Illinois General Assembly - Full Text of HB2285
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Full Text of HB2285  95th General Assembly



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1     AN ACT concerning regulation.
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4     Section 5. The Comprehensive Health Insurance Plan Act is
5 amended by changing Section 8 as follows:
6     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
7     Sec. 8. Minimum benefits.
8     a. Availability. The Plan shall offer in an annually
9 renewable policy major medical expense coverage to every
10 eligible person who is not eligible for Medicare. Major medical
11 expense coverage offered by the Plan shall pay an eligible
12 person's covered expenses, subject to limit on the deductible
13 and coinsurance payments authorized under paragraph (4) of
14 subsection d of this Section, up to a lifetime benefit limit of
15 $1,500,000 per covered individual. The maximum limit under this
16 subsection shall not be altered by the Board, and no actuarial
17 equivalent benefit may be substituted by the Board. Any person
18 who otherwise would qualify for coverage under the Plan, but is
19 excluded because he or she is eligible for Medicare, shall be
20 eligible for any separate Medicare supplement policy or
21 policies which the Board may offer.
22     b. Outline of benefits. Covered expenses shall be limited
23 to the usual and customary charge, including negotiated fees,



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1 in the locality for the following services and articles when
2 prescribed by a physician and determined by the Plan to be
3 medically necessary for the following areas of services,
4 subject to such separate deductibles, co-payments, exclusions,
5 and other limitations on benefits as the Board shall establish
6 and approve, and the other provisions of this Section:
7         (1) Hospital services, except that any services
8     provided by a hospital that is located more than 75 miles
9     outside the State of Illinois shall be covered only for a
10     maximum of 45 days in any calendar year. With respect to
11     covered expenses incurred during any calendar year ending
12     on or after December 31, 1999, inpatient hospitalization of
13     an eligible person for the treatment of mental illness at a
14     hospital located within the State of Illinois shall be
15     subject to the same terms and conditions as for any other
16     illness.
17         (2) Professional services for the diagnosis or
18     treatment of injuries, illnesses or conditions, other than
19     dental and mental and nervous disorders as described in
20     paragraph (17), which are rendered by a physician, or by
21     other licensed professionals at the physician's direction.
22     This includes reconstruction of the breast on which a
23     mastectomy was performed; surgery and reconstruction of
24     the other breast to produce a symmetrical appearance; and
25     prostheses and treatment of physical complications at all
26     stages of the mastectomy, including lymphedemas.



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1         (2.5) Professional services provided by a physician to
2     children under the age of 16 years for physical
3     examinations and age appropriate immunizations ordered by
4     a physician licensed to practice medicine in all its
5     branches.
6         (3) (Blank).
7         (4) Outpatient prescription drugs that by law require a
8     prescription written by a physician licensed to practice
9     medicine in all its branches subject to such separate
10     deductible, copayment, and other limitations or
11     restrictions as the Board shall approve, including the use
12     of a prescription drug card or any other program, or both.
13         (5) Skilled nursing services of a licensed skilled
14     nursing facility for not more than 120 days during a policy
15     year.
16         (6) Services of a home health agency in accord with a
17     home health care plan, up to a maximum of 270 visits per
18     year.
19         (7) Services of a licensed hospice for not more than
20     180 days during a policy year.
21         (8) Use of radium or other radioactive materials.
22         (9) Oxygen.
23         (10) Anesthetics.
24         (11) Orthoses and prostheses other than dental.
25         (12) Rental or purchase in accordance with Board
26     policies or procedures of durable medical equipment, other



