State of Illinois
90th General Assembly

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[ Introduced ]


      215 ILCS 105/8            from Ch. 73, par. 1308
          Amends  the  Comprehensive  Health  Insurance  Plan  Act.
      Extends coverage to include physicals and  immunizations  for
      children under the age of 16 years.  Effective immediately.
HB2908 Engrossed                               LRB9010539JSmg
 1        AN  ACT  to amend the Comprehensive Health Insurance Plan
 2    Act by changing Section 8.
 3        Be it enacted by the People of  the  State  of  Illinois,
 4    represented in the General Assembly:
 5        Section  5.   The Comprehensive Health Insurance Plan Act
 6    is amended by changing Section 8 as follows:
 7        (215 ILCS 105/8) (from Ch. 73, par. 1308)
 8        Sec. 8.  Minimum benefits.
 9        a.  Availability. The Plan shall  offer  in  an  annually
10    renewable  policy  major  medical  expense  coverage to every
11    eligible person who is  not  eligible  for  Medicare.   Major
12    medical  expense  coverage  offered  by the Plan shall pay an
13    eligible person's covered expenses, subject to limit  on  the
14    deductible   and   coinsurance   payments   authorized  under
15    paragraph (4) of subsection  d  of  this  Section,  up  to  a
16    lifetime  benefit limit of $1,000,000 per covered individual.
17    The maximum limit under this subsection shall not be  altered
18    by  the  Board,  and  no  actuarial equivalent benefit may be
19    substituted by the Board.  Any  person  who  otherwise  would
20    qualify  for coverage under the Plan, but is excluded because
21    he or she is eligible for Medicare, shall be eligible for any
22    separate Medicare supplement policy  or  policies  which  the
23    Board may offer.
24        b.  Outline  of  benefits.   Covered  expenses  shall  be
25    limited   to   the  usual  and  customary  charge,  including
26    negotiated fees, in the locality for the  following  services
27    and articles when prescribed by a physician and determined by
28    the Plan to be medically necessary for the following areas of
29    services,  subject to such separate deductibles, co-payments,
30    exclusions, and other limitations on benefits  as  the  Board
31    shall establish and approve, and the other provisions of this
HB2908 Engrossed            -2-                LRB9010539JSmg
 1    Section:
 2             (1)  Hospital services.
 3             (2)  Professional  services  for  the  diagnosis  or
 4        treatment  of  injuries,  illnesses  or conditions, other
 5        than dental and mental and nervous disorders as described
 6        in paragraph (17), which are rendered by a physician,  or
 7        by   other  licensed  professionals  at  the  physician's
 8        direction.
 9             (2.5)  Professional services provided by a physician
10        to children under  the  age  of  16  years  for  physical
11        examinations and age appropriate immunizations.
12             (3)  (Blank).
13             (4)  Drugs requiring a physician's prescription.
14             (5)  Skilled  nursing services of a licensed skilled
15        nursing facility for not more  than  120  days  during  a
16        policy year.
17             (6)  Services of a home health agency in accord with
18        a  home  health  care plan, up to a maximum of 270 visits
19        per year.
20             (7)  Services of a licensed  hospice  for  not  more
21        than 180 days during a policy year.
22             (8)  Use of radium or other radioactive materials.
23             (9)  Oxygen.
24             (10)  Anesthetics.
25             (11)  Orthoses and prostheses other than dental.
26             (12)  Rental  or  purchase  in accordance with Board
27        policies or  procedures  of  durable  medical  equipment,
28        other than eyeglasses or hearing aids, for which there is
29        no personal use in the absence of the condition for which
30        it is prescribed.
31             (13)  Diagnostic x-rays and laboratory tests.
32             (14)  Oral  surgery  for  excision  of  partially or
33        completely unerupted  impacted  teeth  or  the  gums  and
34        tissues  of  the  mouth, when not performed in connection
HB2908 Engrossed            -3-                LRB9010539JSmg
 1        with the routine extraction or repair of teeth, and  oral
 2        surgery   and   procedures,  including  orthodontics  and
 3        prosthetics necessary for craniofacial  or  maxillofacial
 4        conditions  and to correct congenital defects or injuries
 5        due to accident.
