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| [ Engrossed ] | [ Enrolled ] | [ Senate Amendment 001 ] |
91_HB4433
LRB9110326JSsb
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, except that any services
3 provided by a hospital that is located more than 75 miles
4 outside the State of Illinois shall be covered only for a
5 maximum of 45 days in any calendar year. With respect to
6 covered expenses incurred during any calendar year ending
7 on or after December 31, 1999, inpatient hospitalization
8 of an eligible person for the treatment of mental illness
9 at a hospital located within the State of Illinois shall
10 be subject to the same terms and conditions as for any
11 other illness.
12 (2) Professional services for the diagnosis or
13 treatment of injuries, illnesses or conditions, other
14 than dental and mental and nervous disorders as described
15 in paragraph (17), which are rendered by a physician, or
16 by other licensed professionals at the physician's
17 direction.
18 (2.5) Professional services provided by a physician
19 to children under the age of 16 years for physical
20 examinations and age appropriate immunizations ordered by
21 a physician licensed to practice medicine in all its
22 branches.
23 (3) (Blank).
24 (4) Outpatient prescription drugs that by law
25 require a prescription written by a physician licensed to
26 practice medicine in all its branches subject to such
27 separate deductible, copayment, and other limitations or
28 restrictions as the Board shall approve, including the
29 use of a prescription drug card or any other program, or
30 both.
31 (5) Skilled nursing services of a licensed skilled
32 nursing facility for not more than 120 days during a
33 policy year.
34 (6) Services of a home health agency in accord with
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1 a home health care plan, up to a maximum of 270 visits
2 per year.
3 (7) Services of a licensed hospice for not more
4 than 180 days during a policy year.
5 (8) Use of radium or other radioactive materials.
6 (9) Oxygen.
7 (10) Anesthetics.
8 (11) Orthoses and prostheses other than dental.
9 (12) Rental or purchase in accordance with Board
10 policies or procedures of durable medical equipment,
11 other than eyeglasses or hearing aids, for which there is
12 no personal use in the absence of the condition for which
13 it is prescribed.
14 (13) Diagnostic x-rays and laboratory tests.
15 (14) Oral surgery, when not performed in connection
16 with the routine extraction or repair of teeth, that is
17 required to treat injuries to natural teeth or a
18 fractured jaw due to an accident that occurred while a
19 covered person.
20 (15) Physical, speech, and functional occupational
21 therapy as medically necessary and provided by
22 appropriate licensed professionals.
23 (16) Emergency and other medically necessary
24 transportation provided by a licensed ambulance service
25 to the nearest health care facility qualified to treat a
26 covered illness, injury, or condition, subject to the
27 provisions of the Emergency Medical Systems (EMS) Act.
28 (17) Outpatient services for diagnosis and
29 treatment of mental and nervous disorders provided that a
30 covered person shall be required to make a copayment not
31 to exceed 50% and that the Plan's payment shall not
32 exceed such amounts as are established by the Board.
33 (18) Human organ or tissue transplants specified by
34 the Board that are performed at a hospital designated by
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1 the Board as a participating transplant center for that
2 specific organ or tissue transplant.
3 (19) Naprapathic services, as appropriate, provided
4 by a licensed naprapathic practitioner.
5 c. Exclusions. Covered expenses of the Plan shall not
6 include the following:
7 (1) Any charge for treatment for cosmetic purposes
8 other than for reconstructive surgery when the service is
9 incidental to or follows surgery resulting from injury,
10 sickness or other diseases of the involved part or
11 surgery for the repair or treatment of a congenital
12 bodily defect to restore normal bodily functions.
13 (2) Any charge for care that is primarily for rest,
14 custodial, educational, or domiciliary purposes.
15 (3) Any charge for services in a private room to
16 the extent it is in excess of the institution's charge
17 for its most common semiprivate room, unless a private
18 room is prescribed as medically necessary by a physician.
19 (4) That part of any charge for room and board or
20 for services rendered or articles prescribed by a
21 physician, dentist, or other health care personnel that
22 exceeds the reasonable and customary charge in the
23 locality or for any services or supplies not medically
24 necessary for the diagnosed injury or illness.
25 (5) Any charge for services or articles the
26 provision of which is not within the scope of licensure
27 of the institution or individual providing the services
28 or articles.
29 (6) Any expense incurred prior to the effective
30 date of coverage by the Plan for the person on whose
31 behalf the expense is incurred.
32 (7) Dental care, dental surgery, dental treatment
33 or dental appliances, except as provided in paragraph
34 (14) of subsection b of this Section.
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1 (8) Eyeglasses, contact lenses, hearing aids or
2 their fitting.
