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92_HB3004enr HB3004 Enrolled LRB9200745JSpc 1 AN ACT to amend the Comprehensive Health Insurance Plan 2 Act by changing Sections 2 and 15. 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 Sections 2 and 15 as follows: 7 (215 ILCS 105/2) (from Ch. 73, par. 1302) 8 Sec. 2. Definitions. As used in this Act, unless the 9 context otherwise requires: 10 "Plan administrator" means the insurer or third party 11 administrator designated under Section 5 of this Act. 12 "Benefits plan" means the coverage to be offered by the 13 Plan to eligible persons and federally eligible individuals 14 pursuant to this Act. 15 "Board" means the Illinois Comprehensive Health Insurance 16 Board. 17 "Church plan" has the same meaning given that term in the 18 federal Health Insurance Portability and Accountability Act 19 of 1996. 20 "Continuation coverage" means continuation of coverage 21 under a group health plan or other health insurance coverage 22 for former employees or dependents of former employees that 23 would otherwise have terminated under the terms of that 24 coverage pursuant to any continuation provisions under 25 federal or State law, including the Consolidated Omnibus 26 Budget Reconciliation Act of 1985 (COBRA), as amended, 27 Sections 367.2 and 367e of the Illinois Insurance Code, or 28 any other similar requirement in another State. 29 "Covered person" means a person who is and continues to 30 remain eligible for Plan coverage and is covered under one of 31 the benefit plans offered by the Plan. HB3004 Enrolled -2- LRB9200745JSpc 1 "Creditable coverage" means, with respect to a federally 2 eligible individual, coverage of the individual under any of 3 the following: 4 (A) A group health plan. 5 (B) Health insurance coverage (including group 6 health insurance coverage). 7 (C) Medicare. 8 (D) Medical assistance. 9 (E) Chapter 55 of title 10, United States Code. 10 (F) A medical care program of the Indian Health 11 Service or of a tribal organization. 12 (G) A state health benefits risk pool. 13 (H) A health plan offered under Chapter 89 of title 14 5, United States Code. 15 (I) A public health plan (as defined in regulations 16 consistent with Section 104 of the Health Care 17 Portability and Accountability Act of 1996 that may be 18 promulgated by the Secretary of the U.S. Department of 19 Health and Human Services). 20 (J) A health benefit plan under Section 5(e) of the 21 Peace Corps Act (22 U.S.C. 2504(e)). 22 (K) Any other qualifying coverage required by the 23 federal Health Insurance Portability and Accountability 24 Act of 1996, as it may be amended, or regulations under 25 that Act. 26 "Creditable coverage" does not include coverage 27 consisting solely of coverage of excepted benefits,(as 28 defined in Section 2791(c) of title XXVII of the Public 29 Health Service Act (42 U.S.C. 300 gg-91), nor does it include 30 any period of coverage under any of items (A) through (K) 31 that occurred before a break of more than 9063days during 32 all of which the individual was not covered under any of 33 items (A) through (K) above. Any period that an individual 34 is in a waiting period for any coverage under a group health HB3004 Enrolled -3- LRB9200745JSpc 1 plan (or for group health insurance coverage) or is in an 2 affiliation period under the terms of health insurance 3 coverage offered by a health maintenance organization shall 4 not be taken into account in determining if there has been a 5 break of more than 9063days in any creditablecredible6 coverage. 7 "Department" means the Illinois Department of Insurance. 8 "Dependent" means an Illinois resident: who is a spouse; 9 or who is claimed as a dependent by the principal insured for 10 purposes of filing a federal income tax return and resides in 11 the principal insured's household, and is a resident 12 unmarried child under the age of 19 years; or who is an 13 unmarried child who also is a full-time student under the age 14 of 23 years and who is financially dependent upon the 15 principal insured; or who is a child of any age and who is 16 disabled and financially dependent upon the principal 17 insured. 18 "Direct Illinois premiums" means, for Illinois business, 19 an insurer's direct premium income for the kinds of business 20 described in clause (b) of Class 1 or clause (a) of Class 2 21 of Section 4 of the Illinois Insurance Code, and direct 22 premium income of a health maintenance organization or a 23 voluntary health services plan, except it shall not include 24 credit health insurance as defined in Article IX 1/2 of the 25 Illinois Insurance Code. 26 "Director" means the Director of the Illinois Department 27 of Insurance. 