State of Illinois
92nd General Assembly
Legislation

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92_HB3005

 
                                               LRB9200746JSpc

 1        AN  ACT  to amend the Comprehensive Health Insurance Plan
 2    Act by changing Section 2.

 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 2 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.
 
                            -2-                LRB9200746JSpc
 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 63 days during  all
32    of  which  the  individual was not covered under any of items
33    (A) through (K) above.  Any period that an individual is in a
34    waiting period for any coverage under a group health plan (or
 
                            -3-                LRB9200746JSpc
 1    for group health insurance coverage) or is in an  affiliation
 2    period  under  the terms of health insurance coverage offered
 3    by a health maintenance organization shall not be taken  into
 4    account in determining if there has been a break of more than
 5    63 days in any creditable credible coverage.
 6        "Department" means the Illinois Department of Insurance.
 7        "Dependent"  means an Illinois resident: who is a spouse;
 8    or who is claimed as a dependent by the principal insured for
 9    purposes of filing a federal income tax return and resides in
10    the  principal  insured's  household,  and  is   a   resident
11    unmarried  child  under  the  age  of  19 years; or who is an
12    unmarried child who also is a full-time student under the age
13    of 23  years  and  who  is  financially  dependent  upon  the
14    principal  insured;  or  who is a child of any age and who is
15    disabled  and  financially  dependent  upon   the   principal
16    insured.
17        "Direct  Illinois premiums" means, for Illinois business,
18    an insurer's direct premium income for the kinds of  business
19    described  in  clause (b) of Class 1 or clause (a) of Class 2
20    of Section 4 of  the  Illinois  Insurance  Code,  and  direct
21    premium  income  of  a  health  maintenance organization or a
22    voluntary health services plan, except it shall  not  include
23    credit  health  insurance as defined in Article IX 1/2 of the
24    Illinois Insurance Code.
25        "Director" means the Director of the Illinois  Department
26    of Insurance.
27        "Eligible  person"  means  a  resident  of this State who
28    qualifies for Plan coverage under Section 7 of this Act.
29        "Employee" means a resident of this State who is employed
30    by an employer or has entered into the employment of or works
31    under contract  or  service  of  an  employer  including  the
32    officers,  managers and employees of subsidiary or affiliated
33    corporations and the  individual  proprietors,  partners  and
34    employees  of  affiliated  individuals  and  firms  when  the
 
                            -4-                LRB9200746JSpc
 1    business  of the subsidiary or affiliated corporations, firms
 2    or individuals is controlled by  a  common  employer  through
 3    stock ownership, contract, or otherwise.
 4        "Employer"    means    any    individual,    partnership,
 5    association,  corporation,  business  trust, or any person or
 6    group  of  persons  acting  directly  or  indirectly  in  the
 7    interest of an employer in relation to an employee, for which
 8    one or more persons is gainfully employed.
 9        "Family" coverage means the coverage provided by the Plan
10    for the covered person and his or her eligible dependents who
11    also are covered persons.
12        "Federally  eligible  individual"  means  an   individual
13    resident of this State:
14             (1)(A)  for  whom,  as  of  the  date  on  which the
15        individual seeks Plan coverage under Section 15  of  this
16        Act,  the aggregate of the periods of creditable coverage
17        is 18 or more months, and (B)  whose  most  recent  prior
18        creditable  coverage  was  under  group  health insurance
19        coverage offered by a health insurance  issuer,  a  group
20        health  plan,  a  governmental plan, or a church plan (or
21        health insurance coverage offered in connection with  any
22        such plans) or any other type of creditable coverage that
23        may   be   required   by  the  federal  Health  Insurance
24        Portability and Accountability Act of 1996, as it may  be
25        amended, or the regulations under that Act;
26             (2)  who  is  not  eligible for coverage under (A) a
27        group health plan, (B) part A or part B of  Medicare  due
28        to  age,  or  (C)  medical  assistance, and does not have
29        other health insurance coverage;
30             (3)  with respect to whom the most  recent  coverage
31        within  the coverage period described in paragraph (1)(A)
32        of this definition was not terminated based upon a factor
33        relating to nonpayment of premiums or fraud;
34             (4)  if the individual had been offered  the  option
 
