Bill Text: IL SB0663 | 2009-2010 | 96th General Assembly | Enrolled
Bill Title: Amends the Electronic Fund Transfer Act. Makes a technical change in a Section concerning the powers of the Commissioner of Banks and Real Estate.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2010-06-24 - Public Act . . . . . . . . . 96-0938 [SB0663 Detail]
Download: Illinois-2009-SB0663-Enrolled.html
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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois, | ||||||
3 | represented in the General Assembly:
| ||||||
4 | Section 5. The Comprehensive Health Insurance Plan Act is | ||||||
5 | amended by changing Sections 7 and 8 as follows:
| ||||||
6 | (215 ILCS 105/7) (from Ch. 73, par. 1307) | ||||||
7 | Sec. 7. Eligibility. | ||||||
8 | a. Except as provided in subsection (e) of this Section or | ||||||
9 | in Section
15 of this Act, any person who is either a citizen | ||||||
10 | of the United States or an
alien lawfully admitted for | ||||||
11 | permanent residence and who has been for a period
of at least | ||||||
12 | 180 days and continues to be a resident of this State shall be
| ||||||
13 | eligible for Plan coverage under this Section if evidence is | ||||||
14 | provided of: | ||||||
15 | (1) A notice of rejection or refusal to issue | ||||||
16 | substantially
similar individual health insurance coverage | ||||||
17 | for health reasons by a
health insurance issuer; or | ||||||
18 | (2) A refusal by a health insurance issuer to issue | ||||||
19 | individual
health insurance coverage except at a rate | ||||||
20 | exceeding the
applicable Plan rate for which the person is | ||||||
21 | responsible. | ||||||
22 | A rejection or refusal by a group health plan or health | ||||||
23 | insurance issuer
offering only
stop-loss or excess of loss |
| |||||||
| |||||||
1 | insurance or contracts,
agreements, or other arrangements for | ||||||
2 | reinsurance coverage with respect
to the applicant shall not be | ||||||
3 | sufficient evidence under this subsection. | ||||||
4 | b. The board shall promulgate a list of medical or health | ||||||
5 | conditions for
which a person who is either a citizen of the | ||||||
6 | United States or an
alien lawfully admitted for permanent | ||||||
7 | residence and a resident of this State
would be eligible for | ||||||
8 | Plan coverage without applying for
health insurance coverage | ||||||
9 | pursuant to subsection a. of this Section.
Persons who
can | ||||||
10 | demonstrate the existence or history of any medical or health
| ||||||
11 | conditions on the list promulgated by the board shall not be | ||||||
12 | required to
provide the evidence specified in subsection a. of | ||||||
13 | this Section. The list
shall be effective
on the first day of | ||||||
14 | the operation of the Plan and may be amended from time
to time | ||||||
15 | as appropriate. | ||||||
16 | c. Family members of the same household who each are | ||||||
17 | covered
persons are
eligible for optional family coverage under | ||||||
18 | the Plan. | ||||||
19 | d. For persons qualifying for coverage in accordance with | ||||||
20 | Section 7 of
this Act, the board shall, if it determines that | ||||||
21 | such appropriations as are
made pursuant to Section 12 of this | ||||||
22 | Act are insufficient to allow the board
to accept all of the | ||||||
23 | eligible persons which it projects will apply for
enrollment | ||||||
24 | under the Plan, limit or close enrollment to ensure that the
| ||||||
25 | Plan is not over-subscribed and that it has sufficient | ||||||
26 | resources to meet
its obligations to existing enrollees. The |
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| |||||||
1 | board shall not limit or close
enrollment for federally | ||||||
2 | eligible individuals. | ||||||
3 | e. A person shall not be eligible for coverage under the | ||||||
4 | Plan if: | ||||||
5 | (1) He or she has or obtains other coverage under a | ||||||
6 | group health plan
or health insurance coverage
| ||||||
7 | substantially similar to or better than a Plan policy as an | ||||||
8 | insured or
covered dependent or would be eligible to have | ||||||
9 | that coverage if he or she
elected to obtain it. Persons | ||||||
10 | otherwise eligible for Plan coverage may,
however, solely | ||||||
11 | for the purpose of having coverage for a pre-existing
| ||||||
12 | condition, maintain other coverage only while satisfying | ||||||
13 | any pre-existing
condition waiting period under a Plan | ||||||
14 | policy or a subsequent replacement
policy of a Plan policy. | ||||||
15 | (1.1) His or her prior coverage under a group health | ||||||
16 | plan or health
insurance coverage, provided or arranged by | ||||||
17 | an employer of more than 10 employees was discontinued
for | ||||||
18 | any reason without the entire group or plan being | ||||||
19 | discontinued and not
replaced, provided he or she remains | ||||||
20 | an employee, or dependent thereof, of the
same employer. | ||||||
21 | (2) He or she is a recipient of or is approved to | ||||||
22 | receive medical
assistance, except that a person may | ||||||
23 | continue to receive medical
assistance through the medical | ||||||
24 | assistance no grant program, but only
while satisfying the | ||||||
25 | requirements for a preexisting condition under
Section 8, | ||||||
26 | subsection f. of this Act. Payment of premiums pursuant to |
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| |||||||
1 | this
Act shall be allocable to the person's spenddown for | ||||||
2 | purposes of the
medical assistance no grant program, but | ||||||
