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Illinois Compiled Statutes

Information maintained by the Legislative Reference Bureau
Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process. Recent laws may not yet be included in the ILCS database, but they are found on this site as Public Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the Guide.

Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If the source note at the end of a Section of the statutes includes a Public Act that has not yet taken effect, the version of the law that is currently in effect may have already been removed from the database and you should refer to that Public Act to see the changes made to the current law.

INSURANCE
(215 ILCS 5/) Illinois Insurance Code.

215 ILCS 5/351A-8

    (215 ILCS 5/351A-8) (from Ch. 73, par. 963A-8)
    Sec. 351A-8. Outline of coverage.
    (a) An outline of coverage shall be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means which prominently direct the attention of the recipient to the document and its purpose.
        (1) The Director shall prescribe a standard format
    
including style, arrangement and overall appearance and the content of an outline of coverage.
        (2) In the case of agent solicitations, an agent must
    
deliver the outline of coverage prior to the presentation of an application or enrollment form.
        (3) In the case of direct response solicitations, the
    
outline of coverage must be presented in conjunction with any application or enrollment form.
    (b) The outline of coverage shall include:
        (1) A description of the principal benefits and
    
coverage provided in the policy.
        (2) A statement of the principal exclusions,
    
reductions and limitations contained in the policy.
        (3) A statement of the terms under which the policy
    
or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described.
        (4) A statement that the outline of coverage is a
    
summary only, not a contract of insurance, and that the policy or group master policy contain governing contractual provisions.
        (5) A description of the terms under which the policy
    
or certificate may be returned and premium refunded.
        (6) A brief description of the relationship of cost
    
of care and benefits.
        (7) A statement that discloses to the policyholder or
    
certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract under 7702B(b) of the Internal Revenue Code of 1986, as amended.
(Source: P.A. 92-148, eff. 7-24-01.)

215 ILCS 5/351A-9

    (215 ILCS 5/351A-9) (from Ch. 73, par. 963A-9)
    Sec. 351A-9. Disclosure in certificate. A certificate issued pursuant to a group long-term care insurance policy, which policy is delivered or issued for delivery in this State, shall include each of the following:
    (1) A description of the principal benefits and coverage provided in the policy.
    (2) A statement of the principal exclusions, reductions and limitations contained in the policy.
    (3) A statement that the group master policy determines governing contractual provisions.
(Source: P.A. 85-1172; 85-1174; 85-1440.)

215 ILCS 5/351A-9.1

    (215 ILCS 5/351A-9.1) (from Ch. 73, par. 963A-9.1)
    Sec. 351A-9.1. Policy summary and benefit reports.
    (a) At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy which provides long-term care benefits within the policy or by rider. In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make such delivery no later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary shall also include:
        (1) an explanation of how the long-term care benefit
    
interacts with other components of the policy, including deductions from death benefits;
        (2) an illustration of the amount of benefits, the
    
length of benefit, and the guaranteed lifetime benefits if any, for each covered person;
        (3) any exclusions, reductions and limitations on
    
benefits of long-term care; and
        (4) if applicable to the policy type, the summary
    
shall also include:
            (A) disclosure of the effects of exercising other
        
rights under the policy;
            (B) disclosure of guarantees related to long-term
        
care costs of insurance charges; and
            (C) current and projected maximum lifetime
        
benefits.
    (b) Any time a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder. Such report shall include:
        (1) any long-term care benefits paid during the month;
        (2) an explanation of any changes in the policy,
    
including changes in death benefits or cash values, due to long-term care benefits being paid out; and
        (3) the amount of long-term care benefits existing or
    
remaining.
(Source: P.A. 86-384.)

215 ILCS 5/351A-9.2

    (215 ILCS 5/351A-9.2)
    Sec. 351A-9.2. Delivery of policy. If an applicant for a long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later than 30 days after the date of approval.
(Source: P.A. 92-148, eff. 7-24-01.)

215 ILCS 5/351A-9.3

    (215 ILCS 5/351A-9.3)
    Sec. 351A-9.3. Claim denial; explanation. If a claim under a long-term care insurance contract is denied, the issuer, within 60 days after receipt of a written request by a policyholder or certificate holder or a policyholder's or certificate holder's representative shall:
        (1) provide a written explanation of the reasons for
    
the denial; and
        (2) make available all information directly related
    
to the denial.
(Source: P.A. 92-148, eff. 7-24-01.)

215 ILCS 5/351A-10

    (215 ILCS 5/351A-10) (from Ch. 73, par. 963A-10)
    Sec. 351A-10. Any policy or rider advertised, marketed or offered as long-term care or nursing home insurance shall comply with the provisions of this Article.
(Source: P.A. 85-1440; 86-384.)

215 ILCS 5/351A-11

    (215 ILCS 5/351A-11) (from Ch. 73, par. 963A-11)
    Sec. 351A-11. Rules and regulations. The Director may adopt rules and regulations establishing minimum standards for marketing practices and reporting practices, penalties for violating those standards, and loss ratio standards for long-term care insurance policies, provided that a specific reference to long-term care insurance policies is contained in the regulation. Rules adopted pursuant to this Article shall be in accordance with the provisions of the Illinois Administrative Procedure Act.
(Source: P.A. 87-601.)

215 ILCS 5/Art. XIXB

 
    (215 ILCS 5/Art. XIXB heading)
ARTICLE XIXB
SMALL EMPLOYER GROUP HEALTH INSURANCE LAW

215 ILCS 5/351B-1

    (215 ILCS 5/351B-1) (from Ch. 73, par. 963B-1)
    Sec. 351B-1. Short title. This Article may be cited as the Small Employer Group Health Insurance Law.
(Source: P.A. 86-1407.)

215 ILCS 5/351B-2

    (215 ILCS 5/351B-2) (from Ch. 73, par. 963B-2)
    Sec. 351B-2. Findings and purpose.
    (a) The General Assembly finds that the cost of group health insurance is becoming unaffordable to many small employers and their employees. Further, because of the unaffordability of this type of insurance, in some cases due to the cost of mandated benefits, a significant segment of the State's working population is unable to pay for many health care services which is increasing the cost of health insurance for current purchasers through a cost shift.
    (b) It is the purpose and intent of this amendatory Act of 1990 to authorize a program whereby small employers may obtain affordable group health insurance that will increase access to health care, assist in the reduction of the amount of uncompensated care, and reduce the number of uninsured people in this State.
(Source: P.A. 86-1407.)

215 ILCS 5/351B-3

    (215 ILCS 5/351B-3) (from Ch. 73, par. 963B-3)
    Sec. 351B-3. Small employer group accident and health insurance.
    (a) Small employer group accident and health insurance is hereby declared to be that form of accident and health insurance that provides coverage for each person insured under the group policy for the expenses incurred because of care rendered by a physician or hospital for the treatment of an injury or sickness and which covers not more than 25 employees, members, or employees of members (exclusive of dependents) written under a master policy issued to any governmental corporation, unit, agency, or department thereof or to any corporation, copartnership, or individual employer or to any association upon application of an executive officer or trustee of an association having a constitution or bylaws and formed in good faith for purposes other than that of obtaining insurance, where officers, members, employees, or employees of members or classes or departments thereof may be insured for their individual benefit. In addition, a small employer group accident and health policy may be written to insure any group that may be insured under a group life insurance policy as long as the number of employees, members, or employees of members (exclusive of dependents) does not exceed 25. 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 or firms when the business of the subsidiary or affiliated corporations or affiliated firms or individuals is controlled by a common employer through stock ownership, contract, or otherwise.
    (b) For the purpose of providing coverage authorized under this Article a trust composed of employers or members each of which has 25 or fewer employees (exclusive of dependents) may serve as the master policyholder.
(Source: P.A. 86-1407.)

215 ILCS 5/351B-4

    (215 ILCS 5/351B-4) (from Ch. 73, par. 963B-4)
    Sec. 351B-4. Small employer group accident and health insurance policy requirements.
    (a) Any insurance company authorized to write accident and health insurance in this State shall have power to issue small employer group accident and health policies. No policy of small employer group accident and health insurance may be issued or delivered in this State unless a copy of the form thereof has been filed with the Department and approved by it in accordance with Section 355, unless it contains in substance those provisions contained in Sections 357.1 through 357.30 as may be applicable to small employer group accident and health insurance and unless it contains the provisions set forth in this Section.
    (b) The policy must provide that the policy, the application of the employer or the 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 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 none of those statements may be used in defense to a claim under the policy unless it is contained in a written application.
    (c) The policy must provide 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 the policy, an individual certificate setting forth a statement as to the insurance protection to which he is entitled and to whom payable.
    (d) The policy must provide that all new employees of the employer, new members of the association, or new employees of members eligible and applying for insurance in the group or class shall be added periodically to the group or class originally insured.
    (e) Anything in this Code to the contrary notwithstanding, any small employer group accident and health insurance policy may provide that all or any portion of any indemnities provided by the 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 the 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 shall prohibit an insurer from providing incentives for insureds to utilize the services of a particular hospital or person.
    (f) Whenever the Department of Public Health finds that it has paid all or part of any hospital or medical expenses that an insurance carrier is obligated to pay under this Article, the Department of Public Health shall be entitled to receive reimbursement for its payments from the 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.
    (g) No group hospital, medical, or surgical expense policy under this Article 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 the reduction would operate to reduce total benefits payable under the policies below an amount equal to 100% of total allowable expenses provided under the policies.
    (h) 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 shall promulgate rules defining the order of benefit determination under this subsection.
    (i) Discrimination between individuals of the same class of risk in the issuance of policies, in the amount of premiums or rates charged for any insurance covered by this Article, in benefits payable thereon, in any of the terms or conditions of the policy, or in any other manner whatsoever is prohibited. Nothing in this subsection shall prohibit an insurer from providing incentives for insureds to utilize the services of a particular hospital or person.
    (j) No company shall make or permit any distinction or discrimination against individuals solely because of handicaps or disabilities in (i) the amount of payment of premiums or rates charged for policies of insurance, (ii) the amount of any dividends or other benefits payable thereon, or (iii) any other terms and conditions of the contract it makes, except where the distinction or discrimination is based on sound actuarial principles or is related to actual or reasonably anticipated experience.
    (k) No company shall refuse to insure or refuse to continue to insure, limit the amount or extent or kind of coverage available to an individual, or charge an individual a different rate for the same coverage solely because of blindness or partial blindness. With respect to all other conditions, including the underlying cause of the blindness or partial blindness, persons who are blind or partially blind shall be subject to the same standards of sound actuarial principles or actual or reasonably anticipated experience as are sighted persons. Refusal to insure includes denial by an insurer of disability insurance coverage on the grounds that the policy defines "disability" as being presumed in the event that the insured loses his or her eyesight. However, an insurer may exclude from coverage disability consisting solely of blindness or partial blindness when the condition existed at the time the policy was issued.
(Source: P.A. 86-1407.)

215 ILCS 5/351B-5

    (215 ILCS 5/351B-5) (from Ch. 73, par. 963B-5)
    Sec. 351B-5. Applicability of other Code provisions. All policies of accident and health insurance issued under this Article shall be subject to the provisions of Sections 356c, subsection (a) of Section 356g, 356h, 356n, 367c, 367d, 370, 370a, and 370e of this Code.
(Source: P.A. 86-1407; 87-792; 87-1066.)

215 ILCS 5/351B-6

    (215 ILCS 5/351B-6) (from Ch. 73, par. 963B-6)
    Sec. 351B-6. The Director shall by rule prescribe a method to collect data from health insurers and employers relating to the coverage sold under this Article. The data shall include the number of groups purchasing this coverage, the extent to which other coverage has been replaced with this coverage, if any, the number of insureds, and a summary of the types of coverage provided by policies authorized by this Article. Statistically valid survey methods may be used to compile this data.
    Not later than March 31, 1993, the Director shall provide a written report of this data to the Governor and to the General Assembly.
(Source: P.A. 86-1407.)

215 ILCS 5/351B-7

    (215 ILCS 5/351B-7) (from Ch. 73, par. 963B-7)
    Sec. 351B-7. (Repealed).
(Source: Repealed by P.A. 88-190.)

215 ILCS 5/Art. XX

 
    (215 ILCS 5/Art. XX heading)
ARTICLE XX. ACCIDENT AND HEALTH INSURANCE

215 ILCS 5/352

    (215 ILCS 5/352) (from Ch. 73, par. 964)
    Sec. 352. Scope of Article.
    (a) Except as provided in subsections (b), (c), (d), and (e), this Article shall apply to all companies transacting in this State the kinds of business enumerated in clause (b) of Class 1 and clause (a) of Class 2 of section 4. Nothing in this Article shall apply to, or in any way affect policies or contracts described in clause (a) of Class 1 of Section 4; however, this Article shall apply to policies and contracts which contain benefits providing reimbursement for the expenses of long term health care which are certified or ordered by a physician including but not limited to professional nursing care, custodial nursing care, and non-nursing custodial care provided in a nursing home or at a residence of the insured.
    (b) This Article does not apply to policies of accident and health insurance issued in compliance with Article XIXB of this Code.
    (c) A policy issued and delivered in this State that provides coverage under that policy for certificate holders who are neither residents of nor employed in this State does not need to provide to those nonresident certificate holders who are not employed in this State the coverages or services mandated by this Article.
    (d) Stop-loss insurance is exempt from all Sections of this Article, except this Section and Sections 353a, 354, 357.30, and 370. For purposes of this exemption, stop-loss insurance is further defined as follows:
        (1) The policy must be issued to and insure an
    
employer, trustee, or other sponsor of the plan, or the plan itself, but not employees, members, or participants.
        (2) Payments by the insurer must be made to the
    
employer, trustee, or other sponsors of the plan, or the plan itself, but not to the employees, members, participants, or health care providers.
    (e) A policy issued or delivered in this State to the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) and providing coverage, under clause (b) of Class 1 or clause (a) of Class 2 as described in Section 4, to persons who are enrolled under Article V of the Illinois Public Aid Code or under the Children's Health Insurance Program Act is exempt from all restrictions, limitations, standards, rules, or regulations respecting benefits imposed by or under authority of this Code, except those specified by subsection (1) of Section 143. Nothing in this subsection, however, affects the total medical services available to persons eligible for medical assistance under the Illinois Public Aid Code.
(Source: P.A. 95-331, eff. 8-21-07.)

215 ILCS 5/352a

    (215 ILCS 5/352a) (from Ch. 73, par. 964a)
    Sec. 352a. Mandated Coverages. No legislation enacted after the effective date of this Amendatory Act of 1990 which mandates or requires the offering of health care coverages or services shall apply to any insurer unless the legislation applies equally to employee welfare benefit plans described in 29 U.S.C. 1001 et seq.
(Source: P.A. 86-1365.)

215 ILCS 5/353

    (215 ILCS 5/353) (from Ch. 73, par. 965)
    Sec. 353. Non-cancellable accident and health insurance reserves.
    (1) The legal minimum standard for computing the active life reserve, including the unearned premium reserve, of non-cancellable accident and health policies issued on and after January 1 of the year following that during which this Code becomes effective shall be based on Class III Disability Experience with interest at not to exceed three and one-half per centum per annum on the full preliminary term basis; and the minimum standard for computing the active life reserve of such policies issued prior to January 1 of the year following that during which this Code becomes effective shall be such as to place an adequate value, as determined by sound insurance practices, on the liabilities thereunder.
    (2) For policies with a waiting period of less than three (3) months, or providing benefits at ages beyond the limits of Class III Disability Experience, such tables shall be extended to cover the provisions of such policies on such basis as may be approved by the Director.
    (3) The reserve for losses under non-cancellable accident and health policies issued on and after January 1 of the year following that during which this Code becomes effective shall be based on Class III Disability Experience, except that for claims of less than twenty-seven months duration the reserve may be taken as equivalent to the prospective claim payments for three and one-half times the elapsed period of disability, provided, that in no case shall the reserve be less than the equivalent of seven weeks' claim payments; and the minimum standard for computing the reserve for losses under such policies issued prior to January 1 of the year following that during which the Code becomes effective shall be such as to place an adequate value, as determined by sound insurance practices, on such losses.
    (4) The Director shall modify the application of the tables and requirements prescribed in this section to policies or to claims arising under policies in accordance with the waiting period contained in such policies and in accordance with any limitation as to the time for which indemnity is payable. The company shall give the notice required in section 234 on all non-cancellable accident and health policies.
    This section shall apply only to accident and health policies issued prior to the operative date under section 353a as defined therein.
(Source: Laws 1965, p. 740.)

215 ILCS 5/353a

    (215 ILCS 5/353a) (from Ch. 73, par. 965a)
    Sec. 353a. Accident and health reserves.
    The reserves for all accident and health policies issued after the operative date of this section shall be computed and maintained on a basis which shall place an actuarially sound value on the liabilities under such policies. To provide a basis for the determination of such actuarially sound value, the Director from time to time shall adopt rules requiring the use of appropriate tables of morbidity, mortality, interest rates and valuation methods for such reserves. In no event shall such reserves be less than the pro rata gross unearned premium reserve for such policies.
    The company shall give the notice required in section 234 on all non-cancellable accident and health policies.
    After this section becomes effective, any company may file with the Director written notice of its election to comply with the provisions of this section after a specified date before January 1, 1967. After the filing of such notice, then upon such specified date (which shall be the operative date of this section for such company), this section shall become operative with respect to the accident and health policies thereafter issued by such company. If a company makes no such election, the operative date of this section for such company shall be January 1, 1967.
    After this section becomes effective, any company may file with the Director written notice of its election to establish and maintain reserves upon its accident and health policies issued prior to the operative date of this section in accordance with the standards for reserves established by this section, and thereafter the reserve standards prescribed pursuant to this section shall be effective with respect to said accident and health policies issued prior to the operative date of this section.
(Source: Laws 1965, p. 740.)

215 ILCS 5/354

    (215 ILCS 5/354) (from Ch. 73, par. 966)
    Sec. 354. Accident and health loss reserves.
    The loss reserves of all accident and health policies other than non-cancellable accident and health policies shall be computed and maintained in accordance with the applicable provisions of Article XXII. The unearned premium reserve of all accident and health policies other than non-cancellable accident and health policies shall be computed and maintained on the monthly pro rata basis.
    This Section shall apply only to accident and health policies issued prior to the operative date under section 353a as defined therein.
(Source: P.A. 83-584.)