 6             (15)  Physical, speech, and functional  occupational
 7        therapy   as   medically   necessary   and   provided  by
 8        appropriate licensed professionals.
 9             (16)  Emergency  and   other   medically   necessary
10        transportation  provided  by a licensed ambulance service
11        to the nearest health care facility qualified to treat  a
12        covered  illness,  injury,  or  condition, subject to the
13        provisions of the Emergency Medical Systems (EMS) Act.
14             (17)  Outpatient   services   for   diagnosis    and
15        treatment of mental and nervous disorders provided that a
16        covered  person shall be required to make a copayment not
17        to exceed 50% and  that  the  Plan's  payment  shall  not
18        exceed such amounts as are established by the Board.
19             (18)  Human organ or tissue transplants specified by
20        the  Board that are performed at a hospital designated by
21        the Board as a participating transplant center  for  that
22        specific organ or tissue transplant.
23             (19)  Naprapathic services, as appropriate, provided
24        by a licensed naprapathic practitioner.
25        c.  Exclusions.   Covered  expenses of the Plan shall not
26    include the following:
27             (1)  Any charge for treatment for cosmetic  purposes
28        other than for reconstructive surgery when the service is
29        incidental  to  or follows surgery resulting from injury,
30        sickness or  other  diseases  of  the  involved  part  or
31        surgery  for  the  repair  or  treatment  of a congenital
32        bodily defect to restore normal bodily functions.
33             (2)  Any charge for care that is primarily for rest,
34        custodial, educational, or domiciliary purposes.
HB2908 Engrossed            -4-                LRB9010539JSmg
 1             (3)  Any charge for services in a  private  room  to
 2        the  extent  it  is in excess of the institution's charge
 3        for its most common semiprivate room,  unless  a  private
 4        room is prescribed as medically necessary by a physician.
 5             (4)  That  part  of any charge for room and board or
 6        for  services  rendered  or  articles  prescribed  by   a
 7        physician,  dentist,  or other health care personnel that
 8        exceeds  the  reasonable  and  customary  charge  in  the
 9        locality or for any services or  supplies  not  medically
10        necessary for the diagnosed injury or illness.
11             (5)  Any   charge   for  services  or  articles  the
12        provision of which is not within the scope  of  licensure
13        of  the  institution or individual providing the services
14        or articles.
15             (6)  Any expense incurred  prior  to  the  effective
16        date  of  coverage  by  the  Plan for the person on whose
17        behalf the expense is incurred.
18             (7)  Dental care, dental surgery,  dental  treatment
19        or  dental  appliances,  except  as provided in paragraph
20        (14) of subsection b of this Section.
21             (8)  Eyeglasses, contact  lenses,  hearing  aids  or
22        their fitting.
23             (9)  Illness or injury due to acts of war.
24             (10)  Services  of  blood  donors  and  any  fee for
25        failure to replace the first 3 pints of blood provided to
26        a covered  person each policy year.
27             (11)  Personal supplies or services  provided  by  a
28        hospital  or  nursing  home,  or  any other nonmedical or
29        nonprescribed supply or service.
30             (12)  Routine maternity  charges  for  a  pregnancy,
31        except  where  added as optional coverage with payment of
32        an  additional  premium  for  pregnancy  resulting   from
33        conception  occurring  after  the  effective  date of the
34        optional coverage.
HB2908 Engrossed            -5-                LRB9010539JSmg
 1             (13)  (Blank).
 2             (14)  Any expense or charge for services, drugs,  or
 3        supplies  that  are:  (i)  not  provided  in  accord with
 4        generally accepted standards of current medical practice;
 5        (ii) for procedures, treatments, equipment,  transplants,
 6        or   implants,   any   of   which   are  investigational,
 7        experimental,   or   for   research    purposes;    (iii)
 8        investigative  and not proven safe and effective; or (iv)
 9        for,  or  resulting   from,   a   gender   transformation
10        operation.
11             (15)  Any  expense  or  charge  for routine physical
12        examinations or tests.
