(215 ILCS 106/1)

Sec. 1.

Short title.

This Act may be cited as the

Children's Health Insurance Program Act.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/10)

Sec. 10.

Definitions.

As used in this Act:

"Benchmarking" means health benefits coverage as defined in Section 2103 of the Social Security Act.

"Child" means a person under the age of 19.

"Department" means the Department of Public Aid.

"Medical assistance" means health care benefits provided under Article V of the Illinois Public Aid Code.

"Medical visit" means a hospital, dental, physician, optical, or other health care visit where services are provided pursuant to this Act.

"Program" means the Children's Health Insurance Program, which includes subsidizing the cost of privately sponsored health insurance and purchasing or providing health care benefits for eligible children.

"Resident" means a person who meets the residency requirements as defined in Section 5‑3 of the Illinois Public Aid Code.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/15)

Sec. 15.

Operation of the Program.

There is hereby created a Children's Health Insurance Program. The Program shall operate subject to appropriation and shall be administered by the Department of Public Aid. The Department shall have the powers and authority granted to the Department under the Illinois Public Aid Code. The Department may contract with a Third Party Administrator or other entities to administer and oversee any portion of this Program.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/20)

Sec. 20.

Eligibility.

(a) To be eligible for this Program, a person must be a person who has a child eligible under this Act and who is eligible under a waiver of federal requirements pursuant to an application made pursuant to subdivision (a)(1) of Section 40 of this Act or who is a child who:

(1) is a child who is not eligible for medical

assistance;

(2) is a child whose annual household income, as

determined by the Department, is above 133% of the federal poverty level and at or below 200% of the federal poverty level;

(3) is a resident of the State of Illinois; and

(4) is a child who is either a United States citizen

or included in one of the following categories of non‑citizens:

(A) unmarried dependent children of either a

United States Veteran honorably discharged or a person on active military duty;

(B) refugees under Section 207 of the

Immigration and Nationality Act;

(C) asylees under Section 208 of the Immigration

and Nationality Act;

(D) persons for whom deportation has been

withheld under Section 243(h) of the Immigration and Nationality Act;

(E) persons granted conditional entry under

Section 203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980;

(F) persons lawfully admitted for permanent

residence under the Immigration and Nationality Act; and

(G) parolees, for at least one year, under

Section 212(d)(5) of the Immigration and Nationality Act.

Those children who are in the categories set forth in subdivisions (4)(F) and (4)(G) of this subsection, who enter the United States on or after August 22, 1996, shall not be eligible for 5 years beginning on the date the child entered the United States.

(b) A child who is determined to be eligible for assistance may remain eligible for 12 months, provided the child maintains his or her residence in the State, has not yet attained 19 years of age, and is not excluded pursuant to subsection (c). A child who has been determined to be eligible for assistance must reapply or otherwise establish eligibility at least annually. An eligible child shall be required, as determined by the Department by rule, to report promptly those changes in income and other circumstances that affect eligibility. The eligibility of a child may be redetermined based on the information reported or may be terminated based on the failure to report or failure to report accurately. A child's responsible relative or caretaker may also be held liable to the Department for any payments made by the Department on such child's behalf that were inappropriate. An applicant shall be provided with notice of these obligations.

(c) A child shall not be eligible for coverage under this Program if:

(1) the premium required pursuant to Section 30 of

this Act has not been paid. If the required premiums are not paid the liability of the Program shall be limited to benefits incurred under the Program for the time period for which premiums had been paid. If the required monthly premium is not paid, the child shall be ineligible for re‑enrollment for a minimum period of 3 months. Re‑enrollment shall be completed prior to the next covered medical visit and the first month's required premium shall be paid in advance of the next covered medical visit. The Department shall promulgate rules regarding grace periods, notice requirements, and hearing procedures pursuant to this subsection;

(2) the child is an inmate of a public institution

or a patient in an institution for mental diseases; or

(3) the child is a member of a family that is

eligible for health benefits covered under the State of Illinois health benefits plan on the basis of a member's employment with a public agency.

(Source: P.A. 92‑597, eff. 6‑28‑02; 93‑63, eff. 6‑30‑03.)

(215 ILCS 106/22)

Sec. 22.

Enrollment in program.

The Department shall develop procedures to allow community providers, schools, youth service agencies, employers, labor unions, local chambers of commerce, and religious organizations to assist in enrolling children in the Program.

(Source: P.A. 91‑470, eff. 8‑10‑99; 91‑471, eff. 8‑10‑99; 92‑16, eff. 6‑28‑01

.)

(215 ILCS 106/25)

Sec. 25.

Health benefits for children.

(a) The Department shall, subject to appropriation, provide health benefits coverage to eligible children by:

(1) Subsidizing the cost of privately sponsored

health insurance, including employer based health insurance, to assist families to take advantage of available privately sponsored health insurance for their eligible children; and

(2) Purchasing or providing health care benefits for

eligible children. The health benefits provided under this subdivision (a)(2) shall, subject to appropriation and without regard to any applicable cost sharing under Section 30, be identical to the benefits provided for children under the State's approved plan under Title XIX of the Social Security Act. Providers under this subdivision (a)(2) shall be subject to approval by the Department to provide health care under the Illinois Public Aid Code and shall be reimbursed at the same rate as providers under the State's approved plan under Title XIX of the Social Security Act. In addition, providers may retain co‑payments when determined appropriate by the Department.

