HB 5648 — CHIP-ELGIBILITY-PLAN COVERAGE

In"Dependent" thatmeans circumstance,an coverageIllinois underresident: the plan shall terminate as of the expiration of the preexisting condition limitation period.

Underwho all other circumstances, coverage under the Plan shall automatically terminate as of the effective date of any medical assistance, except in cases where the effective date of the medical assistance is thea datespouse; that the application for medical assistance was submitted to the Department of Human Services and that date is different than the date that the applicant is determined to be eligible for medical assistance.

Inor thatwho circumstance,is coverageclaimed underas a dependent by the planprincipal shallinsured terminatefor onpurposes theof datefiling thata federal income tax return and resides in HB5648 Engrossed - 4 - LRB095 19208 KBJ 45459 b the applicantprincipal wasinsured’s determinedhousehold, toand beis eligiblea forresident medicalunmarried assistance.child under the age of 19 years;

(3)or Exceptwho asis providedan inunmarried Sectionchild 15,who thealso personis hasa previouslyfull-time participatedstudent inunder the Planage andof voluntarily23 terminatedyears Planand coverage,who unlessis 12financially monthsdependent haveupon elapsed since the person’sprincipal latestinsured; voluntary termination of HB5648 - 5 - LRB095 19208 KBJ 45459 b coverage.

(4)or Thewho personis failsa tochild payof theany requiredage premiumand underwho theis covereddisabled person’s terms of enrollment and participation,financially independent whichupon event the liabilityprincipal ofinsured. the Plan shall be limited to benefits incurred under the Plan for the time period for which premiums had been paid and the covered person remained eligible for Plan coverage.

(5)"Direct TheIllinois Planpremiums" (i)means, untilfor 3Illinois yearsbusiness, afteran theinsurer’s effectivedirect datepremium ofincome thisfor amendatorythe Actkinds of thebusiness 95thdescribed Generalin Assemblyclause has(b) paidof aClass total1 or clause (a) of $2,000,000Class in2 benefitsof onSection behalf4 of the coveredIllinois personInsurance orCode, (ii)and 3direct yearspremium orincome moreof aftera thehealth effectivemaintenance dateorganization ofor thisa amendatoryvoluntary Acthealth ofservices theplan, 95thexcept Generalit Assemblyshall hasnot paidinclude acredit totalhealth ofinsurance $1,500,000as defined in benefitsArticle onIX behalf1/2 of the coveredIllinois person.Insurance Code.

(6)"Director" Themeans personthe isDirector aof residentthe ofIllinois aDepartment publicof institution.Insurance.

(7)"Effective Thedate person’sof premiummedical isassistance" paidmeans forthe ordate reimbursedthat undereligibility anyfor governmentmedical sponsoredassistance programfor ora byperson anyis governmentapproved agencyby orthe healthDepartment care provider, except as an otherwise qualifying full-time employee, or dependent of suchHuman employee,Services, of a government agency or health care provider or, except when athe person’sDepartment premiumof isHuman paidServices bydetermines theeligibility U.S.retroactively.

TreasuryIn Departmentsuch pursuantcircumstances, tothe effective date of the federalmedical Tradeassistance Actis the date the Department of 2002.Human Services determines the person to be eligible for medical assistance.

(8)"Eligible Theperson" personmeans hasa orresident later receives other benefits or funds from any settlement, judgement, or award resulting from any accident or injury, regardless of thethis dateState ofwho thequalifies HB5648 - 6 - LRB095 19208 KBJ 45459 b accident or injury, or any other circumstances creating a legal liability for damagesPlan duecoverage thatunder personSection by7 a third party, whether the settlement, judgment, or award is in the form of athis contract,Act. agreement, or trust on behalf of a minor or otherwise and whether the settlement, judgment, or award is payable to the person, his or her dependent, estate, personal representative, or guardian in a lump sum or over time, so long as there continues to be benefits or assets remaining from those sources in an amount in excess of $300,000.

(9)"Employee" Withinmeans thea resident of this State who is employed HB5648 Engrossed - 5 years- priorLRB095 to19208 KBJ 45459 b by an employer or has entered into the dateemployment aof person’sor Planworks applicationunder iscontract receivedor byservice of an employer including the Board,officers, managers and employees of subsidiary or affiliated corporations and the person’sindividual coverageproprietors, underpartners anyand healthemployees careof benefitaffiliated programindividuals asand definedfirms inwhen 18the U.S.C.business of the subsidiary or affiliated corporations, firms or individuals is controlled by a common employer through stock ownership, contract, or otherwise.

