Illinois Chapter 215 Insurance

215 ILCS 105/      Comprehensive Health Insurance Plan Act.
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    (215 ILCS 105/1) (from Ch. 73, par. 1301)
    Sec. 1. Short Title. This Act shall be known and may be cited as the Comprehensive Health Insurance Plan Act.
(Source: P.A. 84‑1478.)

    (215 ILCS 105/1.1) (from Ch. 73, par. 1301.1)
    Sec. 1.1. The General Assembly hereby makes the following findings and declarations:
    (a) The Comprehensive Health Insurance Plan is established as a State program that is intended to provide an alternate market for health insurance for certain uninsurable Illinois residents, and further is intended to provide an acceptable alternative mechanism as described in the federal Health Insurance Portability and Accountability Act of 1996 for providing portable and accessible individual health insurance coverage for federally eligible individuals as defined in this Act.
    (b) The State of Illinois may subsidize the cost of health insurance coverage offered by the Plan. However, since the State has only a limited amount of resources, the General Assembly declares that it intends for this program to provide portable and accessible individual health insurance coverage for every federally eligible individual who qualifies for coverage in accordance with Section 15 of this Act, but does not intend for every eligible person who qualifies for Plan coverage in accordance with Section 7 of this Act to be guaranteed a right to be issued a policy under this Plan as a matter of entitlement.
    (c) The Comprehensive Health Insurance Plan Board shall operate the Plan in a manner so that the estimated cost of the program during any fiscal year will not exceed the total income it expects to receive from policy premiums, investment income, assessments, or fees collected or received by the Board and other funds which are made available from appropriations for the Plan by the General Assembly for that fiscal year.
(Source: P.A. 90‑30, eff. 7‑1‑97.)

    (215 ILCS 105/2) (from Ch. 73, par. 1302)
    Sec. 2. Definitions. As used in this Act, unless the context otherwise requires:
    "Plan administrator" means the insurer or third party administrator designated under Section 5 of this Act.
    "Benefits plan" means the coverage to be offered by the Plan to eligible persons and federally eligible individuals pursuant to this Act.
    "Board" means the Illinois Comprehensive Health Insurance Board.
    "Church plan" has the same meaning given that term in the federal Health Insurance Portability and Accountability Act of 1996.
    "Continuation coverage" means continuation of coverage under a group health plan or other health insurance coverage for former employees or dependents of former employees that would otherwise have terminated under the terms of that coverage pursuant to any continuation provisions under federal or State law, including the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, Sections 367.2, 367e, and 367e.1 of the Illinois Insurance Code, or any other similar requirement in another State.
    "Covered person" means a person who is and continues to remain eligible for Plan coverage and is covered under one of the benefit plans offered by the Plan.
    "Creditable coverage" means, with respect to a federally eligible individual, coverage of the individual under any of the following:
        (A) A group health plan.
        (B) Health insurance coverage (including group health
    
insurance coverage).
        (C) Medicare.
        (D) Medical assistance.
        (E) Chapter 55 of title 10, United States Code.
        (F) A medical care program of the Indian Health
    
Service or of a tribal organization.
        (G) A state health benefits risk pool.
        (H) A health plan offered under Chapter 89 of title
    
5, United States Code.
        (I) A public health plan (as defined in regulations
    
consistent with Section 104 of the Health Care Portability and Accountability Act of 1996 that may be promulgated by the Secretary of the U.S. Department of Health and Human Services).
        (J) A health benefit plan under Section 5(e) of the
    
Peace Corps Act (22 U.S.C. 2504(e)).
        (K) Any other qualifying coverage required by the
    
