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91_HB2166enr HB2166 Enrolled LRB9102918JSpc 1 AN ACT to amend the Comprehensive Health Insurance Plan 2 Act by changing Sections 7 and 8 and repealing Section 8.5. 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 Sections 7 and 8 as follows: 7 (215 ILCS 105/7) (from Ch. 73, par. 1307) 8 Sec. 7. Eligibility. 9 a. Except as provided in subsection (e) of this Section 10 or in Section 15 of this Act, any individual person who is 11 either a citizen of the United States or an alien lawfully 12 admitted for permanent residence and continues to be a 13 resident of this State shall be eligible for Plan coverage if 14 evidence is provided of: 15 (1) A notice of rejection or refusal to issue 16 substantially similar individual health insurance 17 coverage for health reasons by a health insurance issuer; 18 or 19 (2) A refusal by a health insurance issuer to issue 20 individual health insurance coverage except at a rate 21 exceeding the applicable Plan rate for which the person 22 is responsible. 23 A rejection or refusal by a group health plan or health 24 insurance issuer offering only stop-loss or excess of loss 25 insurance or contracts, agreements, or other arrangements for 26 reinsurance coverage with respect to the applicant shall not 27 be sufficient evidence under this subsection. 28 b. The board shall promulgate a list of medical or 29 health conditions for which a person who is either a citizen 30 of the United States or an alien lawfully admitted for 31 permanent residence and a resident of this State would be HB2166 Enrolled -2- LRB9102918JSpc 1 eligible for Plan coverage without applying for health 2 insurance coverage pursuant to subsection a. of this Section. 3 Persons who can demonstrate the existence or history of any 4 medical or health conditions on the list promulgated by the 5 board shall not be required to provide the evidence specified 6 in subsection a. of this Section. The list shall be 7 effective on the first day of the operation of the Plan and 8 may be amended from time to time as appropriate. 9 c. Family members of the same household who each are 10 covered persons are eligible for optional family coverage 11 under the Plan. 12 d. For persons qualifying for coverage in accordance 13 with Section 7 of this Act, the board shall, if it determines 14 that such appropriations as are made pursuant to Section 12 15 of this Act are insufficient to allow the board to accept all 16 of the eligible persons which it projects will apply for 17 enrollment under the Plan, limit or close enrollment to 18 ensure that the Plan is not over-subscribed and that it has 19 sufficient resources to meet its obligations to existing 20 enrollees. The board shall not limit or close enrollment for 21 federally eligible individuals. 22 e. A person shall not be eligible for coverage under the 23 Plan if: 24 (1) He or she has or obtains other coverage under a 25 group health plan or health insurance coverage 26 substantially similar to or better than a Plan policy as 27 an insured or covered dependent or would be eligible to 28 have that coverage if he or she elected to obtain it. 29 Persons otherwise eligible for Plan coverage may, 30 however, solely for the purpose of having coverage for a 31 pre-existing condition, maintain other coverage only 32 while satisfying any pre-existing condition waiting 33 period under a Plan policy or a subsequent replacement 34 policy of a Plan policy. HB2166 Enrolled -3- LRB9102918JSpc 1 (1.1) His or her prior coverage under a group 2 health plan or health insurance coverage, provided or 3 arranged by an employer of more than 10 employees was 4 discontinued for any reason without the entire group or 5 plan being discontinued and not replaced, provided he or 6 she remains an employee, or dependent thereof, of the 7 same employer. 8 (2) He or she is a recipient of or is approved to 9 receive medical assistance, except that a person may 10 continue to receive medical assistance through the 11 medical assistance no grant program, but only while 12 satisfying the requirements for a preexisting condition 13 under Section 8, subsection f. of this Act. Payment of 14 premiums pursuant to this Act shall be allocable to the 15 person's spenddown for purposes of the medical assistance 16 no grant program, but that person shall not be eligible 17 for any Plan benefits while that person remains eligible 18 for medical assistance. If the person continues to 19 receive or be approved to receive medical assistance 20 through the medical assistance no grant program at or 21 after the time that requirements for a preexisting 22 condition are satisfied, the person shall not be eligible 23 for coverage under the Plan. In that circumstance, 24 coverage under the plan shall terminate as of the 25 expiration of the preexisting condition limitation 26 period. Under all other circumstances, coverage under 27 the Plan shall automatically terminate as of the 28 effective date of any medical assistance. 