Public Act 096-0791
SB2052 Enrolled LRB096 11280 JAM 21707 b

    AN ACT concerning State government.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Comprehensive Health Insurance Plan Act is
amended by changing Section 8 as follows:
    (215 ILCS 105/8)  (from Ch. 73, par. 1308)
    Sec. 8. Minimum benefits.
    a. Availability. The Plan shall offer in a periodically an
annually renewable policy major medical expense coverage to
every eligible person who is not eligible for Medicare. Major
medical expense coverage offered by the Plan shall pay an
eligible person's covered expenses, subject to limit on the
deductible and coinsurance payments authorized under paragraph
(4) of subsection d of this Section, up to a lifetime benefit
limit of $2,000,000 until 3 years after the effective date of
this amendatory Act of the 95th General Assembly, and
$1,500,000 in benefits 3 years or more after the effective date
of this amendatory Act of the 95th General Assembly per covered
individual. The maximum limit under this subsection shall not
be altered by the Board, and no actuarial equivalent benefit
may be substituted by the Board. Any person who otherwise would
qualify for coverage under the Plan, but is excluded because he
or she is eligible for Medicare, shall be eligible for any
separate Medicare supplement policy or policies which the Board
may offer.
    b. Outline of benefits. Covered expenses shall be limited
to the usual and customary charge, including negotiated fees,
in the locality for the following services and articles when
prescribed by a physician and determined by the Plan to be
medically necessary for the following areas of services,
subject to such separate deductibles, co-payments, exclusions,
and other limitations on benefits as the Board shall establish
and approve, and the other provisions of this Section:
        (1) Hospital services, except that any services
    provided by a hospital that is located more than 75 miles
    outside the State of Illinois shall be covered only for a
    maximum of 45 days in any calendar year. With respect to
    covered expenses incurred during any calendar year ending
    on or after December 31, 1999, inpatient hospitalization of
    an eligible person for the treatment of mental illness at a
    hospital located within the State of Illinois shall be
    subject to the same terms and conditions as for any other
        (2) Professional services for the diagnosis or
    treatment of injuries, illnesses or conditions, other than
    dental and mental and nervous disorders as described in
    paragraph (17), which are rendered by a physician, or by
    other licensed professionals at the physician's direction.
    This includes reconstruction of the breast on which a
    mastectomy was performed; surgery and reconstruction of
    the other breast to produce a symmetrical appearance; and
    prostheses and treatment of physical complications at all
    stages of the mastectomy, including lymphedemas.
        (2.5) Professional services provided by a physician to
    children under the age of 16 years for physical
    examinations and age appropriate immunizations ordered by
    a physician licensed to practice medicine in all its
        (3) (Blank).
        (4) Outpatient prescription drugs that by law require a
    prescription written by a physician licensed to practice
    medicine in all its branches subject to such separate
    deductible, copayment, and other limitations or
    restrictions as the Board shall approve, including the use
    of a prescription drug card or any other program, or both.
        (5) Skilled nursing services of a licensed skilled
    nursing facility for not more than 120 days during a policy
        (6) Services of a home health agency in accord with a
    home health care plan, up to a maximum of 270 visits per
        (7) Services of a licensed hospice for not more than
    180 days during a policy year.
        (8) Use of radium or other radioactive materials.
        (9) Oxygen.
        (10) Anesthetics.
        (11) Orthoses and prostheses other than dental.
        (12) Rental or purchase in accordance with Board
    policies or procedures of durable medical equipment, other
    than eyeglasses or hearing aids, for which there is no
    personal use in the absence of the condition for which it
    is prescribed.
        (13) Diagnostic x-rays and laboratory tests.
        (14) Oral surgery (i) for excision of partially or
    completely unerupted impacted teeth when not performed in
    connection with the routine extraction or repair of teeth;
    (ii) for excision of tumors or cysts of the jaws, cheeks,
    lips, tongue, and roof and floor of the mouth; (iii)
    required for correction of cleft lip and palate and other
    craniofacial and maxillofacial birth defects; or (iv) for
    treatment of injuries to natural teeth or a fractured jaw
    due to an accident.