3 | that person shall not be
eligible for any Plan benefits | ||||||
4 | while that person remains eligible for
medical assistance. | ||||||
5 | If the person continues to receive
or be approved to | ||||||
6 | receive medical assistance through the medical
assistance | ||||||
7 | no grant program at or after the time that requirements for | ||||||
8 | a
preexisting condition are satisfied, the person shall not | ||||||
9 | be eligible for
coverage under the Plan. In that | ||||||
10 | circumstance, coverage under the plan
shall terminate as of | ||||||
11 | the expiration of the preexisting condition
limitation | ||||||
12 | period. Under all other circumstances, coverage under the | ||||||
13 | Plan
shall automatically terminate as of the effective date | ||||||
14 | of any medical
assistance. | ||||||
15 | (3) Except as provided in Section 15, the person has | ||||||
16 | previously
participated in the Plan and voluntarily
| ||||||
17 | terminated Plan coverage, unless 12 months have elapsed
| ||||||
18 | since the person's
latest voluntary termination of | ||||||
19 | coverage. | ||||||
20 | (4) The person fails to pay the required premium under | ||||||
21 | the covered
person's
terms of enrollment and | ||||||
22 | participation, in which event the liability of the
Plan | ||||||
23 | shall be limited to benefits incurred under the Plan for | ||||||
24 | the time
period for which premiums had been paid and the | ||||||
25 | covered person remained
eligible for Plan coverage. | ||||||
26 | (5) The Plan (i) until 3 years after the effective date |
| |||||||
| |||||||
1 | of this amendatory Act of the 95th General Assembly has | ||||||
2 | paid a total of
$5,000,000 $2,000,000
in benefits
on behalf | ||||||
3 | of the covered person or (ii) 3 years or more after the | ||||||
4 | effective date of this amendatory Act of the 95th General | ||||||
5 | Assembly has paid a total of $1,500,000 in benefits on | ||||||
6 | behalf of the covered person . | ||||||
7 | (6) The person is a resident of a public institution. | ||||||
8 | (7) The person's premium is paid for or reimbursed | ||||||
9 | under any
government sponsored program or by any government | ||||||
10 | agency or health
care provider, except as an otherwise | ||||||
11 | qualifying full-time employee, or
dependent of such | ||||||
12 | employee, of a government agency or health care provider
| ||||||
13 | or, except when a person's premium is paid by the U.S. | ||||||
14 | Treasury Department
pursuant to the federal Trade Act of | ||||||
15 | 2002. | ||||||
16 | (8) The person has or later receives other benefits or | ||||||
17 | funds from
any settlement, judgement, or award resulting | ||||||
18 | from any accident or injury,
regardless of the date of the | ||||||
19 | accident or injury, or any other
circumstances creating a | ||||||
20 | legal liability for damages due that person by a
third | ||||||
21 | party, whether the settlement, judgment, or award is in the | ||||||
22 | form of a
contract, agreement, or trust on behalf of a | ||||||
23 | minor or otherwise and whether
the settlement, judgment, or | ||||||
24 | award is payable to the person, his or her
dependent, | ||||||
25 | estate, personal representative, or guardian in a lump sum | ||||||
26 | or
over time, so long as there continues to be benefits or |
| |||||||
| |||||||
1 | assets remaining
from those sources in an amount in excess | ||||||
2 | of $300,000. | ||||||
3 | (9) Within the 5 years prior to the date a person's | ||||||
4 | Plan application is
received by the Board, the person's | ||||||
5 | coverage under any health care benefit
program as defined | ||||||
6 | in 18 U.S.C. 24, including any public or private plan or
| ||||||
7 | contract under which any
medical benefit, item, or service | ||||||
8 | is provided, was terminated as a result of
any act or | ||||||
9 | practice that constitutes fraud under State or federal law | ||||||
10 | or as a
result of an intentional misrepresentation of | ||||||
11 | material fact; or if that person
knowingly and willfully | ||||||
12 | obtained or attempted to obtain, or fraudulently aided
or | ||||||
13 | attempted to aid any other person in obtaining, any | ||||||
14 | coverage or benefits
under the Plan to which that person | ||||||
15 | was not entitled. | ||||||
16 | f. The board or the administrator shall require | ||||||
17 | verification of
residency and may require any additional | ||||||
18 | information or documentation, or
statements under oath, when | ||||||
19 | necessary to determine residency upon initial
application and | ||||||
20 | for the entire term of the policy. | ||||||
21 | g. Coverage shall cease (i) on the date a person is no | ||||||
22 | longer a
resident of Illinois, (ii) on the date a person | ||||||
23 | requests coverage to end,
(iii) upon the death of the covered | ||||||
24 | person, (iv) on the date State law
requires cancellation of the | ||||||
25 | policy, or (v) at the Plan's option, 30 days
after the Plan | ||||||
26 | makes any inquiry concerning a person's eligibility or place
of |
| |||||||
| |||||||
1 | residence to which the person does not reply. | ||||||
2 | h. Except under the conditions set forth in subsection g of | ||||||
3 | this
Section, the coverage of any person who ceases to meet the
| ||||||
4 | eligibility requirements of this Section shall be terminated at | ||||||
5 | the end of
the current policy period for which the necessary | ||||||
6 | premiums have been paid. | ||||||
7 | (Source: P.A. 94-17, eff. 1-1-06; 94-737, eff. 5-3-06; 95-547, | ||||||
8 | eff. 8-29-07.)