29 (3) Except as provided in Section 15, the person 30 has previously participated in the Plan and voluntarily 31 terminated Plan coverage, unless 12 months have elapsed 32 since the person's latest voluntary termination of 33 coverage. 34 (4) The person fails to pay the required premium HB2166 Enrolled -4- LRB9102918JSpc 1 under the covered person's terms of enrollment and 2 participation, in which event the liability of the Plan 3 shall be limited to benefits incurred under the Plan for 4 the time period for which premiums had been paid and the 5 covered person remained eligible for Plan coverage. 6 (5) The Plan has paid a total of $1,000,000 in 7 benefits on behalf of the covered person. 8 (6) The person is a resident of a public 9 institution. 10 (7) The person's premium is paid for or reimbursed 11 under any government sponsored program or by any 12 government agency or health care provider, except as an 13 otherwise qualifying full-time employee, or dependent of 14 such employee, of a government agency or health care 15 provider. 16 (8) The person has or later receives other benefits 17 or funds from any settlement, judgement, or award 18 resulting from any accident or injury, regardless of the 19 date of the accident or injury, or any other 20 circumstances creating a legal liability for damages due 21 that person by a third party, whether the settlement, 22 judgment, or award is in the form of a contract, 23 agreement, or trust on behalf of a minor or otherwise and 24 whether the settlement, judgment, or award is payable to 25 the person, his or her dependent, estate, personal 26 representative, or guardian in a lump sum or over time, 27 so long as there continues to be benefits or assets 28 remaining from those sources in an amount in excess of 29 $100,000. 30 (9) Within the 5 years prior to the date a person's 31 Plan application is received by the Board, the person's 32 coverage under any health care benefit program as defined 33 in 18 U.S.C. 24, including any public or private plan or 34 contract under which any medical benefit, item, or HB2166 Enrolled -5- LRB9102918JSpc 1 service is provided, was terminated as a result of any 2 act or practice that constitutes fraud under State or 3 federal law or as a result of an intentional 4 misrepresentation of material fact; or if that person 5 knowingly and willfully obtained or attempted to obtain, 6 or fraudulently aided or attempted to aid any other 7 person in obtaining, any coverage or benefits under the 8 Plan to which that person was not entitled. 9 f. The board or the administrator shall require 10 verification of residency and may require any additional 11 information or documentation, or statements under oath, when 12 necessary to determine residency upon initial application and 13 for the entire term of the policy. 14 g. Coverage shall cease (i) on the date a person is no 15 longer a resident of Illinois, (ii) on the date a person 16 requests coverage to end, (iii) upon the death of the covered 17 person, (iv) on the date State law requires cancellation of 18 the policy, or (v) at the Plan's option, 30 days after the 19 Plan makes any inquiry concerning a person's eligibility or 20 place of residence to which the person does not reply. 21 h. Except under the conditions set forth in subsection g 22 of this Section, the coverage of any person who ceases to 23 meet the eligibility requirements of this Section shall be 24 terminated at the end of the current policy period for which 25 the necessary premiums have been paid. 26 (Source: P.A. 89-486, eff. 6-21-96; 90-30, eff. 7-1-97.) 27 (215 ILCS 105/8) (from Ch. 73, par. 1308) 28 Sec. 8. Minimum benefits. 29 a. Availability. The Plan shall offer in an annually 30 renewable policy major medical expense coverage to every 31 eligible person who is not eligible for Medicare. Major 32 medical expense coverage offered by the Plan shall pay an 33 eligible person's covered expenses, subject to limit on the HB2166 Enrolled -6- LRB9102918JSpc 1 deductible and coinsurance payments authorized under 2 paragraph (4) of subsection d of this Section, up to a 3 lifetime benefit limit of $1,000,000 per covered individual. 4 The maximum limit under this subsection shall not be altered 5 by the Board, and no actuarial equivalent benefit may be 6 substituted by the Board. Any person who otherwise would 7 qualify for coverage under the Plan, but is excluded because 8 he or she is eligible for Medicare, shall be eligible for any 9 separate Medicare supplement policy or policies which the 10 Board may offer. 