federal Health Insurance Portability and Accountability Act of 1996, as it may be amended, or regulations under that Act.
    "Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in Section 2791(c) of title XXVII of the Public Health Service Act (42 U.S.C. 300 gg‑91), nor does it include any period of coverage under any of items (A) through (K) that occurred before a break of more than 90 days or, if the individual has been certified as eligible pursuant to the federal Trade Act of 2002, a break of more than 63 days during all of which the individual was not covered under any of items (A) through (K) above.
    Any period that an individual is in a waiting period for any coverage under a group health plan (or for group health insurance coverage) or is in an affiliation period under the terms of health insurance coverage offered by a health maintenance organization shall not be taken into account in determining if there has been a break of more than 90 days in any creditable coverage.
    "Department" means the Illinois Department of Insurance.
    "Dependent" means an Illinois resident: who is a spouse; or who is claimed as a dependent by the principal insured for purposes of filing a federal income tax return and resides in the principal insured's household, and is a resident unmarried child under the age of 19 years; or who is an unmarried child who also is a full‑time student under the age of 23 years and who is financially dependent upon the principal insured; or who is a child of any age and who is disabled and financially dependent upon the principal insured.
    "Direct Illinois premiums" means, for Illinois business, an insurer's direct premium income for the kinds of business described in clause (b) of Class 1 or clause (a) of Class 2 of Section 4 of the Illinois Insurance Code, and direct premium income of a health maintenance organization or a voluntary health services plan, except it shall not include credit health insurance as defined in Article IX 1/2 of the Illinois Insurance Code.
    "Director" means the Director of the Illinois Department of Insurance.
    "Eligible person" means a resident of this State who qualifies for Plan coverage under Section 7 of this Act.
    "Employee" means a resident of this State who is employed by an employer or has entered into the employment of or works under contract or service of an employer including the officers, managers and employees of subsidiary or affiliated corporations and the individual proprietors, partners and employees of affiliated individuals and firms when the business of the subsidiary or affiliated corporations, firms or individuals is controlled by a common employer through stock ownership, contract, or otherwise.
    "Employer" means any individual, partnership, association, corporation, business trust, or any person or group of persons acting directly or indirectly in the interest of an employer in relation to an employee, for which one or more persons is gainfully employed.
    "Family" coverage means the coverage provided by the Plan for the covered person and his or her eligible dependents who also are covered persons.
    "Federally eligible individual" means an individual resident of this State:
        (1)(A) for whom, as of the date on which the
    
individual seeks Plan coverage under Section 15 of this Act, the aggregate of the periods of creditable coverage is 18 or more months or, if the individual has been certified as eligible pursuant to the federal Trade Act of 2002, 3 or more months, and (B) whose most recent prior creditable coverage was under group health insurance coverage offered by a health insurance issuer, a group health plan, a governmental plan, or a church plan (or health insurance coverage offered in connection with any such plans) or any other type of creditable coverage that may be required by the federal Health Insurance Portability and Accountability Act of 1996, as it may be amended, or the regulations under that Act;
        (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);
        (3) with respect to whom (other than an individual
    
who has been certified as eligible pursuant to the federal Trade Act of 2002) the most recent coverage within the coverage period described in paragraph (1)(A) of this definition was not terminated based upon a factor relating to nonpayment of premiums or fraud;
        (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; and
        (5) who, if the individual elected such continuation
    
coverage, has exhausted such continuation coverage under such provision or program.
    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 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 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 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 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 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.
(Source: P.A. 92‑153, eff. 7‑25‑01; 93‑33, eff. 6‑23‑03; 93‑34, eff. 6‑23‑03; 93‑477, eff. 8‑8‑03; 93‑622, eff. 12‑18‑03.)

