Bill Text: IL HB3462 | 2011-2012 | 97th General Assembly | Engrossed

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

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Bill Title: Amends the Comprehensive Health Insurance Plan Act. Deletes from the list of expenses that are not covered under the Plan, any expense or charge for routine physical examinations or tests.

Spectrum: Partisan Bill (Democrat 16-0)

Status: (Passed) 2012-01-13 - Public Act . . . . . . . . . 97-0661 [HB3462 Detail]

Download: Illinois-2011-HB3462-Engrossed.html

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AN ACT concerning insurance.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Comprehensive Health Insurance Plan Act is
amended by changing Section 8 as follows:
(215 ILCS 105/8) (from Ch. 73, par. 1308)
Sec. 8. Minimum benefits.
a. Availability. The Plan shall offer in a periodically
renewable policy major medical expense coverage to every
eligible person who is not eligible for Medicare. Major medical
expense coverage offered by the Plan shall pay an eligible
person's covered expenses, subject to limit on the deductible
and coinsurance payments authorized under paragraph (4) of
subsection d of this Section, up to a lifetime benefit limit of
$5,000,000. The maximum limit under this subsection shall not
be altered by the Board, and no actuarial equivalent benefit
may be substituted by the Board. Any person who otherwise would
qualify for coverage under the Plan, but is excluded because he
or she is eligible for Medicare, shall be eligible for any
separate Medicare supplement policy or policies which the Board
may offer.
b. Outline of benefits. Covered expenses shall be limited
to the usual and customary charge, including negotiated fees,

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in the locality for the following services and articles when
prescribed by a physician and determined by the Plan to be
medically necessary for the following areas of services,
subject to such separate deductibles, co-payments, exclusions,
and other limitations on benefits as the Board shall establish
and approve, and the other provisions of this Section:
(1) Hospital services, except that any services
provided by a hospital that is located more than 75 miles
outside the State of Illinois shall be covered only for a
maximum of 45 days in any calendar year. With respect to
covered expenses incurred during any calendar year ending
on or after December 31, 1999, inpatient hospitalization of
an eligible person for the treatment of mental illness at a
hospital located within the State of Illinois shall be
subject to the same terms and conditions as for any other
illness.
(2) Professional services for the diagnosis or
treatment of injuries, illnesses or conditions, other than
dental and mental and nervous disorders as described in
paragraph (17), which are rendered by a physician, or by
other licensed professionals at the physician's direction.
This includes reconstruction of the breast on which a
mastectomy was performed; surgery and reconstruction of
the other breast to produce a symmetrical appearance; and
prostheses and treatment of physical complications at all
stages of the mastectomy, including lymphedemas.

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(2.5) Professional services provided by a physician to
children under the age of 16 years for physical
examinations and age appropriate immunizations ordered by
a physician licensed to practice medicine in all its
branches.
(3) (Blank).
(4) Outpatient prescription drugs that by law require a
prescription written by a physician licensed to practice
medicine in all its branches subject to such separate
deductible, copayment, and other limitations or
restrictions as the Board shall approve, including the use
of a prescription drug card or any other program, or both.
(5) Skilled nursing services of a licensed skilled
nursing facility for not more than 120 days during a policy
year.
(6) Services of a home health agency in accord with a
home health care plan, up to a maximum of 270 visits per
year.
(7) Services of a licensed hospice for not more than
180 days during a policy year.
(8) Use of radium or other radioactive materials.
(9) Oxygen.
(10) Anesthetics.
(11) Orthoses and prostheses other than dental.
(12) Rental or purchase in accordance with Board
policies or procedures of durable medical equipment, other

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than eyeglasses or hearing aids, for which there is no
personal use in the absence of the condition for which it
is prescribed.
(13) Diagnostic x-rays and laboratory tests.
(14) Oral surgery (i) for excision of partially or
completely unerupted impacted teeth when not performed in
connection with the routine extraction or repair of teeth;
(ii) for excision of tumors or cysts of the jaws, cheeks,
lips, tongue, and roof and floor of the mouth; (iii)
required for correction of cleft lip and palate and other
craniofacial and maxillofacial birth defects; or (iv) for
treatment of injuries to natural teeth or a fractured jaw
due to an accident.
(15) Physical, speech, and functional occupational
therapy as medically necessary and provided by appropriate
licensed professionals.
(16) Emergency and other medically necessary
transportation provided by a licensed ambulance service to
the nearest health care facility qualified to treat a
covered illness, injury, or condition, subject to the
provisions of the Emergency Medical Systems (EMS) Act.
(17) Outpatient services for diagnosis and treatment
of mental and nervous disorders provided that a covered
person shall be required to make a copayment not to exceed
50% and that the Plan's payment shall not exceed such
amounts as are established by the Board.