11 b. Outline of benefits. Covered expenses shall be 12 limited to the usual and customary charge, including 13 negotiated fees, in the locality for the following services 14 and articles when prescribed by a physician and determined by 15 the Plan to be medically necessary for the following areas of 16 services, subject to such separate deductibles, co-payments, 17 exclusions, and other limitations on benefits as the Board 18 shall establish and approve, and the other provisions of this 19 Section: 20 (1) Hospital services, except that any services 21 provided by a hospital that is located more than 75 miles 22 outside the State of Illinois shall be covered only for a 23 maximum of 45 days in any calendar year. With respect to 24 covered expenses incurred during any calendar year ending 25 on or after December 31, 1999, inpatient hospitalization 26 of an eligible person for the treatment of mental illness 27 at a hospital located within the State of Illinois shall 28 be subject to the same terms and conditions as for any 29 other illness. 30 (2) Professional services for the diagnosis or 31 treatment of injuries, illnesses or conditions, other 32 than dental and mental and nervous disorders as described 33 in paragraph (17), which are rendered by a physician, or 34 by other licensed professionals at the physician's HB2166 Enrolled -7- LRB9102918JSpc 1 direction. 2 (2.5) Professional services provided by a physician 3 to children under the age of 16 years for physical 4 examinations and age appropriate immunizations ordered by 5 a physician licensed to practice medicine in all its 6 branches. 7 (3) (Blank). 8 (4) Outpatient prescription drugs that by law 9 requirerequiringaphysician'sprescription written by a 10 physician licensed to practice medicine in all its 11 branches subject to such separate deductible, copayment, 12 and other limitations or restrictions as the Board shall 13 approve, including the use of a prescription drug card or 14 any other program, or both. 15 (5) Skilled nursing services of a licensed skilled 16 nursing facility for not more than 120 days during a 17 policy year. 18 (6) Services of a home health agency in accord with 19 a home health care plan, up to a maximum of 270 visits 20 per year. 21 (7) Services of a licensed hospice for not more 22 than 180 days during a policy year. 23 (8) Use of radium or other radioactive materials. 24 (9) Oxygen. 25 (10) Anesthetics. 26 (11) Orthoses and prostheses other than dental. 27 (12) Rental or purchase in accordance with Board 28 policies or procedures of durable medical equipment, 29 other than eyeglasses or hearing aids, for which there is 30 no personal use in the absence of the condition for which 31 it is prescribed. 32 (13) Diagnostic x-rays and laboratory tests. 33 (14) Oral surgeryfor excision of partially or34completely unerupted impacted teeth or the gums andHB2166 Enrolled -8- LRB9102918JSpc 1tissues of the mouth, when not performed in connection 2 with the routine extraction or repair of teeth, that is 3 required to treatand oral surgery and procedures,4including orthodontics and prosthetics necessary for5craniofacial or maxillofacial conditions and to correct6congenital defects orinjuries to natural teeth or a 7 fractured jaw due to an accident that occurred while a 8 covered person. 9 (15) Physical, speech, and functional occupational 10 therapy as medically necessary and provided by 11 appropriate licensed professionals. 12 (16) Emergency and other medically necessary 13 transportation provided by a licensed ambulance service 14 to the nearest health care facility qualified to treat a 15 covered illness, injury, or condition, subject to the 16 provisions of the Emergency Medical Systems (EMS) Act. 17 (17) Outpatient services for diagnosis and 18 treatment of mental and nervous disorders provided that a 19 covered person shall be required to make a copayment not 20 to exceed 50% and that the Plan's payment shall not 21 exceed such amounts as are established by the Board. 22 (18) Human organ or tissue transplants specified by 23 the Board that are performed at a hospital designated by 24 the Board as a participating transplant center for that 25 specific organ or tissue transplant. 26 (19) Naprapathic services, as appropriate, provided 27 by a licensed naprapathic practitioner. 28 c. Exclusions. Covered expenses of the Plan shall not 29 include the following: 30 (1) Any charge for treatment for cosmetic purposes 31 other than for reconstructive surgery when the service is 32 incidental to or follows surgery resulting from injury, 33 sickness or other diseases of the involved part or 34 surgery for the repair or treatment of a congenital HB2166 Enrolled -9- LRB9102918JSpc 1 bodily defect to restore normal bodily functions. 