(215 ILCS 5/355a) (from Ch. 73, par. 967a)
Sec. 355a. Standardization of terms and coverage.
(1) The purposes 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.
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(b) "Service corporations" means voluntary health and
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| dental corporations organized and operating respectively under the Voluntary Health Services Plans Act and the Dental Service Plan Act.
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(c) "Accident and health insurance" means insurance
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| written under Article XX of this 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.
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(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.
(c) (Blank).
(d) (Blank).
(e) (Blank).
(f) (Blank).
(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 this
Code.
(Source: P.A. 102-775, eff. 5-13-22.)
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(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 |
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(2) An annual mammogram for women 40 years of age or
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(3) A mammogram at the age and intervals considered
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| 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.
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(4) For an individual or group policy of accident and
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| 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 101st General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
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(5) A screening MRI when medically necessary, as
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| determined by a physician licensed to practice medicine in all of its branches.
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(6) For an individual or group policy of accident and
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| 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 101st General Assembly, a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.
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A policy subject to this subsection shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223).
For purposes of this Section:
"Diagnostic
mammogram" means a mammogram obtained using diagnostic mammography.
"Diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.
"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 and includes breast tomosynthesis. As used in this Section, the term "breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this subsection, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this subsection.
(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
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| mastectomy has been performed;
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(2) surgery and reconstruction of the other breast to
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| produce a symmetrical appearance; and
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(3) prostheses and treatment for physical
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| complications at all stages of mastectomy, including lymphedemas.
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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 Public Act 95-1045, 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. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20 .)
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(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 the 99th General Assembly 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:
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(A) the covered individual has been unable to
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| attain a viable pregnancy, maintain a viable pregnancy, or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract;
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(B) the covered individual has not undergone 4
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| completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and
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(C) the procedures are performed at medical
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| 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.
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(2) The procedures required to be covered under this
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| 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.
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(c) As used in this Section, "infertility" means a disease, condition, or status characterized by:
(1) a failure to establish a pregnancy or to carry a
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| pregnancy to live birth after 12 months of regular, unprotected sexual intercourse if the woman is 35 years of age or younger, or after 6 months of regular, unprotected sexual intercourse if the woman is over 35 years of age; conceiving but having a miscarriage does not restart the 12-month or 6-month term for determining infertility;
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(2) a person's inability to reproduce either as a
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| single individual or with a partner without medical intervention; or
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(3) a licensed physician's findings based on a
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| patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.
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(d) A policy, contract, or certificate may not impose any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on any other prescription medications, nor may it impose any exclusions, limitations, or other restrictions on coverage of any fertility services based on a covered individual's participation in fertility services provided by or to a third party, nor may it impose deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for the diagnosis of infertility, treatment for infertility, and standard fertility preservation services, except as provided in this Section, that are different from those imposed upon benefits for services not related to infertility.
(Source: P.A. 102-170, eff. 1-1-22 .)
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(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.
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Your woman's principal health care provider must be a
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| 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.".
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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
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| 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.".
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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
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| physician licensed to practice medicine in all of its branches specializing in obstetrics or gynecology or specializing in family practice.
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(2) "Managed care entity" means any entity including
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| 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.
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(3) "Managed care plan" means a plan operated by a
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| managed care entity that provides for the financing of health care services to persons enrolled in the plan through:
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(A) organizational arrangements for ongoing
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| quality assurance, utilization review programs, or dispute resolution; or
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(B) financial incentives for persons enrolled in
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| the plan to use the participating providers and procedures covered by the plan.
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(4) "Participating provider" means a physician who
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| has contracted with an insurer or managed care plan to provide services to insureds or enrollees as defined by the contract.
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(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.)
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(215 ILCS 5/356u)
(Text of Section before amendment by P.A. 103-30 )
Sec. 356u. Pap tests and prostate cancer screenings.
(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 January 1, 2024 shall provide coverage, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement, for all of
the
following:
(1) An annual cervical smear or Pap smear test for |
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(2) An annual prostate cancer screening for male
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| insureds upon the recommendation of a physician licensed to practice medicine in all its branches for:
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(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
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(3) Surveillance tests for ovarian cancer for female
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| insureds who are at risk for ovarian cancer.
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(b) This Section shall not apply to agreements, contracts, or policies that
provide coverage for a specified disease or other limited benefit coverage.
(c) This Section does not apply to coverage of prostate cancer screenings to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(d) For the purposes of this Section:
"At risk for ovarian cancer" means:
(1) having a family history (i) with one or more
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| first-degree relatives with ovarian cancer, (ii) of clusters of women relatives with breast cancer, or (iii) of nonpolyposis colorectal cancer; or
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(2) testing positive for BRCA1 or BRCA2 mutations.
"Prostate cancer screening" means medically viable methods for the detection and diagnosis of prostate cancer, including a digital rectal exam and the prostate-specific antigen test and associated laboratory work. "Prostate cancer screening" includes medically necessary subsequent follow-up testing as directed by a health care provider, including, but not limited to:
(1) urinary analysis;
(2) serum biomarkers; and
(3) medical imaging, including, but not limited to,
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| magnetic resonance imaging.
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"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. 102-1073, eff. 1-1-23 .)
(Text of Section after amendment by P.A. 103-30 )
Sec. 356u. Pap tests and prostate cancer screenings.
(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 January 1, 2024 shall provide coverage, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement, for all of
the
following:
(1) An annual cervical smear or Pap smear test for
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(2) An annual prostate cancer screening for insureds
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| upon the recommendation of a physician licensed to practice medicine in all its branches for:
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(A) asymptomatic individuals age 50 and over;
(B) African-American individuals age 40 and over;
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(C) individuals age 40 and over with a family
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| history of or genetic predisposition to prostate cancer.
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(3) Surveillance tests for ovarian cancer for
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| insureds who are at risk for ovarian cancer.
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(b) This Section shall not apply to agreements, contracts, or policies that
provide coverage for a specified disease or other limited benefit coverage.
(c) This Section does not apply to coverage of prostate cancer screenings to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(d) For the purposes of this Section:
"At risk for ovarian cancer" means:
(1) having a family history (i) with one or more
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| first-degree relatives with ovarian cancer, (ii) of clusters of relatives with breast cancer, or (iii) of nonpolyposis colorectal cancer; or
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(2) testing positive for BRCA1 or BRCA2 mutations.
"Prostate cancer screening" means medically viable methods for the detection and diagnosis of prostate cancer, including a digital rectal exam and the prostate-specific antigen test and associated laboratory work. "Prostate cancer screening" includes medically necessary subsequent follow-up testing as directed by a health care provider, including, but not limited to:
(1) urinary analysis;
(2) serum biomarkers; and
(3) medical imaging, including, but not limited to,
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| magnetic resonance imaging.
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"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. 102-1073, eff. 1-1-23; 103-30, eff. 1-1-25.)
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(215 ILCS 5/356z.3a) Sec. 356z.3a. Billing; emergency services; nonparticipating providers. (a) As used in this Section: "Ancillary services" means: (1) items and services related to emergency |
| medicine, anesthesiology, pathology, radiology, and neonatology that are provided by any health care provider;
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(2) items and services provided by assistant
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| surgeons, hospitalists, and intensivists;
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(3) diagnostic services, including radiology and
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| laboratory services, except for advanced diagnostic laboratory tests identified on the most current list published by the United States Secretary of Health and Human Services under 42 U.S.C. 300gg-132(b)(3);
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(4) items and services provided by other specialty
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| practitioners as the United States Secretary of Health and Human Services specifies through rulemaking under 42 U.S.C. 300gg-132(b)(3);
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(5) items and services provided by a
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| nonparticipating provider if there is no participating provider who can furnish the item or service at the facility; and
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(6) items and services provided by a
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| nonparticipating provider if there is no participating provider who will furnish the item or service because a participating provider has asserted the participating provider's rights under the Health Care Right of Conscience Act.
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"Cost sharing" means the amount an insured, beneficiary, or enrollee is responsible for paying for a covered item or service under the terms of the policy or certificate. "Cost sharing" includes copayments, coinsurance, and amounts paid toward deductibles, but does not include amounts paid towards premiums, balance billing by out-of-network providers, or the cost of items or services that are not covered under the policy or certificate.
"Emergency department of a hospital" means any hospital department that provides emergency services, including a hospital outpatient department.
"Emergency medical condition" has the meaning ascribed to that term in Section 10 of the Managed Care Reform and Patient Rights Act.
"Emergency medical screening examination" has the meaning ascribed to that term in Section 10 of the Managed Care Reform and Patient Rights Act.
"Emergency services" means, with respect to an emergency medical condition:
(1) in general, an emergency medical screening
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| examination, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and such further medical examination and treatment as would be required to stabilize the patient regardless of the department of the hospital or other facility in which such further examination or treatment is furnished; or
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(2) additional items and services for which
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| benefits are provided or covered under the coverage and that are furnished by a nonparticipating provider or nonparticipating emergency facility regardless of the department of the hospital or other facility in which such items are furnished after the insured, beneficiary, or enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in paragraph (1) are furnished. Services after stabilization cease to be emergency services only when all the conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and regulations thereunder are met.
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"Freestanding Emergency Center" means a facility licensed under Section 32.5 of the Emergency Medical Services (EMS) Systems Act.
"Health care facility" means, in the context of non-emergency services, any of the following:
(1) a hospital as defined in 42 U.S.C. 1395x(e);
(2) a hospital outpatient department;
(3) a critical access hospital certified under 42
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(4) an ambulatory surgical treatment center as
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| defined in the Ambulatory Surgical Treatment Center Act; or
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(5) any recipient of a license under the Hospital
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| Licensing Act that is not otherwise described in this definition.
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"Health care provider" means a provider as defined in subsection (d) of Section 370g. "Health care provider" does not include a provider of air ambulance or ground ambulance services.
"Health care services" has the meaning ascribed to that term in subsection (a) of Section 370g.
"Health insurance issuer" has the meaning ascribed to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.
"Nonparticipating emergency facility" means, with respect to the furnishing of an item or service under a policy of group or individual health insurance coverage, any of the following facilities that does not have a contractual relationship directly or indirectly with a health insurance issuer in relation to the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as
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| defined in the Ambulatory Surgical Treatment Center Act; or
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(4) with respect to emergency services described in
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| paragraph (2) of the definition of "emergency services", a hospital.
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"Nonparticipating provider" means, with respect to the furnishing of an item or service under a policy of group or individual health insurance coverage, any health care provider who does not have a contractual relationship directly or indirectly with a health insurance issuer in relation to the coverage.
"Participating emergency facility" means any of the following facilities that has a contractual relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as
|
| defined in the Ambulatory Surgical Treatment Center Act; or
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(4) with respect to emergency services described in
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| paragraph (2) of the definition of "emergency services", a hospital.
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For purposes of this definition, a single case agreement between an emergency facility and an issuer that is used to address unique situations in which an insured, beneficiary, or enrollee requires services that typically occur out-of-network constitutes a contractual relationship and is limited to the parties to the agreement.
"Participating health care facility" means any health care facility that has a contractual
relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage. A single case agreement between an emergency facility and an issuer that is used to address unique situations in which an insured, beneficiary, or enrollee requires services that typically occur out-of-network constitutes a contractual relationship for purposes of this definition and is limited to the parties to the agreement.
"Participating provider" means any health care provider that has a
contractual relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage.
"Qualifying payment amount" has the meaning given to that term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations promulgated thereunder.
"Recognized amount" means the lesser of the amount initially billed by the provider or the qualifying payment amount.
"Stabilize" means "stabilization" as defined in Section 10 of the Managed Care Reform and Patient Rights Act.
"Treating provider" means a health care provider who has evaluated the individual.
"Visit" means, with respect to health care services furnished to an individual at a health care facility, health care services furnished by a provider at the facility, as well as equipment, devices, telehealth services, imaging services, laboratory services, and preoperative and postoperative services regardless of whether the provider furnishing such services is at the facility.
(b) Emergency services. When a beneficiary, insured, or enrollee receives emergency services from a nonparticipating provider or a nonparticipating emergency facility, the health insurance issuer 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 provider or a participating emergency facility. Any cost-sharing requirements shall be applied as though the emergency services had been received from a participating provider or a participating facility. Cost sharing shall be calculated based on the recognized amount for the emergency services. If the cost sharing for the same item or service furnished by a participating provider would have been a flat-dollar copayment, that amount shall be the cost-sharing amount unless the provider has billed a lesser total amount. In no event shall the beneficiary, insured, enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the nonparticipating emergency facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the emergency services delivered. Administrative requirements or limitations shall be no greater than those applicable to emergency services received from a participating provider or a participating emergency facility.
(b-5) Non-emergency services at participating health care facilities.
(1) When a beneficiary, insured, or enrollee utilizes
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| a participating health care facility and, due to any reason, covered ancillary services are provided by a nonparticipating provider during or resulting from the visit, the health insurance issuer 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 provider for the ancillary services. Any cost-sharing requirements shall be applied as though the ancillary services had been received from a participating provider. Cost sharing shall be calculated based on the recognized amount for the ancillary services. If the cost sharing for the same item or service furnished by a participating provider would have been a flat-dollar copayment, that amount shall be the cost-sharing amount unless the provider has billed a lesser total amount. In no event shall the beneficiary, insured, enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the participating health care facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the ancillary services delivered. In addition to ancillary services, the requirements of this paragraph shall also apply with respect to covered items or services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the nonparticipating provider satisfied the notice and consent criteria under paragraph (2) of this subsection.
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(2) When a beneficiary, insured, or enrollee utilizes
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| a participating health care facility and receives non-emergency covered health care services other than those described in paragraph (1) of this subsection from a nonparticipating provider during or resulting from the visit, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee incurs no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider unless the nonparticipating provider or the participating health care facility on behalf of the nonparticipating provider satisfies the notice and consent criteria provided in 42 U.S.C. 300gg-132 and regulations promulgated thereunder. If the notice and consent criteria are not satisfied, then:
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(A) any cost-sharing requirements shall be
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| applied as though the health care services had been received from a participating provider;
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(B) cost sharing shall be calculated based on
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| the recognized amount for the health care services; and
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(C) in no event shall the beneficiary, insured,
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| enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the participating health care facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the health care services delivered.
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|
(c) Notwithstanding any other provision of this Code, except when the notice and consent criteria are satisfied for the situation in paragraph (2) of subsection (b-5), any benefits a beneficiary, insured, or enrollee receives for services under the situations in subsection (b) or (b-5) are assigned to the nonparticipating providers or the facility acting on their behalf. Upon receipt of the provider's bill or facility's bill, the health insurance issuer shall provide the nonparticipating provider or the facility 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 health insurance issuer shall pay any reimbursement subject to this Section directly to the nonparticipating provider or the facility.