    (215 ILCS 105/3) (from Ch. 73, par. 1303)
    Sec. 3. Operation of the Plan.
    a. There is hereby created an Illinois Comprehensive Health Insurance Plan.
    b. The Plan shall operate subject to the supervision and control of the board. The board is created as a political subdivision and body politic and corporate and, as such, is not a State agency. The board shall consist of 10 public members, appointed by the Governor with the advice and consent of the Senate.
    Initial members shall be appointed to the Board by the Governor as follows: 2 members to serve until July 1, 1988, and until their successors are appointed and qualified; 2 members to serve until July 1, 1989, and until their successors are appointed and qualified; 3 members to serve until July 1, 1990, and until their successors are appointed and qualified; and 3 members to serve until July 1, 1991, and until their successors are appointed and qualified. As terms of initial members expire, their successors shall be appointed for terms to expire the first day in July 3 years thereafter, and until their successors are appointed and qualified.
    Any vacancy in the Board occurring for any reason other than the expiration of a term shall be filled for the unexpired term in the same manner as the original appointment.
    Any member of the Board may be removed by the Governor for neglect of duty, misfeasance, malfeasance, or nonfeasance in office.
    In addition, a representative of the Governor's Office of Management and Budget, a representative of the Office of the Attorney General and the Director or the Director's designated representative shall be members of the board. Four members of the General Assembly, one each appointed by the President and Minority Leader of the Senate and by the Speaker and Minority Leader of the House of Representatives, shall serve as nonvoting members of the board. At least 2 of the public members shall be individuals reasonably expected to qualify for coverage under the Plan, the parent or spouse of such an individual, or a surviving family member of an individual who could have qualified for the plan during his lifetime. The Director or Director's representative shall be the chairperson of the board. Members of the board shall receive no compensation, but shall be reimbursed for reasonable expenses incurred in the necessary performance of their duties.
    c. The board shall make an annual report in September and shall file the report with the Secretary of the Senate and the Clerk of the House of Representatives. The report shall summarize the activities of the Plan in the preceding calendar year, including net written and earned premiums, the expense of administration, the paid and incurred losses for the year and other information as may be requested by the General Assembly. The report shall also include analysis and recommendations regarding utilization review, quality assurance and access to cost effective quality health care.
    d. In its plan of operation the board shall:
        (1) Establish procedures for selecting a plan
    
administrator in accordance with Section 5 of this Act.
        (2) Establish procedures for the operation of the
    
board.
        (3) Create a Plan fund, under management of the
    
board, to fund administrative, claim, and other expenses of the Plan.
        (4) Establish procedures for the handling and
    
accounting of assets and monies of the Plan.
        (5) Develop and implement a program to publicize the
    
existence of the Plan, the eligibility requirements and procedures for enrollment and to maintain public awareness of the Plan.
        (6) Establish procedures under which applicants and
    
participants may have grievances reviewed by a grievance committee appointed by the board. The grievances shall be reported to the board immediately after completion of the review. The Department and the board shall retain all written complaints regarding the Plan for at least 3 years. Oral complaints shall be reduced to written form and maintained for at least 3 years.
        (7) Provide for other matters as may be necessary and
    
proper for the execution of its powers, duties and obligations under the Plan.
    e. No later than 5 years after the Plan is operative the board and the Department shall conduct cooperatively a study of the Plan and the persons insured by the Plan to determine: (1) claims experience including a breakdown of medical conditions for which claims were paid; (2) whether availability of the Plan affected employment opportunities for participants; (3) whether availability of the Plan affected the receipt of medical assistance benefits by Plan participants; (4) whether a change occurred in the number of personal bankruptcies due to medical or other health related costs; (5) data regarding all complaints received about the Plan including its operation and services; (6) and any other significant observations regarding utilization of the Plan. The study shall culminate in a written report to be presented to the Governor, the President of the Senate, the Speaker of the House and the chairpersons of the House and Senate Insurance Committees. The report shall be filed with the Secretary of the Senate and the Clerk of the House of Representatives. The report shall also be available to members of the general public upon request.
    (e‑5) The board shall conduct a feasibility study of establishing a small employer health insurance pool in which employers may provide affordable health insurance coverage to their employees. The board may contract with a private entity or enter into intergovernmental agreements with State agencies for the completion of all or part of the study. The study shall:
        (i) Analyze other states' experience in establishing
    
small employer health insurance pools;
        (ii) Assess the need for a small employer health
    
insurance pool, including the number of individuals who might benefit from it;
        (iii) Recommend means of establishing a small
    
employer health insurance pool; and
        (iv) Estimate the cost of providing a small employer
    
health insurance pool through the Illinois Comprehensive Health Insurance Plan or another, public or private entity.
    The board may accept donations, in trust, from any legal
    
source, public or private, for deposit into a trust account specifically created for expenditure, without the necessity of being appropriated, solely for the purpose of conducting all or part of the study. The board shall issue a report with recommendations to the Governor and the General Assembly by January 1, 2005. As used in this subsection e‑5, "small employer" means an employer having between one and 50 employees.
    f. The board may:
        (1) Prepare and distribute certificate of eligibility
    
forms and enrollment instruction forms to insurance producers and to the general public in this State.
        (2) Provide for reinsurance of risks incurred by the
    