        (15) Physical, speech, and functional occupational
    therapy as medically necessary and provided by appropriate
    licensed professionals.
        (16) Emergency and other medically necessary
    transportation provided by a licensed ambulance service to
    the nearest health care facility qualified to treat a
    covered illness, injury, or condition, subject to the
    provisions of the Emergency Medical Systems (EMS) Act.
        (17) Outpatient services for diagnosis and treatment
    of mental and nervous disorders provided that a covered
    person shall be required to make a copayment not to exceed
    50% and that the Plan's payment shall not exceed such
    amounts as are established by the Board.
        (18) Human organ or tissue transplants specified by the
    Board that are performed at a hospital designated by the
    Board as a participating transplant center for that
    specific organ or tissue transplant.
        (19) Naprapathic services, as appropriate, provided by
    a licensed naprapathic practitioner.
    c. Exclusions. Covered expenses of the Plan shall not
include the following:
        (1) Any charge for treatment for cosmetic purposes
    other than for reconstructive surgery when the service is
    incidental to or follows surgery resulting from injury,
    sickness or other diseases of the involved part or surgery
    for the repair or treatment of a congenital bodily defect
    to restore normal bodily functions.
        (2) Any charge for care that is primarily for rest,
    custodial, educational, or domiciliary purposes.
        (3) Any charge for services in a private room to the
    extent it is in excess of the institution's charge for its
    most common semiprivate room, unless a private room is
    prescribed as medically necessary by a physician.
        (4) That part of any charge for room and board or for
    services rendered or articles prescribed by a physician,
    dentist, or other health care personnel that exceeds the
    reasonable and customary charge in the locality or for any
    services or supplies not medically necessary for the
    diagnosed injury or illness.
        (5) Any charge for services or articles the provision
    of which is not within the scope of licensure of the
    institution or individual providing the services or
        (6) Any expense incurred prior to the effective date of
    coverage by the Plan for the person on whose behalf the
    expense is incurred.
        (7) Dental care, dental surgery, dental treatment, any
    other dental procedure involving the teeth or
    periodontium, or any dental appliances, including crowns,
    bridges, implants, or partial or complete dentures, except
    as specifically provided in paragraph (14) of subsection b
    of this Section.
        (8) Eyeglasses, contact lenses, hearing aids or their
        (9) Illness or injury due to acts of war.
        (10) Services of blood donors and any fee for failure
    to replace the first 3 pints of blood provided to a covered
    person each policy year.
        (11) Personal supplies or services provided by a
    hospital or nursing home, or any other nonmedical or
    nonprescribed supply or service.
        (12) Routine maternity charges for a pregnancy, except
    where added as optional coverage with payment of an
    additional premium for pregnancy resulting from conception
    occurring after the effective date of the optional
        (13) (Blank).
        (14) Any expense or charge for services, drugs, or
    supplies that are: (i) not provided in accord with
    generally accepted standards of current medical practice;
    (ii) for procedures, treatments, equipment, transplants,
    or implants, any of which are investigational,
    experimental, or for research purposes; (iii)
    investigative and not proven safe and effective; or (iv)
    for, or resulting from, a gender transformation operation.
        (15) Any expense or charge for routine physical
    examinations or tests except as provided in item (2.5) of
    subsection b of this Section.
        (16) Any expense for which a charge is not made in the
    absence of insurance or for which there is no legal
    obligation on the part of the patient to pay.
        (17) Any expense incurred for benefits provided under
    the laws of the United States and this State, including
    Medicare, Medicaid, and other medical assistance, maternal
    and child health services and any other program that is
    administered or funded by the Department of Human Services,
    Department of Healthcare and Family Services, or
    Department of Public Health, military service-connected
    disability payments, medical services provided for members
    of the armed forces and their dependents or employees of
    the armed forces of the United States, and medical services
    financed on behalf of all citizens by the United States.