(d) For bills assigned under subsection (c), the nonparticipating provider or the facility may bill the health insurance issuer for the services rendered, and the health insurance issuer may pay the billed amount or attempt to negotiate reimbursement with the nonparticipating provider or the facility. Within 30 calendar days after the provider or facility transmits the bill to the health insurance issuer, the issuer shall send an initial payment or notice of denial of payment with the written explanation of benefits to the provider or facility. If attempts to negotiate reimbursement for services provided by a nonparticipating provider do not result in a resolution of the payment dispute within 30 days after receipt of written explanation of benefits by the health insurance issuer, then the health insurance issuer or nonparticipating provider or the facility may initiate binding arbitration to determine payment for services provided on a per-bill or batched-bill basis, in accordance with Section 300gg-111 of the Public Health Service Act and the regulations promulgated thereunder. 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 or its approved entity's list of arbitrators. If no agreement can be reached, then a list of 5 arbitrators shall be provided by the Department of Insurance or the approved entity. From the list of 5 arbitrators, the health insurance issuer can veto 2 arbitrators and the provider or facility 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. The arbitrator shall not establish a rebuttable presumption that the qualifying payment amount should be the total amount owed to the provider or facility by the combination of the issuer and the insured, beneficiary, or enrollee. 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) (Blank).
(g) Section 368a of this Act shall not apply during the pendency of a decision under subsection (d). Upon the issuance of the arbitrator's decision, Section 368a applies with respect to the amount, if any, by which the arbitrator's determination exceeds the issuer's initial payment under subsection (c), or the entire amount of the arbitrator's determination if initial payment was denied. Any interest required to be paid to 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 the 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.
(i) Nothing in this Section shall preclude a health care provider from billing a beneficiary, insured, or enrollee for reasonable administrative fees, such as service fees for checks returned for nonsufficient funds and missed appointments.
(j) Nothing in this Section shall preclude a beneficiary, insured, or enrollee from assigning benefits to a nonparticipating provider when the notice and consent criteria are satisfied under paragraph (2) of subsection (b-5) or in any other situation not described in subsection (b) or (b-5).
(k) Except when the notice and consent criteria are satisfied under paragraph (2) of subsection (b-5), if an individual receives health care services under the situations described in subsection (b) or (b-5), no referral requirement or any other provision contained in the policy or certificate of coverage shall deny coverage, reduce benefits, or otherwise defeat the requirements of this Section for services that would have been covered with a participating provider. However, this subsection shall not be construed to preclude a provider contract with a health insurance issuer, or with an administrator or similar entity acting on the issuer's behalf, from imposing requirements on the participating provider, participating emergency facility, or participating health care facility relating to the referral of covered individuals to nonparticipating providers.
(l) Except if the notice and consent criteria are satisfied under paragraph (2) of subsection (b-5), cost-sharing amounts calculated in conformity with this Section shall count toward any deductible or out-of-pocket maximum applicable to in-network coverage.
(m) The Department has the authority to enforce the requirements of this Section in the situations described in subsections (b) and (b-5), and in any other situation for which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and regulations promulgated thereunder would prohibit an individual from being billed or liable for emergency services furnished by a nonparticipating provider or nonparticipating emergency facility or for non-emergency health care services furnished by a nonparticipating provider at a participating health care facility.
(n) This Section does not apply with respect to air ambulance or ground ambulance services. This Section does not apply to any policy of excepted benefits or to short-term, limited-duration health insurance coverage.
(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23; 103-440, eff. 1-1-24 .)
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(215 ILCS 5/356z.4)
Sec. 356z.4. Coverage for contraceptives. (a)(1) The General Assembly hereby finds and declares all of the following: (A) Illinois has a long history of expanding |
| timely access to birth control to prevent unintended pregnancy.
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|
(B) The federal Patient Protection and Affordable
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| Care Act includes a contraceptive coverage guarantee as part of a broader requirement for health insurance to cover key preventive care services without out-of-pocket costs for patients.
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|
(C) The General Assembly intends to build on
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| existing State and federal law to promote gender equity and women's health and to ensure greater contraceptive coverage equity and timely access to all federal Food and Drug Administration approved methods of birth control for all individuals covered by an individual or group health insurance policy in Illinois.
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|
(D) Medical management techniques such as denials,
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| step therapy, or prior authorization in public and private health care coverage can impede access to the most effective contraceptive methods.
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|
(2) As used in this subsection (a):
"Contraceptive services" includes consultations, examinations, procedures, and medical services related to the use of contraceptive methods (including natural family planning) to prevent an unintended pregnancy.
"Medical necessity", for the purposes of this subsection (a), includes, but is not limited to, considerations such as severity of side effects, differences in permanence and reversibility of contraceptive, and ability to adhere to the appropriate use of the item or service, as determined by the attending provider.
"Therapeutic equivalent version" means drugs, devices, or products that can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling and satisfy the following general criteria:
(i) they are approved as safe and effective;
(ii) they are pharmaceutical equivalents in that they
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| (A) contain identical amounts of the same active drug ingredient in the same dosage form and route of administration and (B) meet compendial or other applicable standards of strength, quality, purity, and identity;
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|
(iii) they are bioequivalent in that (A) they do not
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| present a known or potential bioequivalence problem and they meet an acceptable in vitro standard or (B) if they do present such a known or potential problem, they are shown to meet an appropriate bioequivalence standard;
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(iv) they are adequately labeled; and
(v) they are manufactured in compliance with Current
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| Good Manufacturing Practice regulations.
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(3) 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 99th General Assembly shall provide coverage for all of the following services and contraceptive methods:
(A) All contraceptive drugs, devices, and other
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| products approved by the United States Food and Drug Administration. This includes all over-the-counter contraceptive drugs, devices, and products approved by the United States Food and Drug Administration, excluding male condoms, except as provided in the current comprehensive guidelines supported by the Health Resources and Services Administration. The following apply:
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(i) If the United States Food and Drug
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| Administration has approved one or more therapeutic equivalent versions of a contraceptive drug, device, or product, a policy is not required to include all such therapeutic equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing and in accordance with this Section.
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(ii) If an individual's attending provider
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| recommends a particular service or item approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. The plan or issuer must defer to the determination of the attending provider.
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(iii) If a drug, device, or product is not
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| covered, plans and issuers must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or other individual acting as a patient's authorized representative to ensure coverage without cost sharing.
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(iv) This coverage must provide for the
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| dispensing of 12 months' worth of contraception at one time.
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(B) Voluntary sterilization procedures.
(C) Contraceptive services, patient education, and
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| counseling on contraception.
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(D) Follow-up services related to the drugs,
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| devices, products, and procedures covered under this Section, including, but not limited to, management of side effects, counseling for continued adherence, and device insertion and removal.
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(4) Except as otherwise provided in this subsection (a), a policy subject to this subsection (a) shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided. The provisions of this paragraph do not apply to coverage of voluntary male sterilization procedures to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 223.
(5) Except as otherwise authorized under this subsection (a), a policy shall not impose any restrictions or delays on the coverage required under this subsection (a).
(6) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage outlined in this subsection (a), then this subsection (a) is inoperative with respect to all coverage outlined in this subsection (a) other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage set forth in this subsection (a).
(b) This subsection (b) shall become operative if and only if subsection (a) becomes inoperative.
An individual or group policy of accident and health insurance amended,
delivered, issued, or renewed in this State after the date this subsection (b) becomes operative 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.
Nothing in this subsection (b) shall be construed to require an insurance
company to cover services related to permanent sterilization that requires a
surgical procedure.
As used in this subsection (b), "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) (Blank).
(d) If a plan or issuer utilizes a network of providers, nothing in this Section shall be construed to require coverage or to prohibit the plan or issuer from imposing cost-sharing for items or services described in this Section that are provided or delivered by an out-of-network provider, unless the plan or issuer does not have in its network a provider who is able to or is willing to provide the applicable items or services.
(Source: P.A. 103-551, eff. 8-11-23.)
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(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 December 12, 2008 (the effective date of Public Act 95-1005) 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. (e-5) An insurer may not deny or refuse to provide otherwise covered services under a group or individual policy of accident and health insurance or a managed care plan solely because of the location wherein the clinically appropriate services are provided. (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. Adm. 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. (h-10) An insurer may not deny or refuse to provide covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract, for a person diagnosed with an autism spectrum disorder on the basis that the individual declined an alternative medication or covered service when the individual's health care provider has determined that such medication or covered service may exacerbate clinical symptomatology and is medically contraindicated for the individual and the individual has requested and received a medical exception as provided for under Section 45.1 of the Managed Care Reform and Patient Rights Act. For the purposes of this subsection (h-10), "clinical symptomatology" means any indication of disorder or disease when experienced by an individual as a change from normal function, sensation, or appearance. (h-15) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage outlined in subsection (h-10), then subsection (h-10) is inoperative with respect to all coverage outlined in subsection (h-10) other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage set forth in subsection (h-10). (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.
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|
(2) Psychological care, meaning direct or
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| consultative services provided by a licensed psychologist.
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|
(3) Habilitative or rehabilitative care, meaning
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| 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.
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|
(4) Therapeutic care, including behavioral, speech,
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| 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.
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(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. 102-322, eff. 1-1-22; 103-154, eff. 6-30-23.)
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(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.
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|
(2) The treatment is administered by a licensed
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| 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.
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|
(3) The initial or continued treatment must be
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| medically necessary and therapeutic and not experimental or investigational.
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|
(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.
(j) An insurer may not deny or refuse to provide
otherwise covered services under a group or individual policy
of accident and health insurance or a managed care plan solely
because of the location wherein the clinically appropriate
services are provided.
(Source: P.A. 102-322, eff. 1-1-22 .)
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(215 ILCS 5/356z.18) (Text of Section before amendment by P.A. 103-512 ) 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 .) (Text of Section after amendment by P.A. 103-512 ) 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) With respect to an enrollee at any age, in addition to coverage of a prosthetic or custom orthotic device required by this Section, benefits shall be provided for a prosthetic or custom orthotic device determined by the enrollee's provider to be the most appropriate model that is medically necessary for the enrollee to perform physical activities, as applicable, such as running, biking, swimming, and lifting weights, and to maximize the enrollee's whole body health and strengthen the lower and upper limb function. (e) The requirements of this Section do not constitute an addition to this State's essential health benefits that requires defrayal of costs by this State pursuant to 42 U.S.C. 18031(d)(3)(B). (f) 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. (g) Repairs and replacements of prosthetic and orthotic devices are also covered, subject to the co-payments and deductibles, unless necessitated by misuse or loss. (h) 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. (i) 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. (j) 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. 103-512, eff. 1-1-25.) |
(215 ILCS 5/356z.22) Sec. 356z.22. Coverage for telehealth services. (a) For purposes of this Section: "Asynchronous store and forward system" has the meaning given to that term in Section 5 of the Telehealth Act. "Distant site" has the meaning given to that term in Section 5 of the Telehealth Act. "E-visits" has the meaning given to that term in Section 5 of the Telehealth Act. "Facility" means any hospital facility licensed under the Hospital Licensing Act or the University of Illinois Hospital Act, a federally qualified health center, a community mental health center, a behavioral health clinic, a substance use disorder treatment program licensed by the Division of Substance Use Prevention and Recovery of the Department of Human Services, or other building, place, or institution that is owned or operated by a person that is licensed or otherwise authorized to deliver health care services. "Health care professional" has the meaning given to that term in Section 5 of the Telehealth Act. "Interactive telecommunications system" has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, "interactive telecommunications system" does not include virtual check-ins. "Originating site" has the meaning given to that term in Section 5 of the Telehealth Act. "Telehealth services" has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, "telehealth services" do not include asynchronous store and forward systems, remote patient monitoring technologies, e-visits, or virtual check-ins. "Virtual check-in" has the meaning given to that term in Section 5 of the Telehealth Act. (b) An individual or group policy of accident or health insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall cover telehealth services, e-visits, and virtual check-ins rendered by a health care professional when clinically appropriate and medically necessary to insureds, enrollees, and members in the same manner as any other benefits covered under the policy. An individual or group policy of accident or health insurance may provide reimbursement to a facility that serves as the originating site at the time a telehealth service is rendered. (c) To ensure telehealth service, e-visit, and virtual check-in access is equitable for all patients in receipt of health care services under this Section and health care professionals and facilities are able to deliver medically necessary services that can be appropriately delivered via telehealth within the scope of their licensure or certification, coverage required under this Section shall comply with all of the following: (1) An individual or group policy of accident or |
| health insurance shall not:
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(A) require that in-person contact occur between
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| a health care professional and a patient before the provision of a telehealth service;
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(B) require patients, health care professionals,
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| or facilities to prove or document a hardship or access barrier to an in-person consultation for coverage and reimbursement of telehealth services, e-visits, or virtual check-ins;
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(C) require the use of telehealth services,
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| e-visits, or virtual check-ins when the health care professional has determined that it is not appropriate;
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(D) require the use of telehealth services when
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| a patient chooses an in-person consultation;
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(E) require a health care professional to be
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| physically present in the same room as the patient at the originating site, unless deemed medically necessary by the health care professional providing the telehealth service;
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(F) create geographic or facility restrictions
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| or requirements for telehealth services, e-visits, or virtual check-ins;
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(G) require health care professionals or
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| facilities to offer or provide telehealth services, e-visits, or virtual check-ins;
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(H) require patients to use telehealth
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| services, e-visits, or virtual check-ins, or require patients to use a separate panel of health care professionals or facilities to receive telehealth service, e-visit, or virtual check-in coverage and reimbursement; or
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(I) impose upon telehealth services, e-visits,
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| or virtual check-ins utilization review requirements that are unnecessary, duplicative, or unwarranted or impose any treatment limitations, prior authorization, documentation, or recordkeeping requirements that are more stringent than the requirements applicable to the same health care service when rendered in-person, except procedure code modifiers may be required to document telehealth.
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(2) Deductibles, copayments, coinsurance, or any
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| other cost-sharing applicable to services provided through telehealth shall not exceed the deductibles, copayments, coinsurance, or any other cost-sharing required by the individual or group policy of accident or health insurance for the same services provided through in-person consultation.
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(3) An individual or group policy of accident or
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| health insurance shall notify health care professionals and facilities of any instructions necessary to facilitate billing for telehealth services, e-visits, and virtual check-ins.
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(d) For purposes of reimbursement, an individual or group policy of accident or health insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall reimburse an in-network health care professional or facility, including a health care professional or facility in a tiered network, for telehealth services provided through an interactive telecommunications system on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by an in-network or tiered network health care professional or facility. This subsection applies only to those services provided by telehealth that may otherwise be billed as an in-person service. This subsection is inoperative on and after January 1, 2028, except that this subsection is operative after that date with respect to mental health and substance use disorder telehealth services.
(e) The Department and the Department of Public Health shall commission a report to the General Assembly administered by an established medical college in this State wherein supervised clinical training takes place at an affiliated institution that uses telehealth services, subject to appropriation. The report shall study the telehealth coverage and reimbursement policies established in subsections (b) and (d) of this Section, to determine if the policies improve access to care, reduce health disparities, promote health equity, have an impact on utilization and cost-avoidance, including direct or indirect cost savings to the patient, and to provide any recommendations for telehealth access expansion in the future. An individual or group policy of accident or health insurance shall provide data necessary to carry out the requirements of this subsection upon request of the Department. The Department and the Department of Public Health shall submit the report by December 31, 2026. The established medical college may utilize subject matter expertise to complete any necessary actuarial analysis.
