215 ILCS 5/ Illinois Insurance Code.

(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)

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

(2) national standards pertaining to electronic prior authorization.

(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.)

(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.

(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.

(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.

(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.

(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).

(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.)

(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 coverage;

(ii) the amount of periodic premiums to be charged for continuation coverage and the method and place of payment; and

(iii) instructions for returning the election form within 30 days after the date it is received from the insurance company.

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;

(ii) an amount, if any, that the employer would contribute toward the premium if the former spouse were a current employee.

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

(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

(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

(iv) the date on which the former spouse remarries; or

(v) the expiration of 2 years from the date continuation coverage began.

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;

(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.

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;

(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.

(iii) an additional amount, not to exceed 20% of (i) and (ii) above, for costs of administration.

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

(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

(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

(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.

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.)

(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 coverage;

(2) the amount of periodic premiums to be charged for continuation coverage and the method and place of payment; and

(3) instructions for returning the election form within 30 days after the date it is received from the insurance company.

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;

(2) an amount, if any, that the employer would contribute toward the premium if the dependent child were a current employee.

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;

(2) when coverage would terminate under the terms of the existing policy if the dependent child was still an eligible dependent of the employee;

(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

(4) the expiration of 2 years from the date continuation coverage began.

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.)

(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 public interest;

(2) the issuance of the policy will result in economies of acquisition and administration; and

(3) the benefits under the policy are reasonable in relation to the premium charged.

(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;

(3) evidence of approval by the state of situs of the group master policy; and

(4) copies of all supportive material furnished to the state of situs to satisfy the criteria for approval.

(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.)

(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.)

(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.)

(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.)

(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.)

(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.)

(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.

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.

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.

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.

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.

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.

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.

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.

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:

(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.

(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.

(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:

(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.

(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.

7. A notification of the continuation privilege shall be included in each certificate of coverage.

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.

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.

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.

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.

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.

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.

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.)

(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.

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.

(2) The converted policy shall be issued without evidence of insurability.

(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.

(4) The effective date of the converted policy shall be the day following the termination of insurance under the group policy.

(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.

(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.

(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.

(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.

(9) A notification of the conversion privilege shall be included in each certificate.

(10) The insurer may elect to provide group insurance coverage in lieu of the issuance of a converted policy.

(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:

(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.

(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.

(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.

(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.

(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:

(a) A maximum benefit at least equal to (i) or (ii) below:

(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

(ii) A maximum payment of twenty-five thousand dollars for each unrelated injury or illness.

(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.

(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.

(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.

(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.

(4) The insurer may, at its option, also offer alternative plans for group accident and health conversion.

(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.

(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).

(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.

(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.

(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.

(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.

(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.

(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.

(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.)

(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

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.

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.)

(215 ILCS 5/367g) (from Ch. 73, par. 979g)

Sec. 367g. Police officer's continuance privilege. As used in this Section:

1. The terms "municipality" and "creditable service" shall have the meaning ascribed to such terms by Sections 3-103 and 3-110, respectively, of the Illinois Pension Code, as now or hereafter amended.

The term "deferred pensioner" means a police officer who has retired, having accumulated enough creditable service to qualify for a pension, but who has not attained the required age.

2. The term "police officer" shall have the meaning ascribed to it by Section 3-106 of the Illinois Pension Code, and include those persons under the coverage of Article 3 of that Code, as heretofore or hereafter amended.

3. The "retirement or disability period" of a police officer means the period:

a. which begins on the day the police officer is removed from a municipality's police department payroll because of the occurrence of any of the following events, to wit: (i) the police officer retires as a deferred pensioner, (ii) the police officer retires from active service as a police officer with an attained age and accumulated creditable service which together qualify the police officer for immediate receipt of retirement pension benefits under Section 3-111 of the Illinois Pension Code, or (iii) the police officer's disability is established under Section 3-115 of the Illinois Pension Code; and

b. which ends on the first to occur of any of the following events, to wit: (i) the police officer's reinstatement or reentry into active service on the municipality's police department as provided for under Article 3 of the Illinois Pension Code, (ii) the police officer's exercise of any refund option available under Section 3-124 of the Illinois Pension Code, (iii) the police officer's loss pursuant to Section 3-147 of the Illinois Pension Code of any benefits provided for in Article 3 of that Code, or (iv) the police officer's death or -- if at the time of the police officer's death the police officer is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 3 of the Illinois Pension Code -- the death or remarriage of that spouse.

No policy of group accident and health insurance under which policemen 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 police officer 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 police officer 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 police officer throughout the retirement or disability period of the police officer and, unless the police officer 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 police officer who are insured under the group policy on the day immediately preceding the day on which the retirement or disability period of the police officer begins; provided, however, that when such continued group insurance coverage is in effect with respect to a police officer on the date of the police officer's death but the retirement or disability period of the police officer does not end with such police officer's death, then the deceased police officer'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 policemen 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 policemen 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 the group policy provides for a reduction in benefits and premium for insureds who become eligible for medicare, such provision shall apply to persons electing continued coverage under this Section.