13             (16)  Any expense for which a charge is not made  in
14        the  absence  of insurance or for which there is no legal
15        obligation on the part of the patient to pay.
16             (17)  Any expense  incurred  for  benefits  provided
17        under  the  laws  of  the  United  States and this State,
18        including  Medicare  and  Medicaid  and   other   medical
19        assistance,    military    service-connected   disability
20        payments, medical services provided for  members  of  the
21        armed  forces  and  their  dependents or employees of the
22        armed forces of the United States, and  medical  services
23        financed on behalf of all citizens by the United States.
24             (18)  Any   expense   or   charge   for   in   vitro
25        fertilization,  artificial  insemination,  or  any  other
26        artificial means used to cause pregnancy.
27             (19)  Any  expense or charge for oral contraceptives
28        used for birth  control  or  any  other  temporary  birth
29        control measures.
30             (20)  Any  expense  or  charge  for sterilization or
31        sterilization reversals.
32             (21)  Any  expense  or  charge   for   weight   loss
33        programs,  exercise  equipment,  or treatment of obesity,
34        except when certified by a physician  as  morbid  obesity
HB2908 Engrossed            -6-                LRB9010539JSmg
 1        (at least 2 times normal body weight).
 2             (22)  Any   expense   or   charge   for  acupuncture
 3        treatment unless  used  as  an  anesthetic  agent  for  a
 4        covered surgery.
 5             (23)  Any  expense or charge for or related to organ
 6        or tissue transplants other than  those  performed  at  a
 7        hospital  with  a Board approved organ transplant program
 8        that has been designated by the Board as a  preferred  or
 9        exclusive  provider  organization for that specific organ
10        or tissue transplant.
11             (24)  Any  expense   or   charge   for   procedures,
12        treatments,  equipment,  or services that are provided in
13        special settings for research purposes or in a controlled
14        environment, are being studied  for  safety,  efficiency,
15        and  effectiveness,  and  are awaiting endorsement by the
16        appropriate  national  medical  speciality  college   for
17        general use within the medical community.
18        d.  Deductibles and coinsurance.
19        The  Plan coverage defined in Section 6 shall provide for
20    a choice of deductibles per individual as authorized  by  the
21    Board.  If 2 individual members of the same family household,
22    who are both covered persons under the Plan, satisfy the same
23    applicable deductibles, no other member of that family who is
24    also  a  covered  person  under the Plan shall be required to
25    meet any deductibles for the balance of that  calendar  year.
26    The  deductibles  must  be  applied  first  to the authorized
27    amount of covered expenses incurred by the covered person.  A
28    mandatory coinsurance requirement shall  be  imposed  at  the
29    rate  authorized  by  the  Board  in  excess of the mandatory
30    deductible, the coinsurance in the aggregate  not  to  exceed
31    such  amounts  as  are authorized by the Board per annum.  At
32    its discretion the Board  may,  however,  offer  catastrophic
33    coverages   or   other   policies  that  provide  for  larger
34    deductibles with or without  coinsurance  requirements.   The
HB2908 Engrossed            -7-                LRB9010539JSmg
 1    deductibles  and coinsurance factors may be adjusted annually
 2    according to the Medical  Component  of  the  Consumer  Price
 3    Index.
 4        e.  Scope of coverage.
 5        (1)  In  approving any of the benefit plans to be offered
 6    by the Plan, the Board shall establish such  benefit  levels,
 7    deductibles, coinsurance factors, exclusions, and limitations
 8    as  it  may  deem  appropriate  and  that  it  believes to be
 9    generally  reflective  of  and   commensurate   with   health
10    insurance  coverage that is provided in the individual market
11    in this State.
12        (2)  The benefit plans approved by  the  Board  may  also
13    provide  for and employ various cost containment measures and
14    other   requirements   including,   but   not   limited   to,
15    preadmission certification, prior approval,  second  surgical
16    opinions,  concurrent utilization review programs, individual
17    case management,  preferred  provider  organizations,  health
18    maintenance   organizations,   and   other   cost   effective
19    arrangements for paying for covered expenses.
20        f.  Preexisting conditions.
