093_HB0707enr

 
HB0707 Enrolled                      LRB093 05485 MKM 05576 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.  If  and  only if House Bill 3298 of the 93rd
 6    General  Assembly  becomes  law,  the  Comprehensive   Health
 7    Insurance  Plan  Act is amended by changing Sections 2, 4, 7,
 8    and 15 as follows:

 9        (215 ILCS 105/2) (from Ch. 73, par. 1302)
10        Sec. 2.  Definitions.  As used in this  Act,  unless  the
11    context otherwise requires:
12        "Plan  administrator"  means  the  insurer or third party
13    administrator designated under Section 5 of this Act.
14        "Benefits plan" means the coverage to be offered  by  the
15    Plan  to  eligible persons and federally eligible individuals
16    pursuant to this Act.
17        "Board" means the Illinois Comprehensive Health Insurance
18    Board.
19        "Church plan" has the same meaning given that term in the
20    federal Health Insurance Portability and  Accountability  Act
21    of 1996.
22        "Continuation  coverage"  means  continuation of coverage
23    under a group health plan or other health insurance  coverage
24    for  former  employees or dependents of former employees that
25    would otherwise have  terminated  under  the  terms  of  that
26    coverage   pursuant  to  any  continuation  provisions  under
27    federal or State  law,  including  the  Consolidated  Omnibus
28    Budget  Reconciliation  Act  of  1985  (COBRA),  as  amended,
29    Sections  367.2  and  367e of the Illinois Insurance Code, or
30    any other similar requirement in another State.
31        "Covered person" means a person who is and  continues  to
 
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 1    remain eligible for Plan coverage and is covered under one of
 2    the benefit plans offered by the Plan.
 3        "Creditable  coverage" means, with respect to a federally
 4    eligible individual, coverage of the individual under any  of
 5    the following:
 6             (A)  A group health plan.
 7             (B)  Health   insurance  coverage  (including  group
 8        health insurance coverage).
 9             (C)  Medicare.
10             (D)  Medical assistance.
11             (E)  Chapter 55 of title 10, United States Code.
12             (F)  A medical care program  of  the  Indian  Health
13        Service or of a tribal organization.
14             (G)  A state health benefits risk pool.
15             (H)  A health plan offered under Chapter 89 of title
16        5, United States Code.
17             (I)  A public health plan (as defined in regulations
18        consistent   with   Section   104   of  the  Health  Care
19        Portability and Accountability Act of 1996  that  may  be
20        promulgated  by  the  Secretary of the U.S. Department of
21        Health and Human Services).
22             (J)  A health benefit plan under Section 5(e) of the
23        Peace Corps Act (22 U.S.C. 2504(e)).
24             (K)  Any other qualifying coverage required  by  the
25        federal  Health  Insurance Portability and Accountability
26        Act of 1996, as it may be amended, or  regulations  under
27        that Act.
28        "Creditable   coverage"   does   not   include   coverage
29    consisting  solely  of  coverage  of  excepted  benefits,  as
30    defined  in  Section  2791(c)  of  title  XXVII of the Public
31    Health Service Act (42 U.S.C. 300 gg-91), nor does it include
32    any period of coverage under any of  items  (A)  through  (K)
33    that  occurred  before  a  break  of more than 90 days or, if
34    after September 30, 2003,  the  individual  has  either  been
 
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 1    certified as an eligible person pursuant to the federal Trade
 2    Adjustment  Act  of  2002 or initially been paid a benefit by
 3    the Pension Benefit Guaranty Corporation,  a  break  of  more
 4    than  63  days  during  all  of  which the individual was not
 5    covered under any of items (A) through (K) above.
 6        For an  individual  who  between  December  1,  2002  and
 7    September  30, 2003 has either (1) been certified as eligible
 8    pursuant to the federal Trade Act of 2002, (2) initially been
 9    paid a benefit by the Pension Benefit  Guaranty  Corporation,
10    or  (3)  as of December 1, 2002, been receiving benefits from
11    the  Pension  Benefit  Guaranty  Corporation  and   who   has
12    qualified  health  insurance, as defined by the federal Trade
13    Act of 2002, "creditable coverage"  includes  any  period  of
14    coverage  aggregating 3 or more months under any of items (A)
15    through (K), irrespective of the length of a break during all
16    of which the individual was not covered under  any  of  items
17    (A) through (K).
18        Any  period that an individual is in a waiting period for
19    any coverage under a group health plan (or for  group  health
20    insurance  coverage) or is in an affiliation period under the
21    terms of  health  insurance  coverage  offered  by  a  health
22    maintenance  organization  shall not be taken into account in
23    determining if there has been a break of more than 90 days in
24    any creditable coverage.
25        "Department" means the Illinois Department of Insurance.
26        "Dependent" means an Illinois resident: who is a  spouse;
27    or who is claimed as a dependent by the principal insured for
28    purposes of filing a federal income tax return and resides in
29    the   principal   insured's  household,  and  is  a  resident
30    unmarried child under the age of  19  years;  or  who  is  an
31    unmarried child who also is a full-time student under the age
32    of  23  years  and  who  is  financially  dependent  upon the
33    principal insured; or who is a child of any age  and  who  is
34    disabled   and   financially  dependent  upon  the  principal
 