215 ILCS 5/355

    (215 ILCS 5/355) (from Ch. 73, par. 967)
    Sec. 355. Accident and health policies-Provisions.) No policy of insurance against loss or damage from the sickness, or from the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining thereto have been filed with the Director; nor shall it be so issued or delivered until the Director shall have approved such policy pursuant to the provisions of Section 143. If the Director disapproves the policy form he shall make a written decision stating the respects in which such form does not comply with the requirements of law and shall deliver a copy thereof to the company and it shall be unlawful thereafter for any such company to issue any policy in such form.
(Source: P.A. 79-777.)

215 ILCS 5/355.1

    (215 ILCS 5/355.1) (from Ch. 73, par. 967.1)
    Sec. 355.1. No claim for benefits for loss of time from the insured person's occupation, under a group or individual accident and health insurance policy delivered in this State more than 120 days after the effective date of this Section, shall be reduced by reason of any cost-of-living increase, designated as such under the Federal Social Security Act, if such cost-of-living increase occurs while the policy's benefits are payable for that claim.
(Source: P.A. 78-603.)

215 ILCS 5/355.2

    (215 ILCS 5/355.2) (from Ch. 73, par. 967.2)
    Sec. 355.2. Dental coverage reimbursement rates.
    (a) Every company that issues, delivers, amends, or renews any individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of 1991 that provides dental insurance and bases payment for those benefits upon a usual and customary fee charged by licensed dentists must disclose all of the following:
        (1) The frequency of the determination of the usual
    
and customary fee.
        (2) A general description of the methodology used to
    
determine usual and customary fees.
        (3) The percentile that determines the maximum
    
benefit that the company will pay for any dental procedure, if the usual and customary fee is determined by taking a sample of fees submitted on actual claims from licensed dentists and then determining the benefit by selecting a percentile of those fees.
    (b) The disclosure must be provided upon request to all group and individual policy holders and group certificate holders. All proposals for dental insurance must notify the prospective policy holder that information regarding usual and customary fee determinations is available from the insurer. All employee benefit descriptions or supplemental documents must notify the employee that information regarding reimbursement rates is available from the employer.
(Source: P.A. 87-587.)

215 ILCS 5/355.3

    (215 ILCS 5/355.3)
    Sec. 355.3. Noncovered dental services.
    (a) In this Section:
    "Covered services" means dental care services for which a reimbursement is available under an enrollee's plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
    "Dental insurance" means any policy of insurance that is issued by a company that provides coverage for dental services not covered by a medical plan.
    (b) No company that issues, delivers, amends, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 97th General Assembly that provides dental insurance shall issue a service provider contract that requires a dentist to provide services to the insurer's policyholders at a fee set by the insurer unless the services are covered services under the applicable policyholder agreement.
(Source: P.A. 97-805, eff. 1-1-13.)

215 ILCS 5/355a

    (215 ILCS 5/355a) (from Ch. 73, par. 967a)
    Sec. 355a. Standardization of terms and coverage.
    (1) The purpose of this Section shall be (a) to provide reasonable standardization and simplification of terms and coverages of individual accident and health insurance policies to facilitate public understanding and comparisons; (b) to eliminate provisions contained in individual accident and health insurance policies which may be misleading or unreasonably confusing in connection either with the purchase of such coverages or with the settlement of claims; and (c) to provide for reasonable disclosure in the sale of accident and health coverages.
    (2) Definitions applicable to this Section are as follows:
        (a) "Policy" means all or any part of the forms
    
constituting the contract between the insurer and the insured, including the policy, certificate, subscriber contract, riders, endorsements, and the application if attached, which are subject to filing with and approval by the Director.
        (b) "Service corporations" means voluntary health and
    
dental corporations organized and operating respectively under the Voluntary Health Services Plans Act and the Dental Service Plan Act.
        (c) "Accident and health insurance" means insurance
    
written under Article XX of the Insurance Code, other than credit accident and health insurance, and coverages provided in subscriber contracts issued by service corporations. For purposes of this Section such service corporations shall be deemed to be insurers engaged in the business of insurance.
    (3) The Director shall issue such rules as he shall deem necessary or desirable to establish specific standards, including standards of full and fair disclosure that set forth the form and content and required disclosure for sale, of individual policies of accident and health insurance, which rules and regulations shall be in addition to and in accordance with the applicable laws of this State, and which may cover but shall not be limited to: (a) terms of renewability; (b) initial and subsequent conditions of eligibility; (c) non-duplication of coverage provisions; (d) coverage of dependents; (e) pre-existing conditions; (f) termination of insurance; (g) probationary periods; (h) limitation, exceptions, and reductions; (i) elimination periods; (j) requirements regarding replacements; (k) recurrent conditions; and (l) the definition of terms including but not limited to the following: hospital, accident, sickness, injury, physician, accidental means, total disability, partial disability, nervous disorder, guaranteed renewable, and non-cancellable.
    The Director may issue rules that specify prohibited policy provisions not otherwise specifically authorized by statute which in the opinion of the Director are unjust, unfair or unfairly discriminatory to the policyholder, any person insured under the policy, or beneficiary.
    (4) The Director shall issue such rules as he shall deem necessary or desirable to establish minimum standards for benefits under each category of coverage in individual accident and health policies, other than conversion policies issued pursuant to a contractual conversion privilege under a group policy, including but not limited to the following categories: (a) basic hospital expense coverage; (b) basic medical-surgical expense coverage; (c) hospital confinement indemnity coverage; (d) major medical expense coverage; (e) disability income protection coverage; (f) accident only coverage; and (g) specified disease or specified accident coverage.
    Nothing in this subsection (4) shall preclude the issuance of any policy which combines two or more of the categories of coverage enumerated in subparagraphs (a) through (f) of this subsection.
    No policy shall be delivered or issued for delivery in this State which does not meet the prescribed minimum standards for the categories of coverage listed in this subsection unless the Director finds that such policy is necessary to meet specific needs of individuals or groups and such individuals or groups will be adequately informed that such policy does not meet the prescribed minimum standards, and such policy meets the requirement that the benefits provided therein are reasonable in relation to the premium charged. The standards and criteria to be used by the Director in approving such policies shall be included in the rules required under this Section with as much specificity as practicable.
    The Director shall prescribe by rule the method of identification of policies based upon coverages provided.
    (5) (a) In order to provide for full and fair disclosure in the sale of individual accident and health insurance policies, no such policy shall be delivered or issued for delivery in this State unless the outline of coverage described in paragraph (b) of this subsection either accompanies the policy, or is delivered to the applicant at the time the application is made, and an acknowledgment signed by the insured, of receipt of delivery of such outline, is provided to the insurer. In the event the policy is issued on a basis other than that applied for, the outline of coverage properly describing the policy must accompany the policy when it is delivered and such outline shall clearly state that the policy differs, and to what extent, from that for which application was originally made. All policies, except single premium nonrenewal policies, shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance, that the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if after examination of the policy the policyholder is not satisfied for any reason.
    (b) The Director shall issue such rules as he shall deem necessary or desirable to prescribe the format and content of the outline of coverage required by paragraph (a) of this subsection. "Format" means style, arrangement, and overall appearance, including such items as the size, color, and prominence of type and the arrangement of text and captions. "Content" shall include without limitation thereto, statements relating to the particular policy as to the applicable category of coverage prescribed under subsection 4; principal benefits; exceptions, reductions and limitations; and renewal provisions, including any reservation by the insurer of a right to change premiums. Such outline of coverage shall clearly state that it constitutes a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.
    (6) Prior to the issuance of rules pursuant to this Section, the Director shall afford the public, including the companies affected thereby, reasonable opportunity for comment. Such rulemaking is subject to the provisions of the Illinois Administrative Procedure Act.
    (7) When a rule has been adopted, pursuant to this Section, all policies of insurance or subscriber contracts which are not in compliance with such rule shall, when so provided in such rule, be deemed to be disapproved as of a date specified in such rule not less than 120 days following its effective date, without any further or additional notice other than the adoption of the rule.
    (8) When a rule adopted pursuant to this Section so provides, a policy of insurance or subscriber contract which does not comply with the rule shall not less than 120 days from the effective date of such rule, be construed, and the insurer or service corporation shall be liable, as if the policy or contract did comply with the rule.
    (9) Violation of any rule adopted pursuant to this Section shall be a violation of the insurance law for purposes of Sections 370 and 446 of the Insurance Code.
(Source: P.A. 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; 90-655, eff. 7-30-98.)

215 ILCS 5/355b

    (215 ILCS 5/355b)
    Sec. 355b. Claim-related information; alternative means of communication.
    (a) For the purposes of this Section, "claim-related information" means all claim or billing information relating specifically to an insured, subscriber, or person covered by an individual or group policy of accident and health insurance issued, delivered, amended, or renewed by a company doing business in this State.
    (b) A company that issues, delivers, amends, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 98th General Assembly shall accommodate a reasonable request by a person covered by a policy issued by the company to receive communications of claim-related information from the company by alternative means or at alternative locations if the person clearly states that disclosure of all or part of the information could endanger the person.
    (c) If a child is covered by a policy issued by a company, then the child's parent or guardian may make a request to the company pursuant to subsection (b) of this Section.
    (d) A company may require (1) a person making a request pursuant to subsection (b) of this Section to do so in writing, (2) the request to contain a statement that disclosure of all or part of the claim-related information to which the request pertains could endanger the person or child, and (3) the specification of an alternative address, telephone number, or other method of contact.
    (e) Except with the express consent of the person making a request pursuant to subsection (b) of this Section, a company may not disclose to the policyholder (1) the address, telephone number, or any other personally identifying information of the person who made the request or child for whose benefit a request was made, (2) the nature of the health care services provided, or (3) the name or address of the provider of the health care services.
    (f) A company that makes reasonable and good faith efforts to comply with this Section shall not be subject to civil or criminal liability on the grounds of noncompliance with this Section.
    (g) The Director shall adopt rules to guide companies in guarding against the disclosure of the information protected pursuant to this Section.
    (h) Nothing in this Section shall prevent, hinder, or otherwise affect the entry of an appropriate order made in the best interests of a child by a court of competent jurisdiction adjudicating disputed issues of child welfare or custody.
(Source: P.A. 98-189, eff. 1-1-14.)

215 ILCS 5/356a

    (215 ILCS 5/356a) (from Ch. 73, par. 968a)
    Sec. 356a. Form of policy.
    (1) No policy of accident and health insurance shall be delivered or issued for delivery to any person in this state unless:
    (a) the entire money and other considerations therefor are expressed therein; and
    (b) the time at which the insurance takes effect and terminates is expressed therein; and
    (c) it purports to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, any two or more eligible members of that family, including husband, wife, dependent children or any children under a specified age which shall not exceed 19 years and any other person dependent upon the policyholder; and
    (d) the style, arrangement and over-all appearance of the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than ten-point with a lower-case unspaced alphabet length not less than one hundred and twenty-point (the "text" shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and captions and subcaptions); and
    (e) the exceptions and reductions of indemnity are set forth in the policy and, except those which are set forth in Sections 357.1 through 357.30 of this act, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and
    (f) each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and
    (g) it contains no provision purporting to make any portion of the charter, rules, constitution, or by-laws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the Director.
    (2) If any policy is issued by an insurer domiciled in this state for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the Director that any such policy is not subject to approval or disapproval by such official, the Director may by ruling require that such policy meet the standards set forth in subsection (1) of this section and in Sections 357.1 through 357.30.
(Source: P.A. 76-860.)

215 ILCS 5/356b

    (215 ILCS 5/356b) (from Ch. 73, par. 968b)
    Sec. 356b. (a) This Section applies to the hospital and medical expense provisions of an accident or health insurance policy.
    (b) If a policy provides that coverage of a dependent person 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 handicapped 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 policyholder 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 disabled and dependent person and, in the absence of proof submitted within 60 days of such inquiry that such dependent is a disabled and dependent person may terminate coverage of such person at or after attainment of the limiting age. In the absence of such inquiry, coverage of any disabled and dependent person shall continue through the term of such policy or any extension or renewal thereof.
    (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. 95-331, eff. 8-21-07.)

215 ILCS 5/356c

    (215 ILCS 5/356c) (from Ch. 73, par. 968c)
    Sec. 356c. (1) No policy of accident and health insurance providing coverage of hospital expenses or medical expenses or both on an expense incurred basis which in addition to covering the insured, also covers members of the insured's immediate family, shall contain any disclaimer, waiver or other limitation of coverage relative to the hospital or medical coverage or insurability of newborn infants from and after the moment of birth.
    (2) Each such policy of accident and health insurance shall contain a provision stating that the accident and health insurance benefits applicable for children shall be granted immediately with respect to a newly born child from the moment of birth. The coverage for newly born children shall include coverage of illness, injury, congenital defects, birth abnormalities and premature birth.
    (3) If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of a newly born child must be furnished to the insurer within 31 days after the date of birth in order to have the coverage continue beyond such 31 day period and may require payment of the appropriate premium.
    (4) In the event that no other members of the insured's immediate family are covered, immediate coverage for the first newborn infant shall be provided if the insured applies for dependent's coverage within 31 days of the newborn's birth. Such coverage shall be contingent upon payment of the additional premium.
    (5) The requirements of this Section shall apply, on or after the sixtieth day following the effective date of this Section, (a) to all such non-group policies delivered or issued for delivery, and (b) to all such group policies delivered, issued for delivery, renewed or amended. The insurers of such non-group policies in effect on the sixtieth day following the effective date of this Section shall extend to owners of said policies, on or before the first policy anniversary following such date, the opportunity to apply for the addition to their policies of a provision as set forth in paragraph (2) above, with, at the option of the insurer, payment of a premium appropriate thereto.
(Source: P.A. 85-220.)

215 ILCS 5/356d

    (215 ILCS 5/356d) (from Ch. 73, par. 968d)
    Sec. 356d. Conversion privileges for insured former spouses. (1) No policy of accident and health insurance providing coverage of hospital and/or medical expense on either an expense incurred basis or other than an expense incurred basis, which in addition to covering the insured also provides coverage to the spouse of the insured shall contain a provision for termination of coverage for a spouse covered under the policy solely as a result of a break in the marital relationship except by reason of an entry of a valid judgment of dissolution of marriage between the parties.
    (2) Every policy which contains a provision for termination of coverage of the spouse upon dissolution of marriage shall contain a provision to the effect that upon the entry of a valid judgment of dissolution of marriage between the insured parties the spouse whose marriage was dissolved shall be entitled to have issued to him or her, without evidence of insurability, upon application made to the company within 60 days following the entry of such judgment, and upon the payment of the appropriate premium, an individual policy of accident and health insurance. Such policy shall provide the coverage then being issued by the insurer which is most nearly similar to, but not greater than, such terminated coverages. Any and all probationary and/or waiting periods set forth in such policy shall be considered as being met to the extent coverage was in force under the prior policy.
    (3) The requirements of this Section shall apply to all policies delivered or issued for delivery on or after the 60th day following the effective date of this Section.
(Source: P.A. 84-545.)

215 ILCS 5/356e

    (215 ILCS 5/356e) (from Ch. 73, par. 968e)
    Sec. 356e. Victims of certain offenses.
    (1) No policy of accident and health insurance, which provides benefits for hospital or medical expenses based upon the actual expenses incurred, delivered or issued for delivery to any person in this State shall contain any specific exception to coverage which would preclude the payment under that policy 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 a victim of such offense arising out of the offense. Every 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 Section shall not apply to a policy which covers hospital and medical expenses for specified illnesses or injuries only.
    (2) 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.
    (3) 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 claims before the carrier has paid such benefits to its insureds or in behalf of its insureds.
(Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13.)

215 ILCS 5/356f

    (215 ILCS 5/356f) (from Ch. 73, par. 968f)
    Sec. 356f. No policy of accident or health insurance or any renewal thereof shall be denied or cancelled by the insurer, nor shall any such policy contain any exception or exclusion of benefits, solely because the mother of the insured has taken diethylstilbestrol, commonly referred to as DES.
(Source: P.A. 81-656.)

215 ILCS 5/356g

    (215 ILCS 5/356g) (from Ch. 73, par. 968g)
    Sec. 356g. Mammograms; mastectomies.
    (a) Every insurer shall provide in each group or individual policy, contract, or certificate of insurance issued or renewed for persons who are residents of this State, coverage for screening by low-dose mammography for all women 35 years of age or older for the presence of occult breast cancer within the provisions of the policy, contract, or certificate. The coverage shall be as follows:
         (1) A baseline mammogram for women 35 to 39 years of
    
age.
         (2) An annual mammogram for women 40 years of age or
    
older.
         (3) A mammogram at the age and intervals considered
    
medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
        (4) A comprehensive ultrasound screening of an entire
    
breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
    For purposes of this Section, "low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with radiation exposure delivery of less than 1 rad per breast for 2 views of an average size breast. The term also includes digital mammography.
    (a-5) Coverage as described by subsection (a) shall be provided at no cost to the insured and shall not be applied to an annual or lifetime maximum benefit.
    (a-10) When health care services are available through contracted providers and a person does not comply with plan provisions specific to the use of contracted providers, the requirements of subsection (a-5) are not applicable. When a person does not comply with plan provisions specific to the use of contracted providers, plan provisions specific to the use of non-contracted providers must be applied without distinction for coverage required by this Section and shall be at least as favorable as for other radiological examinations covered by the policy or contract.
    (b) No policy of accident or health insurance that provides for the surgical procedure known as a mastectomy shall be issued, amended, delivered, or renewed in this State unless that coverage also provides for prosthetic devices or reconstructive surgery incident to the mastectomy. Coverage for breast reconstruction in connection with a mastectomy shall include:
        (1) reconstruction of the breast upon which the
    
mastectomy has been performed;
        (2) surgery and reconstruction of the other breast to
    
produce a symmetrical appearance; and
        (3) prostheses and treatment for physical
    
complications at all stages of mastectomy, including lymphedemas.
Care shall be determined in consultation with the attending physician and the patient. The offered coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy, and all other terms and conditions applicable to other benefits. When a mastectomy is performed and there is no evidence of malignancy then the offered coverage may be limited to the provision of prosthetic devices and reconstructive surgery to within 2 years after the date of the mastectomy. As used in this Section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician.
    Written notice of the availability of coverage under this Section shall be delivered to the insured upon enrollment and annually thereafter. An insurer may not deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Section. An insurer may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives (monetary or otherwise) to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with this Section.
    (c) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; 95-1045, eff. 3-27-09.)

