State of Illinois
92nd General Assembly

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[ Introduced ][ Engrossed ][ Senate Amendment 001 ]


SB962 Enrolled                                 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
SB962 Enrolled              -2-                LRB9207521JSpc
 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
SB962 Enrolled              -3-                LRB9207521JSpc
 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
SB962 Enrolled              -4-                LRB9207521JSpc
 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
SB962 Enrolled              -5-                LRB9207521JSpc
 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)
SB962 Enrolled              -6-                LRB9207521JSpc
 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
SB962 Enrolled              -7-                LRB9207521JSpc
 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.
SB962 Enrolled              -8-                LRB9207521JSpc
 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   federally  eligible  individuals
20        qualifying for Plan coverage under Section 15 of this Act
21        or eligible persons who qualify for the waiver authorized
22        in paragraph (3) of this subsection, plan coverage  shall
23        exclude  charges  or expenses incurred during the first 6
24        months following the effective date of coverage as to any
25        condition for which medical advice, care or treatment was
26        recommended  or  received  during  the  6  month   period
27        immediately preceding the effective date of coverage.
28             (2)  (Blank).
29             (3)  Waiver: The preexisting condition exclusions as
30        set  forth  in  paragraph (1) of this subsection shall be
31        waived to the extent to which the eligible person (a) has
32        satisfied similar exclusions under any  prior  individual
33        health insurance policy that was involuntarily terminated
34        because of the insolvency of the issuer of the policy and
SB962 Enrolled              -9-                LRB9207521JSpc
 1        (b)   has  applied  for  Plan  coverage  within  63  days
 2        following the involuntary termination of that  individual
 3        health insurance coverage (Blank).
 4        g.  Other sources primary;  nonduplication of benefits.
 5             (1)  The  Plan  shall  be the last payor of benefits
 6        whenever any other  benefit  or  source  of  third  party
 7        payment  is  available.   Subject  to  the  provisions of
 8        subsection e of Section  7,  benefits  otherwise  payable
 9        under  Plan coverage shall be reduced by all amounts paid
10        or payable by Medicare or any other government program or
11        through any health insurance  coverage  or  group  health
12        plan,  whether by insurance, reimbursement, or otherwise,
13        or  through  any  third  party   liability,   settlement,
14        judgment,  or  award,  regardless  of  the  date  of  the
15        settlement,  judgment,  or award, whether the settlement,
16        judgment,  or  award  is  in  the  form  of  a  contract,
17        agreement, or trust on behalf of a minor or otherwise and
18        whether the settlement, judgment, or award is payable  to
19        the   covered  person,  his  or  her  dependent,  estate,
20        personal representative, or guardian in  a  lump  sum  or
21        over  time,  and  by  all  hospital  or  medical  expense
22        benefits  paid or payable under any worker's compensation
23        coverage,  automobile  medical  payment,   or   liability
24        insurance,  whether  provided  on  the  basis of fault or
25        nonfault, and by any hospital or medical benefits paid or
26        payable under  or  provided  pursuant  to  any  State  or
27        federal law or program.
28             (2)  The  Plan  shall have a cause of action against
29        any covered person or any other person or entity for  the
30        recovery  of any amount paid to the extent the amount was
31        for treatment, services, or supplies not covered in  this
32        Section  or  in  excess  of benefits as set forth in this
33        Section.
34             (3)  Whenever benefits are due from the Plan because
SB962 Enrolled              -10-               LRB9207521JSpc
 1        of sickness or an injury to a  covered  person  resulting
 2        from  a  third party's wrongful act or negligence and the
 3        covered person has recovered or may recover damages  from
 4        a  third  party  or  its insurer, the Plan shall have the
 5        right to reduce benefits or to  refuse  to  pay  benefits
 6        that  otherwise  may  be payable by the amount of damages
 7        that the covered person  has  recovered  or  may  recover
 8        regardless  of  the date of the sickness or injury or the
 9        date of any settlement, judgment, or award resulting from
10        that sickness or injury.
