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| [ Engrossed ] | [ Enrolled ] | [ Senate Amendment 001 ] |
92_SB0962
LRB9207521JSpc
1 AN ACT concerning the comprehensive health insurance
2 plan.
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
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1 Section:
2 (1) Hospital services, except that any services
3 provided by a hospital that is located more than 75 miles
4 outside the State of Illinois shall be covered only for a
5 maximum of 45 days in any calendar year. With respect to
6 covered expenses incurred during any calendar year ending
7 on or after December 31, 1999, inpatient hospitalization
8 of an eligible person for the treatment of mental illness
9 at a hospital located within the State of Illinois shall
10 be subject to the same terms and conditions as for any
11 other illness.
12 (2) Professional services for the diagnosis or
13 treatment of injuries, illnesses or conditions, other
14 than dental and mental and nervous disorders as described
15 in paragraph (17), which are rendered by a physician, or
16 by other licensed professionals at the physician's
17 direction. This includes reconstruction of the breast on
18 which a mastectomy was performed; surgery and
19 reconstruction of the other breast to produce a
20 symmetrical appearance; and prostheses and treatment of
21 physical complications at all stages of the mastectomy,
22 including lymphedemas.
23 (2.5) Professional services provided by a physician
24 to children under the age of 16 years for physical
25 examinations and age appropriate immunizations ordered by
26 a physician licensed to practice medicine in all its
27 branches.
28 (3) (Blank).
29 (4) Outpatient prescription drugs that by law
30 require a prescription written by a physician licensed to
31 practice medicine in all its branches subject to such
32 separate deductible, copayment, and other limitations or
33 restrictions as the Board shall approve, including the
34 use of a prescription drug card or any other program, or
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1 both.
2 (5) Skilled nursing services of a licensed skilled
3 nursing facility for not more than 120 days during a
4 policy year.
5 (6) Services of a home health agency in accord with
6 a home health care plan, up to a maximum of 270 visits
7 per year.
8 (7) Services of a licensed hospice for not more
9 than 180 days during a policy year.
10 (8) Use of radium or other radioactive materials.
11 (9) Oxygen.
12 (10) Anesthetics.
13 (11) Orthoses and prostheses other than dental.
14 (12) Rental or purchase in accordance with Board
15 policies or procedures of durable medical equipment,
16 other than eyeglasses or hearing aids, for which there is
17 no personal use in the absence of the condition for which
18 it is prescribed.
19 (13) Diagnostic x-rays and laboratory tests.
20 (14) Oral surgery (i) for excision of partially or
21 completely unerupted impacted teeth when not performed in
22 connection with the routine extraction or repair of
23 teeth; (ii) for excision of tumors or cysts of the jaws,
24 cheeks, lips, tongue, and roof and floor of the mouth;
25 (iii) required for correction of cleft lip and palate and
26 other craniofacial and maxillofacial birth defects; or
27 (iv) for treatment of injuries to natural teeth or a
28 fractured jaw due to an accident.
29 (15) Physical, speech, and functional occupational
30 therapy as medically necessary and provided by
31 appropriate licensed professionals.
32 (16) Emergency and other medically necessary
33 transportation provided by a licensed ambulance service
34 to the nearest health care facility qualified to treat a
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1 covered illness, injury, or condition, subject to the
2 provisions of the Emergency Medical Systems (EMS) Act.
3 (17) Outpatient services for diagnosis and
4 treatment of mental and nervous disorders provided that a
5 covered person shall be required to make a copayment not
6 to exceed 50% and that the Plan's payment shall not
7 exceed such amounts as are established by the Board.
8 (18) Human organ or tissue transplants specified by
9 the Board that are performed at a hospital designated by
10 the Board as a participating transplant center for that
11 specific organ or tissue transplant.
12 (19) Naprapathic services, as appropriate, provided
13 by a licensed naprapathic practitioner.
14 c. Exclusions. Covered expenses of the Plan shall not
15 include the following:
16 (1) Any charge for treatment for cosmetic purposes
17 other than for reconstructive surgery when the service is
18 incidental to or follows surgery resulting from injury,
19 sickness or other diseases of the involved part or
20 surgery for the repair or treatment of a congenital
21 bodily defect to restore normal bodily functions.
22 (2) Any charge for care that is primarily for rest,
23 custodial, educational, or domiciliary purposes.
24 (3) Any charge for services in a private room to
25 the extent it is in excess of the institution's charge
26 for its most common semiprivate room, unless a private
27 room is prescribed as medically necessary by a physician.
28 (4) That part of any charge for room and board or
29 for services rendered or articles prescribed by a
30 physician, dentist, or other health care personnel that
31 exceeds the reasonable and customary charge in the
32 locality or for any services or supplies not medically
33 necessary for the diagnosed injury or illness.
