98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB0104

 

Introduced 1/10/2013, by Rep. Elizabeth Hernandez

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/5.5
215 ILCS 170/20
305 ILCS 5/12-4.45 new
305 ILCS 5/12-9  from Ch. 23, par. 12-9

    Amends the Illinois Insurance Code, the Covering ALL KIDS Health Insurance Act, and the Illinois Public Aid Code. Provides that to the extent authorized under federal law, the Department of Healthcare and Family Services shall identify individuals receiving services under medical assistance programs funded or partially funded by the State who may be or may have been covered by a third party health insurer, the period of coverage for such individuals, and the nature of the coverage. Requires a third party health insurer to provide the Department with eligibility information in a federally recommended or mutually agreed-upon format that includes, at a minimum, the names, addresses, dates, and sex of primary covered persons, the policy group numbers of the covered persons, and other identifiable information. Permits the Department to impose an administrative penalty on a third party health insurer that does not comply with the request for information. Provides that the Attorney General may bring suit on behalf of the Department to collect the penalty. Provides that recoveries made by the Department in connection with the imposition of this administrative penalty shall be deposited into the Public Aid Recoveries Trust Fund. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning the Department of Healthcare and Family
2Services.
 
3    Be it enacted by the People of the State of Illinois,
4represented in the General Assembly:
 
5    Section 5. The Illinois Insurance Code is amended by
6changing Section 5.5 as follows:
 
7    (215 ILCS 5/5.5)
8    Sec. 5.5. Compliance with the Department of Healthcare and
9Family Services. A company authorized to do business in this
10State or accredited by the State to issue policies of health
11insurance, including but not limited to, self-insured plans,
12group health plans (as defined in Section 607(1) of the
13Employee Retirement Income Security Act of 1974), service
14benefit plans, managed care organizations, pharmacy benefit
15managers, or other parties that are by statute, contract, or
16agreement legally responsible for payment of a claim for a
17health care item or service as a condition of doing business in
18the State must:
19        (1) provide to the Department of Healthcare and Family
20    Services, or any successor agency, on at least a quarterly
21    basis if so requested by the Department, information to
22    determine during what period any individual may be, or may
23    have been, covered by a health insurer and the nature of

 

 

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1    the coverage that is or was provided by the health insurer,
2    including the name, address, and identifying number of the
3    plan;
4        (2) accept the State's right of recovery and the
5    assignment to the State of any right of an individual or
6    other entity to payment from the party for an item or
7    service for which payment has been made under the medical
8    programs of the Department of Healthcare and Family
9    Services, or any successor agency, under this Code or the
10    Illinois Public Aid Code;
11        (3) respond to any inquiry by the Department of
12    Healthcare and Family Services regarding a claim for
13    payment for any health care item or service that is
14    submitted not later than 3 years after the date of the
15    provision of such health care item or service; and
16        (4) agree not to deny a claim submitted by the
17    Department of Healthcare and Family Services solely on the
18    basis of the date of submission of the claim, the type or
19    format of the claim form, or a failure to present proper
20    documentation at the point-of-sale that is the basis of the
21    claim if (i) the claim is submitted by the Department of
22    Healthcare and Family Services within the 3-year period
23    beginning on the date on which the item or service was
24    furnished and (ii) any action by the Department of
25    Healthcare and Family Services to enforce its rights with
26    respect to such claim is commenced within 6 years of its

 

 

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1    submission of such claim.
2    The Department of Healthcare and Family Services may impose
3an administrative penalty as provided under Section 12-4.45 of
4the Illinois Public Aid Code on entities that have established
5a pattern of failure to provide the information required under
6this Section, or in In cases in which the Department of
7Healthcare and Family Services has determined that an entity
8that provides health insurance coverage has established a
9pattern of failure to provide the information required under
10this Section, and has subsequently certified that
11determination, along with supporting documentation, to the
12Director of the Department of Insurance, the Director of the
13Department of Insurance, based upon the certification of
14determination made by the Department of Healthcare and Family
15Services, may commence regulatory proceedings in accordance
16with all applicable provisions of the Illinois Insurance Code.
17(Source: P.A. 95-632, eff. 9-25-07; 96-1501, eff. 1-25-11.)
 
18    Section 10. The Covering ALL KIDS Health Insurance Act is
19amended by changing Section 20 as follows:
 
20    (215 ILCS 170/20)
21    (Section scheduled to be repealed on July 1, 2016)
22    Sec. 20. Eligibility.
23    (a) To be eligible for the Program, a person must be a
24child:

 

 

