215 ILCS 5/ Illinois Insurance Code.

(215 ILCS 5/370c.2)

Sec. 370c.2. (Repealed).

(Source: P.A. 102-304, eff. 8-6-21. Repealed internally, eff. 1-1-23.)

(215 ILCS 5/370d) (from Ch. 73, par. 982d)

Sec. 370d. Companies which issue insurance policies under this Article containing business overhead expense coverage shall make available to persons whose occupation is that of homemaker and who are not otherwise gainfully employed, coverage which provides for reimbursement of certain specified expenses ordinarily incurred by members of the household due to the incapacity of the homemaker during periods of his or her total disability resulting from injury or sickness, provided that such companies shall be required to offer coverage which is at least 80% of total eligible expenses or $300 per month, whichever provides the lesser coverage.

(Source: P.A. 81-916.)

(215 ILCS 5/370d.1)

Sec. 370d.1. Group policies; chambers of commerce. Companies that issue group policies of accident and health insurance under this Article must offer such policies to local chambers of commerce.

(Source: P.A. 102-611, eff. 1-1-22.)

(215 ILCS 5/370e) (from Ch. 73, par. 982e)

Sec. 370e. Companies which issue group accident and health policies or blanket accident and health plans to employer groups in this State shall provide the employer with notice of termination of a group or blanket accident and health plan because of the employer's failure to pay the premium when due. The insurance company shall send a copy of such notice to the Department.

(Source: P.A. 83-1006.)

(215 ILCS 5/Art. XX.5 heading) ARTICLE XX-1/2 HEALTH CARE REIMBURSEMENT

(215 ILCS 5/370f) (from Ch. 73, par. 982f)

Sec. 370f. Short Title. This Article may be cited as the "Health Care Reimbursement Reform Act of 1985".

(Source: P.A. 84-618.)

(215 ILCS 5/370g) (from Ch. 73, par. 982g)

Sec. 370g. Definitions. As used in this Article, the following definitions apply:

(a) "Health care services" means health care services or products rendered or sold by a provider within the scope of the provider's license or legal authorization. The term includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.

(b) "Insurer" means an insurance company or a health service corporation authorized in this State to issue policies or subscriber contracts which reimburse for expenses of health care services.

(c) "Insured" means an individual entitled to reimbursement for expenses of health care services under a policy or subscriber contract issued or administered by an insurer.

(d) "Provider" means an individual or entity duly licensed or legally authorized to provide health care services.

(e) "Noninstitutional provider" means any person licensed under the Medical Practice Act of 1987, as now or hereafter amended.

(f) "Beneficiary" means an individual entitled to reimbursement for expenses of or the discount of provider fees for health care services under a program where the beneficiary has an incentive to utilize the services of a provider which has entered into an agreement or arrangement with an administrator.

(g) "Administrator" means any person, partnership or corporation, other than an insurer or health maintenance organization holding a certificate of authority under the "Health Maintenance Organization Act", as now or hereafter amended, that arranges, contracts with, or administers contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider.

(h) "Emergency medical condition" has the meaning given to that term in Section 10 of the Managed Care Reform and Patient Rights Act.

(Source: P.A. 102-409, eff. 1-1-22.)

(215 ILCS 5/370h) (from Ch. 73, par. 982h)

Sec. 370h. Noninstitutional providers. Before entering into any agreement under this Article an insurer or administrator shall establish terms and conditions that must be met by noninstitutional providers wishing to enter into an agreement with the insurer or administrator. These terms and conditions may not discriminate unreasonably against or among noninstitutional providers. Neither difference in prices among noninstitutional providers produced by a process of individual negotiation nor price differences among other noninstitutional providers in different geographical areas or different specialties constitutes unreasonable discrimination.

An insurer or administrator shall not refuse to contract with any noninstitutional provider who meets the terms and conditions established by the insurer or administrator.

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

(215 ILCS 5/370i) (from Ch. 73, par. 982i)

Sec. 370i. Policies, agreements or arrangements with incentives or limits on reimbursement authorized.

(a) Policies, agreements or arrangements issued under this Article may not contain terms or conditions that would operate unreasonably to restrict the access and availability of health care services for the insured.