24,"Employer" includingmeans any publicindividual, orpartnership, privateassociation, plancorporation, orbusiness contracttrust, underor which any medicalperson benefit,or item,group orof servicepersons isacting provided,directly wasor terminatedindirectly asin athe resultinterest of anyan actemployer orin practicerelation thatto constitutesan fraudemployee, underfor Statewhich orone federal law or asmore apersons resultis ofgainfully anemployed. intentional misrepresentation of material fact;

or"Family" ifcoverage thatmeans personthe knowinglycoverage andprovided willfullyby obtainedthe orPlan attemptedfor tothe obtain,covered or fraudulently aided or attempted to aid any other person inand obtaining,his any coverage or benefitsher undereligible thedependents Planwho toalso whichare thatcovered personpersons. was not entitled.

f."Federally eligible individual" means an individual resident of this State:

The(1)(A) boardfor orwhom, as of the administratordate shallon requirewhich verificationthe individual seeks Plan coverage under Section 15 of residencythis andAct, maythe requireaggregate anyof additionalthe informationperiods of creditable coverage is 18 or documentation,more months or, if the individual has been certified as eligible pursuant to the federal Trade Act of 2002, 3 or statementsmore months, and (B) whose most recent prior creditable coverage was under oath,group whenhealth insurance coverage offered by a health insurance issuer, a group health plan, a HB5648 Engrossed - 76 - LRB095 19208 KBJ 45459 b necessarygovernmental toplan, determineor residencya uponchurch initialplan application(or andhealth forinsurance coverage offered in connection with any such plans) or any other type of creditable coverage that may be required by the entirefederal termHealth Insurance Portability and Accountability Act of 1996, as it may be amended, or the policy.regulations under that Act;

g.(2) who is not eligible for coverage under (A) a group health plan (other than an individual who has been certified as eligible pursuant to the federal Trade Act of 2002), (B) part A or part B of Medicare due to age (other than an individual who has been certified as eligible pursuant to the federal Trade Act of 2002), or (C) medical assistance, and does not have other health insurance coverage (other than an individual who has been certified as eligible pursuant to the federal Trade Act of 2002);

Coverage(3) shallwith ceaserespect (i)to onwhom the(other datethan aan personindividual iswho nohas longerbeen acertified residentas ofeligible Illinois,pursuant (ii)to on the datefederal aTrade personAct requests coverage to end, (iii) upon the death of the2002) covered person, (iv) on the datemost Staterecent lawcoverage requireswithin cancellation of the policy,coverage orperiod (v)described atin theparagraph Plan’s(1)(A) option,of 30this daysdefinition afterwas thenot Planterminated makesbased anyupon inquiry concerning a person’sfactor eligibilityrelating orto placenonpayment of residencepremiums toor whichfraud; the person does not reply.

h.(4) if the individual (other than an individual who has been certified as eligible pursuant to the federal Trade Act of 2002) had been offered the option of continuation coverage under a COBRA continuation provision or under a similar State program, who elected such coverage;

Exceptand underHB5648 theEngrossed conditions- set7 forth- inLRB095 subsection19208 gKBJ of45459 thisb Section,(5) thewho, coverageif of any person who ceases to meet the eligibilityindividual requirementselected ofsuch thiscontinuation Sectioncoverage, shallhas beexhausted terminatedsuch atcontinuation thecoverage endunder ofsuch theprovision currentor policyprogram. period for which the necessary premiums have been paid.

However, an individual who has been certified as eligible pursuant to the federal Trade Act of 2002 shall not be required to elect continuation coverage under a COBRA continuation provision or under a similar state program.

"Group health insurance coverage" means, in connection with a group health plan, health insurance coverage offered in connection with that plan.

"Group health plan" has the same meaning given that term in the federal Health Insurance Portability and Accountability Act of 1996.

"Governmental plan" has the same meaning given that term in the federal Health Insurance Portability and Accountability Act of 1996.

"Health insurance coverage" means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital and medical expense-incurred policy, certificate, or contract provided by an insurer, non-profit health care service plan contract, health maintenance organization or other subscriber contract, or any other health care plan or arrangement that pays for or furnishes medical or health care services whether by insurance or otherwise.

Health insurance coverage shall not include short HB5648 Engrossed - 8 - LRB095 19208 KBJ 45459 b term, accident only, disability income, hospital confinement or fixed indemnity, dental only, vision only, limited benefit, or credit insurance, coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law, automobile medical-payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

"Health insurance issuer" means an insurance company, insurance service, or insurance organization (including a health maintenance organization and a voluntary health services plan) that is authorized to transact health insurance business in this State.

Such term does not include a group health plan.

