Full Text of HB3405 97th General Assembly
HB3405enr 97TH GENERAL ASSEMBLY |
| | HB3405 Enrolled | | LRB097 05453 RPM 45511 b |
|
| 1 | | AN ACT concerning insurance.
| 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 2 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 of | 18 | | 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
| 23 | | coverage pursuant to any continuation provisions under federal |
| | | HB3405 Enrolled | - 2 - | LRB097 05453 RPM 45511 b |
|
| 1 | | or State law,
including the Consolidated Omnibus Budget | 2 | | Reconciliation Act of 1985 (COBRA),
as amended, Sections 367.2, | 3 | | 367e, and 367e.1 of the Illinois Insurance Code, or
any
other | 4 | | similar requirement in another State.
| 5 | | "Covered person" means a person who is and continues to | 6 | | remain eligible for
Plan coverage and is covered under one of | 7 | | the benefit plans offered by the
Plan.
| 8 | | "Creditable coverage" means, with respect to a federally | 9 | | eligible
individual, coverage of the individual under any of | 10 | | the following:
| 11 | | (A) A group health plan.
| 12 | | (B) Health insurance coverage (including group health | 13 | | insurance coverage).
| 14 | | (C) Medicare.
| 15 | | (D) Medical assistance.
| 16 | | (E) Chapter 55 of title 10, United States Code.
| 17 | | (F) A medical care program of the Indian Health Service | 18 | | or of a tribal
organization.
| 19 | | (G) A state health benefits risk pool.
| 20 | | (H) A health plan offered under Chapter 89 of title 5, | 21 | | United States Code.
| 22 | | (I) A public health plan (as defined in regulations | 23 | | consistent with
Section
104 of the Health Care Portability | 24 | | and Accountability Act of 1996 that may be
promulgated by | 25 | | the Secretary of the U.S. Department of Health and Human
| 26 | | Services).
|
| | | HB3405 Enrolled | - 3 - | LRB097 05453 RPM 45511 b |
|
| 1 | | (J) A health benefit plan under Section 5(e) of the | 2 | | Peace Corps Act (22
U.S.C. 2504(e)).
| 3 | | (K) Any other qualifying coverage required by the | 4 | | federal Health Insurance
Portability and Accountability | 5 | | Act of 1996, as it may be amended, or
regulations under | 6 | | that
Act.
| 7 | | "Creditable coverage" does not include coverage consisting | 8 | | solely of coverage
of excepted benefits, as defined in Section | 9 | | 2791(c) of title XXVII of
the
Public Health Service Act (42 | 10 | | U.S.C. 300 gg-91), nor does it include any
period
of coverage | 11 | | under any of items (A) through (K) that occurred before a break | 12 | | of
more than 90 days or, if the individual has
been certified | 13 | | as eligible pursuant to the federal Trade Act
of 2002, a
break | 14 | | of more than 63 days during all of which the individual was not | 15 | | covered
under any of items (A) through (K) above.
| 16 | | Any period that an individual is in a waiting period for
| 17 | | any coverage under a group health plan (or for group health | 18 | | insurance
coverage) or is in an affiliation period under the | 19 | | terms of health insurance
coverage offered by a health | 20 | | maintenance organization shall not be taken into
account in | 21 | | determining if there has been a break of more than 90
days in | 22 | | any
creditable coverage.
| 23 | | "Department" means the Illinois Department of Insurance.
| 24 | | "Dependent" means an Illinois resident: who is a spouse; or | 25 | | who is claimed
as a dependent by the principal insured for | 26 | | purposes of filing a federal income
tax return and resides in |
| | | HB3405 Enrolled | - 4 - | LRB097 05453 RPM 45511 b |
|
| 1 | | the principal insured's household, and is a resident
unmarried | 2 | | child under the age of 19 years; or who is an unmarried child | 3 | | who
also is a full-time student under the age of 23 years and | 4 | | who is financially
dependent upon the principal insured; or who | 5 | | is a child of any age and who is
disabled and financially | 6 | | dependent upon the
principal insured.
| 7 | | "Direct Illinois premiums" means, for Illinois business, | 8 | | an insurer's direct
premium income for the kinds of business | 9 | | described in clause (b) of Class 1 or
clause (a) of Class 2 of | 10 | | Section 4 of the Illinois Insurance Code, and direct
premium | 11 | | income of a health maintenance organization or a voluntary | 12 | | health
services plan, except it shall not include credit health | 13 | | insurance as defined
in Article IX 1/2 of the Illinois | 14 | | Insurance Code.
