093_HB3298enr

 
HB3298 Enrolled                      LRB093 11158 JLS 12059 b

 1        AN  ACT  concerning  the  Comprehensive  Health Insurance
 2    Plan.

 3        Be it enacted by the People of  the  State  of  Illinois,
 4    represented in the General Assembly:

 5        Section  5.  The  Comprehensive Health Insurance Plan Act
 6    is amended by changing Sections 2, 4, 7, and 15 as follows:

 7        (215 ILCS 105/2) (from Ch. 73, par. 1302)
 8        Sec. 2.  Definitions.  As used in this  Act,  unless  the
 9    context otherwise requires:
10        "Plan  administrator"  means  the  insurer or third party
11    administrator designated under Section 5 of this Act.
12        "Benefits plan" means the coverage to be offered  by  the
13    Plan  to  eligible persons and federally eligible individuals
14    pursuant to this Act.
15        "Board" means the Illinois Comprehensive Health Insurance
16    Board.
17        "Church plan" has the same meaning given that term in the
18    federal Health Insurance Portability and  Accountability  Act
19    of 1996.
20        "Continuation  coverage"  means  continuation of coverage
21    under a group health plan or other health insurance  coverage
22    for  former  employees or dependents of former employees that
23    would otherwise have  terminated  under  the  terms  of  that
24    coverage   pursuant  to  any  continuation  provisions  under
25    federal or State  law,  including  the  Consolidated  Omnibus
26    Budget  Reconciliation  Act  of  1985  (COBRA),  as  amended,
27    Sections  367.2  and  367e of the Illinois Insurance Code, or
28    any other similar requirement in another State.
29        "Covered person" means a person who is and  continues  to
30    remain eligible for Plan coverage and is covered under one of
31    the benefit plans offered by the Plan.
 
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 1        "Creditable  coverage" means, with respect to a federally
 2    eligible individual, coverage of the individual under any  of
 3    the following:
 4             (A)  A group health plan.
 5             (B)  Health   insurance  coverage  (including  group
 6        health insurance coverage).
 7             (C)  Medicare.
 8             (D)  Medical assistance.
 9             (E)  Chapter 55 of title 10, United States Code.
10             (F)  A medical care program  of  the  Indian  Health
11        Service or of a tribal organization.
12             (G)  A state health benefits risk pool.
13             (H)  A health plan offered under Chapter 89 of title
14        5, United States Code.
15             (I)  A public health plan (as defined in regulations
16        consistent   with   Section   104   of  the  Health  Care
17        Portability and Accountability Act of 1996  that  may  be
18        promulgated  by  the  Secretary of the U.S. Department of
19        Health and Human Services).
20             (J)  A health benefit plan under Section 5(e) of the
21        Peace Corps Act (22 U.S.C. 2504(e)).
22             (K)  Any other qualifying coverage required  by  the
23        federal  Health  Insurance Portability and Accountability
24        Act of 1996, as it may be amended, or  regulations  under
25        that Act.
26        "Creditable   coverage"   does   not   include   coverage
27    consisting  solely  of  coverage  of  excepted  benefits,  as
28    defined  in  Section  2791(c)  of  title  XXVII of the Public
29    Health Service Act (42 U.S.C. 300 gg-91), nor does it include
30    any period of coverage under any of  items  (A)  through  (K)
31    that  occurred before a break of more than 90 days or, if the
32    individual has been certified as an eligible person  pursuant
33    to  the federal Trade Adjustment Act of 2002, a break of more
34    than 63 days during all  of  which  the  individual  was  not
 