34 (5) Any charge for services or articles the
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1 provision of which is not within the scope of licensure
2 of the institution or individual providing the services
3 or articles.
4 (6) Any expense incurred prior to the effective
5 date of coverage by the Plan for the person on whose
6 behalf the expense is incurred.
7 (7) Dental care, dental surgery, dental treatment,
8 any other dental procedure involving the teeth or
9 periodontium, or any dental appliances, including crowns,
10 bridges, implants, or partial or complete dentures,
11 except as specifically provided in paragraph (14) of
12 subsection b of this Section.
13 (8) Eyeglasses, contact lenses, hearing aids or
14 their fitting.
15 (9) Illness or injury due to acts of war.
16 (10) Services of blood donors and any fee for
17 failure to replace the first 3 pints of blood provided to
18 a covered person each policy year.
19 (11) Personal supplies or services provided by a
20 hospital or nursing home, or any other nonmedical or
21 nonprescribed supply or service.
22 (12) Routine maternity charges for a pregnancy,
23 except where added as optional coverage with payment of
24 an additional premium for pregnancy resulting from
25 conception occurring after the effective date of the
26 optional coverage.
27 (13) (Blank).
28 (14) Any expense or charge for services, drugs, or
29 supplies that are: (i) not provided in accord with
30 generally accepted standards of current medical practice;
31 (ii) for procedures, treatments, equipment, transplants,
32 or implants, any of which are investigational,
33 experimental, or for research purposes; (iii)
34 investigative and not proven safe and effective; or (iv)
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1 for, or resulting from, a gender transformation
2 operation.
3 (15) Any expense or charge for routine physical
4 examinations or tests except as provided in item (2.5) of
5 subsection b of this Section.
6 (16) Any expense for which a charge is not made in
7 the absence of insurance or for which there is no legal
8 obligation on the part of the patient to pay.
9 (17) Any expense incurred for benefits provided
10 under the laws of the United States and this State,
11 including Medicare, Medicaid, and other medical
12 assistance, maternal and child health services and any
13 other program that is administered or funded by the
14 Department of Human Services, Department of Public Aid,
15 or Department of Public Health, military
16 service-connected disability payments, medical services
17 provided for members of the armed forces and their
18 dependents or employees of the armed forces of the United
19 States, and medical services financed on behalf of all
20 citizens by the United States.
21 (18) Any expense or charge for in vitro
22 fertilization, artificial insemination, or any other
23 artificial means used to cause pregnancy.
24 (19) Any expense or charge for oral contraceptives
25 used for birth control or any other temporary birth
26 control measures.
27 (20) Any expense or charge for sterilization or
28 sterilization reversals.
29 (21) Any expense or charge for weight loss
30 programs, exercise equipment, or treatment of obesity,
31 except when certified by a physician as morbid obesity
32 (at least 2 times normal body weight).
33 (22) Any expense or charge for acupuncture
34 treatment unless used as an anesthetic agent for a
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1 covered surgery.
2 (23) Any expense or charge for or related to organ
3 or tissue transplants other than those performed at a
4 hospital with a Board approved organ transplant program
5 that has been designated by the Board as a preferred or
6 exclusive provider organization for that specific organ
7 or tissue transplant.
8 (24) Any expense or charge for procedures,
9 treatments, equipment, or services that are provided in
10 special settings for research purposes or in a controlled
11 environment, are being studied for safety, efficiency,
12 and effectiveness, and are awaiting endorsement by the
13 appropriate national medical speciality college for
14 general use within the medical community.
15 d. Deductibles and coinsurance.
16 The Plan coverage defined in Section 6 shall provide for
17 a choice of deductibles per individual as authorized by the
18 Board. If 2 individual members of the same family household,
19 who are both covered persons under the Plan, satisfy the same
20 applicable deductibles, no other member of that family who is
21 also a covered person under the Plan shall be required to
22 meet any deductibles for the balance of that calendar year.
23 The deductibles must be applied first to the authorized
24 amount of covered expenses incurred by the covered person. A
25 mandatory coinsurance requirement shall be imposed at the
26 rate authorized by the Board in excess of the mandatory
27 deductible, the coinsurance in the aggregate not to exceed
28 such amounts as are authorized by the Board per annum. At
29 its discretion the Board may, however, offer catastrophic
30 coverages or other policies that provide for larger
31 deductibles with or without coinsurance requirements. The
32 deductibles and coinsurance factors may be adjusted annually
33 according to the Medical Component of the Consumer Price
34 Index.
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1 e. Scope of coverage.
2 (1) In approving any of the benefit plans to be
3 offered by the Plan, the Board shall establish such
4 benefit levels, deductibles, coinsurance factors,
5 exclusions, and limitations as it may deem appropriate
6 and that it believes to be generally reflective of and
7 commensurate with health insurance coverage that is
8 provided in the individual market in this State.