(f) Nothing in this Section is intended to limit the ability of an individual or group policy of accident or health insurance and a health care professional or facility to voluntarily negotiate alternate reimbursement rates for telehealth services. Such voluntary negotiations shall take into consideration the ongoing investment necessary to ensure these telehealth platforms may be continuously maintained, seamlessly updated, and integrated with a patient's electronic medical records.
(g) An individual or group policy of accident or health insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall provide coverage for telehealth services for licensed dietitian nutritionists and certified diabetes educators who counsel diabetes patients in the diabetes patients' homes to remove the hurdle of transportation for diabetes patients to receive treatment, in accordance with the Dietitian Nutritionist Practice Act.
(h) Any policy, contract, or certificate of health insurance coverage that does not distinguish between in-network and out-of-network health care professionals and facilities shall be subject to this Section as though all health care professionals and facilities were in-network.
(i) Health care professionals and facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 and the Mental Health and Developmental Disabilities Confidentiality Act.
(j) Nothing in this Section shall be deemed as precluding a health insurer from providing benefits for other telehealth services, including, but not limited to, services not required for coverage provided through an asynchronous store and forward system, remote patient monitoring services, other monitoring services, or oral communications otherwise covered under the policy.
(k) There shall be no restrictions on originating site requirements for telehealth coverage or reimbursement to the distant site under this Section other than requiring the telehealth services to be medically necessary and clinically appropriate.
(l) The Department may adopt rules, including emergency rules subject to the provisions of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(Source: P.A. 102-104, eff. 7-22-21.)
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(215 ILCS 5/356z.30) (Text of Section before amendment by P.A. 103-530 ) Sec. 356z.30. Coverage for hearing aids for individuals under the age of 18. (a) As used in this Section: "Hearing care professional" means a person who is a
licensed hearing instrument dispenser, licensed audiologist, or licensed physician. "Hearing instrument" or "hearing aid" means any wearable
non-disposable, non-experimental instrument or device designed to aid or
compensate for impaired human hearing and any parts, attachments, or accessories for the instrument or device, including
an ear mold but excluding batteries and cords. (b) An individual or group policy of accident and health
insurance or managed care plan that is amended, delivered,
issued, or renewed after August 22, 2018 (the effective date of Public Act 100-1026) must provide coverage for
medically necessary hearing instruments and related services for all individuals under the age of 18
when a hearing care professional prescribes a hearing instrument to augment communication. (c) An insurer shall provide coverage, subject to all applicable co-payments, co-insurance, deductibles, and out-of-pocket limits, subject to the following restrictions: (1) one hearing instrument shall be covered for each |
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(2) related services, such as audiological exams and
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| selection, fitting, and adjustment of ear molds to maintain optimal fit shall be covered when deemed medically necessary by a hearing care professional; and
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(3) hearing instrument repairs may be covered when
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| deemed medically necessary.
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(d) If, at any time before or after August 22, 2018 (the effective date of Public Act 100-1026), the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register, publishes a comment in the Federal Register, or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Pub. L. 111–148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of coverage for medically necessary hearing instruments and related services for individuals under the age of 18, then this Section is inoperative with respect to all such coverage other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for medically necessary hearing instruments and related services for individuals under the age of 18.
(Source: P.A. 100-1026, eff. 8-22-18; 101-81, eff. 7-12-19.)
(Text of Section after amendment by P.A. 103-530 )
Sec. 356z.30. Coverage for hearing aids.
(a) As used in this Section:
"Hearing care professional" means a person who is a
licensed hearing instrument dispenser, licensed audiologist, or licensed physician.
"Hearing instrument" or "hearing aid" means any wearable
non-disposable, non-experimental instrument or device designed to aid or
compensate for impaired human hearing and any parts, attachments, or accessories for the instrument or device, including
an ear mold but excluding batteries and cords.
(b) An individual or group 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 103rd General Assembly must provide coverage for
medically necessary hearing instruments and related services for all individuals
when a hearing care professional prescribes a hearing instrument to augment communication.
(c) An insurer shall provide coverage, subject to all applicable co-payments, co-insurance, deductibles, and out-of-pocket limits, subject to the following restrictions:
(1) one hearing instrument shall be covered for each
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(2) related services, such as audiological exams and
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| selection, fitting, and adjustment of ear molds to maintain optimal fit shall be covered when deemed medically necessary by a hearing care professional; and
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(3) hearing instrument repairs may be covered when
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| deemed medically necessary.
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(d) If, at any time before or after the effective date of this amendatory Act of the 103rd General Assembly, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register, publishes a comment in the Federal Register, or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Pub. L. 111–148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of coverage for medically necessary hearing instruments and related services for any individual, then this Section is inoperative with respect to all such coverage other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for medically necessary hearing instruments and related services for any individual subject to federally defrayed cost of coverage.
(Source: P.A. 103-530, eff. 1-1-25.)
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(215 ILCS 5/356z.31) Sec. 356z.31. Recovery housing for persons with substance use
disorders. (a) Definitions. As used in this Section: "Substance use disorder" and "case management" have the meanings ascribed to those terms in Section 1-10 of the Substance Use Disorder Act. "Hospital" means a facility licensed by the Department of Public Health under the Hospital Licensing Act. "Federally qualified health center" means a facility as defined in Section 1905(l)(2)(B) of the federal Social Security Act. "Recovery housing" means a residential extended care treatment facility or a recovery home as defined and licensed in 77 Illinois Administrative Code, Part 2060, by the Illinois Department of Human Services, Division of Substance Use Prevention and Recovery. (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2019 (the effective date of Public Act 100-1065) may provide coverage for residential extended care services and supports for persons recovery housing for persons with substance use disorders who are at risk of a relapse following discharge from a health care clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department so long as all of the following conditions are met: (1) A health care clinic, federally qualified health |
| center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department has conducted an individualized assessment, using criteria established by the American Society of Addiction Medicine, of the person's condition prior to discharge and has identified the person as being at risk of a relapse and in need of supportive services, including employment and training and case management, to maintain long-term recovery. A determination of whether a person is in need of supportive services shall also be based on whether the person has a history of poverty, job insecurity, and lack of a safe and sober living environment.
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(2) The recovery housing is administered by a
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| community-based agency that is licensed by or under contract with the Department of Human Services, Division of Substance Use Prevention and Recovery.
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(3) The recovery housing is administered by a
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| community-based agency as described in paragraph (2) upon the referral of a health care clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department.
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(c) Based on the individualized needs assessment, any coverage provided in accordance with this Section may include, but not be limited to, the following:
(1) Substance use disorder treatment services that
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| are in accordance with licensure standards promulgated by the Department of Human Services, Division of Substance Use Prevention and Recovery.
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(2) Transitional housing services, including food or
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(3) Individualized case management and referral
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| services, including case management and social services for the families of persons who are seeking treatment for a substance use disorder.
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(4)
Job training or placement services.
(d) The insurer may rate each community-based agency that is licensed by or under contract with the Department of Human Services, Division of Substance Use Prevention and Recovery to provide recovery housing based on an evaluation of each agency's ability to:
(1) reduce health care costs;
(2) reduce recidivism rates for persons suffering
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| from a substance use disorder;
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(3) improve outcomes;
(4) track persons with substance use disorders; and
(5) improve the quality of life of persons with
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| substance use disorders through the utilization of sustainable recovery, education, employment, and housing services.
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The insurer may publish the results of the ratings on its official website and shall, on an annual basis, update the posted results.
(e) The Department of Insurance may adopt any rules necessary to implement the provisions of this Section in accordance with 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. 100-1065, eff. 1-1-19; 101-81, eff. 7-12-19.)
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(215 ILCS 5/356z.38) Sec. 356z.38. Human breast milk coverage. (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under an individual or group health insurance for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that |
| meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
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(2) the infant's mother is medically or physically
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| unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the infant's needs or the maternal breast milk is contraindicated;
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(3) the milk has been determined to be medically
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| necessary for the infant; and
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(4) one or more of the following applies:
(A) the infant's birth weight is below 1,500
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(B) the infant has a congenital or acquired
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| condition that places the infant at a high risk for development of necrotizing enterocolitis;
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(C) the infant has infant hypoglycemia;
(D) the infant has congenital heart disease;
(E) the infant has had or will have an organ
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(F) the infant has sepsis; or
(G) the infant has any other serious congenital
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| or acquired condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the infant.
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(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under an individual or group health insurance for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
(1) the milk is obtained from a human milk bank that
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| meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
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(2) the child's mother is medically or physically
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| unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
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(3) the milk has been determined to be medically
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| necessary for the child; and
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(4) one or more of the following applies:
(A) the child has spinal muscular atrophy;
(B) the child's birth weight was below 1,500
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| grams and he or she has long-term feeding or gastrointestinal complications related to prematurity;
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(C) the child has had or will have an organ
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(D) the child has a congenital or acquired
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| condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the child.
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(Source: P.A. 101-511, eff. 1-1-20; 102-558, eff. 8-20-21.)
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(215 ILCS 5/356z.40) Sec. 356z.40. Pregnancy and postpartum coverage. (a) An individual or group policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall provide coverage for pregnancy and newborn care in accordance with 42 U.S.C. 18022(b) regarding essential health benefits. (b) Benefits under this Section shall be as follows: (1) An individual who has been identified as |
| experiencing a high-risk pregnancy by the individual's treating provider shall have access to clinically appropriate case management programs. As used in this subsection, "case management" means a mechanism to coordinate and assure continuity of services, including, but not limited to, health services, social services, and educational services necessary for the individual. "Case management" involves individualized assessment of needs, planning of services, referral, monitoring, and advocacy to assist an individual in gaining access to appropriate services and closure when services are no longer required. "Case management" is an active and collaborative process involving a single qualified case manager, the individual, the individual's family, the providers, and the community. This includes close coordination and involvement with all service providers in the management plan for that individual or family, including assuring that the individual receives the services. As used in this subsection, "high-risk pregnancy" means a pregnancy in which the pregnant or postpartum individual or baby is at an increased risk for poor health or complications during pregnancy or childbirth, including, but not limited to, hypertension disorders, gestational diabetes, and hemorrhage.
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(2) An individual shall have access to medically
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| necessary treatment of a mental, emotional, nervous, or substance use disorder or condition consistent with the requirements set forth in this Section and in Sections 370c and 370c.1 of this Code.
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(3) The benefits provided for inpatient and
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| outpatient services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided if determined to be medically necessary, consistent with the requirements of Sections 370c and 370c.1 of this Code. The facility or provider shall notify the insurer of both the admission and the initial treatment plan within 48 hours after admission or initiation of treatment. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy.
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(4) The benefits for the first 48 hours of initiation
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| of services for an inpatient admission, detoxification or withdrawal management program, or partial hospitalization admission for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided without post-service or concurrent review of medical necessity, as the medical necessity for the first 48 hours of such services shall be determined solely by the covered pregnant or postpartum individual's provider. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review, including the review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy, of any inpatient admission, detoxification or withdrawal management program admission, or partial hospitalization admission services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications received 48 hours after the initiation of such services. If an insurer determines that the services are no longer medically necessary, then the covered person shall have the right to external review pursuant to the requirements of the Health Carrier External Review Act.
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(5) If an insurer determines that continued inpatient
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| care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment in a facility is no longer medically necessary, the insurer shall, within 24 hours, provide written notice to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider of its decision and the right to file an expedited internal appeal of the determination. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider. If the determination is to uphold the denial, the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider have the right to file an expedited external appeal. An independent utilization review organization shall make a determination within 72 hours. If the insurer's determination is upheld and it is determined that continued inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment is not medically necessary, the insurer shall remain responsible for providing benefits for the inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment through the day following the date the determination is made, and the covered pregnant or postpartum individual shall only be responsible for any applicable copayment, deductible, and coinsurance for the stay through that date as applicable under the policy. The covered pregnant or postpartum individual shall not be discharged or released from the inpatient facility, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment until all internal appeals and independent utilization review organization appeals are exhausted. A decision to reverse an adverse determination shall comply with the Health Carrier External Review Act.
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|
(6) Except as otherwise stated in this subsection
|
| (b), the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.
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|
(7) The benefits required by paragraphs (2) and (6)
|
| of this subsection (b) are to be provided to all covered pregnant or postpartum individuals with a diagnosis of a mental, emotional, nervous, or substance use disorder or condition. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this subsection (b).
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|
(Source: P.A. 102-665, eff. 10-8-21.)
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(215 ILCS 5/356z.60) Sec. 356z.60. Coverage for abortifacients, hormonal therapy, and human immunodeficiency virus pre-exposure prophylaxis and post-exposure prophylaxis. (a) As used in this Section: "Abortifacients" means any medication administered to terminate a pregnancy as prescribed or ordered by a health care professional. "Health care professional" means a physician licensed to practice medicine in all of its branches, licensed advanced practice registered nurse, or physician assistant. "Hormonal therapy medication" means hormonal treatment administered to treat gender dysphoria. "Therapeutic equivalent version" means drugs, devices, or products that can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling and that satisfy the following general criteria: (1) it is approved as safe and effective; (2) it is a pharmaceutical equivalent in that it: (A) contains identical amounts of the same |
| active drug ingredient in the same dosage form and route of administration; and
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|
(B) meets compendial or other applicable
|
| standards of strength, quality, purity, and identity;
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|
(3) it is bioequivalent in that:
(A) it does not present a known or potential
|
| bioequivalence problem and it meets an acceptable in vitro standard; or
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|
(B) if it does present such a known or
|
| potential problem, it is shown to meet an appropriate bioequivalence standard;
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|
(4) it is adequately labeled; and
(5) it is manufactured in compliance with Current
|
| Good Manufacturing Practice regulations adopted by the United States Food and Drug Administration.
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|
(b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2024 shall provide coverage for all abortifacients, hormonal therapy medication, human immunodeficiency virus pre-exposure prophylaxis, and post-exposure prophylaxis drugs approved by the United States Food and Drug Administration, and follow-up services related to that coverage, including, but not limited to, management of side effects, medication self-management or adherence counseling, risk reduction strategies, and mental health counseling. This coverage shall include drugs approved by the United States Food and Drug Administration that are prescribed or ordered for off-label use for the purposes described in this Section.
(c) The coverage required under subsection (b) is subject to the following conditions:
(1) If the United States Food and Drug
|
| Administration has approved one or more therapeutic equivalent versions of an abortifacient drug, a policy is not required to include all such therapeutic equivalent versions in its formulary so long as at least one is included and covered without cost sharing and in accordance with this Section.
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|
(2) If an individual's attending provider
|
| recommends a particular drug approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must defer to the determination of the attending provider and must cover that service or item without cost sharing.
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|
(3) If a drug is not covered, plans and issuers
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| must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or other individual acting as a patient's authorized representative to ensure coverage without cost sharing.
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|
The conditions listed under this subsection (c) also apply to drugs prescribed for off-label use as abortifacients.
(d) Except as otherwise provided in this Section, a policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided. The provisions of this subsection do not apply to coverage of procedures to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 223.
(e) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section.
(f) The coverage requirements in this Section for
abortifacients do not, pursuant to 42 U.S.C. 18054(a)(6),
apply to a multistate plan that does not provide coverage for
abortion.