        (18) Any expense or charge for in vitro fertilization,
    artificial insemination, or any other artificial means
    used to cause pregnancy.
        (19) Any expense or charge for oral contraceptives used
    for birth control or any other temporary birth control
        (20) Any expense or charge for sterilization or
    sterilization reversals.
        (21) Any expense or charge for weight loss programs,
    exercise equipment, or treatment of obesity, except when
    certified by a physician as morbid obesity (at least 2
    times normal body weight).
        (22) Any expense or charge for acupuncture treatment
    unless used as an anesthetic agent for a covered surgery.
        (23) Any expense or charge for or related to organ or
    tissue transplants other than those performed at a hospital
    with a Board approved organ transplant program that has
    been designated by the Board as a preferred or exclusive
    provider organization for that specific organ or tissue
        (24) Any expense or charge for procedures, treatments,
    equipment, or services that are provided in special
    settings for research purposes or in a controlled
    environment, are being studied for safety, efficiency, and
    effectiveness, and are awaiting endorsement by the
    appropriate national medical speciality college for
    general use within the medical community.
    d. Deductibles and coinsurance.
    The Plan coverage defined in Section 6 shall provide for a
choice of deductibles per individual as authorized by the
Board. If 2 individual members of the same family household,
who are both covered persons under the Plan, satisfy the same
applicable deductibles, no other member of that family who is
also a covered person under the Plan shall be required to meet
any deductibles for the balance of that calendar year. The
deductibles must be applied first to the authorized amount of
covered expenses incurred by the covered person. A mandatory
coinsurance requirement shall be imposed at the rate authorized
by the Board in excess of the mandatory deductible, the
coinsurance in the aggregate not to exceed such amounts as are
authorized by the Board per annum. At its discretion the Board
may, however, offer catastrophic coverages or other policies
that provide for larger deductibles with or without coinsurance
requirements. The deductibles and coinsurance factors may be
adjusted annually according to the Medical Component of the
Consumer Price Index.
    e. Scope of coverage.
        (1) In approving any of the benefit plans to be offered
    by the Plan, the Board shall establish such benefit levels,
    deductibles, coinsurance factors, exclusions, and
    limitations as it may deem appropriate and that it believes
    to be generally reflective of and commensurate with health
    insurance coverage that is provided in the individual
    market in this State.
        (2) The benefit plans approved by the Board may also
    provide for and employ various cost containment measures
    and other requirements including, but not limited to,
    preadmission certification, prior approval, second
    surgical opinions, concurrent utilization review programs,
    individual case management, preferred provider
    organizations, health maintenance organizations, and other
    cost effective arrangements for paying for covered
    f. Preexisting conditions.
        (1) Except for federally eligible individuals
    qualifying for Plan coverage under Section 15 of this Act
    or eligible persons who qualify for the waiver authorized
    in paragraph (3) of this subsection, plan coverage shall
    exclude charges or expenses incurred during the first 6
    months following the effective date of coverage as to any
    condition for which medical advice, care or treatment was
    recommended or received during the 6 month period
    immediately preceding the effective date of coverage.
        (2) (Blank).
        (3) Waiver: The preexisting condition exclusions as
    set forth in paragraph (1) of this subsection shall be
    waived to the extent to which the eligible person (a) has
    satisfied similar exclusions under any prior individual
    health insurance policy that was involuntarily terminated
    because of the insolvency of the issuer of the policy and
    (b) has applied for Plan coverage within 90 days following
    the involuntary termination of that individual health
    insurance coverage.
    g. Other sources primary; nonduplication of benefits.