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1     than eyeglasses or hearing aids, for which there is no
2     personal use in the absence of the condition for which it
3     is prescribed.
4         (13) Diagnostic x-rays and laboratory tests.
5         (14) Oral surgery (i) for excision of partially or
6     completely unerupted impacted teeth when not performed in
7     connection with the routine extraction or repair of teeth;
8     (ii) for excision of tumors or cysts of the jaws, cheeks,
9     lips, tongue, and roof and floor of the mouth; (iii)
10     required for correction of cleft lip and palate and other
11     craniofacial and maxillofacial birth defects; or (iv) for
12     treatment of injuries to natural teeth or a fractured jaw
13     due to an accident.
14         (15) Physical, speech, and functional occupational
15     therapy as medically necessary and provided by appropriate
16     licensed professionals.
17         (16) Emergency and other medically necessary
18     transportation provided by a licensed ambulance service to
19     the nearest health care facility qualified to treat a
20     covered illness, injury, or condition, subject to the
21     provisions of the Emergency Medical Systems (EMS) Act.
22         (17) Outpatient services for diagnosis and treatment
23     of mental and nervous disorders provided that a covered
24     person shall be required to make a copayment not to exceed
25     50% and that the Plan's payment shall not exceed such
26     amounts as are established by the Board.



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1         (18) Human organ or tissue transplants specified by the
2     Board that are performed at a hospital designated by the
3     Board as a participating transplant center for that
4     specific organ or tissue transplant.
5         (19) Naprapathic services, as appropriate, provided by
6     a licensed naprapathic practitioner.
7         (20) Coverage for benefits as required under Sections
8     356g, 356u, 356x, and 356z.4 of the Illinois Insurance
9     Code.
10     c. Exclusions. Covered expenses of the Plan shall not
11 include the following:
12         (1) Any charge for treatment for cosmetic purposes
13     other than for reconstructive surgery when the service is
14     incidental to or follows surgery resulting from injury,
15     sickness or other diseases of the involved part or surgery
16     for the repair or treatment of a congenital bodily defect
17     to restore normal bodily functions.
18         (2) Any charge for care that is primarily for rest,
19     custodial, educational, or domiciliary purposes.
20         (3) Any charge for services in a private room to the
21     extent it is in excess of the institution's charge for its
22     most common semiprivate room, unless a private room is
23     prescribed as medically necessary by a physician.
24         (4) That part of any charge for room and board or for
25     services rendered or articles prescribed by a physician,
26     dentist, or other health care personnel that exceeds the



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1     reasonable and customary charge in the locality or for any
2     services or supplies not medically necessary for the
3     diagnosed injury or illness.
4         (5) Any charge for services or articles the provision
5     of which is not within the scope of licensure of the
6     institution or individual providing the services or
7     articles.
8         (6) Any expense incurred prior to the effective date of
9     coverage by the Plan for the person on whose behalf the
10     expense is incurred.
11         (7) Dental care, dental surgery, dental treatment, any
12     other dental procedure involving the teeth or
13     periodontium, or any dental appliances, including crowns,
14     bridges, implants, or partial or complete dentures, except
15     as specifically provided in paragraph (14) of subsection b
16     of this Section.
17         (8) Eyeglasses, contact lenses, hearing aids or their
18     fitting.
19         (9) Illness or injury due to acts of war.
20         (10) Services of blood donors and any fee for failure
21     to replace the first 3 pints of blood provided to a covered
22     person each policy year.
23         (11) Personal supplies or services provided by a
24     hospital or nursing home, or any other nonmedical or
25     nonprescribed supply or service.
26         (12) Routine maternity charges for a pregnancy, except



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1     where added as optional coverage with payment of an
2     additional premium for pregnancy resulting from conception
3     occurring after the effective date of the optional
4     coverage.
5         (13) (Blank).
6         (14) Any expense or charge for services, drugs, or
7     supplies that are: (i) not provided in accord with
8     generally accepted standards of current medical practice;
9     (ii) for procedures, treatments, equipment, transplants,
10     or implants, any of which are investigational,
11     experimental, or for research purposes; (iii)
12     investigative and not proven safe and effective; or (iv)
13     for, or resulting from, a gender transformation operation.
14         (15) Any expense or charge for routine physical
15     examinations or tests except as provided in items item
16     (2.5) and (20) of subsection b of this Section.
17         (16) Any expense for which a charge is not made in the
18     absence of insurance or for which there is no legal
19     obligation on the part of the patient to pay.
20         (17) Any expense incurred for benefits provided under
21     the laws of the United States and this State, including
22     Medicare, Medicaid, and other medical assistance, maternal
23     and child health services and any other program that is
24     administered or funded by the Department of Human Services,
25     Department of Healthcare and Family Services, or
26     Department of Public Health, military service-connected



