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91_HB2166sam002
LRB9102918JSpcam04
1 AMENDMENT TO HOUSE BILL 2166
2 AMENDMENT NO. . Amend House Bill 2166 on page 1,
3 lines 2 and 6, by changing "Section 8" each time it appears
4 to "Sections 7 and 8"; and
5 on page 1 by inserting immediately below line 6 the
6 following:
7 "(215 ILCS 105/7) (from Ch. 73, par. 1307)
8 Sec. 7. Eligibility.
9 a. Except as provided in subsection (e) of this Section
10 or in Section 15 of this Act, any individual person who is
11 either a citizen of the United States or an alien lawfully
12 admitted for permanent residence and continues to be a
13 resident of this State shall be eligible for Plan coverage if
14 evidence is provided of:
15 (1) A notice of rejection or refusal to issue
16 substantially similar individual health insurance
17 coverage for health reasons by a health insurance issuer;
18 or
19 (2) A refusal by a health insurance issuer to issue
20 individual health insurance coverage except at a rate
21 exceeding the applicable Plan rate for which the person
22 is responsible.
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1 A rejection or refusal by a group health plan or health
2 insurance issuer offering only stop-loss or excess of loss
3 insurance or contracts, agreements, or other arrangements for
4 reinsurance coverage with respect to the applicant shall not
5 be sufficient evidence under this subsection.
6 b. The board shall promulgate a list of medical or
7 health conditions for which a person who is either a citizen
8 of the United States or an alien lawfully admitted for
9 permanent residence and a resident of this State would be
10 eligible for Plan coverage without applying for health
11 insurance coverage pursuant to subsection a. of this Section.
12 Persons who can demonstrate the existence or history of any
13 medical or health conditions on the list promulgated by the
14 board shall not be required to provide the evidence specified
15 in subsection a. of this Section. The list shall be
16 effective on the first day of the operation of the Plan and
17 may be amended from time to time as appropriate.
18 c. Family members of the same household who each are
19 covered persons are eligible for optional family coverage
20 under the Plan.
21 d. For persons qualifying for coverage in accordance
22 with Section 7 of this Act, the board shall, if it determines
23 that such appropriations as are made pursuant to Section 12
24 of this Act are insufficient to allow the board to accept all
25 of the eligible persons which it projects will apply for
26 enrollment under the Plan, limit or close enrollment to
27 ensure that the Plan is not over-subscribed and that it has
28 sufficient resources to meet its obligations to existing
29 enrollees. The board shall not limit or close enrollment for
30 federally eligible individuals.
31 e. A person shall not be eligible for coverage under the
32 Plan if:
33 (1) He or she has or obtains other coverage under a
34 group health plan or health insurance coverage
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1 substantially similar to or better than a Plan policy as
2 an insured or covered dependent or would be eligible to
3 have that coverage if he or she elected to obtain it.
4 Persons otherwise eligible for Plan coverage may,
5 however, solely for the purpose of having coverage for a
6 pre-existing condition, maintain other coverage only
7 while satisfying any pre-existing condition waiting
8 period under a Plan policy or a subsequent replacement
9 policy of a Plan policy.
10 (1.1) His or her prior coverage under a group
11 health plan or health insurance coverage, provided or
12 arranged by an employer of more than 10 employees was
13 discontinued for any reason without the entire group or
14 plan being discontinued and not replaced, provided he or
15 she remains an employee, or dependent thereof, of the
16 same employer.
17 (2) He or she is a recipient of or is approved to
18 receive medical assistance, except that a person may
19 continue to receive medical assistance through the
20 medical assistance no grant program, but only while
21 satisfying the requirements for a preexisting condition
22 under Section 8, subsection f. of this Act. Payment of
23 premiums pursuant to this Act shall be allocable to the
24 person's spenddown for purposes of the medical assistance
25 no grant program, but that person shall not be eligible
26 for any Plan benefits while that person remains eligible
27 for medical assistance. If the person continues to
28 receive or be approved to receive medical assistance
29 through the medical assistance no grant program at or
30 after the time that requirements for a preexisting
31 condition are satisfied, the person shall not be eligible
32 for coverage under the Plan. In that circumstance,
33 coverage under the plan shall terminate as of the
34 expiration of the preexisting condition limitation
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1 period. Under all other circumstances, coverage under
2 the Plan shall automatically terminate as of the
3 effective date of any medical assistance.
4 (3) Except as provided in Section 15, the person
5 has previously participated in the Plan and voluntarily
6 terminated Plan coverage, unless 12 months have elapsed
7 since the person's latest voluntary termination of
8 coverage.
9 (4) The person fails to pay the required premium
10 under the covered person's terms of enrollment and
11 participation, in which event the liability of the Plan
12 shall be limited to benefits incurred under the Plan for
13 the time period for which premiums had been paid and the
14 covered person remained eligible for Plan coverage.
15 (5) The Plan has paid a total of $1,000,000 in
16 benefits on behalf of the covered person.
17 (6) The person is a resident of a public
18 institution.
19 (7) The person's premium is paid for or reimbursed
20 under any government sponsored program or by any
21 government agency or health care provider, except as an
22 otherwise qualifying full-time employee, or dependent of
23 such employee, of a government agency or health care
24 provider.
25 (8) The person has or later receives other benefits
26 or funds from any settlement, judgement, or award
27 resulting from any accident or injury, regardless of the
28 date of the accident or injury, or any other
29 circumstances creating a legal liability for damages due
30 that person by a third party, whether the settlement,
31 judgment, or award is in the form of a contract,
32 agreement, or trust on behalf of a minor or otherwise and
33 whether the settlement, judgment, or award is payable to
34 the person, his or her dependent, estate, personal
-5- LRB9102918JSpcam04
1 representative, or guardian in a lump sum or over time,
2 so long as there continues to be benefits or assets
3 remaining from those sources in an amount in excess of
4 $100,000.
5 (9) Within the 5 years prior to the date a person's
6 Plan application is received by the Board, the person's
7 coverage under any health care benefit program as defined
8 in 18 U.S.C. 24, including any public or private plan or
9 contract under which any medical benefit, item, or
10 service is provided, was terminated as a result of any
11 act or practice that constitutes fraud under State or
12 federal law or as a result of an intentional
13 misrepresentation of material fact; or if that person
14 knowingly and willfully obtained or attempted to obtain,
15 or fraudulently aided or attempted to aid any other
16 person in obtaining, any coverage or benefits under the
17 Plan to which that person was not entitled.
18 f. The board or the administrator shall require
19 verification of residency and may require any additional
20 information or documentation, or statements under oath, when
21 necessary to determine residency upon initial application and
22 for the entire term of the policy.
23 g. Coverage shall cease (i) on the date a person is no
24 longer a resident of Illinois, (ii) on the date a person
25 requests coverage to end, (iii) upon the death of the covered
26 person, (iv) on the date State law requires cancellation of
27 the policy, or (v) at the Plan's option, 30 days after the
28 Plan makes any inquiry concerning a person's eligibility or
29 place of residence to which the person does not reply.
30 h. Except under the conditions set forth in subsection g
31 of this Section, the coverage of any person who ceases to
32 meet the eligibility requirements of this Section shall be
33 terminated at the end of the current policy period for which
34 the necessary premiums have been paid.
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1 (Source: P.A. 89-486, eff. 6-21-96; 90-30, eff. 7-1-97.)".