11             During the pendency of any action or claim  that  is
12        brought  by  or  on  behalf of a covered person against a
13        third party or  its  insurer,  any  benefits  that  would
14        otherwise  be  payable  except for the provisions of this
15        paragraph (3) shall be paid if  payment  by  or  for  the
16        third  party has not yet been made and the covered person
17        or, if  incapable,  that  person's  legal  representative
18        agrees  in writing to pay back promptly the benefits paid
19        as a result of the sickness or injury to  the  extent  of
20        any  future  payments  made by or for the third party for
21        the sickness or  injury.   This  agreement  is  to  apply
22        whether  or not liability for the payments is established
23        or admitted by the third party or whether those  payments
24        are itemized.
25             Any  amounts  due  the plan to repay benefits may be
26        deducted from other benefits payable by  the  Plan  after
27        payments by or for the third party are made.
28             (4)  Benefits  due  from  the Plan may be reduced or
29        refused  as  an  offset  against  any  amount   otherwise
30        recoverable under this Section.
31        h.  Right of subrogation; recoveries.
32             (1)  Whenever  the Plan has paid benefits because of
33        sickness or an injury to  any  covered  person  resulting
34        from  a  third party's wrongful act or negligence, or for
SB962 Enrolled              -11-               LRB9207521JSpc
 1        which  an  insurer  is  liable  in  accordance  with  the
 2        provisions of any policy of insurance,  and  the  covered
 3        person  has recovered or may recover damages from a third
 4        party that is liable for the damages, the Plan shall have
 5        the right to  recover  the  benefits  it  paid  from  any
 6        amounts  that  the  covered  person  has  received or may
 7        receive regardless of the date of the sickness or  injury
 8        or  the  date  of  any  settlement,  judgment,  or  award
 9        resulting  from  that sickness or injury.  The Plan shall
10        be subrogated to any right of recovery the covered person
11        may have under the terms of any private or public  health
12        care  coverage  or liability coverage, including coverage
13        under the  Workers'  Compensation  Act  or  the  Workers'
14        Occupational  Diseases  Act,  without  the  necessity  of
15        assignment  of claim or other authorization to secure the
16        right of recovery.  To enforce its subrogation right, the
17        Plan may (i) intervene or join in an action or proceeding
18        brought  by  the   covered   person   or   his   personal
19        representative,   including  his  guardian,  conservator,
20        estate, dependents, or survivors, against any third party
21        or the third party's insurer that may be liable  or  (ii)
22        institute  and  prosecute  legal  proceedings against any
23        third party or the third  party's  insurer  that  may  be
24        liable for the sickness or injury in an appropriate court
25        either  in  the  name  of  the Plan or in the name of the
26        covered person or his personal representative,  including
27        his   guardian,   conservator,   estate,  dependents,  or
28        survivors.
29             (2)  If any action or claim  is  brought  by  or  on
30        behalf  of  a covered person against a third party or the
31        third party's insurer, the covered person or his personal
32        representative,  including  his  guardian,   conservator,
33        estate,  dependents,  or survivors, shall notify the Plan
34        by personal service or registered mail of the  action  or
SB962 Enrolled              -12-               LRB9207521JSpc
 1        claim and of the name of the court in which the action or
 2        claim  is  brought, filing proof thereof in the action or
 3        claim.  The Plan may, at any time thereafter, join in the
 4        action or claim upon its motion so  that  all  orders  of
 5        court  after  hearing  and judgment shall be made for its
 6        protection.  No release or  settlement  of  a  claim  for
 7        damages  and  no  satisfaction  of judgment in the action
 8        shall be valid without the written consent of the Plan to
 9        the extent of its interest in the settlement or  judgment
10        and of the covered person or his personal representative.
