093_HB3298ham002











                                     LRB093 11158 JLS 13065 a

 1                    AMENDMENT TO HOUSE BILL 3298

 2        AMENDMENT NO.     .  Amend House Bill 3298  by  replacing
 3    everything after the enacting clause with the following:

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

 6        (215 ILCS 105/2) (from Ch. 73, par. 1302)
 7        Sec. 2.  Definitions.  As used in this  Act,  unless  the
 8    context otherwise requires:
 9        "Plan  administrator"  means  the  insurer or third party
10    administrator designated under Section 5 of this Act.
11        "Benefits plan" means the coverage to be offered  by  the
12    Plan  to  eligible persons and federally eligible individuals
13    pursuant to this Act.
14        "Board" means the Illinois Comprehensive Health Insurance
15    Board.
16        "Church plan" has the same meaning given that term in the
17    federal Health Insurance Portability and  Accountability  Act
18    of 1996.
19        "Continuation  coverage"  means  continuation of coverage
20    under a group health plan or other health insurance  coverage
21    for  former  employees or dependents of former employees that
22    would otherwise have  terminated  under  the  terms  of  that
 
                            -2-      LRB093 11158 JLS 13065 a
 1    coverage   pursuant  to  any  continuation  provisions  under
 2    federal or State  law,  including  the  Consolidated  Omnibus
 3    Budget  Reconciliation  Act  of  1985  (COBRA),  as  amended,
 4    Sections  367.2  and  367e of the Illinois Insurance Code, or
 5    any other similar requirement in another State.
 6        "Covered person" means a person who is and  continues  to
 7    remain eligible for Plan coverage and is covered under one of
 8    the benefit plans offered by the Plan.
 9        "Creditable  coverage" means, with respect to a federally
10    eligible individual, coverage of the individual under any  of
11    the following:
12             (A)  A group health plan.
13             (B)  Health   insurance  coverage  (including  group
14        health insurance coverage).
15             (C)  Medicare.
16             (D)  Medical assistance.
17             (E)  Chapter 55 of title 10, United States Code.
18             (F)  A medical care program  of  the  Indian  Health
19        Service or of a tribal organization.
20             (G)  A state health benefits risk pool.
21             (H)  A health plan offered under Chapter 89 of title
22        5, United States Code.
23             (I)  A public health plan (as defined in regulations
24        consistent   with   Section   104   of  the  Health  Care
25        Portability and Accountability Act of 1996  that  may  be
26        promulgated  by  the  Secretary of the U.S. Department of
27        Health and Human Services).
28             (J)  A health benefit plan under Section 5(e) of the
29        Peace Corps Act (22 U.S.C. 2504(e)).
30             (K)  Any other qualifying coverage required  by  the
31        federal  Health  Insurance Portability and Accountability
32        Act of 1996, as it may be amended, or  regulations  under
33        that Act.
34        "Creditable   coverage"   does   not   include   coverage
 
                            -3-      LRB093 11158 JLS 13065 a
 1    consisting  solely  of  coverage  of  excepted  benefits,  as
 2    defined  in  Section  2791(c)  of  title  XXVII of the Public
 3    Health Service Act (42 U.S.C. 300 gg-91), nor does it include
 4    any period of coverage under any of  items  (A)  through  (K)
 5    that  occurred before a break of more than 90 days or, if the
 6    individual has been certified as an eligible person  pursuant
 7    to  the federal Trade Adjustment Act of 2002, a break of more
 8    than 63 days during all  of  which  the  individual  was  not
 9    covered under any of items (A) through (K) above.  Any period
10    that  an  individual  is in a waiting period for any coverage
11    under a group health plan  (or  for  group  health  insurance
12    coverage)  or  is in an affiliation period under the terms of
13    health insurance coverage offered  by  a  health  maintenance
14    organization  shall  not be taken into account in determining
15    if there has been a  break  of  more  than  90  days  in  any
16    creditable coverage.
17        "Department" means the Illinois Department of Insurance.
18        "Dependent"  means an Illinois resident: who is a spouse;
19    or who is claimed as a dependent by the principal insured for
20    purposes of filing a federal income tax return and resides in
21    the  principal  insured's  household,  and  is   a   resident
22    unmarried  child  under  the  age  of  19 years; or who is an
23    unmarried child who also is a full-time student under the age
24    of 23  years  and  who  is  financially  dependent  upon  the
25    principal  insured;  or  who is a child of any age and who is
26    disabled  and  financially  dependent  upon   the   principal
27    insured.
28        "Direct  Illinois premiums" means, for Illinois business,
29    an insurer's direct premium income for the kinds of  business
30    described  in  clause (b) of Class 1 or clause (a) of Class 2
31    of Section 4 of  the  Illinois  Insurance  Code,  and  direct
32    premium  income  of  a  health  maintenance organization or a
33    voluntary health services plan, except it shall  not  include
34    credit  health  insurance as defined in Article IX 1/2 of the
 
