215 ILCS 5/ Illinois Insurance Code.

(215 ILCS 5/367m)

Sec. 367m. Early intervention services. A policy of accident and health insurance that provides coverage for early intervention services must conform to the following criteria:

(1) The use of private health insurance to pay for early intervention services under Part C of the federal Individuals with Disabilities Education Act may not count towards or result in a loss of benefits due to annual or lifetime insurance caps for an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy.

(2) The use of private health insurance to pay for early intervention services under Part C of the federal Individuals with Disabilities Education Act may not negatively affect the availability of health insurance to an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy, and health insurance coverage may not be discontinued for these individuals due to the use of the health insurance to pay for services under Part C of the federal Individuals with Disabilities Education Act.

(3) The use of private health insurance to pay for early intervention services under Part C of the federal Individuals with Disabilities Education Act may not be the basis for increasing the health insurance premiums of an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members covered under that health insurance policy.

For the purposes of this Section, "early intervention services" has the same meaning as in the Early Intervention Services System Act.

(Source: P.A. 98-41, eff. 6-28-13.)

(215 ILCS 5/368) (from Ch. 73, par. 980)

Sec. 368. Industrial accident and health insurance.

(1) Industrial accident and health insurance is hereby declared to be that form of accident and health insurance in which the premium is payable weekly.

(2) Any insurance company authorized to write accident and health insurance in this State shall have power to issue industrial accident and health policies. No policy of industrial accident and health insurance may be issued or delivered in this State unless it has printed thereon the words "Industrial Policy," a copy of the form thereof shall have been filed with the department and approved by it in accordance with section 355.

(Source: Laws 1951, p. 611.)

(215 ILCS 5/368a)

Sec. 368a. Timely payment for health care services.

(a) This Section applies to insurers, health maintenance organizations, managed care plans, health care plans, preferred provider organizations, third party administrators, independent practice associations, and physician-hospital organizations (hereinafter referred to as "payors") that provide periodic payments, which are payments not requiring a claim, bill, capitation encounter data, or capitation reconciliation reports, such as prospective capitation payments, to health care professionals and health care facilities to provide medical or health care services for insureds or enrollees.

(1) A payor shall make periodic payments in accordance with item (3). Failure to make periodic payments within the period of time specified in item (3) shall entitle the health care professional or health care facility to interest at the rate of 9% per year from the date payment was required to be made to the date of the late payment, provided that interest amounting to less than $1 need not be paid. Any required interest payments shall be made within 30 days after the payment.

(2) When a payor requires selection of a health care professional or health care facility, the selection shall be completed by the insured or enrollee no later than 30 days after enrollment. The payor shall provide written notice of this requirement to all insureds and enrollees. Nothing in this Section shall be construed to require a payor to select a health care professional or health care facility for an insured or enrollee.

(3) A payor shall provide the health care professional or health care facility with notice of the selection as a health care professional or health care facility by an insured or enrollee and the effective date of the selection within 60 calendar days after the selection. No later than the 60th day following the date an insured or enrollee has selected a health care professional or health care facility or the date that selection becomes effective, whichever is later, or in cases of retrospective enrollment only, 30 days after notice by an employer to the payor of the selection, a payor shall begin periodic payment of the required amounts to the insured's or enrollee's health care professional or health care facility, or the designee of either, calculated from the date of selection or the date the selection becomes effective, whichever is later. All subsequent payments shall be made in accordance with a monthly periodic cycle.

(b) Notwithstanding any other provision of this Section, independent practice associations and physician-hospital organizations shall make periodic payment of the required amounts in accordance with a monthly periodic schedule after an insured or enrollee has selected a health care professional or health care facility or after that selection becomes effective, whichever is later.

Notwithstanding any other provision of this Section, independent practice associations and physician-hospital organizations shall make all other payments for health services within 30 days after receipt of due proof of loss. Independent practice associations and physician-hospital organizations shall notify the insured, insured's assignee, health care professional, or health care facility of any failure to provide sufficient documentation for a due proof of loss within 30 days after receipt of the claim for health services.

Failure to pay within the required time period shall entitle the payee to interest at the rate of 9% per year from the date the payment is due to the date of the late payment, provided that interest amounting to less than $1 need not be paid. Any required interest payments shall be made within 30 days after the payment.