| ||||||
9 | (215 ILCS 105/8) (from Ch. 73, par. 1308) | ||||||
10 | Sec. 8. Minimum benefits. | ||||||
11 | a. Availability. The Plan shall offer in a periodically | ||||||
12 | renewable policy major medical expense coverage to every | ||||||
13 | eligible
person who is not eligible for Medicare. Major medical
| ||||||
14 | expense coverage offered by the Plan shall pay an eligible | ||||||
15 | person's
covered expenses, subject to limit on the deductible | ||||||
16 | and coinsurance
payments authorized under paragraph (4) of | ||||||
17 | subsection d of this Section,
up to a lifetime benefit limit of | ||||||
18 | $5,000,000 $2,000,000 until 3 years after the effective date of | ||||||
19 | this amendatory Act of the 95th General Assembly, and
| ||||||
20 | $1,500,000 in benefits 3 years or more after the effective date | ||||||
21 | of this amendatory Act of the 95th General Assembly per covered
| ||||||
22 | individual . The maximum
limit under this subsection shall not | ||||||
23 | be altered by the Board, and no
actuarial equivalent benefit | ||||||
24 | may be substituted by the Board.
Any person who otherwise would | ||||||
25 | qualify for coverage under the Plan, but
is excluded because he |
| |||||||
| |||||||
1 | or she is eligible for Medicare, shall be eligible
for any | ||||||
2 | separate Medicare supplement policy or policies which the Board | ||||||
3 | may
offer. | ||||||
4 | b. Outline of benefits. Covered expenses shall be
limited | ||||||
5 | to the usual and customary charge, including negotiated fees, | ||||||
6 | in
the locality for the following services and articles when | ||||||
7 | prescribed by a
physician and determined by the Plan to be | ||||||
8 | medically necessary
for the following areas of services, | ||||||
9 | subject to such separate deductibles,
co-payments, exclusions, | ||||||
10 | and other limitations on benefits as the Board shall
establish | ||||||
11 | and approve, and the other provisions of this Section: | ||||||
12 | (1) Hospital
services, except that
any services | ||||||
13 | provided by a hospital that is
located more than 75 miles | ||||||
14 | outside the State of Illinois shall be covered only
for a | ||||||
15 | maximum of 45 days in any calendar year. With respect to | ||||||
16 | covered
expenses incurred during any calendar year ending | ||||||
17 | on or after December 31,
1999, inpatient hospitalization of | ||||||
18 | an eligible person for the
treatment of mental illness at a | ||||||
19 | hospital located within the State of
Illinois
shall be | ||||||
20 | subject to the same terms and conditions as for any other | ||||||
21 | illness. | ||||||
22 | (2) Professional services for the diagnosis or | ||||||
23 | treatment of injuries,
illnesses or conditions, other than | ||||||
24 | dental and mental
and
nervous disorders as
described in | ||||||
25 | paragraph (17), which are rendered by a physician, or by | ||||||
26 | other
licensed professionals at the physician's
direction. |
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| |||||||
1 | This includes reconstruction of the breast on which a | ||||||
2 | mastectomy
was performed; surgery and reconstruction of | ||||||
3 | the other breast to produce a
symmetrical appearance; and | ||||||
4 | prostheses and treatment of physical complications
at all | ||||||
5 | stages of the mastectomy, including lymphedemas. | ||||||
6 | (2.5) Professional services provided by a physician to | ||||||
7 | children under
the age of 16 years for physical | ||||||
8 | examinations and age appropriate
immunizations ordered by | ||||||
9 | a physician licensed to practice medicine in all its
| ||||||
10 | branches. | ||||||
11 | (3) (Blank). | ||||||
12 | (4) Outpatient prescription drugs that by law require
a
| ||||||
13 | prescription
written by a physician licensed to practice | ||||||
14 | medicine in all its branches
subject to such separate | ||||||
15 | deductible, copayment, and other limitations or
| ||||||
16 | restrictions as the Board shall approve, including the use | ||||||
17 | of a prescription
drug card or any other program, or both. | ||||||
18 | (5) Skilled nursing services of a licensed
skilled
| ||||||
19 | nursing facility for not more than 120 days during a policy | ||||||
20 | year. | ||||||
21 | (6) Services of a home health agency in accord with a | ||||||
22 | home health care
plan, up to a maximum of 270 visits per | ||||||
23 | year. | ||||||
24 | (7) Services of a licensed hospice for not more than | ||||||
25 | 180
days during a policy year. | ||||||
26 | (8) Use of radium or other radioactive materials. |
| |||||||
| |||||||
1 | (9) Oxygen. | ||||||
2 | (10) Anesthetics. | ||||||
3 | (11) Orthoses and prostheses other than dental. | ||||||
4 | (12) Rental or purchase in accordance with Board | ||||||
5 | policies or
procedures of durable medical equipment, other | ||||||
6 | than eyeglasses or hearing