21             (1)  Except   for   federally  eligible  individuals
22        qualifying for Plan coverage under Section 15 of this Act
23        or eligible persons who qualify for and elect to purchase
24        the  waiver  authorized  in   paragraph   (3)   of   this
25        subsection,   plan  coverage  shall  exclude  charges  or
26        expenses incurred during the first 6 months following the
27        effective date of coverage as to any  condition  if:  (a)
28        the  condition  had  manifested itself within the 6 month
29        period  immediately  preceding  the  effective  date   of
30        coverage  in  such  a manner as would cause an ordinarily
31        prudent person to seek diagnosis, care or  treatment;  or
32        (b)  medical advice, care or treatment was recommended or
33        received within the 6 month period immediately  preceding
34        the effective date of coverage.
HB2908 Engrossed            -8-                LRB9010539JSmg
 1             (2)  (Blank).
 2             (3)  Waiver: The preexisting condition exclusions as
 3        set  forth  in  paragraph (1) of this subsection shall be
 4        waived to the extent to which the  eligible  person:  (a)
 5        has  satisfied  similar exclusions under any prior health
 6        insurance  coverage  or  group  health  plan   that   was
 7        involuntarily  terminated;  (b)  is  ineligible  for  any
 8        continuation  coverage  that  would  continue  or provide
 9        substantially    similar    coverage    following    that
10        termination; and (c) has applied for  Plan  coverage  not
11        later than 30 days following the involuntary termination.
12        No   policy   or  plan  shall  be  deemed  to  have  been
13        involuntarily terminated if the  master  policyholder  or
14        other  controlling  party  elected  to  change  insurance
15        coverage from one health insurance issuer or group health
16        plan  to  another  even  if  that  decision resulted in a
17        discontinuation of coverage for any individual under  the
18        plan,  either  totally  or for any medical condition. For
19        each eligible person who qualifies for  and  elects  this
20        waiver,  there shall be added to each payment of premium,
21        on a prorated basis, a surcharge of  up  to  10%  of  the
22        otherwise  applicable  annual premium for as long as that
23        individual's coverage under the Plan remains in effect or
24        60 months, whichever is less.
25        g.  Other sources primary;  nonduplication of benefits.
26             (1)  The Plan shall be the last  payor  of  benefits
27        whenever  any  other  benefit  or  source  of third party
28        payment is  available.   Subject  to  the  provisions  of
29        subsection  e  of  Section  7, benefits otherwise payable
30        under Plan coverage shall be reduced by all amounts  paid
31        or payable by Medicare or any other government program or
32        through  any  health  insurance  or  group  health  plan,
33        whether  by  insurance,  reimbursement,  or otherwise, or
34        through any third party liability, settlement,  judgment,
HB2908 Engrossed            -9-                LRB9010539JSmg
 1        or  award,  regardless  of  the  date  of the settlement,
 2        judgment, or award, whether the settlement, judgment,  or
 3        award  is  in the form of a contract, agreement, or trust
 4        on behalf  of  a  minor  or  otherwise  and  whether  the
 5        settlement,  judgment, or award is payable to the covered
 6        person,  his   or   her   dependent,   estate,   personal
 7        representative,  or  guardian in a lump sum or over time,
 8        and by all hospital or medical expense benefits  paid  or
 9        payable   under   any   worker's  compensation  coverage,
10        automobile  medical  payment,  or  liability   insurance,
11        whether  provided  on the basis of fault or nonfault, and
12        by any hospital or medical benefits paid or payable under
13        or provided pursuant to  any  State  or  federal  law  or
14        program.
15             (2)  The  Plan  shall have a cause of action against
16        any 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
22        of sickness or an injury to a  covered  person  resulting
23        from  a  third party's wrongful act or negligence and the
24        covered person has recovered or may recover damages  from
25        a  third  party  or  its insurer, the Plan shall have the
26        right to reduce benefits or to  refuse  to  pay  benefits
27        that  otherwise  may  be payable by the amount of damages
28        that the covered person  has  recovered  or  may  recover
29        regardless  of  the date of the sickness or injury or the
30        date of any settlement, judgment, or award resulting from
31        that sickness or injury.