215 ILCS 5/356g.5

    (215 ILCS 5/356g.5)
    Sec. 356g.5. Clinical breast exam.
    (a) The General Assembly finds that clinical breast examinations are a critical tool in the early detection of breast cancer, while the disease is in its earlier and potentially more treatable stages. Insurer reimbursement of clinical breast examinations is essential to the effort to reduce breast cancer deaths in Illinois.
    (b) Every insurer shall provide, in each group or individual policy, contract, or certificate of accident or health insurance issued or renewed for persons who are residents of Illinois, coverage for complete and thorough clinical breast examinations as indicated by guidelines of practice, performed by a physician licensed to practice medicine in all its branches, an advanced practice nurse who has a collaborative agreement with a collaborating physician that authorizes breast examinations, or a physician assistant who has been delegated authority to provide breast examinations, to check for lumps and other changes for the purpose of early detection and prevention of breast cancer as follows:
        (1) at least every 3 years for women at least 20
    
years of age but less than 40 years of age; and
        (2) annually for women 40 years of age or older.
    (c) Upon approval of a nationally recognized separate and distinct clinical breast exam code that is compliant with all State and federal laws, rules, and regulations, public and private insurance plans shall take action to cover clinical breast exams on a separate and distinct basis.
(Source: P.A. 95-189, eff. 8-16-07.)

215 ILCS 5/356g.5-1

    (215 ILCS 5/356g.5-1)
    Sec. 356g.5-1. Breast cancer pain medication and therapy. A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage for all medically necessary pain medication and pain therapy related to the treatment of breast cancer on the same terms and conditions that are generally applicable to coverage for other conditions. For purposes of this Section, "pain therapy" means pain therapy that is medically based and includes reasonably defined goals, including, but not limited to, stabilizing or reducing pain, with periodic evaluations of the efficacy of the pain therapy against these goals. The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified-disease policies, or to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under State or federal governmental plans.
    Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 95-1045, eff. 3-27-09.)

215 ILCS 5/356h

    (215 ILCS 5/356h) (from Ch. 73, par. 968h)
    Sec. 356h. No individual or group policy of accident and health insurance which covers the insured's immediate family or children, as well as covering the insured, shall exclude a child from coverage or limit coverage for a child solely because the child is an adopted child, or solely because the child does not reside with the insured. For purposes of this Section, a child who is in the custody of the insured, pursuant to an interim court order of adoption or, in the case of group insurance, placement of adoption, whichever comes first, vesting temporary care of the child in the insured, is an adopted child, regardless of whether a final order granting adoption is ultimately issued.
(Source: P.A. 91-549, eff. 8-14-99.)

215 ILCS 5/356i

    (215 ILCS 5/356i) (from Ch. 73, par. 968i)
    Sec. 356i. Medical assistance; coverage of child.
    (a) In this Section, "Medicaid" means medical assistance authorized under Section 1902 of the Social Security Act.
    (b) An individual or group policy of accident and health insurance that is delivered or issued for delivery to any person in this State or renewed or amended may not contain any provision which limits or excludes payments of hospital or medical benefits coverage to or on behalf of the insured because the insured or any covered dependent is eligible for or receiving Medicaid benefits in this or any other state.
    (c) To the extent that payment for covered expenses has been made under Article V, VI, or VII of the Illinois Public Aid Code for health care services provided to an individual, if a third party has a legal liability to make payments for those health care services, the State is considered to have acquired the rights of the individual to payment.
    (d) If a child is covered under an accident and health insurance policy issued to the child's noncustodial parent, the issuer of the policy shall do all of the following:
        (1) Provide necessary information to the child's
    
custodial parent to enable the child to obtain benefits under that coverage.
        (2) Permit the child's custodial parent (or the
    
provider, with the custodial parent's approval) to submit claims for payment for covered services without the approval of the noncustodial parent.
        (3) Make payments on claims submitted in accordance
    
with paragraph (2) directly to the custodial parent, the provider of health care services, or the state Medicaid agency.
    (e) An insurer may not deny enrollment of a child under the accident and health insurance coverage of the child's parent on any of the following grounds:
        (1) The child was born out of wedlock.
        (2) The child is not claimed as a dependent on the
    
parent's federal income tax return.
        (3) The child does not reside with the parent or in
    
the insurer's service area.
    (f) If a parent is required by a court or administrative order to provide accident and health insurance coverage for a child and the parent is insured under a plan that offers coverage for eligible dependents, the insurer, upon receiving a copy of the order, shall:
        (1) Upon application, permit the parent to add to the
    
parent's coverage such a child who is otherwise eligible for that coverage, without regard to any enrollment season restrictions.
        (2) Add the child to the parent's coverage upon
    
application of the child's other parent, the state agency administering the Medicaid program, or the state agency administering a program for enforcing child support and establishing paternity under 42 U.S.C. 651 through 669 (or another child support enforcement program), if the parent is covered but fails to apply for coverage for the child.
    (g) An insurer may not impose, on a state agency that has been assigned the rights of a covered individual who receives Medicaid benefits, requirements that are different from requirements applicable to an assignee of any other individual covered under the same insurance policy.
    (h) Nothing in subsections (e) and (f) prevents an insurer from denying any such application if the child is not eligible for coverage according to the insurer's medical underwriting standards.
    (i) The insurer may not eliminate coverage of such a child unless the insurer is provided satisfactory written evidence of either of the following:
        (1) The court or administrative order is no longer in
    
effect.
        (2) The child is or will be covered under a
    
comparable health care plan obtained by the parent under such order and that coverage is currently in effect or will take effect not later than the date the prior coverage is terminated.
(Source: P.A. 89-183, eff. 1-1-96.)

215 ILCS 5/356j

    (215 ILCS 5/356j) (from Ch. 73, par. 968j)
    Sec. 356j. (Repealed).
(Source: Repealed by P.A. 89-183, eff. 1-1-96.)

215 ILCS 5/356K

    (215 ILCS 5/356K) (from Ch. 73, par. 968K)
    Sec. 356K. Coverage for Organ Transplantation Procedures. No accident and health insurer providing coverage under this Act for hospital or medical expenses 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.
(Source: P.A. 87-218.)

215 ILCS 5/356L

    (215 ILCS 5/356L) (from Ch. 73, par. 968L)
    Sec. 356L. No policy of accident or health insurance shall include any provision which shall have the effect of denying coverage to or on behalf of an insured under such policy on the basis of a failure by the insured to file a notice of claim within the time period required by the policy, provided such failure is caused solely by the physical inability or mental incapacity of the insured to file such notice of claim because of a period of emergency hospitalization.
(Source: P.A. 86-784.)

215 ILCS 5/356m

    (215 ILCS 5/356m) (from Ch. 73, par. 968m)
    Sec. 356m. Infertility coverage.
    (a) No group policy of accident and health insurance providing coverage for more than 25 employees that provides pregnancy related benefits may be issued, amended, delivered, or renewed in this State after the effective date of this amendatory Act of 1991 unless the policy contains coverage for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.
    (b) The coverage required under subsection (a) is subject to the following conditions:
        (1) Coverage for procedures for in vitro
    
fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if:
            (A) the covered individual has been unable to
        
attain or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract;
            (B) the covered individual has not undergone 4
        
completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and
            (C) the procedures are performed at medical
        
facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.
        (2) The procedures required to be covered under this
    
Section are not required to be contained in any policy or plan issued to or by a religious institution or organization or to or by an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this Section to violate its religious and moral teachings and beliefs.
    (c) For purpose of this Section, "infertility" means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.
(Source: P.A. 89-669, eff. 1-1-97.)

215 ILCS 5/356n

    (215 ILCS 5/356n) (from Ch. 73, par. 968n)
    Sec. 356n. Fibrocystic condition; denial of coverage. No group or individual policy of accident or health insurance or any renewal thereof shall be denied by the insurer, nor shall any policy contain any exception or exclusion of benefits, solely because the insured has been diagnosed as having a fibrocystic breast condition, unless the condition is diagnosed by a breast biopsy that demonstrates an increased disposition to the development of breast cancer or unless the insured's medical history confirms a chronic, relapsing, symptomatic breast condition.
(Source: P.A. 87-519; 87-895; 87-1066.)

215 ILCS 5/356p

    (215 ILCS 5/356p) (from Ch. 73, par. 968p)
    Sec. 356p. Breast implant removal. No individual or group policy of accident and health insurance shall deny coverage for the removal of breast implants when the removal of the implants is medically necessary treatment for a sickness or injury. This Section does not apply to surgery performed for removal of breast implants that were implanted solely for cosmetic reasons. For the purpose of this Section, cosmetic reasons does not include cosmetic surgery performed as reconstruction resulting from sickness or injury.
(Source: P.A. 87-938.)

215 ILCS 5/356q

    (215 ILCS 5/356q)
    Sec. 356q. On or after the effective date of this Section, every insurer which delivers or issues for delivery in this State a group accident and health policy providing coverage for hospital, medical, or surgical treatment on an expense-incurred basis shall offer, for an additional premium and subject to the insurer's standard of insurability, optional coverage for the reasonable and necessary medical treatment of temporomandibular joint disorder and craniomandibular disorder. The group policyholder shall accept or reject the coverage in writing on the application or an amendment thereto for the master group policy. Benefits may be subject to the same pre-existing conditions, limitations, deductibles, co-payments and co-insurance that generally apply to any other sickness. The maximum lifetime benefits for temporomandibular joint disorder and craniomandibular treatment shall be no less than $2,500. Nothing herein shall prevent an insurer from including such coverage for temporomandibular joint disorder and craniomandibular disorder as part of a policy's basic coverage, in lieu of offering optional coverage.
(Source: P.A. 88-592, eff. 1-1-95.)

215 ILCS 5/356r

    (215 ILCS 5/356r)
    Sec. 356r. Woman's principal health care provider.
    (a) An individual or group policy of accident and health insurance or a managed care plan amended, delivered, issued, or renewed in this State after November 14, 1996 that requires an insured or enrollee to designate an individual to coordinate care or to control access to health care services shall also permit a female insured or enrollee to designate a participating woman's principal health care provider, and the insurer or managed care plan shall provide the following written notice to all female insureds or enrollees no later than 120 days after the effective date of this amendatory Act of 1998; to all new enrollees at the time of enrollment; and thereafter to all existing enrollees at least annually, as a part of a regular publication or informational mailing:
"NOTICE TO ALL FEMALE PLAN MEMBERS:
YOUR RIGHT TO SELECT A WOMAN'S PRINCIPAL
HEALTH CARE PROVIDER.
        Illinois law allows you to select "a woman's
    
principal health care provider" in addition to your selection of a primary care physician. A woman's principal health care provider is a physician licensed to practice medicine in all its branches specializing in obstetrics or gynecology or specializing in family practice. A woman's principal health care provider may be seen for care without referrals from your primary care physician. If you have not already selected a woman's principal health care provider, you may do so now or at any other time. You are not required to have or to select a woman's principal health care provider.
        Your woman's principal health care provider must be a
    
part of your plan. You may get the list of participating obstetricians, gynecologists, and family practice specialists from your employer's employee benefits coordinator, or for your own copy of the current list, you may call [insert plan's toll free number]. The list will be sent to you within 10 days after your call. To designate a woman's principal health care provider from the list, call [insert plan's toll free number] and tell our staff the name of the physician you have selected.".
If the insurer or managed care plan exercises the option set forth in subsection (a-5), the notice shall also state:
        "Your plan requires that your primary care physician
    
and your woman's principal health care provider have a referral arrangement with one another. If the woman's principal health care provider that you select does not have a referral arrangement with your primary care physician, you will have to select a new primary care physician who has a referral arrangement with your woman's principal health care provider or you may select a woman's principal health care provider who has a referral arrangement with your primary care physician. The list of woman's principal health care providers will also have the names of the primary care physicians and their referral arrangements.".
    No later than 120 days after the effective date of this amendatory Act of 1998, the insurer or managed care plan shall provide each employer who has a policy of insurance or a managed care plan with the insurer or managed care plan with a list of physicians licensed to practice medicine in all its branches specializing in obstetrics or gynecology or specializing in family practice who have contracted with the plan. At the time of enrollment and thereafter within 10 days after a request by an insured or enrollee, the insurer or managed care plan also shall provide this list directly to the insured or enrollee. The list shall include each physician's address, telephone number, and specialty. No insurer or plan formal or informal policy may restrict a female insured's or enrollee's right to designate a woman's principal health care provider, except as set forth in subsection (a-5). If the female enrollee is an enrollee of a managed care plan under contract with the Department of Healthcare and Family Services, the physician chosen by the enrollee as her woman's principal health care provider must be a Medicaid-enrolled provider. This requirement does not require a female insured or enrollee to make a selection of a woman's principal health care provider. The female insured or enrollee may designate a physician licensed to practice medicine in all its branches specializing in family practice as her woman's principal health care provider.
    (a-5) The insured or enrollee may be required by the insurer or managed care plan to select a woman's principal health care provider who has a referral arrangement with the insured's or enrollee's individual who coordinates care or controls access to health care services if such referral arrangement exists or to select a new individual to coordinate care or to control access to health care services who has a referral arrangement with the woman's principal health care provider chosen by the insured or enrollee, if such referral arrangement exists. If an insurer or a managed care plan requires an insured or enrollee to select a new physician under this subsection (a-5), the insurer or managed care plan must provide the insured or enrollee with both options to select a new physician provided in this subsection (a-5).
    Notwithstanding a plan's restrictions of the frequency or timing of making designations of primary care providers, a female enrollee or insured who is subject to the selection requirements of this subsection, may, at any time, effect a change in primary care physicians in order to make a selection of a woman's principal health care provider.
    (a-6) If an insurer or managed care plan exercises the option in subsection (a-5), the list to be provided under subsection (a) shall identify the referral arrangements that exist between the individual who coordinates care or controls access to health care services and the woman's principal health care provider in order to assist the female insured or enrollee to make a selection within the insurer's or managed care plan's requirement.
    (b) If a female insured or enrollee has designated a woman's principal health care provider, then the insured or enrollee must be given direct access to the woman's principal health care provider for services covered by the policy or plan without the need for a referral or prior approval. Nothing shall prohibit the insurer or managed care plan from requiring prior authorization or approval from either a primary care provider or the woman's principal health care provider for referrals for additional care or services.
    (c) For the purposes of this Section the following terms are defined:
        (1) "Woman's principal health care provider" means a
    
physician licensed to practice medicine in all of its branches specializing in obstetrics or gynecology or specializing in family practice.
        (2) "Managed care entity" means any entity including
    
a licensed insurance company, hospital or medical service plan, health maintenance organization, limited health service organization, preferred provider organization, third party administrator, an employer or employee organization, or any person or entity that establishes, operates, or maintains a network of participating providers.
        (3) "Managed care plan" means a plan operated by a
    
managed care entity that provides for the financing of health care services to persons enrolled in the plan through:
            (A) organizational arrangements for ongoing
        
quality assurance, utilization review programs, or dispute resolution; or
            (B) financial incentives for persons enrolled in
        
the plan to use the participating providers and procedures covered by the plan.
        (4) "Participating provider" means a physician who
    
has contracted with an insurer or managed care plan to provide services to insureds or enrollees as defined by the contract.
    (d) The original provisions of this Section became law on July 17, 1996 and took effect November 14, 1996, which is 120 days after becoming law.
(Source: P.A. 95-331, eff. 8-21-07.)

215 ILCS 5/356s

    (215 ILCS 5/356s)
    Sec. 356s. Post-parturition care. An individual or group policy of accident and health insurance that provides maternity coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1996 shall provide coverage for the following:
        (1) a minimum of 48 hours of inpatient care following
    
a vaginal delivery for the mother and the newborn, except as otherwise provided in this Section; or
        (2) a minimum of 96 hours of inpatient care following
    
a delivery by caesarian section for the mother and newborn, except as otherwise provided in this Section.
    A shorter length of hospital inpatient stay for services related to maternity and newborn care may be provided if the attending physician licensed to practice medicine in all of its branches determines, in accordance with the protocols and guidelines developed by the American College of Obstetricians and Gynecologists or the American Academy of Pediatrics, that the mother and the newborn meet the appropriate guidelines for that length of stay based upon evaluation of the mother and newborn and the coverage and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the infant in the first 48 hours after discharge.
(Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)

215 ILCS 5/356t

    (215 ILCS 5/356t)
    Sec. 356t. Post-mastectomy care. An individual or group policy of accident and health insurance or managed care plan that provides surgical coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1997 shall provide inpatient coverage following a mastectomy for a length of time determined by the attending physician to be medically necessary and in accordance with protocols and guidelines based on sound scientific evidence and upon evaluation of the patient and the coverage for and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the patient in the first 48 hours after discharge.
(Source: P.A. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98.)

215 ILCS 5/356u

    (215 ILCS 5/356u)
    Sec. 356u. Pap tests and prostate-specific antigen tests.
    (a) A group policy of accident and health insurance that provides coverage for hospital or medical treatment or services for illness on an expense-incurred basis and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1997 shall provide coverage for all of the following:
        (1) An annual cervical smear or Pap smear test for
    
female insureds.
        (2) An annual digital rectal examination and a
    
prostate-specific antigen test, for male insureds upon the recommendation of a physician licensed to practice medicine in all its branches for:
            (A) asymptomatic men age 50 and over;
            (B) African-American men age 40 and over; and
            (C) men age 40 and over with a family history of
        
prostate cancer.
        (3) Surveillance tests for ovarian cancer for female
    
insureds who are at risk for ovarian cancer.
    (b) This Section shall not apply to agreements, contracts, or policies that provide coverage for a specified disease or other limited benefit coverage.
    (c) For the purposes of this Section:
    "At risk for ovarian cancer" means:
        (1) having a family history (i) with one or more
    
first-degree relatives with ovarian cancer, (ii) of clusters of women relatives with breast cancer, or (iii) of nonpolyposis colorectal cancer; or
        (2) testing positive for BRCA1 or BRCA2 mutations.
    "Surveillance tests for ovarian cancer" means annual screening using (i) CA-125 serum tumor marker testing, (ii) transvaginal ultrasound, (iii) pelvic examination.
(Source: P.A. 94-122, eff. 1-1-06.)