28 "Eligible person" means a resident of this State who 29 qualifies for Plan coverage under Section 7 of this Act. 30 "Employee" means a resident of this State who is employed 31 by an employer or has entered into the employment of or works 32 under contract or service of an employer including the 33 officers, managers and employees of subsidiary or affiliated 34 corporations and the individual proprietors, partners and HB3004 Enrolled -4- LRB9200745JSpc 1 employees of affiliated individuals and firms when the 2 business of the subsidiary or affiliated corporations, firms 3 or individuals is controlled by a common employer through 4 stock ownership, contract, or otherwise. 5 "Employer" means any individual, partnership, 6 association, corporation, business trust, or any person or 7 group of persons acting directly or indirectly in the 8 interest of an employer in relation to an employee, for which 9 one or more persons is gainfully employed. 10 "Family" coverage means the coverage provided by the Plan 11 for the covered person and his or her eligible dependents who 12 also are covered persons. 13 "Federally eligible individual" means an individual 14 resident of this State: 15 (1)(A) for whom, as of the date on which the 16 individual seeks Plan coverage under Section 15 of this 17 Act, the aggregate of the periods of creditable coverage 18 is 18 or more months, and (B) whose most recent prior 19 creditable coverage was under group health insurance 20 coverage offered by a health insurance issuer, a group 21 health plan, a governmental plan, or a church plan (or 22 health insurance coverage offered in connection with any 23 such plans) or any other type of creditable coverage that 24 may be required by the federal Health Insurance 25 Portability and Accountability Act of 1996, as it may be 26 amended, or the regulations under that Act; 27 (2) who is not eligible for coverage under (A) a 28 group health plan, (B) part A or part B of Medicare due 29 to age, or (C) medical assistance, and does not have 30 other health insurance coverage; 31 (3) with respect to whom the most recent coverage 32 within the coverage period described in paragraph (1)(A) 33 of this definition was not terminated based upon a factor 34 relating to nonpayment of premiums or fraud; HB3004 Enrolled -5- LRB9200745JSpc 1 (4) if the individual had been offered the option 2 of continuation coverage under a COBRA continuation 3 provision or under a similar State program, who elected 4 such coverage; and 5 (5) who, if the individual elected such 6 continuation coverage, has exhausted such continuation 7 coverage under such provision or program. 8 "Group health insurance coverage" means, in connection 9 with a group health plan, health insurance coverage offered 10 in connection with that plan. 11 "Group health plan" has the same meaning given that term 12 in the federal Health Insurance Portability and 13 Accountability Act of 1996. 14 "Governmental plan" has the same meaning given that term 15 in the federal Health Insurance Portability and 16 Accountability Act of 1996. 17 "Health insurance coverage" means benefits consisting of 18 medical care (provided directly, through insurance or 19 reimbursement, or otherwise and including items and services 20 paid for as medical care) under any hospital and medical 21 expense-incurred policy, certificate, or contract provided by 22 an insurer, non-profit health care service plan contract, 23 health maintenance organization or other subscriber contract, 24 or any other health care plan or arrangement that pays for or 25 furnishes medical or health care services whether by 26 insurance or otherwise. Health insurance coverage shall not 27 include short term, accident only, disability income, 28 hospital confinement or fixed indemnity, dental only, vision 29 only, limited benefit, or credit insurance, coverage issued 30 as a supplement to liability insurance, insurance arising out 31 of a workers' compensation or similar law, automobile 32 medical-payment insurance, or insurance under which benefits 33 are payable with or without regard to fault and which is 34 statutorily required to be contained in any liability HB3004 Enrolled -6- LRB9200745JSpc 1 insurance policy or equivalent self-insurance. 