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 1    covered under any of items (A) through (K) above.  Any period
 2    that  an  individual  is in a waiting period for any coverage
 3    under a group health plan  (or  for  group  health  insurance
 4    coverage)  or  is in an affiliation period under the terms of
 5    health insurance coverage offered  by  a  health  maintenance
 6    organization  shall  not be taken into account in determining
 7    if there has been a  break  of  more  than  90  days  in  any
 8    creditable coverage.
 9        "Department" means the Illinois Department of Insurance.
10        "Dependent"  means an Illinois resident: who is a spouse;
11    or who is claimed as a dependent by the principal insured for
12    purposes of filing a federal income tax return and resides in
13    the  principal  insured's  household,  and  is   a   resident
14    unmarried  child  under  the  age  of  19 years; or who is an
15    unmarried child who also is a full-time student under the age
16    of 23  years  and  who  is  financially  dependent  upon  the
17    principal  insured;  or  who is a child of any age and who is
18    disabled  and  financially  dependent  upon   the   principal
19    insured.
20        "Direct  Illinois premiums" means, for Illinois business,
21    an insurer's direct premium income for the kinds of  business
22    described  in  clause (b) of Class 1 or clause (a) of Class 2
23    of Section 4 of  the  Illinois  Insurance  Code,  and  direct
24    premium  income  of  a  health  maintenance organization or a
25    voluntary health services plan, except it shall  not  include
26    credit  health  insurance as defined in Article IX 1/2 of the
27    Illinois Insurance Code.
28        "Director" means the Director of the Illinois  Department
29    of Insurance.
30        "Eligible  person"  means  a  resident  of this State who
31    qualifies for Plan coverage under Section 7 of this Act.
32        "Employee" means a resident of this State who is employed
33    by an employer or has entered into the employment of or works
34    under contract  or  service  of  an  employer  including  the
 
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 1    officers,  managers and employees of subsidiary or affiliated
 2    corporations and the  individual  proprietors,  partners  and
 3    employees  of  affiliated  individuals  and  firms  when  the
 4    business  of the subsidiary or affiliated corporations, firms
 5    or individuals is controlled by  a  common  employer  through
 6    stock ownership, contract, or otherwise.
 7        "Employer"    means    any    individual,    partnership,
 8    association,  corporation,  business  trust, or any person or
 9    group  of  persons  acting  directly  or  indirectly  in  the
10    interest of an employer in relation to an employee, for which
11    one or more persons is gainfully employed.
12        "Family" coverage means the coverage provided by the Plan
13    for the covered person and his or her eligible dependents who
14    also are covered persons.
15        "Federally  eligible  individual"  means  an   individual
16    resident of this State:
17             (1)(A)  for  whom,  as  of  the  date  on  which the
18        individual seeks Plan coverage under Section 15  of  this
19        Act,  the aggregate of the periods of creditable coverage
20        is 18 or more months  or,  if  the  individual  has  been
21        certified  as  an eligible person pursuant to the federal
22        Trade Adjustment Act of 2002, 3 or more months,  and  (B)
23        whose  most  recent  prior  creditable coverage was under
24        group health  insurance  coverage  offered  by  a  health
25        insurance  issuer,  a  group  health plan, a governmental
26        plan, or a church  plan  (or  health  insurance  coverage
27        offered  in  connection with any such plans) or any other
28        type of creditable coverage that may be required  by  the
29        federal  Health  Insurance Portability and Accountability
30        Act of 1996, as it may be  amended,  or  the  regulations
31        under that Act;
32             (2)  who  is  not  eligible for coverage under (A) a
33        group health plan, (B) part A or part B of  Medicare  due
34        to  age,  or  (C)  medical  assistance, and does not have
 
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 1        other health insurance coverage;
 2             (3)  with respect to whom the most  recent  coverage
 3        within  the coverage period described in paragraph (1)(A)
 4        of this definition was not terminated based upon a factor
 5        relating to nonpayment of premiums or fraud;
 6             (4)  if the individual, other than an individual who
 7        has been certified as an eligible person pursuant to  the
 8        federal  Trade  Adjustment  Act of 2002, had been offered
 9        the  option  of  continuation  coverage  under  a   COBRA
10        continuation  provision or under a similar State program,
11        who elected such coverage; and
12             (5)  who,   if   the   individual    elected    such
13        continuation  coverage,  has  exhausted such continuation
14        coverage under such provision or program.
15        An individual who  has  been  certified  as  an  eligible
16    person  pursuant  to the federal Trade Adjustment Act of 2002
17    shall not be required to elect continuation coverage under  a
18    COBRA   continuation  provision  or  under  a  similar  state
19    program.
20        "Group health insurance coverage"  means,  in  connection
21    with  a  group health plan, health insurance coverage offered
22    in connection with that plan.
23        "Group health plan" has the same meaning given that  term
24    in    the    federal   Health   Insurance   Portability   and
25    Accountability Act of 1996.
26        "Governmental plan" has the same meaning given that  term
27    in    the    federal   Health   Insurance   Portability   and
28    Accountability Act of 1996.
29        "Health insurance coverage" means benefits consisting  of
30    medical   care   (provided  directly,  through  insurance  or
31    reimbursement, or otherwise and including items and  services
32    paid  for  as  medical  care)  under any hospital and medical
33    expense-incurred policy, certificate, or contract provided by
34    an insurer, non-profit health  care  service  plan  contract,
 