(g) If the Department concludes that enforcement of any
coverage requirement of this Section for abortifacients may
adversely affect the allocation of federal funds to this
State, the Department may grant an exemption to that
requirement, but only to the minimum extent necessary to ensure the continued receipt of federal funds.
(Source: P.A. 102-1117, eff. 1-13-23; 103-462, eff. 8-4-23.)
|
(215 ILCS 5/356z.61) (Text of Section from P.A. 103-1) Sec. 356z.61. Coverage of pharmacy testing, screening, vaccinations, and treatment. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for health care or patient care services provided by a pharmacist if: (1) the pharmacist meets the requirements and scope |
| of practice described in paragraph (15), (16), or (17) of subsection (d) of Section 3 of the Pharmacy Practice Act;
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|
(2) the health plan provides coverage for the same
|
| service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;
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|
(3) the pharmacist is included in the health benefit
|
| plan's network of participating providers; and
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|
(4) reimbursement has been successfully negotiated in
|
| good faith between the pharmacist and the health plan.
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|
(Source: P.A. 103-1, eff. 4-27-23.)
(Text of Section from P.A. 103-84)
Sec. 356z.61. Coverage for liver disease screening. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for preventative liver disease screenings for individuals 35 years of age or older and under the age of 65 at high risk for liver disease, including liver ultrasounds and alpha-fetoprotein blood tests every 6 months, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this Section does not apply to coverage of liver disease screenings to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(Source: P.A. 103-84, eff. 1-1-24.)
(Text of Section from P.A. 103-91)
Sec. 356z.61. Coverage for compression sleeves. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for compression sleeves that is medically necessary for the enrollee to prevent or mitigate lymphedema.
(Source: P.A. 103-91, eff. 1-1-24.)
(Text of Section from P.A. 103-123)
Sec. 356z.61. Coverage for reconstructive services.
(a) As used in this Section, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance.
(b) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 may not deny coverage for medically necessary reconstructive services that are intended to restore physical appearance.
(Source: P.A. 103-123, eff. 1-1-24.)
(Text of Section from P.A. 103-325)
Sec. 356z.61. Proton beam therapy.
(a) As used in this Section:
"Medically necessary" has the meaning given to that term in the Prior Authorization Reform Act.
"Proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells.
"Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.
(b) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage for the treatment of cancer shall not apply a higher standard of clinical evidence for the coverage of proton beam therapy than the insurer applies for the coverage of any other form of radiation therapy treatment.
(c) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage or benefits to any resident of this State for radiation oncology shall include coverage or benefits for medically necessary proton beam therapy for the treatment of cancer.
(Source: P.A. 103-325, eff. 1-1-24.)
(Text of Section from P.A. 103-420)
Sec. 356z.61. Coverage of prescription estrogen.
(a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 and that provides coverage for prescription drugs shall include coverage for one or more therapeutic equivalent versions of vaginal estrogen in its formulary.
(b) If a particular vaginal estrogen product or its therapeutic equivalent version approved by the United States Food and Drug Administration is determined to be medically necessary, the issuer must cover that service or item pursuant to the cost-sharing requirement contained in subsection (c).
(c) A policy subject to this Section shall not impose a deductible, copayment, or any other cost sharing requirement that exceeds any deductible, coinsurance, copayment, or any other cost-sharing requirement imposed on any prescription drug authorized for the treatment of erectile dysfunction covered by the policy; except that this subsection does not apply to coverage of vaginal estrogen to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(d) As used in this Section, "therapeutic equivalent version" has the meaning given to that term in paragraph (2) of subsection (a) of Section 356z.4.
(Source: P.A. 103-420, eff. 1-1-24.)
(Text of Section from P.A. 103-445)
Sec. 356z.61. Home saliva cancer screening.
(a) As used in this Section, "home saliva cancer screening" means an outpatient test that utilizes an individual's saliva to detect biomarkers for early-stage cancer.
(b) An individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2025 shall cover a medically necessary home saliva cancer screening every 24 months if the patient:
(1) is asymptomatic and at high risk for the disease
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|
(2) demonstrates symptoms of the disease being tested
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|
(Source: P.A. 103-445, eff. 1-1-24.)
(Text of Section from P.A. 103-458)
Sec. 356z.61. Coverage for children with neuromuscular, neurological, or cognitive impairment. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for therapy, diagnostic testing, and equipment necessary to increase quality of life for children who have been clinically or genetically diagnosed with any disease, syndrome, or disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.
(Source: P.A. 103-458, eff. 1-1-24.)
(Text of Section from P.A. 103-535)
Sec. 356z.61. Coverage of no-cost mental health prevention and wellness visits.
(a) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for one annual mental health prevention and wellness visit for children and for adults.
(b) Mental health prevention and wellness visits shall include any age-appropriate screening recommended by the United States Preventive Services Task Force or by the American Academy of Pediatrics' Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents for purposes of identifying a mental health issue, condition, or disorder; discussing mental health symptoms that might be present, including symptoms of a previously diagnosed mental health condition or disorder; performing an evaluation of adverse childhood experiences; and discussing mental health and wellness.
(c) A mental health prevention and wellness visit shall be covered for up to 60 minutes and may be performed by a physician licensed to practice medicine in all of its branches, a licensed clinical psychologist, a licensed clinical social worker, a licensed clinical professional counselor, a licensed marriage and family therapist, a licensed social worker, or a licensed professional counselor.
(d) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement for mental health prevention and wellness visits. The cost-sharing prohibition in this subsection (d) does not apply to coverage of mental health prevention and wellness visits to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(e) A mental health prevention and wellness visit shall be in addition to an annual physical examination and shall not replace a well-child visit or a general health or medical visit.
(f) A mental health prevention and wellness visit shall be reimbursed through the following American Medical Association current procedural terminology codes and at the same rate that current procedural terminology codes are reimbursed for the provision of other medical care: 99381-99387 and 99391-99397. The Department shall update the current procedural terminology codes through adoption of rules if the codes listed in this subsection are altered, amended, changed, deleted, or supplemented.
(g) Reimbursement of any of the current procedural terminology codes listed in this Section shall comply with the following:
(1) reimbursement may be adjusted for payment of
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| claims that are billed by a nonphysician clinician so long as the methodology to determine the adjustments are comparable to and applied no more stringently than the methodology for adjustments made for reimbursement of claims billed by nonphysician clinicians for other medical care, in accordance with 45 CFR 146.136(c)(4); and
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|
(2) for a mental health prevention and wellness visit
|
| and for a service other than a mental health prevention and wellness visit, reimbursement shall not be denied if they occur on the same date by the same provider and the provider is a primary care provider.
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|
(h) A mental health prevention and wellness visit may be incorporated into and reimbursed within any type of integrated primary care service delivery method, including, but not limited to, a psychiatric collaborative care model as provided for under this Code.
(i) The Department shall adopt any rules necessary to implement this Section by no later than October 31, 2024.
(Source: P.A. 103-535, eff. 8-11-23.)
|
(215 ILCS 5/356z.62) Sec. 356z.62. Coverage of preventive health services. (a) A policy of group health insurance coverage or individual health insurance coverage as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act shall, at a minimum, provide coverage for and shall not impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for: (1) evidence-based items or services that have in |
| effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;
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|
(2) immunizations that have in effect a
|
| recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;
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|
(3) with respect to infants, children, and
|
| adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
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|
(4) with respect to women, such additional preventive
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| care and screenings not described in paragraph (1) of this subsection (a) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.
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|
(b) For purposes of this Section, and for purposes of any other provision of State law, recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current.
(c) For office visits:
(1) if an item or service described in subsection (a)
|
| is billed separately or is tracked as individual encounter data separately from an office visit, then a policy may impose cost-sharing requirements with respect to the office visit;
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|
(2) if an item or service described in subsection (a)
|
| is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a policy may not impose cost-sharing requirements with respect to the office visit; and
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|
(3) if an item or service described in subsection (a)
|
| is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a policy may impose cost-sharing requirements with respect to the office visit.
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|
(d) A policy must provide coverage pursuant to subsection (a) for plan or policy years that begin on or after the date that is one year after the date the recommendation or guideline is issued. If a recommendation or guideline is in effect on the first day of the plan or policy year, the policy shall cover the items and services specified in the recommendation or guideline through the last day of the plan or policy year unless either:
(1) a recommendation under paragraph (1) of
|
| subsection (a) is downgraded to a "D" rating; or
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|
(2) the item or service is subject to a safety recall
|
| or is otherwise determined to pose a significant safety concern by a federal agency authorized to regulate the item or service during the plan or policy year.
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|
(e) Network limitations.
(1) Subject to paragraph (3) of this subsection,
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| nothing in this Section requires coverage for items or services described in subsection (a) that are delivered by an out-of-network provider under a health maintenance organization health care plan, other than a point-of-service contract, or under a voluntary health services plan that generally excludes coverage for out-of-network services except as otherwise required by law.
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|
(2) Subject to paragraph (3) of this subsection,
|
| nothing in this Section precludes a policy with a preferred provider program under Article XX-1/2 of this Code, a health maintenance organization point-of-service contract, or a similarly designed voluntary health services plan from imposing cost-sharing requirements for items or services described in subsection (a) that are delivered by an out-of-network provider.
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|
(3) If a policy does not have in its network a
|
| provider who can provide an item or service described in subsection (a), then the policy must cover the item or service when performed by an out-of-network provider and it may not impose cost-sharing with respect to the item or service.
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|
(f) Nothing in this Section prevents a company from using reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in subsection (a) to the extent not specified in the recommendation or guideline.
(g) Nothing in this Section shall be construed to prohibit a policy from providing coverage for items or services in addition to those required under subsection (a) or from denying coverage for items or services that are not required under subsection (a). Unless prohibited by other law, a policy may impose cost-sharing requirements for a treatment not described in subsection (a) even if the treatment results from an item or service described in subsection (a). Nothing in this Section shall be construed to limit coverage requirements provided under other law.
(h) The Director may develop guidelines to permit a company to utilize value-based insurance designs. In the absence of guidelines developed by the Director, any such guidelines developed by the Secretary of the U.S. Department of Health and Human Services that are in force under 42 U.S.C. 300gg-13 shall apply.
(i) For student health insurance coverage as defined at 45 CFR 147.145, student administrative health fees are not considered cost-sharing requirements with respect to preventive services specified under subsection (a). As used in this subsection, "student administrative health fee" means a fee charged by an institution of higher education on a periodic basis to its students to offset the cost of providing health care through health clinics regardless of whether the students utilize the health clinics or enroll in student health insurance coverage.
(j) For any recommendation or guideline specifically referring to women or men, a company shall not deny or limit the coverage required or a claim made under subsection (a) based solely on the individual's recorded sex or actual or perceived gender identity, or for the reason that the individual is gender nonconforming, intersex, transgender, or has undergone, or is in the process of undergoing, gender transition, if, notwithstanding the sex or gender assigned at birth, the covered individual meets the conditions for the recommendation or guideline at the time the item or service is furnished.
(k) This Section does not apply to grandfathered health plans, excepted benefits, or short-term, limited-duration health insurance coverage.
(Source: P.A. 103-551, eff. 8-11-23.)
|
(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
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|
(b) all certificates issued under group Medicare
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| supplement policies or subscriber contracts, which certificates are issued or issued for delivery in this State on and after January 1, 1989.
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|
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
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| policy, the person who seeks to contract for insurance benefits, and
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|
(ii) in the case of a group Medicare policy or
|
| subscriber contract, the proposed certificate holder.
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|
(b) "Certificate" means any certificate delivered or
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| issued for delivery in this State under a group Medicare supplement policy.
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|
(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.
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|
(d) "Issuer" includes insurance companies, fraternal
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| benefit societies, voluntary health service plans, health maintenance organizations, or any other entity providing Medicare supplement insurance, unless the context clearly indicates otherwise.
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|
(e) "Medicare" means the Health Insurance for the
|
| Aged Act, Title XVIII of the Social Security Amendments of 1965.
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|
(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:
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|
(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;
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|
(ii) has Medicare and an employer group health
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| plan (either primary or secondary to Medicare) that terminates or ceases to provide all such supplemental health benefits;
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|
(iii) is insured by a Medicare Advantage plan
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| 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
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|
(iv) is insured by a Medicare supplement policy
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| 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;
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|
(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;
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|
(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).
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|
(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:
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|
(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
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|
(F) Requirements for replacement.
(G) Recurrent conditions.
(H) Definition of terms.
(I) Requirements for issuing rebates or credits
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| to policyholders if the policy's loss ratio does not comply with subsection (7) of Section 363a.
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|
(J) Uniform methodology for the calculating and
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| reporting of loss ratio information.
|
|
(K) Assuring public access to loss ratio
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| information of an issuer of Medicare supplement insurance.
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|
(L) Establishing a process for approving or
|
| disapproving proposed premium increases.
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|
(M) Establishing a policy for holding public
|
| hearings prior to approval of premium increases.
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|
(N) Establishing standards for Medicare Select
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|
(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.
|
|
(8) If an individual is at least 65 years of age but no more than 75 years of age and has an existing Medicare supplement policy, the individual is entitled to an annual open enrollment period lasting 45 days, commencing with the individual's birthday, and the individual may purchase any Medicare supplement policy with the same issuer that offers benefits equal to or lesser than those provided by the previous coverage. During this open enrollment period, an issuer of a Medicare supplement policy shall not deny or condition the issuance or effectiveness of Medicare supplemental coverage, nor discriminate in the pricing of coverage, because of health status, claims experience, receipt of health care, or a medical condition of the individual. An issuer shall provide notice of this annual open enrollment period for eligible Medicare supplement policyholders at the time that the application is made for a Medicare supplement policy or certificate. The notice shall be in a form that may be prescribed by the Department.
(9) Without limiting an individual's eligibility under Department rules implementing 42 U.S.C. 1395ss(s)(2)(A), for at least 63 days after the later of the applicant's loss of benefits or the notice of termination of benefits, including a notice of claim denial due to termination of benefits, under the State's medical assistance program under Article V of the Illinois Public Aid Code, an issuer shall not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate that is offered and is available for issuance to new enrollees by the issuer; shall not discriminate in the pricing of such a Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition; and shall not include a policy provision that imposes an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy if the individual:
(a) is enrolled for Medicare Part B;
(b) was enrolled in the State's medical assistance
|
| program during the COVID-19 Public Health Emergency described in Section 5-1.5 of the Illinois Public Aid Code;
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|
(c) was terminated or disenrolled from the State's
|
| medical assistance program after the COVID-19 Public Health Emergency and the later of the date of termination of benefits or the date of the notice of termination, including a notice of a claim denial due to termination, occurred on, after, or no more than 63 days before the end of either, as applicable:
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|
(A) the individual's Medicare supplement open
|
| enrollment period described in Department rules implementing 42 U.S.C. 1395ss(s)(2)(A); or
|
|
(B) the 6-month period described in Section
|
| 363(6)(a)(i) of this Code; and
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|
(d) submits evidence of the date of termination of
|
| benefits or notice of termination under the State's medical assistance program with the application for a Medicare supplement policy or certificate.
