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| Public Act 097-0346 | ||||
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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 2 as follows: | ||||
(215 ILCS 105/2) (from Ch. 73, par. 1302)
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Sec. 2. Definitions. As used in this Act, unless the | ||||
context otherwise
requires:
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"Plan administrator" means the insurer or third party
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administrator designated under Section 5 of this Act.
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"Benefits plan" means the coverage to be offered by the | ||||
Plan to
eligible persons and federally eligible individuals | ||||
pursuant to this Act.
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"Board" means the Illinois Comprehensive Health Insurance | ||||
Board.
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"Church plan" has the same meaning given that term in the | ||||
federal Health
Insurance Portability and Accountability Act of | ||||
1996.
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"Continuation coverage" means continuation of coverage | ||||
under a group health
plan or other health insurance coverage | ||||
for former employees or dependents of
former employees that | ||||
would otherwise have terminated under the terms of that
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coverage pursuant to any continuation provisions under federal | ||||
or State law,
including the Consolidated Omnibus Budget | ||
Reconciliation Act of 1985 (COBRA),
as amended, Sections 367.2, | ||
367e, and 367e.1 of the Illinois Insurance Code, or
any
other | ||
similar requirement in another State.
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"Covered person" means a person who is and continues to | ||
remain eligible for
Plan coverage and is covered under one of | ||
the benefit plans offered by the
Plan.
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"Creditable coverage" means, with respect to a federally | ||
eligible
individual, coverage of the individual under any of | ||
the following:
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(A) A group health plan.
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(B) Health insurance coverage (including group health | ||
insurance coverage).
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(C) Medicare.
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(D) Medical assistance.
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(E) Chapter 55 of title 10, United States Code.
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(F) A medical care program of the Indian Health Service | ||
or of a tribal
organization.
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(G) A state health benefits risk pool.
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(H) A health plan offered under Chapter 89 of title 5, | ||
United States Code.
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(I) A public health plan (as defined in regulations | ||
consistent with
Section
104 of the Health Care Portability | ||
and Accountability Act of 1996 that may be
promulgated by | ||
the Secretary of the U.S. Department of Health and Human
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Services).
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(J) A health benefit plan under Section 5(e) of the | ||
Peace Corps Act (22
U.S.C. 2504(e)).
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(K) Any other qualifying coverage required by the | ||
federal Health Insurance
Portability and Accountability | ||
Act of 1996, as it may be amended, or
regulations under | ||
that
Act.
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"Creditable coverage" does not include coverage consisting | ||
solely of coverage
of excepted benefits, as defined in Section | ||
2791(c) of title XXVII of
the
Public Health Service Act (42 | ||
U.S.C. 300 gg-91), nor does it include any
period
of coverage | ||
under any of items (A) through (K) that occurred before a break | ||
of
more than 90 days or, if the individual has
been certified | ||
as eligible pursuant to the federal Trade Act
of 2002, a
break | ||
of more than 63 days during all of which the individual was not | ||
covered
under any of items (A) through (K) above.
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Any period that an individual is in a waiting period for
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any coverage under a group health plan (or for group health | ||
insurance
coverage) or is in an affiliation period under the | ||
terms of health insurance
coverage offered by a health | ||
maintenance organization shall not be taken into
account in | ||
determining if there has been a break of more than 90
days in | ||
any
creditable coverage.
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"Department" means the Illinois Department of Insurance.
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"Dependent" means an Illinois resident: who is a spouse; or | ||
who is claimed
as a dependent by the principal insured for | ||
purposes of filing a federal income
tax return and resides in | ||
the principal insured's household, and is a resident
unmarried | ||
child under the age of 19 years; or who is an unmarried child | ||
who
also is a full-time student under the age of 23 years and | ||
who is financially
dependent upon the principal insured; or who | ||
is a child of any age and who is
disabled and financially | ||
dependent upon the
principal insured.
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"Direct Illinois premiums" means, for Illinois business, | ||
an insurer's direct
premium income for the kinds of business | ||
described in clause (b) of Class 1 or
clause (a) of Class 2 of | ||
Section 4 of the Illinois Insurance Code, and direct
premium | ||
income of a health maintenance organization or a voluntary | ||
health
services plan, except it shall not include credit health | ||
insurance as defined
in Article IX 1/2 of the Illinois | ||
Insurance Code.
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"Director" means the Director of the Illinois Department of | ||
Insurance.
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"Effective date of medical assistance" means the date that | ||
eligibility for medical assistance for a person is approved by | ||
the Department of Human Services or the Department of | ||
Healthcare and Family Services, except when the Department of | ||
Human Services or the Department of Healthcare and Family | ||
Services determines eligibility retroactively. In such | ||
circumstances, the effective date of the medical assistance is | ||
the date the Department of Human Services or the Department of | ||
Healthcare and Family Services determines the person to be | ||
eligible for medical assistance. As it pertains to Medicare, | ||
the effective date is 24 months after the entitlement date as | ||
approved by the Social Security Administration, except when | ||
eligibility is made retroactive to a prior date. In such | ||
circumstances, the effective date of Medicare is the date on | ||
the Notice of Award letter issued by the Social Security | ||
Administration. | ||
"Eligible person" means a resident of this State who | ||
qualifies
for Plan coverage under Section 7 of this Act.
