Rep. Frank J. Mautino

Filed: 6/23/2009





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2     AMENDMENT NO. ______. Amend Senate Bill 2052 by replacing
3 everything after the enacting clause with the following:
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 a periodically an
9 annually renewable policy major medical expense coverage to
10 every eligible person who is not eligible for Medicare. Major
11 medical expense coverage offered by the Plan shall pay an
12 eligible person's covered expenses, subject to limit on the
13 deductible and coinsurance payments authorized under paragraph
14 (4) of subsection d of this Section, up to a lifetime benefit
15 limit of $2,000,000 until 3 years after the effective date of
16 this amendatory Act of the 95th General Assembly, and



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1 $1,500,000 in benefits 3 years or more after the effective date
2 of this amendatory Act of the 95th General Assembly per covered
3 individual. The maximum limit under this subsection shall not
4 be altered by the Board, and no actuarial equivalent benefit
5 may be substituted by the Board. Any person who otherwise would
6 qualify for coverage under the Plan, but is excluded because he
7 or she is eligible for Medicare, shall be eligible for any
8 separate Medicare supplement policy or policies which the Board
9 may offer.
10     b. Outline of benefits. Covered expenses shall be limited
11 to the usual and customary charge, including negotiated fees,
12 in the locality for the following services and articles when
13 prescribed by a physician and determined by the Plan to be
14 medically necessary for the following areas of services,
15 subject to such separate deductibles, co-payments, exclusions,
16 and other limitations on benefits as the Board shall establish
17 and approve, and the other provisions of this Section:
18         (1) Hospital services, except that any services
19     provided by a hospital that is located more than 75 miles
20     outside the State of Illinois shall be covered only for a
21     maximum of 45 days in any calendar year. With respect to
22     covered expenses incurred during any calendar year ending
23     on or after December 31, 1999, inpatient hospitalization of
24     an eligible person for the treatment of mental illness at a
25     hospital located within the State of Illinois shall be
26     subject to the same terms and conditions as for any other



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1     illness.
2         (2) Professional services for the diagnosis or
3     treatment of injuries, illnesses or conditions, other than
4     dental and mental and nervous disorders as described in
5     paragraph (17), which are rendered by a physician, or by
6     other licensed professionals at the physician's direction.
7     This includes reconstruction of the breast on which a
8     mastectomy was performed; surgery and reconstruction of
9     the other breast to produce a symmetrical appearance; and
10     prostheses and treatment of physical complications at all
11     stages of the mastectomy, including lymphedemas.
12         (2.5) Professional services provided by a physician to
13     children under the age of 16 years for physical
14     examinations and age appropriate immunizations ordered by
15     a physician licensed to practice medicine in all its
16     branches.
17         (3) (Blank).
18         (4) Outpatient prescription drugs that by law require a
19     prescription written by a physician licensed to practice
20     medicine in all its branches subject to such separate
21     deductible, copayment, and other limitations or
22     restrictions as the Board shall approve, including the use
23     of a prescription drug card or any other program, or both.
24         (5) Skilled nursing services of a licensed skilled
25     nursing facility for not more than 120 days during a policy
26     year.



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1         (6) Services of a home health agency in accord with a
2     home health care plan, up to a maximum of 270 visits per
3     year.
4         (7) Services of a licensed hospice for not more than
5     180 days during a policy year.
6         (8) Use of radium or other radioactive materials.
7         (9) Oxygen.
8         (10) Anesthetics.
9         (11) Orthoses and prostheses other than dental.
10         (12) Rental or purchase in accordance with Board
11     policies or procedures of durable medical equipment, other
12     than eyeglasses or hearing aids, for which there is no
13     personal use in the absence of the condition for which it
14     is prescribed.
15         (13) Diagnostic x-rays and laboratory tests.
16         (14) Oral surgery (i) for excision of partially or
17     completely unerupted impacted teeth when not performed in
18     connection with the routine extraction or repair of teeth;
19     (ii) for excision of tumors or cysts of the jaws, cheeks,
20     lips, tongue, and roof and floor of the mouth; (iii)
21     required for correction of cleft lip and palate and other
22     craniofacial and maxillofacial birth defects; or (iv) for
23     treatment of injuries to natural teeth or a fractured jaw
24     due to an accident.
25         (15) Physical, speech, and functional occupational
26     therapy as medically necessary and provided by appropriate