        (1) The Plan shall be the last payor of benefits
    whenever any other benefit or source of third party payment
    is available. Subject to the provisions of subsection e of
    Section 7, benefits otherwise payable under Plan coverage
    shall be reduced by all amounts paid or payable by Medicare
    or any other government program or through any health
    insurance coverage or group health plan, whether by
    insurance, reimbursement, or otherwise, or through any
    third party liability, settlement, judgment, or award,
    regardless of the date of the settlement, judgment, or
    award, whether the settlement, judgment, or award is in the
    form of a contract, agreement, or trust on behalf of a
    minor or otherwise and whether the settlement, judgment, or
    award is payable to the covered person, his or her
    dependent, estate, personal representative, or guardian in
    a lump sum or over time, and by all hospital or medical
    expense benefits paid or payable under any worker's
    compensation coverage, automobile medical payment, or
    liability insurance, whether provided on the basis of fault
    or nonfault, and by any hospital or medical benefits paid
    or payable under or provided pursuant to any State or
    federal law or program.
        (2) The Plan shall have a cause of action against any
    covered person or any other person or entity for the
    recovery of any amount paid to the extent the amount was
    for treatment, services, or supplies not covered in this
    Section or in excess of benefits as set forth in this
        (3) Whenever benefits are due from the Plan because of
    sickness or an injury to a covered person resulting from a
    third party's wrongful act or negligence and the covered
    person has recovered or may recover damages from a third
    party or its insurer, the Plan shall have the right to
    reduce benefits or to refuse to pay benefits that otherwise
    may be payable by the amount of damages that the covered
    person has recovered or may recover regardless of the date
    of the sickness or injury or the date of any settlement,
    judgment, or award resulting from that sickness or injury.
        During the pendency of any action or claim that is
    brought by or on behalf of a covered person against a third
    party or its insurer, any benefits that would otherwise be
    payable except for the provisions of this paragraph (3)
    shall be paid if payment by or for the third party has not
    yet been made and the covered person or, if incapable, that
    person's legal representative agrees in writing to pay back
    promptly the benefits paid as a result of the sickness or
    injury to the extent of any future payments made by or for
    the third party for the sickness or injury. This agreement
    is to apply whether or not liability for the payments is
    established or admitted by the third party or whether those
    payments are itemized.
        Any amounts due the plan to repay benefits may be
    deducted from other benefits payable by the Plan after
    payments by or for the third party are made.
        (4) Benefits due from the Plan may be reduced or
    refused as an offset against any amount otherwise
    recoverable under this Section.
    h. Right of subrogation; recoveries.
        (1) Whenever the Plan has paid benefits because of
    sickness or an injury to any covered person resulting from
    a third party's wrongful act or negligence, or for which an
    insurer is liable in accordance with the provisions of any
    policy of insurance, and the covered person has recovered
    or may recover damages from a third party that is liable
    for the damages, the Plan shall have the right to recover
    the benefits it paid from any amounts that the covered
    person has received or may receive regardless of the date
    of the sickness or injury or the date of any settlement,
    judgment, or award resulting from that sickness or injury.
    The Plan shall be subrogated to any right of recovery the
    covered person may have under the terms of any private or
    public health care coverage or liability coverage,
    including coverage under the Workers' Compensation Act or
    the Workers' Occupational Diseases Act, without the
    necessity of assignment of claim or other authorization to
    secure the right of recovery. To enforce its subrogation
    right, the Plan may (i) intervene or join in an action or
    proceeding brought by the covered person or his personal
    representative, including his guardian, conservator,
    estate, dependents, or survivors, against any third party
    or the third party's insurer that may be liable or (ii)
    institute and prosecute legal proceedings against any
    third party or the third party's insurer that may be liable
    for the sickness or injury in an appropriate court either
    in the name of the Plan or in the name of the covered
    person or his personal representative, including his
    guardian, conservator, estate, dependents, or survivors.
