(215 ILCS 5/Art. XIX heading) ARTICLE XIX.
BURIAL SOCIETIES
|
(215 ILCS 5/338) (from Ch. 73, par. 950)
Sec. 338.
Scope of
Article.
(1) This Article shall apply to:
(a) all societies organized or operating, prior to | ||
| ||
(b) any person, firm, corporation, society, or | ||
| ||
(2) Each person, firm, corporation, society or association mentioned in
subsection (1) is referred to in this Article as a "burial society" and
subscribers to and certificate holders of such a society are referred to in
this Article as "members."
(Source: P.A. 91-357, eff. 7-29-99.)
|
(215 ILCS 5/339) (from Ch. 73, par. 951)
Sec. 339.
Present
authorized burial societies may transact business.
Every society organized prior to the effective date of this amendatory
Act of 1959 and which society on that date was transacting business under a
certificate of authority issued by the Director may continue to transact
such business subject to the provisions of this article, but except as
provided in Section 336a no person, firm, corporation, society or
association shall enter business as a burial society after the effective
date of this amendatory Act of 1959.
(Source: Laws 1959, p. 1150.)
|
(215 ILCS 5/340) (from Ch. 73, par. 952)
Sec. 340.
Article of
Incorporation.
The articles of incorporation of a burial society shall state:
(a) The corporate name which shall not resemble the name of any existing
society or corporation organized under the laws of this State or authorized
to transact business therein as to mislead the public or cause confusion,
the purpose for which it is formed and the place in this State where its
principal office is located;
(b) The mode and manner in which the corporate powers of the society
shall be exercised; the manner of electing directors; the number of
directors which shall not be less than 3 nor more than 7; terms of office
of directors which shall be not more than 4 years; the manner of electing
officers and filling vacancies and such other particulars as may be
necessary to explain and manifest the object and purpose of the society and
the manner in which it is to be conducted.
A copy of the by-laws and forms of applications for members and a copy
of all forms of policies or certificates, literature and advertisements
shall be filed with the Director.
The Director shall examine the articles of incorporation and other
papers so filed with him and if he finds no objection thereto he shall
submit the articles of incorporation to the Attorney General for
examination and if found by the Attorney General to be in accordance with
the provisions of this Code and not inconsistent with the laws and
constitution of this State and of the United States, he shall certify to
the same and deliver it back to the Director who shall cause the articles
to be recorded in his records and issue to the incorporators a certified
copy thereof, and thereupon such incorporators and their associates shall
become and be a body corporate with the power to sue and be sued, contract
and be contracted with, adopt by-laws not in conflict with the provisions
of this Code, adopt a seal and do such other acts, subject to the
provisions and restrictions of this Code, as shall be needful to accomplish
the purposes of its organization. The management of the affairs of the
society shall at all times be vested in the board of directors.
(Source: P.A. 82-498.)
|
(215 ILCS 5/341) (from Ch. 73, par. 953)
Sec. 341.
Deposit
required.
(1) A burial society shall maintain with the Director a
deposit of
cash or securities in an amount of at least $1,000. A
society having a membership of more than 2,500
members and
less than 5,000 members shall maintain a deposit with the
Director
of $5,000. A society having a
membership of
more than 5,000 members and less than 10,000 members shall
maintain a
deposit with the Director of $10,000. A society
having more
than 10,000 members shall maintain a deposit with the
Director of $10,000 and an additional $1,000 for
each 1,000 members in excess of 10,000.
(2) All deposits as required herein shall be in cash or in securities
permitted by section 346.
(3) The Director may release the required deposit of cash or securities
upon receipt of
an order of a court having proper jurisdiction or
upon: (i) certification by the burial society that it has no outstanding
creditors, policyholders, certificate holders, or member obligations in effect
and no plans to engage in the business of insurance; (ii) receipt of a lawful
resolution of the burial society's board of directors effecting the surrender
of its articles of incorporation for administrative dissolution by the
Director; and (iii) receipt of the name and forwarding address for each of the
final officers and directors of the burial society, together with a plan of
dissolution approved by the Director.
(Source: P.A. 92-75, eff. 7-12-01.)
|
(215 ILCS 5/342) (from Ch. 73, par. 954)
Sec. 342.
Officers
bond.
The officer or officers of the society entrusted with the custody of its
funds shall give bond to the association in double the amount of the
minimum deposit required by this article, but in no event less than Two
Thousand ($2,000) Dollars or more than Five Thousand ($5,000) Dollars,
conditioned upon the faithful performance of his or their duties and
accounting for the funds entrusted to his or their custody.