Within 15 days of the beginning of the retirement or disability period of any police officer entitled to elect continued group insurance coverage under any group policy affected by this Section, the municipality last employing such police officer 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 police officer's name and last known place of residence and the beginning date of the police officer'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 police officer at the police officer's last known place of residence that coverage under the group policy may be continued for the retirement or disability period of the police officer as provided in this Section. Such notice shall set forth: (i) a statement of election to be filed by the police officer if the police officer 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 police officer 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 police officer elects to continue coverage, it shall be the obligation of the police officer 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 police officer 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 Police Pension Fund from any monthly pension payment otherwise payable to or on behalf of the police officer pursuant to Article 3 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 police officer'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 police officers 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 police officers or both, such police officers 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 police officers of the municipality and qualifying surviving spouses not later than July 1, 1986.

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.

(Source: P.A. 84-1010.)

(215 ILCS 5/367h) (from Ch. 73, par. 979h)

Sec. 367h. Deputy's continuance privilege. As used in this Section:

1. The terms "municipality" and "creditable service" shall have the meaning ascribed to such terms by Sections 7-105 and 7-113, respectively, of the Illinois Pension Code, as now or hereafter amended.

The term "deferred pensioner" means a deputy who has retired, having accumulated enough creditable service to qualify for a pension, but who has not attained the required age.

2. The term "deputy" shall mean a "sheriff's law enforcement employee" as defined in Section 7-109.3 of the Illinois Pension Code, and include only persons under the coverage of Article 7 of that Code, as heretofore or hereafter amended.

3. The "retirement or disability period" of a deputy means the period:

a. which begins on the day the deputy is removed from a sheriff's police department payroll because of the occurrence of any of the following events, to wit: (i) the deputy retires as a deferred pensioner, (ii) the deputy retires from active service as a deputy with an attained age and accumulated creditable service which together qualify the deputy for immediate receipt of retirement pension benefits under Section 7-142.1 of the Illinois Pension Code, or (iii) the deputy's disability is established under Article 7 of the Illinois Pension Code; and

b. which ends on the first to occur of any of the following events, to wit: (i) the deputy's reinstatement or reentry into active service in the sheriff's police department as provided for under Article 7 of the Illinois Pension Code, (ii) the deputy's exercise of any refund option or acceptance of any separation benefit available under Article 7 of the Illinois Pension Code, (iii) the deputy's loss pursuant to Section 7-219 of the Illinois Pension Code of any benefits provided for in Article 7 of that Code, or (iv) the deputy's death or -- if at the time of the deputy's death the deputy is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 7 of the Illinois Pension Code -- the death or remarriage of that spouse.

No policy of group accident and health insurance under which deputies 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 deputy 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 deputy 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 deputy throughout the retirement or disability period of the deputy and, unless the deputy 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 deputy who are insured under the group policy on the day immediately preceding the day on which the retirement or disability period of the deputy begins; provided, however, that when such continued group insurance coverage is in effect with respect to a deputy on the date of the deputy's death but the retirement or disability period of the deputy does not end with such deputy's death, then the deceased deputy'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 deputies 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 deputies 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 the group policy provides for a reduction in benefits and premium for insureds who become eligible for medicare, such provision shall apply to persons electing continued coverage under this Section.

Within 15 days of the beginning of the retirement or disability period of any deputy entitled to elect continued group insurance coverage under any group policy affected by this Section, the municipality last employing such deputy 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 deputy's name and last known place of residence and the beginning date of the deputy'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 deputy at the deputy's last known place of residence that coverage under the group policy may be continued for the retirement or disability period of the deputy as provided in this Section. Such notice shall set forth: (i) a statement of election to be filed by the deputy if the deputy 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 deputy 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 deputy elects to continue coverage, it shall be the obligation of the deputy 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 deputy 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 the Illinois Municipal Retirement Fund from the monthly pension payment otherwise payable to or on behalf of the deputy pursuant to Article 7 of the Illinois Pension Code, and be remitted by such 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 directly to the insurance company issuing the group insurance policy, or as directed by the insurance company. Such continued group insurance coverage shall relate back to the beginning of the deputy'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 deputies 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 deputies or both, such deputies 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 deputies of the municipality and qualifying surviving spouses not later than July 1, 1986.

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.

(Source: P.A. 90-655, eff. 7-30-98.)

(215 ILCS 5/367i) (from Ch. 73, par. 979i)

Sec. 367i. Discontinuance and replacement of coverage. Group health insurance policies issued, amended, delivered or renewed on and after the effective date of this amendatory Act of 1989, shall provide a reasonable extension of benefits in the event of total disability on the date the policy is discontinued for any reason.

Any applicable extension of benefits or accrued liability shall be described in the policy and group certificate. Benefits payable during any extension of benefits may be subject to the policy's regular benefit limits.

Any insurer discontinuing a group health insurance policy shall provide to the policyholder for delivery to covered employees or members a notice as to the date such discontinuation is to be effective and urging them to refer to their group certificates to determine what contract rights, if any, are available to them.

In the event a discontinued policy is replaced by another group policy, the prior insurer or plan shall be liable only to the extent of its accrued liabilities and extension of benefits. Persons eligible for coverage under the succeeding insurer's plan shall include all employees and dependents covered under the prior insurer's plan, including individuals with disabilities covered under the prior plan but absent from work on the effective date and thereafter. The prior insurer shall provide extension of benefits for an insured's disabling condition when no coverage is available under the succeeding insurer's plan whether due to the absence of coverage in the contract or lack of required creditable coverage for a preexisting condition.

The Director shall promulgate reasonable rules as necessary to carry out this Section.

(Source: P.A. 99-143, eff. 7-27-15.)