3 (9) Illness or injury due to acts of war.
4 (10) Services of blood donors and any fee for
5 failure to replace the first 3 pints of blood provided to
6 a covered person each policy year.
7 (11) Personal supplies or services provided by a
8 hospital or nursing home, or any other nonmedical or
9 nonprescribed supply or service.
10 (12) Routine maternity charges for a pregnancy,
11 except where added as optional coverage with payment of
12 an additional premium for pregnancy resulting from
13 conception occurring after the effective date of the
14 optional coverage.
15 (13) (Blank).
16 (14) Any expense or charge for services, drugs, or
17 supplies that are: (i) not provided in accord with
18 generally accepted standards of current medical practice;
19 (ii) for procedures, treatments, equipment, transplants,
20 or implants, any of which are investigational,
21 experimental, or for research purposes; (iii)
22 investigative and not proven safe and effective; or (iv)
23 for, or resulting from, a gender transformation
24 operation.
25 (15) Any expense or charge for routine physical
26 examinations or tests except as provided in item (2.5) of
27 subsection b of this Section.
28 (16) Any expense for which a charge is not made in
29 the absence of insurance or for which there is no legal
30 obligation on the part of the patient to pay.
31 (17) Any expense incurred for benefits provided
32 under the laws of the United States and this State,
33 including Medicare, Medicaid, and other medical
34 assistance, maternal and child health services and any
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1 other program that is administered or funded by the
2 Department of Human Services, Department of Public Aid,
3 or Department of Public Health, military
4 service-connected disability payments, medical services
5 provided for members of the armed forces and their
6 dependents or employees of the armed forces of the United
7 States, and medical services financed on behalf of all
8 citizens by the United States.
9 (18) Any expense or charge for in vitro
10 fertilization, artificial insemination, or any other
11 artificial means used to cause pregnancy.
12 (19) Any expense or charge for oral contraceptives
13 used for birth control or any other temporary birth
14 control measures.
15 (20) Any expense or charge for sterilization or
16 sterilization reversals.
17 (21) Any expense or charge for weight loss
18 programs, exercise equipment, or treatment of obesity,
19 except when certified by a physician as morbid obesity
20 (at least 2 times normal body weight).
21 (22) Any expense or charge for acupuncture
22 treatment unless used as an anesthetic agent for a
23 covered surgery.
24 (23) Any expense or charge for or related to organ
25 or tissue transplants other than those performed at a
26 hospital with a Board approved organ transplant program
27 that has been designated by the Board as a preferred or
28 exclusive provider organization for that specific organ
29 or tissue transplant.
30 (24) Any expense or charge for procedures,
31 treatments, equipment, or services that are provided in
32 special settings for research purposes or in a controlled
33 environment, are being studied for safety, efficiency,
34 and effectiveness, and are awaiting endorsement by the
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1 appropriate national medical speciality college for
2 general use within the medical community.
3 d. Deductibles and coinsurance.
4 The Plan coverage defined in Section 6 shall provide for
5 a choice of deductibles per individual as authorized by the
6 Board. If 2 individual members of the same family household,
7 who are both covered persons under the Plan, satisfy the same
8 applicable deductibles, no other member of that family who is
9 also a covered person under the Plan shall be required to
10 meet any deductibles for the balance of that calendar year.
11 The deductibles must be applied first to the authorized
12 amount of covered expenses incurred by the covered person. A
13 mandatory coinsurance requirement shall be imposed at the
14 rate authorized by the Board in excess of the mandatory
15 deductible, the coinsurance in the aggregate not to exceed
16 such amounts as are authorized by the Board per annum. At
17 its discretion the Board may, however, offer catastrophic
18 coverages or other policies that provide for larger
19 deductibles with or without coinsurance requirements. The
20 deductibles and coinsurance factors may be adjusted annually
21 according to the Medical Component of the Consumer Price
22 Index.
23 e. Scope of coverage.
24 (1) In approving any of the benefit plans to be
25 offered by the Plan, the Board shall establish such
26 benefit levels, deductibles, coinsurance factors,
27 exclusions, and limitations as it may deem appropriate
28 and that it believes to be generally reflective of and
29 commensurate with health insurance coverage that is
30 provided in the individual market in this State.
31 (2) The benefit plans approved by the Board may
32 also provide for and employ various cost containment
33 measures and other requirements including, but not
34 limited to, preadmission certification, prior approval,
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1 second surgical opinions, concurrent utilization review
2 programs, individual case management, preferred provider
3 organizations, health maintenance organizations, and
4 other cost effective arrangements for paying for covered
5 expenses.