                            -4-      LRB093 11158 JLS 13065 a
 1    Illinois Insurance Code.
 2        "Director" means the Director of the Illinois  Department
 3    of Insurance.
 4        "Eligible  person"  means  a  resident  of this State who
 5    qualifies for Plan coverage under Section 7 of this Act.
 6        "Employee" means a resident of this State who is employed
 7    by an employer or has entered into the employment of or works
 8    under contract  or  service  of  an  employer  including  the
 9    officers,  managers and employees of subsidiary or affiliated
10    corporations and the  individual  proprietors,  partners  and
11    employees  of  affiliated  individuals  and  firms  when  the
12    business  of the subsidiary or affiliated corporations, firms
13    or individuals is controlled by  a  common  employer  through
14    stock ownership, contract, or otherwise.
15        "Employer"    means    any    individual,    partnership,
16    association,  corporation,  business  trust, or any person or
17    group  of  persons  acting  directly  or  indirectly  in  the
18    interest of an employer in relation to an employee, for which
19    one or more persons is gainfully employed.
20        "Family" coverage means the coverage provided by the Plan
21    for the covered person and his or her eligible dependents who
22    also are covered persons.
23        "Federally  eligible  individual"  means  an   individual
24    resident of this State:
25             (1)(A)  for  whom,  as  of  the  date  on  which the
26        individual seeks Plan coverage under Section 15  of  this
27        Act,  the aggregate of the periods of creditable coverage
28        is 18 or more months  or,  if  the  individual  has  been
29        certified  as  an eligible person pursuant to the federal
30        Trade Adjustment Act of 2002, 3 or more months,  and  (B)
31        whose  most  recent  prior  creditable coverage was under
32        group health  insurance  coverage  offered  by  a  health
33        insurance  issuer,  a  group  health plan, a governmental
34        plan, or a church  plan  (or  health  insurance  coverage
 
                            -5-      LRB093 11158 JLS 13065 a
 1        offered  in  connection with any such plans) or any other
 2        type of creditable coverage that may be required  by  the
 3        federal  Health  Insurance Portability and Accountability
 4        Act of 1996, as it may be  amended,  or  the  regulations
 5        under that Act;
 6             (2)  who  is  not  eligible for coverage under (A) a
 7        group health plan, (B) part A or part B of  Medicare  due
 8        to  age,  or  (C)  medical  assistance, and does not have
 9        other health insurance coverage;
10             (3)  with respect to whom the most  recent  coverage
11        within  the coverage period described in paragraph (1)(A)
12        of this definition was not terminated based upon a factor
13        relating to nonpayment of premiums or fraud;
14             (4)  if the individual, other than an individual who
15        has been certified as an eligible person pursuant to  the
16        federal  Trade  Adjustment  Act of 2002, had been offered
17        the  option  of  continuation  coverage  under  a   COBRA
18        continuation  provision or under a similar State program,
19        who elected such coverage; and
20             (5)  who,   if   the   individual    elected    such
21        continuation  coverage,  has  exhausted such continuation
22        coverage under such provision or program.
23        An individual who  has  been  certified  as  an  eligible
24    person  pursuant  to the federal Trade Adjustment Act of 2002
25    shall not be required to elect continuation coverage under  a
26    COBRA   continuation  provision  or  under  a  similar  state
27    program.
28        "Group health insurance coverage"  means,  in  connection
29    with  a  group health plan, health insurance coverage offered
30    in connection with that plan.
31        "Group health plan" has the same meaning given that  term
32    in    the    federal   Health   Insurance   Portability   and
33    Accountability Act of 1996.
34        "Governmental plan" has the same meaning given that  term
 
