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91_HB2166
LRB9102918JSpc
1 AN ACT to amend the Comprehensive Health Insurance Plan
2 Act by changing Section 8.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Comprehensive Health Insurance Plan Act
6 is amended by changing Section 8 as follows:
7 (215 ILCS 105/8) (from Ch. 73, par. 1308)
8 Sec. 8. Minimum benefits.
9 a. Availability. The Plan shall offer in an annually
10 renewable policy major medical expense coverage to every
11 eligible person who is not eligible for Medicare. Major
12 medical expense coverage offered by the Plan shall pay an
13 eligible person's covered expenses, subject to limit on the
14 deductible and coinsurance payments authorized under
15 paragraph (4) of subsection d of this Section, up to a
16 lifetime benefit limit of $1,000,000 per covered individual.
17 The maximum limit under this subsection shall not be altered
18 by the Board, and no actuarial equivalent benefit may be
19 substituted by the Board. Any person who otherwise would
20 qualify for coverage under the Plan, but is excluded because
21 he or she is eligible for Medicare, shall be eligible for any
22 separate Medicare supplement policy or policies which the
23 Board may offer.
24 b. Outline of benefits. Covered expenses shall be
25 limited to the usual and customary charge, including
26 negotiated fees, in the locality for the following services
27 and articles when prescribed by a physician and determined by
28 the Plan to be medically necessary for the following areas of
29 services, subject to such separate deductibles, co-payments,
30 exclusions, and other limitations on benefits as the Board
31 shall establish and approve, and the other provisions of this
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1 Section:
2 (1) Hospital services.
3 (2) Professional services for the diagnosis or
4 treatment of injuries, illnesses or conditions, other
5 than dental and mental and nervous disorders as described
6 in paragraph (17), which are rendered by a physician, or
7 by other licensed professionals at the physician's
8 direction.
9 (2.5) Professional services provided by a physician
10 to children under the age of 16 years for physical
11 examinations and age appropriate immunizations.
12 (3) (Blank).
13 (4) Drugs requiring a physician's prescription.
14 (5) Skilled nursing services of a licensed skilled
15 nursing facility for not more than 120 days during a
16 policy year.
17 (6) Services of a home health agency in accord with
18 a home health care plan, up to a maximum of 270 visits
19 per year.
20 (7) Services of a licensed hospice for not more
21 than 180 days during a policy year.
22 (8) Use of radium or other radioactive materials.
23 (9) Oxygen.
24 (10) Anesthetics.
25 (11) Orthoses and prostheses other than dental.
26 (12) Rental or purchase in accordance with Board
27 policies or procedures of durable medical equipment,
28 other than eyeglasses or hearing aids, for which there is
29 no personal use in the absence of the condition for which
30 it is prescribed.
31 (13) Diagnostic x-rays and laboratory tests.
32 (14) Oral surgery for excision of partially or
33 completely unerupted impacted teeth or the gums and
34 tissues of the mouth, when not performed in connection
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1 with the routine extraction or repair of teeth, and oral
2 surgery and procedures, including orthodontics and
3 prosthetics necessary for craniofacial or maxillofacial
4 conditions and to correct congenital defects or injuries
5 due to accident.
6 (15) Physical, speech, and functional occupational
7 therapy as medically necessary and provided by
8 appropriate licensed professionals.
9 (16) Emergency and other medically necessary
10 transportation provided by a licensed ambulance service
11 to the nearest health care facility qualified to treat a
12 covered illness, injury, or condition, subject to the
13 provisions of the Emergency Medical Systems (EMS) Act.
14 (17) Outpatient services for diagnosis and
15 treatment of mental and nervous disorders provided that a
16 covered person shall be required to make a copayment not
17 to exceed 50% and that the Plan's payment shall not
18 exceed such amounts as are established by the Board.
19 (18) Human organ or tissue transplants specified by
20 the Board that are performed at a hospital designated by
21 the Board as a participating transplant center for that
22 specific organ or tissue transplant.
23 (19) Naprapathic services, as appropriate, provided
24 by a licensed naprapathic practitioner.