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(18) Human organ or tissue transplants specified by the
Board that are performed at a hospital designated by the
Board as a participating transplant center for that
specific organ or tissue transplant.
(19) Naprapathic services, as appropriate, provided by
a licensed naprapathic practitioner.
c. Exclusions. Covered expenses of the Plan shall not
include the following:
(1) Any charge for treatment for cosmetic purposes
other than for reconstructive surgery when the service is
incidental to or follows surgery resulting from injury,
sickness or other diseases of the involved part or surgery
for the repair or treatment of a congenital bodily defect
to restore normal bodily functions.
(2) Any charge for care that is primarily for rest,
custodial, educational, or domiciliary purposes.
(3) Any charge for services in a private room to the
extent it is in excess of the institution's charge for its
most common semiprivate room, unless a private room is
prescribed as medically necessary by a physician.
(4) That part of any charge for room and board or for
services rendered or articles prescribed by a physician,
dentist, or other health care personnel that exceeds the
reasonable and customary charge in the locality or for any
services or supplies not medically necessary for the
diagnosed injury or illness.

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(5) Any charge for services or articles the provision
of which is not within the scope of licensure of the
institution or individual providing the services or
articles.
(6) Any expense incurred prior to the effective date of
coverage by the Plan for the person on whose behalf the
expense is incurred.
(7) Dental care, dental surgery, dental treatment, any
other dental procedure involving the teeth or
periodontium, or any dental appliances, including crowns,
bridges, implants, or partial or complete dentures, except
as specifically provided in paragraph (14) of subsection b
of this Section.
(8) Eyeglasses, contact lenses, hearing aids or their
fitting.
(9) Illness or injury due to acts of war.
(10) Services of blood donors and any fee for failure
to replace the first 3 pints of blood provided to a covered
person each policy year.
(11) Personal supplies or services provided by a
hospital or nursing home, or any other nonmedical or
nonprescribed supply or service.
(12) Routine maternity charges for a pregnancy, except
where added as optional coverage with payment of an
additional premium for pregnancy resulting from conception
occurring after the effective date of the optional

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coverage.
(13) (Blank).
(14) Any expense or charge for services, drugs, or
supplies that are: (i) not provided in accord with
generally accepted standards of current medical practice;
(ii) for procedures, treatments, equipment, transplants,
or implants, any of which are investigational,
experimental, or for research purposes; (iii)
investigative and not proven safe and effective; or (iv)
for, or resulting from, a gender transformation operation.
(15) (Blank) Any expense or charge for routine physical
examinations or tests except as provided in item (2.5) of
subsection b of this Section.
(16) Any expense for which a charge is not made in the
absence of insurance or for which there is no legal
obligation on the part of the patient to pay.
(17) Any expense incurred for benefits provided under
the laws of the United States and this State, including
Medicare, Medicaid, and other medical assistance, maternal
and child health services and any other program that is
administered or funded by the Department of Human Services,
Department of Healthcare and Family Services, or
Department of Public Health, military service-connected
disability payments, medical services provided for members
of the armed forces and their dependents or employees of
the armed forces of the United States, and medical services

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financed on behalf of all citizens by the United States.
(18) Any expense or charge for in vitro fertilization,
artificial insemination, or any other artificial means
used to cause pregnancy.
(19) Any expense or charge for oral contraceptives used
for birth control or any other temporary birth control
measures.
(20) Any expense or charge for sterilization or
sterilization reversals.
(21) Any expense or charge for weight loss programs,
exercise equipment, or treatment of obesity, except when
certified by a physician as morbid obesity (at least 2
times normal body weight).
(22) Any expense or charge for acupuncture treatment
unless used as an anesthetic agent for a covered surgery.
(23) Any expense or charge for or related to organ or
tissue transplants other than those performed at a hospital
with a Board approved organ transplant program that has
been designated by the Board as a preferred or exclusive
provider organization for that specific organ or tissue
transplant.
(24) Any expense or charge for procedures, treatments,
equipment, or services that are provided in special
settings for research purposes or in a controlled
environment, are being studied for safety, efficiency, and
effectiveness, and are awaiting endorsement by the

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appropriate national medical speciality college for
general use within the medical community.
d. Deductibles and coinsurance.
The Plan coverage defined in Section 6 shall provide for a
choice of deductibles per individual as authorized by the
Board. If 2 individual members of the same family household,
who are both covered persons under the Plan, satisfy the same
applicable deductibles, no other member of that family who is
also a covered person under the Plan shall be required to meet
any deductibles for the balance of that calendar year. The
deductibles must be applied first to the authorized amount of
covered expenses incurred by the covered person. A mandatory
coinsurance requirement shall be imposed at the rate authorized
by the Board in excess of the mandatory deductible, the
coinsurance in the aggregate not to exceed such amounts as are
authorized by the Board per annum. At its discretion the Board
may, however, offer catastrophic coverages or other policies
that provide for larger deductibles with or without coinsurance
requirements. The deductibles and coinsurance factors may be
adjusted annually according to the Medical Component of the
Consumer Price Index.
e. Scope of coverage.
(1) In approving any of the benefit plans to be offered
by the Plan, the Board shall establish such benefit levels,
deductibles, coinsurance factors, exclusions, and
limitations as it may deem appropriate and that it believes

