Public Act 098-0130
 
HB0104 EnrolledLRB098 01530 KTG 31534 b


  
    AN ACT concerning the Department of Healthcare and Family 
Services.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  
 
 
    Section 5. The Illinois Insurance Code is amended  by 
changing Section 5.5 as follows:
 
    (215 ILCS 5/5.5)
    Sec. 5.5. Compliance with the Department of Healthcare and 
Family Services. A company authorized to do business in this 
State or accredited by the State to issue policies of health 
insurance, including but not limited to, self-insured plans, 
group health plans (as defined in Section 607(1) of the 
Employee Retirement Income Security Act of 1974), service 
benefit plans, managed care organizations, pharmacy benefit 
managers, or other parties that are by statute, contract, or 
agreement legally responsible for payment of a claim for a 
health care item or service as a condition of doing business in 
the State must:
        (1) provide to the  Department of Healthcare and Family 
    Services, or any successor agency, on at least a quarterly 
    basis if so requested by the Department, information to 
    determine during what period any individual may be, or may 
    have been, covered by a health insurer and the nature of 
    the coverage that is or was provided by the health insurer, 
    including the name, address, and identifying number of the 
    plan;
        (2)  accept the State's right of recovery and the 
    assignment to the State of any right of an individual or 
    other entity to payment from the party for an item or 
    service for which payment has been made under the medical 
    programs of the Department of Healthcare and Family 
    Services, or any successor agency, under this Code or the 
    Illinois Public Aid Code;
        (3) respond to any inquiry by the Department of 
    Healthcare and Family Services regarding a claim for 
    payment for any health care item or service that is 
    submitted not later than 3 years after the date of the 
    provision of such health care item or service; and
        (4) agree not to deny a claim submitted by the 
    Department of Healthcare and Family Services solely on the 
    basis of the date of submission of the claim, the type or 
    format of the claim form, or a failure to present proper 
    documentation at the point-of-sale that is the basis of the 
    claim if (i) the claim is submitted by the Department of 
    Healthcare and Family Services within the 3-year period 
    beginning on the date on which the item or service was 
    furnished and (ii) any action by the Department of 
    Healthcare and Family Services to enforce its rights with 
    respect to such claim is commenced within 6 years of its 
    submission of such claim.

    The Department of Healthcare and Family Services may impose 
an administrative penalty as provided under Section 12-4.45 of 
the Illinois Public Aid Code on entities that have established 
a pattern of failure to provide the information required under 
this Section, or in In cases in which the Department of 
Healthcare and Family Services has  determined that an entity 
that provides health insurance coverage has established a 
pattern of failure to provide the information required under 
this Section, and has subsequently certified that 
determination, along with supporting documentation, to the 
Director of the Department of Insurance, the Director of the 
Department of Insurance, based upon the certification of 
determination made by the Department of Healthcare and Family 
Services,  may commence regulatory proceedings in accordance 
with all applicable provisions of  the Illinois Insurance Code. 
(Source: P.A. 95-632, eff. 9-25-07; 96-1501, eff. 1-25-11.)
 
    Section 10. The Covering ALL KIDS Health Insurance  Act is 
amended  by changing Section 20 as follows:
 
    (215 ILCS 170/20)
    (Section scheduled to be repealed on July 1, 2016)

    Sec. 20. Eligibility. 
    (a) To be eligible for the Program, a person must be a 
child:

        (1) who is a resident of the State of Illinois;
        (2) who is ineligible for medical assistance under the 
    Illinois Public Aid Code or benefits under the Children's 
    Health Insurance Program Act;

        (3) either (i) who has been without health insurance 
    coverage for 12 months, (ii) whose parent has lost 
    employment that made available affordable dependent health 
    insurance coverage, until such time as affordable  
    employer-sponsored dependent health insurance coverage is 
    again available for the child as set forth by the 
    Department in rules, (iii) who is a newborn whose 
    responsible relative does not have available affordable 
    private or employer-sponsored health insurance, or (iv) 
    who, within one year of applying for coverage under this 
    Act, lost medical benefits under the Illinois Public Aid 
    Code or the Children's Health Insurance Program Act; and
        (3.5) whose household income, as determined by the 
    Department, is at or below 300% of the federal poverty 
    level. This item (3.5) is effective July 1, 2011. 
    An entity that provides health insurance coverage (as 
defined in Section 2 of the Comprehensive Health Insurance Plan 
Act) to Illinois residents shall provide health insurance data 
match to the Department of Healthcare and Family Services as 
provided by and subject to Section 5.5 of the Illinois 
Insurance Code. The Department of Healthcare and Family 
Services may impose an administrative penalty as provided under 
Section 12-4.45 of the Illinois Public Aid Code on entities 
that have established a pattern of failure to provide the 
information required under this Section. 
    The Department of Healthcare and Family Services, in 
collaboration with the  Department of Insurance, shall adopt 
rules governing the exchange of information under this Section.  
The rules shall be consistent with all laws relating to the 
confidentiality or privacy of personal information or medical 
records, including provisions under the Federal Health 
Insurance Portability and Accountability Act (HIPAA).
    (b) The Department shall monitor the availability and 
retention of employer-sponsored dependent health insurance 
coverage and shall modify the period described in subdivision 
(a)(3) if necessary to promote retention of private or 
employer-sponsored health insurance and timely access to 
healthcare services, but at no time shall the period described 
in subdivision (a)(3) be less than 6 months.