2 "Health insurance issuer" means an insurance company, 3 insurance service, or insurance organization (including a 4 health maintenance organization and a voluntary health 5 services plan) that is authorized to transact health 6 insurance business in this State. Such term does not include 7 a group health plan. 8 "Health Maintenance Organization" means an organization 9 as defined in the Health Maintenance Organization Act. 10 "Hospice" means a program as defined in and licensed 11 under the Hospice Program Licensing Act. 12 "Hospital" means a duly licensed institution as defined 13 in the Hospital Licensing Act, an institution that meets all 14 comparable conditions and requirements in effect in the state 15 in which it is located, or the University of Illinois 16 Hospital as defined in the University of Illinois Hospital 17 Act. 18 "Individual health insurance coverage" means health 19 insurance coverage offered to individuals in the individual 20 market, but does not include short-term, limited-duration 21 insurance. 22 "Insured" means any individual resident of this State who 23 is eligible to receive benefits from any insurer (including 24 health insurance coverage offered in connection with a group 25 health plan) or health insurance issuer as defined in this 26 Section. 27 "Insurer" means any insurance company authorized to 28 transact health insurance business in this State and any 29 corporation that provides medical services and is organized 30 under the Voluntary Health Services Plans Act or the Health 31 Maintenance Organization Act. 32 "Medical assistance" means the State medical assistance 33 or medical assistance no grant (MANG) programs provided under 34 Title XIX of the Social Security Act and Articles V (Medical HB3004 Enrolled -7- LRB9200745JSpc 1 Assistance) and VI (General Assistance) of the Illinois 2 Public Aid Code (or any successor program) or under any 3 similar program of health care benefits in a state other than 4 Illinois. 5 "Medically necessary" means that a service, drug, or 6 supply is necessary and appropriate for the diagnosis or 7 treatment of an illness or injury in accord with generally 8 accepted standards of medical practice at the time the 9 service, drug, or supply is provided. When specifically 10 applied to a confinement it further means that the diagnosis 11 or treatment of the covered person's medical symptoms or 12 condition cannot be safely provided to that person as an 13 outpatient. A service, drug, or supply shall not be medically 14 necessary if it: (i) is investigational, experimental, or for 15 research purposes; or (ii) is provided solely for the 16 convenience of the patient, the patient's family, physician, 17 hospital, or any other provider; or (iii) exceeds in scope, 18 duration, or intensity that level of care that is needed to 19 provide safe, adequate, and appropriate diagnosis or 20 treatment; or (iv) could have been omitted without adversely 21 affecting the covered person's condition or the quality of 22 medical care; or (v) involves the use of a medical device, 23 drug, or substance not formally approved by the United States 24 Food and Drug Administration. 25 "Medical care" means the ordinary and usual professional 26 services rendered by a physician or other specified provider 27 during a professional visit for treatment of an illness or 28 injury. 29 "Medicare" means coverage under both Part A and Part B of 30 Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395, 31 et seq. 32 "Minimum premium plan" means an arrangement whereby a 33 specified amount of health care claims is self-funded, but 34 the insurance company assumes the risk that claims will HB3004 Enrolled -8- LRB9200745JSpc 1 exceed that amount. 2 "Participating transplant center" means a hospital 3 designated by the Board as a preferred or exclusive provider 4 of services for one or more specified human organ or tissue 5 transplants for which the hospital has signed an agreement 6 with the Board to accept a transplant payment allowance for 7 all expenses related to the transplant during a transplant 8 benefit period. 9 "Physician" means a person licensed to practice medicine 10 pursuant to the Medical Practice Act of 1987. 11 "Plan" means the Comprehensive Health Insurance Plan 12 established by this Act. 13 "Plan of operation" means the plan of operation of the 14 Plan, including articles, bylaws and operating rules, adopted 15 by the board pursuant to this Act. 16 "Provider" means any hospital, skilled nursing facility, 17 hospice, home health agency, physician, registered pharmacist 18 acting within the scope of that registration, or any other 19 person or entity licensed in Illinois to furnish medical 20 care. 21 "Qualified high risk pool" has the same meaning given 22 that term in the federal Health Insurance Portability and 23 Accountability Act of 1996. 24 "Resident" means a person who is and continues to be 25 legally domiciled and physically residing on a permanent and 26 full-time basis in a place of permanent habitation in this 27 State that remains that person's principal residence and from 28 which that person is absent only for temporary or transitory 29 purpose. 