Public Act 094-0017
 		





HB0197 Enrolled
LRB094 05352 LJB 35397 b






    AN ACT concerning insurance.

 
    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 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

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.

    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

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

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

    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

    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

    terminated Plan coverage, unless 12 months have elapsed

    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 $1,000,000 in benefits

    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

    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
$100,000.


        (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

    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

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. 93-33, eff. 6-23-03; 93-34, eff. 6-23-03.)