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|
(10) Each Medicare supplement policy and certificate available from an insurer on and after the effective date of this amendatory Act of the 103rd General Assembly shall be made available to all applicants who qualify under subparagraph (i) of paragraph (a) of subsection (6) or Department rules implementing 42 U.S.C. 1395ss(s)(2)(A) without regard to age or applicability of a Medicare Part B late enrollment penalty.
(Source: P.A. 102-142, eff. 1-1-22; 103-102, eff. 6-16-23.)
|
(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.
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|
(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.
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|
(c) It must prominently disclose that it is an
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| advertisement for insurance or is intended to obtain insurance prospects.
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|
(d) It must prominently identify and set forth the
|
| actual address of the insurer or insurers that issue the coverage.
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|
(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.
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|
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
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|
(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.
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|
(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.
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|
(e) Fully and completely disclose the purchaser's
|
| medical history on the application if required for issue.
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|
(f) Complete a Policy Check List in duplicate as
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|
POLICY CHECK LIST
Applicant's Name:
Policy Number:
Name of Existing Insurer:
Expiration Date of Existing Insurance:
|
Medicare |
Existing |
Supplement |
Insured's |
Pays |
Coverage |
Pays |
Responsibility |
|
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.
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|
(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.
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|
(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:
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|
(i) Is offering insurance that is approved or
|
| recommended by the State or federal government to supplement Medicare.
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|
(ii) Is in any way representing, working for, or
|
| compensated by a local, State, or federal government agency.
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|
(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.
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|
(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.
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|
(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
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|
(ii) That the assistance programs of the State or
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| 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.
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|
(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.
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|
(iv) The coverage of the policy being sold.
(v) The effective date of coverage under the
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|
(vi) That any pre-existing health condition of
|
| the purchaser is irrelevant.
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|
(vii) The right of the purchaser to cancel the
|
| policy within 30 days after receiving it.
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|
(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.
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|
(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.
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|
(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
|
|
(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.
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|
(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.
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|
(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.
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|
(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 5/364.01) 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;
|
|
(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 Ill. Adm. Code Part 2051 Preferred Provider Programs apply to these terms in this Section.
(j) The external review procedures established under the Health Carrier External Review Act shall apply to the provisions under this Section.
(Source: P.A. 103-154, eff. 6-30-23.)
|
(215 ILCS 5/367) (from Ch. 73, par. 979)
Sec. 367. Group accident and health insurance.
(1) Group accident and health insurance is hereby declared to be that
form of accident and health insurance covering not less than 2
employees,
members, or employees of members, written under a
master policy issued to any governmental corporation, unit, agency or
department thereof, or to any corporation, copartnership, individual
employer, or to any association upon application of an executive officer or
trustee of such association having a constitution or bylaws and formed in
good faith for purposes other than that of obtaining insurance, where
officers, members, employees, employees of members or classes or department
thereof, may be insured for their individual benefit. In addition a group
accident and health policy may be written to insure any group which may be
insured under a group life insurance policy. The term "employees" shall
include the officers, managers and employees of subsidiary or affiliated
corporations, and the individual proprietors, partners and employees of
affiliated individuals and firms, when the business of such subsidiary or
affiliated corporations, firms or individuals, is controlled by a common
employer through stock ownership, contract or otherwise.
(2) Any insurance company authorized to write accident and health
insurance in this State shall have power to issue group accident and
health policies. No policy of group accident and health insurance may
be issued or delivered in this State unless a copy of the form thereof
shall have been filed with the department and approved by it in
accordance with Section 355, and it contains in substance those
provisions contained in Sections 357.1 through 357.30 as may be applicable
to group accident and health insurance and the following provisions:
(a) A provision that the policy, the application of |
| the employer, or executive officer or trustee of any association, and the individual applications, if any, of the employees, members or employees of members insured shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer or trustee, or by the individual employees, members or employees of members shall (in the absence of fraud) be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the policy, unless it is contained in a written application.
|
|
(b) A provision that the insurer will issue to the
|
| employer, or to the executive officer or trustee of the association, for delivery to the employee, member or employee of a member, who is insured under such policy, an individual certificate setting forth a statement as to the insurance protection to which he is entitled and to whom payable.
|
|
(c) A provision that to the group or class thereof
|
| originally insured shall be added from time to time all new employees of the employer, members of the association or employees of members eligible to and applying for insurance in such group or class.
|
|
(3) Anything in this code to the contrary notwithstanding, any group
accident and health policy may provide that all or any portion of any
indemnities provided by any such policy on account of hospital, nursing,
medical or surgical services, may, at the insurer's option, be paid
directly to the hospital or person rendering such services; but the
policy may not require that the service be rendered by a particular
hospital or person. Payment so made shall discharge the insurer's
obligation with respect to the amount of insurance so paid. Nothing in this
subsection (3) shall prohibit an insurer from providing incentives for
insureds to utilize the services of a particular hospital or person.
(4) Special group policies may be issued to school districts
providing medical or hospital service, or both, for pupils of the
district injured while participating in any athletic activity under the
jurisdiction of or sponsored or controlled by the district or the
authorities of any school thereof. The provisions of this Section
governing the issuance of group accident and health insurance shall,
insofar as applicable, control the issuance of such policies issued to
schools.
(5) No policy of group accident and health insurance may be issued
or delivered in this State unless it provides that upon the death of the
insured employee or group member the dependents' coverage, if any,
continues for a period of at least 90 days subject to any other policy
provisions relating to termination of dependents' coverage.
(6) No group hospital policy covering miscellaneous hospital
expenses issued or delivered in this State shall contain any exception
or exclusion from coverage which would preclude the payment of expenses
incurred for the processing and administration of blood and its
components.
(7) No policy of group accident and health insurance, delivered in
this State more than 120 days after the effective day of the Section,
which provides inpatient hospital coverage for sicknesses shall exclude
from such coverage the treatment of alcoholism. This subsection shall
not apply to a policy which covers only specified sicknesses.
(8) No policy of group accident and health insurance, which
provides benefits for hospital or medical expenses based upon the actual
expenses incurred, issued or delivered in this State shall contain any
specific exception to coverage which would preclude the payment of
actual expenses incurred in the examination and testing of a victim of
an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code
of 1961 or the Criminal Code of 2012, or an attempt to commit such offense,
to establish that sexual contact did occur or did not occur, and to
establish the presence or absence of sexually transmitted
disease or infection, and
examination and treatment of injuries and trauma sustained by the victim of
such offense, arising out of the offense. Every group policy of accident
and health insurance which specifically provides benefits for routine
physical examinations shall provide full coverage for expenses incurred in
the examination and testing of a victim of an offense defined in Sections
11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such
offense, as set forth in this
Section. This subsection shall not apply to a policy which covers hospital
and medical expenses for specified illnesses and injuries only.
(9) For purposes of enabling the recovery of State funds, any insurance
carrier subject to this Section shall upon reasonable demand by the Department
of Public Health disclose the names and identities of its insureds entitled
to benefits under this provision to the Department of Public Health whenever
the Department of Public Health has determined that it has paid, or is about
to pay, hospital or medical expenses for which an insurance carrier is liable
under this Section. All information received by the Department of Public
Health under this provision shall be held on a confidential basis and shall
not be subject to subpoena and shall not be made public by the Department
of Public Health or used for any purpose other than that authorized by this
Section.
(10) Whenever the Department of Public Health finds that it has paid all
or part of any hospital or medical expenses which an insurance carrier is
obligated to pay under this Section, the Department of Public Health shall
be entitled to receive reimbursement for its payments from such insurance
carrier provided that the Department of Public Health has notified the
insurance carrier of its claim before the carrier has paid the benefits to
its insureds or the insureds' assignees.
(11) (a) No group hospital, medical or surgical expense
|
| policy shall contain any provision whereby benefits otherwise payable thereunder are subject to reduction solely on account of the existence of similar benefits provided under other group or group-type accident and sickness insurance policies where such reduction would operate to reduce total benefits payable under these policies below an amount equal to 100% of total allowable expenses provided under these policies.
|
|
(b) When dependents of insureds are covered under 2
|
| policies, both of which contain coordination of benefits provisions, benefits of the policy of the insured whose birthday falls earlier in the year are determined before those of the policy of the insured whose birthday falls later in the year. Birthday, as used herein, refers only to the month and day in a calendar year, not the year in which the person was born. The Department of Insurance shall promulgate rules defining the order of benefit determination pursuant to this paragraph (b).
|
|
(12) Every group policy under this Section shall be subject to the
provisions of Sections 356g and 356n of this Code.
(13) No accident and health insurer providing coverage for hospital
or medical expenses on an expense incurred basis shall deny
reimbursement for an otherwise covered expense incurred for any organ
transplantation procedure solely on the basis that such procedure is deemed
experimental or investigational unless supported by the determination of
the Office of Health Care Technology Assessment within the Agency for
Health Care Policy and Research within the federal Department of Health and
Human Services that such procedure is either experimental or investigational or
that there is insufficient data or experience to determine whether an organ
transplantation procedure is clinically acceptable. If an accident and
health insurer has made written request, or had one made on its behalf by a
national organization, for determination by the Office of Health Care
Technology Assessment within the Agency for Health Care Policy and Research
within the federal Department of Health and Human Services as to whether a
specific organ transplantation procedure is clinically acceptable and said
organization fails to respond to such a request within a period of 90 days,
the failure to act may be deemed a determination that the procedure is
deemed to be experimental or investigational.
(14) Whenever a claim for benefits by an insured under a dental
prepayment program is denied or reduced, based on the review of x-ray
films, such review must be performed by a dentist.
(Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13 .)
|
(215 ILCS 5/367.2) (from Ch. 73, par. 979.2)
Sec. 367.2.
Spousal continuation privilege; group contracts.
A. No policy of group accident or health insurance, nor any
certificate thereunder shall be delivered or issued for delivery in this
State after December 1, 1985, unless the policy provides for a continuation
of the existing insurance benefits for an employee's spouse and dependent
children who are insured under the provisions of that group policy or
certificate thereunder, notwithstanding that the marriage is dissolved by
judgment or terminated by the death of the employee or, after the
effective date of this amendatory Act of the 93rd General Assembly, notwithstanding the
retirement of the employee provided that
the employee's
spouse is at
least 55 years of age, in each case without any other eligibility
requirements. The provisions of this amendatory Act of the 93rd General
Assembly apply to every
group policy of accident or health insurance and every certificate issued
thereunder delivered or issued for delivery after the effective date of
this amendatory Act of the 93rd General Assembly.
B. Within 30 days of the entry of judgment or the death or
retirement of the employee, the spouse of an employee insured under
the policy who seeks a continuation of coverage thereunder shall give the
employer or the insurer written notice of the dissolution of the
marriage
or the death or retirement of the employee. The employer, within 15
days of receipt of the notice
shall give written notice
of the dissolution of the employee's marriage or the death or retirement of
the employee and that former spouse's or retired employee's spouse's
residence
to the insurance
company issuing the policy.
The employer shall immediately send a copy of the notice to the former
spouse of the employee or the spouse of the retired employee at the retired
employee's spouse's residence or at the former spouse's residence. For
purposes of this Act, the term "former spouse" includes "widow" or "widower".
C. Within 30 days after the date of receipt of a notice from the
employer, retired employee's spouse or former spouse or of the initiation
of a new group policy, the insurance company, by certified mail, return
receipt requested, shall notify the retired employee's spouse or former
spouse at his or her residence that the policy may be continued for that
retired employee's spouse or former spouse and covered dependents, and the
notice shall include:
(i) a form for election to continue the insurance |
|
(ii) the amount of periodic premiums to be charged
|
| for continuation coverage and the method and place of payment; and
|
|
(iii) instructions for returning the election form
|
| within 30 days after the date it is received from the insurance company.
|
|
Failure of the retired employee's spouse or former spouse to exercise the
election to continue insurance coverage by notifying the insurance company
in writing within such 30
day period
shall terminate the continuation of benefits and the right to continuation.
If the insurance company fails to notify the retired employee's spouse
or former spouse as provided for in subsection C hereof, all premiums shall
be waived from the date the notice was required until notice is sent, and
the benefits shall continue under the terms and provisions of the policy,
from the date the notice was required until the notice is sent,
notwithstanding any other provision hereof, except where the benefits in
existence at the time the company's notice was to be sent pursuant to
subsection C are terminated as to all employees.
D. With respect to a former spouse who has not attained the age of 55
at the time continuation coverage begins, the monthly premium
for
continuation shall be computed as follows:
(i) an amount, if any, that would be charged an
|
| employee if the former spouse were a current employee of the employer, plus;
|
|
(ii) an amount, if any, that the employer would
|
| contribute toward the premium if the former spouse were a current employee.
|
|
Failure to pay the initial monthly premium within 30 days after the date of
receipt of notice required in subsection C of this Section terminates
the continuation benefits and the right to continuation benefits.
The continuation coverage for former
spouses who have not attained the
age of 55 at the time coverage begins shall terminate upon the
earliest to happen of the following:
(i) The failure to pay premiums when due, including
|
| any grace period allowed by the policy; or
|
|
(ii) When coverage would terminate under the terms of
|
| the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
|
|
(iii) the date on which the former spouse first
|
| becomes, after the date of election, an insured employee under any other group health plan; or
|
|
(iv) the date on which the former spouse remarries; or
(v) the expiration of 2 years from the date
|
| continuation coverage began.
|
|
Upon the termination of continuation coverage, the former
spouse shall be
entitled to convert the coverage to an individual policy.
The continuation rights granted to former spouses who have not attained age
55
shall also
include eligible dependents insured prior to the dissolution of marriage or the
death of the
employee.
E. With respect to a retired employee's spouse or former spouse who
has attained the age of 55 at the time continuation coverage begins, the
monthly premium for the continuation shall be computed as follows:
(i) an amount, if any, that would be charged an
|
| employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
|
|
(ii) an amount, if any, that the employer would
|
| contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
|
|
Beginning 2 years after coverage begins under this paragraph, the
monthly premium shall be computed as follows:
(i) an amount, if any, that would be charged an
|
| employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
|
|
(ii) an amount, if any, that the employer would
|
| contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
|
|
(iii) an additional amount, not to exceed 20% of (i)
|
| and (ii) above, for costs of administration.
|
|
Failure to pay the initial monthly premium within 30 days after the date
of receipt of the notice required in subsection C of this Section
terminates the continuation benefits and the right to continuation benefits.
The continuation coverage for retired employees'
spouses and former spouses
who have attained the age of 55 at the time coverage begins shall
terminate upon the earliest to happen of the following:
(i) The failure to pay premiums when due, including
|
| any grace period allowed by the policy; or
|
|
(ii) When coverage would terminate, except due to the
|
| retirement of an employee, under the terms of the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or retirement to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
|
|
(iii) the date on which the retired employee's spouse
|
| or former spouse first becomes, after the date of election, an insured employee under any other group health plan; or
|
|
(iv) the date on which the former spouse remarries; or
(v) the date that person reaches the qualifying age
|
| or otherwise establishes eligibility under the Medicare Program pursuant to Title XVIII of the federal Social Security Act.
|
|
Upon the termination of continuation coverage, the former
spouse shall be
entitled to convert the coverage to an individual policy.
