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91_HB2166eng HB2166 Engrossed 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 HB2166 Engrossed -2- LRB9102918JSpc 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 HB2166 Engrossed -3- LRB9102918JSpc 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. HB2166 Engrossed -4- LRB9102918JSpc 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. HB2166 Engrossed -5- LRB9102918JSpc 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 HB2166 Engrossed -6- LRB9102918JSpc 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 HB2166 Engrossed -7- LRB9102918JSpc 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. HB2166 Engrossed -8- LRB9102918JSpc 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, HB2166 Engrossed -9- LRB9102918JSpc 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 HB2166 Engrossed -10- LRB9102918JSpc 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' HB2166 Engrossed -11- LRB9102918JSpc 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 HB2166 Engrossed -12- LRB9102918JSpc 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 HB2166 Engrossed -13- LRB9102918JSpc 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. HB2166 Engrossed -14- LRB9102918JSpc 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.