Plan and enter into reinsurance agreements with insurers to establish a reinsurance plan for risks of coverage described in the Plan, or obtain commercial reinsurance to reduce the risk of loss through the Plan.
        (3) Issue additional types of health insurance
    
policies to provide optional coverages as are otherwise permitted by this Act including a Medicare supplement policy designed to supplement Medicare.
        (4) Provide for and employ cost containment measures
    
and requirements including, but not limited to, preadmission certification, second surgical opinion, concurrent utilization review programs, and individual case management for the purpose of making the pool more cost effective.
        (5) Design, utilize, contract, or otherwise arrange
    
for the delivery of cost effective health care services, including establishing or contracting with preferred provider organizations, health maintenance organizations, and other limited network provider arrangements.
        (6) Adopt bylaws, rules, regulations, policies and
    
procedures as may be necessary or convenient for the implementation of the Act and the operation of the Plan.
        (7) Administer separate pools, separate accounts, or
    
other plans or arrangements as required by this Act to separate federally eligible individuals or groups of federally eligible individuals who qualify for plan coverage under Section 15 of this Act from eligible persons or groups of eligible persons who qualify for plan coverage under Section 7 of this Act and apportion the costs of the administration among such separate pools, separate accounts, or other plans or arrangements.
    g. The Director may, by rule, establish additional powers and duties of the board and may adopt rules for any other purposes, including the operation of the Plan, as are necessary or proper to implement this Act.
    h. The board is not liable for any obligation of the Plan. There is no liability on the part of any member or employee of the board or the Department, and no cause of action of any nature may arise against them, for any action taken or omission made by them in the performance of their powers and duties under this Act, unless the action or omission constitutes willful or wanton misconduct. The board may provide in its bylaws or rules for indemnification of, and legal representation for, its members and employees.
    i. There is no liability on the part of any insurance producer for the failure of any applicant to be accepted by the Plan unless the failure of the applicant to be accepted by the Plan is due to an act or omission by the insurance producer which constitutes willful or wanton misconduct.
(Source: P.A. 92‑597, eff. 6‑28‑02; 93‑622, eff. 12‑18‑03; 93‑824, eff. 7‑28‑04.)

    (215 ILCS 105/4) (from Ch. 73, par. 1304)
    Sec. 4. Powers and authority of the board. The board shall have the general powers and authority granted under the laws of this State to insurance companies licensed to transact health and accident insurance and in addition thereto, the specific authority to:
    a. Enter into contracts as are necessary or proper to carry out the provisions and purposes of this Act, including the authority, with the approval of the Director, to enter into contracts with similar plans of other states for the joint performance of common administrative functions, or with persons or other organizations for the performance of administrative functions including, without limitation, utilization review and quality assurance programs, or with health maintenance organizations or preferred provider organizations for the provision of health care services.
    b. Sue or be sued, including taking any legal actions necessary or proper.
    c. Take such legal action as necessary to:
        (1) avoid the payment of improper claims against the
    
plan or the coverage provided by or through the plan;
        (2) to recover any amounts erroneously or improperly
    
paid by the plan;
        (3) to recover any amounts paid by the plan as a
    
result of a mistake of fact or law; or
        (4) to recover or collect any other amounts,
    