                            -5-                LRB9200746JSpc
 1        of  continuation  coverage  under  a  COBRA  continuation
 2        provision  or  under a similar State program, who elected
 3        such coverage; and
 4             (5)  who,   if   the   individual    elected    such
 5        continuation  coverage,  has  exhausted such continuation
 6        coverage under such provision or program.
 7        "Group health insurance coverage"  means,  in  connection
 8    with  a  group health plan, health insurance coverage offered
 9    in connection with that plan.
10        "Group health plan" has the same meaning given that  term
11    in    the    federal   Health   Insurance   Portability   and
12    Accountability Act of 1996.
13        "Governmental plan" has the same meaning given that  term
14    in    the    federal   Health   Insurance   Portability   and
15    Accountability Act of 1996.
16        "Health insurance coverage" means benefits consisting  of
17    medical   care   (provided  directly,  through  insurance  or
18    reimbursement, or otherwise and including items and  services
19    paid  for  as  medical  care)  under any hospital and medical
20    expense-incurred policy, certificate, or contract provided by
21    an insurer, non-profit health  care  service  plan  contract,
22    health maintenance organization or other subscriber contract,
23    or any other health care plan or arrangement that pays for or
24    furnishes   medical   or  health  care  services  whether  by
25    insurance or otherwise.  Health insurance coverage shall  not
26    include   short   term,  accident  only,  disability  income,
27    hospital confinement or fixed indemnity, dental only,  vision
28    only,  limited  benefit, or credit insurance, coverage issued
29    as a supplement to liability insurance, insurance arising out
30    of  a  workers'  compensation  or  similar  law,   automobile
31    medical-payment  insurance, or insurance under which benefits
32    are payable with or without regard  to  fault  and  which  is
33    statutorily   required  to  be  contained  in  any  liability
34    insurance policy or equivalent self-insurance.
 
                            -6-                LRB9200746JSpc
 1        "Health insurance issuer"  means  an  insurance  company,
 2    insurance  service,  or  insurance  organization (including a
 3    health  maintenance  organization  and  a  voluntary   health
 4    services   plan)   that  is  authorized  to  transact  health
 5    insurance business in this State.  Such term does not include
 6    a group health plan.
 7        "Health Maintenance Organization" means  an  organization
 8    as defined in the Health Maintenance Organization Act.
 9        "Hospice"  means  a  program  as  defined in and licensed
10    under the Hospice Program Licensing Act.
11        "Hospital" means a duly licensed institution  as  defined
12    in  the Hospital Licensing Act, an institution that meets all
13    comparable conditions and requirements in effect in the state
14    in which  it  is  located,  or  the  University  of  Illinois
15    Hospital  as  defined  in the University of Illinois Hospital
16    Act.
17        "Individual  health  insurance  coverage"  means   health
18    insurance  coverage  offered to individuals in the individual
19    market, but does  not  include  short-term,  limited-duration
20    insurance.
21        "Insured" means any individual resident of this State who
22    is  eligible  to receive benefits from any insurer (including
23    health insurance coverage offered in connection with a  group
24    health  plan)  or  health insurance issuer as defined in this
25    Section.
26        "Insurer"  means  any  insurance  company  authorized  to
27    transact health insurance business  in  this  State  and  any
28    corporation  that  provides medical services and is organized
29    under the Voluntary Health Services Plans Act or  the  Health
30    Maintenance Organization Act.
31        "Medical  assistance"  means the State medical assistance
32    or medical assistance no grant (MANG) programs provided under
33    Title XIX of the Social Security Act and Articles V  (Medical
34    Assistance)  and  VI  (General  Assistance)  of  the Illinois
 