HB3298 Enrolled             -6-      LRB093 11158 JLS 12059 b
 1    health maintenance organization or other subscriber contract,
 2    or any other health care plan or arrangement that pays for or
 3    furnishes   medical   or  health  care  services  whether  by
 4    insurance or otherwise.  Health insurance coverage shall  not
 5    include   short   term,  accident  only,  disability  income,
 6    hospital confinement or fixed indemnity, dental only,  vision
 7    only,  limited  benefit, or credit insurance, coverage issued
 8    as a supplement to liability insurance, insurance arising out
 9    of  a  workers'  compensation  or  similar  law,   automobile
10    medical-payment  insurance, or insurance under which benefits
11    are payable with or without regard  to  fault  and  which  is
12    statutorily   required  to  be  contained  in  any  liability
13    insurance policy or equivalent self-insurance.
14        "Health insurance issuer"  means  an  insurance  company,
15    insurance  service,  or  insurance  organization (including a
16    health  maintenance  organization  and  a  voluntary   health
17    services   plan)   that  is  authorized  to  transact  health
18    insurance business in this State.  Such term does not include
19    a group health plan.
20        "Health Maintenance Organization" means  an  organization
21    as defined in the Health Maintenance Organization Act.
22        "Hospice"  means  a  program  as  defined in and licensed
23    under the Hospice Program Licensing Act.
24        "Hospital" means a duly licensed institution  as  defined
25    in  the Hospital Licensing Act, an institution that meets all
26    comparable conditions and requirements in effect in the state
27    in which  it  is  located,  or  the  University  of  Illinois
28    Hospital  as  defined  in the University of Illinois Hospital
29    Act.
30        "Individual  health  insurance  coverage"  means   health
31    insurance  coverage  offered to individuals in the individual
32    market, but does  not  include  short-term,  limited-duration
33    insurance.
34        "Insured" means any individual resident of this State who
 
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 1    is  eligible  to receive benefits from any insurer (including
 2    health insurance coverage offered in connection with a  group
 3    health  plan)  or  health insurance issuer as defined in this
 4    Section.
 5        "Insurer"  means  any  insurance  company  authorized  to
 6    transact health insurance business  in  this  State  and  any
 7    corporation  that  provides medical services and is organized
 8    under the Voluntary Health Services Plans Act or  the  Health
 9    Maintenance Organization Act.
10        "Medical  assistance"  means the State medical assistance
11    or medical assistance no grant (MANG) programs provided under
12    Title XIX of the Social Security Act and Articles V  (Medical
13    Assistance)  and  VI  (General  Assistance)  of  the Illinois
14    Public Aid Code (or  any  successor  program)  or  under  any
15    similar program of health care benefits in a state other than
16    Illinois.
17        "Medically  necessary"  means  that  a  service, drug, or
18    supply is necessary and  appropriate  for  the  diagnosis  or
19    treatment  of  an  illness or injury in accord with generally
20    accepted standards  of  medical  practice  at  the  time  the
21    service,  drug,  or  supply  is  provided.  When specifically
22    applied to a confinement it further means that the  diagnosis
23    or  treatment  of  the  covered  person's medical symptoms or
24    condition cannot be safely provided  to  that  person  as  an
25    outpatient. A service, drug, or supply shall not be medically
26    necessary if it: (i) is investigational, experimental, or for
27    research  purposes;  or  (ii)  is  provided  solely  for  the
28    convenience  of the patient, the patient's family, physician,
29    hospital, or any other provider; or (iii) exceeds  in  scope,
30    duration,  or  intensity that level of care that is needed to
31    provide  safe,  adequate,  and   appropriate   diagnosis   or
32    treatment;  or (iv) could have been omitted without adversely
33    affecting the covered person's condition or  the  quality  of
34    medical  care;  or  (v) involves the use of a medical device,
 