215 ILCS 5/356v

    (215 ILCS 5/356v)
    Sec. 356v. Use of information derived from genetic testing. After the effective date of this amendatory Act of 1997, an insurer must comply with the provisions of the Genetic Information Privacy Act in connection with the amendment, delivery, issuance, or renewal of, or claims for or denial of coverage under, an individual or group policy of accident and health insurance. Additionally, genetic information shall not be treated as a condition described in item (1) of subsection (A) of Section 20 of the Illinois Health Insurance Portability and Accountability Act in the absence of a diagnosis of the condition related to that genetic information.
(Source: P.A. 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 91-549, eff. 8-14-99.)

215 ILCS 5/356w

    (215 ILCS 5/356w)
    Sec. 356w. Diabetes self-management training and education.
    (a) A group policy of accident and health insurance that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1998 shall provide coverage for outpatient self-management training and education, equipment, and supplies, as set forth in this Section, for the treatment of type 1 diabetes, type 2 diabetes, and gestational diabetes mellitus.
    (b) As used in this Section:
    "Diabetes self-management training" means instruction in an outpatient setting which enables a diabetic patient to understand the diabetic management process and daily management of diabetic therapy as a means of avoiding frequent hospitalization and complications. Diabetes self-management training shall include the content areas listed in the National Standards for Diabetes Self-Management Education Programs as published by the American Diabetes Association, including medical nutrition therapy and education programs, as defined by the contract of insurance, that allow the patient to maintain an A1c level within the range identified in nationally recognized standards of care.
    "Medical nutrition therapy" shall have the meaning ascribed to that term in the Dietitian Nutritionist Practice Act.
    "Physician" means a physician licensed to practice medicine in all of its branches providing care to the individual.
    "Qualified provider" for an individual that is enrolled in:
        (1) a health maintenance organization that uses a
    
primary care physician to control access to specialty care means (A) the individual's primary care physician licensed to practice medicine in all of its branches, (B) a physician licensed to practice medicine in all of its branches to whom the individual has been referred by the primary care physician, or (C) a certified, registered, or licensed network health care professional with expertise in diabetes management to whom the individual has been referred by the primary care physician.
        (2) an insurance plan means (A) a physician licensed
    
to practice medicine in all of its branches or (B) a certified, registered, or licensed health care professional with expertise in diabetes management to whom the individual has been referred by a physician.
    (c) Coverage under this Section for diabetes self-management training, including medical nutrition education, shall be limited to the following:
        (1) Up to 3 medically necessary visits to a qualified
    
provider upon initial diagnosis of diabetes by the patient's physician or, if diagnosis of diabetes was made within one year prior to the effective date of this amendatory Act of 1998 where the insured was a covered individual, up to 3 medically necessary visits to a qualified provider within one year after that effective date.
        (2) Up to 2 medically necessary visits to a qualified
    
provider upon a determination by a patient's physician that a significant change in the patient's symptoms or medical condition has occurred. A "significant change" in condition means symptomatic hyperglycemia (greater than 250 mg/dl on repeated occasions), severe hypoglycemia (requiring the assistance of another person), onset or progression of diabetes, or a significant change in medical condition that would require a significantly different treatment regimen.
    Payment by the insurer or health maintenance organization for the coverage required for diabetes self-management training pursuant to the provisions of this Section is only required to be made for services provided. No coverage is required for additional visits beyond those specified in items (1) and (2) of this subsection.
    Coverage under this subsection (c) for diabetes self-management training shall be subject to the same deductible, co-payment, and co-insurance provisions that apply to coverage under the policy for other services provided by the same type of provider.
    (d) Coverage shall be provided for the following equipment when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items shall be subject to deductible, co-payment and co-insurance provisions provided for under the policy or a durable medical equipment rider to the policy:
        (1) blood glucose monitors;
        (2) blood glucose monitors for the legally blind;
        (3) cartridges for the legally blind; and
        (4) lancets and lancing devices.
    This subsection does not apply to a group policy of accident and health insurance that does not provide a durable medical equipment benefit.
    (e) Coverage shall be provided for the following pharmaceuticals and supplies when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items shall be subject to the same coverage, deductible, co-payment, and co-insurance provisions under the policy or a drug rider to the policy:
        (1) insulin;
        (2) syringes and needles;
        (3) test strips for glucose monitors;
        (4) FDA approved oral agents used to control blood
    
sugar; and
        (5) glucagon emergency kits.
    This subsection does not apply to a group policy of accident and health insurance that does not provide a drug benefit.
    (f) Coverage shall be provided for regular foot care exams by a physician or by a physician to whom a physician has referred the patient. Coverage for regular foot care exams shall be subject to the same deductible, co-payment, and co-insurance provisions that apply under the policy for other services provided by the same type of provider.
    (g) If authorized by a physician, diabetes self-management training may be provided as a part of an office visit, group setting, or home visit.
    (h) This Section shall not apply to agreements, contracts, or policies that provide coverage for a specified diagnosis or other limited benefit coverage.
(Source: P.A. 97-281, eff. 1-1-12; 97-1141, eff. 12-28-12.)

215 ILCS 5/356x

    (215 ILCS 5/356x)
    Sec. 356x. Coverage for colorectal cancer examination and screening.
    (a) An individual or group policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 93rd General Assembly that provides coverage to a resident of this State must provide benefits or coverage for all colorectal cancer examinations and laboratory tests for colorectal cancer as prescribed by a physician, in accordance with the published American Cancer Society guidelines on colorectal cancer screening or other existing colorectal cancer screening guidelines issued by nationally recognized professional medical societies or federal government agencies, including the National Cancer Institute, the Centers for Disease Control and Prevention, and the American College of Gastroenterology.
    (b) Coverage required under this Section may not impose any deductible, coinsurance, waiting period, or other cost-sharing limitation that is greater than that required for other coverage under the policy.
(Source: P.A. 93-568, eff. 1-1-04.)

215 ILCS 5/356y

    (215 ILCS 5/356y)
    Sec. 356y. (Repealed).
(Source: P.A. 91-406, eff. 1-1-00. Repealed internally, eff. 1-1-03.)

215 ILCS 5/356z.1

    (215 ILCS 5/356z.1)
    Sec. 356z.1. Prenatal HIV testing. An individual or group policy of accident and health insurance that provides maternity coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 92nd General Assembly must provide coverage for prenatal HIV testing ordered by an attending physician licensed to practice medicine in all its branches, or by a physician assistant or advanced practice registered nurse who has a written collaborative agreement with a collaborating physician that authorizes these services, including but not limited to orders consistent with the recommendations of the American College of Obstetricians and Gynecologists or the American Academy of Pediatrics.
(Source: P.A. 92-130, eff. 7-20-01.)

215 ILCS 5/356z.2

    (215 ILCS 5/356z.2)
    Sec. 356z.2. Coverage for adjunctive services in dental care.
    (a) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 92nd General Assembly shall cover charges incurred, and anesthetics provided, in conjunction with dental care that is provided to a covered individual in a hospital or an ambulatory surgical treatment center if any of the following applies:
        (1) the individual is a child age 6 or under;
        (2) the individual has a medical condition that
    
requires hospitalization or general anesthesia for dental care; or
        (3) the individual is disabled.
    (b) For purposes of this Section, "ambulatory surgical treatment center" has the meaning given to that term in Section 3 of the Ambulatory Surgical Treatment Center Act.
    For purposes of this Section, "disabled" means a person, regardless of age, with a chronic disability if the chronic disability meets all of the following conditions:
        (1) It is attributable to a mental or physical
    
impairment or     combination of mental and physical impairments.
        (2) It is likely to continue.
        (3) It results in substantial functional limitations
    
in one or more of the following areas of major life activity:
            (A) self-care;
            (B) receptive and expressive language;
            (C) learning;
            (D) mobility;
            (E) capacity for independent living; or
            (F) economic self-sufficiency.
    (c) The coverage required under this Section may be subject to any limitations, exclusions, or cost-sharing provisions that apply generally under the insurance policy.
    (d) This Section does not apply to a policy that covers only dental care.
    (e) Nothing in this Section requires that the dental services be covered.
    (f) The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified disease policies, nor to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under State or federal governmental plans.
(Source: P.A. 95-331, eff. 8-21-07.)

215 ILCS 5/356z.3

    (215 ILCS 5/356z.3)
    Sec. 356z.3. Disclosure of limited benefit. An insurer that issues, delivers, amends, or renews an individual or group policy of accident and health insurance in this State after the effective date of this amendatory Act of the 92nd General Assembly and 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 as provided in Section 356z.3a of the Illinois Insurance Code. 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. 96-1523, eff. 6-1-11; 97-813, eff. 7-13-12.)

215 ILCS 5/356z.3a

    (215 ILCS 5/356z.3a)
    Sec. 356z.3a. Nonparticipating facility-based physicians and providers.
    (a) For purposes of this Section, "facility-based provider" means a physician or other provider who provide radiology, anesthesiology, pathology, neonatology, or emergency department services to insureds, beneficiaries, or enrollees in a participating hospital or participating ambulatory surgical treatment center.
    (b) When a beneficiary, insured, or enrollee utilizes a participating network hospital or a participating network ambulatory surgery center and, due to any reason, in network services for radiology, anesthesiology, pathology, emergency physician, or neonatology are unavailable and are provided by a nonparticipating facility-based physician or provider, the insurer or health plan shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating physician or provider for covered services.
    (c) If a beneficiary, insured, or enrollee agrees in writing, notwithstanding any other provision of this Code, any benefits a beneficiary, insured, or enrollee receives for services under the situation in subsection (b) are assigned to the nonparticipating facility-based providers. The insurer or health plan shall provide the nonparticipating provider with a written explanation of benefits that specifies the proposed reimbursement and the applicable deductible, copayment or coinsurance amounts owed by the insured, beneficiary or enrollee. The insurer or health plan shall pay any reimbursement directly to the nonparticipating facility-based provider. The nonparticipating facility-based physician or provider shall not bill the beneficiary, insured, or enrollee, except for applicable deductible, copayment, or coinsurance amounts that would apply if the beneficiary, insured, or enrollee utilized a participating physician or provider for covered services. If a beneficiary, insured, or enrollee specifically rejects assignment under this Section in writing to the nonparticipating facility-based provider, then the nonparticipating facility-based provider may bill the beneficiary, insured, or enrollee for the services rendered.
    (d) For bills assigned under subsection (c), the nonparticipating facility-based provider may bill the insurer or health plan for the services rendered, and the insurer or health plan may pay the billed amount or attempt to negotiate reimbursement with the nonparticipating facility-based provider. If attempts to negotiate reimbursement for services provided by a nonparticipating facility-based provider do not result in a resolution of the payment dispute within 30 days after receipt of written explanation of benefits by the insurer or health plan, then an insurer or health plan or nonparticipating facility-based physician or provider may initiate binding arbitration to determine payment for services provided on a per bill basis. The party requesting arbitration shall notify the other party arbitration has been initiated and state its final offer before arbitration. In response to this notice, the nonrequesting party shall inform the requesting party of its final offer before the arbitration occurs. Arbitration shall be initiated by filing a request with the Department of Insurance.
    (e) The Department of Insurance shall publish a list of approved arbitrators or entities that shall provide binding arbitration. These arbitrators shall be American Arbitration Association or American Health Lawyers Association trained arbitrators. Both parties must agree on an arbitrator from the Department of Insurance's list of arbitrators. If no agreement can be reached, then a list of 5 arbitrators shall be provided by the Department of Insurance. From the list of 5 arbitrators, the insurer can veto 2 arbitrators and the provider can veto 2 arbitrators. The remaining arbitrator shall be the chosen arbitrator. This arbitration shall consist of a review of the written submissions by both parties. Binding arbitration shall provide for a written decision within 45 days after the request is filed with the Department of Insurance. Both parties shall be bound by the arbitrator's decision. The arbitrator's expenses and fees, together with other expenses, not including attorney's fees, incurred in the conduct of the arbitration, shall be paid as provided in the decision.
    (f) This Section 356z.3a does not apply to a beneficiary, insured, or enrollee who willfully chooses to access a nonparticipating facility-based physician or provider for health care services available through the insurer's or plan's network of participating physicians and providers. In these circumstances, the contractual requirements for nonparticipating facility-based provider reimbursements will apply.
    (g) Section 368a of this Act shall not apply during the pendency of a decision under subsection (d) any interest required to be paid a provider under Section 368a shall not accrue until after 30 days of an arbitrator's decision as provided in subsection (d), but in no circumstances longer than 150 days from date the nonparticipating facility-based provider billed for services rendered.
    (h) Nothing in this Section shall be interpreted to change the prudent layperson provisions with respect to emergency services under the Managed Care Reform and Patient Rights Act.
(Source: P.A. 98-154, eff. 8-2-13.)

215 ILCS 5/356z.4

    (215 ILCS 5/356z.4)
    Sec. 356z.4. Coverage for contraceptives.
    (a) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State after the effective date of this amendatory Act of the 93rd General Assembly that provides coverage for outpatient services and outpatient prescription drugs or devices must provide coverage for the insured and any dependent of the insured covered by the policy for all outpatient contraceptive services and all outpatient contraceptive drugs and devices approved by the Food and Drug Administration. Coverage required under this Section may not impose any deductible, coinsurance, waiting period, or other cost-sharing or limitation that is greater than that required for any outpatient service or outpatient prescription drug or device otherwise covered by the policy.
    (b) As used in this Section, "outpatient contraceptive service" means consultations, examinations, procedures, and medical services, provided on an outpatient basis and related to the use of contraceptive methods (including natural family planning) to prevent an unintended pregnancy.
    (c) Nothing in this Section shall be construed to require an insurance company to cover services related to an abortion as the term "abortion" is defined in the Illinois Abortion Law of 1975.
    (d) Nothing in this Section shall be construed to require an insurance company to cover services related to permanent sterilization that requires a surgical procedure.
(Source: P.A. 95-331, eff. 8-21-07.)

215 ILCS 5/356z.5

    (215 ILCS 5/356z.5)
    Sec. 356z.5. Prescription inhalants. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 93rd General Assembly that provides coverage for prescription drugs may not deny or limit coverage for prescription inhalants to enable persons to breathe when suffering from asthma or other life-threatening bronchial ailments based upon any restriction on the number of days before an inhaler refill may be obtained if, contrary to those restrictions, the inhalants have been ordered or prescribed by the treating physician and are medically appropriate.
(Source: P.A. 95-331, eff. 8-21-07.)

215 ILCS 5/356z.6

    (215 ILCS 5/356z.6)
    Sec. 356z.6. Bone mass measurement; osteoporosis. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 93rd General Assembly must provide coverage for medically necessary bone mass measurement and for the diagnosis and treatment of osteoporosis on the same terms and conditions that are generally applicable to coverage for other medical conditions.
(Source: P.A. 93-853, eff. 1-1-05.)

215 ILCS 5/356z.7

    (215 ILCS 5/356z.7) (was 215 ILCS 5/370r)
    Sec. 356z.7. Prescription drugs; cancer treatment. No group policy of accident or health insurance that provides coverage for prescribed drugs approved by the federal Food and Drug Administration for the treatment of certain types of cancer shall exclude coverage of any drug on the basis that the drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the federal Food and Drug Administration. The drug, however, must be approved by the federal Food and Drug Administration and must be recognized for the treatment of the specific type of cancer for which the drug has been prescribed in any one of the following established reference compendia:
        (a) the American Hospital Formulary Service Drug
    
Information;
        (b) National Comprehensive Cancer Network's Drugs &
    
Biologics Compendium;
        (c) Thomson Micromedex's Drug Dex;
        (d) Elsevier Gold Standard's Clinical Pharmacology; or
        (e) other authoritative compendia as identified from
    
time to time by the Federal Secretary of Health and Human Services;
or if not in the compendia, recommended for that particular type of cancer in formal clinical studies, the results of which have been published in at least two peer reviewed professional medical journals published in the United States or Great Britain.
    Any coverage required by this Section shall also include those medically necessary services associated with the administration of a drug.
    Despite the provisions of this Section, coverage shall not be required for any experimental or investigational drugs or any drug that the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed. This Section shall apply only to cancer drugs. Nothing in this Section shall be construed, expressly or by implication, to create, impair, alter, limit, notify, enlarge, abrogate or prohibit reimbursement for drugs used in the treatment of any other disease or condition.
(Source: P.A. 95-331, eff. 8-21-07; 96-457, eff. 8-14-09.)

215 ILCS 5/356z.8

    (215 ILCS 5/356z.8)
    Sec. 356z.8. Multiple sclerosis preventative physical therapy. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 94th General Assembly must provide coverage for medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis. For the purposes of this Section, "preventative physical therapy" means physical therapy that is prescribed by a physician licensed to practice medicine in all of its branches for the purpose of treating parts of the body affected by multiple sclerosis, but only where the physical therapy includes reasonably defined goals, including, but not limited to, sustaining the level of function the person has achieved, with periodic evaluation of the efficacy of the physical therapy against those goals. The coverage required under this Section shall be subject to the same deductible, coinsurance, waiting period, cost sharing limitation, treatment limitation, calendar year maximum, or other limitations as provided for other physical or rehabilitative therapy benefits covered by the policy.
(Source: P.A. 94-1076, eff. 12-29-06.)

215 ILCS 5/356z.9

    (215 ILCS 5/356z.9)
    Sec. 356z.9. Human papillomavirus vaccine. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage for a human papillomavirus vaccine (HPV) that is approved for marketing by the federal Food and Drug Administration.
(Source: P.A. 95-422, eff. 8-24-07; 95-876, eff. 8-21-08.)