The continuation rights granted to former spouses who have attained age 55
shall also
include eligible dependents insured prior to the dissolution of marriage, the
death of the
employee, or the retirement of the employee.
F. The renewal, amendment, or extension of any group policy affected by
this Section shall be deemed to be delivery or issuance for delivery of a
new policy or contract of insurance in this State.
G. If (i) the policy is canceled, and (ii) another
insurance company
contracts to provide group health and accident insurance to the employer,
and (iii) continuation coverage is in effect for the retired employee's
spouse or former spouse at the time of cancellation and (iv) the employee
is or would have been included under the new group policy, then the new
insurer must also offer continuation coverage to the retired employee's
spouse and to an employee's former spouse under the same terms and
conditions as contained in this Section.
H. This Section shall not limit the right of the retired employee's spouse
or any former spouse to exercise
the privilege to convert to an individual policy as contained in this Code.
I. No person who obtains coverage under this Section shall be required
to pay a rate greater than that applicable to any employee or member
covered under that group except as provided in clause (iii) of the
second paragraph of subsection E.
(Source: P.A. 93-477, eff. 1-1-04.)
|
(215 ILCS 5/367.2-5)
Sec. 367.2-5.
Dependent child continuation privilege; group contracts.
(a) No policy of group accident or health insurance, nor any certificate
thereunder
shall be amended, renewed, delivered, or issued for delivery in this State
after
July 1,
2004, unless the policy provides for a continuation of the existing insurance
benefits for
an employee's dependent child who is insured under the provisions of that group
policy
or certificate in the event of the death of the employee and the child is not
eligible for
coverage as a dependent under the provisions of Section 367.2 or the dependent
child has
attained the limiting age under the policy.
(b) In the event of the death of the employee, if continuation coverage is
desired,
the dependent child or a responsible adult acting on behalf of the dependent
child shall
give the employer or the insurer written notice of the death of employee within
30 days of
the date the coverage terminates. The employer, within 15 days of receipt of
the notice,
shall give written notice to the insurance company issuing the policy of the
death of the
employee and the dependent child's residence. The employer shall immediately
send a
copy of the notice to the dependent child or responsible adult at the dependent
child's
residence.
(c) In the event of the dependent child attaining the limiting age under the
policy,
if continuation coverage is desired, the dependent child shall give the
employer or the
insurer written notice of the attainment of the limiting age within 30 days of
the date the
coverage terminates. The employer, within 15 days of receipt of the notice,
shall give
written notice to the insurance company issuing the policy of the attainment
of the
limiting age by the dependent child and of the dependent child's residence.
(d) Within 30 days after the date of receipt of a notice from the employer,
dependent child, or responsible adult acting on behalf of the dependent child,
or of the
initiation of a new group policy, the insurance company, by certified mail,
return receipt
requested, shall notify the dependent child or responsible adult at the
dependent child's
residence that the policy may be continued for the dependent child. The
notice shall
include:
(1) a form for election to continue the insurance |
|
(2) the amount of periodic premiums to be charged for
|
| continuation coverage and the method and place of payment; and
|
|
(3) instructions for returning the election form
|
| within 30 days after the date it is received from the insurance company.
|
|
Failure of the dependent child or the responsible adult acting on behalf of
the dependent
child to exercise the election to continue insurance coverage by notifying the
insurance
company in writing within such 30 day period shall terminate the continuation
of benefits
and the right to continuation.
If the insurance company fails to notify the dependent child or responsible
adult acting on
behalf of the dependent child as provided for in this subsection (d), all
premiums shall
be waived from the date the notice was required until notice was sent, and the
benefits shall
continue under the terms and provisions of the policy, from the date the notice
was
required until the notice was sent, notwithstanding any other provision hereof,
except where
the benefits in existence at the time the company's notice was to be sent
pursuant to
this subsection (d) are terminated as to all employees.
(e) The monthly premium for continuation shall be computed as follows:
(1) an amount, if any, that would be charged an
|
| employee if the dependent child were a current employee of the employer, plus;
|
|
(2) an amount, if any, that the employer would
|
| contribute toward the premium if the dependent child were a current employee.
|
|
Failure to pay the initial monthly premium within 30 days after the date of
receipt of
notice required in subsection (d) of this Section terminates the continuation
benefits and
the right to continuation benefits.
Continuation coverage provided under this Act shall terminate upon the
earliest to happen
of the following:
(1) the failure to pay premiums when due, including
|
| any grace period allowed by the policy;
|
|
(2) when coverage would terminate under the terms of
|
| the existing policy if the dependent child was still an eligible dependent of the employee;
|
|
(3) the date on which the dependent child first
|
| becomes, after the date of election, an insured employee under any other group health plan; or
|
|
(4) the expiration of 2 years from the date
|
| continuation coverage began.
|
|
Upon the termination of continuation coverage, the dependent child shall be
entitled to
convert the coverage to an individual policy.
(f) The renewal, amendment, or extension of any group policy affected by
this
Section shall be deemed to be delivery or issuance for delivery of a new policy
or
contract of insurance in this State.
(g) If (1) the policy is cancelled, and (2) another insurance company
contracts to
provide group health and accident insurance to the employer, and (3)
continuation
coverage is in effect for the dependent child at the time of cancellation, and
(4) the
employee is or would have been included under the new group policy, then the
new
insurer must also offer continuation coverage to the dependent child under the
same
terms and conditions as contained in this Section.
(h) This Section shall not limit the right of any dependent child to
exercise the
privilege to convert to an individual policy as contained in this Code.
(i) No person who obtains coverage under this Section shall be required to
pay a
rate greater than that applicable to any employee or member covered under that
group.
(Source: P.A. 93-477, eff. 1-1-04.)
|
(215 ILCS 5/367e) (from Ch. 73, par. 979e)
Sec. 367e. Continuation of Group Hospital, Surgical and Major Medical
Coverage After Termination of Employment or Membership.
A group policy delivered, issued for delivery, renewed or amended in this
state which insures employees or members
for hospital, surgical or major medical insurance on an expense incurred
or service basis, other than for specific diseases or for accidental injuries
only, shall provide that employees or members whose insurance under the
group policy would otherwise terminate because of termination of employment
or membership or because of a reduction in hours below the minimum required
by the group plan shall be entitled to continue their hospital, surgical and
major medical insurance under that group policy, for themselves and their
eligible dependents, subject to all of the group policy's terms and conditions
applicable to those forms of insurance and to the following conditions:
1. Continuation shall only be available to an |
| employee or member who has been continuously insured under the group policy (and for similar benefits under any group policy which it replaced) during the entire 3 months period ending with such termination or reduction in hours below the minimum required by the group plan. With respect to an employee or member who is involuntarily terminated between September 1, 2008 and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, continuation shall be available if the employee or member was insured under the group policy on the day prior to the termination.
|
|
2. Continuation shall not be available for any person
|
| who is covered by Medicare, except for those individuals who have been covered under a group Medicare supplement policy. Neither shall continuation be available for any person who is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan or who exercises his conversion privilege under the group policy.
|
|
3. Continuation need not include dental, vision care,
|
| prescription drug benefits, disability income, specified disease, or similar supplementary benefits which are provided under the group policy in addition to its hospital, surgical or major medical benefits.
|
|
4. Within 10 days after the employee's or member's
|
| termination or reduction in hours below the minimum required by the group plan written notice of continuation shall be presented to the employee or member by the employer. If the employee or member is unavailable, written notice shall be mailed by the employer to the last known address of the employee or member within 10 days after the employee's or member's termination or reduction in hours below the minimum required by the group plan. The employer shall also send a copy of the notice to the insurer. An employee or member who wishes continuation of coverage must request such continuation in writing within the 30 day period following the later of: (i) the date of such termination or reduction in hours below the minimum required by the group plan, or (ii) the date the employee is presented or mailed written notice of the right of continuation by either the employer or the group policyholder. In no event, however, may the employee or member elect continuation more than 60 days after the date of such termination or reduction in hours below the minimum required by the group plan. Written notice of continuation presented to the employee or member by the policyholder, or mailed by the policyholder to the last known address of the employee, shall constitute the giving of notice for the purpose of this provision.
|
|
The insurer shall not deny coverage to the employee
|
| or member due to the employer's failure to provide notice pursuant to this Section to the employee or member. Until the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, in the event the employee or member contacts the insurer regarding continuation rights and advises that notice has not been provided by the employer or group policyholder, the insurer shall provide a written explanation to the employee or member of the employee's or member's continuation rights pursuant to this Section.
|
|
4a. Unless contrary to the provisions of, or any
|
| rules promulgated pursuant to, the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage and who are terminated or whose reduction in hours below the minimum required by the group occurs between the effective date of this amendatory Act of the 96th General Assembly and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, the notice requirements of this Section are not satisfied unless notice is presented or mailed to the employee or member by the insurer informing the employee or member of the availability of premium reduction with respect to such coverage under the American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 4a.
|
|
4b. Unless contrary to the provisions of, or any
|
| rules promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage who were terminated or whose reduction in hours below the minimum required by the group occurred between September 1, 2008 and the effective date of this amendatory Act of the 96th General Assembly and who have an election of continuation of coverage pursuant to this Section in effect, notice shall be presented or mailed to the employee or member by the insurer informing the employee or member of the availability of premium reduction with respect to such coverage under the federal American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009 and shall be presented or mailed to the employee or member within 14 days of the effective date of this amendatory Act of the 96th General Assembly. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 4b.
|
|
5. An employee or member electing continuation must
|
| pay to the group policyholder or his employer, on a monthly basis in advance, the total amount of premium required by the insurer, including that portion of the premium contributed by the policyholder or employer, if any, but not more than the group rate for the insurance being continued with appropriate reduction in premium for any supplementary benefits which have been discontinued under paragraph (3) of this Section. The premium rate required by the insurer shall be the applicable premium required on the due date of each payment.
|
|
6. Continuation of insurance under the group policy
|
| for any person shall terminate when he becomes eligible for Medicare or is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan as provided in condition 2 above or, if earlier, at the first to occur of the following:
|
|
(a) The date 12 months after the date the
|
| employee's or member's insurance under the policy would otherwise have terminated because of termination of employment or membership or reduction in hours below the minimum required by the group plan or, with respect to an employee or member who is an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, the date that the individual ceases to be eligible for premium assistance under Section 3001(a)(2)(A)(ii)(I) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended.
|
|
(b) If the employee or member fails to make
|
| timely payment of a required contribution, the end of the period for which contributions were made.
|
|
(c) The date on which the group policy is
|
| terminated or, in the case of an employee, the date his employer terminates participation under the group policy. However, if this (c) applies and the coverage ceasing by reason of such termination is replaced by similar coverage under another group policy, the following shall apply:
|
|
(i) The employee or member shall have the
|
| right to become covered under that other group policy, for the balance of the period that he would have remained covered under the prior group policy in accordance with condition 6 had a termination described in this (c) not occurred.
|
|
(ii) The prior group policy shall continue to
|
| provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.
|
|
7. A notification of the continuation privilege shall
|
| be included in each certificate of coverage.
|
|
8. Continuation shall not be available for any
|
| employee who was discharged because of the commission of a felony in connection with his work, or because of theft in connection with his work, for which the employer was in no way responsible; provided the employee admitted his commission of the felony or theft or such act has resulted in a conviction or order of supervision by a court of competent jurisdiction.
|
|
9. An employee or member without an election of
|
| continuation of coverage pursuant to this Section in effect on the effective date of this amendatory Act of the 96th General Assembly may elect continuation pursuant to this paragraph 9 if the employee or member: (i) would be an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, if such an election were in effect and (ii) at the time of termination was eligible for continuation pursuant to paragraphs 1 and 2 of this Section.
|
|
Unless contrary to the provisions of, or any rules
|
| promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, written notice of continuation pursuant to this paragraph 9 shall be presented to the employee or member by the insurer or mailed by the insurer to the last known address of the employee or member within 30 days after the effective date of this amendatory Act of the 96th General Assembly. Such written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 9.
|
|
An employee or member electing continuation of
|
| coverage under this paragraph 9 must request such continuation in writing within 60 days after the date the employee or member receives written notice of the right of continuation by the insurer.
|
|
Continuation of coverage elected pursuant to this
|
| paragraph 9 shall commence with the first period of coverage beginning on or after February 17, 2009, the effective date of the federal American Recovery and Reinvestment Act of 2009, and shall not extend beyond the period of continuation that would have been required if the coverage had been elected pursuant to paragraph 4 of this Section.
|
|
With respect to an employee or member who elects
|
| continuation of coverage under this paragraph 9, the period beginning on the date of the employee's or member's involuntary termination of employment and ending on the date of the first period of coverage on or after February 17, 2009 shall be disregarded for purposes of determining the 63-day period referred to in Section 20 of the Illinois Health Insurance Portability and Accountability Act.
|
|
The requirements of this amendatory Act of 1983 shall apply to any group
policy as defined in this Section, delivered or issued for delivery on or after
180 days following the effective date of this amendatory Act of 1983.
The requirements of this amendatory Act of 1985 shall apply to any
group policy as defined in this Section, delivered, issued for delivery,
renewed or amended on or after 180 days following the effective date of
this amendatory Act of 1985.
(Source: P.A. 96-13, eff. 6-18-09; 96-894, eff. 5-17-10.)
|
(215 ILCS 5/367e.1)
Sec. 367e.1.
Group Accident and Health Insurance Conversion Privilege.