                            -6-      LRB093 11158 JLS 13065 a
 1    in    the    federal   Health   Insurance   Portability   and
 2    Accountability Act of 1996.
 3        "Health insurance coverage" means benefits consisting  of
 4    medical   care   (provided  directly,  through  insurance  or
 5    reimbursement, or otherwise and including items and  services
 6    paid  for  as  medical  care)  under any hospital and medical
 7    expense-incurred policy, certificate, or contract provided by
 8    an insurer, non-profit health  care  service  plan  contract,
 9    health maintenance organization or other subscriber contract,
10    or any other health care plan or arrangement that pays for or
11    furnishes   medical   or  health  care  services  whether  by
12    insurance or otherwise.  Health insurance coverage shall  not
13    include   short   term,  accident  only,  disability  income,
14    hospital confinement or fixed indemnity, dental only,  vision
15    only,  limited  benefit, or credit insurance, coverage issued
16    as a supplement to liability insurance, insurance arising out
17    of  a  workers'  compensation  or  similar  law,   automobile
18    medical-payment  insurance, or insurance under which benefits
19    are payable with or without regard  to  fault  and  which  is
20    statutorily   required  to  be  contained  in  any  liability
21    insurance policy or equivalent self-insurance.
22        "Health insurance issuer"  means  an  insurance  company,
23    insurance  service,  or  insurance  organization (including a
24    health  maintenance  organization  and  a  voluntary   health
25    services   plan)   that  is  authorized  to  transact  health
26    insurance business in this State.  Such term does not include
27    a group health plan.
28        "Health Maintenance Organization" means  an  organization
29    as defined in the Health Maintenance Organization Act.
30        "Hospice"  means  a  program  as  defined in and licensed
31    under the Hospice Program Licensing Act.
32        "Hospital" means a duly licensed institution  as  defined
33    in  the Hospital Licensing Act, an institution that meets all
34    comparable conditions and requirements in effect in the state
 
                            -7-      LRB093 11158 JLS 13065 a
 1    in which  it  is  located,  or  the  University  of  Illinois
 2    Hospital  as  defined  in the University of Illinois Hospital
 3    Act.
 4        "Individual  health  insurance  coverage"  means   health
 5    insurance  coverage  offered to individuals in the individual
 6    market, but does  not  include  short-term,  limited-duration
 7    insurance.
 8        "Insured" means any individual resident of this State who
 9    is  eligible  to receive benefits from any insurer (including
10    health insurance coverage offered in connection with a  group
11    health  plan)  or  health insurance issuer as defined in this
12    Section.
13        "Insurer"  means  any  insurance  company  authorized  to
14    transact health insurance business  in  this  State  and  any
15    corporation  that  provides medical services and is organized
16    under the Voluntary Health Services Plans Act or  the  Health
17    Maintenance Organization Act.
18        "Medical  assistance"  means the State medical assistance
19    or medical assistance no grant (MANG) programs provided under
20    Title XIX of the Social Security Act and Articles V  (Medical
21    Assistance)  and  VI  (General  Assistance)  of  the Illinois
22    Public Aid Code (or  any  successor  program)  or  under  any
23    similar program of health care benefits in a state other than
24    Illinois.
25        "Medically  necessary"  means  that  a  service, drug, or
26    supply is necessary and  appropriate  for  the  diagnosis  or
27    treatment  of  an  illness or injury in accord with generally
28    accepted standards  of  medical  practice  at  the  time  the
29    service,  drug,  or  supply  is  provided.  When specifically
30    applied to a confinement it further means that the  diagnosis
31    or  treatment  of  the  covered  person's medical symptoms or
32    condition cannot be safely provided  to  that  person  as  an
33    outpatient. A service, drug, or supply shall not be medically
34    necessary if it: (i) is investigational, experimental, or for
 