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 1    insured.
 2        "Direct Illinois premiums" means, for Illinois  business,
 3    an  insurer's direct premium income for the kinds of business
 4    described in clause (b) of Class 1 or clause (a) of  Class  2
 5    of  Section  4  of  the  Illinois  Insurance Code, and direct
 6    premium income of a  health  maintenance  organization  or  a
 7    voluntary  health  services plan, except it shall not include
 8    credit health insurance as defined in Article IX 1/2  of  the
 9    Illinois Insurance Code.
10        "Director"  means the Director of the Illinois Department
11    of Insurance.
12        "Eligible person" means a  resident  of  this  State  who
13    qualifies for Plan coverage under Section 7 of this Act.
14        "Employee" means a resident of this State who is employed
15    by an employer or has entered into the employment of or works
16    under  contract  or  service  of  an  employer  including the
17    officers, managers and employees of subsidiary or  affiliated
18    corporations  and  the  individual  proprietors, partners and
19    employees  of  affiliated  individuals  and  firms  when  the
20    business of the subsidiary or affiliated corporations,  firms
21    or  individuals  is  controlled  by a common employer through
22    stock ownership, contract, or otherwise.
23        "Employer"    means    any    individual,    partnership,
24    association, corporation, business trust, or  any  person  or
25    group  of  persons  acting  directly  or  indirectly  in  the
26    interest of an employer in relation to an employee, for which
27    one or more persons is gainfully employed.
28        "Family" coverage means the coverage provided by the Plan
29    for the covered person and his or her eligible dependents who
30    also are covered persons.
31        "Federally   eligible  individual"  means  an  individual
32    resident of this State:
33             (1)(A)  for whom,  as  of  the  date  on  which  the
34        individual  seeks  Plan coverage under Section 15 of this
 
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 1        Act, the aggregate of the periods of creditable  coverage
 2        is 18 or more months or, if the individual has either (i)
 3        been  certified  as  an  eligible  person pursuant to the
 4        federal Trade Adjustment Act of 2002, (ii) initially been
 5        paid  a  benefit  by   the   Pension   Benefit   Guaranty
 6        Corporation,  or  (iii)  as  of  December  1,  2002, been
 7        receiving benefits  from  the  Pension  Benefit  Guaranty
 8        Corporation   and  has  qualified  health  insurance,  as
 9        defined by the federal Trade  Act  of  2002,  3  or  more
10        months,  and  (B)  whose  most  recent  prior  creditable
11        coverage   was  under  group  health  insurance  coverage
12        offered by a health  insurance  issuer,  a  group  health
13        plan,  a  governmental  plan, or a church plan (or health
14        insurance coverage offered in connection  with  any  such
15        plans)  or any other type of creditable coverage that may
16        be required by the federal Health  Insurance  Portability
17        and  Accountability Act of 1996, as it may be amended, or
18        the regulations under that Act;
19             (2)  who is not eligible for coverage  under  (A)  a
20        group  health  plan, (B) part A or part B of Medicare due
21        to age, or (C) medical  assistance,  and  does  not  have
22        other health insurance coverage;
23             (3)  with  respect  to whom the most recent coverage
24        within the coverage period described in paragraph  (1)(A)
25        of this definition was not terminated based upon a factor
26        relating to nonpayment of premiums or fraud;
27             (4)  if  the  individual (, other than an individual
28        who has either (A) been certified as an  eligible  person
29        pursuant to the federal Trade Adjustment Act of 2002, (B)
30        initially  been  paid  a  benefit  by the Pension Benefit
31        Guaranty Corporation, or (C) as of December 1, 2002, been
32        receiving benefits  from  the  Pension  Benefit  Guaranty
33        Corporation  and  who  has qualified health insurance, as
34        defined by the federal  Trade  Act  of  2002),  had  been
 