including assessments, that are due or owed the Plan or have been billed on its or the Plan's behalf.
    d. Establish appropriate rates, rate schedules, rate adjustments, expense allowances, agents' referral fees, claim reserves, and formulas and any other actuarial function appropriate to the operation of the plan. Rates and rate schedules may be adjusted for appropriate risk factors such as age and area variation in claim costs and shall take into consideration appropriate risk factors in accordance with established actuarial and underwriting practices.
    e. Issue policies of insurance in accordance with the requirements of this Act.
    f. Appoint appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the plan, policy and other contract design, and any other function within the authority of the plan.
    g. Borrow money to effect the purposes of the Illinois Comprehensive Health Insurance Plan. Any notes or other evidence of indebtedness of the plan not in default shall be legal investments for insurers and may be carried as admitted assets.
    h. Establish rules, conditions and procedures for reinsuring risks under this Act.
    i. Employ and fix the compensation of employees. Such employees may be paid on a warrant issued by the State Treasurer pursuant to a payroll voucher certified by the Board and drawn by the Comptroller against appropriations or trust funds held by the State Treasurer.
    j. Enter into intergovernmental cooperation agreements with other agencies or entities of State government for the purpose of sharing the cost of providing health care services that are otherwise authorized by this Act for children who are both plan participants and eligible for financial assistance from the Division of Specialized Care for Children of the University of Illinois.
    k. Establish conditions and procedures under which the plan may, if funds permit, discount or subsidize premium rates that are paid directly by senior citizens, as defined by the Board, and other plan participants, who are retired or unemployed and meet other qualifications.
    l. Establish and maintain the Plan Fund authorized in Section 3 of this Act, which shall be divided into separate accounts, as follows:
        (1) accounts to fund the administrative, claim, and
    
other expenses of the Plan associated with eligible persons who qualify for Plan coverage under Section 7 of this Act, which shall consist of:
            (A) premiums paid on behalf of covered persons;
            (B) appropriated funds and other revenues
        
collected or received by the Board;
            (C) reserves for future losses maintained by the
        
Board; and
            (D) interest earnings from investment of the
        
funds in the Plan Fund or any of its accounts other than the funds in the account established under item 2 of this subsection;
        (2) an account, to be denominated the federally
    
eligible individuals account, to fund the administrative, claim, and other expenses of the Plan associated with federally eligible individuals who qualify for Plan coverage under Section 15 of this Act, which shall consist of:
            (A) premiums paid on behalf of covered persons;
            (B) assessments and other revenues collected or
        
received by the Board;
            (C) reserves for future losses maintained by the
        
Board; and
            (D) interest earnings from investment of the
        
federally eligible individuals account funds; and
            (E) grants provided pursuant to the federal
        
Trade Act of 2002; and
        (3) such other accounts as may be appropriate.
    m. Charge and collect assessments paid by insurers pursuant to Section 12 of this Act and recover any assessments for, on behalf of, or against those insurers.
(Source: P.A. 93‑33, eff. 6‑23‑03; 93‑34, eff. 6‑23‑03.)

    (215 ILCS 105/5) (from Ch. 73, par. 1305)
    Sec. 5. Plan administrator.
    a. The board shall select a plan administrator through a competitive bidding process to administer the plan. The board shall evaluate bids submitted under this Section based on criteria established by the board which shall include:
        (1) The plan administrator's proven ability to
    
handle other large group accident and health benefit plans.
        (2) The efficiency and timeliness of the plan
    
administrator's claim processing procedures.
        (3) An estimate of total net cost for administering
    
the plan, including any discounts or income the Plan could expect to receive or benefit from.
        (4) The plan administrator's ability to apply
    
effective cost containment programs and procedures and to administer the plan in a cost‑efficient manner.
        (5) The financial condition and stability of the
    
plan administrator.
    b. The plan administrator shall serve for a period of 5 years subject to removal for cause and subject to the terms, conditions and limitations of the contract between the board and the plan administrator. At least one year prior to the expiration of each 5 year period of service by the current plan administrator, the board shall begin to advertise for bids to serve as the plan administrator for the succeeding 5 year period. Selection of the plan administrator for the succeeding period shall be made at least 6 months prior to the end of the current 5 year period.
    c. The plan administrator shall perform such functions relating to the plan as may be assigned to it including:
        (1) establishment of a premium billing procedure for
    
collection of premiums from plan participants. Billings shall be made on a periodic basis as determined by the board;
        (2) payment and processing of claims and various
    
cost containment functions; and
        (3) other functions to assure timely payment of
    
benefits to participants under the plan, including:
            (a) making available information relating to the
        
proper manner of submitting a claim for benefits under the plan and distributing forms upon which submissions shall be made, and
            (b) evaluating the eligibility of each claim for
        