        (2) If any action or claim is brought by or on behalf
    of a covered person against a third party or the third
    party's insurer, the covered person or his personal
    representative, including his guardian, conservator,
    estate, dependents, or survivors, shall notify the Plan by
    personal service or registered mail of the action or claim
    and of the name of the court in which the action or claim
    is brought, filing proof thereof in the action or claim.
    The Plan may, at any time thereafter, join in the action or
    claim upon its motion so that all orders of court after
    hearing and judgment shall be made for its protection. No
    release or settlement of a claim for damages and no
    satisfaction of judgment in the action shall be valid
    without the written consent of the Plan to the extent of
    its interest in the settlement or judgment and of the
    covered person or his personal representative.
        (3) In the event that the covered person or his
    personal representative fails to institute a proceeding
    against any appropriate third party before the fifth month
    before the action would be barred, the Plan may, in its own
    name or in the name of the covered person or personal
    representative, commence a proceeding against any
    appropriate third party for the recovery of damages on
    account of any sickness, injury, or death to the covered
    person. The covered person shall cooperate in doing what is
    reasonably necessary to assist the Plan in any recovery and
    shall not take any action that would prejudice the Plan's
    right to recovery. The Plan shall pay to the covered person
    or his personal representative all sums collected from any
    third party by judgment or otherwise in excess of amounts
    paid in benefits under the Plan and amounts paid or to be
    paid as costs, attorneys fees, and reasonable expenses
    incurred by the Plan in making the collection or enforcing
    the judgment.
        (4) In the event that a covered person or his personal
    representative, including his guardian, conservator,
    estate, dependents, or survivors, recovers damages from a
    third party for sickness or injury caused to the covered
    person, the covered person or the personal representative
    shall pay to the Plan from the damages recovered the amount
    of benefits paid or to be paid on behalf of the covered
        (5) When the action or claim is brought by the covered
    person alone and the covered person incurs a personal
    liability to pay attorney's fees and costs of litigation,
    the Plan's claim for reimbursement of the benefits provided
    to the covered person shall be the full amount of benefits
    paid to or on behalf of the covered person under this Act
    less a pro rata share that represents the Plan's reasonable
    share of attorney's fees paid by the covered person and
    that portion of the cost of litigation expenses determined
    by multiplying by the ratio of the full amount of the
    expenditures to the full amount of the judgement, award, or
        (6) In the event of judgment or award in a suit or
    claim against a third party or insurer, the court shall
    first order paid from any judgement or award the reasonable
    litigation expenses incurred in preparation and
    prosecution of the action or claim, together with
    reasonable attorney's fees. After payment of those
    expenses and attorney's fees, the court shall apply out of
    the balance of the judgment or award an amount sufficient
    to reimburse the Plan the full amount of benefits paid on
    behalf of the covered person under this Act, provided the
    court may reduce and apportion the Plan's portion of the
    judgement proportionate to the recovery of the covered
    person. The burden of producing evidence sufficient to
    support the exercise by the court of its discretion to
    reduce the amount of a proven charge sought to be enforced
    against the recovery shall rest with the party seeking the
    reduction. The court may consider the nature and extent of
    the injury, economic and non-economic loss, settlement
    offers, comparative negligence as it applies to the case at
    hand, hospital costs, physician costs, and all other
    appropriate costs. The Plan shall pay its pro rata share of
    the attorney fees based on the Plan's recovery as it
    compares to the total judgment. Any reimbursement rights of
    the Plan shall take priority over all other liens and
    charges existing under the laws of this State with the
    exception of any attorney liens filed under the Attorneys
    Lien Act.
        (7) The Plan may compromise or settle and release any
    claim for benefits provided under this Act or waive any
    claims for benefits, in whole or in part, for the
    convenience of the Plan or if the Plan determines that
    collection would result in undue hardship upon the covered
(Source: P.A. 94-737, eff. 5-3-06; 95-547, eff. 8-29-07.)
    Section 99. Effective date. This Act takes effect upon
becoming law.