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Illinois Compiled Statutes
Information maintained by the Legislative Reference Bureau Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process. Recent laws may not yet be included in the ILCS database, but they are found on this site as Public Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the Guide. Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If the source note at the end of a Section of the statutes includes a Public Act that has not yet taken effect, the version of the law that is currently in effect may have already been removed from the database and you should refer to that Public Act to see the changes made to the current law.
INSURANCE (215 ILCS 5/) Illinois Insurance Code. 215 ILCS 5/364
(215 ILCS 5/364) (from Ch. 73, par. 976)
Sec. 364. Discrimination prohibited. Discrimination between
individuals of the same class of risk in the issuance of its policies
or in the amount of premiums or rates charged
for any insurance covered by this article, or in the benefits
payable thereon, or in any of the terms or conditions of such policy, or
in any other manner whatsoever is prohibited. Nothing in this provision
shall prohibit an insurer from providing incentives for insureds to utilize
the services of a particular hospital or person. It is hereby expressly
provided that whenever the terms "physician" or "doctor" appear or are
used in any way in any policy of accident or health insurance issued in
this state, said terms shall include within their meaning persons
licensed to practice dentistry under the Illinois Dental Practice Act with
regard to benefits payable for services performed by a person so
licensed, which such services are within the coverage provided by the
particular policy or contract of insurance and are within the
professional services authorized to be performed by such person under
and in accordance with the said Act.
No company, in any policy of accident or health insurance issued in this
State, shall make or permit any distinction or discrimination against
individuals solely because of the individuals' disabilities in the amount of
payment of premiums or rates charged for policies of insurance, in the
amount of any dividends or other benefits payable thereon, or in any other
terms and conditions of the contract it makes, except where the distinction
or discrimination is based on sound actuarial principles or is related to
actual or reasonably anticipated experience.
No company shall refuse to insure, or refuse to continue to insure,
or limit the amount or extent or kind of coverage available to an
individual, or charge an individual a different rate for the same coverage
solely because of blindness or partial blindness. With respect to all
other conditions, including the underlying cause of the blindness or
partial blindness, persons who are blind or partially blind shall be
subject to the same standards of sound actuarial principles or actual or
reasonably anticipated experience as are sighted persons. Refusal to
insure includes denial by an insurer of disability insurance coverage on
the grounds that the policy defines "disability" as being presumed in the
event that the insured loses his or her eyesight.
(Source: P.A. 99-143, eff. 7-27-15.)
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215 ILCS 5/364.01 (215 ILCS 5/364.01) Sec. 364.01. Qualified clinical cancer trials. (a) No individual or group policy of accident and health insurance issued or renewed in this State may be cancelled or non-renewed for any individual based on that individual's participation in a qualified clinical cancer trial. (b) Qualified clinical cancer trials must meet the following criteria: (1) the effectiveness of the treatment has not been | | determined relative to established therapies;
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| (2) the trial is under clinical investigation as part
| | of an approved cancer research trial in Phase II, Phase III, or Phase IV of investigation;
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| (3) the trial is:
(A) approved by the Food and Drug Administration;
| | (B) approved and funded by the National
| | Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the United States Department of Defense, the United States Department of Veterans Affairs, or the United States Department of Energy in the form of an investigational new drug application, or a cooperative group or center of any entity described in this subdivision (B); and
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| (4) the patient's primary care physician, if any, is
| | involved in the coordination of care.
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(c) No group policy of accident and health insurance shall exclude coverage for any routine patient care administered to an insured who is a qualified individual participating in a qualified clinical cancer trial, if the policy covers that same routine patient care of insureds not enrolled in a qualified clinical cancer trial.
(d) The coverage that may not be excluded under subsection (c) of this Section is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to the same routine patient care received by an insured not enrolled in a qualified clinical cancer trial, including the application of any authorization requirement, utilization review, or medical management practices. The insured or enrollee shall incur no greater out-of-pocket liability than had the insured or enrollee not enrolled in a qualified clinical cancer trial.
(e) If the group policy of accident and health insurance uses a preferred provider program and a preferred provider provides routine patient care in connection with a qualified clinical cancer trial, then the insurer may require the insured to use the preferred provider if the preferred provider agrees to provide to the insured that routine patient care.
(f) A qualified clinical cancer trial may not pay or refuse to pay for routine patient care of an individual participating in the trial, based in whole or in part on the person's having or not having coverage for routine patient care under a group policy of accident and health insurance.
(g) Nothing in this Section shall be construed to limit an insurer's coverage with respect to clinical trials.
(h) Nothing in this Section shall require coverage for out-of-network services where the underlying health benefit plan does not provide coverage for out-of-network services.
(i) As used in this Section, "routine patient care" means all health care services provided in the qualified clinical cancer trial that are otherwise generally covered under the policy if those items or services were not provided in connection with a qualified clinical cancer trial consistent with the standard of care for the treatment of cancer, including the type and frequency of any diagnostic modality, that a provider typically provides to a cancer patient who is not enrolled in a qualified clinical cancer trial. "Routine patient care" does not include, and a group policy of accident and health insurance may exclude, coverage for:
(1) a health care service, item, or drug that is the
| | subject of the cancer clinical trial;
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| (2) a health care service, item, or drug provided
| | solely to satisfy data collection and analysis needs for the qualified clinical cancer trial that is not used in the direct clinical management of the patient;
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| (3) an investigational drug or device that has not
| | been approved for market by the United States Food and Drug Administration;
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| (4) transportation, lodging, food, or other expenses
| | for the patient or a family member or companion of the patient that are associated with the travel to or from a facility providing the qualified clinical cancer trial, unless the policy covers these expenses for a cancer patient who is not enrolled in a qualified clinical cancer trial;
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| (5) a health care service, item, or drug customarily
| | provided by the qualified clinical cancer trial sponsors free of charge for any patient;
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| (6) a health care service or item, which except for
| | the fact that it is being provided in a qualified clinical cancer trial, is otherwise specifically excluded from coverage under the insured's policy, including:
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| (A) costs of extra treatments, services,
| | procedures, tests, or drugs that would not be performed or administered except for the fact that the insured is participating in the cancer clinical trial; and
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| (B) costs of nonhealth care services that the
| | patient is required to receive as a result of participation in the approved cancer clinical trial;
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| (7) costs for services, items, or drugs that are
| | eligible for reimbursement from a source other than a patient's contract or policy providing for third-party payment or prepayment of health or medical expenses, including the sponsor of the approved cancer clinical trial;
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| (8) costs associated with approved cancer clinical
| | trials designed exclusively to test toxicity or disease pathophysiology, unless the policy covers these expenses for a cancer patient who is not enrolled in a qualified clinical cancer trial; or
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| (9) a health care service or item that is eligible
| | for reimbursement by a source other than the insured's policy, including the sponsor of the qualified clinical cancer trial.
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| The definitions of the terms "health care services", "Non-Preferred Provider", "Preferred Provider", and "Preferred Provider Program", stated in 50 Ill. Adm. Code Part 2051 Preferred Provider Programs apply to these terms in this Section.
(j) The external review procedures established under the Health Carrier External Review Act shall apply to the provisions under this Section.
(Source: P.A. 103-154, eff. 6-30-23.)
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215 ILCS 5/364.1
(215 ILCS 5/364.1) (from Ch. 73, par. 976.1)
Sec. 364.1.
Every policy of accident and health insurance
delivered or issued for delivery to any person in this State after the
effective date of this amendatory Act of 1979 which provides coverage
for services coming within the practice of
optometry as defined in the Illinois Optometric Practice Act of
1987, as now or hereafter amended shall, upon
issuance or delivery, be accompanied by a written notice to the
policyholder that such policyholder may elect for optometric services
received to be reimbursed to either a physician licensed to practice
medicine in all its branches or to an optometrist licensed in this State.