25 c. Exclusions. Covered expenses of the Plan shall not
26 include the following:
27 (1) Any charge for treatment for cosmetic purposes
28 other than for reconstructive surgery when the service is
29 incidental to or follows surgery resulting from injury,
30 sickness or other diseases of the involved part or
31 surgery for the repair or treatment of a congenital
32 bodily defect to restore normal bodily functions.
33 (2) Any charge for care that is primarily for rest,
34 custodial, educational, or domiciliary purposes.
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1 (3) Any charge for services in a private room to
2 the extent it is in excess of the institution's charge
3 for its most common semiprivate room, unless a private
4 room is prescribed as medically necessary by a physician.
5 (4) That part of any charge for room and board or
6 for services rendered or articles prescribed by a
7 physician, dentist, or other health care personnel that
8 exceeds the reasonable and customary charge in the
9 locality or for any services or supplies not medically
10 necessary for the diagnosed injury or illness.
11 (5) Any charge for services or articles the
12 provision of which is not within the scope of licensure
13 of the institution or individual providing the services
14 or articles.
15 (6) Any expense incurred prior to the effective
16 date of coverage by the Plan for the person on whose
17 behalf the expense is incurred.
18 (7) Dental care, dental surgery, dental treatment
19 or dental appliances, except as provided in paragraph
20 (14) of subsection b of this Section.
21 (8) Eyeglasses, contact lenses, hearing aids or
22 their fitting.
23 (9) Illness or injury due to acts of war.
24 (10) Services of blood donors and any fee for
25 failure to replace the first 3 pints of blood provided to
26 a covered person each policy year.
27 (11) Personal supplies or services provided by a
28 hospital or nursing home, or any other nonmedical or
29 nonprescribed supply or service.
30 (12) Routine maternity charges for a pregnancy,
31 except where added as optional coverage with payment of
32 an additional premium for pregnancy resulting from
33 conception occurring after the effective date of the
34 optional coverage.
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1 (13) (Blank).
2 (14) Any expense or charge for services, drugs, or
3 supplies that are: (i) not provided in accord with
4 generally accepted standards of current medical practice;
5 (ii) for procedures, treatments, equipment, transplants,
6 or implants, any of which are investigational,
7 experimental, or for research purposes; (iii)
8 investigative and not proven safe and effective; or (iv)
9 for, or resulting from, a gender transformation
10 operation.
11 (15) Any expense or charge for routine physical
12 examinations or tests.
13 (16) Any expense for which a charge is not made in
14 the absence of insurance or for which there is no legal
15 obligation on the part of the patient to pay.
16 (17) Any expense incurred for benefits provided
17 under the laws of the United States and this State,
18 including Medicare and Medicaid and other medical
19 assistance, military service-connected disability
20 payments, medical services provided for members of the
21 armed forces and their dependents or employees of the
22 armed forces of the United States, and medical services
23 financed on behalf of all citizens by the United States.
24 (18) Any expense or charge for in vitro
25 fertilization, artificial insemination, or any other
26 artificial means used to cause pregnancy.
27 (19) Any expense or charge for oral contraceptives
28 used for birth control or any other temporary birth
29 control measures.
30 (20) Any expense or charge for sterilization or
31 sterilization reversals.
32 (21) Any expense or charge for weight loss
33 programs, exercise equipment, or treatment of obesity,
34 except when certified by a physician as morbid obesity
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1 (at least 2 times normal body weight).
2 (22) Any expense or charge for acupuncture
3 treatment unless used as an anesthetic agent for a
4 covered surgery.
5 (23) Any expense or charge for or related to organ
6 or tissue transplants other than those performed at a
7 hospital with a Board approved organ transplant program
8 that has been designated by the Board as a preferred or
9 exclusive provider organization for that specific organ
10 or tissue transplant.
11 (24) Any expense or charge for procedures,
12 treatments, equipment, or services that are provided in
13 special settings for research purposes or in a controlled
14 environment, are being studied for safety, efficiency,
15 and effectiveness, and are awaiting endorsement by the
16 appropriate national medical speciality college for
17 general use within the medical community.