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1     disability payments, medical services provided for members
2     of the armed forces and their dependents or employees of
3     the armed forces of the United States, and medical services
4     financed on behalf of all citizens by the United States.
5         (18) Any expense or charge for in vitro fertilization,
6     artificial insemination, or any other artificial means
7     used to cause pregnancy.
8         (19) (Blank). Any expense or charge for oral
9     contraceptives used for birth control or any other
10     temporary birth control measures.
11         (20) Any expense or charge for sterilization or
12     sterilization reversals.
13         (21) Any expense or charge for weight loss programs,
14     exercise equipment, or treatment of obesity, except when
15     certified by a physician as morbid obesity (at least 2
16     times normal body weight).
17         (22) Any expense or charge for acupuncture treatment
18     unless used as an anesthetic agent for a covered surgery.
19         (23) Any expense or charge for or related to organ or
20     tissue transplants other than those performed at a hospital
21     with a Board approved organ transplant program that has
22     been designated by the Board as a preferred or exclusive
23     provider organization for that specific organ or tissue
24     transplant.
25         (24) Any expense or charge for procedures, treatments,
26     equipment, or services that are provided in special



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1     settings for research purposes or in a controlled
2     environment, are being studied for safety, efficiency, and
3     effectiveness, and are awaiting endorsement by the
4     appropriate national medical speciality college for
5     general use within the medical community.
6     d. Deductibles and coinsurance.
7     The Plan coverage defined in Section 6 shall provide for a
8 choice of deductibles per individual as authorized by the
9 Board. If 2 individual members of the same family household,
10 who are both covered persons under the Plan, satisfy the same
11 applicable deductibles, no other member of that family who is
12 also a covered person under the Plan shall be required to meet
13 any deductibles for the balance of that calendar year. The
14 deductibles must be applied first to the authorized amount of
15 covered expenses incurred by the covered person. A mandatory
16 coinsurance requirement shall be imposed at the rate authorized
17 by the Board in excess of the mandatory deductible, the
18 coinsurance in the aggregate not to exceed such amounts as are
19 authorized by the Board per annum. At its discretion the Board
20 may, however, offer catastrophic coverages or other policies
21 that provide for larger deductibles with or without coinsurance
22 requirements. The deductibles and coinsurance factors may be
23 adjusted annually according to the Medical Component of the
24 Consumer Price Index.
25     e. Scope of coverage.
26         (1) In approving any of the benefit plans to be offered



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1     by the Plan, the Board shall establish such benefit levels,
2     deductibles, coinsurance factors, exclusions, and
3     limitations as it may deem appropriate and that it believes
4     to be generally reflective of and commensurate with health
5     insurance coverage that is provided in the individual
6     market in this State.
7         (2) The benefit plans approved by the Board may also
8     provide for and employ various cost containment measures
9     and other requirements including, but not limited to,
10     preadmission certification, prior approval, second
11     surgical opinions, concurrent utilization review programs,
12     individual case management, preferred provider
13     organizations, health maintenance organizations, and other
14     cost effective arrangements for paying for covered
15     expenses.
16     f. Preexisting conditions.
17         (1) Except for federally eligible individuals
18     qualifying for Plan coverage under Section 15 of this Act
19     or eligible persons who qualify for the waiver authorized
20     in paragraph (3) of this subsection, plan coverage shall
21     exclude charges or expenses incurred during the first 6
22     months following the effective date of coverage as to any
23     condition for which medical advice, care or treatment was
24     recommended or received during the 6 month period
25     immediately preceding the effective date of coverage.
26         (2) (Blank).