(Source: P.A. 85-1209.)
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215 ILCS 5/364.2 (215 ILCS 5/364.2) Sec. 364.2. Purchase of ophthalmic goods or services. An insurer may not require a provider, as a condition of participation by the provider, to purchase ophthalmic goods or services, including but not limited to eyeglass frames, in a quantity or dollar amount in excess of the quantity or dollar amount an enrollee purchases under the terms of the policy.
(Source: P.A. 93-1077, eff. 1-18-05.) |
215 ILCS 5/364.3 (215 ILCS 5/364.3) Sec. 364.3. Insurer uniform electronic prior authorization form; prescription benefits. (a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured. (b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, an insurer that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits. (c) On or before July 1, 2020, the Department shall develop a uniform electronic prior authorization form that shall be used by commercial insurers. Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits and every insurer shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits. (d) The Department shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents commercial insurers, from at least one public meeting. (e) The Department, in development of the uniform electronic prior authorization form, shall take into consideration the following: (1) existing prior authorization forms established by | | the federal Centers for Medicare and Medicaid Services and the Department; and
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| (2) national standards pertaining to electronic prior
| | (f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, an insurer fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours (if the patient has urgent medication needs) or within 72 hours (if the patient has regular medication needs), then the prior authorization request shall be deemed to have been granted.
(Source: P.A. 101-463, eff. 1-1-20 .)
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215 ILCS 5/367
(215 ILCS 5/367) (from Ch. 73, par. 979)
Sec. 367. Group accident and health insurance.
(1) Group accident and health insurance is hereby declared to be that
form of accident and health insurance covering not less than 2
employees,
members, or employees of members, written under a
master policy issued to any governmental corporation, unit, agency or
department thereof, or to any corporation, copartnership, individual
employer, or to any association upon application of an executive officer or
trustee of such association having a constitution or bylaws and formed in
good faith for purposes other than that of obtaining insurance, where
officers, members, employees, employees of members or classes or department
thereof, may be insured for their individual benefit. In addition a group
accident and health policy may be written to insure any group which may be
insured under a group life insurance policy. The term "employees" shall
include 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 such subsidiary or
affiliated corporations, firms or individuals, is controlled by a common
employer through stock ownership, contract or otherwise.
(2) Any insurance company authorized to write accident and health
insurance in this State shall have power to issue group accident and
health policies. No policy of group accident and health insurance may
be issued or delivered in this State unless a copy of the form thereof
shall have been filed with the department and approved by it in
accordance with Section 355, and it contains in substance those
provisions contained in Sections 357.1 through 357.30 as may be applicable
to group accident and health insurance and the following provisions:
(a) A provision that the policy, the application of | | the employer, or executive officer or trustee of any association, and the individual applications, if any, of the employees, members or employees of members insured shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer or trustee, or by the individual employees, members or employees of members shall (in the absence of fraud) be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the policy, unless it is contained in a written application.
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(b) A provision that the insurer will issue to the
| | employer, or to the executive officer or trustee of the association, for delivery to the employee, member or employee of a member, who is insured under such policy, an individual certificate setting forth a statement as to the insurance protection to which he is entitled and to whom payable.
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(c) A provision that to the group or class thereof
| | originally insured shall be added from time to time all new employees of the employer, members of the association or employees of members eligible to and applying for insurance in such group or class.
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(3) Anything in this code to the contrary notwithstanding, any group
accident and health policy may provide that all or any portion of any
indemnities provided by any such policy on account of hospital, nursing,
medical or surgical services, may, at the insurer's option, be paid
directly to the hospital or person rendering such services; but the
policy may not require that the service be rendered by a particular
hospital or person. Payment so made shall discharge the insurer's
obligation with respect to the amount of insurance so paid. Nothing in this
subsection (3) shall prohibit an insurer from providing incentives for
insureds to utilize the services of a particular hospital or person.
(4) Special group policies may be issued to school districts
providing medical or hospital service, or both, for pupils of the
district injured while participating in any athletic activity under the
jurisdiction of or sponsored or controlled by the district or the
authorities of any school thereof. The provisions of this Section
governing the issuance of group accident and health insurance shall,
insofar as applicable, control the issuance of such policies issued to
schools.
(5) No policy of group accident and health insurance may be issued
or delivered in this State unless it provides that upon the death of the
insured employee or group member the dependents' coverage, if any,
continues for a period of at least 90 days subject to any other policy
provisions relating to termination of dependents' coverage.
(6) No group hospital policy covering miscellaneous hospital
expenses issued or delivered in this State shall contain any exception
or exclusion from coverage which would preclude the payment of expenses
incurred for the processing and administration of blood and its
components.
(7) No policy of group accident and health insurance, delivered in
this State more than 120 days after the effective day of the Section,
which provides inpatient hospital coverage for sicknesses shall exclude
from such coverage the treatment of alcoholism. This subsection shall
not apply to a policy which covers only specified sicknesses.
(8) No policy of group accident and health insurance, which
provides benefits for hospital or medical expenses based upon the actual
expenses incurred, issued or delivered in this State shall contain any
specific exception to coverage which would preclude the payment of
actual expenses incurred in the examination and testing of a victim of
an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code
of 1961 or the Criminal Code of 2012, or an attempt to commit such offense,
to establish that sexual contact did occur or did not occur, and to
establish the presence or absence of sexually transmitted
disease or infection, and
examination and treatment of injuries and trauma sustained by the victim of
such offense, arising out of the offense. Every group policy of accident
and health insurance which specifically provides benefits for routine
physical examinations shall provide full coverage for expenses incurred in
the examination and testing of a victim of an offense defined in Sections
11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such
offense, as set forth in this
Section. This subsection shall not apply to a policy which covers hospital
and medical expenses for specified illnesses and injuries only.
(9) For purposes of enabling the recovery of State funds, any insurance
carrier subject to this Section shall upon reasonable demand by the Department
of Public Health disclose the names and identities of its insureds entitled
to benefits under this provision to the Department of Public Health whenever
the Department of Public Health has determined that it has paid, or is about
to pay, hospital or medical expenses for which an insurance carrier is liable
under this Section. All information received by the Department of Public
Health under this provision shall be held on a confidential basis and shall
not be subject to subpoena and shall not be made public by the Department
of Public Health or used for any purpose other than that authorized by this
Section.
(10) Whenever the Department of Public Health finds that it has paid all
or part of any hospital or medical expenses which an insurance carrier is
obligated to pay under this Section, the Department of Public Health shall
be entitled to receive reimbursement for its payments from such insurance
carrier provided that the Department of Public Health has notified the
insurance carrier of its claim before the carrier has paid the benefits to
its insureds or the insureds' assignees.
(11) (a) No group hospital, medical or surgical expense
| | policy shall contain any provision whereby benefits otherwise payable thereunder are subject to reduction solely on account of the existence of similar benefits provided under other group or group-type accident and sickness insurance policies where such reduction would operate to reduce total benefits payable under these policies below an amount equal to 100% of total allowable expenses provided under these policies.
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(b) When dependents of insureds are covered under 2
| | policies, both of which contain coordination of benefits provisions, benefits of the policy of the insured whose birthday falls earlier in the year are determined before those of the policy of the insured whose birthday falls later in the year. Birthday, as used herein, refers only to the month and day in a calendar year, not the year in which the person was born. The Department of Insurance shall promulgate rules defining the order of benefit determination pursuant to this paragraph (b).
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(12) Every group policy under this Section shall be subject to the
provisions of Sections 356g and 356n of this Code.
