 2002, 3 or
24     more months, and (B) whose most recent prior creditable
25     coverage was under group health insurance coverage offered
26     by a health insurance issuer, a group health plan, a

 

 

HB5648 Engrossed - 6 - LRB095 19208 KBJ 45459 b

1     governmental plan, or a church plan (or health insurance
2     coverage offered in connection with any such plans) or any
3     other type of creditable coverage that may be required by
4     the federal Health Insurance Portability and
5     Accountability Act of 1996, as it may be amended, or the
6     regulations under that Act;
7         (2) who is not eligible for coverage under (A) a group
8     health plan (other than an individual who has been
9     certified as eligible pursuant to the federal Trade Act of
10     2002), (B) part A or part B of Medicare due to age (other
11     than an individual who has been certified as eligible
12     pursuant to the federal Trade Act of 2002), or (C) medical
13     assistance, and does not have other health insurance
14     coverage (other than an individual who has been certified
15     as eligible pursuant to the federal Trade Act of 2002);
16         (3) with respect to whom (other than an individual who
17     has been certified as eligible pursuant to the federal
18     Trade Act of 2002) the most recent coverage within the
19     coverage period described in paragraph (1)(A) of this
20     definition was not terminated based upon a factor relating
21     to nonpayment of premiums or fraud;
22         (4) if the individual (other than an individual who has
23     been certified as eligible pursuant to the federal Trade
24     Act of 2002) had been offered the option of continuation
25     coverage under a COBRA continuation provision or under a
26     similar State program, who elected such coverage; and

 

 

HB5648 Engrossed - 7 - LRB095 19208 KBJ 45459 b

1         (5) who, if the individual elected such continuation
2     coverage, has exhausted such continuation coverage under
3     such provision or program.
4     However, an individual who has been certified as eligible
5 pursuant to the federal Trade Act of 2002 shall not be required
6 to elect continuation coverage under a COBRA continuation
7 provision or under a similar state program.
8     "Group health insurance coverage" means, in connection
9 with a group health plan, health insurance coverage offered in
10 connection with that plan.
11     "Group health plan" has the same meaning given that term in
12 the federal Health Insurance Portability and Accountability
13 Act of 1996.
14     "Governmental plan" has the same meaning given that term in
15 the federal Health Insurance Portability and Accountability
16 Act of 1996.
17     "Health insurance coverage" means benefits consisting of
18 medical care (provided directly, through insurance or
19 reimbursement, or otherwise and including items and services
20 paid for as medical care) under any hospital and medical
21 expense-incurred policy, certificate, or contract provided by
22 an insurer, non-profit health care service plan contract,
23 health maintenance organization or other subscriber contract,
24 or any other health care plan or arrangement that pays for or
25 furnishes medical or health care services whether by insurance
26 or otherwise. Health insurance coverage shall not include short

 

 

HB5648 Engrossed - 8 - LRB095 19208 KBJ 45459 b

1 term, accident only, disability income, hospital confinement
2 or fixed indemnity, dental only, vision only, limited benefit,
3 or credit insurance, coverage issued as a supplement to
4 liability insurance, insurance arising out of a workers'
5 compensation or similar law, automobile medical-payment
6 insurance, or insurance under which benefits are payable with
7 or without regard to fault and which is statutorily required to
8 be contained in any liability insurance policy or equivalent
9 self-insurance.
10     "Health insurance issuer" means an insurance company,
11 insurance service, or insurance organization (including a
12 health maintenance organization and a voluntary health
13 services plan) that is authorized to transact health insurance
14 business in this State. Such term does not include a group
15 health plan.
16     "Health Maintenance Organization" means an organization as
17 defined in the Health Maintenance Organization Act.
18     "Hospice" means a program as defined in and licensed under
19 the Hospice Program Licensing Act.
20     "Hospital" means a duly licensed institution as defined in
21 the Hospital Licensing Act, an institution that meets all
22 comparable conditions and requirements in effect in the state
23 in which it is located, or the University of Illinois Hospital
24 as defined in the University of Illinois Hospital Act.
25     "Individual health insurance coverage" means health
26 insurance coverage offered to individuals in the individual

 

 