18 d. Deductibles and coinsurance.
19 The Plan coverage defined in Section 6 shall provide for
20 a choice of deductibles per individual as authorized by the
21 Board. If 2 individual members of the same family household,
22 who are both covered persons under the Plan, satisfy the same
23 applicable deductibles, no other member of that family who is
24 also a covered person under the Plan shall be required to
25 meet any deductibles for the balance of that calendar year.
26 The deductibles must be applied first to the authorized
27 amount of covered expenses incurred by the covered person. A
28 mandatory coinsurance requirement shall be imposed at the
29 rate authorized by the Board in excess of the mandatory
30 deductible, the coinsurance in the aggregate not to exceed
31 such amounts as are authorized by the Board per annum. At
32 its discretion the Board may, however, offer catastrophic
33 coverages or other policies that provide for larger
34 deductibles with or without coinsurance requirements. The
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1 deductibles and coinsurance factors may be adjusted annually
2 according to the Medical Component of the Consumer Price
3 Index.
4 e. Scope of coverage.
5 (1) In approving any of the benefit plans to be offered
6 by the Plan, the Board shall establish such benefit levels,
7 deductibles, coinsurance factors, exclusions, and limitations
8 as it may deem appropriate and that it believes to be
9 generally reflective of and commensurate with health
10 insurance coverage that is provided in the individual market
11 in this State.
12 (2) The benefit plans approved by the Board may also
13 provide for and employ various cost containment measures and
14 other requirements including, but not limited to,
15 preadmission certification, prior approval, second surgical
16 opinions, concurrent utilization review programs, individual
17 case management, preferred provider organizations, health
18 maintenance organizations, and other cost effective
19 arrangements for paying for covered expenses.
20 f. Preexisting conditions.
21 (1) Except for federally eligible individuals
22 qualifying for Plan coverage under Section 15 of this Act
23 or eligible persons who qualify for and elect to purchase
24 the waiver authorized in paragraph (3) of this
25 subsection, plan coverage shall exclude charges or
26 expenses incurred during the first 6 months following the
27 effective date of coverage as to any condition if: (a)
28 the condition had manifested itself within the 6 month
29 period immediately preceding the effective date of
30 coverage in such a manner as would cause an ordinarily
31 prudent person to seek diagnosis, care or treatment; or
32 (b) medical advice, care or treatment was recommended or
33 received within the 6 month period immediately preceding
34 the effective date of coverage.
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1 (2) (Blank).
2 (3) Waiver: The preexisting condition exclusions as
3 set forth in paragraph (1) of this subsection shall be
4 waived to the extent to which the eligible person: (a)
5 has satisfied similar exclusions under any prior health
6 insurance coverage or group health plan that was
7 involuntarily terminated; (b) is ineligible for any
8 continuation coverage that would continue or provide
9 substantially similar coverage following that
10 termination; and (c) has applied for Plan coverage not
11 later than 30 days following the involuntary termination.
12 No policy or plan shall be deemed to have been
13 involuntarily terminated if the master policyholder or
14 other controlling party elected to change insurance
15 coverage from one health insurance issuer or group health
16 plan to another even if that decision resulted in a
17 discontinuation of coverage for any individual under the
18 plan, either totally or for any medical condition. For
19 each eligible person who qualifies for and elects this
20 waiver, there shall be added to each payment of premium,
21 on a prorated basis, a surcharge of up to 10% of the
22 otherwise applicable annual premium for as long as that
23 individual's coverage under the Plan remains in effect or
24 60 months, whichever is less.
25 g. Other sources primary; nonduplication of benefits.