(A) A group policy which provides hospital, medical, or major
medical expense insurance, or any combination of these coverages, on an
expense-incurred basis, but not including a policy which provides
benefits for specific diseases or for accidental injuries only, shall
provide that an employee or member (i) whose insurance under the group
policy has been terminated for any reason other than discontinuance of
the group policy in its entirety where there is a succeeding carrier, or
failure of the employee or member to pay any required contribution; and
(ii) who has been continuously insured under the group policy (and under
any group policy providing similar benefits which it replaces) for at
least three months immediately prior to termination, shall be entitled
to have issued to him by the insurer a policy of health insurance
(hereafter referred to as the converted policy), subject to the
following conditions:
(1) Written application for the converted policy |
| shall be made and the first premium paid to the insurer not later than the latter of (i) thirty-one days after such termination or (ii) 15 days after the employee or member has been given written notice of the existence of the conversion privilege, but in no event later than 60 days after such termination.
|
|
Written notice presented to the employee or member by
|
| the policyholder, or mailed by the policyholder to the last known address of the employee or member, shall constitute the giving of notice for the purpose of this provision.
|
|
(2) The converted policy shall be issued without
|
| evidence of insurability.
|
|
(3) The initial premium for the converted policy
|
| shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of each person to be covered under the converted policy and to the type and amount of the insurance provided. Conditions pertaining to health shall not be an acceptable basis of classification for the purposes of this subsection. The frequency of premium payment shall be the frequency customarily required by the insurer for the policy form and plan selected, provided that the insurer shall not require premium payments less frequently than quarterly without the consent of the insured.
|
|
(4) The effective date of the converted policy shall
|
| be the day following the termination of insurance under the group policy.
|
|
(5) The converted policy shall cover the employee or
|
| member and his dependents who were covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.
|
|
(6) The insurer shall not be required to issue a
|
| converted policy covering any person if such person is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded). Furthermore, the insurer shall not be required to issue a converted policy covering any person if (i) such person is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) such person is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any statute, and the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person together with the converted policy would result in overinsurance according to the insurer's standards.
|
|
(7) In the event that coverage would be continued
|
| under the group policy on an employee following his retirement prior to the time he is or could be covered by Medicare, he may elect, in lieu of such continuation of such group insurance, to have the same conversion rights as would apply had his insurance terminated at retirement by reason of termination of employment or membership.
|
|
(8) Subject to the conditions set forth above, the
|
| conversion privilege shall also be available (i) to the surviving spouse, if any, at the death of the employee or member, with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death, otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or, if the group policy provides for continuation of dependents' coverage following the employee's or member's death, at the end of such continuation; (ii) to the spouse of the employee or member upon termination of coverage of the spouse, while the employee or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time; or (iii) to a child solely with respect to himself upon termination of his coverage by reason of ceasing to be a qualified family member under the group policy, if a conversion privilege is not otherwise provided above with respect to such termination.
|
|
(9) A notification of the conversion privilege shall
|
| be included in each certificate.
|
|
(10) The insurer may elect to provide group insurance
|
| coverage in lieu of the issuance of a converted policy.
|
|
(B) A converted policy issued upon the exercise of the conversion
privilege required by subsection (A) of this Section shall conform to
the following minimum standards:
(1) If the group policy provided hospital, surgical,
|
| or medical expense insurance, or a combination thereof, the converted policy shall provide benefits on an expense-incurred basis equal to the lesser of (i) the hospital room and board, miscellaneous hospital, surgical and medical benefits provided under the group policy; and (ii) the corresponding benefits described below:
|
|
(a) Hospital room and board benefits in an amount
|
| per day elected by the group policyholder, but in no event less than 60% of the then average semi-private hospital room and board charge in the State, such benefits to be payable for a maximum of not less than 70 days for any period of hospital confinement, as defined in the converted policy.
|
|
(b) Miscellaneous hospital benefits for any one
|
| period of hospital confinement in an amount up to twenty times the hospital room and board daily benefit provided under the converted policy.
|
|
(c) Surgical benefits according to a surgical
|
| schedule providing a benefit amount elected by the group policy holder, but in no event less than 60% of the then average surgical charge in the State and with a maximum amount appropriate thereto. The maximum surgical benefit shall be applicable to all surgical operations of an individual resulting from or contributed to by the same and all related causes occurring in one period of disability. Two or more surgical procedures performed in the course of a single operation through the same incision, or in the same natural body orifice, may be treated as one surgical procedure with the payment determined by the scheduled benefit for the most expensive procedure performed. The surgical schedule shall be consistent with the schedule of operations customarily offered by the insurer under group or individual health insurance policies.
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|
(d) Non-surgical medical attendance benefits for
|
| in-hospital services in an amount elected by the group policyholder, but in no event less than 60% of the then average in-hospital physician's visit charge in the State, such benefits may be limited to one visit per day of hospitalization and a maximum number of visits numbering not less than seventy for any period of hospital confinement as defined in the converted policy.
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|
(2) If the group policy provided major medical
|
| insurance, the insurer may offer the insurance described in (1) above only, major medical insurance only, or a combination of the insurance described in (1) above and major medical insurance. If the insurer elects to provide major medical insurance, the converted policy shall provide:
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|
(a) A maximum benefit at least equal to (i) or
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|
(i) A maximum payment of twenty-five thousand
|
| dollars for all covered medical expenses incurred during the covered person's lifetime with an annual restoration of the lesser of, while coverage is in force, one thousand dollars and the amount counted against the maximum benefit which was not previously restored; or
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|
(ii) A maximum payment of twenty-five
|
| thousand dollars for each unrelated injury or illness.
|
|
(b) Payment of benefits for covered medical
|
| expenses, in excess of the deductible, at a rate not less than 80% except as otherwise permitted below.
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|
(c) A deductible for each benefit period which,
|
| at the option of the insurer, shall be (i) the greater of $500 and the benefits deductible; (ii) the sum of the benefits deductible and $100; or (iii) the corresponding deductible in the group policy. The term "benefit period," as used herein, means, when the maximum payment is determined by (a) (i) above, either a calendar year or a period of twelve consecutive months; and, when the maximum payment is determined by (a) (ii) above, a period of twenty-four consecutive months. The term "benefits deductible," as used herein, means the value of any benefits provided on an expense-incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical, or medical insurance policy or hospital or medical service subscriber contract of medical practice or other prepayment plan, or any other plans or program whether on an insured or uninsured basis, or of any similar benefits which are provided or made available pursuant to or in accordance with the requirements of any statute and, if, pursuant to the provisions of this subsection, the converted policy provides both the coverage described in (1) above and major medical insurance, the value of the coverage described in (1) above. The insurer may require that the deductible be satisfied during a period of not less than three months. If the maximum payment is determined by (a) (i) above, and if no benefits become payable during the preceding benefit period due to the cash deductible not being satisfied; credit shall be given, in the succeeding benefit period, to any expense applied toward the cash deductible of the preceding benefit period and incurred during the last three months of such preceding benefit period, subject to any requirement that the deductible be satisfied during a specified period of time.
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|
(d) The term "covered medical expenses," as used
|
| above, may be limited (i) in the case of hospital room and board benefits, maximum surgical schedule, and non-surgical medical attendance benefits to amounts not less than the amounts provided in (1) (a), (1) (c) and (1) (d) above; and (ii) in the case of mental and nervous condition treatments while the patient is not a hospital in-patient, to co-insurance of 50%, a maximum benefit of $500 per calendar year or twelve consecutive month periods subject to the inclusion by the insurer of reasonable limits on the number of visits and the maximum permissible expense per visit.
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|
(3) The converted policy may contain any exclusion,
|
| reduction, or limitation contained in the group policy and any exclusion, reduction, or limitation customarily used in individual accident and health policies delivered or issued for delivery in this state. It is not required that the converted policy contain all of the covered medical expenses or the same level of benefits as provided in the group policy.
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|
(4) The insurer may, at its option, also offer
|
| alternative plans for group accident and health conversion.
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|
(5) The converted policy may only exclude a
|
| pre-existing condition excluded by the group policy. Any hospital, surgical, medical or major medical benefits payable under the converted policy may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder and, during the first policy year of such converted policy, the benefits payable under the converted policy may be so reduced so that they are not in excess of the benefits that would have been payable had the individual's insurance under the group policy remained in force and effect.
|
|
(6) The converted policy may provide for the
|
| termination of coverage thereunder of any person when he is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded).
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|
(7) The converted policy may provide that the insurer
|
| may request information from the converted policyholder, in advance of any premium due date of the converted policy, to determine whether any person covered thereunder (i) is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) has similar benefits provided for or available to such person, pursuant to or in accordance with the requirements of any statute. The converted policy may also provide that the insurer need not renew the converted policy or the coverage of any person insured thereunder if either the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person, together with the converted policy, would result in overinsurance according to the insurer's standards, or if the converted policyholder refuses to provide the requested information.
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|
(8) The converted policy shall not contain any
|
| provision allowing the insurer to non-renew due to a change in the health of an insured.
|
|
(9) The converted policy may contain any provisions
|
| permitted herein and may also include any other provisions not expressly prohibited by law. Any provisions required or permitted herein may be made a part of the converted policy by means of an endorsement or rider.
|
|
(10) In the conversion of group health insurance in
|
| accordance with the provisions of subsection (A) above, the insurer may, at its option, accomplish the conversion by issuing one or more converted policies.
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|
(11) With respect to any person who was covered by
|
| the group policy, the period specified in the Time Limit on Certain Defenses provisions of the converted policy shall commence with the date the person's insurance became effective under the group policy.
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|
(12) If the insurer elects to provide group insurance
|
| coverage in lieu of a converted policy, the benefit levels required for a converted policy must be applicable to such group insurance coverage.
|
|
(C) The requirements of this Section shall apply to any group policy
of accident and health insurance delivered, issued for delivery, renewed
or amended on or after 180 days following the effective date of this
Section.
(Source: P.A. 93-477, eff. 1-1-04.)
|
(215 ILCS 5/367f) (from Ch. 73, par. 979f)
Sec. 367f. Firefighters' continuance privilege. As used in this Section:
1. The terms "municipality", "deferred pensioner" and "creditable service"
shall have the meaning ascribed to such terms by Sections 4-103, 4-105a and
4-108, respectively, of the Illinois Pension Code, as now or hereafter amended.
2. "Firefighter" means a person who is a "firefighter" as defined in Section 4-106 of the Illinois Pension Code, a paramedic who is employed by a unit of local government, or an emergency medical technician, emergency medical technician-basic, emergency medical technician-intermediate, or advanced emergency medical technician who is employed by a unit of local government.
3. The "retirement or disability period" of a firefighter means the period:
a. which begins on the day the firefighter is |
| removed from a municipality's fire department payroll because of the occurrence of any of the following events, to wit: (i) the firefighter retires as a deferred pensioner under Section 4-105a of the Illinois Pension Code, (ii) the firefighter retires from active service as a firefighter with an attained age and accumulated creditable service which together qualify the firefighter for immediate receipt of retirement pension benefits under Section 4-109 of the Illinois Pension Code, or (iii) the firefighter's disability is established under Section 4-112 of the Illinois Pension Code; and
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|
b. which ends on the first to occur of any of the
|
| following events, to wit: (i) the firefighter's reinstatement or reentry into active service on the municipality's fire department as provided for under Article 4 of the Illinois Pension Code, (ii) the firefighter's exercise of any refund option available under Section 4-116 of the Illinois Pension Code, (iii) the firefighter's loss pursuant to Section 4-138 of the Illinois Pension Code of any benefits provided for in Article 4 of that Code, or (iv) the firefighter's death or -- if at the time of the firefighter's death the firefighter is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 4 of the Illinois Pension Code -- then the death or remarriage of that spouse.
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|
No policy of group accident and health insurance under which firefighters
employed by a municipality are insured for their individual benefit shall
be issued or delivered in this State to any municipality unless such group
policy provides for the election of continued group insurance coverage for
the retirement or disability period of each firefighter who is insured under the
provisions of the group policy on the day immediately preceding the day
on which the retirement or disability period of such firefighter begins. So
long as any required premiums for continued group insurance coverage are
paid in accordance with the provisions of the group policy, an election
made pursuant to this Section shall provide continued group insurance
coverage for a firefighter throughout the retirement or disability period of
the firefighter and, unless the firefighter otherwise elects and subject to any
other provisions of the group policy which relate either to the provision
or to the termination of dependents' coverage and which are not
inconsistent with this Section, for any dependents of the firefighter who are
insured under the group policy on the day immediately preceding the day on
which the retirement or disability period of the firefighter begins; provided,
however, that when such continued group insurance coverage is in effect
with respect to a firefighter on the date
of the firefighter's death but the retirement or disability period of the firefighter
does not end with such firefighter's death, then the deceased firefighter's surviving
spouse upon whose death or remarriage such retirement or disability period
will end shall be entitled, without further election and upon payment of
any required premiums in accordance with the provisions of the group policy,
to maintain such continued group
insurance coverage in effect until the end of such retirement or disability
period. Continued group insurance coverage shall be provided in accordance
with this Section at the same premium rate from time to time charged for
equivalent coverage provided under the group policy with respect to covered
firefighters whose retirement or disability period has not begun, and no distinction
or discrimination in the amount or rate of premiums or in any waiver of premium
or other benefit provision shall be made between continued group insurance
coverage elected pursuant to this Section and equivalent coverage provided
to firefighters under the group policy other than pursuant to the provisions
of this Section; provided that no municipality shall be required by reason
of any provision of this Section to pay any group insurance premium other
than one that may be negotiated in a collective bargaining agreement.
If a person electing continued coverage under this Section becomes
eligible for medicare coverage, benefits under the group policy may
continue as a supplement to the medicare coverage upon payment of any
required premiums to maintain the benefits of the group policy as
supplemental coverage.
Within 15 days of the beginning of the retirement or disability period
of any firefighter entitled to elect continued group insurance coverage under any
group policy affected by this Section, the municipality last employing such
firefighter shall give written notice of such beginning by certified mail, return
receipt requested to the insurance company issuing such policy. The notice
shall include the firefighter's name and last known place of residence and the
beginning date of the firefighter's retirement or disability period.
Within 15 days of the date of receipt of such notice from the municipality,
the insurance company by certified mail, return receipt requested, shall
give written notice to the firefighter at the firefighter's last known place of
residence that coverage under the group policy may be continued for the
retirement or disability period of the firefighter as provided in this Section.
Such notice shall set forth: (i) a statement of election to be filed by
the firefighter if the firefighter wishes to continue such group insurance coverage,
(ii) the amount of monthly premium, including a statement of the portion
of such monthly premium attributable to any dependents' coverage which the
firefighter may elect, and (iii) instructions as to the return of the election
form to the insurance company issuing such policy. Election shall be made,
if at all, by returning the statement of election to the insurance company by
certified mail, return receipt requested within 15 days after having received it.
If the firefighter elects to continue coverage, it shall be the obligation
of the firefighter to pay the monthly premium directly to the municipality which
shall forward it to the insurance company
issuing the group insurance policy, or as otherwise directed by the insurance
company; provided, however, that the firefighter shall be entitled to designate
on the statement of election required to be filed with the insurance company
that the total monthly premium, or such portion thereof as is not
contributed by a municipality, be deducted by a Firefighter's Pension
Fund from any monthly pension payment otherwise payable
to or on behalf of the firefighter pursuant to Article 4 of the Illinois Pension
Code, and be remitted by such Pension Fund to the insurance company. The
portion, if any, of the monthly premium contributed by a
municipality for such continued group insurance coverage shall be paid by
the municipality directly to the insurance company issuing the group insurance
policy, or as otherwise directed by the insurance company. Such continued
group insurance coverage shall relate back to the beginning of the firefighter's
retirement or disability period.
The amendment, renewal or extension of any group insurance policy affected
by this Section shall be deemed to be the issuance of a new policy of insurance
for purposes of this Section.
In the event that a municipality makes a program of accident, health,
hospital or medical benefits available to its firefighters through
self-insurance, or by participation in a pool or reciprocal insurer, or by
contract in a form other than a policy of group insurance with one or more
medical service plans, health care service corporations, health maintenance
organizations, or any other professional corporations or plans under which
health care or reimbursement for the costs thereof is
provided, whether the cost of such benefits is borne by the municipality or
the firefighters or both, such firefighters and their surviving spouses shall have
the same right to elect continued coverage under such program of benefits
as they would have if such benefits were provided by a policy of group
accident and health insurance. In such cases, the notice of right to elect
continued coverage shall be sent by the municipality; the statement of
election shall be sent to the municipality; and references to the required
premium shall refer to that portion of the cost of such benefits which is not
borne by the municipality, either voluntarily or pursuant to the provisions
of a collective bargaining agreement. In the case of a municipality
providing such benefits through self-insurance or participation in a pool or
reciprocal insurer, the right to elect continued coverage which is provided
by this paragraph shall be implemented and made available to the firefighters of
the municipality and qualifying surviving spouses not later than July 1, 1985.