6 f. Preexisting conditions.
7 (1) Except for federally eligible individuals
8 qualifying for Plan coverage under Section 15 of this
9 Act, plan coverage shall exclude charges or expenses
10 incurred during the first 6 months following the
11 effective date of coverage as to any condition for which
12 if: (a) the condition had manifested itself within the 6
13 month period immediately preceding the effective date of
14 coverage in such a manner as would cause an ordinarily
15 prudent person to seek diagnosis, care or treatment; or
16 (b) medical advice, care or treatment was recommended or
17 received during within the 6 month period immediately
18 preceding the effective date of coverage.
19 (2) (Blank).
20 (3) (Blank).
21 g. Other sources primary; nonduplication of benefits.
22 (1) The Plan shall be the last payor of benefits
23 whenever any other benefit or source of third party
24 payment is available. Subject to the provisions of
25 subsection e of Section 7, benefits otherwise payable
26 under Plan coverage shall be reduced by all amounts paid
27 or payable by Medicare or any other government program or
28 through any health insurance or group health plan,
29 whether by insurance, reimbursement, or otherwise, or
30 through any third party liability, settlement, judgment,
31 or award, regardless of the date of the settlement,
32 judgment, or award, whether the settlement, judgment, or
33 award is in the form of a contract, agreement, or trust
34 on behalf of a minor or otherwise and whether the
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1 settlement, judgment, or award is payable to the covered
2 person, his or her dependent, estate, personal
3 representative, or guardian in a lump sum or over time,
4 and by all hospital or medical expense benefits paid or
5 payable under any worker's compensation coverage,
6 automobile medical payment, or liability insurance,
7 whether provided on the basis of fault or nonfault, and
8 by any hospital or medical benefits paid or payable under
9 or provided pursuant to any State or federal law or
10 program.
11 (2) The Plan shall have a cause of action against
12 any covered person or any other person or entity for the
13 recovery of any amount paid to the extent the amount was
14 for treatment, services, or supplies not covered in this
15 Section or in excess of benefits as set forth in this
16 Section.
17 (3) Whenever benefits are due from the Plan because
18 of sickness or an injury to a covered person resulting
19 from a third party's wrongful act or negligence and the
20 covered person has recovered or may recover damages from
21 a third party or its insurer, the Plan shall have the
22 right to reduce benefits or to refuse to pay benefits
23 that otherwise may be payable by the amount of damages
24 that the covered person has recovered or may recover
25 regardless of the date of the sickness or injury or the
26 date of any settlement, judgment, or award resulting from
27 that sickness or injury.
28 During the pendency of any action or claim that is
29 brought by or on behalf of a covered person against a
30 third party or its insurer, any benefits that would
31 otherwise be payable except for the provisions of this
32 paragraph (3) shall be paid if payment by or for the
33 third party has not yet been made and the covered person
34 or, if incapable, that person's legal representative
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1 agrees in writing to pay back promptly the benefits paid
2 as a result of the sickness or injury to the extent of
3 any future payments made by or for the third party for
4 the sickness or injury. This agreement is to apply
5 whether or not liability for the payments is established
6 or admitted by the third party or whether those payments
7 are itemized.
8 Any amounts due the plan to repay benefits may be
9 deducted from other benefits payable by the Plan after
10 payments by or for the third party are made.
11 (4) Benefits due from the Plan may be reduced or
12 refused as an offset against any amount otherwise
13 recoverable under this Section.
14 h. Right of subrogation; recoveries.
15 (1) Whenever the Plan has paid benefits because of
16 sickness or an injury to any covered person resulting
17 from a third party's wrongful act or negligence, or for
18 which an insurer is liable in accordance with the
19 provisions of any policy of insurance, and the covered
20 person has recovered or may recover damages from a third
21 party that is liable for the damages, the Plan shall have
22 the right to recover the benefits it paid from any
23 amounts that the covered person has received or may
24 receive regardless of the date of the sickness or injury
25 or the date of any settlement, judgment, or award
26 resulting from that sickness or injury. The Plan shall
27 be subrogated to any right of recovery the covered person
28 may have under the terms of any private or public health
29 care coverage or liability coverage, including coverage
30 under the Workers' Compensation Act or the Workers'
31 Occupational Diseases Act, without the necessity of
32 assignment of claim or other authorization to secure the
33 right of recovery. To enforce its subrogation right, the
34 Plan may (i) intervene or join in an action or proceeding
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1 brought by the covered person or his personal
2 representative, including his guardian, conservator,
3 estate, dependents, or survivors, against any third party
4 or the third party's insurer that may be liable or (ii)
5 institute and prosecute legal proceedings against any
6 third party or the third party's insurer that may be
7 liable for the sickness or injury in an appropriate court
8 either in the name of the Plan or in the name of the
9 covered person or his personal representative, including
10 his guardian, conservator, estate, dependents, or
11 survivors.