26 (1) The Plan shall be the last payor of benefits
27 whenever any other benefit or source of third party
28 payment is available. Subject to the provisions of
29 subsection e of Section 7, benefits otherwise payable
30 under Plan coverage shall be reduced by all amounts paid
31 or payable by Medicare or any other government program or
32 through any health insurance or group health plan,
33 whether by insurance, reimbursement, or otherwise, or
34 through any third party liability, settlement, judgment,
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1 or award, regardless of the date of the settlement,
2 judgment, or award, whether the settlement, judgment, or
3 award is in the form of a contract, agreement, or trust
4 on behalf of a minor or otherwise and whether the
5 settlement, judgment, or award is payable to the covered
6 person, his or her dependent, estate, personal
7 representative, or guardian in a lump sum or over time,
8 and by all hospital or medical expense benefits paid or
9 payable under any worker's compensation coverage,
10 automobile medical payment, or liability insurance,
11 whether provided on the basis of fault or nonfault, and
12 by any hospital or medical benefits paid or payable under
13 or provided pursuant to any State or federal law or
14 program.
15 (2) The Plan shall have a cause of action against
16 any covered person or any other person or entity for the
17 recovery of any amount paid to the extent the amount was
18 for treatment, services, or supplies not covered in this
19 Section or in excess of benefits as set forth in this
20 Section.
21 (3) Whenever benefits are due from the Plan because
22 of sickness or an injury to a covered person resulting
23 from a third party's wrongful act or negligence and the
24 covered person has recovered or may recover damages from
25 a third party or its insurer, the Plan shall have the
26 right to reduce benefits or to refuse to pay benefits
27 that otherwise may be payable by the amount of damages
28 that the covered person has recovered or may recover
29 regardless of the date of the sickness or injury or the
30 date of any settlement, judgment, or award resulting from
31 that sickness or injury.
32 During the pendency of any action or claim that is
33 brought by or on behalf of a covered person against a
34 third party or its insurer, any benefits that would
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1 otherwise be payable except for the provisions of this
2 paragraph (3) shall be paid if payment by or for the
3 third party has not yet been made and the covered person
4 or, if incapable, that person's legal representative
5 agrees in writing to pay back promptly the benefits paid
6 as a result of the sickness or injury to the extent of
7 any future payments made by or for the third party for
8 the sickness or injury. This agreement is to apply
9 whether or not liability for the payments is established
10 or admitted by the third party or whether those payments
11 are itemized.
12 Any amounts due the plan to repay benefits may be
13 deducted from other benefits payable by the Plan after
14 payments by or for the third party are made.
15 (4) Benefits due from the Plan may be reduced or
16 refused as an offset against any amount otherwise
17 recoverable under this Section.
18 h. Right of subrogation; recoveries.
19 (1) Whenever the Plan has paid benefits because of
20 sickness or an injury to any covered person resulting
21 from a third party's wrongful act or negligence, or for
22 which an insurer is liable in accordance with the
23 provisions of any policy of insurance, and the covered
24 person has recovered or may recover damages from a third
25 party that is liable for the damages, the Plan shall have
26 the right to recover the benefits it paid from any
27 amounts that the covered person has received or may
28 receive regardless of the date of the sickness or injury
29 or the date of any settlement, judgment, or award
30 resulting from that sickness or injury. The Plan shall
31 be subrogated to any right of recovery the covered person
32 may have under the terms of any private or public health
33 care coverage or liability coverage, including coverage
34 under the Workers' Compensation Act or the Workers'
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1 Occupational Diseases Act, without the necessity of
2 assignment of claim or other authorization to secure the
3 right of recovery. To enforce its subrogation right, the
4 Plan may (i) intervene or join in an action or proceeding
5 brought by the covered person or his personal
6 representative, including his guardian, conservator,
7 estate, dependents, or survivors, against any third party
8 or the third party's insurer that may be liable or (ii)
9 institute and prosecute legal proceedings against any
10 third party or the third party's insurer that may be
11 liable for the sickness or injury in an appropriate court
12 either in the name of the Plan or in the name of the
13 covered person or his personal representative, including
14 his guardian, conservator, estate, dependents, or
15 survivors.
