SB 663 — CHIP-ELIGIBILITY FOR COVERAGE

SB0663 EngrossedEnrolled LRB096 06728 MJR 16812 b AN ACT concerning regulation.

A rejection or refusal by a group health plan or health insurance issuer offering only stop-loss or excess of loss SB0663 EngrossedEnrolled - 2 - LRB096 06728 MJR 16812 b insurance or contracts, agreements, or other arrangements for reinsurance coverage with respect to the applicant shall not be sufficient evidence under this subsection.

The SB0663 EngrossedEnrolled - 3 - LRB096 06728 MJR 16812 b board shall not limit or close enrollment for federally eligible individuals.

Payment of premiums pursuant to SB0663 EngrossedEnrolled - 4 - LRB096 06728 MJR 16812 b this Act shall be allocable to the person's spenddown for purposes of the medical assistance no grant program, but that person shall not be eligible for any Plan benefits while that person remains eligible for medical assistance.

(5) The Plan (i) until 3 years after the effective date SB0663 EngrossedEnrolled - 5 - LRB096 06728 MJR 16812 b of this amendatory Act of the 95th General Assembly has paid a total of $5,000,000 $2,000,000 in benefits on behalf of the covered person or (ii) 3 years or more after the effective date of this amendatory Act of the 95th General Assembly has paid a total of $1,500,000 in benefits on behalf of the covered person.

(8) The person has or later receives other benefits or funds from any settlement, judgement, or award resulting from any accident or injury, regardless of the date of the accident or injury, or any other circumstances creating a legal liability for damages due that person by a third party, 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 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 SB0663 EngrossedEnrolled - 6 - LRB096 06728 MJR 16812 b assets remaining from those sources in an amount in excess of $300,000.

Coverage shall cease (i) on the date a person is no longer a resident of Illinois, (ii) on the date a person requests coverage to end, (iii) upon the death of the covered person, (iv) on the date State law requires cancellation of the policy, or (v) at the Plan's option, 30 days after the Plan makes any inquiry concerning a person's eligibility or place of SB0663 EngrossedEnrolled - 7 - LRB096 06728 MJR 16812 b residence to which the person does not reply.

Any person who otherwise would qualify for coverage under the Plan, but is excluded because he SB0663 EngrossedEnrolled - 8 - LRB096 06728 MJR 16812 b or she is eligible for Medicare, shall be eligible for any separate Medicare supplement policy or policies which the Board may offer.

SB0663 EngrossedEnrolled - 9 - LRB096 06728 MJR 16812 b This includes reconstruction of the breast on which a mastectomy was performed;

SB0663 EngrossedEnrolled - 10 - LRB096 06728 MJR 16812 b (9) Oxygen.

SB0663 EngrossedEnrolled - 11 - LRB096 06728 MJR 16812 b (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.

(4) That part of any charge for room and board or for SB0663 EngrossedEnrolled - 12 - LRB096 06728 MJR 16812 b 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.

(11) Personal supplies or services provided by a hospital or nursing home, or any other nonmedical or SB0663 EngrossedEnrolled - 13 - LRB096 06728 MJR 16812 b nonprescribed supply or service.

(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, SB0663 EngrossedEnrolled - 14 - LRB096 06728 MJR 16812 b 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 financed on behalf of all citizens by the United States.

SB0663 EngrossedEnrolled - 15 - LRB096 06728 MJR 16812 b (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.

SB0663 EngrossedEnrolled - 16 - LRB096 06728 MJR 16812 b e.

(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 SB0663 EngrossedEnrolled - 17 - LRB096 06728 MJR 16812 b immediately preceding the effective date of 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.

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 SB0663 Enrolled - 18 - LRB096 06728 MJR 16812 b 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 SB0663 Engrossed - 18 - LRB096 06728 MJR 16812 b 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.

(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 SB0663 Enrolled - 19 - LRB096 06728 MJR 16812 b 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 SB0663 Engrossed - 19 - LRB096 06728 MJR 16812 b 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.

SB0663 Enrolled - 20 - LRB096 06728 MJR 16812 b h.

(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 SB0663 Engrossed - 20 - LRB096 06728 MJR 16812 b 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.

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 SB0663 Enrolled - 21 - LRB096 06728 MJR 16812 b 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 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 SB0663 Engrossed - 21 - LRB096 06728 MJR 16812 b 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.

(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 SB0663 Enrolled - 22 - LRB096 06728 MJR 16812 b appropriate third party for the recovery of damages on account of any sickness, injury, or death to the covered person.

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 SB0663 Engrossed - 22 - LRB096 06728 MJR 16812 b paid as costs, attorneys fees, and reasonable expenses incurred by the Plan in making the collection or enforcing the judgment.

(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 SB0663 Enrolled - 23 - LRB096 06728 MJR 16812 b 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 SB0663 Engrossed - 23 - LRB096 06728 MJR 16812 b litigation expenses incurred in preparation and prosecution of the action or claim, together with reasonable attorney's fees.

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 SB0663 Enrolled - 24 - LRB096 06728 MJR 16812 b appropriate costs.

(7) The Plan may compromise or settle and release any claim for benefits provided under this Act or waive any SB0663 Engrossed - 24 - LRB096 06728 MJR 16812 b 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.