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 1        offered the option of continuation coverage under a COBRA
 2        continuation  provision or under a similar State program,
 3        who elected such coverage; and
 4             (5)  who,   if   the   individual    elected    such
 5        continuation  coverage,  has  exhausted such continuation
 6        coverage under such provision or program.
 7        An  individual  who  has  either  been  certified  as  an
 8    eligible person pursuant to the federal Trade Adjustment  Act
 9    of  2002  or  initially  been  paid  a benefit by the Pension
10    Benefit Guaranty Corporation shall not be required  to  elect
11    continuation coverage under a COBRA continuation provision or
12    under a similar state program.
13        "Group  health  insurance  coverage" means, in connection
14    with a group health plan, health insurance  coverage  offered
15    in connection with that plan.
16        "Group  health plan" has the same meaning given that term
17    in   the   federal   Health   Insurance    Portability    and
18    Accountability Act of 1996.
19        "Governmental  plan" has the same meaning given that term
20    in   the   federal   Health   Insurance    Portability    and
21    Accountability Act of 1996.
22        "Health  insurance coverage" means benefits consisting of
23    medical  care  (provided  directly,  through   insurance   or
24    reimbursement,  or otherwise and including items and services
25    paid for as medical care)  under  any  hospital  and  medical
26    expense-incurred policy, certificate, or contract provided by
27    an  insurer,  non-profit  health  care service plan contract,
28    health maintenance organization or other subscriber contract,
29    or any other health care plan or arrangement that pays for or
30    furnishes  medical  or  health  care  services   whether   by
31    insurance  or otherwise.  Health insurance coverage shall not
32    include  short  term,  accident  only,   disability   income,
33    hospital  confinement or fixed indemnity, dental only, vision
34    only, limited benefit, or credit insurance,  coverage  issued
 
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 1    as a supplement to liability insurance, insurance arising out
 2    of   a  workers'  compensation  or  similar  law,  automobile
 3    medical-payment insurance, or insurance under which  benefits
 4    are  payable  with  or  without  regard to fault and which is
 5    statutorily  required  to  be  contained  in  any   liability
 6    insurance policy or equivalent self-insurance.
 7        "Health  insurance  issuer"  means  an insurance company,
 8    insurance service, or  insurance  organization  (including  a
 9    health   maintenance  organization  and  a  voluntary  health
10    services  plan)  that  is  authorized  to   transact   health
11    insurance business in this State.  Such term does not include
12    a group health plan.
13        "Health  Maintenance  Organization" means an organization
14    as defined in the Health Maintenance Organization Act.
15        "Hospice" means a program  as  defined  in  and  licensed
16    under the Hospice Program Licensing Act.
17        "Hospital"  means  a duly licensed institution as defined
18    in the Hospital Licensing Act, an institution that meets  all
19    comparable conditions and requirements in effect in the state
20    in  which  it  is  located,  or  the  University  of Illinois
21    Hospital as defined in the University  of  Illinois  Hospital
22    Act.
23        "Individual   health  insurance  coverage"  means  health
24    insurance coverage offered to individuals in  the  individual
25    market,  but  does  not  include short-term, limited-duration
26    insurance.
27        "Insured" means any individual resident of this State who
28    is eligible to receive benefits from any  insurer  (including
29    health  insurance coverage offered in connection with a group
30    health plan) or health insurance issuer as  defined  in  this
31    Section.
32        "Insurer"  means  any  insurance  company  authorized  to
33    transact  health  insurance  business  in  this State and any
34    corporation that provides medical services and  is  organized
 
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 1    under  the  Voluntary Health Services Plans Act or the Health
 2    Maintenance Organization Act.
 3        "Medical assistance" means the State  medical  assistance
 4    or medical assistance no grant (MANG) programs provided under
 5    Title  XIX of the Social Security Act and Articles V (Medical
 6    Assistance) and  VI  (General  Assistance)  of  the  Illinois
 7    Public  Aid  Code  (or  any  successor  program) or under any
 8    similar program of health care benefits in a state other than
 9    Illinois.
10        "Medically necessary" means  that  a  service,  drug,  or
11    supply  is  necessary  and  appropriate  for the diagnosis or
12    treatment of an illness or injury in  accord  with  generally
13    accepted  standards  of  medical  practice  at  the  time the
14    service, drug,  or  supply  is  provided.  When  specifically
15    applied  to a confinement it further means that the diagnosis
16    or treatment of the  covered  person's  medical  symptoms  or
17    condition  cannot  be  safely  provided  to that person as an
18    outpatient. A service, drug, or supply shall not be medically
19    necessary if it: (i) is investigational, experimental, or for
20    research  purposes;  or  (ii)  is  provided  solely  for  the
21    convenience of the patient, the patient's family,  physician,
22    hospital,  or  any other provider; or (iii) exceeds in scope,
23    duration, or intensity that level of care that is  needed  to
24    provide   safe,   adequate,   and  appropriate  diagnosis  or
25    treatment; or (iv) could have been omitted without  adversely
26    affecting  the  covered  person's condition or the quality of
27    medical care; or (v) involves the use of  a  medical  device,
28    drug, or substance not formally approved by the United States
29    Food and Drug Administration.
30        "Medical  care" means the ordinary and usual professional
31    services rendered by a physician or other specified  provider
32    during  a  professional  visit for treatment of an illness or
33    injury.
34        "Medicare" means coverage under both Part A and Part B of
 