32             During the pendency of any action or claim  that  is
33        brought  by  or  on  behalf of a covered person against a
34        third party or  its  insurer,  any  benefits  that  would
HB2908 Engrossed            -10-               LRB9010539JSmg
 1        otherwise  be  payable  except for the provisions of this
 2        paragraph (3) shall be paid if  payment  by  or  for  the
 3        third  party has not yet been made and the covered person
 4        or, if  incapable,  that  person's  legal  representative
 5        agrees  in writing to pay back promptly the benefits paid
 6        as a result of the sickness or injury to  the  extent  of
 7        any  future  payments  made by or for the third party for
 8        the sickness or  injury.   This  agreement  is  to  apply
 9        whether  or not liability for the payments is established
10        or admitted by the third party or whether those  payments
11        are itemized.
12             Any  amounts  due  the plan to repay benefits may be
13        deducted from other benefits payable by  the  Plan  after
14        payments by or for the third party are made.
15             (4)  Benefits  due  from  the Plan may be reduced or
16        refused  as  an  offset  against  any  amount   otherwise
17        recoverable under this Section.
18        h.  Right of subrogation; recoveries.
19             (1)  Whenever  the Plan has paid benefits because of
20        sickness or an injury to  any  covered  person  resulting
21        from  a  third party's wrongful act or negligence, or for
22        which  an  insurer  is  liable  in  accordance  with  the
23        provisions of any policy of insurance,  and  the  covered
24        person  has recovered or may recover damages from a third
25        party that is liable for the damages, the Plan shall have
26        the right to  recover  the  benefits  it  paid  from  any
27        amounts  that  the  covered  person  has  received or may
28        receive regardless of the date of the sickness or  injury
29        or  the  date  of  any  settlement,  judgment,  or  award
30        resulting  from  that sickness or injury.  The Plan shall
31        be subrogated to any right of recovery the covered person
32        may have under the terms of any private or public  health
33        care  coverage  or liability coverage, including coverage
34        under the  Workers'  Compensation  Act  or  the  Workers'
HB2908 Engrossed            -11-               LRB9010539JSmg
 1        Occupational  Diseases  Act,  without  the  necessity  of
 2        assignment  of claim or other authorization to secure the
 3        right of recovery.  To enforce its subrogation right, the
 4        Plan may (i) intervene or join in an action or proceeding
 5        brought  by  the   covered   person   or   his   personal
 6        representative,   including  his  guardian,  conservator,
 7        estate, dependents, or survivors, against any third party
 8        or the third party's insurer that may be liable  or  (ii)
 9        institute  and  prosecute  legal  proceedings against any
10        third party or the third  party's  insurer  that  may  be
11        liable for the sickness or injury in an appropriate court
12        either  in  the  name  of  the Plan or in the name of the
13        covered person or his personal representative,  including
14        his   guardian,   conservator,   estate,  dependents,  or
15        survivors.
16             (2)  If any action or claim  is  brought  by  or  on
17        behalf  of  a covered person against a third party or the
18        third party's insurer, the covered person or his personal
19        representative,  including  his  guardian,   conservator,
20        estate,  dependents,  or survivors, shall notify the Plan
21        by personal service or registered mail of the  action  or
22        claim and of the name of the court in which the action or
23        claim  is  brought, filing proof thereof in the action or
24        claim.  The Plan may, at any time thereafter, join in the
25        action or claim upon its motion so  that  all  orders  of
26        court  after  hearing  and judgment shall be made for its
27        protection.  No release or  settlement  of  a  claim  for
28        damages  and  no  satisfaction  of judgment in the action
29        shall be valid without the written consent of the Plan to
30        the extent of its interest in the settlement or  judgment
31        and of the covered person or his personal representative.