                            -7-                LRB9200746JSpc
 1    Public Aid Code (or  any  successor  program)  or  under  any
 2    similar program of health care benefits in a state other than
 3    Illinois.
 4        "Medically  necessary"  means  that  a  service, drug, or
 5    supply is necessary and  appropriate  for  the  diagnosis  or
 6    treatment  of  an  illness or injury in accord with generally
 7    accepted standards  of  medical  practice  at  the  time  the
 8    service,  drug,  or  supply  is  provided.  When specifically
 9    applied to a confinement it further means that the  diagnosis
10    or  treatment  of  the  covered  person's medical symptoms or
11    condition cannot be safely provided  to  that  person  as  an
12    outpatient. A service, drug, or supply shall not be medically
13    necessary if it: (i) is investigational, experimental, or for
14    research  purposes;  or  (ii)  is  provided  solely  for  the
15    convenience  of the patient, the patient's family, physician,
16    hospital, or any other provider; or (iii) exceeds  in  scope,
17    duration,  or  intensity that level of care that is needed to
18    provide  safe,  adequate,  and   appropriate   diagnosis   or
19    treatment;  or (iv) could have been omitted without adversely
20    affecting the covered person's condition or  the  quality  of
21    medical  care;  or  (v) involves the use of a medical device,
22    drug, or substance not formally approved by the United States
23    Food and Drug Administration.
24        "Medical care" means the ordinary and usual  professional
25    services  rendered by a physician or other specified provider
26    during a professional visit for treatment of  an  illness  or
27    injury.
28        "Medicare" means coverage under both Part A and Part B of
29    Title  XVIII of the Social Security Act, 42 U.S.C. Sec. 1395,
30    et seq.
31        "Minimum premium plan" means  an  arrangement  whereby  a
32    specified  amount  of  health care claims is self-funded, but
33    the insurance company  assumes  the  risk  that  claims  will
34    exceed that amount.
 
                            -8-                LRB9200746JSpc
 1        "Participating   transplant   center"  means  a  hospital
 2    designated by the Board as a preferred or exclusive  provider
 3    of  services  for one or more specified human organ or tissue
 4    transplants for which the hospital has  signed  an  agreement
 5    with  the  Board to accept a transplant payment allowance for
 6    all expenses related to the transplant  during  a  transplant
 7    benefit period.
 8        "Physician"  means a person licensed to practice medicine
 9    pursuant to the Medical Practice Act of 1987.
10        "Plan" means  the  Comprehensive  Health  Insurance  Plan
11    established by this Act.
12        "Plan  of  operation"  means the plan of operation of the
13    Plan, including articles, bylaws and operating rules, adopted
14    by the board pursuant to this Act.
15        "Provider" means any hospital, skilled nursing  facility,
16    hospice, home health agency, physician, registered pharmacist
17    acting  within  the  scope of that registration, or any other
18    person or entity licensed  in  Illinois  to  furnish  medical
19    care.
20        "Qualified  high  risk  pool"  has the same meaning given
21    that term in the federal  Health  Insurance  Portability  and
22    Accountability Act of 1996.
23        "Resident"  means  a  person  who  is and continues to be
24    legally domiciled and physically residing on a permanent  and
25    full-time  basis  in  a place of permanent habitation in this
26    State that remains that person's principal residence and from
27    which that person is absent only for temporary or  transitory
28    purpose.
29        "Skilled  nursing  facility"  means  a  facility  or that
30    portion of a  facility  that  is  licensed  by  the  Illinois
31    Department  of  Public Health under the Nursing Home Care Act
32    or a comparable  licensing  authority  in  another  state  to
33    provide skilled nursing care.
34        "Stop-loss  coverage"  means  an  arrangement  whereby an
 
                            -9-                LRB9200746JSpc
 1    insurer insures against the risk  that  any  one  claim  will
 2    exceed  a specific dollar amount or that the entire loss of a
 3    self-insurance plan will exceed a specific amount.
 4        "Third party administrator"  means  an  administrator  as
 5    defined in Section 511.101 of the Illinois Insurance Code who
 6    is licensed under Article XXXI 1/4 of that Code.
 7    (Source:  P.A.  90-30,  eff.  7-1-97;  91-357,  eff. 7-29-99;
 8    91-735, eff. 6-2-00.)

 9        Section 99.  Effective date.  This Act takes effect  upon
10    becoming law.

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