                            -8-      LRB093 11158 JLS 13065 a
 1    research  purposes;  or  (ii)  is  provided  solely  for  the
 2    convenience  of the patient, the patient's family, physician,
 3    hospital, or any other provider; or (iii) exceeds  in  scope,
 4    duration,  or  intensity that level of care that is needed to
 5    provide  safe,  adequate,  and   appropriate   diagnosis   or
 6    treatment;  or (iv) could have been omitted without adversely
 7    affecting the covered person's condition or  the  quality  of
 8    medical  care;  or  (v) involves the use of a medical device,
 9    drug, or substance not formally approved by the United States
10    Food and Drug Administration.
11        "Medical care" means the ordinary and usual  professional
12    services  rendered by a physician or other specified provider
13    during a professional visit for treatment of  an  illness  or
14    injury.
15        "Medicare" means coverage under both Part A and Part B of
16    Title  XVIII of the Social Security Act, 42 U.S.C. Sec. 1395,
17    et seq.
18        "Minimum premium plan" means  an  arrangement  whereby  a
19    specified  amount  of  health care claims is self-funded, but
20    the insurance company  assumes  the  risk  that  claims  will
21    exceed that amount.
22        "Participating   transplant   center"  means  a  hospital
23    designated by the Board as a preferred or exclusive  provider
24    of  services  for one or more specified human organ or tissue
25    transplants for which the hospital has  signed  an  agreement
26    with  the  Board to accept a transplant payment allowance for
27    all expenses related to the transplant  during  a  transplant
28    benefit period.
29        "Physician"  means a person licensed to practice medicine
30    pursuant to the Medical Practice Act of 1987.
31        "Plan" means  the  Comprehensive  Health  Insurance  Plan
32    established by this Act.
33        "Plan  of  operation"  means the plan of operation of the
34    Plan, including articles, bylaws and operating rules, adopted
 
                            -9-      LRB093 11158 JLS 13065 a
 1    by the board pursuant to this Act.
 2        "Provider" means any hospital, skilled nursing  facility,
 3    hospice, home health agency, physician, registered pharmacist
 4    acting  within  the  scope of that registration, or any other
 5    person or entity licensed  in  Illinois  to  furnish  medical
 6    care.
 7        "Qualified  high  risk  pool"  has the same meaning given
 8    that term in the federal  Health  Insurance  Portability  and
 9    Accountability Act of 1996.
10        "Resident"  means  a  person  who  is and continues to be
11    legally domiciled and physically residing on a permanent  and
12    full-time  basis  in  a place of permanent habitation in this
13    State that remains that person's principal residence and from
14    which that person is absent only for temporary or  transitory
15    purpose.
16        "Skilled  nursing  facility"  means  a  facility  or that
17    portion of a  facility  that  is  licensed  by  the  Illinois
18    Department  of  Public Health under the Nursing Home Care Act
19    or a comparable  licensing  authority  in  another  state  to
20    provide skilled nursing care.
21        "Stop-loss  coverage"  means  an  arrangement  whereby an
22    insurer insures against the risk  that  any  one  claim  will
23    exceed  a specific dollar amount or that the entire loss of a
24    self-insurance plan will exceed a specific amount.
25        "Third party administrator"  means  an  administrator  as
26    defined in Section 511.101 of the Illinois Insurance Code who
27    is licensed under Article XXXI 1/4 of that Code.
28    (Source:  P.A.  91-357,  eff.  7-29-99;  91-735, eff. 6-2-00;
29    92-153, eff. 7-25-01.)

30        (215 ILCS 105/4) (from Ch. 73, par. 1304)
31        Sec. 4.  Powers and authority of the  board.   The  board
32    shall have the general powers and authority granted under the
33    laws  of  this  State  to  insurance  companies  licensed  to
 
                            -10-     LRB093 11158 JLS 13065 a
 1    transact  health  and  accident  insurance  and  in  addition
 2    thereto, the specific authority to:
 3        a.  Enter  into  contracts  as are necessary or proper to
 4    carry out the provisions and purposes of this Act,  including
 5    the  authority,  with  the approval of the Director, to enter
 6    into contracts with similar plans of  other  states  for  the
 7    joint performance of common administrative functions, or with
 8    persons   or  other  organizations  for  the  performance  of
 9    administrative  functions  including,   without   limitation,
10    utilization  review  and  quality assurance programs, or with
11    health  maintenance  organizations  or   preferred   provider
12    organizations for the provision of health care services.
13        b.  Sue  or  be  sued, including taking any legal actions
14    necessary or proper.
15        c.  Take such legal action as necessary to:
16             (1)  avoid the payment of  improper  claims  against
17        the plan or the coverage provided by or through the plan;
18             (2)  to   recover   any   amounts   erroneously   or
19        improperly paid by the plan;
20             (3)  to  recover  any  amounts paid by the plan as a
21        result of a mistake of fact or law; or
22             (4)  to  recover  or  collect  any  other   amounts,
23        including  assessments,  that are due or owed the Plan or
24        have been billed on its or the Plan's behalf.
25        d.  Establish appropriate  rates,  rate  schedules,  rate
26    adjustments, expense allowances, agents' referral fees, claim
27    reserves,  and  formulas  and  any  other  actuarial function
28    appropriate to the operation of the plan.    Rates  and  rate
29    schedules  may  be adjusted for appropriate risk factors such
30    as age and area variation in claim costs and shall take  into
31    consideration  appropriate  risk  factors  in accordance with
32    established actuarial and underwriting practices.
33        e.  Issue policies of insurance in  accordance  with  the
34    requirements of this Act.
 
