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92_HB0745
LRB9205282JSpc
1 AN ACT concerning the comprehensive health insurance
2 plan.
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 2 as follows:
7 (215 ILCS 105/2) (from Ch. 73, par. 1302)
8 Sec. 2. Definitions. As used In this Act, unless the
9 context otherwise requires:
10 "Plan administrator" means the insurer or third party
11 administrator designated under Section 5 of this Act.
12 "Benefits plan" means the coverage to be offered by the
13 Plan to eligible persons and federally eligible individuals
14 pursuant to this Act.
15 "Board" means the Illinois Comprehensive Health Insurance
16 Board.
17 "Church plan" has the same meaning given that term in the
18 federal Health Insurance Portability and Accountability Act
19 of 1996.
20 "Continuation coverage" means continuation of coverage
21 under a group health plan or other health insurance coverage
22 for former employees or dependents of former employees that
23 would otherwise have terminated under the terms of that
24 coverage pursuant to any continuation provisions under
25 federal or State law, including the Consolidated Omnibus
26 Budget Reconciliation Act of 1985 (COBRA), as amended,
27 Sections 367.2 and 367e of the Illinois Insurance Code, or
28 any other similar requirement in another State.
29 "Covered person" means a person who is and continues to
30 remain eligible for Plan coverage and is covered under one of
31 the benefit plans offered by the Plan.
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1 "Creditable coverage" means, with respect to a federally
2 eligible individual, coverage of the individual under any of
3 the following:
4 (A) A group health plan.
5 (B) Health insurance coverage (including group
6 health insurance coverage).
7 (C) Medicare.
8 (D) Medical assistance.
9 (E) Chapter 55 of title 10, United States Code.
10 (F) A medical care program of the Indian Health
11 Service or of a tribal organization.
12 (G) A state health benefits risk pool.
13 (H) A health plan offered under Chapter 89 of title
14 5, United States Code.
15 (I) A public health plan (as defined in regulations
16 consistent with Section 104 of the Health Care
17 Portability and Accountability Act of 1996 that may be
18 promulgated by the Secretary of the U.S. Department of
19 Health and Human Services).
20 (J) A health benefit plan under Section 5(e) of the
21 Peace Corps Act (22 U.S.C. 2504(e)).
22 (K) Any other qualifying coverage required by the
23 federal Health Insurance Portability and Accountability
24 Act of 1996, as it may be amended, or regulations under
25 that Act.
26 "Creditable coverage" does not include coverage
27 consisting solely of coverage of excepted benefits (as
28 defined in Section 2791(c) of title XXVII of the Public
29 Health Service Act (42 U.S.C. 300 gg-91) nor does it include
30 any period of coverage under any of items (A) through (K)
31 that occurred before a break of more than 63 days during all
32 of which the individual was not covered under any of items
33 (A) through (K) above. Any period that an individual is in a
34 waiting period for any coverage under a group health plan (or
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1 for group health insurance coverage) or is in an affiliation
2 period under the terms of health insurance coverage offered
3 by a health maintenance organization shall not be taken into
4 account in determining if there has been a break of more than
5 63 days in any credible coverage.
6 "Department" means the Illinois Department of Insurance.
7 "Dependent" means an Illinois resident: who is a spouse;
8 or who is claimed as a dependent by the principal insured for
9 purposes of filing a federal income tax return and resides in
10 the principal insured's household, and is a resident
11 unmarried child under the age of 19 years; or who is an
12 unmarried child who also is a full-time student under the age
13 of 23 years and who is financially dependent upon the
14 principal insured; or who is a child of any age and who is
15 disabled and financially dependent upon the principal
16 insured.
17 "Direct Illinois premiums" means, for Illinois business,
18 an insurer's direct premium income for the kinds of business
19 described in clause (b) of Class 1 or clause (a) of Class 2
20 of Section 4 of the Illinois Insurance Code, and direct
21 premium income of a health maintenance organization or a
22 voluntary health services plan, except it shall not include
23 credit health insurance as defined in Article IX 1/2 of the
24 Illinois Insurance Code.
25 "Director" means the Director of the Illinois Department
26 of Insurance.
27 "Eligible person" means a resident of this State who
28 qualifies for Plan coverage under Section 7 of this Act.