215 ILCS 5/356z.10

    (215 ILCS 5/356z.10)
    Sec. 356z.10. Amino acid-based elemental formulas. A group or individual major medical accident and health insurance policy or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
(Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)

215 ILCS 5/356z.11

    (215 ILCS 5/356z.11)
    Sec. 356z.11. Dependent students; medical leave of absence. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must continue to provide coverage for a dependent college student who takes a medical leave of absence or reduces his or her course load to part-time status because of a catastrophic illness or injury.
    Continuation of coverage under this Section is subject to all of the policy's terms and conditions applicable to those forms of insurance. Continuation of insurance under the policy shall terminate 12 months after notice of the illness or injury or until the coverage would have otherwise lapsed pursuant to the terms and conditions of the policy, whichever comes first, provided the need for part-time status or medical leave of absence is supported by a clinical certification of need from a physician licensed to practice medicine in all its branches.
    The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified disease policies or to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under State or federal governmental plans.
(Source: P.A. 95-958, eff. 6-1-09; 96-328, eff. 8-11-09.)

215 ILCS 5/356z.12

    (215 ILCS 5/356z.12)
    Sec. 356z.12. Dependent coverage.
    (a) A group or individual policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly shall not terminate coverage or deny the election of coverage for an unmarried dependent by reason of the dependent's age before the dependent's 26th birthday.
    (b) A policy or plan subject to this Section shall, upon amendment, delivery, issuance, or renewal, establish an initial enrollment period of not less than 90 days during which an insured may make a written election for coverage of an unmarried person as a dependent under this Section. After the initial enrollment period, enrollment by a dependent pursuant to this Section shall be consistent with the enrollment terms of the plan or policy.
    (c) A policy or plan subject to this Section shall allow for dependent coverage during the annual open enrollment date or the annual renewal date if the dependent, as of the date on which the insured elects dependent coverage under this subsection, has:
        (1) a period of continuous creditable coverage of 90
    
days or more; and
        (2) not been without creditable coverage for more
    
than 63 days.
An insured may elect coverage for a dependent who does not meet the continuous creditable coverage requirements of this subsection (c) and that dependent shall not be denied coverage due to age.
    For purposes of this subsection (c), "creditable coverage" shall have the meaning provided under subsection (C)(1) of Section 20 of the Illinois Health Insurance Portability and Accountability Act.
    (d) Military personnel. A group or individual policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly shall not terminate coverage or deny the election of coverage for an unmarried dependent by reason of the dependent's age before the dependent's 30th birthday if the dependent (i) is an Illinois resident, (ii) served as a member of the active or reserve components of any of the branches of the Armed Forces of the United States, and (iii) has received a release or discharge other than a dishonorable discharge. To be eligible for coverage under this subsection (d), the eligible dependent shall submit to the insurer a form approved by the Illinois Department of Veterans' Affairs stating the date on which the dependent was released from service.
    (e) Calculation of the cost of coverage provided to an unmarried dependent under this Section shall be identical.
    (f) Nothing in this Section shall prohibit an employer from requiring an employee to pay all or part of the cost of coverage provided under this Section.
    (g) No exclusions or limitations may be applied to coverage elected pursuant to this Section that do not apply to all dependents covered under the policy.
    (h) A policy or plan subject to this Section shall not condition eligibility for dependent coverage provided pursuant to this Section on enrollment in any educational institution.
    (i) Notice regarding coverage for a dependent as provided pursuant to this Section shall be provided to an insured by the insurer:
        (1) upon application or enrollment;
        (2) in the certificate of coverage or equivalent
    
document prepared for an insured and delivered on or about the date on which the coverage commences; and
        (3) (blank).
(Source: P.A. 98-226, eff. 1-1-14.)

215 ILCS 5/356z.13

    (215 ILCS 5/356z.13)
    Sec. 356z.13. Shingles vaccine. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of the amendatory Act of this 95th General Assembly must provide coverage for a vaccine for shingles that is approved for marketing by the federal Food and Drug Administration if the vaccine is ordered by a physician licensed to practice medicine in all its branches and the enrollee is 60 years of age or older.
(Source: P.A. 95-978, eff. 1-1-09; 96-328, eff. 8-11-09.)

215 ILCS 5/356z.14

    (215 ILCS 5/356z.14)
    Sec. 356z.14. Autism spectrum disorders.
    (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the policy of accident and health insurance or managed care plan.
    (b) Coverage provided under this Section shall be subject to a maximum benefit of $36,000 per year, but shall not be subject to any limits on the number of visits to a service provider. After December 30, 2009, the Director of the Division of Insurance shall, on an annual basis, adjust the maximum benefit for inflation using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition not diagnosed as an autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.
    (c) Coverage under this Section shall be subject to copayment, deductible, and coinsurance provisions of a policy of accident and health insurance or managed care plan to the extent that other medical services covered by the policy of accident and health insurance or managed care plan are subject to these provisions.
    (d) This Section shall not be construed as limiting benefits that are otherwise available to an individual under a policy of accident and health insurance or managed care plan and benefits provided under this Section may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally.
    (e) An insurer may not deny or refuse to provide otherwise covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract to provide services to an individual because the individual or their dependent is diagnosed with an autism spectrum disorder or due to the individual utilizing benefits in this Section.
    (f) Upon request of the reimbursing insurer, a provider of treatment for autism spectrum disorders shall furnish medical records, clinical notes, or other necessary data that substantiate that initial or continued medical treatment is medically necessary and is resulting in improved clinical status. When treatment is anticipated to require continued services to achieve demonstrable progress, the insurer may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated outcomes stated as goals, and the frequency by which the treatment plan will be updated.
    (g) When making a determination of medical necessity for a treatment modality for autism spectrum disorders, an insurer must make the determination in a manner that is consistent with the manner used to make that determination with respect to other diseases or illnesses covered under the policy, including an appeals process. During the appeals process, any challenge to medical necessity must be viewed as reasonable only if the review includes a physician with expertise in the most current and effective treatment modalities for autism spectrum disorders.
    (h) Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists, as defined in 89 Ill. Admin. Code 500 and any subsequent amendments thereto.
    (h-5) If an individual has been diagnosed as having an autism spectrum disorder, meeting the diagnostic criteria in place at the time of diagnosis, and treatment is determined medically necessary, then that individual shall remain eligible for coverage under this Section even if subsequent changes to the diagnostic criteria are adopted by the American Psychiatric Association. If no changes to the diagnostic criteria are adopted after April 1, 2012, and before December 31, 2014, then this subsection (h-5) shall be of no further force and effect.
    (i) As used in this Section:
    "Autism spectrum disorders" means pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autism, Asperger's disorder, and pervasive developmental disorder not otherwise specified.
    "Diagnosis of autism spectrum disorders" means one or more tests, evaluations, or assessments to diagnose whether an individual has autism spectrum disorder that is prescribed, performed, or ordered by (A) a physician licensed to practice medicine in all its branches or (B) a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders.
    "Medically necessary" means any care, treatment, intervention, service or item which will or is reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, disease or disability; (ii) reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury, disease or disability; or (iii) assist to achieve or maintain maximum functional activity in performing daily activities.
    "Treatment for autism spectrum disorders" shall include the following care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder by (A) a physician licensed to practice medicine in all its branches or (B) a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches:
        (1) Psychiatric care, meaning direct, consultative,
    
or diagnostic services provided by a licensed psychiatrist.
        (2) Psychological care, meaning direct or
    
consultative services provided by a licensed psychologist.
        (3) Habilitative or rehabilitative care, meaning
    
professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are intended to develop, maintain, and restore the functioning of an individual. As used in this subsection (i), "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
        (4) Therapeutic care, including behavioral, speech,
    
occupational, and physical therapies that provide treatment in the following areas: (i) self care and feeding, (ii) pragmatic, receptive, and expressive language, (iii) cognitive functioning, (iv) applied behavior analysis, intervention, and modification, (v) motor planning, and (vi) sensory processing.
    (j) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 96-1000, eff. 7-2-10; 97-972, eff. 1-1-13.)

215 ILCS 5/356z.15

    (215 ILCS 5/356z.15)
    Sec. 356z.15. Habilitative services for children.
    (a) As used in this Section, "habilitative services" means occupational therapy, physical therapy, speech therapy, and other services prescribed by the insured's treating physician pursuant to a treatment plan to enhance the ability of a child to function with a congenital, genetic, or early acquired disorder. A congenital or genetic disorder includes, but is not limited to, hereditary disorders. An early acquired disorder refers to a disorder resulting from illness, trauma, injury, or some other event or condition suffered by a child prior to that child developing functional life skills such as, but not limited to, walking, talking, or self-help skills. Congenital, genetic, and early acquired disorders may include, but are not limited to, autism or an autism spectrum disorder, cerebral palsy, and other disorders resulting from early childhood illness, trauma, or injury.
    (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage for habilitative services for children under 19 years of age with a congenital, genetic, or early acquired disorder so long as all of the following conditions are met:
        (1) A physician licensed to practice medicine in all
    
its branches has diagnosed the child's congenital, genetic, or early acquired disorder.
        (2) The treatment is administered by a licensed
    
speech-language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, licensed physician, licensed nurse, licensed optometrist, licensed nutritionist, licensed social worker, or licensed psychologist upon the referral of a physician licensed to practice medicine in all its branches.
        (3) The initial or continued treatment must be
    
medically necessary and therapeutic and not experimental or investigational.
    (c) The coverage required by this Section shall be subject to other general exclusions and limitations of the policy, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, utilization review of health care services, including review of medical necessity, case management, experimental, and investigational treatments, and other managed care provisions.
    (d) Coverage under this Section does not apply to those services that are solely educational in nature or otherwise paid under State or federal law for purely educational services. Nothing in this subsection (d) relieves an insurer or similar third party from an otherwise valid obligation to provide or to pay for services provided to a child with a disability.
    (e) Coverage under this Section for children under age 19 shall not apply to treatment of mental or emotional disorders or illnesses as covered under Section 370 of this Code as well as any other benefit based upon a specific diagnosis that may be otherwise required by law.
    (f) The provisions of this Section do not apply to short-term travel, accident-only, limited, or specific disease policies.
    (g) Any denial of care for habilitative services shall be subject to appeal and external independent review procedures as provided by Section 45 of the Managed Care Reform and Patient Rights Act.
    (h) Upon request of the reimbursing insurer, the provider under whose supervision the habilitative services are being provided shall furnish medical records, clinical notes, or other necessary data to allow the insurer to substantiate that initial or continued medical treatment is medically necessary and that the patient's condition is clinically improving. When the treating provider anticipates that continued treatment is or will be required to permit the patient to achieve demonstrable progress, the insurer may request that the provider furnish a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated goals of treatment, and how frequently the treatment plan will be updated.
    (i) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10; 96-1000, eff. 7-2-10.)

215 ILCS 5/356z.16

    (215 ILCS 5/356z.16)
    Sec. 356z.16. Applicability of mandated benefits to supplemental policies. Unless specified otherwise, the following Sections of the Illinois Insurance Code do not apply to short-term travel, disability income, long-term care, accident only, or limited or specified disease policies: 355b, 356b, 356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t, 356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.12, 356z.14, 356z.19, 356z.21, 364.01, 367.2-5, and 367e.
(Source: P.A. 97-91, eff. 1-1-12; 97-282, eff. 8-9-11; 97-592, eff. 1-1-12; 97-813, eff. 7-13-12; 97-972, eff. 1-1-13; 98-189, eff. 1-1-14.)

215 ILCS 5/356z.17

    (215 ILCS 5/356z.17)
    Sec. 356z.17. Wellness coverage.
    (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after January 1, 2010 (the effective date of Public Act 96-639) that provides coverage for hospital or medical treatment on an expense incurred basis may offer a reasonably designed program for wellness coverage that allows for a reward, a contribution, a reduction in premiums or reduced medical, prescription drug, or equipment copayments, coinsurance, or deductibles, or a combination of these incentives, for participation in any health behavior wellness, maintenance, or improvement program approved or offered by the insurer or managed care plan. The insured or enrollee may be required to provide evidence of participation in a program. Individuals unable to participate in these incentives due to an adverse health factor shall not be penalized based upon an adverse health status.
    (b) For purposes of this Section, "wellness coverage" means health care coverage with the primary purpose to engage and motivate the insured or enrollee through: incentives; provision of health education, counseling, and self-management skills; identification of modifiable health risks; and other activities to influence health behavior changes.
    For the purposes of this Section, "reasonably designed program" means a program of wellness coverage that has a reasonable chance of improving health or preventing disease; is not overly burdensome; does not discriminate based upon factors of health; and is not otherwise contrary to law.
    (c) Incentives as outlined in this Section are specific and unique to the offering of wellness coverage and have no application to any other required or optional health care benefit.
    (d) Such wellness coverage must satisfy the requirements for an exception from the general prohibition against discrimination based on a health factor under the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191; 110 Stat. 1936), including any federal regulations that are adopted pursuant to that Act.
    (e) A plan offering wellness coverage must do the following:
        (i) give participants the opportunity to qualify for
    
offered incentives at least once a year;
        (ii) allow a reasonable alternative to any individual
    
for whom it is unreasonably difficult, due to a medical condition, to satisfy otherwise applicable wellness program standards. Plans may seek physician verification that health factors make it unreasonably difficult or medically inadvisable for the participant to satisfy the standards; and
        (iii) not provide a total incentive that exceeds 20%
    
of the cost of employee-only coverage. The cost of employee-only coverage includes both employer and employee contributions. For plans offering family coverage, the 20% limitation applies to cost of family coverage and applies to the entire family.
    (f) A reward, contribution, or reduction established under this Section and included in the policy or certificate does not violate Section 151 of this Code.
(Source: P.A. 96-639, eff. 1-1-10; 96-833, eff. 6-1-10.)

215 ILCS 5/356z.18

    (215 ILCS 5/356z.18)
    Sec. 356z.18. Prosthetic and customized orthotic devices.
    (a) For the purposes of this Section:
    "Customized orthotic device" means a supportive device for the body or a part of the body, the head, neck, or extremities, and includes the replacement or repair of the device based on the patient's physical condition as medically necessary, excluding foot orthotics defined as an in-shoe device designed to support the structural components of the foot during weight-bearing activities.
    "Licensed provider" means a prosthetist, orthotist, or pedorthist licensed to practice in this State.
    "Prosthetic device" means an artificial device to replace, in whole or in part, an arm or leg and includes accessories essential to the effective use of the device and the replacement or repair of the device based on the patient's physical condition as medically necessary.
    (b) This amendatory Act of the 96th General Assembly shall provide benefits to any person covered thereunder for expenses incurred in obtaining a prosthetic or custom orthotic device from any Illinois licensed prosthetist, licensed orthotist, or licensed pedorthist as required under the Orthotics, Prosthetics, and Pedorthics Practice Act.
    (c) A group or individual major medical policy of accident or health insurance or managed care plan or medical, health, or hospital service corporation contract that provides coverage for prosthetic or custom orthotic care and is amended, delivered, issued, or renewed 6 months after the effective date of this amendatory Act of the 96th General Assembly must provide coverage for prosthetic and orthotic devices in accordance with this subsection (c). The coverage required under this Section shall be subject to the other general exclusions, limitations, and financial requirements of the policy, including coordination of benefits, participating provider requirements, utilization review of health care services, including review of medical necessity, case management, and experimental and investigational treatments, and other managed care provisions under terms and conditions that are no less favorable than the terms and conditions that apply to substantially all medical and surgical benefits provided under the plan or coverage.
    (d) The policy or plan or contract may require prior authorization for the prosthetic or orthotic devices in the same manner that prior authorization is required for any other covered benefit.
    (e) Repairs and replacements of prosthetic and orthotic devices are also covered, subject to the co-payments and deductibles, unless necessitated by misuse or loss.
    (f) A policy or plan or contract may require that, if coverage is provided through a managed care plan, the benefits mandated pursuant to this Section shall be covered benefits only if the prosthetic or orthotic devices are provided by a licensed provider employed by a provider service who contracts with or is designated by the carrier, to the extent that the carrier provides in-network and out-of-network service, the coverage for the prosthetic or orthotic device shall be offered no less extensively.
    (g) The policy or plan or contract shall also meet adequacy requirements as established by the Health Care Reimbursement Reform Act of 1985 of the Illinois Insurance Code.
    (h) This Section shall not apply to accident only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers' compensation insurance, or automobile medical payment insurance.
(Source: P.A. 96-833, eff. 6-1-10.)

215 ILCS 5/356z.19

    (215 ILCS 5/356z.19)
    Sec. 356z.19. Cardiovascular disease. Because cardiovascular disease is a leading cause of death and disability, an insurer providing group or individual policies of accident and health insurance or a managed care plan shall develop and implement a process to communicate with their adult enrollees on an annual basis regarding the importance and value of early detection and proactive management of cardiovascular disease. Nothing in this Section affects any change in the terms, conditions, or benefits of the policies and plans, nor the criteria, standards, and procedures related to the application for, enrollment in, or renewal of coverage or conditions of participation of enrollees in the health plans or policies subject to this Code.
(Source: P.A. 97-282, eff. 8-9-11; 97-813, eff. 7-13-12.)

215 ILCS 5/356z.20

    (215 ILCS 5/356z.20)
    Sec. 356z.20. Cancer drug parity.
    (a) As used in this Section:
    "Financial requirement" means deductibles, copayments, coinsurance, out-of-pocket expenses, aggregate lifetime limits, and annual limits.
    "Treatment limitation" means limits on the frequency of treatment, days of coverage, or other similar limits on the scope or duration of treatment.
    (b) On and after the effective date of this amendatory Act of the 97th General Assembly, every insurer that amends, delivers, issues, or renews an individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 97th General Assembly that provides coverage for prescribed orally-administered cancer medications and intravenously administered or injected cancer medications shall ensure that:
        (1) the financial requirements applicable to such
    
prescribed orally-administered cancer medications are no more restrictive than the financial requirements applied to intravenously administered or injected cancer medications that are covered by the policy and that there are no separate cost-sharing requirements that are applicable only with respect to such prescribed orally-administered cancer medications; and
        (2) the treatment limitations applicable to such
    
prescribed orally-administered cancer medications are no more restrictive than the treatment limitations applied to intravenously administered or injected cancer medications that are covered by the policy and that there are no separate treatment limitations that are applicable only with respect to such prescribed orally-administered cancer medications.
    (c) An insurer cannot achieve compliance with this Section by increasing financial requirements or imposing more restrictive treatment limitations on prescribed orally-administered cancer medications or intravenously administered or injected cancer medications covered under the policy on the effective date of this amendatory Act of the 97th General Assembly.
(Source: P.A. 97-198, eff. 1-1-12; 97-813, eff. 7-13-12.)