(13) No accident and health insurer providing coverage for hospital
or medical expenses on an expense incurred basis shall deny
reimbursement for an otherwise covered expense incurred for any organ
transplantation procedure solely on the basis that such procedure is deemed
experimental or investigational unless supported by the determination of
the Office of Health Care Technology Assessment within the Agency for
Health Care Policy and Research within the federal Department of Health and
Human Services that such procedure is either experimental or investigational or
that there is insufficient data or experience to determine whether an organ
transplantation procedure is clinically acceptable. If an accident and
health insurer has made written request, or had one made on its behalf by a
national organization, for determination by the Office of Health Care
Technology Assessment within the Agency for Health Care Policy and Research
within the federal Department of Health and Human Services as to whether a
specific organ transplantation procedure is clinically acceptable and said
organization fails to respond to such a request within a period of 90 days,
the failure to act may be deemed a determination that the procedure is
deemed to be experimental or investigational.
(14) Whenever a claim for benefits by an insured under a dental
prepayment program is denied or reduced, based on the review of x-ray
films, such review must be performed by a dentist.
(Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13 .)
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215 ILCS 5/367.2
(215 ILCS 5/367.2) (from Ch. 73, par. 979.2)
Sec. 367.2.
Spousal continuation privilege; group contracts.
A. No policy of group accident or health insurance, nor any
certificate thereunder shall be delivered or issued for delivery in this
State after December 1, 1985, unless the policy provides for a continuation
of the existing insurance benefits for an employee's spouse and dependent
children who are insured under the provisions of that group policy or
certificate thereunder, notwithstanding that the marriage is dissolved by
judgment or terminated by the death of the employee or, after the
effective date of this amendatory Act of the 93rd General Assembly, notwithstanding the
retirement of the employee provided that
the employee's
spouse is at
least 55 years of age, in each case without any other eligibility
requirements. The provisions of this amendatory Act of the 93rd General
Assembly apply to every
group policy of accident or health insurance and every certificate issued
thereunder delivered or issued for delivery after the effective date of
this amendatory Act of the 93rd General Assembly.
B. Within 30 days of the entry of judgment or the death or
retirement of the employee, the spouse of an employee insured under
the policy who seeks a continuation of coverage thereunder shall give the
employer or the insurer written notice of the dissolution of the
marriage
or the death or retirement of the employee. The employer, within 15
days of receipt of the notice
shall give written notice
of the dissolution of the employee's marriage or the death or retirement of
the employee and that former spouse's or retired employee's spouse's
residence
to the insurance
company issuing the policy.
The employer shall immediately send a copy of the notice to the former
spouse of the employee or the spouse of the retired employee at the retired
employee's spouse's residence or at the former spouse's residence. For
purposes of this Act, the term "former spouse" includes "widow" or "widower".
C. Within 30 days after the date of receipt of a notice from the
employer, retired employee's spouse or former spouse or of the initiation
of a new group policy, the insurance company, by certified mail, return
receipt requested, shall notify the retired employee's spouse or former
spouse at his or her residence that the policy may be continued for that
retired employee's spouse or former spouse and covered dependents, and the
notice shall include:
(i) a form for election to continue the insurance | |
(ii) the amount of periodic premiums to be charged
| | for continuation coverage and the method and place of payment; and
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(iii) instructions for returning the election form
| | within 30 days after the date it is received from the insurance company.
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Failure of the retired employee's spouse or former spouse to exercise the
election to continue insurance coverage by notifying the insurance company
in writing within such 30
day period
shall terminate the continuation of benefits and the right to continuation.
If the insurance company fails to notify the retired employee's spouse
or former spouse as provided for in subsection C hereof, all premiums shall
be waived from the date the notice was required until notice is sent, and
the benefits shall continue under the terms and provisions of the policy,
from the date the notice was required until the notice is sent,
notwithstanding any other provision hereof, except where the benefits in
existence at the time the company's notice was to be sent pursuant to
subsection C are terminated as to all employees.
D. With respect to a former spouse who has not attained the age of 55
at the time continuation coverage begins, the monthly premium
for
continuation shall be computed as follows:
(i) an amount, if any, that would be charged an
| | employee if the former spouse were a current employee of the employer, plus;
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(ii) an amount, if any, that the employer would
| | contribute toward the premium if the former spouse were a current employee.
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Failure to pay the initial monthly premium within 30 days after the date of
receipt of notice required in subsection C of this Section terminates
the continuation benefits and the right to continuation benefits.
The continuation coverage for former
spouses who have not attained the
age of 55 at the time coverage begins shall terminate upon the
earliest to happen of the following:
(i) The failure to pay premiums when due, including
| | any grace period allowed by the policy; or
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(ii) When coverage would terminate under the terms of
| | the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
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(iii) the date on which the former spouse first
| | becomes, after the date of election, an insured employee under any other group health plan; or
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(iv) the date on which the former spouse remarries; or
(v) the expiration of 2 years from the date
| | continuation coverage began.
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Upon the termination of continuation coverage, the former
spouse shall be
entitled to convert the coverage to an individual policy.
The continuation rights granted to former spouses who have not attained age
55
shall also
include eligible dependents insured prior to the dissolution of marriage or the
death of the
employee.
E. With respect to a retired employee's spouse or former spouse who
has attained the age of 55 at the time continuation coverage begins, the
monthly premium for the continuation shall be computed as follows:
(i) an amount, if any, that would be charged an
| | employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
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(ii) an amount, if any, that the employer would
| | contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
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Beginning 2 years after coverage begins under this paragraph, the
monthly premium shall be computed as follows:
(i) an amount, if any, that would be charged an
| | employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
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(ii) an amount, if any, that the employer would
| | contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
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(iii) an additional amount, not to exceed 20% of (i)
| | and (ii) above, for costs of administration.
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Failure to pay the initial monthly premium within 30 days after the date
of receipt of the notice required in subsection C of this Section
terminates the continuation benefits and the right to continuation benefits.
The continuation coverage for retired employees'
spouses and former spouses
who have attained the age of 55 at the time coverage begins shall
terminate upon the earliest to happen of the following:
(i) The failure to pay premiums when due, including
| | any grace period allowed by the policy; or
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(ii) When coverage would terminate, except due to the
| | retirement of an employee, under the terms of the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or retirement to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
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(iii) the date on which the retired employee's spouse
| | or former spouse first becomes, after the date of election, an insured employee under any other group health plan; or
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(iv) the date on which the former spouse remarries; or
(v) the date that person reaches the qualifying age
| | or otherwise establishes eligibility under the Medicare Program pursuant to Title XVIII of the federal Social Security Act.
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Upon the termination of continuation coverage, the former
spouse shall be
entitled to convert the coverage to an individual policy.
The continuation rights granted to former spouses who have attained age 55
shall also
include eligible dependents insured prior to the dissolution of marriage, the
death of the
employee, or the retirement of the employee.
F. The renewal, amendment, or extension of any group policy affected by
this Section shall be deemed to be delivery or issuance for delivery of a
new policy or contract of insurance in this State.
G. If (i) the policy is canceled, and (ii) another
insurance company
contracts to provide group health and accident insurance to the employer,
and (iii) continuation coverage is in effect for the retired employee's
spouse or former spouse at the time of cancellation and (iv) the employee
is or would have been included under the new group policy, then the new
insurer must also offer continuation coverage to the retired employee's
spouse and to an employee's former spouse under the same terms and
conditions as contained in this Section.
H. This Section shall not limit the right of the retired employee's spouse
or any former spouse to exercise
the privilege to convert to an individual policy as contained in this Code.
I. No person who obtains coverage under this Section shall be required
to pay a rate greater than that applicable to any employee or member
covered under that group except as provided in clause (iii) of the
second paragraph of subsection E.