29 "Employee" means a resident of this State who is employed
30 by an employer or has entered into the employment of or works
31 under contract or service of an employer including the
32 officers, managers and employees of subsidiary or affiliated
33 corporations and the individual proprietors, partners and
34 employees of affiliated individuals and firms when the
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1 business of the subsidiary or affiliated corporations, firms
2 or individuals is controlled by a common employer through
3 stock ownership, contract, or otherwise.
4 "Employer" means any individual, partnership,
5 association, corporation, business trust, or any person or
6 group of persons acting directly or indirectly in the
7 interest of an employer in relation to an employee, for which
8 one or more persons is gainfully employed.
9 "Family" coverage means the coverage provided by the Plan
10 for the covered person and his or her eligible dependents who
11 also are covered persons.
12 "Federally eligible individual" means an individual
13 resident of this State:
14 (1)(A) for whom, as of the date on which the
15 individual seeks Plan coverage under Section 15 of this
16 Act, the aggregate of the periods of creditable coverage
17 is 18 or more months, and (B) whose most recent prior
18 creditable coverage was under group health insurance
19 coverage offered by a health insurance issuer, a group
20 health plan, a governmental plan, or a church plan (or
21 health insurance coverage offered in connection with any
22 such plans) or any other type of creditable coverage that
23 may be required by the federal Health Insurance
24 Portability and Accountability Act of 1996, as it may be
25 amended, or the regulations under that Act;
26 (2) who is not eligible for coverage under (A) a
27 group health plan, (B) part A or part B of Medicare, or
28 (C) medical assistance, and does not have other health
29 insurance coverage;
30 (3) with respect to whom the most recent coverage
31 within the coverage period described in paragraph (1)(A)
32 of this definition was not terminated based upon a factor
33 relating to nonpayment of premiums or fraud;
34 (4) if the individual had been offered the option
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1 of continuation coverage under a COBRA continuation
2 provision or under a similar State program, who elected
3 such coverage; and
4 (5) who, if the individual elected such
5 continuation coverage, has exhausted such continuation
6 coverage under such provision or program.
7 "Group health insurance coverage" means, in connection
8 with a group health plan, health insurance coverage offered
9 in connection with that plan.
10 "Group health plan" has the same meaning given that term
11 in the federal Health Insurance Portability and
12 Accountability Act of 1996.
13 "Governmental plan" has the same meaning given that term
14 in the federal Health Insurance Portability and
15 Accountability Act of 1996.
16 "Health insurance coverage" means benefits consisting of
17 medical care (provided directly, through insurance or
18 reimbursement, or otherwise and including items and services
19 paid for as medical care) under any hospital and medical
20 expense-incurred policy, certificate, or contract provided by
21 an insurer, non-profit health care service plan contract,
22 health maintenance organization or other subscriber contract,
23 or any other health care plan or arrangement that pays for or
24 furnishes medical or health care services whether by
25 insurance or otherwise. Health insurance coverage shall not
26 include short term, accident only, disability income,
27 hospital confinement or fixed indemnity, dental only, vision
28 only, limited benefit, or credit insurance, coverage issued
29 as a supplement to liability insurance, insurance arising out
30 of a workers' compensation or similar law, automobile
31 medical-payment insurance, or insurance under which benefits
32 are payable with or without regard to fault and which is
33 statutorily required to be contained in any liability
34 insurance policy or equivalent self-insurance.
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1 "Health insurance issuer" means an insurance company,
2 insurance service, or insurance organization (including a
3 health maintenance organization and a voluntary health
4 services plan) that is authorized to transact health
5 insurance business in this State. Such term does not include
6 a group health plan.
7 "Health Maintenance Organization" means an organization
8 as defined in the Health Maintenance Organization Act.
9 "Hospice" means a program as defined in and licensed
10 under the Hospice Program Licensing Act.
11 "Hospital" means a duly licensed institution as defined
12 in the Hospital Licensing Act, an institution that meets all
13 comparable conditions and requirements in effect in the state
14 in which it is located, or the University of Illinois
15 Hospital as defined in the University of Illinois Hospital
16 Act.
17 "Individual health insurance coverage" means health
18 insurance coverage offered to individuals in the individual
19 market, but does not include short-term, limited-duration
20 insurance.