                            -11-     LRB093 11158 JLS 13065 a
 1        f.  Appoint   appropriate   legal,  actuarial  and  other
 2    committees as necessary to provide  technical  assistance  in
 3    the  operation of the plan, policy and other contract design,
 4    and any other function within the authority of the plan.
 5        g.  Borrow money to effect the purposes of  the  Illinois
 6    Comprehensive  Health  Insurance  Plan.   Any  notes or other
 7    evidence of indebtedness of the plan not in default shall  be
 8    legal investments for insurers and may be carried as admitted
 9    assets.
10        h.  Establish   rules,   conditions  and  procedures  for
11    reinsuring risks under this Act.
12        i.  Employ and fix the compensation  of  employees.  Such
13    employees  may  be  paid  on  a  warrant  issued by the State
14    Treasurer pursuant to a  payroll  voucher  certified  by  the
15    Board  and drawn by the Comptroller against appropriations or
16    trust funds held by the State Treasurer.
17        j.  Enter into intergovernmental  cooperation  agreements
18    with  other  agencies or entities of State government for the
19    purpose of sharing the cost of providing health care services
20    that are otherwise authorized by this Act  for  children  who
21    are   both  plan  participants  and  eligible  for  financial
22    assistance from the Division of Specialized Care for Children
23    of the University of Illinois.
24        k.  Establish conditions and procedures under  which  the
25    plan  may,  if  funds  permit,  discount or subsidize premium
26    rates that are paid directly by senior citizens,  as  defined
27    by the Board, and other plan participants, who are retired or
28    unemployed and meet other qualifications.
29        l.  Establish  and  maintain  the Plan Fund authorized in
30    Section 3 of this Act, which shall be divided  into  separate
31    accounts, as follows:
32             (1)  accounts to fund the administrative, claim, and
33        other  expenses  of  the  Plan  associated  with eligible
34        persons who qualify for Plan coverage under Section 7  of
 
                            -12-     LRB093 11158 JLS 13065 a
 1        this Act, which shall consist of:
 2                  (A)  premiums   paid   on   behalf  of  covered
 3             persons;
 4                  (B)  appropriated  funds  and  other   revenues
 5             collected or received by the Board;
 6                  (C)  reserves  for  future losses maintained by
 7             the Board; and
 8                  (D)  interest earnings from investment  of  the
 9             funds  in the Plan Fund or any of its accounts other
10             than the funds in the account established under item
11             2 of this subsection;
12             (2)  an account, to  be  denominated  the  federally
13        eligible individuals account, to fund the administrative,
14        claim,  and  other  expenses  of the Plan associated with
15        federally  eligible  individuals  who  qualify  for  Plan
16        coverage under  Section  15  of  this  Act,  which  shall
17        consist of:
18                  (A)  premiums   paid   on   behalf  of  covered
19             persons;
20                  (B)  assessments and other  revenues  collected
21             or received by the Board;
22                  (C)  reserves  for  future losses maintained by
23             the Board; and
24                  (D)  interest earnings from investment  of  the
25             federally eligible individuals account funds; and
26                  (E)  grants  provided  pursuant  to the federal
27             Trade Adjustment Act of 2002; and
28             (3)  such other accounts as may be appropriate.
29        m.  Charge  and  collect  assessments  paid  by  insurers
30    pursuant  to  Section  12  of  this  Act  and   recover   any
31    assessments for, on behalf of, or against those insurers.
32    (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99.)