215 ILCS 5/356z.21

    (215 ILCS 5/356z.21)
    Sec. 356z.21. Tobacco use cessation programs; coverage offer.
    (a) Tobacco use is the number one cause of preventable disease and death in Illinois, costing $4.1 billion annually in direct health care costs and an additional $4.35 billion in lost productivity. In Illinois, the smoking rates are highest among African Americans (25.8%). Smoking rates among lesbian, gay, and bisexual adults range from 25% to 44%. The U.S. Public Health Service Clinical Practice Guideline 2008 Update found that tobacco dependence treatments are both clinically effective and highly cost effective. A study in the Journal of Preventive Medicine concluded that comprehensive smoking cessation treatment is one of the 3 most important and cost effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.
    (b) In this Section, "tobacco use cessation program" means a program recommended by a physician that follows evidence-based treatment, such as is outlined in the United States Public Health Service guidelines for tobacco use cessation. "Tobacco use cessation program" includes education and medical treatment components designed to assist a person in ceasing the use of tobacco products. "Tobacco use cessation program" includes education and counseling by physicians or associated medical personnel and all FDA approved medications for the treatment of tobacco dependence irrespective of whether they are available only over the counter, only by prescription, or both over the counter and by prescription.
    (c) On or after the effective date of this amendatory Act of the 97th General Assembly, every insurer that amends, delivers, issues, or renews group accident and health policies providing coverage for hospital or medical treatment or services on an expense-incurred basis shall offer, for an additional premium and subject to the insurer's standard of insurability, optional coverage or optional reimbursement of up to $500 annually for a tobacco use cessation program for a person enrolled in the plan who is 18 years of age or older.
    (d) The coverage required by this Section shall be subject to other general exclusions and limitations of the policy, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, and other managed care provisions.
    (e) For the coverage provided under this Section, an insurer may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives, monetary or otherwise, to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with the coverage under this Section.
(Source: P.A. 97-592, eff. 1-1-12; 97-813, eff. 7-13-12.)

215 ILCS 5/357.1

    (215 ILCS 5/357.1) (from Ch. 73, par. 969.1)
    Sec. 357.1. Accident and health policy provisions required.
    Except as provided in section 357.26 of this article each accident and health policy delivered or issued for delivery to any person in this State shall contain the provisions set forth in sections 357.2 through 357.13 in the words in which the same appear in the specified sections; provided, however, that the company may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the Director which are in each instance not less favorable in any respect to the insured or the beneficiary. Such provisions shall be preceded individually by the caption appearing at the beginning of each such section or, at the option of the company, by such appropriate individual or group captions or subcaptions as the Director may approve.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.2

    (215 ILCS 5/357.2) (from Ch. 73, par. 969.2)
    Sec. 357.2. "ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the company and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions."
    (1) Premium Notice Required. No policy of accident and health insurance, as enumerated in class 1(b) or 2(a) of Section 4, shall be declared forfeited or lapsed within 6 months after default in payment of any premium installment or interest or any portion thereof, nor shall any such policy be forfeited or lapsed by reason of nonpayment when due of any premium, installment or interest, or any portion thereof, required by the terms of the policy to be paid, within 6 months from the default in payment of such premium, installment or interest, unless a written or printed notice stating the amount of such premium, installment, interest or portion thereof due on such policy, the place where it shall be paid and the person to whom the same is payable, shall have been duly addressed and mailed with the required postage affixed, to the person insured or to the premium payor if other than the insured at the last known post office address of the insured or premium payor, at least 15 days and not more than 45 days prior to the day when same is due and payable before the beginning of the grace period.
    Such notice shall also state that unless such premium or other sum due shall be paid to the company or its agent the policy and all payments thereon will become forfeited and void, except as to any right to a surrender value or paid up policy as provided for by the policy. The affidavit of any officer, clerk or agent of the company or of anyone authorized to mail such notice that the notice required by this Section bearing the required postage has been duly addressed and mailed shall be presumptive evidence that such notice has been duly given.
    If the notice is given in a manner other than mailing, then physical proof of the receipt of such notice by the proper recipient shall be maintained by the insurer.
    (2) Paragraph (1) of this Section shall not apply to cancellable policies which are renewable at the option of the company nor shall it apply to group policies, industrial policies, or any policies upon which premiums are payable monthly or at shorter intervals.
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.3

    (215 ILCS 5/357.3) (from Ch. 73, par. 969.3)
    Sec. 357.3. "TIME LIMIT ON CERTAIN DEFENSES: (1) After 2 years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such 2 year period."
    (The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial 2 year period, nor to limit the application of section 357.15 through section 357.19 in the event of misstatement with respect to age or occupation or other insurance.)
    A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue, may contain in lieu of the foregoing the following provisions (from which the clause in parentheses may be omitted at the company's option) under the caption "INCONTESTABLE":
    "After this policy has been in force for a period of 2 years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application."
    (2) "No claim for loss incurred or disability (as defined in the policy) commencing after 2 years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.4

    (215 ILCS 5/357.4) (from Ch. 73, par. 969.4)
    Sec. 357.4. "GRACE PERIOD: A grace period of ....(insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force."
    (A policy which contains a cancellation provision may add, at the end of the above provision: "Subject to the right of the company to cancel in accordance with the cancellation provision hereof."
    A policy in which the company reserves the right to refuse any renewal shall have, at the beginning of the above provision:
    "Unless not less than 30 days prior to the premium due date the company has delivered to the insured or has mailed to his last address as shown by the records of the company written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.")
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.5

    (215 ILCS 5/357.5) (from Ch. 73, par. 969.5)
    Sec. 357.5. "REINSTATEMENT: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the company or by any agent duly authorized by the company to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the company or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the company or, lacking such approval, upon the 45th day following the date of such conditional receipt unless the company has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date. In all other respects the insured and company shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement."
    The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue.
    For the purpose of this Section, the phrase "loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date" shall mean that the reinstated policy shall not cover a loss resulting from accidental injury sustained after the date of lapse of the policy and prior to the date of reinstatement or a loss resulting from sickness which is first manifested after the date of lapse of the policy but not after a date more than 10 days after the date of reinstatement. An accidental injury and a sickness as described in this Section shall be subject to the requirements of Section 357.3 with the exception that references to date of issue and application shall mean date of reinstatement and reinstatement application. All other accidental injuries and sicknesses will be subject to the requirements of 357.3. Provisions endorsed or attached to the policy in connection with the reinstatement shall relate to a disease or physical condition of an insured under the policy.
(Source: P.A. 84-1308.)

215 ILCS 5/357.6

    (215 ILCS 5/357.6) (from Ch. 73, par. 969.6)
    Sec. 357.6. "NOTICE OF CLAIM: Written notice of claim must be given to the company within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the company at ....(insert the location of such office as the company may designate for the purpose), or to any authorized agent of the company, with information sufficient to identify the insured, shall be deemed notice to the company."
    In a policy providing a loss-of-time benefit which may be payable for at least 2 years, a company may at its option insert the following between the first and second sentences of the above provision:
    "Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least 2 years, he shall, at least once in every 6 months after having given notice of claim, give to the company notice of continuance of said disability, except in the event of legal incapacity. The period of 6 months following any filing of proof by the insured or any payment by the company on account of such claim or any denial of liability in whole or in part by the company shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of 6 months preceding the date on which such notice is actually given."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.7

    (215 ILCS 5/357.7) (from Ch. 73, par. 969.7)
    Sec. 357.7. "CLAIM FORMS: The company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.8

    (215 ILCS 5/357.8) (from Ch. 73, par. 969.8)
    Sec. 357.8. "PROOFS OF LOSS: Written proof of loss must be furnished to the company at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the company is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.9

    (215 ILCS 5/357.9) (from Ch. 73, par. 969.9)
    Sec. 357.9. "TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid .... (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability, will be paid immediately upon receipt of due written proof."
    All claims and indemnities payable under the terms of a policy of accident and health insurance shall be paid within 30 days following receipt by the insurer of due proof of loss. Failure to pay within such period shall entitle the insured to interest at the rate of 9 per cent per annum 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. An insured or an insured's assignee shall be notified by the insurer, health maintenance organization, managed care plan, health care plan, preferred provider organization, or third party administrator of any known failure to provide sufficient documentation for a due proof of loss within 30 days after receipt of the claim. Any required interest payments shall be made within 30 days after the payment.
    The requirements of this Section shall apply to any policy of accident and health insurance delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this amendatory Act of 1985. The requirements of this Section also shall specifically apply to any group policy of dental insurance only, delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this amendatory Act of 1987.
(Source: P.A. 91-605, eff. 12-14-99.)

215 ILCS 5/357.9a

    (215 ILCS 5/357.9a) (from Ch. 73, par. 969.9a)
    Sec. 357.9a. Delay in payment of claims. Periodic payments of accrued indemnities for loss-of-time coverage under accident and health policies shall commence not later than 30 days after the receipt by the company of the required written proofs of loss. An insurer which violates this Section if liable under said policy, shall pay to the insured, in addition to any other penalty provided for in this Code, interest at the rate of 9% per annum from the 30th day after receipt of such proofs of loss to the date of late payment of the accrued indemnities, provided that interest amounting to less than one dollar need not be paid.
(Source: P.A. 92-139, eff. 7-24-01.)

215 ILCS 5/357.10

    (215 ILCS 5/357.10) (from Ch. 73, par. 969.10)
    Sec. 357.10. "PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the company, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured."
    The following provisions, or either of them, may be included with the foregoing provision at the option of the company:
    "If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the company may pay such indemnity, up to an amount not exceeding $....(insert an amount which shall not exceed $1000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the company to be equitably entitled thereto. Any payment made by the company in good faith pursuant to this provision shall fully discharge the company to the extent of such payment.
    "Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the company's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person. Nothing in this provision shall prohibit an insurer from providing incentives for insureds to utilize the services of a particular hospital or person."
(Source: P.A. 84-618.)

215 ILCS 5/357.11

    (215 ILCS 5/357.11) (from Ch. 73, par. 969.11)
    Sec. 357.11. "PHYSICAL EXAMINATIONS AND AUTOPSY: The company at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.12

    (215 ILCS 5/357.12) (from Ch. 73, par. 969.12)
    Sec. 357.12. "LEGAL ACTIONS: No civil action shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished."
(Source: P.A. 79-1362.)

215 ILCS 5/357.13

    (215 ILCS 5/357.13) (from Ch. 73, par. 969.13)
    Sec. 357.13. "CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy."
    (The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the company's option.)
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.14

    (215 ILCS 5/357.14) (from Ch. 73, par. 969.14)
    Sec. 357.14. Except as provided in section 357.26, no such policy delivered or issued for delivery to any person in this State shall contain provisions respecting the matters set forth in sections 357.15 through 357.24 unless such provisions are in the words in which the same appear in this article; provided, however, that the company may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the Director which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in the following sections or, at the option of the company, by such appropriate individual or group captions or subcaptions as the Director may approve.
(Source: P.A. 95-230, eff. 1-1-08.)

215 ILCS 5/357.15

    (215 ILCS 5/357.15) (from Ch. 73, par. 969.15)
    Sec. 357.15. "CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having changed his occupation to one classified by the company as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the company will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the company for such more hazardous occupation. If the insured changes his occupation to one classified by the company as less hazardous than that stated in this policy, the company, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the company prior to the occurrence of the loss for which the company is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the company in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.16

    (215 ILCS 5/357.16) (from Ch. 73, par. 969.16)
    Sec. 357.16. "MISSTATEMENT OF AGE: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.17

    (215 ILCS 5/357.17) (from Ch. 73, par. 969.17)
    Sec. 357.17. "OTHER INSURANCE IN THIS COMPANY: If an accident or health or accident and health policy or policies previously issued by the company to the insured be in force concurrently herewith, making the aggregate indemnity for ....(insert type of coverage or coverages) in excess of $....(insert maximum limit of indemnity or indemnities) the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate." or, in lieu thereof:
    "Insurance effective at any one time on the insured under a like policy or policies in this company is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the company will return all premiums paid for all other such policies."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.18

    (215 ILCS 5/357.18) (from Ch. 73, par. 969.18)
    Sec. 357.18. "INSURANCE WITH OTHER COMPANIES: If there be other valid coverage, not with this company, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this company has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this company had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the "like amount" of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage."
    (If the foregoing policy provision is included in a policy which also contains the next following policy provision there shall be added to the caption of the foregoing provision the phrase "--EXPENSE INCURRED BENEFITS". The company may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the Director, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the Director. In the absence of such definition such term does not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute) whether provided by a governmental agency or otherwise is "other valid coverage" of which the company has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage".)
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.19

    (215 ILCS 5/357.19) (from Ch. 73, par. 969.19)
    Sec. 357.19. "INSURANCE WITH OTHER COMPANIES: If there be other valid coverage, not with this company, providing benefits for the same loss on other than an expense incurred basis and of which this company has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the company had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined."
    (If the foregoing policy provision is included in a policy which also contains the next preceding policy provision there shall be added to the caption of the foregoing provision the phrase "--OTHER BENEFITS". The company may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the Director, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the Director. In the absence of such definition such term does not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute) whether provided by a governmental agency or otherwise is "other valid coverage" of which the company has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage".)
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.20

    (215 ILCS 5/357.20) (from Ch. 73, par. 969.20)
    Sec. 357.20. "RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of 2 years immediately preceding a disability for which claim is made, whichever is the greater, the company will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such 2 years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of $200.00 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time."
    (The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue. The company may, at its option, include in this provision a definition of "valid loss of time coverage", approved as to form by the Director, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the Director or any combination of such coverages. In the absence of such definition such term does not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute), or benefits provided by union welfare plans or by employer or employee benefit organizations.)
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.21

    (215 ILCS 5/357.21) (from Ch. 73, par. 969.21)
    Sec. 357.21. "UNPAID PREMIUM: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.22

    (215 ILCS 5/357.22) (from Ch. 73, par. 969.22)
    Sec. 357.22. "CANCELLATION: The company may cancel this policy at any time by written notice delivered to the insured, or mailed to his last address as shown by the records of the company, stating when, not less than 30 days thereafter, such cancellation shall be effective; and after the policy has been continued beyond its original term the insured may cancel this policy at any time by written notice delivered or mailed to the company, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the company will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the company cancels, the earned premium shall be computed pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation." (Notice to the policy holder of the cancellable nature of his policy shall be set forth on the face of the policy.)
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.23

    (215 ILCS 5/357.23) (from Ch. 73, par. 969.23)
    Sec. 357.23. "CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.24

    (215 ILCS 5/357.24) (from Ch. 73, par. 969.24)
    Sec. 357.24. "ILLEGAL OCCUPATION: The company shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.25

    (215 ILCS 5/357.25)
    Sec. 357.25. (Repealed).
(Source: Laws 1967, p. 1735. Repealed by P.A. 95-230, eff. 1-1-08.)

215 ILCS 5/357.26

    (215 ILCS 5/357.26) (from Ch. 73, par. 969.26)
    Sec. 357.26. If any provision of the preceding sections is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy the company, with the approval of the Director, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.27

    (215 ILCS 5/357.27) (from Ch. 73, par. 969.27)
    Sec. 357.27. The provisions which are the subject of Sections 357.2 through 357.25, or any corresponding provisions which are used in lieu thereof in accordance with such sections, shall be printed in the consecutive order of the provisions in such sections or, at the option of the company, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.28

    (215 ILCS 5/357.28) (from Ch. 73, par. 969.28)
    Sec. 357.28. The word "insured", as used in this article, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.29

    (215 ILCS 5/357.29) (from Ch. 73, par. 969.29)
    Sec. 357.29. Any policy of a foreign or alien company, when delivered or issued for delivery to any person in this State, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of this article and which is prescribed or required by the law of the state under which the company is organized.
    Any policy of a domestic company may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.30

    (215 ILCS 5/357.30) (from Ch. 73, par. 969.30)
    Sec. 357.30. The Director may make such reasonable rules and regulations concerning the procedure for the filing or submission of policies subject to this article as are necessary, proper or advisable to the administration of this article. This provision shall not abridge any other authority granted the Director by law. The effective date of the new provisions added by this amendatory Act shall be January 1, 1968.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.31

    (215 ILCS 5/357.31) (from Ch. 73, par. 969.31)
    Sec. 357.31. In the event of the death of a policyholder of an individual accident and health insurance policy, the insurance company, upon receipt of notice of the policyholder's death and a request for a pro-rata refund, supported by a valid death certificate supplied by a party entitled to claim such refund, shall refund the unearned premium pro-rated to the month of the policyholder's death. In no event shall such refund of premium be computed by the use of a short-rate table. Refund of the premium and termination of the coverage shall be without prejudice to any claim originating prior to the date of the policyholder's death. Coverage of persons insured under the same policy other than the policyholder shall not be affected by the premium refund provided for in this Section nor shall the obligation of such other insureds to pay required premiums be diminished pursuant to this Section.
(Source: P.A. 86-665.)

215 ILCS 5/358a

    (215 ILCS 5/358a) (from Ch. 73, par. 970a)
    Sec. 358a. Conforming to statute.
    (1) Other Policy Provisions
    No policy provision which is not subject to section 357a of this act shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to this act.
    (2) Policy Conflicting with this Article
    A policy delivered or issued for delivery to any person in this state in violation of this article shall be held valid but shall be construed as provided in this article. When any provision in a policy subject to this article is in conflict with any provision of this article, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of this article.
    (3) Operating under Old Provisions
    Subsection (3) of Section 356a of this Act is hereby incorporated into and made a part of this section by express reference.
(Source: Laws 1951, p. 611.)