(Source: P.A. 93-477, eff. 1-1-04.)
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215 ILCS 5/367.2-5
(215 ILCS 5/367.2-5)
Sec. 367.2-5.
Dependent child continuation privilege; group contracts.
(a) No policy of group accident or health insurance, nor any certificate
thereunder
shall be amended, renewed, delivered, or issued for delivery in this State
after
July 1,
2004, unless the policy provides for a continuation of the existing insurance
benefits for
an employee's dependent child who is insured under the provisions of that group
policy
or certificate in the event of the death of the employee and the child is not
eligible for
coverage as a dependent under the provisions of Section 367.2 or the dependent
child has
attained the limiting age under the policy.
(b) In the event of the death of the employee, if continuation coverage is
desired,
the dependent child or a responsible adult acting on behalf of the dependent
child shall
give the employer or the insurer written notice of the death of employee within
30 days of
the date the coverage terminates. The employer, within 15 days of receipt of
the notice,
shall give written notice to the insurance company issuing the policy of the
death of the
employee and the dependent child's residence. The employer shall immediately
send a
copy of the notice to the dependent child or responsible adult at the dependent
child's
residence.
(c) In the event of the dependent child attaining the limiting age under the
policy,
if continuation coverage is desired, the dependent child shall give the
employer or the
insurer written notice of the attainment of the limiting age within 30 days of
the date the
coverage terminates. The employer, within 15 days of receipt of the notice,
shall give
written notice to the insurance company issuing the policy of the attainment
of the
limiting age by the dependent child and of the dependent child's residence.
(d) Within 30 days after the date of receipt of a notice from the employer,
dependent child, or responsible adult acting on behalf of the dependent child,
or of the
initiation of a new group policy, the insurance company, by certified mail,
return receipt
requested, shall notify the dependent child or responsible adult at the
dependent child's
residence that the policy may be continued for the dependent child. The
notice shall
include:
(1) a form for election to continue the insurance | |
(2) the amount of periodic premiums to be charged for
| | continuation coverage and the method and place of payment; and
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(3) instructions for returning the election form
| | within 30 days after the date it is received from the insurance company.
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Failure of the dependent child or the responsible adult acting on behalf of
the dependent
child to exercise the election to continue insurance coverage by notifying the
insurance
company in writing within such 30 day period shall terminate the continuation
of benefits
and the right to continuation.
If the insurance company fails to notify the dependent child or responsible
adult acting on
behalf of the dependent child as provided for in this subsection (d), all
premiums shall
be waived from the date the notice was required until notice was sent, and the
benefits shall
continue under the terms and provisions of the policy, from the date the notice
was
required until the notice was sent, notwithstanding any other provision hereof,
except where
the benefits in existence at the time the company's notice was to be sent
pursuant to
this subsection (d) are terminated as to all employees.
(e) The monthly premium for continuation shall be computed as follows:
(1) an amount, if any, that would be charged an
| | employee if the dependent child were a current employee of the employer, plus;
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|
(2) an amount, if any, that the employer would
| | contribute toward the premium if the dependent child were a current employee.
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|
Failure to pay the initial monthly premium within 30 days after the date of
receipt of
notice required in subsection (d) of this Section terminates the continuation
benefits and
the right to continuation benefits.
Continuation coverage provided under this Act shall terminate upon the
earliest to happen
of the following:
(1) the failure to pay premiums when due, including
| | any grace period allowed by the policy;
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|
(2) when coverage would terminate under the terms of
| | the existing policy if the dependent child was still an eligible dependent of the employee;
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|
(3) the date on which the dependent child first
| | becomes, after the date of election, an insured employee under any other group health plan; or
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(4) the expiration of 2 years from the date
| | continuation coverage began.
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Upon the termination of continuation coverage, the dependent child shall be
entitled to
convert the coverage to an individual policy.
(f) The renewal, amendment, or extension of any group policy affected by
this
Section shall be deemed to be delivery or issuance for delivery of a new policy
or
contract of insurance in this State.
(g) If (1) the policy is cancelled, and (2) another insurance company
contracts to
provide group health and accident insurance to the employer, and (3)
continuation
coverage is in effect for the dependent child at the time of cancellation, and
(4) the
employee is or would have been included under the new group policy, then the
new
insurer must also offer continuation coverage to the dependent child under the
same
terms and conditions as contained in this Section.
(h) This Section shall not limit the right of any dependent child to
exercise the
privilege to convert to an individual policy as contained in this Code.
(i) No person who obtains coverage under this Section shall be required to
pay a
rate greater than that applicable to any employee or member covered under that
group.
(Source: P.A. 93-477, eff. 1-1-04.)
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215 ILCS 5/367.3
(215 ILCS 5/367.3) (from Ch. 73, par. 979.3)
Sec. 367.3.
Group accident and health insurance; discretionary groups.
(a) No group health insurance offered to a resident of this State under
a policy issued to a group, other than one specifically described in
Section 367(1), shall be delivered or issued for delivery in this State
unless the Director determines that:
(1) the issuance of the policy is not contrary to the | |
(2) the issuance of the policy will result in
| | economies of acquisition and administration; and
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|
(3) the benefits under the policy are reasonable in
| | relation to the premium charged.
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(b) No such group health insurance may be offered in this State under a
policy issued in another state unless this State or the state in which the
group policy is issued has made a determination that the requirements of
subsection (a) have been met.
Where insurance is to be offered in this State under a policy described
in this subsection, the insurer shall file for informational review purposes:
(1) a copy of the group master contract;
(2) a copy of the statute authorizing the issuance of
| | the group policy in the state of situs, which statute has the same or similar requirements as this State, or in the absence of such statute, a certification by an officer of the company that the policy meets the Illinois minimum standards required for individual accident and health policies under authority of Section 401 of this Code, as now or hereafter amended, as promulgated by rule at 50 Illinois Administrative Code, Ch. I, Sec. 2007, et seq., as now or hereafter amended, or by a successor rule;
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(3) evidence of approval by the state of situs of the
| |
(4) copies of all supportive material furnished to
| | the state of situs to satisfy the criteria for approval.
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(c) The Director may, at any time after receipt of the information
required under subsection (b) and after finding that the standards of
subsection (a) have not been met, order the insurer to cease the issuance
or marketing of that coverage in this State.
(d) Group accident and health insurance subject to the provisions of
this Section is also subject to the provisions of Section 367i of this Code.
(Source: P.A. 90-655, eff. 7-30-98.)
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215 ILCS 5/367a
(215 ILCS 5/367a) (from Ch. 73, par. 979a)
Sec. 367a.
Blanket
accident and health insurance.
(1) Blanket accident and health insurance is that form of accident and
health insurance covering special groups of persons as enumerated in one of
the following paragraphs (a) to (g), inclusive:
(a) Under a policy or contract issued to any carrier for hire, which
shall be deemed the policyholder, covering a group defined as all persons
who may become passengers on such carrier.
(b) Under a policy or contract issued to an employer, who shall be
deemed the policyholder, covering all employees or any group of employees
defined by reference to exceptional hazards incident to such employment.
(c) Under a policy or contract issued to a college, school, or other
institution of learning or to the head or principal thereof, who or which
shall be deemed the policyholder, covering students or teachers.
(d) Under a policy or contract issued in the name of any volunteer fire
department, first aid, or other such volunteer group, which shall be deemed
the policyholder, covering all of the members of such department or group.
(e) Under a policy or contract issued to a creditor, who shall be deemed
the policyholder, to insure debtors of the creditors; Provided, however,
that in the case of a loan which is subject to the Small Loans Act, no
insurance premium or other cost shall be directly or indirectly charged or
assessed against, or collected or received from the borrower.