(b) An insurer or administrator may:

(1) enter into agreements with certain providers of its choice relating to health care services which may be rendered to insureds or beneficiaries of the insurer or administrator, including agreements relating to the amounts to be charged the insureds or beneficiaries for services rendered;

(2) issue or administer programs, policies or subscriber contracts in this State that include incentives for the insured or beneficiary to utilize the services of a provider which has entered into an agreement with the insurer or administrator pursuant to paragraph (1) above.

(c) After the effective date of this amendatory Act of the 92nd General Assembly, any insurer that arranges, contracts with, or administers contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider must include the following disclosure on its contracts and evidences of coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a non-participating provider for a covered service in non-emergency situations, benefit payments to such non-participating provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy's fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-participating providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill. Participating providers have agreed to accept discounted payments for services with no additional billing to the member other than co-insurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll free telephone number on your identification card.".

(Source: P.A. 92-579, eff. 1-1-03.)

(215 ILCS 5/370j) (from Ch. 73, par. 982j)

Sec. 370j. Requirements not applicable to insurers. Except as otherwise provided, no insurer authorized to do business in this State shall be subject to any of the requirements of this Article that are applicable to administrators.

Requirements not applicable to self-insured employers, employee benefit trust funds, other ERISA exempt organizations or the State of Illinois. Such organizations are not subject to any provisions of this Article even though they may contract with administrators for administration of health insurance claims subject to contractual arrangements of the administrator's preferred provider program.

(Source: P.A. 84-1431.)

(215 ILCS 5/370k) (from Ch. 73, par. 982k)

Sec. 370k. Registration.

(a) All administrators of a preferred provider program subject to this Article shall register with the Department of Insurance, which shall by rule establish criteria for such registration including minimum solvency requirements and an annual registration fee for each administrator.

(b) The Department of Insurance shall compile and maintain a listing updated at least annually of administrators and insurers offering agreements authorized under this Article.

(c) Preferred provider administrators are subject to the provisions of Sections 368b, 368c, 368d, and 368e of this Code.

(Source: P.A. 93-261, eff. 1-1-04.)

(215 ILCS 5/370l) (from Ch. 73, par. 982l)

Sec. 370l. Fiduciary and bonding requirements. Each administrator who handles money for purposes of payment for providers services subject to this Article shall (1) establish and maintain a fiduciary account, separate and apart from any and all other accounts, for the receipt and disbursement of funds for reimbursement for programs covered under this Article, or (2) post or cause to be posted, a bond of indemnity in an amount equal to not less than 10% of the total estimated annual reimbursements under such programs.

If a bond of indemnity is posted, it shall be held by the Director of Insurance for the benefit and indemnification of the beneficiaries and payors of services under the programs subject to this Article.

An administrator who operates more than one such program may establish and maintain a separate fiduciary account or bond of indemnity for each such program, or may operate and maintain a consolidated fiduciary account or bond of indemnity for all such programs.

(Source: P.A. 84-618.)

(215 ILCS 5/370m) (from Ch. 73, par. 982m)

Sec. 370m. Program Requirements. Each administrator shall provide to each beneficiary of any program subject to this Article a document which (1) sets forth those providers with which agreements or arrangements have been made to provide health care services to such beneficiary, a source for the beneficiary to contact regarding changes in such providers and a clear description of any incentives for the beneficiary to utilize such providers, (2) discloses the extent of coverage as well as any limitations or exclusions of health care services under the program, (3) clearly sets out the circumstances under which reimbursement will be made to a beneficiary unable to utilize the services of a provider with which an arrangement or agreement has been made, (4) a description of the process for addressing a beneficiary complaint under the program, and (5) discloses deductible and coinsurance amounts charged to any person receiving health care services from such a provider.

(Source: P.A. 84-618.)

(215 ILCS 5/370n) (from Ch. 73, par. 982n)

Sec. 370n. Utilization Review Requirements: Any preferred provider organization providing hospital, medical or dental services must include a program of utilization review.

This Section applies to insurers and administrators.

(Source: P.A. 84-1431.)

(215 ILCS 5/370o) (from Ch. 73, par. 982o)

Sec. 370o. Emergency Care. Any preferred provider contract, subject to this Article shall provide the beneficiary or insured emergency care coverage such that payment for this coverage is not dependent upon whether such services are performed by a preferred or nonpreferred provider and such coverage shall be at the same benefit level as if the service or treatment had been rendered by a plan provider.

(Source: P.A. 85-476.)