"Health Maintenance Organization" means an organization as defined in the Health Maintenance Organization Act.

"Hospice" means a program as defined in and licensed under the Hospice Program Licensing Act.

"Hospital" means a duly licensed institution as defined in the Hospital Licensing Act, an institution that meets all comparable conditions and requirements in effect in the state in which it is located, or the University of Illinois Hospital as defined in the University of Illinois Hospital Act.

"Individual health insurance coverage" means health insurance coverage offered to individuals in the individual HB5648 Engrossed - 9 - LRB095 19208 KBJ 45459 b market, but does not include short-term, limited-duration insurance.

"Insured" means any individual resident of this State who is eligible to receive benefits from any insurer (including health insurance coverage offered in connection with a group health plan) or health insurance issuer as defined in this Section.

"Insurer" means any insurance company authorized to transact health insurance business in this State and any corporation that provides medical services and is organized under the Voluntary Health Services Plans Act or the Health Maintenance Organization Act.

"Medical assistance" means the State medical assistance or medical assistance no grant (MANG) programs provided under Title XIX of the Social Security Act and Articles V (Medical Assistance) and VI (General Assistance) of the Illinois Public Aid Code (or any successor program) or under any similar program of health care benefits in a state other than Illinois.

"Medically necessary" means that a service, drug, or supply is necessary and appropriate for the diagnosis or treatment of an illness or injury in accord with generally accepted standards of medical practice at the time the service, drug, or supply is provided.

When specifically applied to a confinement it further means that the diagnosis or treatment of the covered person’s medical symptoms or condition cannot be safely provided to that person as an outpatient.

A service, drug, or HB5648 Engrossed - 10 - LRB095 19208 KBJ 45459 b supply shall not be medically necessary if it:

(i) is investigational, experimental, or for research purposes;

or (ii) is provided solely for the convenience of the patient, the patient’s family, physician, hospital, or any other provider;

or (iii) exceeds in scope, duration, or intensity that level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment;

or (iv) could have been omitted without adversely affecting the covered person’s condition or the quality of medical care;

or (v) involves the use of a medical device, drug, or substance not formally approved by the United States Food and Drug Administration.

"Medical care" means the ordinary and usual professional services rendered by a physician or other specified provider during a professional visit for treatment of an illness or injury.

"Medicare" means coverage under both Part A and Part B of Title XVIII of the Social Security Act, 42 U.S.C.

Sec.

1395, et seq.

"Minimum premium plan" means an arrangement whereby a specified amount of health care claims is self-funded, but the insurance company assumes the risk that claims will exceed that amount.

"Participating transplant center" means a hospital designated by the Board as a preferred or exclusive provider of services for one or more specified human organ or tissue transplants for which the hospital has signed an agreement with HB5648 Engrossed - 11 - LRB095 19208 KBJ 45459 b the Board to accept a transplant payment allowance for all expenses related to the transplant during a transplant benefit period.

"Physician" means a person licensed to practice medicine pursuant to the Medical Practice Act of 1987.

"Plan" means the Comprehensive Health Insurance Plan established by this Act.

"Plan of operation" means the plan of operation of the Plan, including articles, bylaws and operating rules, adopted by the board pursuant to this Act.

"Provider" means any hospital, skilled nursing facility, hospice, home health agency, physician, registered pharmacist acting within the scope of that registration, or any other person or entity licensed in Illinois to furnish medical care.

"Qualified high risk pool" has the same meaning given that term in the federal Health Insurance Portability and Accountability Act of 1996.

"Resident" means a person who is and continues to be legally domiciled and physically residing on a permanent and full-time basis in a place of permanent habitation in this State that remains that person’s principal residence and from which that person is absent only for temporary or transitory purpose.

"Skilled nursing facility" means a facility or that portion of a facility that is licensed by the Illinois Department of Public Health under the Nursing Home Care Act or a comparable HB5648 Engrossed - 12 - LRB095 19208 KBJ 45459 b licensing authority in another state to provide skilled nursing care.

"Stop-loss coverage" means an arrangement whereby an insurer insures against the risk that any one claim will exceed a specific dollar amount or that the entire loss of a self-insurance plan will exceed a specific amount.

"Third party administrator" means an administrator as defined in Section 511.101 of the Illinois Insurance Code who is licensed under Article XXXI 1/4 of that Code.

94-17,92-153, eff.

1-1-06;7-25-01;

94-737,93-33, eff.

5-3-06;6-23-03;

95-547,93-34, eff.

8-29-07.)6-23-03; Section 99.

93-477, eff.

8-8-03;

93-622, eff.

12-18-03.) Section 99.