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 1    drug, or substance not formally approved by the United States
 2    Food and Drug Administration.
 3        "Medical care" means the ordinary and usual  professional
 4    services  rendered by a physician or other specified provider
 5    during a professional visit for treatment of  an  illness  or
 6    injury.
 7        "Medicare" means coverage under both Part A and Part B of
 8    Title  XVIII of the Social Security Act, 42 U.S.C. Sec. 1395,
 9    et seq.
10        "Minimum premium plan" means  an  arrangement  whereby  a
11    specified  amount  of  health care claims is self-funded, but
12    the insurance company  assumes  the  risk  that  claims  will
13    exceed that amount.
14        "Participating   transplant   center"  means  a  hospital
15    designated by the Board as a preferred or exclusive  provider
16    of  services  for one or more specified human organ or tissue
17    transplants for which the hospital has  signed  an  agreement
18    with  the  Board to accept a transplant payment allowance for
19    all expenses related to the transplant  during  a  transplant
20    benefit period.
21        "Physician"  means a person licensed to practice medicine
22    pursuant to the Medical Practice Act of 1987.
23        "Plan" means  the  Comprehensive  Health  Insurance  Plan
24    established by this Act.
25        "Plan  of  operation"  means the plan of operation of the
26    Plan, including articles, bylaws and operating rules, adopted
27    by the board pursuant to this Act.
28        "Provider" means any hospital, skilled nursing  facility,
29    hospice, home health agency, physician, registered pharmacist
30    acting  within  the  scope of that registration, or any other
31    person or entity licensed  in  Illinois  to  furnish  medical
32    care.
33        "Qualified  high  risk  pool"  has the same meaning given
34    that term in the federal  Health  Insurance  Portability  and
 
HB3298 Enrolled             -9-      LRB093 11158 JLS 12059 b
 1    Accountability Act of 1996.
 2        "Resident"  means  a  person  who  is and continues to be
 3    legally domiciled and physically residing on a permanent  and
 4    full-time  basis  in  a place of permanent habitation in this
 5    State that remains that person's principal residence and from
 6    which that person is absent only for temporary or  transitory
 7    purpose.
 8        "Skilled  nursing  facility"  means  a  facility  or that
 9    portion of a  facility  that  is  licensed  by  the  Illinois
10    Department  of  Public Health under the Nursing Home Care Act
11    or a comparable  licensing  authority  in  another  state  to
12    provide skilled nursing care.
13        "Stop-loss  coverage"  means  an  arrangement  whereby an
14    insurer insures against the risk  that  any  one  claim  will
15    exceed  a specific dollar amount or that the entire loss of a
16    self-insurance plan will exceed a specific amount.
17        "Third party administrator"  means  an  administrator  as
18    defined in Section 511.101 of the Illinois Insurance Code who
19    is licensed under Article XXXI 1/4 of that Code.
20    (Source:  P.A.  91-357,  eff.  7-29-99;  91-735, eff. 6-2-00;
21    92-153, eff. 7-25-01.)

22        (215 ILCS 105/4) (from Ch. 73, par. 1304)
23        Sec. 4.  Powers and authority of the  board.   The  board
24    shall have the general powers and authority granted under the
25    laws  of  this  State  to  insurance  companies  licensed  to
26    transact  health  and  accident  insurance  and  in  addition
27    thereto, the specific authority to:
28        a.  Enter  into  contracts  as are necessary or proper to
29    carry out the provisions and purposes of this Act,  including
30    the  authority,  with  the approval of the Director, to enter
31    into contracts with similar plans of  other  states  for  the
32    joint performance of common administrative functions, or with
33    persons   or  other  organizations  for  the  performance  of
 