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 1    Title XVIII of the Social Security Act, 42 U.S.C. Sec.  1395,
 2    et seq.
 3        "Minimum  premium  plan"  means  an arrangement whereby a
 4    specified amount of health care claims  is  self-funded,  but
 5    the  insurance  company  assumes  the  risk  that claims will
 6    exceed that amount.
 7        "Participating  transplant  center"  means   a   hospital
 8    designated  by the Board as a preferred or exclusive provider
 9    of services for one or more specified human organ  or  tissue
10    transplants  for  which  the hospital has signed an agreement
11    with the Board to accept a transplant payment  allowance  for
12    all  expenses  related  to the transplant during a transplant
13    benefit period.
14        "Physician" means a person licensed to practice  medicine
15    pursuant to the Medical Practice Act of 1987.
16        "Plan"  means  the  Comprehensive  Health  Insurance Plan
17    established by this Act.
18        "Plan of operation" means the plan of  operation  of  the
19    Plan, including articles, bylaws and operating rules, adopted
20    by the board pursuant to this Act.
21        "Provider"  means any hospital, skilled nursing facility,
22    hospice, home health agency, physician, registered pharmacist
23    acting within the scope of that registration,  or  any  other
24    person  or  entity  licensed  in  Illinois to furnish medical
25    care.
26        "Qualified high risk pool" has  the  same  meaning  given
27    that  term  in  the  federal Health Insurance Portability and
28    Accountability Act of 1996.
29        "Resident" means a person who  is  and  continues  to  be
30    legally  domiciled and physically residing on a permanent and
31    full-time basis in a place of permanent  habitation  in  this
32    State that remains that person's principal residence and from
33    which  that person is absent only for temporary or transitory
34    purpose.
 
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 1        "Skilled nursing  facility"  means  a  facility  or  that
 2    portion  of  a  facility  that  is  licensed  by the Illinois
 3    Department of Public Health under the Nursing Home  Care  Act
 4    or  a  comparable  licensing  authority  in  another state to
 5    provide skilled nursing care.
 6        "Stop-loss coverage"  means  an  arrangement  whereby  an
 7    insurer  insures  against  the  risk  that any one claim will
 8    exceed a specific dollar amount or that the entire loss of  a
 9    self-insurance plan will exceed a specific amount.
10        "Third  party  administrator"  means  an administrator as
11    defined in Section 511.101 of the Illinois Insurance Code who
12    is licensed under Article XXXI 1/4 of that Code.
13    (Source: P.A. 91-357,  eff.  7-29-99;  91-735,  eff.  6-2-00;
14    92-153, eff. 7-25-01; 93HB3298enr.)

15        (215 ILCS 105/4) (from Ch. 73, par. 1304)
16        Sec.  4.  Powers  and  authority of the board.  The board
17    shall have the general powers and authority granted under the
18    laws  of  this  State  to  insurance  companies  licensed  to
19    transact  health  and  accident  insurance  and  in  addition
20    thereto, the specific authority to:
21        a.  Enter into contracts as are necessary  or  proper  to
22    carry  out the provisions and purposes of this Act, including
23    the authority, with the approval of the  Director,  to  enter
24    into  contracts  with  similar  plans of other states for the
25    joint performance of common administrative functions, or with
26    persons  or  other  organizations  for  the  performance   of
27    administrative   functions   including,  without  limitation,
28    utilization review and quality assurance  programs,  or  with
29    health   maintenance   organizations  or  preferred  provider
30    organizations for the provision of health care services.
31        b.  Sue or be sued, including taking  any  legal  actions
32    necessary or proper.
33        c.  Take such legal action as necessary to:
 
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 1             (1)  avoid  the  payment  of improper claims against
 2        the plan or the coverage provided by or through the plan;
 3             (2)  to   recover   any   amounts   erroneously   or
 4        improperly paid by the plan;
 5             (3)  to recover any amounts paid by the  plan  as  a
 6        result of a mistake of fact or law; or
 7             (4)  to   recover  or  collect  any  other  amounts,
 8        including assessments, that are due or owed the  Plan  or
 9        have been billed on its or the Plan's behalf.
10        d.  Establish  appropriate  rates,  rate  schedules, rate
11    adjustments, expense allowances, agents' referral fees, claim
12    reserves, and  formulas  and  any  other  actuarial  function
13    appropriate  to  the  operation  of the plan.  Rates and rate
14    schedules may be adjusted for appropriate risk  factors  such
15    as  age and area variation in claim costs and shall take into
16    consideration appropriate risk  factors  in  accordance  with
17    established actuarial and underwriting practices.
18        e.  Issue  policies  of  insurance in accordance with the
19    requirements of this Act.
20        f.  Appoint  appropriate  legal,  actuarial   and   other
21    committees  as  necessary  to provide technical assistance in
22    the operation of the plan, policy and other contract  design,
23    and any other function within the authority of the plan.
24        g.  Borrow  money  to effect the purposes of the Illinois
25    Comprehensive Health Insurance  Plan.   Any  notes  or  other
26    evidence  of indebtedness of the plan not in default shall be
27    legal investments for insurers and may be carried as admitted
28    assets.
29        h.  Establish  rules,  conditions  and   procedures   for
30    reinsuring risks under this Act.
31        i.  Employ  and  fix  the compensation of employees. Such
32    employees may be paid  on  a  warrant  issued  by  the  State
33    Treasurer  pursuant  to  a  payroll  voucher certified by the
34    Board and drawn by the Comptroller against appropriations  or
 