The amendment, renewal or extension of any such contract in a form other
than a policy of group insurance policy shall be deemed the formation of a
new contract for the purposes of this Section.
This Section shall not limit the exercise of any conversion privileges
available under Section 367e.
Pursuant to paragraphs (h) and (i) of Section 6 of Article VII of the
Illinois Constitution, this Section specifically denies and limits the
exercise by a home rule unit of any power which is inconsistent with this
Section and all existing laws and ordinances which are inconsistent with
this Section are hereby superseded. This Section does not preempt the
concurrent exercise by home rule units of powers consistent herewith.
The Division of Insurance of the Department of Financial and Professional Regulation shall enforce the provisions of this Section, including provisions relating to municipality self-insured benefit plans.
(Source: P.A. 103-52, eff. 1-1-24 .)
|
(215 ILCS 5/367h) (from Ch. 73, par. 979h)
Sec. 367h.
Deputy's continuance privilege.
As used in this Section:
1. The terms "municipality" and "creditable service"
shall have the meaning ascribed to such terms by Sections 7-105
and 7-113, respectively, of the Illinois Pension Code, as now or hereafter
amended.
The term "deferred pensioner" means a deputy who has retired,
having accumulated enough creditable service to qualify for a pension, but
who has not attained the required age.
2. The term "deputy" shall mean a "sheriff's
law enforcement employee" as defined in Section 7-109.3 of the Illinois
Pension Code, and include only
persons under the coverage of Article 7 of that Code, as heretofore or
hereafter
amended.
3. The "retirement or disability period" of a deputy means the period:
a. which begins on the day the deputy is removed from |
| a sheriff's police department payroll because of the occurrence of any of the following events, to wit: (i) the deputy retires as a deferred pensioner, (ii) the deputy retires from active service as a deputy with an attained age and accumulated creditable service which together qualify the deputy for immediate receipt of retirement pension benefits under Section 7-142.1 of the Illinois Pension Code, or (iii) the deputy's disability is established under Article 7 of the Illinois Pension Code; and
|
|
b. which ends on the first to occur of any of the
|
| following events, to wit: (i) the deputy's reinstatement or reentry into active service in the sheriff's police department as provided for under Article 7 of the Illinois Pension Code, (ii) the deputy's exercise of any refund option or acceptance of any separation benefit available under Article 7 of the Illinois Pension Code, (iii) the deputy's loss pursuant to Section 7-219 of the Illinois Pension Code of any benefits provided for in Article 7 of that Code, or (iv) the deputy's death or -- if at the time of the deputy's death the deputy is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 7 of the Illinois Pension Code -- the death or remarriage of that spouse.
|
|
No policy of group accident and health insurance under which deputies
employed by a municipality are insured for their individual benefit shall
be issued or delivered in this State to any municipality unless such group
policy provides for the election of continued group insurance coverage for
the retirement or disability period of each deputy who is insured under the
provisions of the group policy on the day immediately preceding the day
on which the retirement or disability period of such deputy begins. So
long as any required premiums for continued group insurance coverage are
paid in accordance with the provisions of the group policy, an election
made pursuant to this Section shall provide continued group insurance coverage
for a deputy throughout the retirement or disability period of the
deputy and, unless
the deputy otherwise elects and subject to any other provisions of the
group policy which relate either to the provision or to the termination
of dependents' coverage and which are not inconsistent with this Section,
for any dependents of the deputy who are insured under the group policy on the
day immediately preceding the day on which the retirement or disability
period of the deputy begins; provided, however, that when such continued
group insurance coverage is in effect with respect to a deputy on the date
of the deputy's death but the retirement or disability period of
the deputy
does not end with such deputy's death, then the deceased deputy's surviving
spouse upon whose death or remarriage such retirement or disability period
will end shall be entitled, without further election and upon payment of
any required premiums in accordance with the provisions of the group policy,
to maintain such continued group insurance coverage in effect until the end of
such retirement or disability period. Continued group insurance coverage shall
be provided in accordance with this Section at the same premium rate from time
to time charged for equivalent coverage provided under the group policy with
respect to covered deputies whose retirement or disability period has not
begun, and no distinction or discrimination in the amount or rate of premiums
or in any waiver of premium
or other benefit provision shall be made between continued group insurance
coverage elected pursuant to this Section and equivalent coverage provided
to deputies under the group policy other than pursuant to the provisions
of this Section; provided that no municipality shall be required by reason
of any provision of this Section to pay any group insurance premium other
than one that may be negotiated in a collective bargaining agreement.
If the group policy provides for a reduction in benefits and premium for
insureds who become eligible for medicare, such provision shall apply to
persons electing continued coverage under this Section.
Within 15 days of the beginning of the retirement or disability period
of any deputy entitled to elect continued group insurance coverage under any
group policy affected by this Section, the municipality last employing such
deputy shall give written notice of such beginning by certified mail, return
receipt requested, to the insurance company issuing such policy. The notice
shall include the deputy's name and last known place of residence and the
beginning date of the deputy's retirement or disability period.
Within 15 days of the date of receipt of such notice from the municipality,
the insurance company by certified mail, return receipt requested, shall
give written notice to the deputy at the deputy's last known place of
residence that coverage under the group policy may be continued for the
retirement or disability period of the deputy as provided in this Section.
Such notice shall set forth: (i) a statement of election to be filed by
the deputy if the deputy wishes to continue such group insurance
coverage,
(ii) the amount of monthly premium, including a statement of the portion
of such monthly premium attributable to any dependents' coverage which the
deputy may elect, and (iii) instructions as to the return of the election
form to the insurance company issuing such policy. Election shall be made,
if at all, by returning the statement of election to the insurance company
by certified mail, return receipt requested, within 15 days after having
received it.
If the deputy elects to continue coverage, it shall be the obligation
of the deputy to pay the monthly premium directly to the municipality which
shall forward it to the insurance company issuing the group insurance
policy, or as otherwise
directed by the insurance company; provided, however, that the deputy
shall be entitled to designate on the statement of election
required to be filed with the insurance company that the total
monthly premium, or such portion thereof as is not contributed by
a municipality, be deducted by the Illinois Municipal Retirement Fund
from the monthly pension payment otherwise payable
to or on behalf of the deputy pursuant to Article 7 of the Illinois Pension Code, and be remitted by such Fund to
the insurance company. The portion, if any, of the monthly premium
contributed by a municipality for such continued group insurance
coverage shall be paid by
the directly to the insurance company issuing the group insurance
policy, or as directed by the insurance company. Such continued
group insurance coverage shall relate back to the beginning of the deputy's
retirement or disability period.
The amendment, renewal or extension of any group insurance policy affected
by this Section shall be deemed to be the issuance of a new policy of insurance
for purposes of this Section.
In the event that a municipality makes a program of accident, health,
hospital or medical benefits available to its deputies through
self-insurance, or by participation in a pool or reciprocal insurer, or by
contract in a form other than a policy of group insurance with one or more
medical service plans, health care service corporations, health maintenance
organizations, or any other professional corporations or plans under which
health care or reimbursement for the costs thereof is
provided, whether the cost of such benefits is borne by the municipality or
the deputies or both, such deputies and their surviving spouses shall have
the same right to elect continued coverage under such program of benefits
as they would have if such benefits were provided by a policy of group
accident and health insurance. In such cases, the notice of right to elect
continued coverage shall be sent by the municipality; the statement of
election shall be sent to the municipality; and references to the required
premium shall refer to that portion of the cost of such benefits which is not
borne by the municipality, either voluntarily or pursuant to the provisions
of a collective bargaining agreement. In the case of a municipality
providing such benefits through self-insurance or participation in a pool or
reciprocal insurer, the right to elect continued coverage which is provided
by this paragraph shall be implemented and made available to the deputies of
the municipality and qualifying surviving spouses not later than July 1, 1986.
The amendment, renewal or extension of any such contract in a form other
than a policy of group insurance policy shall be deemed the formation of a
new contract for the purposes of this Section.
This Section shall not limit the exercise of any conversion privileges
available under Section 367e.
(Source: P.A. 90-655, eff. 7-30-98.)
|
(215 ILCS 5/367j) (from Ch. 73, par. 979j)
Sec. 367j.
Municipal employee's continuance privilege.
(a) As used in this Section:
(1) The term "creditable service" shall have the |
| meaning ascribed to it by Section 7-113 of the Illinois Pension Code.
|
|
(2) The term "municipality" means any municipality,
|
| instrumentality, or participating instrumentality (as those terms are defined in Sections 7-105, 7-107 and 7-108, respectively, of the Illinois Pension Code) that participates in the Illinois Municipal Retirement Fund pursuant to Section 7-132 of the Illinois Pension Code.
|
|
(3) The term "employee" shall mean an employee as
|
| defined in Section 7-109 of the Illinois Pension Code, but does not include any person who is a deputy as defined in Section 367h of this Code.
|
|
(4) The "retirement or disability period" of an
|
| employee means the period:
|
|
(A) which begins on the day the employee is
|
| removed from the municipality payroll because of the occurrence of either of the following events: (i) the employee retires from active service as an employee with an attained age and accumulated creditable service which together qualify the employee for immediate receipt of retirement pension benefits under Article 7 of the Illinois Pension Code, or (ii) the employee's disability is established under Article 7 of the Illinois Pension Code; and
|
|
(B) which ends on the first to occur of any of
|
| the following events: (i) the employee's reinstatement or reentry into active service as provided for under Article 7 of the Illinois Pension Code, (ii) the employee's exercise of any refund option or acceptance of any separation benefit available under Article 7 of the Illinois Pension Code, (iii) the employee's loss pursuant to Section 7-219 of the Illinois Pension Code of any benefits provided for in Article 7 of that Code, or (iv) the employee's death or, if at the time of the employee's death the employee is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 7 of the Illinois Pension Code, the death or remarriage of that spouse.
|
|
(b) No policy of group accident and health insurance under which
employees of a municipality are insured for their individual benefit shall
be issued or delivered in this State to a municipality unless such group
policy provides for the election of continued group insurance coverage for
the retirement or disability period of each employee who is insured under
the provisions of the group policy on the day immediately preceding the day
on which the retirement or disability period of such employee begins. So
long as any required premiums for continued group insurance coverage are
paid in accordance with the provisions of the group policy, an election
made pursuant to this Section shall provide continued group insurance
coverage for an employee throughout the retirement or disability period of
the employee and, unless the employee otherwise elects and subject to any
other provisions of the group policy which relate either to the provision
or to the termination of dependents' coverage and which are not
inconsistent with this Section, for any dependents of the employee who are
insured under the group policy on the day immediately preceding the day on
which the retirement or disability period of the employee begins; provided,
however, that when such continued group insurance coverage is in effect
with respect to an employee on the date of the employee's death but the
retirement or disability period of the employee does not end with the
employee's death, then the deceased employee's surviving spouse upon whose
death or remarriage such retirement or disability period will end shall be
entitled, without further election and upon payment of any required
premiums in accordance with the provisions of the group policy, to maintain
such continued group insurance coverage in effect until the end of the
retirement or disability period. Continued group insurance coverage shall
be provided in accordance with this Section at the same premium rate from
time to time charged for equivalent coverage provided under the group
policy with respect to covered employees whose retirement or disability
period has not begun, and no distinction or discrimination in the amount or
rate of premiums or in any waiver of premium or other benefit provision
shall be made between continued group insurance coverage elected pursuant
to this Section and equivalent coverage provided to employees under the
group policy other than pursuant to the provisions of this Section;
provided that no municipality shall be required by reason of any provision
of this Section to pay any group insurance premium other than one that may
be negotiated in a collective bargaining agreement. If the group policy
provides for a reduction in benefits and premium for insureds who become
eligible for medicare, such provision shall apply to persons electing
continued coverage under this Section.
Within 15 days of the beginning of the retirement or disability period of
any employee entitled to elect continued group insurance coverage under any
group policy affected by this Section, the municipality last employing such
employee shall give written notice of such beginning by certified mail,
return receipt requested, to the insurance company issuing such policy.
The notice shall include the employee's name and last known place of
residence and the beginning date of the employee's retirement or disability
period.
Within 15 days of the date of receipt of such notice from the municipality,
the insurance company by certified mail, return receipt requested, shall
give written notice to the employee at the employee's last known place of
residence that coverage under the group policy may be continued for the
retirement or disability period of the employee as provided in this
Section. Such notice shall set forth: (i) a statement of election to be
filed by the employee if the employee wishes to continue such group
insurance coverage, (ii) the amount of monthly premium, including a
statement of the portion of such monthly premium attributable to any
dependents' coverage which the employee may elect, and (iii) instructions
as to the return of the election form to the insurance company issuing such
policy. Election shall be made, if at all, by returning the statement of
election to the insurance company by certified mail, return receipt
requested, within 15 days after having received it.
If the employee elects to continue coverage, it shall be the obligation
of the employee to pay the monthly premium directly to the municipality
which shall forward it to the insurance company issuing the group insurance
policy, or as otherwise directed by the insurance company; provided,
however, that the employee shall be entitled to designate on the statement
of election required to be filed with the insurance company that the total
monthly premium, or such portion thereof as is not contributed by a
municipality, be deducted by the Illinois Municipal Retirement Fund from
the monthly pension payment otherwise payable to or on behalf of the
employee pursuant to Article 7 of the Illinois Pension Code, and be
remitted by such Fund to the insurance company. The portion, if any, of
the monthly premium contributed by a municipality for such continued group
insurance coverage shall be paid by the municipality directly to the
insurance company issuing the group insurance policy, or as directed by the
insurance company. Such continued group insurance coverage shall relate
back to the beginning of the employee's retirement or disability period.
The amendment, renewal or extension of any group insurance policy affected
by this Section shall be deemed to be the issuance of a new policy of insurance
for purposes of this Section.
(c) In the event that a municipality makes a program of accident,
health, hospital or medical benefits available to its employees through
self-insurance, or by participation in a pool or reciprocal insurer, or by
contract in a form other than a policy of group insurance with one or more
medical service plans, health care service corporations, health maintenance
organizations, or any other professional corporations or plans under which
health care or reimbursement for the costs thereof is provided, whether the
cost of such benefits is borne by the municipality or the employees or
both, such employees and their surviving spouses shall have the same
right to elect continued coverage under such program of benefits
as they would have if such benefits were provided by a policy of group
accident and health insurance. In such cases, the notice of right to elect
continued coverage shall be sent by the municipality; the statement of
election shall be sent to the municipality; and references to the required
premium shall refer to that portion of the cost of such benefits which is not
borne by the municipality, either voluntarily or pursuant to the provisions
of a collective bargaining agreement. In the case of a municipality
providing such benefits through self-insurance or participation in a pool or
reciprocal insurer, the right to elect continued coverage which is provided
by this paragraph shall be implemented and made available to the employees
of the municipality and qualifying surviving spouses not later than July 1,
1991.
The amendment, renewal or extension of any such contract in a form other
than a policy of group insurance policy shall be deemed the formation of a
new contract for the purposes of this Section.
(d) This Section shall not limit the exercise of any conversion
privileges available under Section 367e.
(Source: P.A. 86-1444; 87-435.)
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