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 1    administrative  functions  including,   without   limitation,
 2    utilization  review  and  quality assurance programs, or with
 3    health  maintenance  organizations  or   preferred   provider
 4    organizations for the provision of health care services.
 5        b.  Sue  or  be  sued, including taking any legal actions
 6    necessary or proper.
 7        c.  Take such legal action as necessary to:
 8             (1)  avoid the payment of  improper  claims  against
 9        the plan or the coverage provided by or through the plan;
10             (2)  to   recover   any   amounts   erroneously   or
11        improperly paid by the plan;
12             (3)  to  recover  any  amounts paid by the plan as a
13        result of a mistake of fact or law; or
14             (4)  to  recover  or  collect  any  other   amounts,
15        including  assessments,  that are due or owed the Plan or
16        have been billed on its or the Plan's behalf.
17        d.  Establish appropriate  rates,  rate  schedules,  rate
18    adjustments, expense allowances, agents' referral fees, claim
19    reserves,  and  formulas  and  any  other  actuarial function
20    appropriate to the operation of the plan.    Rates  and  rate
21    schedules  may  be adjusted for appropriate risk factors such
22    as age and area variation in claim costs and shall take  into
23    consideration  appropriate  risk  factors  in accordance with
24    established actuarial and underwriting practices.
25        e.  Issue policies of insurance in  accordance  with  the
26    requirements of this Act.
27        f.  Appoint   appropriate   legal,  actuarial  and  other
28    committees as necessary to provide  technical  assistance  in
29    the  operation of the plan, policy and other contract design,
30    and any other function within the authority of the plan.
31        g.  Borrow money to effect the purposes of  the  Illinois
32    Comprehensive  Health  Insurance  Plan.   Any  notes or other
33    evidence of indebtedness of the plan not in default shall  be
34    legal investments for insurers and may be carried as admitted
 
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 1    assets.
 2        h.  Establish   rules,   conditions  and  procedures  for
 3    reinsuring risks under this Act.
 4        i.  Employ and fix the compensation  of  employees.  Such
 5    employees  may  be  paid  on  a  warrant  issued by the State
 6    Treasurer pursuant to a  payroll  voucher  certified  by  the
 7    Board  and drawn by the Comptroller against appropriations or
 8    trust funds held by the State Treasurer.
 9        j.  Enter into intergovernmental  cooperation  agreements
10    with  other  agencies or entities of State government for the
11    purpose of sharing the cost of providing health care services
12    that are otherwise authorized by this Act  for  children  who
13    are   both  plan  participants  and  eligible  for  financial
14    assistance from the Division of Specialized Care for Children
15    of the University of Illinois.
16        k.  Establish conditions and procedures under  which  the
17    plan  may,  if  funds  permit,  discount or subsidize premium
18    rates that are paid directly by senior citizens,  as  defined
19    by the Board, and other plan participants, who are retired or
20    unemployed and meet other qualifications.
21        l.  Establish  and  maintain  the Plan Fund authorized in
22    Section 3 of this Act, which shall be divided  into  separate
23    accounts, as follows:
24             (1)  accounts to fund the administrative, claim, and
25        other  expenses  of  the  Plan  associated  with eligible
26        persons who qualify for Plan coverage under Section 7  of
27        this Act, which shall consist of:
28                  (A)  premiums   paid   on   behalf  of  covered
29             persons;
30                  (B)  appropriated  funds  and  other   revenues
31             collected or received by the Board;
32                  (C)  reserves  for  future losses maintained by
33             the Board; and
34                  (D)  interest earnings from investment  of  the
 
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 1             funds  in the Plan Fund or any of its accounts other
 2             than the funds in the account established under item
 3             2 of this subsection;
 4             (2)  an account, to  be  denominated  the  federally
 5        eligible individuals account, to fund the administrative,
 6        claim,  and  other  expenses  of the Plan associated with
 7        federally  eligible  individuals  who  qualify  for  Plan
 8        coverage under  Section  15  of  this  Act,  which  shall
 9        consist of:
10                  (A)  premiums   paid   on   behalf  of  covered
11             persons;
12                  (B)  assessments and other  revenues  collected
13             or received by the Board;
14                  (C)  reserves  for  future losses maintained by
15             the Board; and
16                  (D)  interest earnings from investment  of  the
17             federally eligible individuals account funds; and
18                  (E)  grants  provided  pursuant  to the federal
19             Trade Adjustment Act of 2002; and
20             (3)  such other accounts as may be appropriate.
21        m.  Charge  and  collect  assessments  paid  by  insurers
22    pursuant  to  Section  12  of  this  Act  and   recover   any
23    assessments for, on behalf of, or against those insurers.
24    (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99.)