aids, for which there is no | ||||||
7 | personal use in the absence of the condition
for which it | ||||||
8 | is prescribed. | ||||||
9 | (13) Diagnostic x-rays and laboratory tests. | ||||||
10 | (14) Oral surgery (i) for excision of partially or | ||||||
11 | completely unerupted
impacted teeth when not performed in
| ||||||
12 | connection with the routine extraction or repair of teeth; | ||||||
13 | (ii) for excision
of tumors or cysts of the jaws, cheeks, | ||||||
14 | lips, tongue, and roof and floor of the
mouth; (iii) | ||||||
15 | required for correction of cleft lip and palate
and
other | ||||||
16 | craniofacial and maxillofacial birth defects; or (iv) for | ||||||
17 | treatment of injuries to natural teeth or a fractured jaw | ||||||
18 | due to an accident. | ||||||
19 | (15) Physical, speech, and functional occupational | ||||||
20 | therapy as
medically necessary and provided by appropriate | ||||||
21 | licensed professionals. | ||||||
22 | (16) Emergency and other medically necessary | ||||||
23 | transportation provided
by a licensed ambulance service to | ||||||
24 | the
nearest health care facility qualified to treat a | ||||||
25 | covered
illness, injury, or condition, subject to the | ||||||
26 | provisions of the
Emergency Medical Systems (EMS) Act. |
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1 | (17) Outpatient services for
diagnosis and
treatment | ||||||
2 | of mental and nervous disorders provided that a
covered | ||||||
3 | person shall be required to make a copayment not to exceed | ||||||
4 | 50% and that
the Plan's payment shall not exceed such | ||||||
5 | amounts as are established by the
Board. | ||||||
6 | (18) Human organ or tissue transplants specified by the | ||||||
7 | Board that
are performed at a hospital designated by the | ||||||
8 | Board as a participating
transplant center for that | ||||||
9 | specific organ or tissue transplant. | ||||||
10 | (19) Naprapathic services, as appropriate, provided by | ||||||
11 | a licensed
naprapathic practitioner. | ||||||
12 | c. Exclusions. Covered expenses of the Plan shall not
| ||||||
13 | include the following: | ||||||
14 | (1) Any charge for treatment for cosmetic purposes | ||||||
15 | other than for
reconstructive surgery when the service is | ||||||
16 | incidental to or follows
surgery resulting from injury, | ||||||
17 | sickness or other diseases of the involved
part or surgery | ||||||
18 | for the repair or treatment of a congenital bodily defect
| ||||||
19 | to restore normal bodily functions. | ||||||
20 | (2) Any charge for care that is primarily for rest,
| ||||||
21 | custodial, educational, or domiciliary purposes. | ||||||
22 | (3) Any charge for services in a private room to the | ||||||
23 | extent it is in
excess of the institution's charge for its | ||||||
24 | most common semiprivate room,
unless a private room is | ||||||
25 | prescribed as medically necessary by a physician. | ||||||
26 | (4) That part of any charge for room and board or for |
| |||||||
| |||||||
1 | services
rendered or articles prescribed by a physician, | ||||||
2 | dentist, or other health
care personnel that exceeds the | ||||||
3 | reasonable and customary charge in the
locality or for any | ||||||
4 | services or supplies not medically necessary for the
| ||||||
5 | diagnosed injury or illness. | ||||||
6 | (5) Any charge for services or articles the provision | ||||||
7 | of which is not
within the scope of licensure of the | ||||||
8 | institution or individual
providing the services or | ||||||
9 | articles. | ||||||
10 | (6) Any expense incurred prior to the effective date of | ||||||
11 | coverage by the
Plan for the person on whose behalf the | ||||||
12 | expense is incurred. | ||||||
13 | (7) Dental care, dental surgery, dental treatment, any | ||||||
14 | other dental
procedure involving the teeth or | ||||||
15 | periodontium, or any dental appliances,
including crowns, | ||||||
16 | bridges, implants, or partial or complete dentures,
except
| ||||||
17 | as specifically provided in paragraph
(14) of subsection b | ||||||
18 | of this Section. | ||||||
19 | (8) Eyeglasses, contact lenses, hearing aids or their | ||||||
20 | fitting. | ||||||
21 | (9) Illness or injury due to acts of war. | ||||||
22 | (10) Services of blood donors and any fee for failure | ||||||
23 | to replace the
first 3 pints of blood
provided to a covered | ||||||
24 | person each policy year. | ||||||
25 | (11) Personal supplies or services provided by a | ||||||
26 | hospital or nursing
home, or any other nonmedical or |
| |||||||
| |||||||
1 | nonprescribed supply or service. | ||||||
2 | (12) Routine maternity charges for a pregnancy, except | ||||||
3 | where added as
optional coverage with payment of an | ||||||
4 | additional premium for pregnancy
resulting from conception | ||||||
5 | occurring after the effective date of the
optional | ||||||