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1         (3) Waiver: The preexisting condition exclusions as
2     set forth in paragraph (1) of this subsection shall be
3     waived to the extent to which the eligible person (a) has
4     satisfied similar exclusions under any prior individual
5     health insurance policy that was involuntarily terminated
6     because of the insolvency of the issuer of the policy and
7     (b) has applied for Plan coverage within 90 days following
8     the involuntary termination of that individual health
9     insurance coverage.
10     g. Other sources primary; nonduplication of benefits.
11         (1) The Plan shall be the last payor of benefits
12     whenever any other benefit or source of third party payment
13     is available. Subject to the provisions of subsection e of
14     Section 7, benefits otherwise payable under Plan coverage
15     shall be reduced by all amounts paid or payable by Medicare
16     or any other government program or through any health
17     insurance coverage or group health plan, whether by
18     insurance, reimbursement, or otherwise, or through any
19     third party liability, settlement, judgment, or award,
20     regardless of the date of the settlement, judgment, or
21     award, whether the settlement, judgment, or award is in the
22     form of a contract, agreement, or trust on behalf of a
23     minor or otherwise and whether the settlement, judgment, or
24     award is payable to the covered person, his or her
25     dependent, estate, personal representative, or guardian in
26     a lump sum or over time, and by all hospital or medical



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1     expense benefits paid or payable under any worker's
2     compensation coverage, automobile medical payment, or
3     liability insurance, whether provided on the basis of fault
4     or nonfault, and by any hospital or medical benefits paid
5     or payable under or provided pursuant to any State or
6     federal law or program.
7         (2) The Plan shall have a cause of action against any
8     covered person or any other person or entity for the
9     recovery of any amount paid to the extent the amount was
10     for treatment, services, or supplies not covered in this
11     Section or in excess of benefits as set forth in this
12     Section.
13         (3) Whenever benefits are due from the Plan because of
14     sickness or an injury to a covered person resulting from a
15     third party's wrongful act or negligence and the covered
16     person has recovered or may recover damages from a third
17     party or its insurer, the Plan shall have the right to
18     reduce benefits or to refuse to pay benefits that otherwise
19     may be payable by the amount of damages that the covered
20     person has recovered or may recover regardless of the date
21     of the sickness or injury or the date of any settlement,
22     judgment, or award resulting from that sickness or injury.
23         During the pendency of any action or claim that is
24     brought by or on behalf of a covered person against a third
25     party or its insurer, any benefits that would otherwise be
26     payable except for the provisions of this paragraph (3)



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1     shall be paid if payment by or for the third party has not
2     yet been made and the covered person or, if incapable, that
3     person's legal representative agrees in writing to pay back
4     promptly the benefits paid as a result of the sickness or
5     injury to the extent of any future payments made by or for
6     the third party for the sickness or injury. This agreement
7     is to apply whether or not liability for the payments is
8     established or admitted by the third party or whether those
9     payments are itemized.
10         Any amounts due the plan to repay benefits may be
11     deducted from other benefits payable by the Plan after
12     payments by or for the third party are made.
13         (4) Benefits due from the Plan may be reduced or
14     refused as an offset against any amount otherwise
15     recoverable under this Section.
16     h. Right of subrogation; recoveries.
17         (1) Whenever the Plan has paid benefits because of
18     sickness or an injury to any covered person resulting from
19     a third party's wrongful act or negligence, or for which an
20     insurer is liable in accordance with the provisions of any
21     policy of insurance, and the covered person has recovered
22     or may recover damages from a third party that is liable
23     for the damages, the Plan shall have the right to recover
24     the benefits it paid from any amounts that the covered
25     person has received or may receive regardless of the date
26     of the sickness or injury or the date of any settlement,



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1     judgment, or award resulting from that sickness or injury.
2     The Plan shall be subrogated to any right of recovery the
3     covered person may have under the terms of any private or
4     public health care coverage or liability coverage,
5     including coverage under the Workers' Compensation Act or
6     the Workers' Occupational Diseases Act, without the
7     necessity of assignment of claim or other authorization to
8     secure the right of recovery. To enforce its subrogation
9     right, the Plan may (i) intervene or join in an action or
10     proceeding brought by the covered person or his personal
11     representative, including his guardian, conservator,
12     estate, dependents, or survivors, against any third party
13     or the third party's insurer that may be liable or (ii)
14     institute and prosecute legal proceedings against any
15     third party or the third party's insurer that may be liable
16     for the sickness or injury in an appropriate court either
17     in the name of the Plan or in the name of the covered
18     person or his personal representative, including his
19     guardian, conservator, estate, dependents, or survivors.
20         (2) If any action or claim is brought by or on behalf
21     of a covered person against a third party or the third
22     party's insurer, the covered person or his personal
23     representative, including his guardian, conservator,
24     estate, dependents, or survivors, shall notify the Plan by
25     personal service or registered mail of the action or claim
26     and of the name of the court in which the action or claim