(b) The subsidization provided pursuant to subdivision (a)(1) shall be credited to the family of the eligible child.

(c) The Department is prohibited from denying coverage to a child who is enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) because the plan does not meet federal benchmarking standards or cost sharing and contribution requirements. To be eligible for inclusion in the Program, the plan shall contain comprehensive major medical coverage which shall consist of physician and hospital inpatient services. The Department is prohibited from denying coverage to a child who is enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) because the plan offers benefits in addition to physician and hospital inpatient services.

(d) The total dollar amount of subsidizing coverage per child per month pursuant to subdivision (a)(1) shall be equal to the average dollar payments, less premiums incurred, per child per month pursuant to subdivision (a)(2). The Department shall set this amount prospectively based upon the prior fiscal year's experience adjusted for incurred but not reported claims and estimated increases or decreases in the cost of medical care. Payments obligated before July 1, 1999, will be computed using State Fiscal Year 1996 payments for children eligible for Medical Assistance and income assistance under the Aid to Families with Dependent Children Program, with appropriate adjustments for cost and utilization changes through January 1, 1999. The Department is prohibited from providing a subsidy pursuant to subdivision (a)(1) that is more than the individual's monthly portion of the premium.

(e) An eligible child may obtain immediate coverage under this Program only once during a medical visit. If coverage lapses, re‑enrollment shall be completed in advance of the next covered medical visit and the first month's required premium shall be paid in advance of any covered medical visit.

(f) In order to accelerate and facilitate the development of networks to deliver services to children in areas outside counties with populations in excess of 3,000,000, in the event less than 25% of the eligible children in a county or contiguous counties has enrolled with a Health Maintenance Organization pursuant to Section 5‑11 of the Illinois Public Aid Code, the Department may develop and implement demonstration projects to create alternative networks designed to enhance enrollment and participation in the program. The Department shall prescribe by rule the criteria, standards, and procedures for effecting demonstration projects under this Section.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/30)

Sec. 30.

Cost sharing.

(a) Children enrolled in a health benefits program pursuant to subdivision (a)(2) of Section 25 and persons enrolled in a health benefits waiver program pursuant to Section 40 shall be subject to the following cost sharing requirements:

(1) There shall be no co‑payment required for

well‑baby or well‑child care, including age‑appropriate immunizations as required under federal law.

(2) Health insurance premiums for family members,

either children or adults, in families whose household income is above 150% of the federal poverty level shall be payable monthly, subject to rules promulgated by the Department for grace periods and advance payments, and shall be as follows:

(A) $15 per month for one family member.

(B) $25 per month for 2 family members.

(C) $30 per month for 3 family members.

(D) $35 per month for 4 family members.

(E) $40 per month for 5 or more family members.

(3) Co‑payments for children or adults in families

whose income is at or below 150% of the federal poverty level, at a minimum and to the extent permitted under federal law, shall be $2 for all medical visits and prescriptions provided under this Act.

(4) Co‑payments for children or adults in families

whose income is above 150% of the federal poverty level, at a minimum and to the extent permitted under federal law shall be as follows:

(A) $5 for medical visits.

(B) $3 for generic prescriptions and $5 for

brand name prescriptions.

(C) $25 for emergency room use for a

non‑emergency situation as defined by the Department by rule.

(5) The maximum amount of out‑of‑pocket expenses for

co‑payments shall be $100 per family per year.

(b) Individuals enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) of Section 25 shall be subject to the cost sharing provisions as stated in the privately sponsored health insurance plan.

(Source: P.A. 94‑48, eff. 7‑1‑05.)

(215 ILCS 106/35)

Sec. 35.

Funding.

(a) This Program is not an entitlement and shall not be construed to create an entitlement. Eligibility for the Program is subject to appropriation of funds by the State and federal governments. Subdivision (a)(2) of Section 25 shall operate and be funded only if subdivision (a)(1) of Section 25 is operational and funded. The estimated net State share of appropriated funds for subdivision (a)(2) of Section 25 shall be equal to the estimated net State share of appropriated funds for subdivision (a)(1) of Section 25.

(b) Any requirement imposed under this Act and any implementation of this Act by the Department shall cease in the event (1) continued receipt of federal funds for implementation of this Act requires an amendment to this Act, or (2) federal funds for implementation of the Act are not otherwise available.

(c) Payments under this Act shall be appropriated from the General Revenue Fund and other funds that are authorized to be used to reimburse or make medical payments for health care benefits under this Act or Title XXI of the Social Security Act.

(d) Benefits under this Act shall be available only as long as the intergovernmental agreements made pursuant to Section 12‑4.7 and Article XV of the Illinois Public Aid Code and entered into between the Department and the Cook County Board of Commissioners continue to exist.