6 | coverage. | ||||||
7 | (13) (Blank). | ||||||
8 | (14) Any expense or charge for services, drugs, or | ||||||
9 | supplies that are:
(i) not provided in accord with | ||||||
10 | generally accepted standards of current
medical practice; | ||||||
11 | (ii) for procedures, treatments, equipment, transplants,
| ||||||
12 | or implants, any of which are investigational, | ||||||
13 | experimental, or for
research purposes; (iii) | ||||||
14 | investigative and not proven safe and effective;
or (iv) | ||||||
15 | for, or resulting from, a gender
transformation operation. | ||||||
16 | (15) Any expense or charge for routine physical | ||||||
17 | examinations or tests
except as provided in item (2.5) of | ||||||
18 | subsection b of this Section. | ||||||
19 | (16) Any expense for which a charge is not made in the | ||||||
20 | absence of
insurance or for which there is no legal | ||||||
21 | obligation on the part of the
patient to pay. | ||||||
22 | (17) Any expense incurred for benefits provided under | ||||||
23 | the laws of the
United States and this State, including | ||||||
24 | Medicare, Medicaid, and
other
medical assistance, maternal | ||||||
25 | and child health services and any other program
that is | ||||||
26 | administered or funded by the Department of Human Services, |
| |||||||
| |||||||
1 | Department
of Healthcare and Family Services, or | ||||||
2 | Department of Public Health, military service-connected
| ||||||
3 | disability payments, medical
services provided for members | ||||||
4 | of the armed forces and their dependents or
employees of | ||||||
5 | the armed forces of the United States, and medical services
| ||||||
6 | financed on behalf of all citizens by the United States. | ||||||
7 | (18) Any expense or charge for in vitro fertilization, | ||||||
8 | artificial
insemination, or any other artificial means | ||||||
9 | used to cause pregnancy. | ||||||
10 | (19) Any expense or charge for oral contraceptives used | ||||||
11 | for birth
control or any other temporary birth control | ||||||
12 | measures. | ||||||
13 | (20) Any expense or charge for sterilization or | ||||||
14 | sterilization reversals. | ||||||
15 | (21) Any expense or charge for weight loss programs, | ||||||
16 | exercise
equipment, or treatment of obesity, except when | ||||||
17 | certified by a physician as
morbid obesity (at least 2 | ||||||
18 | times normal body weight). | ||||||
19 | (22) Any expense or charge for acupuncture treatment | ||||||
20 | unless used as an
anesthetic agent for a covered surgery. | ||||||
21 | (23) Any expense or charge for or related to organ or | ||||||
22 | tissue
transplants other than those performed at a hospital | ||||||
23 | with a Board approved
organ transplant program that has | ||||||
24 | been designated by the Board as a
preferred or exclusive | ||||||
25 | provider organization for that specific organ or tissue
| ||||||
26 | transplant. |
| |||||||
| |||||||
1 | (24) Any expense or charge for procedures, treatments, | ||||||
2 | equipment, or
services that are provided in special | ||||||
3 | settings for research purposes or in
a controlled | ||||||
4 | environment, are being studied for safety, efficiency, and
| ||||||
5 | effectiveness, and are awaiting endorsement by the | ||||||
6 | appropriate national
medical speciality college for | ||||||
7 | general use within the medical community. | ||||||
8 | d. Deductibles and coinsurance. | ||||||
9 | The Plan coverage defined in Section 6 shall provide for a | ||||||
10 | choice
of
deductibles per individual as authorized by the | ||||||
11 | Board. If 2 individual members
of the same family
household, | ||||||
12 | who are both covered persons under the Plan, satisfy the
same | ||||||
13 | applicable deductibles, no other member of that family who is
| ||||||
14 | also a covered person under the Plan shall be
required to
meet | ||||||
15 | any deductibles for the balance of that calendar year. The
| ||||||
16 | deductibles must be applied first to the authorized amount of | ||||||
17 | covered expenses
incurred by the
covered person. A mandatory | ||||||
18 | coinsurance requirement shall be imposed at
the rate authorized | ||||||
19 | by the Board in excess of the mandatory
deductible, the | ||||||
20 | coinsurance
in the aggregate not to exceed such amounts as are | ||||||
21 | authorized by the Board
per annum. At its discretion the Board | ||||||
22 | may, however, offer catastrophic
coverages or other policies | ||||||
23 | that provide for larger deductibles with or
without coinsurance | ||||||
24 | requirements. The deductibles and coinsurance
factors may be | ||||||
25 | adjusted annually according to the Medical Component of the
| ||||||
26 | Consumer Price Index. |
| |||||||
| |||||||
1 | e. Scope of coverage. | ||||||
2 | (1) In approving any of the benefit plans to be offered | ||||||
3 | by the Plan, the