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 1    trust funds held by the State Treasurer.
 2        j.  Enter  into  intergovernmental cooperation agreements
 3    with other agencies or entities of State government  for  the
 4    purpose of sharing the cost of providing health care services
 5    that  are  otherwise  authorized by this Act for children who
 6    are  both  plan  participants  and  eligible  for   financial
 7    assistance from the Division of Specialized Care for Children
 8    of the University of Illinois.
 9        k.  Establish  conditions  and procedures under which the
10    plan may, if funds  permit,  discount  or  subsidize  premium
11    rates  that  are paid directly by senior citizens, as defined
12    by the Board, and other plan participants, who are retired or
13    unemployed and meet other qualifications.
14        l.  Establish and maintain the Plan  Fund  authorized  in
15    Section  3  of this Act, which shall be divided into separate
16    accounts, as follows:
17             (1)  accounts to fund the administrative, claim, and
18        other expenses  of  the  Plan  associated  with  eligible
19        persons  who qualify for Plan coverage under Section 7 of
20        this Act, which shall consist of:
21                  (A)  premiums  paid  on   behalf   of   covered
22             persons;
23                  (B)  appropriated   funds  and  other  revenues
24             collected or received by the Board;
25                  (C)  reserves for future losses  maintained  by
26             the Board; and
27                  (D)  interest  earnings  from investment of the
28             funds in the Plan Fund or any of its accounts  other
29             than the funds in the account established under item
30             2 of this subsection;
31             (2)  an  account,  to  be  denominated the federally
32        eligible individuals account, to fund the administrative,
33        claim, and other expenses of  the  Plan  associated  with
34        federally  eligible  individuals  who  qualify  for  Plan
 
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 1        coverage  under  Section  15  of  this  Act,  which shall
 2        consist of:
 3                  (A)  premiums  paid  on   behalf   of   covered
 4             persons;
 5                  (B)  assessments  and  other revenues collected
 6             or received by the Board;
 7                  (C)  reserves for future losses  maintained  by
 8             the Board; and
 9                  (D)  interest  earnings  from investment of the
10             federally eligible individuals account funds; and
11                  (E)  grants provided pursuant  to  the  federal
12             Trade Adjustment Act of 2002; and
13             (3)  such other accounts as may be appropriate.
14        m.  Charge  and  collect  assessments  paid  by  insurers
15    pursuant   to   Section  12  of  this  Act  and  recover  any
16    assessments for, on behalf of, or against those insurers.
17    (Source: P.A.  90-30,  eff.  7-1-97;  91-357,  eff.  7-29-99;
18    93HB3298enr.)

19        (215 ILCS 105/7) (from Ch. 73, par. 1307)
20        Sec. 7.  Eligibility.
21        a.  Except  as provided in subsection (e) of this Section
22    or in Section 15 of this Act, any  person  who  is  either  a
23    citizen  of  the  United States or an alien lawfully admitted
24    for permanent residence and who has been for a period  of  at
25    least  180  days and continues to be a resident of this State
26    shall be eligible for Plan coverage  under  this  Section  if
27    evidence is provided of:
28             (1)  A  notice  of  rejection  or  refusal  to issue
29        substantially   similar   individual   health   insurance
30        coverage for health reasons by a health insurance issuer;
31        or
32             (2)  A refusal by a health insurance issuer to issue
33        individual health insurance coverage  except  at  a  rate
 