33        (215 ILCS 105/7) (from Ch. 73, par. 1307)
 
                            -13-     LRB093 11158 JLS 13065 a
 1        Sec. 7.  Eligibility.
 2        a.  Except  as provided in subsection (e) of this Section
 3    or in Section 15 of this Act, any  person  who  is  either  a
 4    citizen  of  the  United States or an alien lawfully admitted
 5    for permanent residence and who has been for a period  of  at
 6    least  180  days and continues to be a resident of this State
 7    shall be eligible for Plan coverage  under  this  Section  if
 8    evidence is provided of:
 9             (1)  A  notice  of  rejection  or  refusal  to issue
10        substantially   similar   individual   health   insurance
11        coverage for health reasons by a health insurance issuer;
12        or
13             (2)  A refusal by a health insurance issuer to issue
14        individual health insurance coverage  except  at  a  rate
15        exceeding  the  applicable Plan rate for which the person
16        is responsible.
17        A rejection or refusal by a group health plan  or  health
18    insurance  issuer  offering  only stop-loss or excess of loss
19    insurance or contracts, agreements, or other arrangements for
20    reinsurance coverage with respect to the applicant shall  not
21    be sufficient evidence under this subsection.
22        b.  The  board  shall  promulgate  a  list  of medical or
23    health conditions for which a person who is either a  citizen
24    of  the  United  States  or  an  alien  lawfully admitted for
25    permanent residence and a resident of  this  State  would  be
26    eligible  for  Plan  coverage  without  applying  for  health
27    insurance coverage pursuant to subsection a. of this Section.
28    Persons  who  can demonstrate the existence or history of any
29    medical or health conditions on the list promulgated  by  the
30    board shall not be required to provide the evidence specified
31    in  subsection  a.  of  this  Section.   The  list  shall  be
32    effective  on  the first day of the operation of the Plan and
33    may be amended from time to time as appropriate.
34        c.  Family members of the same  household  who  each  are
 
                            -14-     LRB093 11158 JLS 13065 a
 1    covered  persons  are  eligible  for optional family coverage
 2    under the Plan.
 3        d.  For persons qualifying  for  coverage  in  accordance
 4    with Section 7 of this Act, the board shall, if it determines
 5    that  such  appropriations as are made pursuant to Section 12
 6    of this Act are insufficient to allow the board to accept all
 7    of the eligible persons which  it  projects  will  apply  for
 8    enrollment  under  the  Plan,  limit  or  close enrollment to
 9    ensure that the Plan is not over-subscribed and that  it  has
10    sufficient  resources  to  meet  its  obligations to existing
11    enrollees.  The board shall not limit or close enrollment for
12    federally eligible individuals.
13        e.  A person shall not be eligible for coverage under the
14    Plan if:
15             (1)  He or she has or obtains other coverage under a
16        group  health   plan   or   health   insurance   coverage
17        substantially  similar to or better than a Plan policy as
18        an insured or covered dependent or would be  eligible  to
19        have  that  coverage  if  he or she elected to obtain it.
20        Persons  otherwise  eligible  for  Plan   coverage   may,
21        however,  solely for the purpose of having coverage for a
22        pre-existing  condition,  maintain  other  coverage  only
23        while  satisfying  any  pre-existing  condition   waiting
24        period  under  a  Plan policy or a subsequent replacement
25        policy of a Plan policy.
26             (1.1)  His or  her  prior  coverage  under  a  group
27        health  plan  or  health  insurance coverage, provided or
28        arranged by an employer of more  than  10  employees  was
29        discontinued  for  any reason without the entire group or
30        plan being discontinued and not replaced, provided he  or
31        she  remains  an  employee,  or dependent thereof, of the
32        same employer.
33             (2)  He or she is a recipient of or is  approved  to
34        receive  medical  assistance,  except  that  a person may
 