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"Employee" means a resident of this State who is employed | ||
by an employer
or has entered into
the employment of or works | ||
under contract or service of an employer
including the | ||
officers, managers and employees of subsidiary or affiliated
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corporations and the individual proprietors, partners and | ||
employees of
affiliated individuals and firms when the business | ||
of the subsidiary or
affiliated corporations, firms or | ||
individuals is controlled by a common
employer through stock | ||
ownership, contract, or otherwise.
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"Employer" means any individual, partnership, association, | ||
corporation,
business trust, or any person or group of persons | ||
acting directly or indirectly
in the interest of an employer in | ||
relation to an employee, for which one or
more
persons is | ||
gainfully employed.
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"Family" coverage means the coverage provided by the Plan | ||
for the
covered person and his or her eligible dependents who | ||
also are
covered persons.
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"Federally eligible individual" means an individual | ||
resident of this State:
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(1)(A) for whom, as of the date on which the individual | ||
seeks Plan
coverage
under Section 15 of this Act, the | ||
aggregate of the periods of creditable
coverage is 18 or | ||
more months or, if the individual has been
certified as
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eligible pursuant to the federal Trade Act of 2002,
3 or | ||
more
months, and (B) whose most recent prior creditable
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coverage was under group health insurance coverage offered | ||
by a health
insurance issuer, a group health plan, a | ||
governmental plan, or a church plan
(or
health insurance | ||
coverage offered in connection with any such plans) or any
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other type of creditable coverage that may be required by | ||
the federal Health
Insurance Portability
and | ||
Accountability Act of 1996, as it may be amended, or the | ||
regulations
under that Act;
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(2) who
is not eligible for coverage under
(A) a group | ||
health plan
(other than an individual who has been | ||
certified as eligible
pursuant to the federal Trade Act of | ||
2002), (B)
part
A or part B of Medicare due to age
(other | ||
than an individual who has been certified as eligible
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pursuant to the federal Trade Act of 2002), or (C) medical | ||
assistance, and
does not
have other
health insurance | ||
coverage (other than an individual who has been certified | ||
as
eligible pursuant to the federal Trade Act of 2002);
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(3) with respect to whom (other than an individual who | ||
has been
certified as eligible pursuant to the federal | ||
Trade Act of 2002) the most
recent coverage within the | ||
coverage
period
described in paragraph (1)(A) of this | ||
definition was not terminated
based upon a factor relating | ||
to nonpayment of premiums or fraud;
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(4) if the individual (other than an individual who has
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been certified
as eligible pursuant to the federal Trade | ||
Act
of 2002)
had been offered the option of continuation
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coverage
under a COBRA continuation provision or under a | ||
similar State program, who
elected such coverage; and
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(5) who, if the individual elected such continuation | ||
coverage, has
exhausted
such continuation coverage under | ||
such provision or program.
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However, an individual who has been certified as
eligible
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pursuant to the
federal Trade Act of 2002
shall not be required | ||
to elect
continuation
coverage under a COBRA continuation | ||
provision or under a similar state
program.
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"Group health insurance coverage" means, in connection | ||
with a group health
plan, health insurance coverage offered in | ||
connection with that plan.
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"Group health plan" has the same meaning given that term in | ||
the federal
Health
Insurance Portability and Accountability | ||
Act of 1996.
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"Governmental plan" has the same meaning given that term in | ||
the federal
Health
Insurance Portability and Accountability | ||
Act of 1996.
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"Health insurance coverage" means benefits consisting of | ||
medical care
(provided directly, through insurance or | ||
reimbursement, or otherwise and
including items and services | ||
paid for as medical care) under any hospital and
medical | ||
expense-incurred policy,
certificate, or
contract provided by | ||
an insurer, non-profit health care service plan
contract, | ||
health maintenance organization or other subscriber contract, | ||
or
any other health care plan or arrangement that pays for or | ||
furnishes
medical or health care services whether by
insurance | ||
or otherwise. Health insurance coverage shall not include short
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term,
accident only,
disability income, hospital confinement | ||
or fixed indemnity, dental only,
vision only, limited benefit, | ||
or credit
insurance, coverage issued as a supplement to | ||
liability insurance,
insurance arising out of a workers' | ||
compensation or similar law, automobile
medical-payment | ||
insurance, or insurance under which benefits are payable
with | ||
or without regard to fault and which is statutorily required to | ||
be
contained in any liability insurance policy or equivalent | ||
self-insurance.
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"Health insurance issuer" means an insurance company, | ||
insurance service,
or insurance organization (including a | ||
health maintenance organization and a
voluntary health | ||
services plan) that is authorized to transact health
insurance
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business in this State. Such term does not include a group | ||
health plan.
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"Health Maintenance Organization" means an organization as
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defined in the Health Maintenance Organization Act.