11             (3)  In  the  event  that  the covered person or his
12        personal representative fails to institute  a  proceeding
13        against  any  appropriate  third  party  before the fifth
14        month before the action would be barred, the Plan may, in
15        its own name or in the name  of  the  covered  person  or
16        personal  representative,  commence  a proceeding against
17        any appropriate third party for the recovery  of  damages
18        on  account  of  any  sickness,  injury,  or death to the
19        covered person.  The covered person  shall  cooperate  in
20        doing  what is reasonably necessary to assist the Plan in
21        any recovery and shall not take  any  action  that  would
22        prejudice  the  Plan's right to recovery.  The Plan shall
23        pay to the covered person or his personal  representative
24        all  sums  collected  from any third party by judgment or
25        otherwise in excess of amounts paid in benefits under the
26        Plan and amounts paid or to be paid as  costs,  attorneys
27        fees,  and  reasonable  expenses  incurred by the Plan in
28        making the collection or enforcing the judgment.
29             (4)  In the event  that  a  covered  person  or  his
30        personal    representative,   including   his   guardian,
31        conservator, estate, dependents, or  survivors,  recovers
32        damages  from a third party for sickness or injury caused
33        to the covered person, the covered person or the personal
34        representative shall pay to the  Plan  from  the  damages
SB962 Enrolled              -13-               LRB9207521JSpc
 1        recovered  the  amount  of benefits paid or to be paid on
 2        behalf of the covered person.
 3             (5)  When the action or  claim  is  brought  by  the
 4        covered  person  alone  and  the  covered person incurs a
 5        personal liability to pay attorney's fees  and  costs  of
 6        litigation,  the  Plan's  claim  for reimbursement of the
 7        benefits provided to the covered person shall be the full
 8        amount of benefits paid to or on behalf  of  the  covered
 9        person  under  this  Act  less  a  pro  rata  share  that
10        represents the Plan's reasonable share of attorney's fees
11        paid  by  the covered person and that portion of the cost
12        of litigation expenses determined by multiplying  by  the
13        ratio  of the full amount of the expenditures to the full
14        amount of the judgement, award, or settlement.
15             (6)  In the event of judgment or award in a suit  or
16        claim  against  a third party or insurer, the court shall
17        first  order  paid  from  any  judgement  or  award   the
18        reasonable  litigation  expenses  incurred in preparation
19        and prosecution of the action  or  claim,  together  with
20        reasonable  attorney's  fees.   After  payment  of  those
21        expenses  and  attorney's fees, the court shall apply out
22        of the  balance  of  the  judgment  or  award  an  amount
23        sufficient  to  reimburse  the  Plan  the  full amount of
24        benefits paid on behalf of the covered person under  this
25        Act,  provided  the  court  may  reduce and apportion the
26        Plan's portion of  the  judgement  proportionate  to  the
27        recovery  of the covered person.  The burden of producing
28        evidence sufficient to support the exercise by the  court
29        of its discretion to reduce the amount of a proven charge
30        sought  to  be  enforced  against the recovery shall rest
31        with the party seeking  the  reduction.   The  court  may
32        consider  the  nature  and extent of the injury, economic
33        and non-economic  loss,  settlement  offers,  comparative
34        negligence  as  it  applies to the case at hand, hospital
SB962 Enrolled              -14-               LRB9207521JSpc
 1        costs, physician costs, and all other appropriate costs.
 2        The Plan shall pay its pro rata  share  of  the  attorney
 3        fees  based  on the Plan's recovery as it compares to the
 4        total judgment.  Any reimbursement  rights  of  the  Plan
 5        shall  take  priority  over  all  other liens and charges
 6        existing under the laws of this State with the  exception
 7        of any attorney liens filed under the Attorneys Lien Act.
 8             (7)  The  Plan  may compromise or settle and release
 9        any claim for benefits provided under this Act  or  waive
10        any  claims  for  benefits,  in whole or in part, for the
11        convenience of the Plan or if the  Plan  determines  that
12        collection  would  result  in  undue  hardship  upon  the
13        covered person.
14    (Source: P.A. 90-7, eff. 6-10-97; 90-30, eff. 7-1-97; 90-655,
15    eff. 7-30-98; 91-639, eff. 8-20-99; 91-735, eff. 6-2-00.)

16        Section  99.  Effective date.  This Act takes effect upon
17    becoming law.

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