2 (2) Any charge for care that is primarily for rest, 3 custodial, educational, or domiciliary purposes. 4 (3) Any charge for services in a private room to 5 the extent it is in excess of the institution's charge 6 for its most common semiprivate room, unless a private 7 room is prescribed as medically necessary by a physician. 8 (4) That part of any charge for room and board or 9 for services rendered or articles prescribed by a 10 physician, dentist, or other health care personnel that 11 exceeds the reasonable and customary charge in the 12 locality or for any services or supplies not medically 13 necessary for the diagnosed injury or illness. 14 (5) Any charge for services or articles the 15 provision of which is not within the scope of licensure 16 of the institution or individual providing the services 17 or articles. 18 (6) Any expense incurred prior to the effective 19 date of coverage by the Plan for the person on whose 20 behalf the expense is incurred. 21 (7) Dental care, dental surgery, dental treatment 22 or dental appliances, except as provided in paragraph 23 (14) of subsection b of this Section. 24 (8) Eyeglasses, contact lenses, hearing aids or 25 their fitting. 26 (9) Illness or injury due to acts of war. 27 (10) Services of blood donors and any fee for 28 failure to replace the first 3 pints of blood provided to 29 a covered person each policy year. 30 (11) Personal supplies or services provided by a 31 hospital or nursing home, or any other nonmedical or 32 nonprescribed supply or service. 33 (12) Routine maternity charges for a pregnancy, 34 except where added as optional coverage with payment of HB2166 Enrolled -10- LRB9102918JSpc 1 an additional premium for pregnancy resulting from 2 conception occurring after the effective date of the 3 optional coverage. 4 (13) (Blank). 5 (14) Any expense or charge for services, drugs, or 6 supplies that are: (i) not provided in accord with 7 generally accepted standards of current medical practice; 8 (ii) for procedures, treatments, equipment, transplants, 9 or implants, any of which are investigational, 10 experimental, or for research purposes; (iii) 11 investigative and not proven safe and effective; or (iv) 12 for, or resulting from, a gender transformation 13 operation. 14 (15) Any expense or charge for routine physical 15 examinations or tests except as provided in item (2.5) of 16 subsection b of this Section. 17 (16) Any expense for which a charge is not made in 18 the absence of insurance or for which there is no legal 19 obligation on the part of the patient to pay. 20 (17) Any expense incurred for benefits provided 21 under the laws of the United States and this State, 22 including Medicare,andMedicaid, and other medical 23 assistance, maternal and child health services and any 24 other program that is administered or funded by the 25 Department of Human Services, Department of Public Aid, 26 or Department of Public Health, military 27 service-connected disability payments, medical services 28 provided for members of the armed forces and their 29 dependents or employees of the armed forces of the United 30 States, and medical services financed on behalf of all 31 citizens by the United States. 32 (18) Any expense or charge for in vitro 33 fertilization, artificial insemination, or any other 34 artificial means used to cause pregnancy. HB2166 Enrolled -11- LRB9102918JSpc 1 (19) Any expense or charge for oral contraceptives 2 used for birth control or any other temporary birth 3 control measures. 4 (20) Any expense or charge for sterilization or 5 sterilization reversals. 6 (21) Any expense or charge for weight loss 7 programs, exercise equipment, or treatment of obesity, 8 except when certified by a physician as morbid obesity 9 (at least 2 times normal body weight). 10 (22) Any expense or charge for acupuncture 11 treatment unless used as an anesthetic agent for a 12 covered surgery. 13 (23) Any expense or charge for or related to organ 14 or tissue transplants other than those performed at a 15 hospital with a Board approved organ transplant program 16 that has been designated by the Board as a preferred or 17 exclusive provider organization for that specific organ 18 or tissue transplant. 19 (24) Any expense or charge for procedures, 20 treatments, equipment, or services that are provided in 21 special settings for research purposes or in a controlled 22 environment, are being studied for safety, efficiency, 23 and effectiveness, and are awaiting endorsement by the 24 appropriate national medical speciality college for 25 general use within the medical community. 26 d. Deductibles and coinsurance. 