9 (2) The benefit plans approved by the Board may
10 also provide for and employ various cost containment
11 measures and other requirements including, but not
12 limited to, preadmission certification, prior approval,
13 second surgical opinions, concurrent utilization review
14 programs, individual case management, preferred provider
15 organizations, health maintenance organizations, and
16 other cost effective arrangements for paying for covered
17 expenses.
18 f. Preexisting conditions.
19 (1) Except for (i) an eligible person whose
20 previous coverage was under an individual policy of
21 accident and health insurance that was terminated because
22 of the insolvency of the issuer of that policy and (ii)
23 federally eligible individuals qualifying for Plan
24 coverage under Section 15 of this Act, plan coverage
25 shall exclude charges or expenses incurred during the
26 first 6 months following the effective date of coverage
27 as to any condition for which medical advice, care or
28 treatment was recommended or received during the 6 month
29 period immediately preceding the effective date of
30 coverage.
31 (2) (Blank).
32 (3) (Blank).
33 g. Other sources primary; nonduplication of benefits.
34 (1) The Plan shall be the last payor of benefits
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1 whenever any other benefit or source of third party
2 payment is available. Subject to the provisions of
3 subsection e of Section 7, benefits otherwise payable
4 under Plan coverage shall be reduced by all amounts paid
5 or payable by Medicare or any other government program or
6 through any health insurance coverage or group health
7 plan, whether by insurance, reimbursement, or otherwise,
8 or through any third party liability, settlement,
9 judgment, or award, regardless of the date of the
10 settlement, judgment, or award, whether the settlement,
11 judgment, or award is in the form of a contract,
12 agreement, or trust on behalf of a minor or otherwise and
13 whether the settlement, judgment, or award is payable to
14 the covered person, his or her dependent, estate,
15 personal representative, or guardian in a lump sum or
16 over time, and by all hospital or medical expense
17 benefits paid or payable under any worker's compensation
18 coverage, automobile medical payment, or liability
19 insurance, whether provided on the basis of fault or
20 nonfault, and by any hospital or medical benefits paid or
21 payable under or provided pursuant to any State or
22 federal law or program.
23 (2) The Plan shall have a cause of action against
24 any covered person or any other person or entity for the
25 recovery of any amount paid to the extent the amount was
26 for treatment, services, or supplies not covered in this
27 Section or in excess of benefits as set forth in this
28 Section.
29 (3) Whenever benefits are due from the Plan because
30 of sickness or an injury to a covered person resulting
31 from a third party's wrongful act or negligence and the
32 covered person has recovered or may recover damages from
33 a third party or its insurer, the Plan shall have the
34 right to reduce benefits or to refuse to pay benefits
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1 that otherwise may be payable by the amount of damages
2 that the covered person has recovered or may recover
3 regardless of the date of the sickness or injury or the
4 date of any settlement, judgment, or award resulting from
5 that sickness or injury.
6 During the pendency of any action or claim that is
7 brought by or on behalf of a covered person against a
8 third party or its insurer, any benefits that would
9 otherwise be payable except for the provisions of this
10 paragraph (3) shall be paid if payment by or for the
11 third party has not yet been made and the covered person
12 or, if incapable, that person's legal representative
13 agrees in writing to pay back promptly the benefits paid
14 as a result of the sickness or injury to the extent of
15 any future payments made by or for the third party for
16 the sickness or injury. This agreement is to apply
17 whether or not liability for the payments is established
18 or admitted by the third party or whether those payments
19 are itemized.
20 Any amounts due the plan to repay benefits may be
21 deducted from other benefits payable by the Plan after
22 payments by or for the third party are made.
23 (4) Benefits due from the Plan may be reduced or
24 refused as an offset against any amount otherwise
25 recoverable under this Section.
26 h. Right of subrogation; recoveries.
27 (1) Whenever the Plan has paid benefits because of
28 sickness or an injury to any covered person resulting
29 from a third party's wrongful act or negligence, or for
30 which an insurer is liable in accordance with the
31 provisions of any policy of insurance, and the covered
32 person has recovered or may recover damages from a third
33 party that is liable for the damages, the Plan shall have
34 the right to recover the benefits it paid from any
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1 amounts that the covered person has received or may
2 receive regardless of the date of the sickness or injury
3 or the date of any settlement, judgment, or award
4 resulting from that sickness or injury. The Plan shall
5 be subrogated to any right of recovery the covered person
6 may have under the terms of any private or public health
7 care coverage or liability coverage, including coverage
8 under the Workers' Compensation Act or the Workers'
9 Occupational Diseases Act, without the necessity of
10 assignment of claim or other authorization to secure the
11 right of recovery. To enforce its subrogation right, the
12 Plan may (i) intervene or join in an action or proceeding
13 brought by the covered person or his personal
14 representative, including his guardian, conservator,
15 estate, dependents, or survivors, against any third party
16 or the third party's insurer that may be liable or (ii)
17 institute and prosecute legal proceedings against any
18 third party or the third party's insurer that may be
19 liable for the sickness or injury in an appropriate court
20 either in the name of the Plan or in the name of the
21 covered person or his personal representative, including
22 his guardian, conservator, estate, dependents, or
23 survivors.