30 "Skilled nursing facility" means a facility or that 31 portion of a facility that is licensed by the Illinois 32 Department of Public Health under the Nursing Home Care Act 33 or a comparable licensing authority in another state to 34 provide skilled nursing care. HB3004 Enrolled -9- LRB9200745JSpc 1 "Stop-loss coverage" means an arrangement whereby an 2 insurer insures against the risk that any one claim will 3 exceed a specific dollar amount or that the entire loss of a 4 self-insurance plan will exceed a specific amount. 5 "Third party administrator" means an administrator as 6 defined in Section 511.101 of the Illinois Insurance Code who 7 is licensed under Article XXXI 1/4 of that Code. 8 (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99; 9 91-735, eff. 6-2-00.) 10 (215 ILCS 105/15) 11 Sec. 15. Alternative portable coverage for federally 12 eligible individuals. 13 (a) Notwithstanding the requirements of subsection a. of 14 Section 7, any federally eligible individual for whom a Plan 15 application, and such enclosures and supporting documentation 16 as the Board may require, is received by the Board within 90 1763days after the termination of prior creditable coverage 18 shall qualify to enroll in the Plan under the portability 19 provisions of this Section. 20 (b) Any federally eligible individual seeking Plan 21 coverage under this Section must submit with his or her 22 application evidence, including acceptable written 23 certification of previous creditable coverage, that will 24 establish to the Board's satisfaction, that he or she meets 25 all of the requirements to be a federally eligible individual 26 and is currently and permanently residing in this State (as 27 of the date his or her application was received by the 28 Board). 29 (c) A period of creditable coverage shall not be 30 counted, with respect to qualifying an applicant for Plan 31 coverage as a federally eligible individual under this 32 Section, if after such period and before the application for 33 Plan coverage was received by the Board, there was at least a HB3004 Enrolled -10- LRB9200745JSpc 1 9063day period during all of which the individual was not 2 covered under any creditable coverage. 3 (d) Any federally eligible individual who the Board 4 determines qualifies for Plan coverage under this Section 5 shall be offered his or her choice of enrolling in one of 6 alternative portability health benefit plans which the Board 7 is authorized under this Section to establish for these 8 federally eligible individuals and their dependents. 9 (e) The Board shall offer a choice of health care 10 coverages consistent with major medical coverage under the 11 alternative health benefit plans authorized by this Section 12 to every federally eligible individual. The coverages to be 13 offered under the plans, the schedule of benefits, 14 deductibles, co-payments, exclusions, and other limitations 15 shall be approved by the Board. One optional form of 16 coverage shall be comparable to comprehensive health 17 insurance coverage offered in the individual market in this 18 State or a standard option of coverage available under the 19 group or individual health insurance laws of the State. The 20 standard benefit plan that is authorized by Section 8 of this 21 Act may be used for this purpose. The Board may also offer a 22 preferred provider option and such other options as the Board 23 determines may be appropriate for these federally eligible 24 individuals who qualify for Plan coverage pursuant to this 25 Section. 26 (f) Notwithstanding the requirements of subsection f. of 27 Section 8, any plan coverage that is issued to federally 28 eligible individuals who qualify for the Plan pursuant to the 29 portability provisions of this Section shall not be subject 30 to any preexisting conditions exclusion, waiting period, or 31 other similar limitation on coverage. 32 (g) Federally eligible individuals who qualify and 33 enroll in the Plan pursuant to this Section shall be required 34 to pay such premium rates as the Board shall establish and HB3004 Enrolled -11- LRB9200745JSpc 1 approve in accordance with the requirements of Section 7.1 of 2 this Act. 3 (h) A federally eligible individual who qualifies and 4 enrolls in the Plan pursuant to this Section must satisfy on 5 an ongoing basis all of the other eligibility requirements of 6 this Act to the extent not inconsistent with the federal 7 Health Insurance Portability and Accountability Act of 1996 8 in order to maintain continued eligibility for coverage under 9 the Plan. 10 (Source: P.A. 90-30, eff. 7-1-97.) 11 Section 99. Effective date. This Act takes effect upon 12 becoming law.