HB0707 Enrolled            -14-      LRB093 05485 MKM 05576 b
 1        exceeding  the  applicable Plan rate for which the person
 2        is responsible.
 3        A rejection or refusal by a group health plan  or  health
 4    insurance  issuer  offering  only stop-loss or excess of loss
 5    insurance or contracts, agreements, or other arrangements for
 6    reinsurance coverage with respect to the applicant shall  not
 7    be sufficient evidence under this subsection.
 8        b.  The  board  shall  promulgate  a  list  of medical or
 9    health conditions for which a person who is either a  citizen
10    of  the  United  States  or  an  alien  lawfully admitted for
11    permanent residence and a resident of  this  State  would  be
12    eligible  for  Plan  coverage  without  applying  for  health
13    insurance coverage pursuant to subsection a. of this Section.
14    Persons  who  can demonstrate the existence or history of any
15    medical or health conditions on the list promulgated  by  the
16    board shall not be required to provide the evidence specified
17    in  subsection  a.  of  this  Section.   The  list  shall  be
18    effective  on  the first day of the operation of the Plan and
19    may be amended from time to time as appropriate.
20        c.  Family members of the same  household  who  each  are
21    covered  persons  are  eligible  for optional family coverage
22    under the Plan.
23        d.  For persons qualifying  for  coverage  in  accordance
24    with Section 7 of this Act, the board shall, if it determines
25    that  such  appropriations as are made pursuant to Section 12
26    of this Act are insufficient to allow the board to accept all
27    of the eligible persons which  it  projects  will  apply  for
28    enrollment  under  the  Plan,  limit  or  close enrollment to
29    ensure that the Plan is not over-subscribed and that  it  has
30    sufficient  resources  to  meet  its  obligations to existing
31    enrollees.  The board shall not limit or close enrollment for
32    federally eligible individuals.
33        e.  A person shall not be eligible for coverage under the
34    Plan if:
 
HB0707 Enrolled            -15-      LRB093 05485 MKM 05576 b
 1             (1)  He or she has or obtains other coverage under a
 2        group  health   plan   or   health   insurance   coverage
 3        substantially  similar to or better than a Plan policy as
 4        an insured or covered dependent or would be  eligible  to
 5        have  that  coverage  if  he or she elected to obtain it.
 6        Persons  otherwise  eligible  for  Plan   coverage   may,
 7        however,  solely for the purpose of having coverage for a
 8        pre-existing  condition,  maintain  other  coverage  only
 9        while  satisfying  any  pre-existing  condition   waiting
10        period  under  a  Plan policy or a subsequent replacement
11        policy of a Plan policy.
12             (1.1)  His or  her  prior  coverage  under  a  group
13        health  plan  or  health  insurance coverage, provided or
14        arranged by an employer of more  than  10  employees  was
15        discontinued  for  any reason without the entire group or
16        plan being discontinued and not replaced, provided he  or
17        she  remains  an  employee,  or dependent thereof, of the
18        same employer.
19             (2)  He or she is a recipient of or is  approved  to
20        receive  medical  assistance,  except  that  a person may
21        continue  to  receive  medical  assistance  through   the
22        medical  assistance  no  grant  program,  but  only while
23        satisfying the requirements for a  preexisting  condition
24        under  Section  8, subsection f. of this Act.  Payment of
25        premiums pursuant to this Act shall be allocable  to  the
26        person's spenddown for purposes of the medical assistance
27        no  grant  program, but that person shall not be eligible
28        for any Plan benefits while that person remains  eligible
29        for  medical  assistance.   If  the  person  continues to
30        receive or be  approved  to  receive  medical  assistance
31        through  the  medical  assistance  no grant program at or
32        after  the  time  that  requirements  for  a  preexisting
33        condition are satisfied, the person shall not be eligible
34        for  coverage  under  the  Plan.  In  that  circumstance,
 
HB0707 Enrolled            -16-      LRB093 05485 MKM 05576 b
 1        coverage  under  the  plan  shall  terminate  as  of  the
 2        expiration  of  the  preexisting   condition   limitation
 3        period.   Under  all  other circumstances, coverage under
 4        the  Plan  shall  automatically  terminate  as   of   the
 5        effective date of any medical assistance.
 6             (3)  Except  as  provided  in Section 15, the person
 7        has previously participated in the Plan  and  voluntarily
 8        terminated  Plan  coverage, unless 12 months have elapsed
 9        since  the  person's  latest  voluntary  termination   of
10        coverage.
11             (4)  The  person  fails  to pay the required premium
12        under  the  covered  person's  terms  of  enrollment  and
13        participation, in which event the liability of  the  Plan
14        shall  be limited to benefits incurred under the Plan for
15        the time period for which premiums had been paid and  the
16        covered person remained eligible for Plan coverage.
17             (5)  The  Plan  has  paid  a  total of $1,000,000 in
18        benefits on behalf of the covered person.
19             (6)  The  person  is  a   resident   of   a   public
20        institution.
21             (7)  The  person's premium is paid for or reimbursed
22        under  any  government  sponsored  program  or   by   any
23        government  agency  or health care provider, except as an
24        otherwise qualifying full-time employee, or dependent  of
25        such  employee,  of  a  government  agency or health care
26        provider or, except when a person's premium  is  paid  by
27        the  U.S.  Treasury  Department  pursuant  to the federal
28        Trade Adjustment Act of 2002.
29             (8)  The person has or later receives other benefits
30        or  funds  from  any  settlement,  judgement,  or   award
31        resulting  from any accident or injury, regardless of the
32        date  of  the  accident   or   injury,   or   any   other
33        circumstances  creating a legal liability for damages due
34        that person by a third  party,  whether  the  settlement,
 