215 ILCS 5/359a

    (215 ILCS 5/359a) (from Ch. 73, par. 971a)
    Sec. 359a. Application.
    (1) No policy of insurance except an Industrial Accident and Health Policy provided for by this article shall be issued, except upon the signed application of the person or persons sought to be insured. Any information or statement of the applicant shall plainly appear upon such application in the form of interrogatories by the insurer and answers by the applicant. The insured shall not be bound by any statement made in an application for any policy, including an Industrial Accident and Health Policy, unless a copy of such application is attached to or endorsed on the policy when issued as a part thereof. If any such policy delivered or issued for delivery to any person in this state shall be reinstated or renewed, and the insured or the beneficiary or assignee of such policy shall make written request to the insurer for a copy of the application, if any, for such reinstatement or renewal, the insurer shall within fifteen days after the receipt of such request at its home office or any branch office of the insurer, deliver or mail to the person making such request, a copy of such application. If such copy shall not be so delivered or mailed, the insurer shall be precluded from introducing such application as evidence in any action or proceeding based upon or involving such policy or its reinstatement or renewal.
    (2) No alteration of any written application for any such policy shall be made by any person other than the applicant without his written consent, except that insertions may be made by the insurer, for administrative purposes only, in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant.
    (3) The falsity of any statement in the application for any policy covered by this act may not bar the right to recovery thereunder unless such false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer.
(Source: Laws 1951, p. 611.)

215 ILCS 5/359b

    (215 ILCS 5/359b)
    Sec. 359b. Committee to create a uniform small employer group-health status questionnaire and individual health statement.
    (a) For the purposes of this Section:
    "Employee health-status questionnaire" means a questionnaire that poses questions about an individual employee's or covered dependent's health history and that is to be completed by the individual employee or covered dependent of a small employer that seeks health insurance coverage from a small employer carrier.
    "Health benefit plan", "small employer", and "small employer carrier" shall have the meaning given the terms in the Small Employer Health Insurance Rating Act.
    "Individual health insurance coverage" and "individual market" shall have the meaning given the terms in the Illinois Health Insurance Portability and Accountability Act.
    (b) A committee is established in the Department consisting of 11 members, including the Director or the Director's designee, who are appointed by the Director. The Director shall appoint to the committee 5 representatives as recommended by the Illinois Insurance Association, Illinois Life Insurance Council, Professional Independent Insurance Agents of Illinois, Illinois Association of Health Underwriters, Illinois Chamber of Commerce, Illinois Manufacturers Association, Illinois Retail Merchants Association, and National Federation of Independent Businesses and 5 consumer representatives. The Director or the Director's designee shall serve as chairperson of the committee.
    (c) The committee shall develop a uniform employee health-status questionnaire to simplify the health insurance application process for small employers. The committee shall study employee-health status questionnaires currently used by major small employer carriers in this State and consolidate the questionnaires into a uniform questionnaire. The questionnaire shall be designed to permit its use both as a written document and through electronic or other alternative delivery formats.
    A uniform employee health-status questionnaire shall allow small employers that are required to provide information regarding their employees to a small employer carrier when applying for a small employer group health insurance policy to use a standardized questionnaire that small employer carriers shall be required to use. The development of the uniform employee health-status questionnaire is intended to relieve small employers of the burden of completing separate application forms for each small employer carrier with which the employer applies for insurance or from which the employer seeks information regarding such matters as rates, coverage, and availability. The use of the uniform employee health-status questionnaire by small employer carriers and small employers shall be mandatory.
    (d) On or before July 1, 2010, the committee shall develop the uniform employee health-status questionnaire for adoption by the Department. Beginning January 1, 2011, a small employer carrier shall use the questionnaire for all small employer groups for which it requires employees and their covered dependents to complete questionnaires.
    (e) The Director, as needed, may reconvene the committee to consider whether changes are necessary to the uniform employee health status questionnaire. If the committee determines that changes to the questionnaire are necessary, then the Director may adopt revisions to the questionnaire as recommended by the committee. Small employer carriers shall use the revised questionnaire beginning 90 days after the Director adopts any revision.
    (f) Nothing in this Section shall be construed to limit or restrict a small employer carrier's ability to appropriately rate risk under a small employer health benefit plan.
    (g) On or before July 1, 2010, the committee shall develop a standard individual market health statement to simplify the health insurance application process for individuals. The committee shall study health statements currently used by major carriers in this State who offer individual health insurance coverage and consolidate the statements into a standard individual market health statement. The standard individual market health statement shall be designed to permit its use both as a written document and through electronic or other alternative delivery formats. For purposes of the individual market health statement, the Director may, but shall not be required to, establish a committee distinct from that formed to develop an application for small employers. In that event, the composition of the committee shall be as prescribed in subsection (b) of this Section, although individual participants may change.
    (h) Beginning January 1, 2011, all carriers who offer individual health insurance coverage and evaluate the health status of individuals shall use the standard individual market health statement.
    (i) The Director, as needed, may reconvene the committee to consider whether changes are necessary to the standard individual market health statement. If the committee determines that changes to the statement are necessary, the Director may adopt revisions to the statement as recommended by the committee. All carriers who offer individual health insurance coverage shall use the revised statement beginning 90 days after the Director adopts any revision.
    (j) Nothing in this Section shall prevent a carrier from using health information after enrollment for the purpose of providing services or arranging for the provision of services under a health benefit plan or a policy of individual health insurance coverage.
    (k) Nothing in this Section shall be construed to limit or restrict a health carrier's ability to appropriately rate risk, refuse to issue or renew coverage, or otherwise rescind, terminate, or restrict coverage under a health benefit plan or a policy of individual health insurance coverage or conduct further review of the information submitted on the statement by contacting an individual, the individual's health care provider, or any other entity for additional health status related information.
    (l) Committee members are not eligible for compensation but may receive reimbursement of expenses.
(Source: P.A. 96-857, eff. 1-5-10.)

215 ILCS 5/359c

    (215 ILCS 5/359c)
    Sec. 359c. Accident and health expense reporting.
    (a) Beginning January 1, 2011 and every 6 months thereafter, any carrier providing a group or individual major medical policy of accident or health insurance shall prepare and provide to the Department of Insurance a statement of the aggregate administrative expenses of the carrier, based on the premiums earned in the immediately preceding 6-month period on the accident or health insurance business of the carrier. The semi-annual statements shall be filed on or before October 1 for the preceding 6-month period ending June 30 and on or before April 1 for the preceding 6-month period ending December 31. The statements shall itemize and separately detail all of the following information with respect to the carrier's accident or health insurance business:
        (1) the amount of premiums earned by the carrier both
    
before and after any costs related to the carrier's purchase of reinsurance coverage;
        (2) the total amount of claims for losses paid by the
    
carrier both before and after any reimbursement from reinsurance coverage including any costs incurred related to:
            (A) disease, case, or chronic care management
        
programs;
            (B) wellness and health education programs;
            (C) fraud prevention;
            (D) maintaining provider networks and provider
        
credentialing;
            (E) health information technology for personal
        
electronic health records; and
            (F) utilization review and utilization management;
        (3) the amount of any losses incurred by the carrier
    
but not reported to the carrier in the current or prior reporting period;
        (4) the amount of costs incurred by the carrier for
    
State fees and federal and State taxes including:
            (A) any high risk pool and guaranty fund
        
assessments levied on the carrier by the State; and
            (B) any regulatory compliance costs including
        
State fees for form and rate filings, licensures, market conduct exams, and financial reports;
        (5) the amount of costs incurred by the carrier for
    
reinsurance coverage;
        (6) the amount of costs incurred by the carrier that
    
are related to the carrier's payment of marketing expenses including commissions; and
        (7) any other administrative expenses incurred by the
    
carrier.
    (b) The information provided pursuant to subsection (a) of this Section shall be separately aggregated for the following lines of major medical insurance:
        (1) individually underwritten;
        (2) groups of 2 to 25 members;
        (3) groups of 26 to 50 members;
        (4) groups of 51 or more members.
    (c) The Department shall make the submitted information publicly available on the Department's website or such other media as appropriate in a form useful for consumers.
(Source: P.A. 96-857, eff. 1-5-10; 97-524, eff. 1-1-12.)

215 ILCS 5/360a

    (215 ILCS 5/360a) (from Ch. 73, par. 972a)
    Sec. 360a. Notice, waiver.
    The acknowledgement by any insurer of the receipt of notice given under any policy covered by this article, or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.
(Source: Laws 1951, p. 611.)

215 ILCS 5/361a

    (215 ILCS 5/361a) (from Ch. 73, par. 973a)
    Sec. 361a. Age limit.
    If any such policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.
(Source: Laws 1951, p. 611.)

215 ILCS 5/362a

    (215 ILCS 5/362a) (from Ch. 73, par. 974a)
    Sec. 362a. Non-application to certain policies. The provisions of sections 356a to 359a, both inclusive, shall not apply to or affect (1) any policy of workers' compensation insurance or any policy of liability insurance with or without supplementary expense coverage therein; or (2) any policy or contract of reinsurance; or (3) any group policy of insurance (unless otherwise specifically provided); or (4) life insurance, endowment or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to accident and sickness insurance as (a) provide additional benefits in case of death or dismemberment or loss of sight by accident, or as (b) operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant shall become totally and permanently disabled, as defined by the contract or supplemental contract.
(Source: P.A. 81-992.)

215 ILCS 5/363

    (215 ILCS 5/363) (from Ch. 73, par. 975)
    Sec. 363. Medicare supplement policies; minimum standards.
    (1) Except as otherwise specifically provided therein, this Section and Section 363a of this Code shall apply to:
        (a) all Medicare supplement policies and subscriber
    
contracts delivered or issued for delivery in this State on and after January 1, 1989; and
        (b) all certificates issued under group Medicare
    
supplement policies or subscriber contracts, which certificates are issued or issued for delivery in this State on and after January 1, 1989.
    This Section shall not apply to "Accident Only" or "Specified Disease" types of policies. The provisions of this Section are not intended to prohibit or apply to policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons, which policies or plans are not marketed or purported or held to be Medicare supplement policies or benefit plans.
    (2) For the purposes of this Section and Section 363a, the following terms have the following meanings:
        (a) "Applicant" means:
            (i) in the case of individual Medicare supplement
        
policy, the person who seeks to contract for insurance benefits, and
            (ii) in the case of a group Medicare policy or
        
subscriber contract, the proposed certificate holder.
        (b) "Certificate" means any certificate delivered or
    
issued for delivery in this State under a group Medicare supplement policy.
        (c) "Medicare supplement policy" means an individual
    
policy of accident and health insurance, as defined in paragraph (a) of subsection (2) of Section 355a of this Code, or a group policy or certificate delivered or issued for delivery in this State by an insurer, fraternal benefit society, voluntary health service plan, or health maintenance organization, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.) or a policy issued under a demonstration project specified in 42 U.S.C. Section 1395ss(g)(1), or any similar organization, that is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of persons eligible for Medicare.
        (d) "Issuer" includes insurance companies, fraternal
    
benefit societies, voluntary health service plans, health maintenance organizations, or any other entity providing Medicare supplement insurance, unless the context clearly indicates otherwise.
        (e) "Medicare" means the Health Insurance for the
    
Aged Act, Title XVIII of the Social Security Amendments of 1965.
    (3) No Medicare supplement insurance policy, contract, or certificate, that provides benefits that duplicate benefits provided by Medicare, shall be issued or issued for delivery in this State after December 31, 1988. No such policy, contract, or certificate shall provide lesser benefits than those required under this Section or the existing Medicare Supplement Minimum Standards Regulation, except where duplication of Medicare benefits would result.
    (4) Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded directly to him or her in a timely manner if, after examination of the policy or certificate, the insured person is not satisfied for any reason.
    (5) A Medicare supplement policy or certificate may not deny a claim for losses incurred more than 6 months from the effective date of coverage for a preexisting condition. The policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
    (6) An issuer of a Medicare supplement policy shall:
        (a) not deny coverage to an applicant under 65 years
    
of age who meets any of the following criteria:
            (i) becomes eligible for Medicare by reason of
        
disability if the person makes application for a Medicare supplement policy within 6 months of the first day on which the person enrolls for benefits under Medicare Part B; for a person who is retroactively enrolled in Medicare Part B due to a retroactive eligibility decision made by the Social Security Administration, the application must be submitted within a 6-month period beginning with the month in which the person received notice of retroactive eligibility to enroll;
            (ii) has Medicare and an employer group health
        
plan (either primary or secondary to Medicare) that terminates or ceases to provide all such supplemental health benefits;
            (iii) is insured by a Medicare Advantage plan
        
that includes a Health Maintenance Organization, a Preferred Provider Organization, and a Private Fee-For-Service or Medicare Select plan and the applicant moves out of the plan's service area; the insurer goes out of business, withdraws from the market, or has its Medicare contract terminated; or the plan violates its contract provisions or is misrepresented in its marketing; or
            (iv) is insured by a Medicare supplement policy
        
and the insurer goes out of business, withdraws from the market, or the insurance company or agents misrepresent the plan and the applicant is without coverage;
        (b) make available to persons eligible for Medicare
    
by reason of disability each type of Medicare supplement policy the issuer makes available to persons eligible for Medicare by reason of age;
        (c) not charge individuals who become eligible for
    
Medicare by reason of disability and who are under the age of 65 premium rates for any medical supplemental insurance benefit plan offered by the issuer that exceed the issuer's highest rate on the current rate schedule filed with the Division of Insurance for that plan to individuals who are age 65 or older; and
        (d) provide the rights granted by items (a) through
    
(d), for 6 months after the effective date of this amendatory Act of the 95th General Assembly, to any person who had enrolled for benefits under Medicare Part B prior to this amendatory Act of the 95th General Assembly who otherwise would have been eligible for coverage under item (a).
    (7) The Director shall issue reasonable rules and regulations for the following purposes:
        (a) To establish specific standards for policy
    
provisions of Medicare policies and certificates. The standards shall be in accordance with the requirements of this Code. No requirement of this Code relating to minimum required policy benefits, other than the minimum standards contained in this Section and Section 363a, shall apply to medicare supplement policies and certificates. The standards may cover, but are not limited to the following:
            (A) Terms of renewability.
            (B) Initial and subsequent terms of eligibility.
            (C) Non-duplication of coverage.
            (D) Probationary and elimination periods.
            (E) Benefit limitations, exceptions and
        
reductions.
            (F) Requirements for replacement.
            (G) Recurrent conditions.
            (H) Definition of terms.
            (I) Requirements for issuing rebates or credits
        
to policyholders if the policy's loss ratio does not comply with subsection (7) of Section 363a.
            (J) Uniform methodology for the calculating and
        
reporting of loss ratio information.
            (K) Assuring public access to loss ratio
        
information of an issuer of Medicare supplement insurance.
            (L) Establishing a process for approving or
        
disapproving proposed premium increases.
            (M) Establishing a policy for holding public
        
hearings prior to approval of premium increases.
            (N) Establishing standards for Medicare Select
        
policies.
            (O) Prohibited policy provisions not otherwise
        
specifically authorized by statute that, in the opinion of the Director, are unjust, unfair, or unfairly discriminatory to any person insured or proposed for coverage under a medicare supplement policy or certificate.
        (b) To establish minimum standards for benefits and
    
claims payments, marketing practices, compensation arrangements, and reporting practices for Medicare supplement policies.
        (c) To implement transitional requirements of
    
Medicare supplement insurance benefits and premiums of Medicare supplement policies and certificates to conform to Medicare program revisions.
(Source: P.A. 95-436, eff. 6-1-08.)

215 ILCS 5/363a

    (215 ILCS 5/363a) (from Ch. 73, par. 975a)
    Sec. 363a. Medicare supplement policies; disclosure, advertising, loss ratio standards.
    (1) Scope. This Section pertains to disclosure requirements of companies and agents and mandatory and prohibited practices of agents when selling a policy to supplement the Medicare program or any other health insurance policy sold to individuals eligible for Medicare. No policy shall be referred to or labeled as a Medicare supplement policy if it does not comply with the minimum standards required by regulation pursuant to Section 363 of this Code. Except as otherwise specifically provided in paragraph (d) of subsection (6), this Section shall not apply to accident only or specified disease type of policies or hospital confinement indemnity or other type policies clearly unrelated to Medicare.
    (2) Advertising. An advertisement that describes or offers to provide information concerning the federal Medicare program shall comply with all of the following:
        (a) It may not include any reference to that program
    
on the envelope, the reply envelope, or the address side of the reply postal card, if any, nor use any language to imply that failure to respond to the advertisement might result in loss of Medicare benefits.
        (b) It must include a prominent statement to the
    
effect that in providing supplemental coverage the insurer and agent involved in the solicitation are not in any manner connected with that program.
        (c) It must prominently disclose that it is an
    
advertisement for insurance or is intended to obtain insurance prospects.
        (d) It must prominently identify and set forth the
    
actual address of the insurer or insurers that issue the coverage.
        (e) It must prominently state that any material or
    
information offered will be delivered in person by a representative of the insurer, if that is the case.
    The Director may issue reasonable rules and regulations for the purpose of establishing criteria and guidelines for the advertising of Medicare supplement insurance.
    (3) Mandatory agent practices. For the purpose of this Act, "home solicitation sale by an agent" means a sale or attempted sale of an insurance policy at the purchaser's residence, agent's transient quarters, or away from the agent's home office when the initial contact is personally solicited by the agent or insurer. Any agent involved in any home solicitation sale of a Medicare supplement policy or other policy of accident and health insurance, subject to subsection (1) of this Section, sold to individuals eligible for Medicare shall promptly do the following:
        (a) Identify himself as an insurance agent.
        (b) Identify the insurer or insurers for which he is
    
a licensed agent.
        (c) Provide the purchaser with a clearly printed or
    
typed identification of his name, address, telephone number, and the name of the insurer in which the insurance is to be written.
        (d) Determine what, if any, policy is appropriate,
    
suitable, and nonduplicative for the purchaser considering existing coverage and be able to provide proof to the company that such a determination has been made.
        (e) Fully and completely disclose the purchaser's
    
medical history on the application if required for issue.
        (f) Complete a Policy Check List in duplicate as
    
follows:
POLICY CHECK LIST
    Applicant's Name:
    Policy Number:
    Name of Existing Insurer:
    Expiration Date of Existing Insurance:
MedicareExistingSupplementInsured's
PaysCoveragePaysResponsibility
    Service
    Hospital
    Skilled
    Nursing
    Home Care
    Prescription
    Drugs
        This policy does/does not (circle one) comply with
    
the minimum standards for Medicare supplements set forth in Section 363 of the Illinois Insurance Code.
                                        Signature of Applicant
                                            Signature of Agent
        This Policy Check List is to be completed in the
    
presence of the purchaser at the point of sale, and copies of it, completed and duly signed, are to be provided to the purchaser and to the company.
        (g) Except in the case of refunds of premium made
    
pursuant to subsection (5) of Section 363 of this Code, send by mail to an insured or an applicant for insurance, when the insurer follows a practice of having agents return premium refund drafts issued by the insurer, a premium refund draft within 2 weeks of its receipt by the agent from the insurer making such refund.
        (h) Deliver to the purchaser, along with every policy
    
issued pursuant to Section 363 of this Code, an Outline of Coverage as described in paragraph (b) of subsection (6) of this Section.
    (4) Prohibited agent practices.
        (a) No insurance agent engaged in a home solicitation
    
sale of a Medicare supplement policy or other policy of accident and health insurance, subject to subsection (1) of this Section, sold to individuals eligible for Medicare shall use any false, deceptive, or misleading representation to induce a sale, or use any plan, scheme, or ruse, that misrepresents the true status or mission of the person making the call, or represent directly or by implication that the agent:
            (i) Is offering insurance that is approved or
        
recommended by the State or federal government to supplement Medicare.
            (ii) Is in any way representing, working for, or
        
compensated by a local, State, or federal government agency.
            (iii) Is engaged in an advisory business in which
        
his compensation is unrelated to the sale of insurance by the use of terms such as Medicare consultant, Medicare advisor, Medicare Bureau, disability insurance consultant, or similar expression in a letter, envelope, reply card, or other.
            (iv) Will provide a continuing service to the
        
purchaser of the policy unless he does provide services to the purchaser beyond the sale and renewal of policies.
        (b) No agent engaged in a home solicitation sale of a
    
