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.