                            -15-     LRB093 11158 JLS 13065 a
 1        continue  to  receive  medical  assistance  through   the
 2        medical  assistance  no  grant  program,  but  only while
 3        satisfying the requirements for a  preexisting  condition
 4        under  Section  8, subsection f. of this Act.  Payment of
 5        premiums pursuant to this Act shall be allocable  to  the
 6        person's spenddown for purposes of the medical assistance
 7        no  grant  program, but that person shall not be eligible
 8        for any Plan benefits while that person remains  eligible
 9        for  medical  assistance.   If  the  person  continues to
10        receive or be  approved  to  receive  medical  assistance
11        through  the  medical  assistance  no grant program at or
12        after  the  time  that  requirements  for  a  preexisting
13        condition are satisfied, the person shall not be eligible
14        for  coverage  under  the  Plan.  In  that  circumstance,
15        coverage  under  the  plan  shall  terminate  as  of  the
16        expiration  of  the  preexisting   condition   limitation
17        period.   Under  all  other circumstances, coverage under
18        the  Plan  shall  automatically  terminate  as   of   the
19        effective date of any medical assistance.
20             (3)  Except  as  provided  in Section 15, the person
21        has previously participated in the Plan  and  voluntarily
22        terminated  Plan  coverage, unless 12 months have elapsed
23        since  the  person's  latest  voluntary  termination   of
24        coverage.
25             (4)  The  person  fails  to pay the required premium
26        under  the  covered  person's  terms  of  enrollment  and
27        participation, in which event the liability of  the  Plan
28        shall  be limited to benefits incurred under the Plan for
29        the time period for which premiums had been paid and  the
30        covered person remained eligible for Plan coverage.
31             (5)  The  Plan  has  paid  a  total of $1,000,000 in
32        benefits on behalf of the covered person.
33             (6)  The  person  is  a   resident   of   a   public
34        institution.
 
                            -16-     LRB093 11158 JLS 13065 a
 1             (7)  The  person's premium is paid for or reimbursed
 2        under  any  government  sponsored  program  or   by   any
 3        government  agency  or health care provider, except as an
 4        otherwise qualifying full-time employee, or dependent  of
 5        such  employee,  of  a  government  agency or health care
 6        provider or, except when a person's premium  is  paid  by
 7        the  U.S.  Treasury  Department  pursuant  to the federal
 8        Trade Adjustment Act of 2002.
 9             (8)  The person has or later receives other benefits
10        or  funds  from  any  settlement,  judgement,  or   award
11        resulting  from any accident or injury, regardless of the
12        date  of  the  accident   or   injury,   or   any   other
13        circumstances  creating a legal liability for damages due
14        that person by a third  party,  whether  the  settlement,
15        judgment,  or  award  is  in  the  form  of  a  contract,
16        agreement, or trust on behalf of a minor or otherwise and
17        whether  the settlement, judgment, or award is payable to
18        the  person,  his  or  her  dependent,  estate,  personal
19        representative, or guardian in a lump sum or  over  time,
20        so  long  as  there  continues  to  be benefits or assets
21        remaining from those sources in an amount  in  excess  of
22        $100,000.
23             (9)  Within the 5 years prior to the date a person's
24        Plan  application  is received by the Board, the person's
25        coverage under any health care benefit program as defined
26        in 18 U.S.C. 24, including any public or private plan  or
27        contract  under  which  any  medical  benefit,  item,  or
28        service  is  provided,  was terminated as a result of any
29        act or practice that constitutes  fraud  under  State  or
30        federal   law   or   as   a   result  of  an  intentional
31        misrepresentation of material fact;  or  if  that  person
32        knowingly  and willfully obtained or attempted to obtain,
33        or fraudulently aided  or  attempted  to  aid  any  other
34        person  in  obtaining, any coverage or benefits under the
 
                            -17-     LRB093 11158 JLS 13065 a
 1        Plan to which that person was not entitled.
 2        f.  The  board  or  the   administrator   shall   require
 3    verification  of  residency  and  may  require any additional
 4    information or documentation, or statements under oath,  when
 5    necessary to determine residency upon initial application and
 6    for the entire term of the policy.
 7        g.  Coverage  shall  cease (i) on the date a person is no
 8    longer a resident of Illinois, (ii)  on  the  date  a  person
 9    requests coverage to end, (iii) upon the death of the covered
10    person,  (iv)  on the date State law requires cancellation of
11    the policy, or (v) at the Plan's option, 30  days  after  the
12    Plan  makes  any inquiry concerning a person's eligibility or
13    place of residence to which the person does not reply.
14        h.  Except under the conditions set forth in subsection g
15    of this Section, the coverage of any  person  who  ceases  to
16    meet  the  eligibility  requirements of this Section shall be
17    terminated at the end of the current policy period for  which
18    the necessary premiums have been paid.
19    (Source: P.A.  90-30,  eff.  7-1-97;  91-639,  eff.  8-20-99;
20    91-735, eff. 6-2-00.)