    (c) The Department, at its discretion, may take into 
account the affordability of dependent health insurance when 
determining whether employer-sponsored dependent health 
insurance coverage is available upon reemployment of a child's 
parent as provided in subdivision (a)(3).
    (d) A child who is determined to be eligible for the 
Program shall remain eligible for 12 months, provided that the 
child maintains his or her residence in this State, has not yet 
attained 19 years of age, and is not excluded under subsection 
(e).
    (e) A child is not eligible for coverage under the Program 
if:
        (1) the premium required under Section 40 has not been 
    timely paid;  if the required premiums are not paid, the 
    liability of the Program shall be limited to benefits 
    incurred under the Program for the time period for which 
    premiums have been paid; re-enrollment shall be completed 
    before the next covered medical visit, and the first 
    month's required premium shall be paid in advance of the 
    next covered medical visit; or
        (2) the child is an inmate of a public institution or 
    an institution for mental diseases.

    (f) The Department may adopt rules, including, but not 
limited to: rules regarding annual renewals of eligibility for 
the Program in conformance with Section 7 of this Act; rules 
providing for re-enrollment, grace periods, notice 
requirements, and hearing procedures under subdivision (e)(1) 
of this Section; and rules regarding what constitutes 
availability and affordability of private or 
employer-sponsored health insurance, with consideration of 
such factors as the percentage of income needed to purchase 
children or family health insurance, the availability of 
employer subsidies, and other relevant factors.

    (g) Each child enrolled in the Program as of July 1, 2011 
whose family income, as established by the Department, exceeds 
300% of the federal poverty level may remain enrolled in the 
Program for 12 additional months commencing July 1, 2011. 
Continued enrollment pursuant to this subsection shall be 
available only if the child continues to meet all eligibility 
criteria established under the Program as of the effective date 
of this amendatory Act of the 96th General Assembly without a 
break in coverage. Nothing contained in this subsection shall 
prevent a child from qualifying for any other health benefits 
program operated by the Department. 
(Source: P.A. 96-1272, eff. 1-1-11; 96-1501, eff. 1-25-11.)
 
    Section 15. The Illinois Public Aid Code is amended  by 
changing Section 12-9 and  by adding Section 12-4.45 as follows:
 
    (305 ILCS 5/12-4.45 new)
    Sec. 12-4.45. Third party liability. 
    (a) To the extent authorized under federal law, the 
Department of Healthcare and Family Services shall identify 
individuals receiving services under medical assistance 
programs funded or partially funded by the State who may be or 
may have been covered by a third party health insurer, the 
period of coverage for such individuals, and the nature of 
coverage.  A company, as defined in Section 5.5 of the Illinois 
Insurance Code and Section 2 of the Comprehensive Health 
Insurance Plan Act, must provide the Department eligibility 
information in a federally recommended or mutually agreed-upon 
format that includes at a minimum:
        (1) The names, addresses, dates, and sex of primary 
    covered persons.
        (2) The policy group numbers of the covered persons.
        (3) The names, dates of birth, and sex of covered 
    dependents, and the relationship of dependents to the 
    primary covered person.
        (4) The effective dates of coverage for each covered 
    person.
        (5) The generally defined covered services 
    information, such as drugs, medical, or any other similar 
    description of services covered.
    (b) The Department may impose an administrative penalty on 
a company that does not comply with the request for information 
made under Section 5.5 of the Illinois Insurance Code and 
paragraph (3) of subsection (a) of Section 20 of the Covering 
ALL KIDS Health Insurance Act.  The amount of the penalty shall 
not exceed $10,000 per day for each day of noncompliance that 
occurs after the 180th day after the date of the request.  The 
first day of the 180-day period commences on the business day 
following the date of the correspondence requesting the 
information sent by the Department to the company. The amount 
shall be based on:
        (1) The seriousness of the violation, including the 
    nature, circumstances, extent, and gravity of the 
    violation.
        (2) The economic harm caused by the violation.
        (3) The history of previous violations.
        (4) The amount necessary to deter a future violation.
        (5) Efforts to correct the violation.
        (6) Any other matter that justice may require.
    (c) The enforcement of the penalty may be stayed during the 
time the order is under administrative review if the company 
files an appeal.
    (d) The Attorney General may bring suit on behalf of the 
Department to collect the penalty.
    (e) Recoveries made by the Department in connection with 
the imposition of an administrative penalty as provided under 
this Section shall be deposited into the Public Aid Recoveries 
Trust Fund created under Section 12-9.
 