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1     licensed professionals.
2         (16) Emergency and other medically necessary
3     transportation provided by a licensed ambulance service to
4     the nearest health care facility qualified to treat a
5     covered illness, injury, or condition, subject to the
6     provisions of the Emergency Medical Systems (EMS) Act.
7         (17) Outpatient services for diagnosis and treatment
8     of mental and nervous disorders provided that a covered
9     person shall be required to make a copayment not to exceed
10     50% and that the Plan's payment shall not exceed such
11     amounts as are established by the Board.
12         (18) Human organ or tissue transplants specified by the
13     Board that are performed at a hospital designated by the
14     Board as a participating transplant center for that
15     specific organ or tissue transplant.
16         (19) Naprapathic services, as appropriate, provided by
17     a licensed naprapathic practitioner.
18     c. Exclusions. Covered expenses of the Plan shall not
19 include the following:
20         (1) Any charge for treatment for cosmetic purposes
21     other than for reconstructive surgery when the service is
22     incidental to or follows surgery resulting from injury,
23     sickness or other diseases of the involved part or surgery
24     for the repair or treatment of a congenital bodily defect
25     to restore normal bodily functions.
26         (2) Any charge for care that is primarily for rest,



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1     custodial, educational, or domiciliary purposes.
2         (3) Any charge for services in a private room to the
3     extent it is in excess of the institution's charge for its
4     most common semiprivate room, unless a private room is
5     prescribed as medically necessary by a physician.
6         (4) That part of any charge for room and board or for
7     services rendered or articles prescribed by a physician,
8     dentist, or other health care personnel that exceeds the
9     reasonable and customary charge in the locality or for any
10     services or supplies not medically necessary for the
11     diagnosed injury or illness.
12         (5) Any charge for services or articles the provision
13     of which is not within the scope of licensure of the
14     institution or individual providing the services or
15     articles.
16         (6) Any expense incurred prior to the effective date of
17     coverage by the Plan for the person on whose behalf the
18     expense is incurred.
19         (7) Dental care, dental surgery, dental treatment, any
20     other dental procedure involving the teeth or
21     periodontium, or any dental appliances, including crowns,
22     bridges, implants, or partial or complete dentures, except
23     as specifically provided in paragraph (14) of subsection b
24     of this Section.
25         (8) Eyeglasses, contact lenses, hearing aids or their
26     fitting.



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1         (9) Illness or injury due to acts of war.
2         (10) Services of blood donors and any fee for failure
3     to replace the first 3 pints of blood provided to a covered
4     person each policy year.
5         (11) Personal supplies or services provided by a
6     hospital or nursing home, or any other nonmedical or
7     nonprescribed supply or service.
8         (12) Routine maternity charges for a pregnancy, except
9     where added as optional coverage with payment of an
10     additional premium for pregnancy resulting from conception
11     occurring after the effective date of the optional
12     coverage.
13         (13) (Blank).
14         (14) Any expense or charge for services, drugs, or
15     supplies that are: (i) not provided in accord with
16     generally accepted standards of current medical practice;
17     (ii) for procedures, treatments, equipment, transplants,
18     or implants, any of which are investigational,
19     experimental, or for research purposes; (iii)
20     investigative and not proven safe and effective; or (iv)
21     for, or resulting from, a gender transformation operation.
22         (15) Any expense or charge for routine physical
23     examinations or tests except as provided in item (2.5) of
24     subsection b of this Section.
25         (16) Any expense for which a charge is not made in the
26     absence of insurance or for which there is no legal



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1     obligation on the part of the patient to pay.
2         (17) Any expense incurred for benefits provided under
3     the laws of the United States and this State, including
4     Medicare, Medicaid, and other medical assistance, maternal
5     and child health services and any other program that is
6     administered or funded by the Department of Human Services,
7     Department of Healthcare and Family Services, or
8     Department of Public Health, military service-connected
9     disability payments, medical services provided for members
10     of the armed forces and their dependents or employees of
11     the armed forces of the United States, and medical services
12     financed on behalf of all citizens by the United States.
13         (18) Any expense or charge for in vitro fertilization,
14     artificial insemination, or any other artificial means
15     used to cause pregnancy.
16         (19) Any expense or charge for oral contraceptives used
17     for birth control or any other temporary birth control
18     measures.
19         (20) Any expense or charge for sterilization or
20     sterilization reversals.
21         (21) Any expense or charge for weight loss programs,
22     exercise equipment, or treatment of obesity, except when
23     certified by a physician as morbid obesity (at least 2
24     times normal body weight).
25         (22) Any expense or charge for acupuncture treatment
26     unless used as an anesthetic agent for a covered surgery.