(f) Under a policy or contract issued to a sports team or to a camp,
which team or camp sponsor shall be deemed the policyholder, covering
members or campers.
(g) Under a policy or contract issued to any other substantially similar
group which, in the discretion of the Director, may be subject to the
issuance of a blanket accident and health policy or contract.
(2) Any insurance company authorized to write accident and health
insurance in this state shall have the power to issue blanket accident and
health insurance. No such blanket policy may be issued or delivered in this
State unless a copy of the form thereof shall have been filed in accordance
with Section 355, and it contains in substance such of those provisions
contained in Sections 357.1 through 357.30 as may be applicable to blanket accident and
health insurance and the following provisions:
(a) A provision that the policy and the application shall constitute the
entire contract between the parties, and that all statements made by the
policyholder shall, in absence of fraud, be deemed representations and not
warranties, and that no such statements shall be used in defense to a claim
under the policy, unless it is contained in a written application.
(b) A provision that to the group or class thereof originally insured
shall be added from time to time all new persons or individuals eligible
for coverage.
(3) An individual application shall not be required from a person
covered under a blanket accident or health policy or contract, nor shall it
be necessary for the insurer to furnish each person a certificate.
(4) All benefits under any blanket accident and health policy shall be
payable to the person insured, or to his designated beneficiary or
beneficiaries, or to his or her estate, except that if the person insured be a
minor or person under legal disability, such
benefits may be made payable to his or her
parent, guardian, or other person actually supporting him or her. Provided
further, however, that the policy may provide that all or any portion of
any indemnities provided by any such policy on account of hospital,
nursing, medical or surgical services may, at the insurer's option, be paid
directly to the hospital or person rendering such services; but the policy
may not require that the service be rendered by a particular hospital or
person. Payment so made shall discharge the insurer's obligation with
respect to the amount of insurance so paid.
(5) Nothing contained in this section shall be deemed to affect the
legal liability of policyholders for the death of or injury to, any such
member of such group.
(Source: P.A. 83-1362.)
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215 ILCS 5/367b
(215 ILCS 5/367b) (from Ch. 73, par. 979b)
Sec. 367b. (a) This Section applies to the hospital and medical expense
provisions of a group accident or health insurance policy.
(b) If a policy
provides that coverage of a dependent of an employee or other member of the
covered group terminates upon attainment of the limiting age for dependent
persons specified in the policy, the
attainment of such limiting age does not operate to terminate the hospital
and medical coverage of a person who, because of a disabling
condition that occurred before attainment of the limiting age, is incapable of
self-sustaining employment and is dependent on his or her parents or other
care providers for lifetime care and supervision.
(c) For purposes of subsection (b), "dependent on other care providers" is
defined as requiring a Community Integrated Living Arrangement, group home,
supervised apartment, or other residential services licensed or certified by
the Department of Human Services (as successor to the Department of Mental
Health and Developmental Disabilities), the Department
of Public Health, or the Department of Healthcare and Family Services (formerly Department of Public Aid).
(d) The insurer may inquire of the person insured 2 months prior to
attainment by a dependent of the limiting age set forth in the policy, or
at any reasonable time thereafter, whether such dependent is in fact a
person who has a disability and is dependent and, in the absence of proof submitted within
31 days of such inquiry that such dependent is a person who has a disability and is dependent may terminate coverage of such person at or after attainment of the
limiting age. In the absence of such inquiry, coverage of any person who has a disability and is dependent shall continue through the term of such policy or any
extension or renewal.
(e) This amendatory Act of 1969 is applicable to policies issued or
renewed
more than 60 days after the effective date of this amendatory Act of 1969.
(Source: P.A. 99-143, eff. 7-27-15.)
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215 ILCS 5/367c
(215 ILCS 5/367c) (from Ch. 73, par. 979c)
Sec. 367c.
No claim shall be denied, under any group accident and health policy
delivered or renewed in this State after the effective date of this
Amendatory Act, for treatment or services for mental illness rendered in a
hospital solely because such hospital lacks surgical facilities.
(Source: P.A. 78-708.)
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215 ILCS 5/367d
(215 ILCS 5/367d) (from Ch. 73, par. 979d)
Sec. 367d.
No claim shall be denied, under any group accident and health
policy delivered or renewed in this State after the effective date of this
amendatory Act, for treatment or services for rehabilitation following either a
physical or mental illness, rendered in a hospital solely because such hospital
lacks surgical facilities.
(Source: P.A. 79-303.)
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215 ILCS 5/367d.1
(215 ILCS 5/367d.1) (from Ch. 73, par. 979d.1)
Sec. 367d.1.
After the effective date of this amendatory Act of 1992,
no group policy of accident and health insurance that provides coverage for
the treatment of alcoholism or other drug abuse or dependency on both an
inpatient and outpatient basis may be issued, delivered or amended in this
State if it excludes from coverage services provided by persons or entities
licensed by the Department of Human Services to provide
substance use disorder treatment, provided however that (a)
the charges are otherwise eligible for reimbursement under the policy and
(b) the services provided are medically necessary and within the scope of
the licensure of the provider. This Section shall not apply to
arrangements, agreements or policies authorized under the Health Care
Reimbursement Reform Act of 1985; the Limited
Health Service Organization Act; or the
Health Maintenance Organization Act.
(Source: P.A. 100-759, eff. 1-1-19 .)
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215 ILCS 5/367e
(215 ILCS 5/367e) (from Ch. 73, par. 979e)
Sec. 367e. Continuation of Group Hospital, Surgical and Major Medical
Coverage After Termination of Employment or Membership.
A group policy delivered, issued for delivery, renewed or amended in this
state which insures employees or members
for hospital, surgical or major medical insurance on an expense incurred
or service basis, other than for specific diseases or for accidental injuries
only, shall provide that employees or members whose insurance under the
group policy would otherwise terminate because of termination of employment
or membership or because of a reduction in hours below the minimum required
by the group plan shall be entitled to continue their hospital, surgical and
major medical insurance under that group policy, for themselves and their
eligible dependents, subject to all of the group policy's terms and conditions
applicable to those forms of insurance and to the following conditions:
1. Continuation shall only be available to an | | employee or member who has been continuously insured under the group policy (and for similar benefits under any group policy which it replaced) during the entire 3 months period ending with such termination or reduction in hours below the minimum required by the group plan. With respect to an employee or member who is involuntarily terminated between September 1, 2008 and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, continuation shall be available if the employee or member was insured under the group policy on the day prior to the termination.
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2. Continuation shall not be available for any person
| | who is covered by Medicare, except for those individuals who have been covered under a group Medicare supplement policy. Neither shall continuation be available for any person who is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan or who exercises his conversion privilege under the group policy.
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3. Continuation need not include dental, vision care,
| | prescription drug benefits, disability income, specified disease, or similar supplementary benefits which are provided under the group policy in addition to its hospital, surgical or major medical benefits.
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4. Within 10 days after the employee's or member's
| | termination or reduction in hours below the minimum required by the group plan written notice of continuation shall be presented to the employee or member by the employer. If the employee or member is unavailable, written notice shall be mailed by the employer to the last known address of the employee or member within 10 days after the employee's or member's termination or reduction in hours below the minimum required by the group plan. The employer shall also send a copy of the notice to the insurer. An employee or member who wishes continuation of coverage must request such continuation in writing within the 30 day period following the later of: (i) the date of such termination or reduction in hours below the minimum required by the group plan, or (ii) the date the employee is presented or mailed written notice of the right of continuation by either the employer or the group policyholder. In no event, however, may the employee or member elect continuation more than 60 days after the date of such termination or reduction in hours below the minimum required by the group plan. Written notice of continuation presented to the employee or member by the policyholder, or mailed by the policyholder to the last known address of the employee, shall constitute the giving of notice for the purpose of this provision.