32             (3)  In  the  event  that  the covered person or his
33        personal representative fails to institute  a  proceeding
34        against  any  appropriate  third  party  before the fifth
HB2908 Engrossed            -12-               LRB9010539JSmg
 1        month before the action would be barred, the Plan may, in
 2        its own name or in the name  of  the  covered  person  or
 3        personal  representative,  commence  a proceeding against
 4        any appropriate third party for the recovery  of  damages
 5        on  account  of  any  sickness,  injury,  or death to the
 6        covered person.  The covered person  shall  cooperate  in
 7        doing  what is reasonably necessary to assist the Plan in
 8        any recovery and shall not take  any  action  that  would
 9        prejudice  the  Plan's right to recovery.  The Plan shall
10        pay to the covered person or his personal  representative
11        all  sums  collected  from any third party by judgment or
12        otherwise in excess of amounts paid in benefits under the
13        Plan and amounts paid or to be paid as  costs,  attorneys
14        fees,  and  reasonable  expenses  incurred by the Plan in
15        making the collection or enforcing the judgment.
16             (4)  In the event  that  a  covered  person  or  his
17        personal    representative,   including   his   guardian,
18        conservator, estate, dependents, or  survivors,  recovers
19        damages  from a third party for sickness or injury caused
20        to the covered person, the covered person or the personal
21        representative shall pay to the  Plan  from  the  damages
22        recovered  the  amount  of benefits paid or to be paid on
23        behalf of the covered person.
24             (5)  When the action or  claim  is  brought  by  the
25        covered  person  alone  and  the  covered person incurs a
26        personal liability to pay attorney's fees  and  costs  of
27        litigation,  the  Plan's  claim  for reimbursement of the
28        benefits provided to the covered person shall be the full
29        amount of benefits paid to or on behalf  of  the  covered
30        person  under  this  Act  less  a  pro  rata  share  that
31        represents the Plan's reasonable share of attorney's fees
32        paid  by  the covered person and that portion of the cost
33        of litigation expenses determined by multiplying  by  the
34        ratio  of the full amount of the expenditures to the full
HB2908 Engrossed            -13-               LRB9010539JSmg
 1        amount of the judgement, award, or settlement.
 2             (6)  In the event of judgment or award in a suit  or
 3        claim  against  a third party or insurer, the court shall
 4        first  order  paid  from  any  judgement  or  award   the
 5        reasonable  litigation  expenses  incurred in preparation
 6        and prosecution of the action  or  claim,  together  with
 7        reasonable  attorney's  fees.   After  payment  of  those
 8        expenses  and  attorney's fees, the court shall apply out
 9        of the  balance  of  the  judgment  or  award  an  amount
10        sufficient  to  reimburse  the  Plan  the  full amount of
11        benefits paid on behalf of the covered person under  this
12        Act,  provided  the  court  may  reduce and apportion the
13        Plan's portion of  the  judgement  proportionate  to  the
14        recovery  of the covered person.  The burden of producing
15        evidence sufficient to support the exercise by the  court
16        of its discretion to reduce the amount of a proven charge
17        sought  to  be  enforced  against the recovery shall rest
18        with the party seeking  the  reduction.   The  court  may
19        consider  the  nature  and extent of the injury, economic
20        and non-economic  loss,  settlement  offers,  comparative
21        negligence  as  it  applies to the case at hand, hospital
22        costs, physician costs, and all other appropriate  costs.
23        The  Plan  shall  pay  its pro rata share of the attorney
24        fees based on the Plan's recovery as it compares  to  the
25        total  judgment.   Any  reimbursement  rights of the Plan
26        shall take priority over  all  other  liens  and  charges
27        existing  under the laws of this State with the exception
28        of any attorney liens filed under the Attorneys Lien Act.
29             (7)  The Plan may compromise or settle  and  release
30        any  claim  for benefits provided under this Act or waive
31        any claims for benefits, in whole or  in  part,  for  the
32        convenience  of  the  Plan or if the Plan determines that
33        collection  would  result  in  undue  hardship  upon  the
34        covered person.
HB2908 Engrossed            -14-               LRB9010539JSmg
 1    (Source: P.A.  89-486,  eff.  6-21-96;  90-7,  eff.  6-10-97;
 2    90-30, eff, 7-1-97; revised 8-7-97.)
 3        Section 99.  Effective date.  This Act takes effect  upon
 4    becoming law.

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