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Public Act 097-0661 | ||||
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Comprehensive Health Insurance Plan Act is | ||||
amended by changing Section 7 as follows: | ||||
(215 ILCS 105/7) (from Ch. 73, par. 1307) | ||||
Sec. 7. Eligibility. | ||||
a. Except as provided in subsection (e) of this Section or | ||||
in Section
15 of this Act, any person who is either a citizen | ||||
of the United States or an
alien lawfully admitted for | ||||
permanent residence and who has been for a period
of at least | ||||
180 days and continues to be a resident of this State shall be
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eligible for Plan coverage under this Section if evidence is | ||||
provided of: | ||||
(1) A notice of rejection or refusal to issue | ||||
substantially
similar individual health insurance coverage | ||||
for health reasons by a
health insurance issuer; or | ||||
(2) A refusal by a health insurance issuer to issue | ||||
individual
health insurance coverage except at a rate | ||||
exceeding the
applicable Plan rate for which the person is | ||||
responsible ; or . | ||||
(3) The absence of available health insurance coverage | ||||
for a person under 19 years of age. |
A rejection or refusal by a group health plan or health | ||
insurance issuer
offering only
stop-loss or excess of loss | ||
insurance or contracts,
agreements, or other arrangements for | ||
reinsurance coverage with respect
to the applicant shall not be | ||
sufficient evidence under this subsection. | ||
b. The board shall promulgate a list of medical or health | ||
conditions for
which a person who is either a citizen of the | ||
United States or an
alien lawfully admitted for permanent | ||
residence and a resident of this State
would be eligible for | ||
Plan coverage without applying for
health insurance coverage | ||
pursuant to subsection a. of this Section.
Persons who
can | ||
demonstrate the existence or history of any medical or health
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conditions on the list promulgated by the board shall not be | ||
required to
provide the evidence specified in subsection a. of | ||
this Section. The list
shall be effective
on the first day of | ||
the operation of the Plan and may be amended from time
to time | ||
as appropriate. | ||
c. Family members of the same household who each are | ||
covered
persons are
eligible for optional family coverage under | ||
the Plan. | ||
d. For persons qualifying for coverage in accordance with | ||
Section 7 of
this Act, the board shall, if it determines that | ||
such appropriations as are
made pursuant to Section 12 of this | ||
Act are insufficient to allow the board
to accept all of the | ||
eligible persons which it projects will apply for
enrollment | ||
under the Plan, limit or close enrollment to ensure that the
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Plan is not over-subscribed and that it has sufficient | ||
resources to meet
its obligations to existing enrollees. The | ||
board shall not limit or close
enrollment for federally | ||
eligible individuals. | ||
e. A person shall not be eligible for coverage under the | ||
Plan if: | ||
(1) He or she has or obtains other coverage under a | ||
group health plan
or health insurance coverage
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substantially similar to or better than a Plan policy as an | ||
insured or
covered dependent or would be eligible to have | ||
that coverage if he or she
elected to obtain it. Persons | ||
otherwise eligible for Plan coverage may,
however, solely | ||
for the purpose of having coverage for a pre-existing
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condition, maintain other coverage only while satisfying | ||
any pre-existing
condition waiting period under a Plan | ||
policy or a subsequent replacement
policy of a Plan policy. | ||
(1.1) His or her prior coverage under a group health | ||
plan or health
insurance coverage, provided or arranged by | ||
an employer of more than 10 employees was discontinued
for | ||
any reason without the entire group or plan being | ||
discontinued and not
replaced, provided he or she remains | ||
an employee, or dependent thereof, of the
same employer. | ||
(2) He or she is a recipient of or is approved to | ||
receive medical
assistance, except that a person may | ||
continue to receive medical
assistance through the medical | ||
assistance no grant program, but only
while satisfying the |
requirements for a preexisting condition under
Section 8, | ||
subsection f. of this Act. Payment of premiums pursuant to | ||
this
Act shall be allocable to the person's spenddown for | ||
purposes of the
medical assistance no grant program, but | ||