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1        (1) who is a resident of the State of Illinois;
2        (2) who is ineligible for medical assistance under the
3    Illinois Public Aid Code or benefits under the Children's
4    Health Insurance Program Act;
5        (3) either (i) who has been without health insurance
6    coverage for 12 months, (ii) whose parent has lost
7    employment that made available affordable dependent health
8    insurance coverage, until such time as affordable
9    employer-sponsored dependent health insurance coverage is
10    again available for the child as set forth by the
11    Department in rules, (iii) who is a newborn whose
12    responsible relative does not have available affordable
13    private or employer-sponsored health insurance, or (iv)
14    who, within one year of applying for coverage under this
15    Act, lost medical benefits under the Illinois Public Aid
16    Code or the Children's Health Insurance Program Act; and
17        (3.5) whose household income, as determined by the
18    Department, is at or below 300% of the federal poverty
19    level. This item (3.5) is effective July 1, 2011.
20    An entity that provides health insurance coverage (as
21defined in Section 2 of the Comprehensive Health Insurance Plan
22Act) to Illinois residents shall provide health insurance data
23match to the Department of Healthcare and Family Services as
24provided by and subject to Section 5.5 of the Illinois
25Insurance Code. The Department of Healthcare and Family
26Services may impose an administrative penalty as provided under

 

 

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1Section 12-4.45 of the Illinois Public Aid Code on entities
2that have established a pattern of failure to provide the
3information required under this Section.
4    The Department of Healthcare and Family Services, in
5collaboration with the Department of Insurance, shall adopt
6rules governing the exchange of information under this Section.
7The rules shall be consistent with all laws relating to the
8confidentiality or privacy of personal information or medical
9records, including provisions under the Federal Health
10Insurance Portability and Accountability Act (HIPAA).
11    (b) The Department shall monitor the availability and
12retention of employer-sponsored dependent health insurance
13coverage and shall modify the period described in subdivision
14(a)(3) if necessary to promote retention of private or
15employer-sponsored health insurance and timely access to
16healthcare services, but at no time shall the period described
17in subdivision (a)(3) be less than 6 months.
18    (c) The Department, at its discretion, may take into
19account the affordability of dependent health insurance when
20determining whether employer-sponsored dependent health
21insurance coverage is available upon reemployment of a child's
22parent as provided in subdivision (a)(3).
23    (d) A child who is determined to be eligible for the
24Program shall remain eligible for 12 months, provided that the
25child maintains his or her residence in this State, has not yet
26attained 19 years of age, and is not excluded under subsection

 

 

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1(e).
2    (e) A child is not eligible for coverage under the Program
3if:
4        (1) the premium required under Section 40 has not been
5    timely paid; if the required premiums are not paid, the
6    liability of the Program shall be limited to benefits
7    incurred under the Program for the time period for which
8    premiums have been paid; re-enrollment shall be completed
9    before the next covered medical visit, and the first
10    month's required premium shall be paid in advance of the
11    next covered medical visit; or
12        (2) the child is an inmate of a public institution or
13    an institution for mental diseases.
14    (f) The Department may adopt rules, including, but not
15limited to: rules regarding annual renewals of eligibility for
16the Program in conformance with Section 7 of this Act; rules
17providing for re-enrollment, grace periods, notice
18requirements, and hearing procedures under subdivision (e)(1)
19of this Section; and rules regarding what constitutes
20availability and affordability of private or
21employer-sponsored health insurance, with consideration of
22such factors as the percentage of income needed to purchase
23children or family health insurance, the availability of
24employer subsidies, and other relevant factors.
25    (g) Each child enrolled in the Program as of July 1, 2011
26whose family income, as established by the Department, exceeds

 

 

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1300% of the federal poverty level may remain enrolled in the
2Program for 12 additional months commencing July 1, 2011.
3Continued enrollment pursuant to this subsection shall be
4available only if the child continues to meet all eligibility
5criteria established under the Program as of the effective date
6of this amendatory Act of the 96th General Assembly without a
7break in coverage. Nothing contained in this subsection shall
8prevent a child from qualifying for any other health benefits
9program operated by the Department.
10(Source: P.A. 96-1272, eff. 1-1-11; 96-1501, eff. 1-25-11.)
 
11    Section 15. The Illinois Public Aid Code is amended by
12changing Section 12-9 and by adding Section 12-4.45 as follows:
 
13    (305 ILCS 5/12-4.45 new)
14    Sec. 12-4.45. Third party liability.
15    (a) To the extent authorized under federal law, the
16Department of Healthcare and Family Services shall identify
17individuals receiving services under medical assistance
18programs funded or partially funded by the State who may be or
19may have been covered by a third party health insurer, the
20period of coverage for such individuals, and the nature of
21coverage. A company, as defined in Section 5.5 of the Illinois
22Insurance Code and Section 2 of the Comprehensive Health
23Insurance Plan Act, must provide the Department eligibility
24information in a federally recommended or mutually agreed-upon

 

 

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1format that includes at a minimum:
2        (1) The names, addresses, dates, and sex of primary
3    covered persons.
4        (2) The policy group numbers of the covered persons.
5        (3) The names, dates of birth, and sex of covered
6    dependents, and the relationship of dependents to the
7    primary covered person.
8        (4) The effective dates of coverage for each covered
9    person.
10        (5) The generally defined covered services
11    information, such as drugs, medical, or any other similar
12    description of services covered.
13    (b) The Department may impose an administrative penalty on
14a company that does not comply with the request for information
15made under Section 5.5 of the Illinois Insurance Code and
16paragraph (3) of subsection (a) of Section 20 of the Covering
17ALL KIDS Health Insurance Act. The amount of the penalty may
18not exceed $10,000 for each day of noncompliance that occurs
19after the 180th day after the date of the request. The amount
20shall be based on:
21        (1) The seriousness of the violation, including the
22    nature, circumstances, extent, and gravity of the
23    violation.
24        (2) The economic harm caused by the violation.
25        (3) The history of previous violations.
26        (4) The amount necessary to deter a future violation.