payment under the plan.
     The plan administrator shall be governed by the requirements of Part 919 of Title 50 of the Illinois Administrative Code, promulgated by the Department of Insurance, regarding the handling of claims under this Act.
    d. The plan administrator shall submit regular reports to the board regarding the operation of the plan. The frequency, content and form of the report shall be as determined by the board.
    e. The plan administrator shall pay or be reimbursed for claims expenses from the premium payments received from or on behalf of plan participants. If the plan administrator's payments or reimbursements for claims expenses exceed the portion of premiums allocated by the board for payment of claims expenses, the board shall provide additional funds to the plan administrator for payment or reimbursement of such claims expenses.
    f. The plan administrator shall be paid as provided in the contract between the Board and the plan administrator.
(Source: P.A. 90‑30, eff. 7‑1‑97; 90‑567, eff. 1‑23‑98; 91‑357, eff. 7‑29‑99.)

    (215 ILCS 105/6) (from Ch. 73, par. 1306)
    Sec. 6. Contents of plan. The plan shall include, but is not limited to, the following:
    a. Schedules of premiums and benefits, limitations, exclusions, deductibles, coinsurance payments, and other policy terms and conditions established in accordance with appropriate actuarial principles and all the requirements of this Act.
    b. Procedures for applicants and participants to submit grievances under Section 3 of this Act.
(Source: P.A. 87‑560.)

    (215 ILCS 105/7) (from Ch. 73, par. 1307)
    Sec. 7. Eligibility.
    a. Except as provided in subsection (e) of this Section or in Section 15 of this Act, any person who is either a citizen of the United States or an alien lawfully admitted for permanent residence and who has been for a period of at least 180 days and continues to be a resident of this State shall be eligible for Plan coverage under this Section if evidence is provided of:
        (1) A notice of rejection or refusal to issue
    
substantially similar individual health insurance coverage for health reasons by a health insurance issuer; or
        (2) A refusal by a health insurance issuer to issue
    
individual health insurance coverage except at a rate exceeding the applicable Plan rate for which the person is responsible.
    A rejection or refusal by a group health plan or health insurance issuer offering only stop‑loss or excess of loss insurance or contracts, agreements, or other arrangements for reinsurance coverage with respect to the applicant shall not be sufficient evidence under this subsection.
    b. The board shall promulgate a list of medical or health conditions for which a person who is either a citizen of the United States or an alien lawfully admitted for permanent residence and a resident of this State would be eligible for Plan coverage without applying for health insurance coverage pursuant to subsection a. of this Section. Persons who can demonstrate the existence or history of any medical or health conditions on the list promulgated by the board shall not be required to provide the evidence specified in subsection a. of this Section. The list shall be effective on the first day of the operation of the Plan and may be amended from time to time as appropriate.
    c. Family members of the same household who each are covered persons are eligible for optional family coverage under the Plan.
    d. For persons qualifying for coverage in accordance with Section 7 of this Act, the board shall, if it determines that such appropriations as are made pursuant to Section 12 of this Act are insufficient to allow the board to accept all of the eligible persons which it projects will apply for enrollment under the Plan, limit or close enrollment to ensure that the Plan is not over‑subscribed and that it has sufficient resources to meet its obligations to existing enrollees. The board shall not limit or close enrollment for federally eligible individuals.
    e. A person shall not be eligible for coverage under the Plan if:
        (1) He or she has or obtains other coverage under a
    
group health plan or health insurance coverage substantially similar to or better than a Plan policy as an insured or covered dependent or would be eligible to have that coverage if he or she elected to obtain it. Persons otherwise eligible for Plan coverage may, however, solely for the purpose of having coverage for a pre‑existing condition, maintain other coverage only while satisfying any pre‑existing condition waiting period under a Plan policy or a subsequent replacement policy of a Plan policy.
        (1.1) His or her prior coverage under a group health
    
plan or health insurance coverage, provided or arranged by an employer of more than 10 employees was discontinued for any reason without the entire group or plan being discontinued and not replaced, provided he or she remains an employee, or dependent thereof, of the same employer.
        (2) He or she is a recipient of or is approved to
    