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"Hospice" means a program as defined in and licensed under | ||
the
Hospice Program Licensing Act.
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"Hospital" means a duly licensed institution as defined in | ||
the
Hospital Licensing Act,
an institution that meets all | ||
comparable conditions and requirements in
effect in the state | ||
in which it is located, or the University of Illinois
Hospital | ||
as defined in the University of Illinois Hospital Act.
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"Individual health insurance coverage" means health | ||
insurance coverage
offered to individuals in the individual | ||
market, but does not include
short-term, limited-duration | ||
insurance.
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"Insured" means any individual resident of this State who | ||
is
eligible to receive benefits from any insurer (including | ||
health insurance
coverage offered in connection with a group | ||
health plan) or health
insurance issuer as
defined in this | ||
Section.
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"Insurer" means any insurance company authorized to | ||
transact health
insurance business in this State and any | ||
corporation that provides medical
services and is organized | ||
under the Voluntary Health Services Plans Act or
the Health | ||
Maintenance Organization
Act.
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"Medical assistance" means the State medical assistance or | ||
medical
assistance no grant (MANG) programs provided under
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Title XIX of the Social Security Act and
Articles V (Medical | ||
Assistance) and VI (General Assistance) of the Illinois
Public | ||
Aid Code (or any successor program) or under any
similar | ||
program of health care benefits in a state other than Illinois.
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"Medically necessary" means that a service, drug, or supply | ||
is
necessary and appropriate for the diagnosis or treatment of | ||
an illness or
injury in accord with generally accepted | ||
standards of medical practice at
the time the service, drug, or | ||
supply is provided. When specifically
applied to a confinement | ||
it further means that the diagnosis or treatment
of the covered | ||
person's medical symptoms or condition cannot be
safely
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provided to that person as an outpatient. A service, drug, or | ||
supply shall
not be medically necessary if it: (i) is | ||
investigational, experimental, or
for research purposes; or | ||
(ii) is provided solely for the convenience of
the patient, the | ||
patient's family, physician, hospital, or any other
provider; | ||
or (iii) exceeds in scope, duration, or intensity that level of
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care that is needed to provide safe, adequate, and appropriate | ||
diagnosis or
treatment; or (iv) could have been omitted without | ||
adversely affecting the
covered person's condition or the | ||
quality of medical care; or
(v) involves
the use of a medical | ||
device, drug, or substance not formally approved by
the United | ||
States Food and Drug Administration.
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"Medical care" means the ordinary and usual professional | ||
services rendered
by a physician or other specified provider | ||
during a professional visit for
treatment of an illness or | ||
injury.
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"Medicare" means coverage under both Part A and Part B of | ||
Title XVIII of
the Social Security
Act, 42 U.S.C. Sec. 1395, et | ||
seq.
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"Minimum premium plan" means an arrangement whereby a | ||
specified
amount of health care claims is self-funded, but the | ||
insurance company
assumes the risk that claims will exceed that | ||
amount.
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"Participating transplant center" means a hospital | ||
designated by the
Board as a preferred or exclusive provider of | ||
services for one or more
specified human organ or tissue | ||
transplants for which the hospital has
signed an agreement with | ||
the Board to accept a transplant payment allowance
for all | ||
expenses related to the transplant during a transplant benefit | ||
period.
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"Physician" means a person licensed to practice medicine | ||
pursuant to
the Medical Practice Act of 1987.
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"Plan" means the Comprehensive Health Insurance Plan
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established by this Act.
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"Plan of operation" means the plan of operation of the
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Plan, including articles, bylaws and operating rules, adopted | ||
by the board
pursuant to this Act.
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"Provider" means any hospital, skilled nursing facility, | ||
hospice, home
health agency, physician, registered pharmacist | ||
acting within the scope of that
registration, or any other | ||
person or entity licensed in Illinois to furnish
medical care.
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"Qualified high risk pool" has the same meaning given that | ||
term in the
federal Health
Insurance Portability and | ||
Accountability Act of 1996.
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"Resident" means a person who is and continues to be | ||
legally domiciled
and physically residing on a permanent and | ||
full-time basis in a
place of permanent habitation
in this | ||
State
that remains that person's principal residence and from | ||
which that person is
absent only for temporary or transitory | ||
purpose.
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"Skilled nursing facility" means a facility or that portion | ||
of a facility
that is licensed by the Illinois Department of | ||
Public Health under the
Nursing Home Care Act or a comparable | ||
licensing authority in another state
to provide skilled nursing | ||
care.
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"Stop-loss coverage" means an arrangement whereby an | ||
insurer
insures against the risk that any one claim will exceed | ||
a specific dollar
amount or that the entire loss of a | ||
self-insurance plan will exceed
a specific amount.
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"Third party administrator" means an administrator as | ||
defined in
Section 511.101 of the Illinois Insurance Code who | ||
is licensed under
Article XXXI 1/4 of that Code.
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(Source: P.A. 95-965, eff. 9-23-08.)
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Section 99. Effective date. This Act takes effect upon | ||
becoming law.
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