Bill Text: IL HB0104 | 2013-2014 | 98th General Assembly | Engrossed

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Amends the Illinois Insurance Code, the Covering ALL KIDS Health Insurance Act, and the Illinois Public Aid Code. Provides that to the extent authorized under federal law, the Department of Healthcare and Family Services shall identify individuals receiving services under medical assistance programs funded or partially funded by the State who may be or may have been covered by a third party health insurer, the period of coverage for such individuals, and the nature of the coverage. Requires a third party health insurer to provide the Department with eligibility information in a federally recommended or mutually agreed-upon format that includes, at a minimum, the names, addresses, dates, and sex of primary covered persons, the policy group numbers of the covered persons, and other identifiable information. Permits the Department to impose an administrative penalty on a third party health insurer that does not comply with the request for information. Provides that the Attorney General may bring suit on behalf of the Department to collect the penalty. Provides that recoveries made by the Department in connection with the imposition of this administrative penalty shall be deposited into the Public Aid Recoveries Trust Fund. Effective immediately.

Spectrum: Partisan Bill (Democrat 5-0)

Status: (Passed) 2013-08-02 - Public Act . . . . . . . . . 98-0130 [HB0104 Detail]

Download: Illinois-2013-HB0104-Engrossed.html

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AN ACT concerning the Department of Healthcare and Family
Services.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Section 5.5 as follows:
(215 ILCS 5/5.5)
Sec. 5.5. Compliance with the Department of Healthcare and
Family Services. A company authorized to do business in this
State or accredited by the State to issue policies of health
insurance, including but not limited to, self-insured plans,
group health plans (as defined in Section 607(1) of the
Employee Retirement Income Security Act of 1974), service
benefit plans, managed care organizations, pharmacy benefit
managers, or other parties that are by statute, contract, or
agreement legally responsible for payment of a claim for a
health care item or service as a condition of doing business in
the State must:
(1) provide to the Department of Healthcare and Family
Services, or any successor agency, on at least a quarterly
basis if so requested by the Department, information to
determine during what period any individual may be, or may
have been, covered by a health insurer and the nature of

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the coverage that is or was provided by the health insurer,
including the name, address, and identifying number of the
plan;
(2) accept the State's right of recovery and the
assignment to the State of any right of an individual or
other entity to payment from the party for an item or
service for which payment has been made under the medical
programs of the Department of Healthcare and Family
Services, or any successor agency, under this Code or the
Illinois Public Aid Code;
(3) respond to any inquiry by the Department of
Healthcare and Family Services regarding a claim for
payment for any health care item or service that is
submitted not later than 3 years after the date of the
provision of such health care item or service; and
(4) agree not to deny a claim submitted by the
Department of Healthcare and Family Services solely on the
basis of the date of submission of the claim, the type or
format of the claim form, or a failure to present proper
documentation at the point-of-sale that is the basis of the
claim if (i) the claim is submitted by the Department of
Healthcare and Family Services within the 3-year period
beginning on the date on which the item or service was
furnished and (ii) any action by the Department of
Healthcare and Family Services to enforce its rights with
respect to such claim is commenced within 6 years of its

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submission of such claim.
The Department of Healthcare and Family Services may impose
an administrative penalty as provided under Section 12-4.45 of
the Illinois Public Aid Code on entities that have established
a pattern of failure to provide the information required under
this Section, or in In cases in which the Department of
Healthcare and Family Services has determined that an entity
that provides health insurance coverage has established a
pattern of failure to provide the information required under
this Section, and has subsequently certified that
determination, along with supporting documentation, to the
Director of the Department of Insurance, the Director of the
Department of Insurance, based upon the certification of
determination made by the Department of Healthcare and Family
Services, may commence regulatory proceedings in accordance
with all applicable provisions of the Illinois Insurance Code.
(Source: P.A. 95-632, eff. 9-25-07; 96-1501, eff. 1-25-11.)
Section 10. The Covering ALL KIDS Health Insurance Act is
amended by changing Section 20 as follows:
(215 ILCS 170/20)
(Section scheduled to be repealed on July 1, 2016)
Sec. 20. Eligibility.
(a) To be eligible for the Program, a person must be a
child:

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(1) who is a resident of the State of Illinois;
(2) who is ineligible for medical assistance under the
Illinois Public Aid Code or benefits under the Children's
Health Insurance Program Act;
(3) either (i) who has been without health insurance
coverage for 12 months, (ii) whose parent has lost
employment that made available affordable dependent health
insurance coverage, until such time as affordable
employer-sponsored dependent health insurance coverage is
again available for the child as set forth by the
Department in rules, (iii) who is a newborn whose
responsible relative does not have available affordable
private or employer-sponsored health insurance, or (iv)
who, within one year of applying for coverage under this
Act, lost medical benefits under the Illinois Public Aid
Code or the Children's Health Insurance Program Act; and
(3.5) whose household income, as determined by the
Department, is at or below 300% of the federal poverty
level. This item (3.5) is effective July 1, 2011.
An entity that provides health insurance coverage (as
defined in Section 2 of the Comprehensive Health Insurance Plan
Act) to Illinois residents shall provide health insurance data
match to the Department of Healthcare and Family Services as
provided by and subject to Section 5.5 of the Illinois
Insurance Code. The Department of Healthcare and Family
Services may impose an administrative penalty as provided under

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Section 12-4.45 of the Illinois Public Aid Code on entities
that have established a pattern of failure to provide the
information required under this Section.
The Department of Healthcare and Family Services, in
collaboration with the Department of Insurance, shall adopt
rules governing the exchange of information under this Section.
The rules shall be consistent with all laws relating to the
confidentiality or privacy of personal information or medical
records, including provisions under the Federal Health
Insurance Portability and Accountability Act (HIPAA).
(b) The Department shall monitor the availability and
retention of employer-sponsored dependent health insurance
coverage and shall modify the period described in subdivision
(a)(3) if necessary to promote retention of private or
employer-sponsored health insurance and timely access to
healthcare services, but at no time shall the period described
in subdivision (a)(3) be less than 6 months.
(c) The Department, at its discretion, may take into
account the affordability of dependent health insurance when
determining whether employer-sponsored dependent health
insurance coverage is available upon reemployment of a child's
parent as provided in subdivision (a)(3).
(d) A child who is determined to be eligible for the
Program shall remain eligible for 12 months, provided that the
child maintains his or her residence in this State, has not yet
attained 19 years of age, and is not excluded under subsection

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(e).
(e) A child is not eligible for coverage under the Program
if:
(1) the premium required under Section 40 has not been
timely paid; if the required premiums are not paid, the
liability of the Program shall be limited to benefits
incurred under the Program for the time period for which
premiums have been paid; re-enrollment shall be completed
before the next covered medical visit, and the first
month's required premium shall be paid in advance of the
next covered medical visit; or
(2) the child is an inmate of a public institution or
an institution for mental diseases.
(f) The Department may adopt rules, including, but not
limited to: rules regarding annual renewals of eligibility for
the Program in conformance with Section 7 of this Act; rules
providing for re-enrollment, grace periods, notice
requirements, and hearing procedures under subdivision (e)(1)
of this Section; and rules regarding what constitutes
availability and affordability of private or
employer-sponsored health insurance, with consideration of
such factors as the percentage of income needed to purchase
children or family health insurance, the availability of
employer subsidies, and other relevant factors.
(g) Each child enrolled in the Program as of July 1, 2011
whose family income, as established by the Department, exceeds

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300% of the federal poverty level may remain enrolled in the
Program for 12 additional months commencing July 1, 2011.
Continued enrollment pursuant to this subsection shall be
available only if the child continues to meet all eligibility
criteria established under the Program as of the effective date
of this amendatory Act of the 96th General Assembly without a
break in coverage. Nothing contained in this subsection shall
prevent a child from qualifying for any other health benefits
program operated by the Department.
(Source: P.A. 96-1272, eff. 1-1-11; 96-1501, eff. 1-25-11.)
Section 15. The Illinois Public Aid Code is amended by
changing Section 12-9 and by adding Section 12-4.45 as follows:
(305 ILCS 5/12-4.45 new)
Sec. 12-4.45. Third party liability.
(a) To the extent authorized under federal law, the
Department of Healthcare and Family Services shall identify
individuals receiving services under medical assistance
programs funded or partially funded by the State who may be or
may have been covered by a third party health insurer, the
period of coverage for such individuals, and the nature of
coverage. A company, as defined in Section 5.5 of the Illinois
Insurance Code and Section 2 of the Comprehensive Health
Insurance Plan Act, must provide the Department eligibility
information in a federally recommended or mutually agreed-upon

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format that includes at a minimum:
(1) The names, addresses, dates, and sex of primary
covered persons.
(2) The policy group numbers of the covered persons.
(3) The names, dates of birth, and sex of covered
dependents, and the relationship of dependents to the
primary covered person.
(4) The effective dates of coverage for each covered
person.
(5) The generally defined covered services
information, such as drugs, medical, or any other similar
description of services covered.
(b) The Department may impose an administrative penalty on
a company that does not comply with the request for information
made under Section 5.5 of the Illinois Insurance Code and
paragraph (3) of subsection (a) of Section 20 of the Covering
ALL KIDS Health Insurance Act. The amount of the penalty shall
not exceed $10,000 per day for each day of noncompliance that
occurs after the 180th day after the date of the request. The
first day of the 180-day period commences on the business day
following the date of the correspondence requesting the
information sent by the Department to the company. The amount
shall be based on:
(1) The seriousness of the violation, including the
nature, circumstances, extent, and gravity of the
violation.