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The insurer shall not deny coverage to the employee
| | or member due to the employer's failure to provide notice pursuant to this Section to the employee or member. Until the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, in the event the employee or member contacts the insurer regarding continuation rights and advises that notice has not been provided by the employer or group policyholder, the insurer shall provide a written explanation to the employee or member of the employee's or member's continuation rights pursuant to this Section.
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| 4a. Unless contrary to the provisions of, or any
| | rules promulgated pursuant to, the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage and who are terminated or whose reduction in hours below the minimum required by the group occurs between the effective date of this amendatory Act of the 96th General Assembly and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, the notice requirements of this Section are not satisfied unless notice is presented or mailed to the employee or member by the insurer informing the employee or member of the availability of premium reduction with respect to such coverage under the American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 4a.
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| 4b. Unless contrary to the provisions of, or any
| | rules promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage who were terminated or whose reduction in hours below the minimum required by the group occurred between September 1, 2008 and the effective date of this amendatory Act of the 96th General Assembly and who have an election of continuation of coverage pursuant to this Section in effect, notice shall be presented or mailed to the employee or member by the insurer informing the employee or member of the availability of premium reduction with respect to such coverage under the federal American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009 and shall be presented or mailed to the employee or member within 14 days of the effective date of this amendatory Act of the 96th General Assembly. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 4b.
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5. An employee or member electing continuation must
| | pay to the group policyholder or his employer, on a monthly basis in advance, the total amount of premium required by the insurer, including that portion of the premium contributed by the policyholder or employer, if any, but not more than the group rate for the insurance being continued with appropriate reduction in premium for any supplementary benefits which have been discontinued under paragraph (3) of this Section. The premium rate required by the insurer shall be the applicable premium required on the due date of each payment.
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6. Continuation of insurance under the group policy
| | for any person shall terminate when he becomes eligible for Medicare or is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan as provided in condition 2 above or, if earlier, at the first to occur of the following:
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(a) The date 12 months after the date the
| | employee's or member's insurance under the policy would otherwise have terminated because of termination of employment or membership or reduction in hours below the minimum required by the group plan or, with respect to an employee or member who is an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, the date that the individual ceases to be eligible for premium assistance under Section 3001(a)(2)(A)(ii)(I) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended.
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(b) If the employee or member fails to make
| | timely payment of a required contribution, the end of the period for which contributions were made.
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(c) The date on which the group policy is
| | terminated or, in the case of an employee, the date his employer terminates participation under the group policy. However, if this (c) applies and the coverage ceasing by reason of such termination is replaced by similar coverage under another group policy, the following shall apply:
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(i) The employee or member shall have the
| | right to become covered under that other group policy, for the balance of the period that he would have remained covered under the prior group policy in accordance with condition 6 had a termination described in this (c) not occurred.
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(ii) The prior group policy shall continue to
| | provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.
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7. A notification of the continuation privilege shall
| | be included in each certificate of coverage.
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8. Continuation shall not be available for any
| | employee who was discharged because of the commission of a felony in connection with his work, or because of theft in connection with his work, for which the employer was in no way responsible; provided the employee admitted his commission of the felony or theft or such act has resulted in a conviction or order of supervision by a court of competent jurisdiction.
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9. An employee or member without an election of
| | continuation of coverage pursuant to this Section in effect on the effective date of this amendatory Act of the 96th General Assembly may elect continuation pursuant to this paragraph 9 if the employee or member: (i) would be an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, if such an election were in effect and (ii) at the time of termination was eligible for continuation pursuant to paragraphs 1 and 2 of this Section.
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| Unless contrary to the provisions of, or any rules
| | promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, written notice of continuation pursuant to this paragraph 9 shall be presented to the employee or member by the insurer or mailed by the insurer to the last known address of the employee or member within 30 days after the effective date of this amendatory Act of the 96th General Assembly. Such written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 9.
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| An employee or member electing continuation of
| | coverage under this paragraph 9 must request such continuation in writing within 60 days after the date the employee or member receives written notice of the right of continuation by the insurer.
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| Continuation of coverage elected pursuant to this
| | paragraph 9 shall commence with the first period of coverage beginning on or after February 17, 2009, the effective date of the federal American Recovery and Reinvestment Act of 2009, and shall not extend beyond the period of continuation that would have been required if the coverage had been elected pursuant to paragraph 4 of this Section.
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| With respect to an employee or member who elects
| | continuation of coverage under this paragraph 9, the period beginning on the date of the employee's or member's involuntary termination of employment and ending on the date of the first period of coverage on or after February 17, 2009 shall be disregarded for purposes of determining the 63-day period referred to in Section 20 of the Illinois Health Insurance Portability and Accountability Act.
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| The requirements of this amendatory Act of 1983 shall apply to any group
policy as defined in this Section, delivered or issued for delivery on or after
180 days following the effective date of this amendatory Act of 1983.
The requirements of this amendatory Act of 1985 shall apply to any
group policy as defined in this Section, delivered, issued for delivery,
renewed or amended on or after 180 days following the effective date of
this amendatory Act of 1985.
(Source: P.A. 96-13, eff. 6-18-09; 96-894, eff. 5-17-10.)
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215 ILCS 5/367e.1
(215 ILCS 5/367e.1)
Sec. 367e.1.
Group Accident and Health Insurance Conversion Privilege.
(A) A group policy which provides hospital, medical, or major
medical expense insurance, or any combination of these coverages, on an
expense-incurred basis, but not including a policy which provides
benefits for specific diseases or for accidental injuries only, shall
provide that an employee or member (i) whose insurance under the group
policy has been terminated for any reason other than discontinuance of
the group policy in its entirety where there is a succeeding carrier, or
failure of the employee or member to pay any required contribution; and
(ii) who has been continuously insured under the group policy (and under
any group policy providing similar benefits which it replaces) for at
least three months immediately prior to termination, shall be entitled
to have issued to him by the insurer a policy of health insurance
(hereafter referred to as the converted policy), subject to the
following conditions:
(1) Written application for the converted policy | | shall be made and the first premium paid to the insurer not later than the latter of (i) thirty-one days after such termination or (ii) 15 days after the employee or member has been given written notice of the existence of the conversion privilege, but in no event later than 60 days after such termination.
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Written notice presented to the employee or member by
| | the policyholder, or mailed by the policyholder to the last known address of the employee or member, shall constitute the giving of notice for the purpose of this provision.
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(2) The converted policy shall be issued without
| | evidence of insurability.
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(3) The initial premium for the converted policy
| | shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of each person to be covered under the converted policy and to the type and amount of the insurance provided. Conditions pertaining to health shall not be an acceptable basis of classification for the purposes of this subsection. The frequency of premium payment shall be the frequency customarily required by the insurer for the policy form and plan selected, provided that the insurer shall not require premium payments less frequently than quarterly without the consent of the insured.
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(4) The effective date of the converted policy shall
| | be the day following the termination of insurance under the group policy.
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(5) The converted policy shall cover the employee or
| | member and his dependents who were covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.
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(6) The insurer shall not be required to issue a
| | converted policy covering any person if such person is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded). Furthermore, the insurer shall not be required to issue a converted policy covering any person if (i) such person is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) such person is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any statute, and the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person together with the converted policy would result in overinsurance according to the insurer's standards.
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(7) In the event that coverage would be continued
| | under the group policy on an employee following his retirement prior to the time he is or could be covered by Medicare, he may elect, in lieu of such continuation of such group insurance, to have the same conversion rights as would apply had his insurance terminated at retirement by reason of termination of employment or membership.