(c) All insurers, health maintenance organizations, managed care plans, health care plans, preferred provider organizations, and third party administrators shall ensure that all claims and indemnities concerning health care services other than for any periodic payment shall be paid within 30 days after receipt of due written proof of such loss. An insured, insured's assignee, health care professional, or health care facility shall be notified of any known failure to provide sufficient documentation for a due proof of loss within 30 days after receipt of the claim for health care services. Failure to pay within such period shall entitle the payee to interest at the rate of 9% per year from the 30th day after receipt of such proof of loss to the date of late payment, provided that interest amounting to less than one dollar need not be paid. Any required interest payments shall be made within 30 days after the payment.

(d) The Department shall enforce the provisions of this Section pursuant to the enforcement powers granted to it by law.

(e) The Department is hereby granted specific authority to issue a cease and desist order, fine, or otherwise penalize independent practice associations and physician-hospital organizations that violate this Section. The Department shall adopt reasonable rules to enforce compliance with this Section by independent practice associations and physician-hospital organizations.

(Source: P.A. 97-813, eff. 7-13-12.)

(215 ILCS 5/368b)

Sec. 368b. Contracting procedures.

(a) A health care professional or health care provider offered a contract by an insurer, health maintenance organization, independent practice association, or physician hospital organization for signature after the effective date of this amendatory Act of the 93rd General Assembly shall be provided with a proposed health care professional or health care provider services contract including, if any, exhibits and attachments that the contract indicates are to be attached. Within 35 days after a written request, the health care professional or health care provider offered a contract shall be given the opportunity to review and obtain a copy of the following: a specialty-specific fee schedule sample based on a minimum of the 50 highest volume fee schedule codes with the rates applicable to the health care professional or health care provider to whom the contract is offered, the network provider administration manual, and a summary capitation schedule, if payment is made on a capitation basis. If 50 codes do not exist for a particular specialty, the health care professional or health care provider offered a contract shall be given the opportunity to review or obtain a copy of a fee schedule sample with the codes applicable to that particular specialty. This information may be provided electronically. An insurer, health maintenance organization, independent practice association, or physician hospital organization may substitute the fee schedule sample with a document providing reference to the information needed to calculate the fee schedule that is available to the public at no charge and the percentage or conversion factor at which the insurer, health maintenance organization, preferred provider organization, independent practice association, or physician hospital organization sets its rates.

(b) The fee schedule, the capitation schedule, and the network provider administration manual constitute confidential, proprietary, and trade secret information and are subject to the provisions of the Illinois Trade Secrets Act. The health care professional or health care provider receiving such protected information may disclose the information on a need to know basis and only to individuals and entities that provide services directly related to the health care professional's or health care provider's decision to enter into the contract or keep the contract in force. Any person or entity receiving or reviewing such protected information pursuant to this Section shall not disclose the information to any other person, organization, or entity, unless the disclosure is requested pursuant to a valid court order or required by a state or federal government agency. Individuals or entities receiving such information from a health care professional or health care provider as delineated in this subsection are subject to the provisions of the Illinois Trade Secrets Act.

(c) The health care professional or health care provider shall be allowed at least 30 days to review the health care professional or health care provider services contract, including exhibits and attachments, if any, before signing. The 30-day review period begins upon receipt of the health care professional or health care provider services contract, unless the information available upon request in subsection (a) is not included. If information is not included in the professional services contract and is requested pursuant to subsection (a), the 30-day review period begins on the date of receipt of the information. Nothing in this subsection shall prohibit a health care professional or health care provider from signing a contract prior to the expiration of the 30-day review period.

(d) As used in this subsection:

"Change" means an increase or decrease in the fee schedule referred to in subsection (a).

"Nonroutine change" means any proposed change to the fee schedule except a change that is otherwise required by law, regulation, or an applicable regulatory authority or that is required as a result of changes in fee schedules, reimbursement methodology, or payment policies established by a government agency or by the American Medical Association's current procedural terminology codes, reporting guidelines, and conventions, or a change that is expressly provided for under the terms of the contract by the inclusion of or reference to a specific fee or fee schedule, reimbursement methodology, or payment policy indexing mechanism.

The insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide all contracted health care professionals or health care providers with any changes to the fee schedule provided under subsection (a) not later than 35 days after the effective date of the changes, unless such changes are specified in the contract and the health care professional or health care provider is able to calculate the changed rates based on information in the contract and information available to the public at no charge. Beginning January 1, 2023, with respect to nonroutine changes to the fee schedule, the insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide all contracted health care professionals or health care providers impacted by the nonroutine change with notice of the change at least 60 days before the effective date of the change. The right to advance notice of nonroutine changes to the fee schedule may not be waived by the health care professional or health care provider. For the purposes of this subsection (d), health maintenance organizations that provide or arrange for and pay or reimburse for the cost of any health care services for persons who are enrolled in the medical assistance programs under the Illinois Public Aid Code shall comply with provider notification requirements established by the Department of Healthcare and Family Services.

This information may be made available by mail, e-mail, newsletter, website listing, or other reasonable method. For nonroutine changes, the information directing the health care professional or health care provider to the information provided by newsletter, website listing, or other reasonable method shall be provided by email or, if requested by the health care professional or health care provider, by mail. Upon request, a health care professional or health care provider may request an updated copy of the fee schedule referred to in subsection (a) every calendar quarter.

(e) Upon termination of a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization and at the request of the patient, a health care professional or health care provider shall transfer copies of the patient's medical records. Any other provision of law notwithstanding, the costs for copying and transferring copies of medical records shall be assigned per the arrangements agreed upon, if any, in the health care professional or health care provider services contract.

(Source: P.A. 102-957, eff. 1-1-23.)

(215 ILCS 5/368c)

Sec. 368c. Remittance advice and procedures.

(a) A remittance advice shall be furnished to a health care professional or health care provider that identifies the disposition of each claim. The remittance advice shall identify the services billed; the patient responsibility, if any; the actual payment, if any, for the services billed; and the reason for any reduction to the amount for which the claim was submitted. For any reductions to the amount for which the claim was submitted, the remittance shall identify any withholds and the reason for any denial or reduction.

A remittance advice for capitation or prospective payment arrangements shall be furnished to a health care professional or health care provider pursuant to a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization in accordance with the terms of the contract.

(b) When health care services are provided by a non-participating health care professional or health care provider, an insurer, health maintenance organization, independent practice association, or physician hospital organization may pay for covered services either to a patient directly or to the non-participating health care professional or health care provider.

(c) When a person presents a benefits information card, a health care professional or health care provider shall make a good faith effort to inform the person if the health care professional or health care provider has a participation contract with the insurer, health maintenance organization, or other entity identified on the card.

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

(215 ILCS 5/368d)

Sec. 368d. Recoupments.

(a) A health care professional or health care provider shall be provided a remittance advice, which must include an explanation of a recoupment or offset taken by an insurer, health maintenance organization, independent practice association, or physician hospital organization, if any. The recoupment explanation shall, at a minimum, include the name of the patient; the date of service; the service code or if no service code is available a service description; the recoupment amount; and the reason for the recoupment or offset. In addition, an insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide with the remittance advice, or with any demand for recoupment or offset, a telephone number or mailing address to initiate an appeal of the recoupment or offset together with the deadline for initiating an appeal. Such information shall be prominently displayed on the remittance advice or written document containing the demand for recoupment or offset. Any appeal of a recoupment or offset by a health care professional or health care provider must be made within 60 days after receipt of the remittance advice.

(b) It is not a recoupment when a health care professional or health care provider is paid an amount prospectively or concurrently under a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization that requires a retrospective reconciliation based upon specific conditions outlined in the contract.

(c) No recoupment or offset may be requested or withheld from future payments 12 months or more after the original payment is made, except in cases in which:

(1) a court, government administrative agency, other tribunal, or independent third-party arbitrator makes or has made a formal finding of fraud or material misrepresentation;

(2) an insurer is acting as a plan administrator for the Comprehensive Health Insurance Plan under the Comprehensive Health Insurance Plan Act;

(3) the provider has already been paid in full by any other payer, third party, or workers' compensation insurer; or

(4) an insurer contracted with the Department of Healthcare and Family Services is required by the Department of Healthcare and Family Services to recoup or offset payments due to a federal Medicaid requirement.

No contract between an insurer and a health care professional or health care provider may provide for recoupments in violation of this Section. Nothing in this Section shall be construed to preclude insurers, health maintenance organizations, independent practice associations, or physician hospital organizations from resolving coordination of benefits between or among each other, including, but not limited to, resolution of workers' compensation and third-party liability cases, without recouping payment from the provider beyond the 18-month time limit provided in this subsection (c).

