Public Act 92-0630 of the 92nd General Assembly
Public Act 92-0630       
HB5606 Enrolled                                LRB9213627JSpc      
    AN ACT  concerning  the  comprehensive  health  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 an annually      
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 $1,000,000 per covered  individual.      
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,  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      
         (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.      
         (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      
         (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      
         (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 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.      
         (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.      
         (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 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      
         (15)  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 Public Aid,      
    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 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      
    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      
    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 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      
    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      
    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  63  days      
    following  the involuntary termination of that individual      
    health insurance coverage.      
    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 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      
         (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 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  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      
         (2)  If  any  action  or  claim  is brought by or on      
    behalf 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 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 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 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. 91-639,  eff.  8-20-99;  91-735,  eff.  6-2-00;      
92-2, eff. 5-1-01.)      
    Section  99.  Effective date.  This Act takes effect upon      
becoming law.      
    Passed in the General Assembly May 07, 2002.      
    Approved July 11, 2002.