21        (215 ILCS 105/15)
22        Sec.  15.  Alternative  portable  coverage  for federally
23    eligible individuals.
24        (a)  Notwithstanding the requirements of subsection a. of
25    Section 7 and except as otherwise provided in  this  Section,
26    any   federally   eligible   individual   for   whom  a  Plan
27    application, and such enclosures and supporting documentation
28    as the Board may require, is received by the Board within  90
29    days after the termination of prior creditable coverage shall
30    qualify   to   enroll  in  the  Plan  under  the  portability
31    provisions of this Section.  A federally eligible person  who
32    has  been  certified  as  an  eligible person pursuant to the
33    federal  Trade  Adjustment  Act  of  2002  and   whose   Plan
 
                            -18-     LRB093 11158 JLS 13065 a
 1    application  and  enclosures  and supporting documentation as
 2    the Board may require is received by the Board within 63 days
 3    after the termination of previous creditable  coverage  shall
 4    qualify   to   enroll  in  the  Plan  under  the  portability
 5    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.  For a federally eligible person who has
23    been certified as an eligible person pursuant to the  federal
24    Trade Adjustment Act of 2002, a period of creditable coverage
25    shall not be counted, with respect to qualifying an applicant
26    for  Plan  coverage  as a federally eligible individual under
27    this Section, if after such period and before the application
28    for Plan coverage was received by the  Board,  there  was  at
29    least  a 63 day period during all of which the individual was
30    not covered under any creditable coverage.
31        (d)  Any federally  eligible  individual  who  the  Board
32    determines  qualifies  for  Plan  coverage under this Section
33    shall be offered his or her choice of  enrolling  in  one  of
34    alternative  portability health benefit plans which the Board
 
                            -19-     LRB093 11158 JLS 13065 a
 1    is authorized under  this  Section  to  establish  for  these
 2    federally eligible individuals and their dependents.
 3        (e)  The  Board  shall  offer  a  choice  of  health care
 4    coverages consistent with major medical  coverage  under  the
 5    alternative  health  benefit plans authorized by this Section
 6    to every federally eligible individual. The coverages  to  be
 7    offered   under   the   plans,   the  schedule  of  benefits,
 8    deductibles, co-payments, exclusions, and  other  limitations
 9    shall  be  approved  by  the  Board.   One  optional  form of
10    coverage  shall  be  comparable   to   comprehensive   health
11    insurance  coverage  offered in the individual market in this
12    State or a standard option of coverage  available  under  the
13    group  or individual health insurance laws of the State.  The
14    standard benefit plan that is authorized by Section 8 of this
15    Act may be used for this purpose.  The Board may also offer a
16    preferred provider option and such other options as the Board
17    determines may be appropriate for  these  federally  eligible
18    individuals  who  qualify  for Plan coverage pursuant to this
19    Section.
20        (f)  Notwithstanding the requirements of subsection f. of
21    Section 8, any plan coverage  that  is  issued  to  federally
22    eligible individuals who qualify for the Plan pursuant to the
23    portability  provisions  of this Section shall not be subject
24    to any preexisting conditions exclusion, waiting  period,  or
25    other similar limitation on coverage.
26        (g)  Federally   eligible  individuals  who  qualify  and
27    enroll in the Plan pursuant to this Section shall be required
28    to pay such premium rates as the Board  shall  establish  and
29    approve in accordance with the requirements of Section 7.1 of
30    this Act.
31        (h)  A  federally  eligible  individual who qualifies and
32    enrolls in the Plan pursuant to this Section must satisfy  on
33    an ongoing basis all of the other eligibility requirements of
34    this  Act  to  the  extent  not inconsistent with the federal
 
                            -20-     LRB093 11158 JLS 13065 a
 1    Health Insurance Portability and Accountability Act  of  1996
 2    in order to maintain continued eligibility for coverage under
 3    the Plan.
 4    (Source: P.A. 92-153, eff. 7-25-01.)

 5        Section  99.  Effective date.  This Act takes effect upon
 6    becoming law.".