12 (2) If any action or claim is brought by or on
13 behalf of a covered person against a third party or the
14 third party's insurer, the covered person or his personal
15 representative, including his guardian, conservator,
16 estate, dependents, or survivors, shall notify the Plan
17 by personal service or registered mail of the action or
18 claim and of the name of the court in which the action or
19 claim is brought, filing proof thereof in the action or
20 claim. The Plan may, at any time thereafter, join in the
21 action or claim upon its motion so that all orders of
22 court after hearing and judgment shall be made for its
23 protection. No release or settlement of a claim for
24 damages and no satisfaction of judgment in the action
25 shall be valid without the written consent of the Plan to
26 the extent of its interest in the settlement or judgment
27 and of the covered person or his personal representative.
28 (3) In the event that the covered person or his
29 personal representative fails to institute a proceeding
30 against any appropriate third party before the fifth
31 month before the action would be barred, the Plan may, in
32 its own name or in the name of the covered person or
33 personal representative, commence a proceeding against
34 any appropriate third party for the recovery of damages
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1 on account of any sickness, injury, or death to the
2 covered person. The covered person shall cooperate in
3 doing what is reasonably necessary to assist the Plan in
4 any recovery and shall not take any action that would
5 prejudice the Plan's right to recovery. The Plan shall
6 pay to the covered person or his personal representative
7 all sums collected from any third party by judgment or
8 otherwise in excess of amounts paid in benefits under the
9 Plan and amounts paid or to be paid as costs, attorneys
10 fees, and reasonable expenses incurred by the Plan in
11 making the collection or enforcing the judgment.
12 (4) In the event that a covered person or his
13 personal representative, including his guardian,
14 conservator, estate, dependents, or survivors, recovers
15 damages from a third party for sickness or injury caused
16 to the covered person, the covered person or the personal
17 representative shall pay to the Plan from the damages
18 recovered the amount of benefits paid or to be paid on
19 behalf of the covered person.
20 (5) When the action or claim is brought by the
21 covered person alone and the covered person incurs a
22 personal liability to pay attorney's fees and costs of
23 litigation, the Plan's claim for reimbursement of the
24 benefits provided to the covered person shall be the full
25 amount of benefits paid to or on behalf of the covered
26 person under this Act less a pro rata share that
27 represents the Plan's reasonable share of attorney's fees
28 paid by the covered person and that portion of the cost
29 of litigation expenses determined by multiplying by the
30 ratio of the full amount of the expenditures to the full
31 amount of the judgement, award, or settlement.
32 (6) In the event of judgment or award in a suit or
33 claim against a third party or insurer, the court shall
34 first order paid from any judgement or award the
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1 reasonable litigation expenses incurred in preparation
2 and prosecution of the action or claim, together with
3 reasonable attorney's fees. After payment of those
4 expenses and attorney's fees, the court shall apply out
5 of the balance of the judgment or award an amount
6 sufficient to reimburse the Plan the full amount of
7 benefits paid on behalf of the covered person under this
8 Act, provided the court may reduce and apportion the
9 Plan's portion of the judgement proportionate to the
10 recovery of the covered person. The burden of producing
11 evidence sufficient to support the exercise by the court
12 of its discretion to reduce the amount of a proven charge
13 sought to be enforced against the recovery shall rest
14 with the party seeking the reduction. The court may
15 consider the nature and extent of the injury, economic
16 and non-economic loss, settlement offers, comparative
17 negligence as it applies to the case at hand, hospital
18 costs, physician costs, and all other appropriate costs.
19 The Plan shall pay its pro rata share of the attorney
20 fees based on the Plan's recovery as it compares to the
21 total judgment. Any reimbursement rights of the Plan
22 shall take priority over all other liens and charges
23 existing under the laws of this State with the exception
24 of any attorney liens filed under the Attorneys Lien Act.
25 (7) The Plan may compromise or settle and release
26 any claim for benefits provided under this Act or waive
27 any claims for benefits, in whole or in part, for the
28 convenience of the Plan or if the Plan determines that
29 collection would result in undue hardship upon the
30 covered person.
31 (Source: P.A. 90-7, eff. 6-10-97; 90-30, eff. 7-1-97; 90-655,
32 eff. 7-30-98; 91-639, eff. 8-20-99.)
33 Section 99. Effective date. This Act takes effect upon
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1 becoming law.