27 The Plan coverage defined in Section 6 shall provide for 28 a choice of deductibles per individual as authorized by the 29 Board. If 2 individual members of the same family household, 30 who are both covered persons under the Plan, satisfy the same 31 applicable deductibles, no other member of that family who is 32 also a covered person under the Plan shall be required to 33 meet any deductibles for the balance of that calendar year. 34 The deductibles must be applied first to the authorized HB2166 Enrolled -12- LRB9102918JSpc 1 amount of covered expenses incurred by the covered person. A 2 mandatory coinsurance requirement shall be imposed at the 3 rate authorized by the Board in excess of the mandatory 4 deductible, the coinsurance in the aggregate not to exceed 5 such amounts as are authorized by the Board per annum. At 6 its discretion the Board may, however, offer catastrophic 7 coverages or other policies that provide for larger 8 deductibles with or without coinsurance requirements. The 9 deductibles and coinsurance factors may be adjusted annually 10 according to the Medical Component of the Consumer Price 11 Index. 12 e. Scope of coverage. 13 (1) In approving any of the benefit plans to be offered 14 by the Plan, the Board shall establish such benefit levels, 15 deductibles, coinsurance factors, exclusions, and limitations 16 as it may deem appropriate and that it believes to be 17 generally reflective of and commensurate with health 18 insurance coverage that is provided in the individual market 19 in this State. 20 (2) The benefit plans approved by the Board may also 21 provide for and employ various cost containment measures and 22 other requirements including, but not limited to, 23 preadmission certification, prior approval, second surgical 24 opinions, concurrent utilization review programs, individual 25 case management, preferred provider organizations, health 26 maintenance organizations, and other cost effective 27 arrangements for paying for covered expenses. 28 f. Preexisting conditions. 29 (1) Except for federally eligible individuals 30 qualifying for Plan coverage under Section 15 of this Act 31or eligible persons who qualify for and elect to purchase32the waiver authorized in paragraph (3) of this subsection33, plan coverage shall exclude charges or expenses 34 incurred during the first 6 months following the HB2166 Enrolled -13- LRB9102918JSpc 1 effective date of coverage as to any condition if: (a) 2 the condition had manifested itself within the 6 month 3 period immediately preceding the effective date of 4 coverage in such a manner as would cause an ordinarily 5 prudent person to seek diagnosis, care or treatment; or 6 (b) medical advice, care or treatment was recommended or 7 received within the 6 month period immediately preceding 8 the effective date of coverage. 9 (2) (Blank). 10 (3) (Blank)Waiver: The preexisting condition11exclusions as set forth in paragraph (1) of this12subsection shall be waived to the extent to which the13eligible person: (a) has satisfied similar exclusions14under any prior health insurance coverage or group health15plan that was involuntarily terminated; (b) is ineligible16for any continuation coverage that would continue or17provide substantially similar coverage following that18termination; and (c) has applied for Plan coverage not19later than 30 days following the involuntary termination.20No policy or plan shall be deemed to have been21involuntarily terminated if the master policyholder or22other controlling party elected to change insurance23coverage from one health insurance issuer or group health24plan to another even if that decision resulted in a25discontinuation of coverage for any individual under the26plan, either totally or for any medical condition. For27each eligible person who qualifies for and elects this28waiver, there shall be added to each payment of premium,29on a prorated basis, a surcharge of up to 10% of the30otherwise applicable annual premium for as long as that31individual's coverage under the Plan remains in effect or3260 months, whichever is less. 33 g. Other sources primary; nonduplication of benefits. 34 (1) The Plan shall be the last payor of benefits HB2166 Enrolled -14- LRB9102918JSpc 1 whenever any other benefit or source of third party 2 payment is available. Subject to the provisions of 3 subsection e of Section 7, benefits otherwise payable 4 under Plan coverage shall be reduced by all amounts paid 5 or payable by Medicare or any other government program or 6 through any health insurance or group health plan, 7 whether by insurance, reimbursement, or otherwise, or 8 through any third party liability, settlement, judgment, 9 or award, regardless of the date of the settlement, 10 judgment, or award, whether the settlement, judgment, or 11 award is in the form of a contract, agreement, or trust 12 on behalf of a minor or otherwise and whether the 13 settlement, judgment, or award is payable to the covered 14 person, his or her dependent, estate, personal 15 representative, or guardian in a lump sum or over time, 16 and by all hospital or medical expense benefits paid or 17 payable under any worker's compensation coverage, 18 automobile medical payment, or liability insurance, 19 whether provided on the basis of fault or nonfault, and 20 by any hospital or medical benefits paid or payable under 21 or provided pursuant to any State or federal law or 22 program. 