    (305 ILCS 5/12-9)  (from Ch. 23, par. 12-9)



    Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The 
Public Aid Recoveries Trust Fund shall consist of (1)

recoveries by the Department of Healthcare and Family Services 
(formerly Illinois Department of Public Aid) authorized by this 
Code
in respect to applicants or recipients under Articles III, 
IV, V, and VI,
including recoveries made by the Department of 
Healthcare and Family Services (formerly Illinois Department 
of Public
Aid) from the estates of deceased recipients, (2) 
recoveries made by the
Department of Healthcare and Family 
Services (formerly Illinois Department of Public Aid) in 
respect to applicants and recipients under
the Children's 
Health Insurance Program Act, and the Covering ALL KIDS Health 
Insurance Act, (2.5) recoveries made by the Department of 
Healthcare and Family Services in connection with the 
imposition of an administrative penalty as provided under 
Section 12-4.45, (3) federal funds received on
behalf of and 
earned by State universities and local governmental entities

for services provided to
applicants or recipients covered under 
this Code, the Children's Health Insurance Program Act, and the 
Covering ALL KIDS Health Insurance Act, (3.5) federal financial 
participation revenue related to eligible disbursements made 
by the Department of Healthcare and Family Services from 
appropriations required by this Section, and (4) all other 
moneys received to the Fund, including interest thereon.  The 
Fund shall be held
as a special fund in the State Treasury.

    Disbursements from this Fund shall be only (1) for the 
reimbursement of
claims collected by the Department of 
Healthcare and Family Services (formerly Illinois Department 
of Public Aid) through error
or mistake, (2) for payment to 
persons or agencies designated as payees or
co-payees on any 
instrument, whether or not negotiable, delivered to the

Department of Healthcare and Family Services (formerly

Illinois Department of Public Aid) as a recovery under this 
Section, such
payment to be in proportion to the respective 
interests of the payees in the
amount so collected, (3) for 
payments to the Department of Human Services
for collections 
made by the Department of Healthcare and Family Services 
(formerly Illinois Department of Public Aid) on behalf of
the 
Department of Human Services under this Code, the Children's 
Health Insurance Program Act, and the Covering ALL KIDS Health 
Insurance Act, (4) for payment of
administrative expenses 
incurred in performing the
activities authorized under this 
Code, the Children's Health Insurance Program Act, and the 
Covering ALL KIDS Health Insurance Act, (5)
for payment of fees 
to persons or agencies in the performance of activities

pursuant to the collection of monies owed the State that are 
collected
under this Code, the Children's Health Insurance 
Program Act, and the Covering ALL KIDS Health Insurance Act, 
(6) for payments of any amounts which are
reimbursable to the 
federal government which are required to be paid by State

warrant by either the State or federal government, and (7) for 
payments
to State universities and local governmental entities 
of federal funds for
services provided to
applicants or 
recipients covered under this Code, the Children's Health 
Insurance Program Act, and the Covering ALL KIDS Health 
Insurance Act.  Disbursements
from this Fund for purposes of 
items (4) and (5) of this
paragraph shall be subject to 
appropriations from the Fund to the Department of Healthcare 
and Family Services (formerly Illinois
Department of Public 
Aid).

    The balance in this Fund on the first day of each calendar 
quarter, after
payment therefrom of  any amounts reimbursable to 
the federal government, and
minus the amount reasonably 
anticipated to be needed to make the disbursements
during that 
quarter authorized by this Section, shall be certified by the

Director of Healthcare and Family Services and transferred by 
the
State Comptroller to the Drug Rebate Fund or the Healthcare 
Provider Relief Fund in
the State Treasury, as appropriate, 
within 30 days of the first day of
each calendar quarter. The 
Director of Healthcare and Family Services may certify and the 
State Comptroller shall transfer to the Drug Rebate Fund 
amounts on a more frequent basis. 

    On July 1, 1999, the State Comptroller shall transfer the 
sum of $5,000,000
from the Public Aid Recoveries Trust Fund 
(formerly the Public Assistance
Recoveries Trust Fund) into the 
DHS Recoveries Trust Fund.

(Source: P.A. 96-1100, eff. 1-1-11; 97-647, eff. 1-1-12; 
97-689, eff. 6-14-12.)

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