HB0707 Enrolled            -17-      LRB093 05485 MKM 05576 b
 1        judgment,  or  award  is  in  the  form  of  a  contract,
 2        agreement, or trust on behalf of a minor or otherwise and
 3        whether  the settlement, judgment, or award is payable to
 4        the  person,  his  or  her  dependent,  estate,  personal
 5        representative, or guardian in a lump sum or  over  time,
 6        so  long  as  there  continues  to  be benefits or assets
 7        remaining from those sources in an amount  in  excess  of
 8        $100,000.
 9             (9)  Within the 5 years prior to the date a person's
10        Plan  application  is received by the Board, the person's
11        coverage under any health care benefit program as defined
12        in 18 U.S.C. 24, including any public or private plan  or
13        contract  under  which  any  medical  benefit,  item,  or
14        service  is  provided,  was terminated as a result of any
15        act or practice that constitutes  fraud  under  State  or
16        federal   law   or   as   a   result  of  an  intentional
17        misrepresentation of material fact;  or  if  that  person
18        knowingly  and willfully obtained or attempted to obtain,
19        or fraudulently aided  or  attempted  to  aid  any  other
20        person  in  obtaining, any coverage or benefits under the
21        Plan to which that person was not entitled.
22        f.  The  board  or  the   administrator   shall   require
23    verification  of  residency  and  may  require any additional
24    information or documentation, or statements under oath,  when
25    necessary to determine residency upon initial application and
26    for the entire term of the policy.
27        g.  Coverage  shall  cease (i) on the date a person is no
28    longer a resident of Illinois, (ii)  on  the  date  a  person
29    requests coverage to end, (iii) upon the death of the covered
30    person,  (iv)  on the date State law requires cancellation of
31    the policy, or (v) at the Plan's option, 30  days  after  the
32    Plan  makes  any inquiry concerning a person's eligibility or
33    place of residence to which the person does not reply.
34        h.  Except under the conditions set forth in subsection g
 
HB0707 Enrolled            -18-      LRB093 05485 MKM 05576 b
 1    of this Section, the coverage of any  person  who  ceases  to
 2    meet  the  eligibility  requirements of this Section shall be
 3    terminated at the end of the current policy period for  which
 4    the necessary premiums have been paid.
 5    (Source: P.A.  90-30,  eff.  7-1-97;  91-639,  eff.  8-20-99;
 6    91-735, eff. 6-2-00; 93HB3298enr.)

 7        (215 ILCS 105/15)
 8        Sec.  15.  Alternative  portable  coverage  for federally
 9    eligible individuals.
10        (a)  Notwithstanding the requirements of subsection a. of
11    Section 7 and except as otherwise provided in  this  Section,
12    any   federally   eligible   individual   for   whom  a  Plan
13    application, and such enclosures and supporting documentation
14    as the Board may require, is received by the Board within  90
15    days after the termination of prior creditable coverage shall
16    qualify   to   enroll  in  the  Plan  under  the  portability
17    provisions of this Section.
18        A federally eligible person who between December 1,  2002
19    and  September  30,  2003  has  either  (1) been certified as
20    eligible pursuant to the  federal  Trade  Act  of  2002,  (2)
21    initially been paid a benefit by the Pension Benefit Guaranty
22    Corporation,  or  (3)  as of December 1, 2002, been receiving
23    benefits from the Pension Benefit Guaranty  Corporation,  who
24    has  qualified  health  insurance,  as defined by the federal
25    Trade Act of 2002, and whose Plan application and  enclosures
26    and  supporting  documentation,  as the Board may require, is
27    received by the  Board  after  the  termination  of  previous
28    creditable coverage shall qualify to enroll in the Plan under
29    the portability provisions of this Section.
30        A  federally  eligible  person  who,  after September 30,
31    2003,  has  either  been  certified  as  an  eligible  person
32    pursuant to the federal  Trade  Adjustment  Act  of  2002  or
33    initially been paid a benefit by the Pension Benefit Guaranty
 