that person shall not be
eligible for any Plan benefits | ||
while that person remains eligible for
medical assistance. | ||
If the person continues to receive
or be approved to | ||
receive medical assistance through the medical
assistance | ||
no grant program at or after the time that requirements for | ||
a
preexisting condition are satisfied, the person shall not | ||
be eligible for
coverage under the Plan. In that | ||
circumstance, coverage under the plan
shall terminate as of | ||
the expiration of the preexisting condition
limitation | ||
period. Under all other circumstances, coverage under the | ||
Plan
shall automatically terminate as of the effective date | ||
of any medical
assistance. | ||
(3) Except as provided in Section 15, the person has | ||
previously
participated in the Plan and voluntarily
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terminated Plan coverage, unless 12 months have elapsed
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since the person's
latest voluntary termination of | ||
coverage. | ||
(4) The person fails to pay the required premium under | ||
the covered
person's
terms of enrollment and | ||
participation, in which event the liability of the
Plan | ||
shall be limited to benefits incurred under the Plan for | ||
the time
period for which premiums had been paid and the |
covered person remained
eligible for Plan coverage. | ||
(5) The Plan has paid a total of
$5,000,000
in benefits
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on behalf of the covered person. | ||
(6) The person is a resident of a public institution. | ||
(7) The person's premium is paid for or reimbursed | ||
under any
government sponsored program or by any government | ||
agency or health
care provider, except as an otherwise | ||
qualifying full-time employee, or
dependent of such | ||
employee, of a government agency or health care provider
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or, except when a person's premium is paid by the U.S. | ||
Treasury Department
pursuant to the federal Trade Act of | ||
2002. | ||
(8) The person has or later receives other benefits or | ||
funds from
any settlement, judgement, or award resulting | ||
from any accident or injury,
regardless of the date of the | ||
accident or injury, or any other
circumstances creating a | ||
legal liability for damages due that person by a
third | ||
party, 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 person, his or her
dependent, | ||
estate, personal representative, or guardian in a lump sum | ||
or
over time, so long as there continues to be benefits or | ||
assets remaining
from those sources in an amount in excess | ||
of $300,000. | ||
(9) Within the 5 years prior to the date a person's |
Plan application is
received by the Board, the person's | ||
coverage under any health care benefit
program as defined | ||
in 18 U.S.C. 24, including any public or private plan or
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contract under which any
medical benefit, item, or service | ||
is provided, was terminated as a result of
any act or | ||
practice that constitutes fraud under State or federal law | ||
or as a
result of an intentional misrepresentation of | ||
material fact; or if that person
knowingly and willfully | ||
obtained or attempted to obtain, or fraudulently aided
or | ||
attempted to aid any other person in obtaining, any | ||
coverage or benefits
under the Plan to which that person | ||
was not entitled. | ||
f. The board or the administrator shall require | ||
verification of
residency and may require any additional | ||
information or documentation, or
statements under oath, when | ||
necessary to determine residency upon initial
application and | ||
for the entire term of the policy. | ||
g. Coverage shall cease (i) on the date a person is no | ||
longer a
resident of Illinois, (ii) on the date a person | ||
requests coverage to end,
(iii) upon the death of the covered | ||
person, (iv) on the date State law
requires cancellation of the | ||
policy, or (v) at the Plan's option, 30 days
after the Plan | ||
makes any inquiry concerning a person's eligibility or place
of | ||
residence to which the person does not reply. | ||
h. Except under the conditions set forth in subsection g of | ||
this
Section, the coverage of any person who ceases to meet the
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eligibility requirements of this Section shall be terminated at | ||
the end of
the current policy period for which the necessary | ||
premiums have been paid. | ||
(Source: P.A. 95-547, eff. 8-29-07; 96-938, eff. 6-24-10.)
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Section 99. Effective date. This Act takes effect upon | ||
becoming law.
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