16 (2) If any action or claim is brought by or on
17 behalf of a covered person against a third party or the
18 third party's insurer, the covered person or his personal
19 representative, including his guardian, conservator,
20 estate, dependents, or survivors, shall notify the Plan
21 by personal service or registered mail of the action or
22 claim and of the name of the court in which the action or
23 claim is brought, filing proof thereof in the action or
24 claim. The Plan may, at any time thereafter, join in the
25 action or claim upon its motion so that all orders of
26 court after hearing and judgment shall be made for its
27 protection. No release or settlement of a claim for
28 damages and no satisfaction of judgment in the action
29 shall be valid without the written consent of the Plan to
30 the extent of its interest in the settlement or judgment
31 and of the covered person or his personal representative.
32 (3) In the event that the covered person or his
33 personal representative fails to institute a proceeding
34 against any appropriate third party before the fifth
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1 month before the action would be barred, the Plan may, in
2 its own name or in the name of the covered person or
3 personal representative, commence a proceeding against
4 any appropriate third party for the recovery of damages
5 on account of any sickness, injury, or death to the
6 covered person. The covered person shall cooperate in
7 doing what is reasonably necessary to assist the Plan in
8 any recovery and shall not take any action that would
9 prejudice the Plan's right to recovery. The Plan shall
10 pay to the covered person or his personal representative
11 all sums collected from any third party by judgment or
12 otherwise in excess of amounts paid in benefits under the
13 Plan and amounts paid or to be paid as costs, attorneys
14 fees, and reasonable expenses incurred by the Plan in
15 making the collection or enforcing the judgment.
16 (4) In the event that a covered person or his
17 personal representative, including his guardian,
18 conservator, estate, dependents, or survivors, recovers
19 damages from a third party for sickness or injury caused
20 to the covered person, the covered person or the personal
21 representative shall pay to the Plan from the damages
22 recovered the amount of benefits paid or to be paid on
23 behalf of the covered person.
24 (5) When the action or claim is brought by the
25 covered person alone and the covered person incurs a
26 personal liability to pay attorney's fees and costs of
27 litigation, the Plan's claim for reimbursement of the
28 benefits provided to the covered person shall be the full
29 amount of benefits paid to or on behalf of the covered
30 person under this Act less a pro rata share that
31 represents the Plan's reasonable share of attorney's fees
32 paid by the covered person and that portion of the cost
33 of litigation expenses determined by multiplying by the
34 ratio of the full amount of the expenditures to the full
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1 amount of the judgement, award, or settlement.
2 (6) In the event of judgment or award in a suit or
3 claim against a third party or insurer, the court shall
4 first order paid from any judgement or award the
5 reasonable litigation expenses incurred in preparation
6 and prosecution of the action or claim, together with
7 reasonable attorney's fees. After payment of those
8 expenses and attorney's fees, the court shall apply out
9 of the balance of the judgment or award an amount
10 sufficient to reimburse the Plan the full amount of
11 benefits paid on behalf of the covered person under this
12 Act, provided the court may reduce and apportion the
13 Plan's portion of the judgement proportionate to the
14 recovery of the covered person. The burden of producing
15 evidence sufficient to support the exercise by the court
16 of its discretion to reduce the amount of a proven charge
17 sought to be enforced against the recovery shall rest
18 with the party seeking the reduction. The court may
19 consider the nature and extent of the injury, economic
20 and non-economic loss, settlement offers, comparative
21 negligence as it applies to the case at hand, hospital
22 costs, physician costs, and all other appropriate costs.
23 The Plan shall pay its pro rata share of the attorney
24 fees based on the Plan's recovery as it compares to the
25 total judgment. Any reimbursement rights of the Plan
26 shall take priority over all other liens and charges
27 existing under the laws of this State with the exception
28 of any attorney liens filed under the Attorneys Lien Act.
29 (7) The Plan may compromise or settle and release
30 any claim for benefits provided under this Act or waive
31 any claims for benefits, in whole or in part, for the
32 convenience of the Plan or if the Plan determines that
33 collection would result in undue hardship upon the
34 covered person.
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1 (Source: P.A. 89-486, eff. 6-21-96; 90-7, eff. 6-10-97;
2 90-30, eff. 7-1-97; 90-655, eff. 7-30-98.)
3 Section 99. Effective date. This Act takes effect upon
4 becoming law.