HB5648 Engrossed - 9 - LRB095 19208 KBJ 45459 b

1 market, but does not include short-term, limited-duration
2 insurance.
3     "Insured" means any individual resident of this State who
4 is eligible to receive benefits from any insurer (including
5 health insurance coverage offered in connection with a group
6 health plan) or health insurance issuer as defined in this
7 Section.
8     "Insurer" means any insurance company authorized to
9 transact health insurance business in this State and any
10 corporation that provides medical services and is organized
11 under the Voluntary Health Services Plans Act or the Health
12 Maintenance Organization Act.
13     "Medical assistance" means the State medical assistance or
14 medical assistance no grant (MANG) programs provided under
15 Title XIX of the Social Security Act and Articles V (Medical
16 Assistance) and VI (General Assistance) of the Illinois Public
17 Aid Code (or any successor program) or under any similar
18 program of health care benefits in a state other than Illinois.
19     "Medically necessary" means that a service, drug, or supply
20 is necessary and appropriate for the diagnosis or treatment of
21 an illness or injury in accord with generally accepted
22 standards of medical practice at the time the service, drug, or
23 supply is provided. When specifically applied to a confinement
24 it further means that the diagnosis or treatment of the covered
25 person's medical symptoms or condition cannot be safely
26 provided to that person as an outpatient. A service, drug, or

 

 

HB5648 Engrossed - 10 - LRB095 19208 KBJ 45459 b

1 supply shall not be medically necessary if it: (i) is
2 investigational, experimental, or for research purposes; or
3 (ii) is provided solely for the convenience of the patient, the
4 patient's family, physician, hospital, or any other provider;
5 or (iii) exceeds in scope, duration, or intensity that level of
6 care that is needed to provide safe, adequate, and appropriate
7 diagnosis or treatment; or (iv) could have been omitted without
8 adversely affecting the covered person's condition or the
9 quality of medical care; or (v) involves the use of a medical
10 device, drug, or substance not formally approved by the United
11 States Food and Drug Administration.
12     "Medical care" means the ordinary and usual professional
13 services rendered by a physician or other specified provider
14 during a professional visit for treatment of an illness or
15 injury.
16     "Medicare" means coverage under both Part A and Part B of
17 Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395, et
18 seq.
19     "Minimum premium plan" means an arrangement whereby a
20 specified amount of health care claims is self-funded, but the
21 insurance company assumes the risk that claims will exceed that
22 amount.
23     "Participating transplant center" means a hospital
24 designated by the Board as a preferred or exclusive provider of
25 services for one or more specified human organ or tissue
26 transplants for which the hospital has signed an agreement with

 

 

HB5648 Engrossed - 11 - LRB095 19208 KBJ 45459 b

1 the Board to accept a transplant payment allowance for all
2 expenses related to the transplant during a transplant benefit
3 period.
4     "Physician" means a person licensed to practice medicine
5 pursuant to the Medical Practice Act of 1987.
6     "Plan" means the Comprehensive Health Insurance Plan
7 established by this Act.
8     "Plan of operation" means the plan of operation of the
9 Plan, including articles, bylaws and operating rules, adopted
10 by the board pursuant to this Act.
11     "Provider" means any hospital, skilled nursing facility,
12 hospice, home health agency, physician, registered pharmacist
13 acting within the scope of that registration, or any other
14 person or entity licensed in Illinois to furnish medical care.
15     "Qualified high risk pool" has the same meaning given that
16 term in the federal Health Insurance Portability and
17 Accountability Act of 1996.
18     "Resident" means a person who is and continues to be
19 legally domiciled and physically residing on a permanent and
20 full-time basis in a place of permanent habitation in this
21 State that remains that person's principal residence and from
22 which that person is absent only for temporary or transitory
23 purpose.
24     "Skilled nursing facility" means a facility or that portion
25 of a facility that is licensed by the Illinois Department of
26 Public Health under the Nursing Home Care Act or a comparable

 

 

HB5648 Engrossed - 12 - LRB095 19208 KBJ 45459 b

1 licensing authority in another state to provide skilled nursing
2 care.
3     "Stop-loss coverage" means an arrangement whereby an
4 insurer insures against the risk that any one claim will exceed
5 a specific dollar amount or that the entire loss of a
6 self-insurance plan will exceed a specific amount.
7     "Third party administrator" means an administrator as
8 defined in Section 511.101 of the Illinois Insurance Code who
9 is licensed under Article XXXI 1/4 of that Code.
10 (Source: P.A. 92-153, eff. 7-25-01; 93-33, eff. 6-23-03; 93-34,
11 eff. 6-23-03; 93-477, eff. 8-8-03; 93-622, eff. 12-18-03.)
 
12     Section 99. Effective date. This Act takes effect upon
13 becoming law.