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to be generally reflective of and commensurate with health
insurance coverage that is provided in the individual
market in this State.
(2) The benefit plans approved by the Board may also
provide for and employ various cost containment measures
and other requirements including, but not limited to,
preadmission certification, prior approval, second
surgical opinions, concurrent utilization review programs,
individual case management, preferred provider
organizations, health maintenance organizations, and other
cost effective arrangements for paying for covered
expenses.
f. Preexisting conditions.
(1) Except for federally eligible individuals
qualifying for Plan coverage under Section 15 of this Act
or eligible persons who qualify for the waiver authorized
in paragraph (3) of this subsection, plan coverage shall
exclude charges or expenses incurred during the first 6
months following the effective date of coverage as to any
condition for which medical advice, care or treatment was
recommended or received during the 6 month period
immediately preceding the effective date of coverage.
(2) (Blank).
(3) Waiver: The preexisting condition exclusions as
set forth in paragraph (1) of this subsection shall be
waived to the extent to which the eligible person (a) has

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satisfied similar exclusions under any prior individual
health insurance policy that was involuntarily terminated
because of the insolvency of the issuer of the policy and
(b) has applied for Plan coverage within 90 days following
the involuntary termination of that individual health
insurance coverage.
(4) Waiver: The preexisting condition exclusions as
set forth in paragraph (1) of this subsection shall be
waived to the extent to which the eligible person (a) has
satisfied the exclusion under prior Comprehensive Health
Insurance Plan coverage that was involuntarily terminated
because of meeting a lower lifetime benefit limit and (b)
has reapplied for Plan coverage within 90 days following an
increase in the lifetime benefit limit set forth in Section
8 of this Act.
g. Other sources primary; nonduplication of benefits.
(1) The Plan shall be the last payor of benefits
whenever any other benefit or source of third party payment
is available. Subject to the provisions of subsection e of
Section 7, benefits otherwise payable under Plan coverage
shall be reduced by all amounts paid or payable by Medicare
or any other government program or through any health
insurance coverage or group health plan, whether by
insurance, reimbursement, or otherwise, or through any
third party liability, settlement, judgment, or award,
regardless of the date of the settlement, judgment, or

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award, whether the settlement, judgment, or award is in the
form of a contract, agreement, or trust on behalf of a
minor or otherwise and whether the settlement, judgment, or
award is payable to the covered person, his or her
dependent, estate, personal representative, or guardian in
a lump sum or over time, and by all hospital or medical
expense benefits paid or payable under any worker's
compensation coverage, automobile medical payment, or
liability insurance, whether provided on the basis of fault
or nonfault, and by any hospital or medical benefits paid
or payable under or provided pursuant to any State or
federal law or program.
(2) The Plan shall have a cause of action against any
covered person or any other person or entity for the
recovery of any amount paid to the extent the amount was
for treatment, services, or supplies not covered in this
Section or in excess of benefits as set forth in this
Section.
(3) Whenever benefits are due from the Plan because of
sickness or an injury to a covered person resulting from a
third party's wrongful act or negligence and the covered
person has recovered or may recover damages from a third
party or its insurer, the Plan shall have the right to
reduce benefits or to refuse to pay benefits that otherwise
may be payable by the amount of damages that the covered
person has recovered or may recover regardless of the date

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of the sickness or injury or the date of any settlement,
judgment, or award resulting from that sickness or injury.
During the pendency of any action or claim that is
brought by or on behalf of a covered person against a third
party or its insurer, any benefits that would otherwise be
payable except for the provisions of this paragraph (3)
shall be paid if payment by or for the third party has not
yet been made and the covered person or, if incapable, that
person's legal representative agrees in writing to pay back
promptly the benefits paid as a result of the sickness or
injury to the extent of any future payments made by or for
the third party for the sickness or injury. This agreement
is to apply whether or not liability for the payments is
established or admitted by the third party or whether those
payments are itemized.
Any amounts due the plan to repay benefits may be
deducted from other benefits payable by the Plan after
payments by or for the third party are made.
(4) Benefits due from the Plan may be reduced or
refused as an offset against any amount otherwise
recoverable under this Section.
h. Right of subrogation; recoveries.
(1) Whenever the Plan has paid benefits because of
sickness or an injury to any covered person resulting from
a third party's wrongful act or negligence, or for which an
insurer is liable in accordance with the provisions of any