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(8) Subject to the conditions set forth above, the
| | conversion privilege shall also be available (i) to the surviving spouse, if any, at the death of the employee or member, with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death, otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or, if the group policy provides for continuation of dependents' coverage following the employee's or member's death, at the end of such continuation; (ii) to the spouse of the employee or member upon termination of coverage of the spouse, while the employee or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time; or (iii) to a child solely with respect to himself upon termination of his coverage by reason of ceasing to be a qualified family member under the group policy, if a conversion privilege is not otherwise provided above with respect to such termination.
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(9) A notification of the conversion privilege shall
| | be included in each certificate.
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(10) The insurer may elect to provide group insurance
| | coverage in lieu of the issuance of a converted policy.
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(B) A converted policy issued upon the exercise of the conversion
privilege required by subsection (A) of this Section shall conform to
the following minimum standards:
(1) If the group policy provided hospital, surgical,
| | or medical expense insurance, or a combination thereof, the converted policy shall provide benefits on an expense-incurred basis equal to the lesser of (i) the hospital room and board, miscellaneous hospital, surgical and medical benefits provided under the group policy; and (ii) the corresponding benefits described below:
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(a) Hospital room and board benefits in an amount
| | per day elected by the group policyholder, but in no event less than 60% of the then average semi-private hospital room and board charge in the State, such benefits to be payable for a maximum of not less than 70 days for any period of hospital confinement, as defined in the converted policy.
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(b) Miscellaneous hospital benefits for any one
| | period of hospital confinement in an amount up to twenty times the hospital room and board daily benefit provided under the converted policy.
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(c) Surgical benefits according to a surgical
| | schedule providing a benefit amount elected by the group policy holder, but in no event less than 60% of the then average surgical charge in the State and with a maximum amount appropriate thereto. The maximum surgical benefit shall be applicable to all surgical operations of an individual resulting from or contributed to by the same and all related causes occurring in one period of disability. Two or more surgical procedures performed in the course of a single operation through the same incision, or in the same natural body orifice, may be treated as one surgical procedure with the payment determined by the scheduled benefit for the most expensive procedure performed. The surgical schedule shall be consistent with the schedule of operations customarily offered by the insurer under group or individual health insurance policies.
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(d) Non-surgical medical attendance benefits for
| | in-hospital services in an amount elected by the group policyholder, but in no event less than 60% of the then average in-hospital physician's visit charge in the State, such benefits may be limited to one visit per day of hospitalization and a maximum number of visits numbering not less than seventy for any period of hospital confinement as defined in the converted policy.
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(2) If the group policy provided major medical
| | insurance, the insurer may offer the insurance described in (1) above only, major medical insurance only, or a combination of the insurance described in (1) above and major medical insurance. If the insurer elects to provide major medical insurance, the converted policy shall provide:
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(a) A maximum benefit at least equal to (i) or
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(i) A maximum payment of twenty-five thousand
| | dollars for all covered medical expenses incurred during the covered person's lifetime with an annual restoration of the lesser of, while coverage is in force, one thousand dollars and the amount counted against the maximum benefit which was not previously restored; or
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(ii) A maximum payment of twenty-five
| | thousand dollars for each unrelated injury or illness.
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(b) Payment of benefits for covered medical
| | expenses, in excess of the deductible, at a rate not less than 80% except as otherwise permitted below.
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(c) A deductible for each benefit period which,
| | at the option of the insurer, shall be (i) the greater of $500 and the benefits deductible; (ii) the sum of the benefits deductible and $100; or (iii) the corresponding deductible in the group policy. The term "benefit period," as used herein, means, when the maximum payment is determined by (a) (i) above, either a calendar year or a period of twelve consecutive months; and, when the maximum payment is determined by (a) (ii) above, a period of twenty-four consecutive months. The term "benefits deductible," as used herein, means the value of any benefits provided on an expense-incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical, or medical insurance policy or hospital or medical service subscriber contract of medical practice or other prepayment plan, or any other plans or program whether on an insured or uninsured basis, or of any similar benefits which are provided or made available pursuant to or in accordance with the requirements of any statute and, if, pursuant to the provisions of this subsection, the converted policy provides both the coverage described in (1) above and major medical insurance, the value of the coverage described in (1) above. The insurer may require that the deductible be satisfied during a period of not less than three months. If the maximum payment is determined by (a) (i) above, and if no benefits become payable during the preceding benefit period due to the cash deductible not being satisfied; credit shall be given, in the succeeding benefit period, to any expense applied toward the cash deductible of the preceding benefit period and incurred during the last three months of such preceding benefit period, subject to any requirement that the deductible be satisfied during a specified period of time.
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(d) The term "covered medical expenses," as used
| | above, may be limited (i) in the case of hospital room and board benefits, maximum surgical schedule, and non-surgical medical attendance benefits to amounts not less than the amounts provided in (1) (a), (1) (c) and (1) (d) above; and (ii) in the case of mental and nervous condition treatments while the patient is not a hospital in-patient, to co-insurance of 50%, a maximum benefit of $500 per calendar year or twelve consecutive month periods subject to the inclusion by the insurer of reasonable limits on the number of visits and the maximum permissible expense per visit.
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(3) The converted policy may contain any exclusion,
| | reduction, or limitation contained in the group policy and any exclusion, reduction, or limitation customarily used in individual accident and health policies delivered or issued for delivery in this state. It is not required that the converted policy contain all of the covered medical expenses or the same level of benefits as provided in the group policy.
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(4) The insurer may, at its option, also offer
| | alternative plans for group accident and health conversion.
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(5) The converted policy may only exclude a
| | pre-existing condition excluded by the group policy. Any hospital, surgical, medical or major medical benefits payable under the converted policy may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder and, during the first policy year of such converted policy, the benefits payable under the converted policy may be so reduced so that they are not in excess of the benefits that would have been payable had the individual's insurance under the group policy remained in force and effect.
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(6) The converted policy may provide for the
| | termination of coverage thereunder of any person when he is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded).
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(7) The converted policy may provide that the insurer
| | may request information from the converted policyholder, in advance of any premium due date of the converted policy, to determine whether any person covered thereunder (i) is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) has similar benefits provided for or available to such person, pursuant to or in accordance with the requirements of any statute. The converted policy may also provide that the insurer need not renew the converted policy or the coverage of any person insured thereunder if either the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person, together with the converted policy, would result in overinsurance according to the insurer's standards, or if the converted policyholder refuses to provide the requested information.
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(8) The converted policy shall not contain any
| | provision allowing the insurer to non-renew due to a change in the health of an insured.
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(9) The converted policy may contain any provisions
| | permitted herein and may also include any other provisions not expressly prohibited by law. Any provisions required or permitted herein may be made a part of the converted policy by means of an endorsement or rider.
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(10) In the conversion of group health insurance in
| | accordance with the provisions of subsection (A) above, the insurer may, at its option, accomplish the conversion by issuing one or more converted policies.
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(11) With respect to any person who was covered by
| | the group policy, the period specified in the Time Limit on Certain Defenses provisions of the converted policy shall commence with the date the person's insurance became effective under the group policy.
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(12) If the insurer elects to provide group insurance
| | coverage in lieu of a converted policy, the benefit levels required for a converted policy must be applicable to such group insurance coverage.
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(C) The requirements of this Section shall apply to any group policy
of accident and health insurance delivered, issued for delivery, renewed
or amended on or after 180 days following the effective date of this
Section.
(Source: P.A. 93-477, eff. 1-1-04.)
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215 ILCS 5/367f
(215 ILCS 5/367f) (from Ch. 73, par. 979f)
Sec. 367f. Firefighters' continuance privilege. As used in this Section:
1. The terms "municipality", "deferred pensioner" and "creditable service"
shall have the meaning ascribed to such terms by Sections 4-103, 4-105a and
4-108, respectively, of the Illinois Pension Code, as now or hereafter amended.