HB0707 Enrolled            -19-      LRB093 05485 MKM 05576 b
 1    Corporation  and  whose  Plan  application and enclosures and
 2    supporting documentation as the Board may require is received
 3    by the Board within 63 days after the termination of previous
 4    creditable coverage shall qualify to enroll in the Plan under
 5    the portability provisions of this Section.
 6        (b)  Any  federally  eligible  individual  seeking   Plan
 7    coverage  under  this  Section  must  submit  with his or her
 8    application   evidence,    including    acceptable    written
 9    certification  of  previous  creditable  coverage,  that will
10    establish to the Board's satisfaction, that he or  she  meets
11    all of the requirements to be a federally eligible individual
12    and  is  currently and permanently residing in this State (as
13    of the date his  or  her  application  was  received  by  the
14    Board).
15        (c)  Except  as  otherwise  provided  in  this Section, a
16    period of creditable coverage  shall  not  be  counted,  with
17    respect  to  qualifying  an  applicant for Plan coverage as a
18    federally eligible individual under this  Section,  if  after
19    such  period and before the application for Plan coverage was
20    received by the Board, there was at least  a  90  day  period
21    during  all of which the individual was not covered under any
22    creditable coverage.
23        For a federally eligible person who between  December  1,
24    2002  and September 30, 2003 has either (1) been certified as
25    eligible pursuant to the  federal  Trade  Act  of  2002,  (2)
26    initially been paid a benefit by the Pension Benefit Guaranty
27    Corporation,  or  (3)  as of December 1, 2002, been receiving
28    benefits from the Pension Benefit  Guaranty  Corporation  and
29    who has qualified health insurance, as defined by the federal
30    Trade  Act  of 2002, a period of creditable coverage shall be
31    counted, with respect to qualifying  an  applicant  for  Plan
32    coverage  as  a  federally  eligible  individual  under  this
33    Section,  when the application for Plan coverage was received
34    by the Board.
 
HB0707 Enrolled            -20-      LRB093 05485 MKM 05576 b
 1        For a federally eligible person who, after September  30,
 2    2003,  has  either  been  certified  as  an  eligible  person
 3    pursuant  to  the  federal  Trade  Adjustment  Act of 2002 or
 4    initially been paid a benefit by the Pension Benefit Guaranty
 5    Corporation, a period of creditable  coverage  shall  not  be
 6    counted,  with  respect  to  qualifying an applicant for Plan
 7    coverage  as  a  federally  eligible  individual  under  this
 8    Section, if after such period and before the application  for
 9    Plan coverage was received by the Board, there was at least a
10    63  day  period  during  all  of which the individual was not
11    covered under any creditable coverage.
12        (d)  Any federally  eligible  individual  who  the  Board
13    determines  qualifies  for  Plan  coverage under this Section
14    shall be offered his or her choice of  enrolling  in  one  of
15    alternative  portability health benefit plans which the Board
16    is authorized under  this  Section  to  establish  for  these
17    federally eligible individuals and their dependents.
18        (e)  The  Board  shall  offer  a  choice  of  health care
19    coverages consistent with major medical  coverage  under  the
20    alternative  health  benefit plans authorized by this Section
21    to every federally eligible individual. The coverages  to  be
22    offered   under   the   plans,   the  schedule  of  benefits,
23    deductibles, co-payments, exclusions, and  other  limitations
24    shall  be  approved  by  the  Board.   One  optional  form of
25    coverage  shall  be  comparable   to   comprehensive   health
26    insurance  coverage  offered in the individual market in this
27    State or a standard option of coverage  available  under  the
28    group  or individual health insurance laws of the State.  The
29    standard benefit plan that is authorized by Section 8 of this
30    Act may be used for this purpose.  The Board may also offer a
31    preferred provider option and such other options as the Board
32    determines may be appropriate for  these  federally  eligible
33    individuals  who  qualify  for Plan coverage pursuant to this
34    Section.
 
HB0707 Enrolled            -21-      LRB093 05485 MKM 05576 b
 1        (f)  Notwithstanding the requirements of subsection f. of
 2    Section 8, any plan coverage  that  is  issued  to  federally
 3    eligible individuals who qualify for the Plan pursuant to the
 4    portability  provisions  of this Section shall not be subject
 5    to any preexisting conditions exclusion, waiting  period,  or
 6    other similar limitation on coverage.
 7        (g)  Federally   eligible  individuals  who  qualify  and
 8    enroll in the Plan pursuant to this Section shall be required
 9    to pay such premium rates as the Board  shall  establish  and
10    approve in accordance with the requirements of Section 7.1 of
11    this Act.
12        (h)  A  federally  eligible  individual who qualifies and
13    enrolls in the Plan pursuant to this Section must satisfy  on
14    an ongoing basis all of the other eligibility requirements of
15    this  Act  to  the  extent  not inconsistent with the federal
16    Health Insurance Portability and Accountability Act  of  1996
17    in order to maintain continued eligibility for coverage under
18    the Plan.
19    (Source: P.A. 92-153, eff. 7-25-01; 93HB3298enr.)

20        Section  99.  Effective date.  This Act takes effect upon
21    becoming law.