21 "Insured" means any individual resident of this State who
22 is eligible to receive benefits from any insurer (including
23 health insurance coverage offered in connection with a group
24 health plan) or health insurance issuer as defined in this
25 Section.
26 "Insurer" means any insurance company authorized to
27 transact health insurance business in this State and any
28 corporation that provides medical services and is organized
29 under the Voluntary Health Services Plans Act or the Health
30 Maintenance Organization Act.
31 "Medical assistance" means the State medical assistance
32 or medical assistance no grant (MANG) programs provided under
33 Title XIX of the Social Security Act and Articles V (Medical
34 Assistance) and VI (General Assistance) of the Illinois
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1 Public Aid Code (or any successor program) or under any
2 similar program of health care benefits in a state other than
3 Illinois.
4 "Medically necessary" means that a service, drug, or
5 supply is necessary and appropriate for the diagnosis or
6 treatment of an illness or injury in accord with generally
7 accepted standards of medical practice at the time the
8 service, drug, or supply is provided. When specifically
9 applied to a confinement it further means that the diagnosis
10 or treatment of the covered person's medical symptoms or
11 condition cannot be safely provided to that person as an
12 outpatient. A service, drug, or supply shall not be medically
13 necessary if it: (i) is investigational, experimental, or for
14 research purposes; or (ii) is provided solely for the
15 convenience of the patient, the patient's family, physician,
16 hospital, or any other provider; or (iii) exceeds in scope,
17 duration, or intensity that level of care that is needed to
18 provide safe, adequate, and appropriate diagnosis or
19 treatment; or (iv) could have been omitted without adversely
20 affecting the covered person's condition or the quality of
21 medical care; or (v) involves the use of a medical device,
22 drug, or substance not formally approved by the United States
23 Food and Drug Administration.
24 "Medical care" means the ordinary and usual professional
25 services rendered by a physician or other specified provider
26 during a professional visit for treatment of an illness or
27 injury.
28 "Medicare" means coverage under both Part A and Part B of
29 Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395,
30 et seq.
31 "Minimum premium plan" means an arrangement whereby a
32 specified amount of health care claims is self-funded, but
33 the insurance company assumes the risk that claims will
34 exceed that amount.
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1 "Participating transplant center" means a hospital
2 designated by the Board as a preferred or exclusive provider
3 of services for one or more specified human organ or tissue
4 transplants for which the hospital has signed an agreement
5 with the Board to accept a transplant payment allowance for
6 all expenses related to the transplant during a transplant
7 benefit period.
8 "Physician" means a person licensed to practice medicine
9 pursuant to the Medical Practice Act of 1987.
10 "Plan" means the Comprehensive Health Insurance Plan
11 established by this Act.
12 "Plan of operation" means the plan of operation of the
13 Plan, including articles, bylaws and operating rules, adopted
14 by the board pursuant to this Act.
15 "Provider" means any hospital, skilled nursing facility,
16 hospice, home health agency, physician, registered pharmacist
17 acting within the scope of that registration, or any other
18 person or entity licensed in Illinois to furnish medical
19 care.
20 "Qualified high risk pool" has the same meaning given
21 that term in the federal Health Insurance Portability and
22 Accountability Act of 1996.
23 "Resident" means a person who is and continues to be
24 legally domiciled and physically residing on a permanent and
25 full-time basis in a place of permanent habitation in this
26 State that remains that person's principal residence and from
27 which that person is absent only for temporary or transitory
28 purpose.
29 "Skilled nursing facility" means a facility or that
30 portion of a facility that is licensed by the Illinois
31 Department of Public Health under the Nursing Home Care Act
32 or a comparable licensing authority in another state to
33 provide skilled nursing care.
34 "Stop-loss coverage" means an arrangement whereby an
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1 insurer insures against the risk that any one claim will
2 exceed a specific dollar amount or that the entire loss of a
3 self-insurance plan will exceed a specific amount.
4 "Third party administrator" means an administrator as
5 defined in Section 511.101 of the Illinois Insurance Code who
6 is licensed under Article XXXI 1/4 of that Code.
7 (Source: P.A. 90-30, eff. 7-1-97; 91-357, eff. 7-29-99;
8 91-735, eff. 6-2-00.)