23 (2) The Plan shall have a cause of action against 24 any covered person or any other person or entity for the 25 recovery of any amount paid to the extent the amount was 26 for treatment, services, or supplies not covered in this 27 Section or in excess of benefits as set forth in this 28 Section. 29 (3) Whenever benefits are due from the Plan because 30 of sickness or an injury to a covered person resulting 31 from a third party's wrongful act or negligence and the 32 covered person has recovered or may recover damages from 33 a third party or its insurer, the Plan shall have the 34 right to reduce benefits or to refuse to pay benefits HB2166 Enrolled -15- LRB9102918JSpc 1 that otherwise may be payable by the amount of damages 2 that the covered person has recovered or may recover 3 regardless of the date of the sickness or injury or the 4 date of any settlement, judgment, or award resulting from 5 that sickness or injury. 6 During the pendency of any action or claim that is 7 brought by or on behalf of a covered person against a 8 third party or its insurer, any benefits that would 9 otherwise be payable except for the provisions of this 10 paragraph (3) shall be paid if payment by or for the 11 third party has not yet been made and the covered person 12 or, if incapable, that person's legal representative 13 agrees in writing to pay back promptly the benefits paid 14 as a result of the sickness or injury to the extent of 15 any future payments made by or for the third party for 16 the sickness or injury. This agreement is to apply 17 whether or not liability for the payments is established 18 or admitted by the third party or whether those payments 19 are itemized. 20 Any amounts due the plan to repay benefits may be 21 deducted from other benefits payable by the Plan after 22 payments by or for the third party are made. 23 (4) Benefits due from the Plan may be reduced or 24 refused as an offset against any amount otherwise 25 recoverable under this Section. 26 h. Right of subrogation; recoveries. 27 (1) Whenever the Plan has paid benefits because of 28 sickness or an injury to any covered person resulting 29 from a third party's wrongful act or negligence, or for 30 which an insurer is liable in accordance with the 31 provisions of any policy of insurance, and the covered 32 person has recovered or may recover damages from a third 33 party that is liable for the damages, the Plan shall have 34 the right to recover the benefits it paid from any HB2166 Enrolled -16- LRB9102918JSpc 1 amounts that the covered person has received or may 2 receive regardless of the date of the sickness or injury 3 or the date of any settlement, judgment, or award 4 resulting from that sickness or injury. The Plan shall 5 be subrogated to any right of recovery the covered person 6 may have under the terms of any private or public health 7 care coverage or liability coverage, including coverage 8 under the Workers' Compensation Act or the Workers' 9 Occupational Diseases Act, without the necessity of 10 assignment of claim or other authorization to secure the 11 right of recovery. To enforce its subrogation right, the 12 Plan may (i) intervene or join in an action or proceeding 13 brought by the covered person or his personal 14 representative, including his guardian, conservator, 15 estate, dependents, or survivors, against any third party 16 or the third party's insurer that may be liable or (ii) 17 institute and prosecute legal proceedings against any 18 third party or the third party's insurer that may be 19 liable for the sickness or injury in an appropriate court 20 either in the name of the Plan or in the name of the 21 covered person or his personal representative, including 22 his guardian, conservator, estate, dependents, or 23 survivors. 24 (2) If any action or claim is brought by or on 25 behalf of a covered person against a third party or the 26 third party's insurer, the covered person or his personal 27 representative, including his guardian, conservator, 28 estate, dependents, or survivors, shall notify the Plan 29 by personal service or registered mail of the action or 30 claim and of the name of the court in which the action or 31 claim is brought, filing proof thereof in the action or 32 claim. The Plan may, at any time thereafter, join in the 33 action or claim upon its motion so that all orders of 34 court after hearing and judgment shall be made for its HB2166 Enrolled -17- LRB9102918JSpc 1 protection. No release or settlement of a claim for 2 damages and no satisfaction of judgment in the action 3 shall be valid without the written consent of the Plan to 4 the extent of its interest in the settlement or judgment 5 and of the covered person or his personal representative. 