Board shall establish such benefit levels, | ||||||
4 | deductibles, coinsurance factors,
exclusions, and | ||||||
5 | limitations as it may deem appropriate and that it believes | ||||||
6 | to
be generally reflective of and commensurate with health | ||||||
7 | insurance coverage that
is provided in the individual | ||||||
8 | market in this State. | ||||||
9 | (2) The benefit plans approved by the Board may also | ||||||
10 | provide for and
employ
various cost containment measures | ||||||
11 | and other requirements including, but not
limited to, | ||||||
12 | preadmission certification, prior approval, second | ||||||
13 | surgical
opinions, concurrent utilization review programs, | ||||||
14 | individual case management,
preferred provider | ||||||
15 | organizations, health maintenance organizations, and other
| ||||||
16 | cost effective arrangements for paying for covered | ||||||
17 | expenses. | ||||||
18 | f. Preexisting conditions. | ||||||
19 | (1) Except for federally eligible individuals | ||||||
20 | qualifying for Plan
coverage under Section 15 of this Act
| ||||||
21 | or eligible persons who qualify
for the waiver authorized | ||||||
22 | in paragraph (3) of this subsection,
plan coverage shall | ||||||
23 | exclude charges or expenses incurred
during the first 6 | ||||||
24 | months following the effective date of coverage as to
any | ||||||
25 | condition for which medical advice, care or treatment was | ||||||
26 | recommended or
received during the 6 month period
|
| |||||||
| |||||||
1 | immediately preceding the effective date
of coverage. | ||||||
2 | (2) (Blank). | ||||||
3 | (3) Waiver: The preexisting condition exclusions as | ||||||
4 | set forth in
paragraph (1) of this subsection shall be | ||||||
5 | waived to the extent to which
the eligible person (a) has | ||||||
6 | satisfied similar exclusions under any prior
individual | ||||||
7 | health insurance policy that was involuntarily terminated
| ||||||
8 | because of the insolvency of the issuer of the policy and | ||||||
9 | (b) has applied
for Plan coverage within 90 days following | ||||||
10 | the involuntary
termination of that individual health | ||||||
11 | insurance coverage. | ||||||
12 | (4) Waiver: The preexisting condition exclusions as | ||||||
13 | set forth in paragraph (1) of this subsection shall be | ||||||
14 | waived to the extent to which the eligible person (a) has | ||||||
15 | satisfied the exclusion under prior Comprehensive Health | ||||||
16 | Insurance Plan coverage that was involuntarily terminated | ||||||
17 | because of meeting a lower lifetime benefit limit and (b) | ||||||
18 | has reapplied for Plan coverage within 90 days following an | ||||||
19 | increase in the lifetime benefit limit set forth in Section | ||||||
20 | 8 of this Act. | ||||||
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 payment | ||||||
24 | is available. Subject to the
provisions of subsection e of | ||||||
25 | Section 7, benefits
otherwise payable under Plan coverage | ||||||
26 | shall be reduced by
all amounts paid or payable by Medicare |
| |||||||
| |||||||
1 | or any other government program
or through any health | ||||||
2 | insurance coverage or group health plan,
whether by | ||||||
3 | insurance, reimbursement, or otherwise, or through
any | ||||||
4 | third party liability,
settlement, judgment, or award,
| ||||||
5 | regardless of the date of the settlement, judgment, or | ||||||
6 | award, whether the
settlement, judgment, or award is in the | ||||||
7 | form of a contract, agreement, or
trust on behalf of a | ||||||
8 | minor or otherwise and whether the settlement,
judgment, or | ||||||
9 | award is payable to the covered person, his or her | ||||||
10 | dependent,
estate, personal representative, or guardian in | ||||||
11 | a lump sum or over time,
and by all hospital or medical | ||||||
12 | expense benefits
paid or payable under any worker's | ||||||
13 | compensation coverage, automobile
medical payment, or | ||||||
14 | liability insurance, whether provided on the basis of
fault | ||||||
15 | or nonfault, and by any hospital or medical benefits paid | ||||||
16 | or payable
under or provided pursuant to any State or | ||||||
17 | federal law or program. | ||||||
18 | (2) The Plan shall have a cause of action against any
| ||||||
19 | covered person or any other person or entity for
the | ||||||
20 | recovery of any amount paid to the extent
the amount was | ||||||
21 | for treatment, services, or supplies not covered in this
| ||||||
22 | Section or in excess of benefits as set forth in this | ||||||
23 | Section. | ||||||
24 | (3) Whenever benefits are due from the Plan because of | ||||||
25 | sickness or
an injury to a covered person resulting from a | ||||||
26 | third party's wrongful act
or negligence and the covered |
| |||||||
| |||||||
1 | person has recovered or may recover damages
from a third | ||||||