| 15 | | "Director" means the Director of the Illinois Department of | 16 | | Insurance.
| 17 | | "Effective date of medical assistance" means the date that | 18 | | eligibility for medical assistance for a person is approved by | 19 | | the Department of Human Services or the Department of | 20 | | Healthcare and Family Services, except when the Department of | 21 | | Human Services or the Department of Healthcare and Family | 22 | | Services determines eligibility retroactively. In such | 23 | | circumstances, the effective date of the medical assistance is | 24 | | the date the Department of Human Services or the Department of | 25 | | Healthcare and Family Services determines the person to be | 26 | | eligible for medical assistance. As it pertains to Medicare, |
| | | HB3405 Enrolled | - 5 - | LRB097 05453 RPM 45511 b |
|
| 1 | | the effective date is 24 months after the entitlement date as | 2 | | approved by the Social Security Administration, except when | 3 | | eligibility is made retroactive to a prior date. In such | 4 | | circumstances, the effective date of Medicare is the date on | 5 | | the Notice of Award letter issued by the Social Security | 6 | | Administration. | 7 | | "Eligible person" means a resident of this State who | 8 | | qualifies
for Plan coverage under Section 7 of this Act.
| 9 | | "Employee" means a resident of this State who is employed | 10 | | by an employer
or has entered into
the employment of or works | 11 | | under contract or service of an employer
including the | 12 | | officers, managers and employees of subsidiary or affiliated
| 13 | | corporations and the individual proprietors, partners and | 14 | | employees of
affiliated individuals and firms when the business | 15 | | of the subsidiary or
affiliated corporations, firms or | 16 | | individuals is controlled by a common
employer through stock | 17 | | ownership, contract, or otherwise.
| 18 | | "Employer" means any individual, partnership, association, | 19 | | corporation,
business trust, or any person or group of persons | 20 | | acting directly or indirectly
in the interest of an employer in | 21 | | relation to an employee, for which one or
more
persons is | 22 | | gainfully employed.
| 23 | | "Family" coverage means the coverage provided by the Plan | 24 | | for the
covered person and his or her eligible dependents who | 25 | | also are
covered persons.
| 26 | | "Federally eligible individual" means an individual |
| | | HB3405 Enrolled | - 6 - | LRB097 05453 RPM 45511 b |
|
| 1 | | resident of this State:
| 2 | | (1)(A) for whom, as of the date on which the individual | 3 | | seeks Plan
coverage
under Section 15 of this Act, the | 4 | | aggregate of the periods of creditable
coverage is 18 or | 5 | | more months or, if the individual has been
certified as
| 6 | | eligible pursuant to the federal Trade Act of 2002,
3 or | 7 | | more
months, and (B) whose most recent prior creditable
| 8 | | coverage was under group health insurance coverage offered | 9 | | by a health
insurance issuer, a group health plan, a | 10 | | governmental plan, or a church plan
(or
health insurance | 11 | | coverage offered in connection with any such plans) or any
| 12 | | other type of creditable coverage that may be required by | 13 | | the federal Health
Insurance Portability
and | 14 | | Accountability Act of 1996, as it may be amended, or the | 15 | | regulations
under that Act;
| 16 | | (2) who
is not eligible for coverage under
(A) a group | 17 | | health plan
(other than an individual who has been | 18 | | certified as eligible
pursuant to the federal Trade Act of | 19 | | 2002), (B)
part
A or part B of Medicare due to age
(other | 20 | | than an individual who has been certified as eligible
| 21 | | pursuant to the federal Trade Act of 2002), or (C) medical | 22 | | assistance, and
does not
have other
health insurance | 23 | | coverage (other than an individual who has been certified | 24 | | as
eligible pursuant to the federal Trade Act of 2002);
| 25 | | (3) with respect to whom (other than an individual who | 26 | | has been
certified as eligible pursuant to the federal |
| | | HB3405 Enrolled | - 7 - | LRB097 05453 RPM 45511 b |
|
| 1 | | Trade Act of 2002) the most
recent coverage within the | 2 | | coverage
period
described in paragraph (1)(A) of this | 3 | | definition was not terminated
based upon a factor relating | 4 | | to nonpayment of premiums or fraud;
| 5 | | (4) if the individual (other than an individual who has
| 6 | | been certified
as eligible pursuant to the federal Trade | 7 | | Act
of 2002)
had been offered the option of continuation
| 8 | | coverage
under a COBRA continuation provision or under a | 9 | | similar State program, who
elected such coverage; and
| 10 | | (5) who, if the individual elected such continuation | 11 | | coverage, has
exhausted
such continuation coverage under | 12 | | such provision or program.