2. "Firefighter" means a person who is a "firefighter" as defined in Section 4-106 of the Illinois Pension Code, a paramedic who is employed by a unit of local government, or an emergency medical technician, emergency medical technician-basic, emergency medical technician-intermediate, or advanced emergency medical technician who is employed by a unit of local government.
3. The "retirement or disability period" of a firefighter means the period:
a. which begins on the day the firefighter is | | removed from a municipality's fire department payroll because of the occurrence of any of the following events, to wit: (i) the firefighter retires as a deferred pensioner under Section 4-105a of the Illinois Pension Code, (ii) the firefighter retires from active service as a firefighter with an attained age and accumulated creditable service which together qualify the firefighter for immediate receipt of retirement pension benefits under Section 4-109 of the Illinois Pension Code, or (iii) the firefighter's disability is established under Section 4-112 of the Illinois Pension Code; and
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b. which ends on the first to occur of any of the
| | following events, to wit: (i) the firefighter's reinstatement or reentry into active service on the municipality's fire department as provided for under Article 4 of the Illinois Pension Code, (ii) the firefighter's exercise of any refund option available under Section 4-116 of the Illinois Pension Code, (iii) the firefighter's loss pursuant to Section 4-138 of the Illinois Pension Code of any benefits provided for in Article 4 of that Code, or (iv) the firefighter's death or -- if at the time of the firefighter's death the firefighter is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 4 of the Illinois Pension Code -- then the death or remarriage of that spouse.
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No policy of group accident and health insurance under which firefighters
employed by a municipality are insured for their individual benefit shall
be issued or delivered in this State to any municipality unless such group
policy provides for the election of continued group insurance coverage for
the retirement or disability period of each firefighter who is insured under the
provisions of the group policy on the day immediately preceding the day
on which the retirement or disability period of such firefighter begins. So
long as any required premiums for continued group insurance coverage are
paid in accordance with the provisions of the group policy, an election
made pursuant to this Section shall provide continued group insurance
coverage for a firefighter throughout the retirement or disability period of
the firefighter and, unless the firefighter otherwise elects and subject to any
other provisions of the group policy which relate either to the provision
or to the termination of dependents' coverage and which are not
inconsistent with this Section, for any dependents of the firefighter who are
insured under the group policy on the day immediately preceding the day on
which the retirement or disability period of the firefighter begins; provided,
however, that when such continued group insurance coverage is in effect
with respect to a firefighter on the date
of the firefighter's death but the retirement or disability period of the firefighter
does not end with such firefighter's death, then the deceased firefighter's surviving
spouse upon whose death or remarriage such retirement or disability period
will end shall be entitled, without further election and upon payment of
any required premiums in accordance with the provisions of the group policy,
to maintain such continued group
insurance coverage in effect until the end of such retirement or disability
period. Continued group insurance coverage shall be provided in accordance
with this Section at the same premium rate from time to time charged for
equivalent coverage provided under the group policy with respect to covered
firefighters whose retirement or disability period has not begun, and no distinction
or discrimination in the amount or rate of premiums or in any waiver of premium
or other benefit provision shall be made between continued group insurance
coverage elected pursuant to this Section and equivalent coverage provided
to firefighters under the group policy other than pursuant to the provisions
of this Section; provided that no municipality shall be required by reason
of any provision of this Section to pay any group insurance premium other
than one that may be negotiated in a collective bargaining agreement.
If a person electing continued coverage under this Section becomes
eligible for medicare coverage, benefits under the group policy may
continue as a supplement to the medicare coverage upon payment of any
required premiums to maintain the benefits of the group policy as
supplemental coverage.
Within 15 days of the beginning of the retirement or disability period
of any firefighter entitled to elect continued group insurance coverage under any
group policy affected by this Section, the municipality last employing such
firefighter shall give written notice of such beginning by certified mail, return
receipt requested to the insurance company issuing such policy. The notice
shall include the firefighter's name and last known place of residence and the
beginning date of the firefighter's retirement or disability period.
Within 15 days of the date of receipt of such notice from the municipality,
the insurance company by certified mail, return receipt requested, shall
give written notice to the firefighter at the firefighter's last known place of
residence that coverage under the group policy may be continued for the
retirement or disability period of the firefighter as provided in this Section.
Such notice shall set forth: (i) a statement of election to be filed by
the firefighter if the firefighter wishes to continue such group insurance coverage,
(ii) the amount of monthly premium, including a statement of the portion
of such monthly premium attributable to any dependents' coverage which the
firefighter may elect, and (iii) instructions as to the return of the election
form to the insurance company issuing such policy. Election shall be made,
if at all, by returning the statement of election to the insurance company by
certified mail, return receipt requested within 15 days after having received it.
If the firefighter elects to continue coverage, it shall be the obligation
of the firefighter to pay the monthly premium directly to the municipality which
shall forward it to the insurance company
issuing the group insurance policy, or as otherwise directed by the insurance
company; provided, however, that the firefighter shall be entitled to designate
on the statement of election required to be filed with the insurance company
that the total monthly premium, or such portion thereof as is not
contributed by a municipality, be deducted by a Firefighter's Pension
Fund from any monthly pension payment otherwise payable
to or on behalf of the firefighter pursuant to Article 4 of the Illinois Pension
Code, and be remitted by such Pension Fund to the insurance company. The
portion, if any, of the monthly premium contributed by a
municipality for such continued group insurance coverage shall be paid by
the municipality directly to the insurance company issuing the group insurance
policy, or as otherwise directed by the insurance company. Such continued
group insurance coverage shall relate back to the beginning of the firefighter's
retirement or disability period.
The amendment, renewal or extension of any group insurance policy affected
by this Section shall be deemed to be the issuance of a new policy of insurance
for purposes of this Section.
In the event that a municipality makes a program of accident, health,
hospital or medical benefits available to its firefighters through
self-insurance, or by participation in a pool or reciprocal insurer, or by
contract in a form other than a policy of group insurance with one or more
medical service plans, health care service corporations, health maintenance
organizations, or any other professional corporations or plans under which
health care or reimbursement for the costs thereof is
provided, whether the cost of such benefits is borne by the municipality or
the firefighters or both, such firefighters and their surviving spouses shall have
the same right to elect continued coverage under such program of benefits
as they would have if such benefits were provided by a policy of group
accident and health insurance. In such cases, the notice of right to elect
continued coverage shall be sent by the municipality; the statement of
election shall be sent to the municipality; and references to the required
premium shall refer to that portion of the cost of such benefits which is not
borne by the municipality, either voluntarily or pursuant to the provisions
of a collective bargaining agreement. In the case of a municipality
providing such benefits through self-insurance or participation in a pool or
reciprocal insurer, the right to elect continued coverage which is provided
by this paragraph shall be implemented and made available to the firefighters of
the municipality and qualifying surviving spouses not later than July 1, 1985.
The amendment, renewal or extension of any such contract in a form other
than a policy of group insurance policy shall be deemed the formation of a
new contract for the purposes of this Section.
This Section shall not limit the exercise of any conversion privileges
available under Section 367e.
Pursuant to paragraphs (h) and (i) of Section 6 of Article VII of the
Illinois Constitution, this Section specifically denies and limits the
exercise by a home rule unit of any power which is inconsistent with this
Section and all existing laws and ordinances which are inconsistent with
this Section are hereby superseded. This Section does not preempt the
concurrent exercise by home rule units of powers consistent herewith.
The Division of Insurance of the Department of Financial and Professional Regulation shall enforce the provisions of this Section, including provisions relating to municipality self-insured benefit plans.
(Source: P.A. 103-52, eff. 1-1-24 .)
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