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1         (23) Any expense or charge for or related to organ or
2     tissue transplants other than those performed at a hospital
3     with a Board approved organ transplant program that has
4     been designated by the Board as a preferred or exclusive
5     provider organization for that specific organ or tissue
6     transplant.
7         (24) Any expense or charge for procedures, treatments,
8     equipment, or services that are provided in special
9     settings for research purposes or in a controlled
10     environment, are being studied for safety, efficiency, and
11     effectiveness, and are awaiting endorsement by the
12     appropriate national medical speciality college for
13     general use within the medical community.
14     d. Deductibles and coinsurance.
15     The Plan coverage defined in Section 6 shall provide for a
16 choice of deductibles per individual as authorized by the
17 Board. If 2 individual members of the same family household,
18 who are both covered persons under the Plan, satisfy the same
19 applicable deductibles, no other member of that family who is
20 also a covered person under the Plan shall be required to meet
21 any deductibles for the balance of that calendar year. The
22 deductibles must be applied first to the authorized amount of
23 covered expenses incurred by the covered person. A mandatory
24 coinsurance requirement shall be imposed at the rate authorized
25 by the Board in excess of the mandatory deductible, the
26 coinsurance in the aggregate not to exceed such amounts as are



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1 authorized by the Board per annum. At its discretion the Board
2 may, however, offer catastrophic coverages or other policies
3 that provide for larger deductibles with or without coinsurance
4 requirements. The deductibles and coinsurance factors may be
5 adjusted annually according to the Medical Component of the
6 Consumer Price Index.
7     e. Scope of coverage.
8         (1) In approving any of the benefit plans to be offered
9     by the Plan, the Board shall establish such benefit levels,
10     deductibles, coinsurance factors, exclusions, and
11     limitations as it may deem appropriate and that it believes
12     to be generally reflective of and commensurate with health
13     insurance coverage that is provided in the individual
14     market in this State.
15         (2) The benefit plans approved by the Board may also
16     provide for and employ various cost containment measures
17     and other requirements including, but not limited to,
18     preadmission certification, prior approval, second
19     surgical opinions, concurrent utilization review programs,
20     individual case management, preferred provider
21     organizations, health maintenance organizations, and other
22     cost effective arrangements for paying for covered
23     expenses.
24     f. Preexisting conditions.
25         (1) Except for federally eligible individuals
26     qualifying for Plan coverage under Section 15 of this Act



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1     or eligible persons who qualify for the waiver authorized
2     in paragraph (3) of this subsection, plan coverage shall
3     exclude charges or expenses incurred during the first 6
4     months following the effective date of coverage as to any
5     condition for which medical advice, care or treatment was
6     recommended or received during the 6 month period
7     immediately preceding the effective date of coverage.
8         (2) (Blank).
9         (3) Waiver: The preexisting condition exclusions as
10     set forth in paragraph (1) of this subsection shall be
11     waived to the extent to which the eligible person (a) has
12     satisfied similar exclusions under any prior individual
13     health insurance policy that was involuntarily terminated
14     because of the insolvency of the issuer of the policy and
15     (b) has applied for Plan coverage within 90 days following
16     the involuntary termination of that individual health
17     insurance coverage.
18     g. Other sources primary; nonduplication of benefits.
19         (1) The Plan shall be the last payor of benefits
20     whenever any other benefit or source of third party payment
21     is available. Subject to the provisions of subsection e of
22     Section 7, benefits otherwise payable under Plan coverage
23     shall be reduced by all amounts paid or payable by Medicare
24     or any other government program or through any health
25     insurance coverage or group health plan, whether by
26     insurance, reimbursement, or otherwise, or through any