(Source: P.A. 102-632, eff. 1-1-22.)

(215 ILCS 5/368e)

Sec. 368e. Administration and enforcement.

(a) Other than the duties specifically created in Sections 368b, 368c, and 368d, nothing in those Sections is intended to preclude, prevent, or require the adoption, modification, or termination of any utilization management, quality management, or claims processing methodologies or other provisions of a contract applicable to services provided under a contract between an insurer, health maintenance organization, independent practice association, or physician hospital organization and a health care professional or health care provider.

(b) Nothing in Sections 368b, 368c, and 368d precludes, prevents, or requires the adoption, modification, or termination of any health plan term, benefit, coverage or eligibility provision, or payment methodology.

(c) The provisions of Sections 368b, 368c, and 368d are deemed incorporated into health care professional and health care provider service contracts entered into on or before the effective date of this amendatory Act of the 93rd General Assembly and do not require an insurer, health maintenance organization, independent practice association, or physician hospital organization to renew or renegotiate the contracts with a health care professional or health care provider.

(d) The Department shall enforce the provisions of this Section and Sections 368b, 368c, and 368d pursuant to the enforcement powers granted to it by law.

(e) The Department is hereby granted specific authority to issue a cease and desist order against, fine, or otherwise penalize independent practice associations and physician-hospital organizations for violations.

(f) The Department shall adopt reasonable rules to enforce compliance with this Section and Sections 368b, 368c, and 368d.

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

(215 ILCS 5/368f)

Sec. 368f. Military service member insurance reinstatement.

(a) No Illinois resident activated for military service and no spouse or dependent of the resident who becomes eligible for a federal government-sponsored health insurance program, including the TriCare program providing coverage for civilian dependents of military personnel, as a result of the activation shall be denied reinstatement into the same individual health insurance coverage with the health insurer that the resident lapsed as a result of activation or becoming covered by the federal government-sponsored health insurance program. The resident shall have the right to reinstatement in the same individual health insurance coverage without medical underwriting, subject to payment of the current premium charged to other persons of the same age and gender that are covered under the same individual health coverage. Except in the case of birth or adoption that occurs during the period of activation, reinstatement must be into the same coverage type as the resident held prior to lapsing the individual health insurance coverage and at the same or, at the option of the resident, higher deductible level. The reinstatement rights provided under this subsection (a) are not available to a resident or dependents if the activated person is discharged from the military under other than honorable conditions.

(b) The health insurer with which the reinstatement is being requested must receive a request for reinstatement no later than 63 days following the later of (i) deactivation or (ii) loss of coverage under the federal government-sponsored health insurance program. The health insurer may request proof of loss of coverage and the timing of the loss of coverage of the government-sponsored coverage in order to determine eligibility for reinstatement into the individual coverage. The effective date of the reinstatement of individual health coverage shall be the first of the month following receipt of the notice requesting reinstatement.

(c) All insurers must provide written notice to the policyholder of individual health coverage of the rights described in subsection (a) of this Section. In lieu of the inclusion of the notice in the individual health insurance policy, an insurance company may satisfy the notification requirement by providing a single written notice:

(1) in conjunction with the enrollment process for a policyholder initially enrolling in the individual coverage on or after the effective date of this amendatory Act of the 94th General Assembly; or

(2) by mailing written notice to policyholders whose coverage was effective prior to the effective date of this amendatory Act of the 94th General Assembly no later than 90 days following the effective date of this amendatory Act of the 94th General Assembly.

(d) The provisions of subsection (a) of this Section do not apply to any policy or certificate providing coverage for any specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care, Medicare supplement, vision care, or short-term nonrenewable health policy or other limited-benefit supplemental insurance, or any coverage issued as a supplement to any liability insurance, workers' compensation or similar insurance, or any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket, or individual basis.

(e) Nothing in this Section shall require an insurer to reinstate the resident if the insurer requires residency in an enrollment area and those residency requirements are not met after deactivation or loss of coverage under the government-sponsored health insurance program.

(f) All terms, conditions, and limitations of the individual coverage into which reinstatement is made apply equally to all insureds enrolled in the coverage.

(g) The Secretary may adopt rules as may be necessary to carry out the provisions of this Section.

(Source: P.A. 94-1037, eff. 7-20-06.)

(215 ILCS 5/368g)

Sec. 368g. Time-based billing.