25        (215 ILCS 105/7) (from Ch. 73, par. 1307)
26        Sec. 7.  Eligibility.
27        a.  Except  as provided in subsection (e) of this Section
28    or in Section 15 of this Act, any  person  who  is  either  a
29    citizen  of  the  United States or an alien lawfully admitted
30    for permanent residence and who has been for a period  of  at
31    least  180  days and continues to be a resident of this State
32    shall be eligible for Plan coverage  under  this  Section  if
33    evidence is provided of:
 
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 1             (1)  A  notice  of  rejection  or  refusal  to issue
 2        substantially   similar   individual   health   insurance
 3        coverage for health reasons by a health insurance issuer;
 4        or
 5             (2)  A refusal by a health insurance issuer to issue
 6        individual health insurance coverage  except  at  a  rate
 7        exceeding  the  applicable Plan rate for which the person
 8        is responsible.
 9        A rejection or refusal by a group health plan  or  health
10    insurance  issuer  offering  only stop-loss or excess of loss
11    insurance or contracts, agreements, or other arrangements for
12    reinsurance coverage with respect to the applicant shall  not
13    be sufficient evidence under this subsection.
14        b.  The  board  shall  promulgate  a  list  of medical or
15    health conditions for which a person who is either a  citizen
16    of  the  United  States  or  an  alien  lawfully admitted for
17    permanent residence and a resident of  this  State  would  be
18    eligible  for  Plan  coverage  without  applying  for  health
19    insurance coverage pursuant to subsection a. of this Section.
20    Persons  who  can demonstrate the existence or history of any
21    medical or health conditions on the list promulgated  by  the
22    board shall not be required to provide the evidence specified
23    in  subsection  a.  of  this  Section.   The  list  shall  be
24    effective  on  the first day of the operation of the Plan and
25    may be amended from time to time as appropriate.
26        c.  Family members of the same  household  who  each  are
27    covered  persons  are  eligible  for optional family coverage
28    under the Plan.
29        d.  For persons qualifying  for  coverage  in  accordance
30    with Section 7 of this Act, the board shall, if it determines
31    that  such  appropriations as are made pursuant to Section 12
32    of this Act are insufficient to allow the board to accept all
33    of the eligible persons which  it  projects  will  apply  for
34    enrollment  under  the  Plan,  limit  or  close enrollment to
 
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 1    ensure that the Plan is not over-subscribed and that  it  has
 2    sufficient  resources  to  meet  its  obligations to existing
 3    enrollees.  The board shall not limit or close enrollment for
 4    federally eligible individuals.
 5        e.  A person shall not be eligible for coverage under the
 6    Plan if:
 7             (1)  He or she has or obtains other coverage under a
 8        group  health   plan   or   health   insurance   coverage
 9        substantially  similar to or better than a Plan policy as
10        an insured or covered dependent or would be  eligible  to
11        have  that  coverage  if  he or she elected to obtain it.
12        Persons  otherwise  eligible  for  Plan   coverage   may,
13        however,  solely for the purpose of having coverage for a
14        pre-existing  condition,  maintain  other  coverage  only
15        while  satisfying  any  pre-existing  condition   waiting
16        period  under  a  Plan policy or a subsequent replacement
17        policy of a Plan policy.
18             (1.1)  His or  her  prior  coverage  under  a  group
19        health  plan  or  health  insurance coverage, provided or
20        arranged by an employer of more  than  10  employees  was
21        discontinued  for  any reason without the entire group or
22        plan being discontinued and not replaced, provided he  or
23        she  remains  an  employee,  or dependent thereof, of the
24        same employer.
25             (2)  He or she is a recipient of or is  approved  to
26        receive  medical  assistance,  except  that  a person may
27        continue  to  receive  medical  assistance  through   the
28        medical  assistance  no  grant  program,  but  only while
29        satisfying the requirements for a  preexisting  condition
30        under  Section  8, subsection f. of this Act.  Payment of
31        premiums pursuant to this Act shall be allocable  to  the
32        person's spenddown for purposes of the medical assistance
33        no  grant  program, but that person shall not be eligible
34        for any Plan benefits while that person remains  eligible
 