 

 

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1        (5) Efforts to correct the violation.
2        (6) Any other matter that justice may require.
3    (c) The enforcement of the penalty may be stayed during the
4time the order is under administrative review if the company
5files an appeal.
6    (d) The Attorney General may bring suit on behalf of the
7Department to collect the penalty.
8    (e) Recoveries made by the Department in connection with
9the imposition of an administrative penalty as provided under
10this Section shall be deposited into the Public Aid Recoveries
11Trust Fund created under Section 12-9.
 
12    (305 ILCS 5/12-9)  (from Ch. 23, par. 12-9)
13    Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
14Public Aid Recoveries Trust Fund shall consist of (1)
15recoveries by the Department of Healthcare and Family Services
16(formerly Illinois Department of Public Aid) authorized by this
17Code in respect to applicants or recipients under Articles III,
18IV, V, and VI, including recoveries made by the Department of
19Healthcare and Family Services (formerly Illinois Department
20of Public Aid) from the estates of deceased recipients, (2)
21recoveries made by the Department of Healthcare and Family
22Services (formerly Illinois Department of Public Aid) in
23respect to applicants and recipients under the Children's
24Health Insurance Program Act, and the Covering ALL KIDS Health
25Insurance Act, (2.5) recoveries made by the Department of

 

 

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1Healthcare and Family Services in connection with the
2imposition of an administrative penalty as provided under
3Section 12-4.45, (3) federal funds received on behalf of and
4earned by State universities and local governmental entities
5for services provided to applicants or recipients covered under
6this Code, the Children's Health Insurance Program Act, and the
7Covering ALL KIDS Health Insurance Act, (3.5) federal financial
8participation revenue related to eligible disbursements made
9by the Department of Healthcare and Family Services from
10appropriations required by this Section, and (4) all other
11moneys received to the Fund, including interest thereon. The
12Fund shall be held as a special fund in the State Treasury.
13    Disbursements from this Fund shall be only (1) for the
14reimbursement of claims collected by the Department of
15Healthcare and Family Services (formerly Illinois Department
16of Public Aid) through error or mistake, (2) for payment to
17persons or agencies designated as payees or co-payees on any
18instrument, whether or not negotiable, delivered to the
19Department of Healthcare and Family Services (formerly
20Illinois Department of Public Aid) as a recovery under this
21Section, such payment to be in proportion to the respective
22interests of the payees in the amount so collected, (3) for
23payments to the Department of Human Services for collections
24made by the Department of Healthcare and Family Services
25(formerly Illinois Department of Public Aid) on behalf of the
26Department of Human Services under this Code, the Children's

 

 

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1Health Insurance Program Act, and the Covering ALL KIDS Health
2Insurance Act, (4) for payment of administrative expenses
3incurred in performing the activities authorized under this
4Code, the Children's Health Insurance Program Act, and the
5Covering ALL KIDS Health Insurance Act, (5) for payment of fees
6to persons or agencies in the performance of activities
7pursuant to the collection of monies owed the State that are
8collected under this Code, the Children's Health Insurance
9Program Act, and the Covering ALL KIDS Health Insurance Act,
10(6) for payments of any amounts which are reimbursable to the
11federal government which are required to be paid by State
12warrant by either the State or federal government, and (7) for
13payments to State universities and local governmental entities
14of federal funds for services provided to applicants or
15recipients covered under this Code, the Children's Health
16Insurance Program Act, and the Covering ALL KIDS Health
17Insurance Act. Disbursements from this Fund for purposes of
18items (4) and (5) of this paragraph shall be subject to
19appropriations from the Fund to the Department of Healthcare
20and Family Services (formerly Illinois Department of Public
21Aid).
22    The balance in this Fund on the first day of each calendar
23quarter, after payment therefrom of any amounts reimbursable to
24the federal government, and minus the amount reasonably
25anticipated to be needed to make the disbursements during that
26quarter authorized by this Section, shall be certified by the

 

 

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1Director of Healthcare and Family Services and transferred by
2the State Comptroller to the Drug Rebate Fund or the Healthcare
3Provider Relief Fund in the State Treasury, as appropriate,
4within 30 days of the first day of each calendar quarter. The
5Director of Healthcare and Family Services may certify and the
6State Comptroller shall transfer to the Drug Rebate Fund
7amounts on a more frequent basis.
8    On July 1, 1999, the State Comptroller shall transfer the
9sum of $5,000,000 from the Public Aid Recoveries Trust Fund
10(formerly the Public Assistance Recoveries Trust Fund) into the
11DHS Recoveries Trust Fund.
12(Source: P.A. 96-1100, eff. 1-1-11; 97-647, eff. 1-1-12;
1397-689, eff. 6-14-12.)
 
14    Section 99. Effective date. This Act takes effect upon
15becoming law.