(a) As used in this Section, "CPT code" means the medical billing code set contained in the most recent version of the Current Procedural Terminology code book published by the American Medical Association.

(b) A health care plan requiring a health care provider to use a time-based CPT code to bill for health care services shall not apply a time measurement standard that results in fewer units billed than allowed by the CPT code book, except as required by federal law for federally funded patients.

(Source: P.A. 101-119, eff. 7-22-19; 102-558, eff. 8-20-21.)

(215 ILCS 5/369) (from Ch. 73, par. 981)

Sec. 369. Rights of minors.

Any minor of the age of fifteen years or more may, notwithstanding such minority, contract for health and accident insurance on his own life for his own benefit or for the benefit of his father, mother, husband, wife, child, brother or sister, and may exercise all such contractual rights and powers with respect to any such contract of insurance as might be exercised by a person of full legal age, and may exercise with like effect all rights and privileges under such contract, including the surrender of his interest therein and the giving of a valid discharge for any benefit accruing or money payable thereunder. Such minor shall not, by reason of his minority, be entitled to rescind, avoid, or repudiate such contract, or any exercise of a right or privilege thereunder.

(Source: Laws 1937, p. 696.)

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

Sec. 370. Policies issued in violation of article-Penalty.

(1) Any company, or any officer or agent thereof, issuing or delivering to any person in this State any policy in wilful violation of the provision of this article shall be guilty of a petty offense.

(2) The Director may revoke the license of any foreign or alien company, or of the agent thereof wilfully violating any provision of this article or suspend such license for any period of time up to, but not to exceed, two years; or may by order require such insurance company or agent to pay to the people of the State of Illinois a penalty in a sum not exceeding $1,000, and upon the failure of such insurance company or agent to pay such penalty within twenty days after the mailing of such order, postage prepaid, registered, and addressed to the last known place of business of such insurance company or agent, unless such order is stayed by an order of a court of competent jurisdiction, the Director of Insurance may revoke or suspend the license of such insurance company or agent for any period of time up to, but not exceeding a period of, two years.

(Source: P.A. 93-32, eff. 7-1-03.)

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

Sec. 370a. Assignability of Accident and Health Insurance.

No provision of the Illinois Insurance Code, or any other law, prohibits an insured under any policy of accident and health insurance or any other person who may be the owner of any rights under such policy from making an assignment of all or any part of his rights and privileges under the policy including but not limited to the right to designate a beneficiary and to have an individual policy issued in accordance with its terms. Subject to the terms of the policy or any contract relating thereto, an assignment by an insured or by any other owner of rights under the policy, made before or after the effective date of this amendatory Act of 1969 is valid for the purpose of vesting in the assignee, in accordance with any provisions included therein as to the time at which it is effective, all rights and privileges so assigned. However, such assignment is without prejudice to the company on account of any payment it makes or individual policy it issues before receipt of notice of the assignment. This amendatory Act of 1969 acknowledges, declares and codifies the existing right of assignment of interests under accident and health insurance policies. If an enrollee or insured of an insurer, health maintenance organization, managed care plan, health care plan, preferred provider organization, or third party administrator assigns a claim to a health care professional or health care facility, then payment shall be made directly to the health care professional or health care facility including any interest required under Section 368a, of this Code for failure to pay claims within 30 days after receipt by the insurer of due proof of loss. Nothing in this Section shall be construed to prevent any parties from reconciling duplicate payments.

(Source: P.A. 91-605, eff. 12-14-99; 91-788, eff. 6-9-00.)

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

Sec. 370b. Reimbursement on equal basis. Notwithstanding any provision of any individual or group policy of accident and health insurance, or any provision of a policy, contract, plan or agreement for hospital or medical service or indemnity, wherever such policy, contract, plan or agreement provides for reimbursement for any service provided by persons licensed under the Medical Practice Act of 1987 or the Podiatric Medical Practice Act of 1987, the person entitled to benefits or person performing services under such policy, contract, plan or agreement is entitled to reimbursement on an equal basis for such service, when the service is performed by a person licensed under the Medical Practice Act of 1987 or the Podiatric Medical Practice Act of 1987. The provisions of this Section do not apply to any policy, contract, plan or agreement in effect prior to September 19, 1969 or to preferred provider arrangements or benefit agreements.

(Source: P.A. 90-14, eff. 7-1-97.)