(Source: P.A. 90‑736, eff. 8‑12‑98; 91‑24, eff. 7‑1‑99

.)

(215 ILCS 106/40)

Sec. 40.

Waivers.

(a) The Department shall request any necessary waivers of federal requirements in order to allow receipt of federal funding for:

(1) the coverage of families with eligible children

under this Act; and

(2) for the coverage of children who would otherwise

be eligible under this Act, but who have health insurance.

(b) The failure of the responsible federal agency to approve a waiver for children who would otherwise be eligible under this Act but who have health insurance shall not prevent the implementation of any Section of this Act provided that there are sufficient appropriated funds.

(c) Eligibility of a person under an approved waiver due to the relationship with a child pursuant to Article V of the Illinois Public Aid Code or this Act shall be limited to such a person whose countable income is determined by the Department to be at or below such income eligibility standard as the Department by rule shall establish. The income level established by the Department shall not be below 90% of the federal poverty level. Such persons who are determined to be eligible must reapply, or otherwise establish eligibility, at least annually. An eligible person shall be required, as determined by the Department by rule, to report promptly those changes in income and other circumstances that affect eligibility. The eligibility of a person may be redetermined based on the information reported or may be terminated based on the failure to report or failure to report accurately. A person may also be held liable to the Department for any payments made by the Department on such person's behalf that were inappropriate. An applicant shall be provided with notice of these obligations.

(Source: P.A. 92‑597, eff. 6‑28‑02; 93‑63, eff. 6‑30‑03.)

(215 ILCS 106/45)

Sec. 45.

Study.

(a) The Department shall conduct a study which includes, but is not limited to, the following:

(1) Establishes estimates, broken down by regions of

the State, of the number of children with health insurance coverage and without health insurance coverage; the number of children who are eligible for Medicaid, and of that number, the number who are enrolled in Medicaid; the number of children with access to dependent coverage through an employer, and of that number, the number who are enrolled in dependent coverage through an employer.

(2) Ascertains, for the population of children

potentially eligible for coverage under any component of the Program, the extent of access to dependent coverage, how many children are enrolled in dependent coverage, the comprehensiveness of dependent coverage benefit packages available, and the amount of cost sharing currently paid by the employees.

(b) The Department shall submit the preliminary results of the study to the Governor and the General Assembly by December 1, 1998 and shall submit the final results to the Governor and the General Assembly by May 1, 1999.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/5)

Sec. 5.

Legislative intent.

The General Assembly finds that, for the economic and social benefit of all citizens of the State, it is important to enable low‑income children of this State, to the extent funding permits, to access health benefits coverage, especially preventive health care. The General Assembly recognizes that assistance to help families purchase health benefits for low‑income children must be provided in a fair and equitable fashion and must treat all children at the same income level in a similar fashion. The State of Illinois should help low‑income families transition from a health care system where government partners with families to provide health benefits to low‑income children to a system where families with higher incomes eventually transition into private or employer based health plans. This Act is not intended to create an entitlement.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/50)

Sec. 50.

Program evaluation.

The Department shall conduct 2 evaluations of the effectiveness of the program implemented under this Act. The first evaluation shall be for the first 6 full months of implementation, and the evaluation shall be completed within 90 days after that period. The second evaluation shall be for the first 12 full months of implementation and shall be completed within 90 days after that period.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/55)

Sec. 55.

Contracts with non‑governmental bodies.

All contracts with non‑governmental bodies that are determined by the Department to be necessary for the implementation of this Act are deemed to be purchase of care as defined in the Illinois Procurement Code.

(Source: P.A. 90‑736, eff. 8‑12‑98; 91‑266, eff. 7‑23‑99

.)

(215 ILCS 106/60)

Sec. 60.

Emergency rulemaking.

Prior to June 30, 1999, the Department may adopt rules necessary to establish and implement this Act through the use of emergency rulemaking in accordance with Section 5‑45 of the Illinois Administrative Procedure Act. For purposes of that Act, the General Assembly finds that the adoption of rules to implement this Act is deemed an emergency and necessary for the public interest, safety, and welfare.

(Source: P.A. 90‑736, eff. 8‑12‑98; 91‑266, eff. 7‑23‑99

.)

(215 ILCS 106/96)

Sec. 96.

Inseverability.

The provisions of this Act are mutually dependent and inseverable. If any provision or its application to any person or circumstance is held invalid, then this entire Act is invalid.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)

(215 ILCS 106/97)

Sec. 97.

(Repealed).

(Source: P.A. 92‑597, eff. 6‑28‑02. Repealed by P.A. 93‑63, eff. 6‑30‑03.)

(215 ILCS 106/98)

Sec. 98.

(Amendatory provisions; text omitted).

(Source: P.A. 90‑736, eff. 8‑12‑98; text omitted

.)

(215 ILCS 106/99)

Sec. 99.

Effective Date.

This Act takes effect upon becoming law.

(Source: P.A. 90‑736, eff. 8‑12‑98

.)