6 (3) In the event that the covered person or his 7 personal representative fails to institute a proceeding 8 against any appropriate third party before the fifth 9 month before the action would be barred, the Plan may, in 10 its own name or in the name of the covered person or 11 personal representative, commence a proceeding against 12 any appropriate third party for the recovery of damages 13 on account of any sickness, injury, or death to the 14 covered person. The covered person shall cooperate in 15 doing what is reasonably necessary to assist the Plan in 16 any recovery and shall not take any action that would 17 prejudice the Plan's right to recovery. The Plan shall 18 pay to the covered person or his personal representative 19 all sums collected from any third party by judgment or 20 otherwise in excess of amounts paid in benefits under the 21 Plan and amounts paid or to be paid as costs, attorneys 22 fees, and reasonable expenses incurred by the Plan in 23 making the collection or enforcing the judgment. 24 (4) In the event that a covered person or his 25 personal representative, including his guardian, 26 conservator, estate, dependents, or survivors, recovers 27 damages from a third party for sickness or injury caused 28 to the covered person, the covered person or the personal 29 representative shall pay to the Plan from the damages 30 recovered the amount of benefits paid or to be paid on 31 behalf of the covered person. 32 (5) When the action or claim is brought by the 33 covered person alone and the covered person incurs a 34 personal liability to pay attorney's fees and costs of HB2166 Enrolled -18- LRB9102918JSpc 1 litigation, the Plan's claim for reimbursement of the 2 benefits provided to the covered person shall be the full 3 amount of benefits paid to or on behalf of the covered 4 person under this Act less a pro rata share that 5 represents the Plan's reasonable share of attorney's fees 6 paid by the covered person and that portion of the cost 7 of litigation expenses determined by multiplying by the 8 ratio of the full amount of the expenditures to the full 9 amount of the judgement, award, or settlement. 10 (6) In the event of judgment or award in a suit or 11 claim against a third party or insurer, the court shall 12 first order paid from any judgement or award the 13 reasonable litigation expenses incurred in preparation 14 and prosecution of the action or claim, together with 15 reasonable attorney's fees. After payment of those 16 expenses and attorney's fees, the court shall apply out 17 of the balance of the judgment or award an amount 18 sufficient to reimburse the Plan the full amount of 19 benefits paid on behalf of the covered person under this 20 Act, provided the court may reduce and apportion the 21 Plan's portion of the judgement proportionate to the 22 recovery of the covered person. The burden of producing 23 evidence sufficient to support the exercise by the court 24 of its discretion to reduce the amount of a proven charge 25 sought to be enforced against the recovery shall rest 26 with the party seeking the reduction. The court may 27 consider the nature and extent of the injury, economic 28 and non-economic loss, settlement offers, comparative 29 negligence as it applies to the case at hand, hospital 30 costs, physician costs, and all other appropriate costs. 31 The Plan shall pay its pro rata share of the attorney 32 fees based on the Plan's recovery as it compares to the 33 total judgment. Any reimbursement rights of the Plan 34 shall take priority over all other liens and charges HB2166 Enrolled -19- LRB9102918JSpc 1 existing under the laws of this State with the exception 2 of any attorney liens filed under the Attorneys Lien Act. 3 (7) The Plan may compromise or settle and release 4 any claim for benefits provided under this Act or waive 5 any claims for benefits, in whole or in part, for the 6 convenience of the Plan or if the Plan determines that 7 collection would result in undue hardship upon the 8 covered person. 9 (Source: P.A. 89-486, eff. 6-21-96; 90-7, eff. 6-10-97; 10 90-30, eff. 7-1-97; 90-655, eff. 7-30-98.) 11 (215 ILCS 105/8.5 rep.) 12 Section 10. The Comprehensive Health Insurance Plan Act 13 is amended by repealing Section 8.5. 14 Section 99. Effective date. This Act takes effect upon 15 becoming law.