| 13 | | However, an individual who has been certified as
eligible
| 14 | | pursuant to the
federal Trade Act of 2002
shall not be required | 15 | | to elect
continuation
coverage under a COBRA continuation | 16 | | provision or under a similar state
program.
| 17 | | "Group health insurance coverage" means, in connection | 18 | | with a group health
plan, health insurance coverage offered in | 19 | | connection with that plan.
| 20 | | "Group health plan" has the same meaning given that term in | 21 | | the federal
Health
Insurance Portability and Accountability | 22 | | Act of 1996.
| 23 | | "Governmental plan" has the same meaning given that term in | 24 | | the federal
Health
Insurance Portability and Accountability | 25 | | Act of 1996.
| 26 | | "Health insurance coverage" means benefits consisting of |
| | | HB3405 Enrolled | - 8 - | LRB097 05453 RPM 45511 b |
|
| 1 | | medical care
(provided directly, through insurance or | 2 | | reimbursement, or otherwise and
including items and services | 3 | | paid for as medical care) under any hospital and
medical | 4 | | expense-incurred policy,
certificate, or
contract provided by | 5 | | an insurer, non-profit health care service plan
contract, | 6 | | health maintenance organization or other subscriber contract, | 7 | | or
any other health care plan or arrangement that pays for or | 8 | | furnishes
medical or health care services whether by
insurance | 9 | | or otherwise. Health insurance coverage shall not include short
| 10 | | term,
accident only,
disability income, hospital confinement | 11 | | or fixed indemnity, dental only,
vision only, limited benefit, | 12 | | or credit
insurance, coverage issued as a supplement to | 13 | | liability insurance,
insurance arising out of a workers' | 14 | | compensation or similar law, automobile
medical-payment | 15 | | insurance, or insurance under which benefits are payable
with | 16 | | or without regard to fault and which is statutorily required to | 17 | | be
contained in any liability insurance policy or equivalent | 18 | | self-insurance.
| 19 | | "Health insurance issuer" means an insurance company, | 20 | | insurance service,
or insurance organization (including a | 21 | | health maintenance organization and a
voluntary health | 22 | | services plan) that is authorized to transact health
insurance
| 23 | | business in this State. Such term does not include a group | 24 | | health plan.
| 25 | | "Health Maintenance Organization" means an organization as
| 26 | | defined in the Health Maintenance Organization Act.
|
| | | HB3405 Enrolled | - 9 - | LRB097 05453 RPM 45511 b |
|
| 1 | | "Hospice" means a program as defined in and licensed under | 2 | | the
Hospice Program Licensing Act.
| 3 | | "Hospital" means a duly licensed institution as defined in | 4 | | the
Hospital Licensing Act,
an institution that meets all | 5 | | comparable conditions and requirements in
effect in the state | 6 | | in which it is located, or the University of Illinois
Hospital | 7 | | as defined in the University of Illinois Hospital Act.
| 8 | | "Individual health insurance coverage" means health | 9 | | insurance coverage
offered to individuals in the individual | 10 | | market, but does not include
short-term, limited-duration | 11 | | insurance.
| 12 | | "Insured" means any individual resident of this State who | 13 | | is
eligible to receive benefits from any insurer (including | 14 | | health insurance
coverage offered in connection with a group | 15 | | health plan) or health
insurance issuer as
defined in this | 16 | | Section.
| 17 | | "Insurer" means any insurance company authorized to | 18 | | transact health
insurance business in this State and any | 19 | | corporation that provides medical
services and is organized | 20 | | under the Voluntary Health Services Plans Act or
the Health | 21 | | Maintenance Organization
Act.
| 22 | | "Medical assistance" means the State medical assistance or | 23 | | medical
assistance no grant (MANG) programs provided under
| 24 | | Title XIX of the Social Security Act and
Articles V (Medical | 25 | | Assistance) and VI (General Assistance) of the Illinois
Public | 26 | | Aid Code (or any successor program) or under any
similar |
| | | HB3405 Enrolled | - 10 - | LRB097 05453 RPM 45511 b |
|
| 1 | | program of health care benefits in a state other than Illinois.