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policy of insurance, and the covered person has recovered
or may recover damages from a third party that is liable
for the damages, the Plan shall have the right to recover
the benefits it paid from any amounts that the covered
person has received or may receive regardless of the date
of the sickness or injury or the date of any settlement,
judgment, or award resulting from that sickness or injury.
The Plan shall be subrogated to any right of recovery the
covered person may have under the terms of any private or
public health care coverage or liability coverage,
including coverage under the Workers' Compensation Act or
the Workers' Occupational Diseases Act, without the
necessity of assignment of claim or other authorization to
secure the right of recovery. To enforce its subrogation
right, the Plan may (i) intervene or join in an action or
proceeding brought by the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, against any third party
or the third party's insurer that may be liable or (ii)
institute and prosecute legal proceedings against any
third party or the third party's insurer that may be liable
for the sickness or injury in an appropriate court either
in the name of the Plan or in the name of the covered
person or his personal representative, including his
guardian, conservator, estate, dependents, or survivors.
(2) If any action or claim is brought by or on behalf

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of a covered person against a third party or the third
party's insurer, the covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, shall notify the Plan by
personal service or registered mail of the action or claim
and of the name of the court in which the action or claim
is brought, filing proof thereof in the action or claim.
The Plan may, at any time thereafter, join in the action or
claim upon its motion so that all orders of court after
hearing and judgment shall be made for its protection. No
release or settlement of a claim for damages and no
satisfaction of judgment in the action shall be valid
without the written consent of the Plan to the extent of
its interest in the settlement or judgment and of the
covered person or his personal representative.
(3) In the event that the covered person or his
personal representative fails to institute a proceeding
against any appropriate third party before the fifth month
before the action would be barred, the Plan may, in its own
name or in the name of the covered person or personal
representative, commence a proceeding against any
appropriate third party for the recovery of damages on
account of any sickness, injury, or death to the covered
person. The covered person shall cooperate in doing what is
reasonably necessary to assist the Plan in any recovery and
shall not take any action that would prejudice the Plan's

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right to recovery. The Plan shall pay to the covered person
or his personal representative all sums collected from any
third party by judgment or otherwise in excess of amounts
paid in benefits under the Plan and amounts paid or to be
paid as costs, attorneys fees, and reasonable expenses
incurred by the Plan in making the collection or enforcing
the judgment.
(4) In the event that a covered person or his personal
representative, including his guardian, conservator,
estate, dependents, or survivors, recovers damages from a
third party for sickness or injury caused to the covered
person, the covered person or the personal representative
shall pay to the Plan from the damages recovered the amount
of benefits paid or to be paid on behalf of the covered
person.
(5) When the action or claim is brought by the covered
person alone and the covered person incurs a personal
liability to pay attorney's fees and costs of litigation,
the Plan's claim for reimbursement of the benefits provided
to the covered person shall be the full amount of benefits
paid to or on behalf of the covered person under this Act
less a pro rata share that represents the Plan's reasonable
share of attorney's fees paid by the covered person and
that portion of the cost of litigation expenses determined
by multiplying by the ratio of the full amount of the
expenditures to the full amount of the judgement, award, or

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settlement.
(6) In the event of judgment or award in a suit or
claim against a third party or insurer, the court shall
first order paid from any judgement or award the reasonable
litigation expenses incurred in preparation and
prosecution of the action or claim, together with
reasonable attorney's fees. After payment of those
expenses and attorney's fees, the court shall apply out of
the balance of the judgment or award an amount sufficient
to reimburse the Plan the full amount of benefits paid on
behalf of the covered person under this Act, provided the
court may reduce and apportion the Plan's portion of the
judgement proportionate to the recovery of the covered
person. The burden of producing evidence sufficient to
support the exercise by the court of its discretion to
reduce the amount of a proven charge sought to be enforced
against the recovery shall rest with the party seeking the
reduction. The court may consider the nature and extent of
the injury, economic and non-economic loss, settlement
offers, comparative negligence as it applies to the case at
hand, hospital costs, physician costs, and all other
appropriate costs. The Plan shall pay its pro rata share of
the attorney fees based on the Plan's recovery as it
compares to the total judgment. Any reimbursement rights of
the Plan shall take priority over all other liens and
charges existing under the laws of this State with the

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exception of any attorney liens filed under the Attorneys
Lien Act.
(7) The Plan may compromise or settle and release any
claim for benefits provided under this Act or waive any
claims for benefits, in whole or in part, for the
convenience of the Plan or if the Plan determines that
collection would result in undue hardship upon the covered
person.
(Source: P.A. 95-547, eff. 8-29-07; 96-791, eff. 9-25-09;
96-938, eff. 6-24-10.)