2 | party or its insurer, the Plan shall have the right to | ||||||
3 | reduce
benefits or to refuse to pay benefits that otherwise | ||||||
4 | may be payable by the
amount of damages that the covered | ||||||
5 | person has recovered or may recover
regardless of the date | ||||||
6 | of the sickness or injury or the date of any
settlement, | ||||||
7 | judgment, or award resulting from that sickness or injury. | ||||||
8 | During the pendency of any action or claim that is | ||||||
9 | brought by or on
behalf of a covered person against a third | ||||||
10 | party or its insurer, any
benefits that would otherwise be | ||||||
11 | payable except for the provisions of this
paragraph (3) | ||||||
12 | shall be paid if payment by or for the third party has not | ||||||
13 | yet
been made and the covered person or, if incapable, that | ||||||
14 | person's legal
representative agrees in writing to pay back | ||||||
15 | promptly the benefits paid as
a result of the sickness or | ||||||
16 | injury to the extent of any future payments
made by or for | ||||||
17 | the third party for the sickness or injury. This agreement
| ||||||
18 | is to apply whether or not liability for the payments is | ||||||
19 | established or
admitted by the third party or whether those | ||||||
20 | payments are itemized. | ||||||
21 | Any amounts due the plan to repay benefits may be | ||||||
22 | deducted from other
benefits payable by the Plan after | ||||||
23 | payments by or for the third party are made. | ||||||
24 | (4) Benefits due from the Plan may be reduced or | ||||||
25 | refused as an offset
against any amount otherwise | ||||||
26 | recoverable under this Section. |
| |||||||
| |||||||
1 | h. Right of subrogation; recoveries. | ||||||
2 | (1) Whenever the Plan has paid benefits because of | ||||||
3 | sickness or an
injury to any covered person resulting from | ||||||
4 | a third party's wrongful act or
negligence, or for which an | ||||||
5 | insurer is liable in accordance with the
provisions of any | ||||||
6 | policy of insurance, and the covered person has recovered
| ||||||
7 | or may recover damages from a third party that is liable | ||||||
8 | for the damages,
the Plan shall have the right to recover | ||||||
9 | the benefits it paid from any
amounts that the covered | ||||||
10 | person has received or may receive regardless of
the date | ||||||
11 | of the sickness or injury or the date of any settlement, | ||||||
12 | judgment,
or award resulting from that sickness
or injury. | ||||||
13 | The Plan shall be subrogated to any right of recovery the
| ||||||
14 | covered person may have under the terms of any private or | ||||||
15 | public health
care coverage or liability coverage, | ||||||
16 | including coverage under the Workers'
Compensation Act or | ||||||
17 | the Workers' Occupational Diseases Act, without the
| ||||||
18 | necessity of assignment of claim or other authorization to | ||||||
19 | secure the right
of recovery. To enforce its subrogation | ||||||
20 | right, the Plan may (i) intervene
or join in an action or | ||||||
21 | proceeding brought by the covered person or his
personal | ||||||
22 | representative, including his guardian, conservator, | ||||||
23 | estate,
dependents, or survivors,
against any third party | ||||||
24 | or the third party's insurer that may be liable or
(ii) | ||||||
25 | institute and prosecute legal proceedings against any | ||||||
26 | third party or
the third party's insurer that may be liable |
| |||||||
| |||||||
1 | for the sickness or injury in
an appropriate court either | ||||||
2 | in the name of the Plan or in the name of the
covered | ||||||
3 | person or his personal representative, including his | ||||||
4 | guardian,
conservator, estate, dependents, or survivors. | ||||||
5 | (2) If any action or claim is brought by or on behalf | ||||||
6 | of a covered
person against a third party or the third | ||||||
7 | party's insurer, the covered
person or his personal | ||||||
8 | representative, including his guardian,
conservator, | ||||||
9 | estate, dependents, or survivors, shall notify the Plan by
| ||||||
10 | personal service or registered mail of the action or claim | ||||||
11 | and of the name
of the court in which the action or claim | ||||||
12 | is brought, filing proof thereof
in the action or claim. | ||||||
13 | The Plan may, at any time thereafter, join in the
action or | ||||||
14 | claim upon its motion so that all orders of court after | ||||||
15 | hearing
and judgment shall be made for its protection. No | ||||||
16 | release or settlement of
a claim for damages and no | ||||||
17 | satisfaction of judgment in the action shall be
valid | ||||||
18 | without the written consent of the Plan to the extent of | ||||||
19 | its interest
in the settlement or judgment and of the | ||||||
20 | covered person or his
personal representative. | ||||||