HB3298 Enrolled             -15-     LRB093 11158 JLS 12059 b
 1        for  medical  assistance.   If  the  person  continues to
 2        receive or be  approved  to  receive  medical  assistance
 3        through  the  medical  assistance  no grant program at or
 4        after  the  time  that  requirements  for  a  preexisting
 5        condition are satisfied, the person shall not be eligible
 6        for  coverage  under  the  Plan.  In  that  circumstance,
 7        coverage  under  the  plan  shall  terminate  as  of  the
 8        expiration  of  the  preexisting   condition   limitation
 9        period.   Under  all  other circumstances, coverage under
10        the  Plan  shall  automatically  terminate  as   of   the
11        effective date of any medical assistance.
12             (3)  Except  as  provided  in Section 15, the person
13        has previously participated in the Plan  and  voluntarily
14        terminated  Plan  coverage, unless 12 months have elapsed
15        since  the  person's  latest  voluntary  termination   of
16        coverage.
17             (4)  The  person  fails  to pay the required premium
18        under  the  covered  person's  terms  of  enrollment  and
19        participation, in which event the liability of  the  Plan
20        shall  be limited to benefits incurred under the Plan for
21        the time period for which premiums had been paid and  the
22        covered person remained eligible for Plan coverage.
23             (5)  The  Plan  has  paid  a  total of $1,000,000 in
24        benefits on behalf of the covered person.
25             (6)  The  person  is  a   resident   of   a   public
26        institution.
27             (7)  The  person's premium is paid for or reimbursed
28        under  any  government  sponsored  program  or   by   any
29        government  agency  or health care provider, except as an
30        otherwise qualifying full-time employee, or dependent  of
31        such  employee,  of  a  government  agency or health care
32        provider or, except when a person's premium  is  paid  by
33        the  U.S.  Treasury  Department  pursuant  to the federal
34        Trade Adjustment Act of 2002.
 
HB3298 Enrolled             -16-     LRB093 11158 JLS 12059 b
 1             (8)  The person has or later receives other benefits
 2        or  funds  from  any  settlement,  judgement,  or   award
 3        resulting  from any accident or injury, regardless of the
 4        date  of  the  accident   or   injury,   or   any   other
 5        circumstances  creating a legal liability for damages due
 6        that person by a third  party,  whether  the  settlement,
 7        judgment,  or  award  is  in  the  form  of  a  contract,
 8        agreement, or trust on behalf of a minor or otherwise and
 9        whether  the settlement, judgment, or award is payable to
10        the  person,  his  or  her  dependent,  estate,  personal
11        representative, or guardian in a lump sum or  over  time,
12        so  long  as  there  continues  to  be benefits or assets
13        remaining from those sources in an amount  in  excess  of
14        $100,000.
15             (9)  Within the 5 years prior to the date a person's
16        Plan  application  is received by the Board, the person's
17        coverage under any health care benefit program as defined
18        in 18 U.S.C. 24, including any public or private plan  or
19        contract  under  which  any  medical  benefit,  item,  or
20        service  is  provided,  was terminated as a result of any
21        act or practice that constitutes  fraud  under  State  or
22        federal   law   or   as   a   result  of  an  intentional
23        misrepresentation of material fact;  or  if  that  person
24        knowingly  and willfully obtained or attempted to obtain,
25        or fraudulently aided  or  attempted  to  aid  any  other
26        person  in  obtaining, any coverage or benefits under the
27        Plan to which that person was not entitled.
28        f.  The  board  or  the   administrator   shall   require
29    verification  of  residency  and  may  require any additional
30    information or documentation, or statements under oath,  when
31    necessary to determine residency upon initial application and
32    for the entire term of the policy.
33        g.  Coverage  shall  cease (i) on the date a person is no
34    longer a resident of Illinois, (ii)  on  the  date  a  person
 
HB3298 Enrolled             -17-     LRB093 11158 JLS 12059 b
 1    requests coverage to end, (iii) upon the death of the covered
 2    person,  (iv)  on the date State law requires cancellation of
 3    the policy, or (v) at the Plan's option, 30  days  after  the
 4    Plan  makes  any inquiry concerning a person's eligibility or
 5    place of residence to which the person does not reply.
 6        h.  Except under the conditions set forth in subsection g
 7    of this Section, the coverage of any  person  who  ceases  to
 8    meet  the  eligibility  requirements of this Section shall be
 9    terminated at the end of the current policy period for  which
10    the necessary premiums have been paid.
11    (Source: P.A.  90-30,  eff.  7-1-97;  91-639,  eff.  8-20-99;
12    91-735, eff. 6-2-00.)