24 (2) If any action or claim is brought by or on
25 behalf of a covered person against a third party or the
26 third party's insurer, the covered person or his personal
27 representative, including his guardian, conservator,
28 estate, dependents, or survivors, shall notify the Plan
29 by personal service or registered mail of the action or
30 claim and of the name of the court in which the action or
31 claim is brought, filing proof thereof in the action or
32 claim. The Plan may, at any time thereafter, join in the
33 action or claim upon its motion so that all orders of
34 court after hearing and judgment shall be made for its
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1 protection. No release or settlement of a claim for
2 damages and no satisfaction of judgment in the action
3 shall be valid without the written consent of the Plan to
4 the extent of its interest in the settlement or judgment
5 and of the covered person or his personal representative.
6 (3) In the event that the covered person or his
7 personal representative fails to institute a proceeding
8 against any appropriate third party before the fifth
9 month before the action would be barred, the Plan may, in
10 its own name or in the name of the covered person or
11 personal representative, commence a proceeding against
12 any appropriate third party for the recovery of damages
13 on account of any sickness, injury, or death to the
14 covered person. The covered person shall cooperate in
15 doing what is reasonably necessary to assist the Plan in
16 any recovery and shall not take any action that would
17 prejudice the Plan's right to recovery. The Plan shall
18 pay to the covered person or his personal representative
19 all sums collected from any third party by judgment or
20 otherwise in excess of amounts paid in benefits under the
21 Plan and amounts paid or to be paid as costs, attorneys
22 fees, and reasonable expenses incurred by the Plan in
23 making the collection or enforcing the judgment.
24 (4) In the event that a covered person or his
25 personal representative, including his guardian,
26 conservator, estate, dependents, or survivors, recovers
27 damages from a third party for sickness or injury caused
28 to the covered person, the covered person or the personal
29 representative shall pay to the Plan from the damages
30 recovered the amount of benefits paid or to be paid on
31 behalf of the covered person.
32 (5) When the action or claim is brought by the
33 covered person alone and the covered person incurs a
34 personal liability to pay attorney's fees and costs of
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1 litigation, the Plan's claim for reimbursement of the
2 benefits provided to the covered person shall be the full
3 amount of benefits paid to or on behalf of the covered
4 person under this Act less a pro rata share that
5 represents the Plan's reasonable share of attorney's fees
6 paid by the covered person and that portion of the cost
7 of litigation expenses determined by multiplying by the
8 ratio of the full amount of the expenditures to the full
9 amount of the judgement, award, or settlement.
10 (6) In the event of judgment or award in a suit or
11 claim against a third party or insurer, the court shall
12 first order paid from any judgement or award the
13 reasonable litigation expenses incurred in preparation
14 and prosecution of the action or claim, together with
15 reasonable attorney's fees. After payment of those
16 expenses and attorney's fees, the court shall apply out
17 of the balance of the judgment or award an amount
18 sufficient to reimburse the Plan the full amount of
19 benefits paid on behalf of the covered person under this
20 Act, provided the court may reduce and apportion the
21 Plan's portion of the judgement proportionate to the
22 recovery of the covered person. The burden of producing
23 evidence sufficient to support the exercise by the court
24 of its discretion to reduce the amount of a proven charge
25 sought to be enforced against the recovery shall rest
26 with the party seeking the reduction. The court may
27 consider the nature and extent of the injury, economic
28 and non-economic loss, settlement offers, comparative
29 negligence as it applies to the case at hand, hospital
30 costs, physician costs, and all other appropriate costs.
31 The Plan shall pay its pro rata share of the attorney
32 fees based on the Plan's recovery as it compares to the
33 total judgment. Any reimbursement rights of the Plan
34 shall take priority over all other liens and charges
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1 existing under the laws of this State with the exception
2 of any attorney liens filed under the Attorneys Lien Act.
3 (7) The Plan may compromise or settle and release
4 any claim for benefits provided under this Act or waive
5 any claims for benefits, in whole or in part, for the
6 convenience of the Plan or if the Plan determines that
7 collection would result in undue hardship upon the
8 covered person.
9 (Source: P.A. 90-7, eff. 6-10-97; 90-30, eff. 7-1-97; 90-655,
10 eff. 7-30-98; 91-639, eff. 8-20-99; 91-735, eff. 6-2-00.)
11 Section 99. Effective date. This Act takes effect upon
12 becoming law.