Medicare supplement policy or other policy of accident and health insurance sold to individuals eligible for Medicare shall misrepresent, directly or by implication, any of the following:
            (i) The identity of the insurance company or
        
companies he represents.
            (ii) That the assistance programs of the State or
        
county or the federal Medicare programs for medical insurance are to be discontinued or are increasing in cost to the prospective buyer or are in any way endangered.
            (iii) That an insurance company in which the
        
prospective purchaser is insured is financially unstable, cancelling its outstanding policies, merging, or withdrawing from the State.
            (iv) The coverage of the policy being sold.
            (v) The effective date of coverage under the
        
policy.
            (vi) That any pre-existing health condition of
        
the purchaser is irrelevant.
            (vii) The right of the purchaser to cancel the
        
policy within 30 days after receiving it.
    (5) Mandatory company practices. Any company involved in the sale of Medicare supplement policies or any policies of accident and health insurance (subject to subsection (1) of this Section) sold to individuals eligible for Medicare shall do the following:
        (a) Be able to readily determine the number of
    
accident and health policies in force with the company on each insured eligible for Medicare.
        (b) Make certain that policies of Medicare supplement
    
insurance are not issued, and any premium collected for those policies is refunded, when they are deemed duplicative, inappropriate, or not suitable considering existing coverage with the company.
        (c) Maintain copies of the Policy Check List as
    
completed by the agent at the point of sale of a Medicare supplement policy or any policy of accident and health insurance (subject to subsection (1) of this Section) sold to individuals eligible for Medicare on file at the company's regional or other administrative office.
    (6) Disclosures. In order to provide for full and fair disclosure in the sale of Medicare supplement policies, there must be compliance with the following:
        (a) No Medicare supplement policy or certificate
    
shall be delivered in this State unless an outline of coverage is delivered to the applicant at the time application is made and, except for direct response policies, an acknowledgement from the applicant of receipt of the outline is obtained.
        (b) Outline of coverage requirements for Medicare
    
supplement policies.
            (i) Insurers issuing Medicare supplement policies
        
or certificates for delivery in this State shall provide an outline of coverage to all applicants at the time application is made and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant.
            (ii) If an outline of coverage is provided at the
        
time of application and the Medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and shall contain immediately above the company name, in no less than 12 point type, the following statement:
            "NOTICE: Read this outline of coverage carefully.
        
It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.".
            (iii) The outline of coverage provided to
        
applicants shall be in the form prescribed by rule by the Department.
        (c) Insurers issuing policies that provide hospital
    
or medical expense coverage on an expense incurred or indemnity basis, other than incidentally, to a person or persons eligible for Medicare shall provide to the policyholder a buyer's guide approved by the Director. Delivery of the buyer's guide shall be made whether or not the policy qualifies as a "Medicare Supplement Coverage" in accordance with Section 363 of this Code. Except in the case of direct response insurers, delivery of the buyer's guide shall be made at the time of application, and acknowledgement of receipt of certification of delivery of the buyer's guide shall be provided to the insurer. Direct response insurers shall deliver the buyer's guide upon request, but not later than at the time the policy is delivered.
        (d) Outlines of coverage delivered in connection with
    
policies defined in subsection (4) of Section 355a of this Code as Hospital confinement Indemnity (Section 4c), Accident Only Coverage (Section 4f), Specified Disease (Section 4g) or Limited Benefit Health Insurance Coverage to persons eligible for Medicare shall contain, in addition to other requirements for those outlines, the following language that shall be printed on or attached to the first page of the outline of coverage:
        "This policy, certificate or subscriber contract IS
    
NOT A MEDICARE SUPPLEMENT policy or certificate. It does not fully supplement your federal Medicare health insurance. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.".
        (e) In the case wherein a policy, as defined in
    
paragraph (a) of subsection (2) of Section 355a of this Code, being sold to a person eligible for Medicare provides one or more but not all of the minimum standards for Medicare supplements set forth in Section 363 of this Code, disclosure must be provided that the policy is not a Medicare supplement and does not meet the minimum benefit standards set for those policies in this State.
    (7) Loss ratio standards.
        (a) Every issuer of Medicare supplement policies or
    
certificates in this State, as defined in Section 363 of this Code, shall file annually its rates, rating schedule, and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall demonstrate that the actual and anticipated losses in relation to premiums comply with the requirements of this Code.
        (b) Medicare supplement policies shall, for the
    
entire period for which rates are computed to provide coverage, on the basis of incurred claims experience and earned premiums for the period and in accordance with accepted actuarial principles and practices, return to policyholders in the form of aggregate benefits the following:
            (i) In the case of group policies, at least 75%
        
of the aggregate amount of premiums earned.
            (ii) In the case of individual policies, at least
        
60% of the aggregate amount of premiums earned; and beginning November 5, 1991, at least 65% of the aggregate amount of premiums earned.
            (iii) In the case of sponsored group policies in
        
which coverage is marketed on an individual basis by direct response to eligible individuals in that group only, at least 65% of the aggregate amount of premiums earned.
        (c) For the purposes of this Section, the insurer
    
shall be deemed to comply with the loss ratio standards if: (i) for the most recent year, the ratio of the incurred losses to earned premiums for policies or certificates that have been in force for 3 years or more is greater than or equal to the applicable percentages contained in this Section; and (ii) the anticipated losses in relation to premiums over the entire period for which the policy is rated comply with the requirements of this Section. An anticipated third-year loss ratio that is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years.
    (8) Applicability. This Section shall apply to those companies writing the kind or kinds of business enumerated in Classes 1(b) and 2(a) of Section 4 of this Code and to those entities organized and operating under the Voluntary Health Services Plans Act and the Health Maintenance Organization Act.
    (9) Penalties.
        (a) Any company or agent who is found to have
    
violated any of the provisions of this Section may be required by order of the Director of Insurance to forfeit by civil penalty not less than $500 nor more than $5,000 for each offense. Written notice will be issued and an opportunity for a hearing will be granted pursuant to subsection (2) of Section 403A of this Code.
        (b) In addition to any other applicable penalties for
    
violations of this Code, the Director may require insurers violating any provision of this Code or regulations promulgated pursuant to this Code to cease marketing in this State any Medicare supplement policy or certificate that is related directly or indirectly to a violation and may require the insurer to take actions as are necessary to comply with the provisions of Sections 363 and 363a of this Code.
        (c) After June 30, 1991, no person may advertise,
    
solicit for the sale or purchase of, offer for sale, or deliver a Medicare supplement policy that has not been approved by the Director. A person who knowingly violates, directly or through an agent, the provisions of this paragraph commits a Class 3 felony. Any person who violates the provisions of this paragraph may be subjected to a civil penalty not to exceed $10,000. The civil penalty authorized in this paragraph shall be enforced in the manner provided in Section 403A of this Code.
    (10) Replacement. Application forms shall include a question designed to elicit information as to whether a Medicare supplement policy or certificate is intended to replace any similar accident and sickness policy or certificate presently in force. A supplementary application or other form to be signed by the applicant containing the question may be used. Upon determining that a sale of Medicare supplement coverage will involve replacement, an insurer, other than a direct response insurer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of the notice shall be provided to the applicant, and an additional copy signed by the applicant shall be retained by the insurer. A direct response insurer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement coverage.
(Source: P.A. 93-32, eff. 7-1-03.)

215 ILCS 5/364

    (215 ILCS 5/364) (from Ch. 73, par. 976)
    Sec. 364. Discrimination prohibited. Discrimination between individuals of the same class of risk in the issuance of its policies or in the amount of premiums or rates charged for any insurance covered by this article, or in the benefits payable thereon, or in any of the terms or conditions of such policy, or in any other manner whatsoever is prohibited. Nothing in this provision shall prohibit an insurer from providing incentives for insureds to utilize the services of a particular hospital or person. It is hereby expressly provided that whenever the terms "physician" or "doctor" appear or are used in any way in any policy of accident or health insurance issued in this state, said terms shall include within their meaning persons licensed to practice dentistry under the Illinois Dental Practice Act with regard to benefits payable for services performed by a person so licensed, which such services are within the coverage provided by the particular policy or contract of insurance and are within the professional services authorized to be performed by such person under and in accordance with the said Act.
    No company, in any policy of accident or health insurance issued in this State, shall make or permit any distinction or discrimination against individuals solely because of handicaps or disabilities in the amount of payment of premiums or rates charged for policies of insurance, in the amount of any dividends or other benefits payable thereon, or in any other terms and conditions of the contract it makes, except where the distinction or discrimination is based on sound actuarial principles or is related to actual or reasonably anticipated experience.
    No company shall refuse to insure, or refuse to continue to insure, or limit the amount or extent or kind of coverage available to an individual, or charge an individual a different rate for the same coverage solely because of blindness or partial blindness. With respect to all other conditions, including the underlying cause of the blindness or partial blindness, persons who are blind or partially blind shall be subject to the same standards of sound actuarial principles or actual or reasonably anticipated experience as are sighted persons. Refusal to insure includes denial by an insurer of disability insurance coverage on the grounds that the policy defines "disability" as being presumed in the event that the insured loses his or her eyesight.
(Source: P.A. 91-549, eff. 8-14-99.)

215 ILCS 5/364.01

    (215 ILCS 5/364.01)
    Sec. 364.01. Qualified clinical cancer trials.
    (a) No individual or group policy of accident and health insurance issued or renewed in this State may be cancelled or non-renewed for any individual based on that individual's participation in a qualified clinical cancer trial.
    (b) Qualified clinical cancer trials must meet the following criteria:
        (1) the effectiveness of the treatment has not been
    
determined relative to established therapies;
        (2) the trial is under clinical investigation as part
    
of an approved cancer research trial in Phase II, Phase III, or Phase IV of investigation;
        (3) the trial is:
            (A) approved by the Food and Drug Administration;
        
or
            (B) approved and funded by the National
        
Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the United States Department of Defense, the United States Department of Veterans Affairs, or the United States Department of Energy in the form of an investigational new drug application, or a cooperative group or center of any entity described in this subdivision (B); and
        (4) the patient's primary care physician, if any, is
    
involved in the coordination of care.
    (c) No group policy of accident and health insurance shall exclude coverage for any routine patient care administered to an insured who is a qualified individual participating in a qualified clinical cancer trial, if the policy covers that same routine patient care of insureds not enrolled in a qualified clinical cancer trial.
    (d) The coverage that may not be excluded under subsection (c) of this Section is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to the same routine patient care received by an insured not enrolled in a qualified clinical cancer trial, including the application of any authorization requirement, utilization review, or medical management practices. The insured or enrollee shall incur no greater out-of-pocket liability than had the insured or enrollee not enrolled in a qualified clinical cancer trial.
    (e) If the group policy of accident and health insurance uses a preferred provider program and a preferred provider provides routine patient care in connection with a qualified clinical cancer trial, then the insurer may require the insured to use the preferred provider if the preferred provider agrees to provide to the insured that routine patient care.
    (f) A qualified clinical cancer trial may not pay or refuse to pay for routine patient care of an individual participating in the trial, based in whole or in part on the person's having or not having coverage for routine patient care under a group policy of accident and health insurance.
    (g) Nothing in this Section shall be construed to limit an insurer's coverage with respect to clinical trials.
    (h) Nothing in this Section shall require coverage for out-of-network services where the underlying health benefit plan does not provide coverage for out-of-network services.
    (i) As used in this Section, "routine patient care" means all health care services provided in the qualified clinical cancer trial that are otherwise generally covered under the policy if those items or services were not provided in connection with a qualified clinical cancer trial consistent with the standard of care for the treatment of cancer, including the type and frequency of any diagnostic modality, that a provider typically provides to a cancer patient who is not enrolled in a qualified clinical cancer trial. "Routine patient care" does not include, and a group policy of accident and health insurance may exclude, coverage for:
        (1) a health care service, item, or drug that is the
    
subject of the cancer clinical trial;
        (2) a health care service, item, or drug provided
    
solely to satisfy data collection and analysis needs for the qualified clinical cancer trial that is not used in the direct clinical management of the patient;
        (3) an investigational drug or device that has not
    
been approved for market by the United States Food and Drug Administration;
        (4) transportation, lodging, food, or other expenses
    
for the patient or a family member or companion of the patient that are associated with the travel to or from a facility providing the qualified clinical cancer trial, unless the policy covers these expenses for a cancer patient who is not enrolled in a qualified clinical cancer trial;
        (5) a health care service, item, or drug customarily
    
provided by the qualified clinical cancer trial sponsors free of charge for any patient;
        (6) a health care service or item, which except for
    
the fact that it is being provided in a qualified clinical cancer trial, is otherwise specifically excluded from coverage under the insured's policy, including:
            (A) costs of extra treatments, services,
        
procedures, tests, or drugs that would not be performed or administered except for the fact that the insured is participating in the cancer clinical trial; and
            (B) costs of nonhealth care services that the
        
patient is required to receive as a result of participation in the approved cancer clinical trial;
        (7) costs for services, items, or drugs that are
    
eligible for reimbursement from a source other than a patient's contract or policy providing for third-party payment or prepayment of health or medical expenses, including the sponsor of the approved cancer clinical trial;
        (8) costs associated with approved cancer clinical
    
trials designed exclusively to test toxicity or disease pathophysiology, unless the policy covers these expenses for a cancer patient who is not enrolled in a qualified clinical cancer trial; or
        (9) a health care service or item that is eligible
    
for reimbursement by a source other than the insured's policy, including the sponsor of the qualified clinical cancer trial.
    The definitions of the terms "health care services", "Non-Preferred Provider", "Preferred Provider", and "Preferred Provider Program", stated in 50 IL Adm. Code Part 2051 Preferred Provider Programs apply to these terms in this Section.
    (j) The external review procedures established under the Health Carrier External Review Act shall apply to the provisions under this Section.
(Source: P.A. 97-91, eff. 1-1-12; 97-813, eff. 7-13-12.)

215 ILCS 5/364.1

    (215 ILCS 5/364.1) (from Ch. 73, par. 976.1)
    Sec. 364.1. Every policy of accident and health insurance delivered or issued for delivery to any person in this State after the effective date of this amendatory Act of 1979 which provides coverage for services coming within the practice of optometry as defined in the Illinois Optometric Practice Act of 1987, as now or hereafter amended shall, upon issuance or delivery, be accompanied by a written notice to the policyholder that such policyholder may elect for optometric services received to be reimbursed to either a physician licensed to practice medicine in all its branches or to an optometrist licensed in this State.
(Source: P.A. 85-1209.)

215 ILCS 5/364.2

    (215 ILCS 5/364.2)
    Sec. 364.2. Purchase of ophthalmic goods or services. An insurer may not require a provider, as a condition of participation by the provider, to purchase ophthalmic goods or services, including but not limited to eyeglass frames, in a quantity or dollar amount in excess of the quantity or dollar amount an enrollee purchases under the terms of the policy.
(Source: P.A. 93-1077, eff. 1-18-05.)

215 ILCS 5/367

    (215 ILCS 5/367) (from Ch. 73, par. 979)
    Sec. 367. Group accident and health insurance.
    (1) Group accident and health insurance is hereby declared to be that form of accident and health insurance covering not less than 2 employees, members, or employees of members, written under a master policy issued to any governmental corporation, unit, agency or department thereof, or to any corporation, copartnership, individual employer, or to any association upon application of an executive officer or trustee of such association having a constitution or bylaws and formed in good faith for purposes other than that of obtaining insurance, where officers, members, employees, employees of members or classes or department thereof, may be insured for their individual benefit. In addition a group accident and health policy may be written to insure any group which may be insured under a group life insurance policy. The term "employees" shall include the officers, managers and employees of subsidiary or affiliated corporations, and the individual proprietors, partners and employees of affiliated individuals and firms, when the business of such subsidiary or affiliated corporations, firms or individuals, is controlled by a common employer through stock ownership, contract or otherwise.
    (2) Any insurance company authorized to write accident and health insurance in this State shall have power to issue group accident and health policies. No policy of group accident and health insurance may be issued or delivered in this State unless a copy of the form thereof shall have been filed with the department and approved by it in accordance with Section 355, and it contains in substance those provisions contained in Sections 357.1 through 357.30 as may be applicable to group accident and health insurance and the following provisions:
        (a) A provision that the policy, the application of
    
the employer, or executive officer or trustee of any association, and the individual applications, if any, of the employees, members or employees of members insured shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer or trustee, or by the individual employees, members or employees of members shall (in the absence of fraud) be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the policy, unless it is contained in a written application.
        (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

    (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

    (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.)