21 | (3) In the event that the covered person or his | ||||||
22 | personal
representative fails to institute a proceeding | ||||||
23 | against any appropriate
third party before the fifth month | ||||||
24 | before the action would be barred, the
Plan may, in its own | ||||||
25 | name or in the name of the covered person or personal
| ||||||
26 | representative, commence a proceeding against any |
| |||||||
| |||||||
1 | appropriate third party
for the recovery of damages on | ||||||
2 | account of any sickness, injury, or death to
the covered | ||||||
3 | person. The covered person shall cooperate in doing what is
| ||||||
4 | reasonably necessary to assist the Plan in any recovery and | ||||||
5 | shall not take
any action that would prejudice the Plan's | ||||||
6 | right to recovery. The Plan
shall pay to the covered person | ||||||
7 | or his personal representative all sums
collected from any | ||||||
8 | third party by judgment or otherwise in excess of
amounts | ||||||
9 | paid in benefits under the Plan and amounts paid or to be | ||||||
10 | paid as
costs, attorneys fees, and reasonable expenses | ||||||
11 | incurred by the Plan in
making the collection or enforcing | ||||||
12 | the judgment. | ||||||
13 | (4) In the event that a covered person or his personal | ||||||
14 | representative,
including his guardian, conservator, | ||||||
15 | estate, dependents, or survivors,
recovers damages from a | ||||||
16 | third party for sickness or injury caused to the
covered | ||||||
17 | person, the covered person or the personal representative | ||||||
18 | shall pay to the Plan
from the damages recovered the amount | ||||||
19 | of benefits paid or to be paid on
behalf of the covered | ||||||
20 | person. | ||||||
21 | (5) When the action or claim is brought by the covered | ||||||
22 | person alone
and the covered person incurs a personal | ||||||
23 | liability to pay attorney's fees
and costs of litigation, | ||||||
24 | the Plan's claim for reimbursement of the benefits
provided | ||||||
25 | to the covered person shall be the full amount of benefits | ||||||
26 | paid to
or on behalf of the covered person under this Act |
| |||||||
| |||||||
1 | less a pro rata share
that represents the Plan's reasonable | ||||||
2 | share of attorney's fees paid by the
covered person and | ||||||
3 | that portion of the cost of litigation expenses
determined | ||||||
4 | by multiplying by the ratio of the full amount of the
| ||||||
5 | expenditures to the full amount of the judgement, award, or | ||||||
6 | settlement. | ||||||
7 | (6) In the event of judgment or award in a suit or | ||||||
8 | claim against a
third party or insurer, the court shall | ||||||
9 | first order paid from any judgement
or award the reasonable | ||||||
10 | litigation expenses incurred in preparation and
| ||||||
11 | prosecution of the action or claim, together with | ||||||
12 | reasonable attorney's
fees. After payment of those | ||||||
13 | expenses and attorney's fees, the court shall
apply out of | ||||||
14 | the balance of the judgment or award an amount sufficient | ||||||
15 | to
reimburse the Plan the full amount of benefits paid on | ||||||
16 | behalf of the
covered person under this Act, provided the | ||||||
17 | court may reduce and apportion
the Plan's portion of the | ||||||
18 | judgement proportionate to the recovery of the
covered | ||||||
19 | person. The burden of producing evidence sufficient to | ||||||
20 | support the
exercise by the court of its discretion to | ||||||
21 | reduce
the amount of a proven charge sought to be enforced | ||||||
22 | against the recovery
shall rest with the party seeking the | ||||||
23 | reduction. The court may consider
the nature and extent of | ||||||
24 | the injury, economic and non-economic loss,
settlement | ||||||
25 | offers, comparative negligence as it applies to the case at
| ||||||
26 | hand, hospital costs, physician costs, and all other |
| |||||||
| |||||||
1 | appropriate costs.
The Plan shall pay its pro rata share of | ||||||
2 | the attorney fees based on the
Plan's recovery as it | ||||||
3 | compares to the total judgment. Any reimbursement
rights of | ||||||
4 | the Plan shall take priority over all other liens and | ||||||
5 | charges
existing under the laws of this State with the | ||||||
6 | exception of any attorney
liens filed under the Attorneys | ||||||
7 | Lien Act. | ||||||
8 | (7) The Plan may compromise or settle and release any | ||||||
9 | claim for
benefits provided under this Act or waive any | ||||||
10 | claims for benefits, in whole
or in part, for the | ||||||
11 | convenience of the Plan or if the Plan determines that
| ||||||
12 | collection would result in undue hardship upon the covered | ||||||
13 | person. | ||||||
14 | (Source: P.A. 95-547, eff. 8-29-07; 96-791, eff. 9-25-09.)
| ||||||
15 | Section 99. Effective date. This Act takes effect upon | ||||||
16 | becoming law.
|