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(2) The economic harm caused by the violation.
(3) The history of previous violations.
(4) The amount necessary to deter a future violation.
(5) Efforts to correct the violation.
(6) Any other matter that justice may require.
(c) The enforcement of the penalty may be stayed during the
time the order is under administrative review if the company
files an appeal.
(d) The Attorney General may bring suit on behalf of the
Department to collect the penalty.
(e) Recoveries made by the Department in connection with
the imposition of an administrative penalty as provided under
this Section shall be deposited into the Public Aid Recoveries
Trust Fund created under Section 12-9.
(305 ILCS 5/12-9) (from Ch. 23, par. 12-9)
Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
Public Aid Recoveries Trust Fund shall consist of (1)
recoveries by the Department of Healthcare and Family Services
(formerly Illinois Department of Public Aid) authorized by this
Code in respect to applicants or recipients under Articles III,
IV, V, and VI, including recoveries made by the Department of
Healthcare and Family Services (formerly Illinois Department
of Public Aid) from the estates of deceased recipients, (2)
recoveries made by the Department of Healthcare and Family
Services (formerly Illinois Department of Public Aid) in

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respect to applicants and recipients under the Children's
Health Insurance Program Act, and the Covering ALL KIDS Health
Insurance Act, (2.5) recoveries made by the Department of
Healthcare and Family Services in connection with the
imposition of an administrative penalty as provided under
Section 12-4.45, (3) federal funds received on behalf of and
earned by State universities and local governmental entities
for services provided to applicants or recipients covered under
this Code, the Children's Health Insurance Program Act, and the
Covering ALL KIDS Health Insurance Act, (3.5) federal financial
participation revenue related to eligible disbursements made
by the Department of Healthcare and Family Services from
appropriations required by this Section, and (4) all other
moneys received to the Fund, including interest thereon. The
Fund shall be held as a special fund in the State Treasury.
Disbursements from this Fund shall be only (1) for the
reimbursement of claims collected by the Department of
Healthcare and Family Services (formerly Illinois Department
of Public Aid) through error or mistake, (2) for payment to
persons or agencies designated as payees or co-payees on any
instrument, whether or not negotiable, delivered to the
Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid) as a recovery under this
Section, such payment to be in proportion to the respective
interests of the payees in the amount so collected, (3) for
payments to the Department of Human Services for collections

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made by the Department of Healthcare and Family Services
(formerly Illinois Department of Public Aid) on behalf of the
Department of Human Services under this Code, the Children's
Health Insurance Program Act, and the Covering ALL KIDS Health
Insurance Act, (4) for payment of administrative expenses
incurred in performing the activities authorized under this
Code, the Children's Health Insurance Program Act, and the
Covering ALL KIDS Health Insurance Act, (5) for payment of fees
to persons or agencies in the performance of activities
pursuant to the collection of monies owed the State that are
collected under this Code, the Children's Health Insurance
Program Act, and the Covering ALL KIDS Health Insurance Act,
(6) for payments of any amounts which are reimbursable to the
federal government which are required to be paid by State
warrant by either the State or federal government, and (7) for
payments to State universities and local governmental entities
of federal funds for services provided to applicants or
recipients covered under this Code, the Children's Health
Insurance Program Act, and the Covering ALL KIDS Health
Insurance Act. Disbursements from this Fund for purposes of
items (4) and (5) of this paragraph shall be subject to
appropriations from the Fund to the Department of Healthcare
and Family Services (formerly Illinois Department of Public
Aid).
The balance in this Fund on the first day of each calendar
quarter, after payment therefrom of any amounts reimbursable to

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the federal government, and minus the amount reasonably
anticipated to be needed to make the disbursements during that
quarter authorized by this Section, shall be certified by the
Director of Healthcare and Family Services and transferred by
the State Comptroller to the Drug Rebate Fund or the Healthcare
Provider Relief Fund in the State Treasury, as appropriate,
within 30 days of the first day of each calendar quarter. The
Director of Healthcare and Family Services may certify and the
State Comptroller shall transfer to the Drug Rebate Fund
amounts on a more frequent basis.
On July 1, 1999, the State Comptroller shall transfer the
sum of $5,000,000 from the Public Aid Recoveries Trust Fund
(formerly the Public Assistance Recoveries Trust Fund) into the
DHS Recoveries Trust Fund.
(Source: P.A. 96-1100, eff. 1-1-11; 97-647, eff. 1-1-12;
97-689, eff. 6-14-12.)
Section 99. Effective date. This Act takes effect upon
becoming law.