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1     is brought, filing proof thereof in the action or claim.
2     The Plan may, at any time thereafter, join in the action or
3     claim upon its motion so that all orders of court after
4     hearing and judgment shall be made for its protection. No
5     release or settlement of a claim for damages and no
6     satisfaction of judgment in the action shall be valid
7     without the written consent of the Plan to the extent of
8     its interest in the settlement or judgment and of the
9     covered person or his personal representative.
10         (3) In the event that the covered person or his
11     personal representative fails to institute a proceeding
12     against any appropriate third party before the fifth month
13     before the action would be barred, the Plan may, in its own
14     name or in the name of the covered person or personal
15     representative, commence a proceeding against any
16     appropriate third party for the recovery of damages on
17     account of any sickness, injury, or death to the covered
18     person. The covered person shall cooperate in doing what is
19     reasonably necessary to assist the Plan in any recovery and
20     shall not take any action that would prejudice the Plan's
21     right to recovery. The Plan shall pay to the covered person
22     or his personal representative all sums collected from any
23     third party by judgment or otherwise in excess of amounts
24     paid in benefits under the Plan and amounts paid or to be
25     paid as costs, attorneys fees, and reasonable expenses
26     incurred by the Plan in making the collection or enforcing



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1     the judgment.
2         (4) In the event that a covered person or his personal
3     representative, including his guardian, conservator,
4     estate, dependents, or survivors, recovers damages from a
5     third party for sickness or injury caused to the covered
6     person, the covered person or the personal representative
7     shall pay to the Plan from the damages recovered the amount
8     of benefits paid or to be paid on behalf of the covered
9     person.
10         (5) When the action or claim is brought by the covered
11     person alone and the covered person incurs a personal
12     liability to pay attorney's fees and costs of litigation,
13     the Plan's claim for reimbursement of the benefits provided
14     to the covered person shall be the full amount of benefits
15     paid to or on behalf of the covered person under this Act
16     less a pro rata share that represents the Plan's reasonable
17     share of attorney's fees paid by the covered person and
18     that portion of the cost of litigation expenses determined
19     by multiplying by the ratio of the full amount of the
20     expenditures to the full amount of the judgement, award, or
21     settlement.
22         (6) In the event of judgment or award in a suit or
23     claim against a third party or insurer, the court shall
24     first order paid from any judgement or award the reasonable
25     litigation expenses incurred in preparation and
26     prosecution of the action or claim, together with



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1     reasonable attorney's fees. After payment of those
2     expenses and attorney's fees, the court shall apply out of
3     the balance of the judgment or award an amount sufficient
4     to reimburse the Plan the full amount of benefits paid on
5     behalf of the covered person under this Act, provided the
6     court may reduce and apportion the Plan's portion of the
7     judgement proportionate to the recovery of the covered
8     person. The burden of producing evidence sufficient to
9     support the exercise by the court of its discretion to
10     reduce the amount of a proven charge sought to be enforced
11     against the recovery shall rest with the party seeking the
12     reduction. The court may consider the nature and extent of
13     the injury, economic and non-economic loss, settlement
14     offers, comparative negligence as it applies to the case at
15     hand, hospital costs, physician costs, and all other
16     appropriate costs. The Plan shall pay its pro rata share of
17     the attorney fees based on the Plan's recovery as it
18     compares to the total judgment. Any reimbursement rights of
19     the Plan shall take priority over all other liens and
20     charges existing under the laws of this State with the
21     exception of any attorney liens filed under the Attorneys
22     Lien Act.
23         (7) The Plan may compromise or settle and release any
24     claim for benefits provided under this Act or waive any
25     claims for benefits, in whole or in part, for the
26     convenience of the Plan or if the Plan determines that



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1     collection would result in undue hardship upon the covered
2     person.
3 (Source: P.A. 94-737, eff. 5-3-06.)