| 2 | | "Medically necessary" means that a service, drug, or supply | 3 | | is
necessary and appropriate for the diagnosis or treatment of | 4 | | an illness or
injury in accord with generally accepted | 5 | | standards of medical practice at
the time the service, drug, or | 6 | | supply is provided. When specifically
applied to a confinement | 7 | | it further means that the diagnosis or treatment
of the covered | 8 | | person's medical symptoms or condition cannot be
safely
| 9 | | provided to that person as an outpatient. A service, drug, or | 10 | | supply shall
not be medically necessary if it: (i) is | 11 | | investigational, experimental, or
for research purposes; or | 12 | | (ii) is provided solely for the convenience of
the patient, the | 13 | | patient's family, physician, hospital, or any other
provider; | 14 | | or (iii) exceeds in scope, duration, or intensity that level of
| 15 | | care that is needed to provide safe, adequate, and appropriate | 16 | | diagnosis or
treatment; or (iv) could have been omitted without | 17 | | adversely affecting the
covered person's condition or the | 18 | | quality of medical care; or
(v) involves
the use of a medical | 19 | | device, drug, or substance not formally approved by
the United | 20 | | States Food and Drug Administration.
| 21 | | "Medical care" means the ordinary and usual professional | 22 | | services rendered
by a physician or other specified provider | 23 | | during a professional visit for
treatment of an illness or | 24 | | injury.
| 25 | | "Medicare" means coverage under both Part A and Part B of | 26 | | Title XVIII of
the Social Security
Act, 42 U.S.C. Sec. 1395, et |
| | | HB3405 Enrolled | - 11 - | LRB097 05453 RPM 45511 b |
|
| 1 | | seq.
| 2 | | "Minimum premium plan" means an arrangement whereby a | 3 | | specified
amount of health care claims is self-funded, but the | 4 | | insurance company
assumes the risk that claims will exceed that | 5 | | amount.
| 6 | | "Participating transplant center" means a hospital | 7 | | designated by the
Board as a preferred or exclusive provider of | 8 | | services for one or more
specified human organ or tissue | 9 | | transplants for which the hospital has
signed an agreement with | 10 | | the Board to accept a transplant payment allowance
for all | 11 | | expenses related to the transplant during a transplant benefit | 12 | | period.
| 13 | | "Physician" means a person licensed to practice medicine | 14 | | pursuant to
the Medical Practice Act of 1987.
| 15 | | "Plan" means the Comprehensive Health Insurance Plan
| 16 | | established by this Act.
| 17 | | "Plan of operation" means the plan of operation of the
| 18 | | Plan, including articles, bylaws and operating rules, adopted | 19 | | by the board
pursuant to this Act.
| 20 | | "Provider" means any hospital, skilled nursing facility, | 21 | | hospice, home
health agency, physician, registered pharmacist | 22 | | acting within the scope of that
registration, or any other | 23 | | person or entity licensed in Illinois to furnish
medical care.
| 24 | | "Qualified high risk pool" has the same meaning given that | 25 | | term in the
federal Health
Insurance Portability and | 26 | | Accountability Act of 1996.
|
| | | HB3405 Enrolled | - 12 - | LRB097 05453 RPM 45511 b |
|
| 1 | | "Resident" means a person who is and continues to be | 2 | | legally domiciled
and physically residing on a permanent and | 3 | | full-time basis in a
place of permanent habitation
in this | 4 | | State
that remains that person's principal residence and from | 5 | | which that person is
absent only for temporary or transitory | 6 | | purpose.
| 7 | | "Skilled nursing facility" means a facility or that portion | 8 | | of a facility
that is licensed by the Illinois Department of | 9 | | Public Health under the
Nursing Home Care Act or a comparable | 10 | | licensing authority in another state
to provide skilled nursing | 11 | | care.
| 12 | | "Stop-loss coverage" means an arrangement whereby an | 13 | | insurer
insures against the risk that any one claim will exceed | 14 | | a specific dollar
amount or that the entire loss of a | 15 | | self-insurance plan will exceed
a specific amount.
| 16 | | "Third party administrator" means an administrator as | 17 | | defined in
Section 511.101 of the Illinois Insurance Code who | 18 | | is licensed under
Article XXXI 1/4 of that Code.
| 19 | | (Source: P.A. 95-965, eff. 9-23-08.)
| 20 | | Section 99. Effective date. This Act takes effect upon | 21 | | becoming law.
|
|