receive medical assistance, except that a person may continue to receive medical assistance through the medical assistance no grant program, but only while satisfying the requirements for a preexisting condition under Section 8, subsection f. of this Act. Payment of premiums pursuant to 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. If the person continues to receive or be approved to receive medical assistance through the medical assistance no grant program at or after the time that requirements for a preexisting condition are satisfied, the person shall not be eligible for coverage under the Plan. In that circumstance, coverage under the plan shall terminate as of the expiration of the preexisting condition limitation period. Under all other circumstances, coverage under the Plan shall automatically terminate as of the effective date of any medical assistance.
        (3) Except as provided in Section 15, the person has
    
previously participated in the Plan and voluntarily terminated Plan coverage, unless 12 months have elapsed since the person's latest voluntary termination of coverage.
        (4) The person fails to pay the required premium
    
under the covered person's terms of enrollment and participation, in which event the liability of 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) The Plan has paid a total of $1,500,000 in
    
benefits on behalf of the covered person.
        (6) The person is a resident of a public institution.
        (7) The person's premium is paid for or reimbursed
    
under any government sponsored program or by any government agency or health care provider, except as an otherwise qualifying full‑time employee, or dependent of such employee, of a government agency or health care provider or, except when a person's premium is paid by the U.S. Treasury Department pursuant to the federal Trade Act of 2002.
        (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 assets remaining from those sources in an amount in excess of $300,000.
        (9) Within the 5 years prior to the date a person's
    
Plan application is received by the Board, the person's coverage under any health care benefit program as defined in 18 U.S.C. 24, including any public or private plan or contract under which any medical benefit, item, or service is provided, was terminated as a result of any act or practice that constitutes fraud under State or federal law or as a result of an intentional misrepresentation of material fact; or if that person knowingly and willfully obtained or attempted to obtain, or fraudulently aided or attempted to aid any other person in obtaining, any coverage or benefits under the Plan to which that person was not entitled.
    f. The board or the administrator shall require verification of residency and may require any additional information or documentation, or statements under oath, when necessary to determine residency upon initial application and for the entire term of the policy.
    g. 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 residence to which the person does not reply.
    h. Except under the conditions set forth in subsection g of this Section, the coverage of any person who ceases to meet the eligibility requirements of this Section shall be terminated at the end of the current policy period for which the necessary premiums have been paid.
(Source: P.A. 93‑33, eff. 6‑23‑03; 93‑34, eff. 6‑23‑03; 94‑17, eff. 1‑1‑06; 94‑737, eff. 5‑3‑06.)

    (215 ILCS 105/7.1)
    Sec. 7.1. Premiums.
    (a) The Board shall establish premium rates for coverage as provided in subsection (d) of this Section.
    (b) Separate schedules of premium rates based on sex, age, geographical location, and benefit plan shall apply for individual risks.
    (c) The Board may provide for separate premium rates for optional family coverage for the spouse or one or more dependents who reside together in any eligible individual's or eligible person's household. The rates for each spouse or dependent who qualifies to be covered under this optional family coverage shall be such percentage of the applicable individual Plan rate as the Board, in accordance with appropriate actuarial principles, shall establish.
    (d) The Board, with the assistance of the Director and in accordance with appropriate actuarial principles, shall determine a standard risk rate by using the average rates that individual standard risks in this State are charged by at least 5 of the largest health insurance issuers providing individual health insurance coverage to residents of Illinois that is substantially similar to the coverage offered by the Plan. In determining the average rate or charges of those health insurance issuers, the rates charged by those issuers shall be actuarially adjusted to determine the rate or charge that would have been charged for benefits similar to those provided by the Plan. The standard risk rates shall be established using reasonable actuarial techniques and shall reflect anticipated claims experience, expenses, and other appropriate risk factors for such coverage.
    (e) Rates for Plan coverage shall not be less than 125% nor more than 150% of rates established as applicable for individual standard risks pursuant to subsection (d).
(Source: P.A. 90‑30, eff. 7‑1‑97.)

    (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 $1,500,000 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 Section:
        (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 branches.
        (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 both.
        (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.
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