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



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



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



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1     guardian, conservator, estate, dependents, or survivors.
2         (2) If any action or claim is brought by or on behalf
3     of a covered person against a third party or the third
4     party's insurer, the covered person or his personal
5     representative, including his guardian, conservator,
6     estate, dependents, or survivors, shall notify the Plan by
7     personal service or registered mail of the action or claim
8     and of the name of the court in which the action or claim
9     is brought, filing proof thereof in the action or claim.
10     The Plan may, at any time thereafter, join in the action or
11     claim upon its motion so that all orders of court after
12     hearing and judgment shall be made for its protection. No
13     release or settlement of a claim for damages and no
14     satisfaction of judgment in the action shall be valid
15     without the written consent of the Plan to the extent of
16     its interest in the settlement or judgment and of the
17     covered person or his personal representative.
18         (3) In the event that the covered person or his
19     personal representative fails to institute a proceeding
20     against any appropriate third party before the fifth month
21     before the action would be barred, the Plan may, in its own
22     name or in the name of the covered person or personal
23     representative, commence a proceeding against any
24     appropriate third party for the recovery of damages on
25     account of any sickness, injury, or death to the covered
26     person. The covered person shall cooperate in doing what is



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1     reasonably necessary to assist the Plan in any recovery and
2     shall not take any action that would prejudice the Plan's
3     right to recovery. The Plan shall pay to the covered person
4     or his personal representative all sums collected from any
5     third party by judgment or otherwise in excess of amounts
6     paid in benefits under the Plan and amounts paid or to be
7     paid as costs, attorneys fees, and reasonable expenses
8     incurred by the Plan in making the collection or enforcing
9     the judgment.
10         (4) In the event that a covered person or his personal
11     representative, including his guardian, conservator,
12     estate, dependents, or survivors, recovers damages from a
13     third party for sickness or injury caused to the covered
14     person, the covered person or the personal representative
15     shall pay to the Plan from the damages recovered the amount
16     of benefits paid or to be paid on behalf of the covered
17     person.
18         (5) When the action or claim is brought by the covered
19     person alone and the covered person incurs a personal
20     liability to pay attorney's fees and costs of litigation,
21     the Plan's claim for reimbursement of the benefits provided
22     to the covered person shall be the full amount of benefits
23     paid to or on behalf of the covered person under this Act
24     less a pro rata share that represents the Plan's reasonable
25     share of attorney's fees paid by the covered person and
26     that portion of the cost of litigation expenses determined



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1     by multiplying by the ratio of the full amount of the
2     expenditures to the full amount of the judgement, award, or
3     settlement.
4         (6) In the event of judgment or award in a suit or
5     claim against a third party or insurer, the court shall
6     first order paid from any judgement or award the reasonable
7     litigation expenses incurred in preparation and
8     prosecution of the action or claim, together with
9     reasonable attorney's fees. After payment of those
10     expenses and attorney's fees, the court shall apply out of
11     the balance of the judgment or award an amount sufficient
12     to reimburse the Plan the full amount of benefits paid on
13     behalf of the covered person under this Act, provided the
14     court may reduce and apportion the Plan's portion of the
15     judgement proportionate to the recovery of the covered
16     person. The burden of producing evidence sufficient to
17     support the exercise by the court of its discretion to
18     reduce the amount of a proven charge sought to be enforced
19     against the recovery shall rest with the party seeking the
20     reduction. The court may consider the nature and extent of
21     the injury, economic and non-economic loss, settlement
22     offers, comparative negligence as it applies to the case at
23     hand, hospital costs, physician costs, and all other
24     appropriate costs. The Plan shall pay its pro rata share of
25     the attorney fees based on the Plan's recovery as it
26     compares to the total judgment. Any reimbursement rights of



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1     the Plan shall take priority over all other liens and
2     charges existing under the laws of this State with the
3     exception of any attorney liens filed under the Attorneys
4     Lien Act.
5         (7) The Plan may compromise or settle and release any
6     claim for benefits provided under this Act or waive any
7     claims for benefits, in whole or in part, for the
8     convenience of the Plan or if the Plan determines that
9     collection would result in undue hardship upon the covered
10     person.
11 (Source: P.A. 94-737, eff. 5-3-06; 95-547, eff. 8-29-07.)
12     Section 99. Effective date. This Act takes effect upon
13 becoming law.".