13        (215 ILCS 105/15)
14        Sec.  15.  Alternative  portable  coverage  for federally
15    eligible individuals.
16        (a)  Notwithstanding the requirements of subsection a. of
17    Section 7 and except as otherwise provided in  this  Section,
18    any   federally   eligible   individual   for   whom  a  Plan
19    application, and such enclosures and supporting documentation
20    as the Board may require, is received by the Board within  90
21    days after the termination of prior creditable coverage shall
22    qualify   to   enroll  in  the  Plan  under  the  portability
23    provisions of this Section.  A federally eligible person  who
24    has  been  certified  as  an  eligible person pursuant to the
25    federal  Trade  Adjustment  Act  of  2002  and   whose   Plan
26    application  and  enclosures  and supporting documentation as
27    the Board may require is received by the Board within 63 days
28    after the termination of previous creditable  coverage  shall
29    qualify   to   enroll  in  the  Plan  under  the  portability
30    provisions of this Section.
31        (b)  Any  federally  eligible  individual  seeking   Plan
32    coverage  under  this  Section  must  submit  with his or her
33    application   evidence,    including    acceptable    written
 
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 1    certification  of  previous  creditable  coverage,  that will
 2    establish to the Board's satisfaction, that he or  she  meets
 3    all of the requirements to be a federally eligible individual
 4    and  is  currently and permanently residing in this State (as
 5    of the date his  or  her  application  was  received  by  the
 6    Board).
 7        (c)  Except  as  otherwise  provided  in  this Section, a
 8    period of creditable coverage  shall  not  be  counted,  with
 9    respect  to  qualifying  an  applicant for Plan coverage as a
10    federally eligible individual under this  Section,  if  after
11    such  period and before the application for Plan coverage was
12    received by the Board, there was at least  a  90  day  period
13    during  all of which the individual was not covered under any
14    creditable coverage.  For a federally eligible person who has
15    been certified as an eligible person pursuant to the  federal
16    Trade Adjustment Act of 2002, a period of creditable coverage
17    shall not be counted, with respect to qualifying an applicant
18    for  Plan  coverage  as a federally eligible individual under
19    this Section, if after such period and before the application
20    for Plan coverage was received by the  Board,  there  was  at
21    least  a 63 day period during all of which the individual was
22    not covered under any creditable coverage.
23        (d)  Any federally  eligible  individual  who  the  Board
24    determines  qualifies  for  Plan  coverage under this Section
25    shall be offered his or her choice of  enrolling  in  one  of
26    alternative  portability health benefit plans which the Board
27    is authorized under  this  Section  to  establish  for  these
28    federally eligible individuals and their dependents.
29        (e)  The  Board  shall  offer  a  choice  of  health care
30    coverages consistent with major medical  coverage  under  the
31    alternative  health  benefit plans authorized by this Section
32    to every federally eligible individual. The coverages  to  be
33    offered   under   the   plans,   the  schedule  of  benefits,
34    deductibles, co-payments, exclusions, and  other  limitations
 
HB3298 Enrolled             -19-     LRB093 11158 JLS 12059 b
 1    shall  be  approved  by  the  Board.   One  optional  form of
 2    coverage  shall  be  comparable   to   comprehensive   health
 3    insurance  coverage  offered in the individual market in this
 4    State or a standard option of coverage  available  under  the
 5    group  or individual health insurance laws of the State.  The
 6    standard benefit plan that is authorized by Section 8 of this
 7    Act may be used for this purpose.  The Board may also offer a
 8    preferred provider option and such other options as the Board
 9    determines may be appropriate for  these  federally  eligible
10    individuals  who  qualify  for Plan coverage pursuant to this
11    Section.
12        (f)  Notwithstanding the requirements of subsection f. of
13    Section 8, any plan coverage  that  is  issued  to  federally
14    eligible individuals who qualify for the Plan pursuant to the
15    portability  provisions  of this Section shall not be subject
16    to any preexisting conditions exclusion, waiting  period,  or
17    other similar limitation on coverage.
18        (g)  Federally   eligible  individuals  who  qualify  and
19    enroll in the Plan pursuant to this Section shall be required
20    to pay such premium rates as the Board  shall  establish  and
21    approve in accordance with the requirements of Section 7.1 of
22    this Act.
23        (h)  A  federally  eligible  individual who qualifies and
24    enrolls in the Plan pursuant to this Section must satisfy  on
25    an ongoing basis all of the other eligibility requirements of
26    this  Act  to  the  extent  not inconsistent with the federal
27    Health Insurance Portability and Accountability Act  of  1996
28    in order to maintain continued eligibility for coverage under
29    the Plan.
30    (Source: P.A. 92-153, eff. 7-25-01.)

31        Section  99.  Effective date.  This Act takes effect upon
32    becoming law.