(Source: Laws 1937, p. 696.)
|
(215 ILCS 5/343) (from Ch. 73, par. 955)
Sec. 343.
Certificate form.
(1) Every burial society shall issue a certificate of membership to
each member, agreeing to pay upon death a specified sum of money not to
exceed $1,000, which specified amount shall not be
diminished during the existence of the contract. The form of certificate
shall be submitted to the Director for his or her approval before the same
shall be issued. Each certificate issued after the effective date of
this Code, shall contain the following provisions, and shall be printed
in clear readable type of uniform size except that the words in capital
letters in the following form may be in larger type:
............, Illinois.
Certificate Number
..................
..............................
(A Burial Insurance Society)
Incorporated under the Illinois Insurance Code.
HEREBY INSURES the life of ...., hereinafter called the Member.
The society hereby agrees to pay to .... Beneficiary, the sum of $....,
upon receipt of due proof of the death of the member, such
payment to be paid only in lawful money of the United States.
This certificate is issued in consideration of the application and
the payment in advance of a first .... premium of .... which maintains
this certificate in force for a period ending .... following its date of
issue, and the payment of a like sum on the .... day of each ....
thereafter during the lifetime of the member.
CHANGE OF BENEFICIARY. The member may change the beneficiary at any
time by giving notice at the principal office of the society.
INCONTESTABLE CLAUSE. This certificate shall be incontestable after
it has been in force during the life-time of the member for 2 years
except for non-payment of premiums provided herein.
GRACE PERIOD. A grace period of 30 days shall be allowed for the
payment of any premium after the first, during which time this
certificate shall be continued in full force. Should the member die
during such grace period, the unpaid premium may be deducted from the
amount otherwise payable. This certificate shall be regarded and
accepted by the society and the member as cancelled and terminated upon
failure to pay any premium before the expiration of the grace period.
REINSTATEMENT. This certificate, after default in payment of any
premium, may be reinstated at the discretion of the Board of Directors
upon the member furnishing to the society satisfactory evidence of good
health and paying the delinquent premiums.
CONTRACT. This certificate and the application therefor, a copy of which
is attached hereto, shall constitute the entire contract with the member.
MISSTATEMENT OF AGE. If the age of the member has been misstated, the
amount payable under the certificate shall be such as the member would
have been entitled to at the true age.
IN WITNESS WHEREOF, the society has caused this certificate to
be signed by its duly authorized officers, on (insert date), which shall be the effective date of this certificate.
.................
(Secretary)
.................
(President)
(2) If the society is operating on an assessment plan, it may
substitute in lieu of the word premium the word assessment in each case
and may substitute in lieu of the consideration clause contained in the
form the following:
This certificate is issued in consideration of the application and
the payment in advance of the first .... assessment and the further
payment of such assessments as may be levied from time to time during
the lifetime of the member.
(Source: P.A. 91-357, eff. 7-29-99.)
|
(215 ILCS 5/344) (from Ch. 73, par. 956)
Sec. 344.
Burial
benefit payable in lawful money.
No society operating under or by virtue of this article shall pay a
burial benefit or award other than in lawful money of the United States and
any provision in any contract to the contrary shall be of no effect, nor
shall any member of any society or representative or beneficiary of such
member be required as a condition of his becoming a member, or otherwise,
to purchase funeral supplies or burial services from any specified or
designated person, firm or corporation so as to deprive the representative,
beneficiary or family of any such member from procuring or purchasing said
supplies and services in the open market.
(Source: Laws 1937, p. 696.)
|
(215 ILCS 5/345) (from Ch. 73, par. 957)
Sec. 345.
Society
and directors or officers may not advertise funeral supplies.
No burial society nor any officer, director or agent of any burial
society shall offer or make any oral or written agreement to furnish, or
shall distribute or cause to be distributed any literature or advertising
of any kind whatsoever which offers or purports to offer, funeral supplies
of any kind in lieu of the cash payment upon the death of a member. Upon
any violation of this section by any society, or officer, director or agent
thereof, the Director shall proceed to liquidate such society in accordance
with the provisions of Article XIII.
(Source: Laws 1937, p. 689.)
|
(215 ILCS 5/346) (from Ch. 73, par. 958)
Sec. 346.
Benefit account and expense account.
(1) All burial societies shall charge a premium or levy an
assessment to be paid by the members. Unless the society
maintains reserves meeting the standards of Article XIV on its benefit
certificates, the society shall not use more
than sixty-five per centum of such premium or assessment for the purpose
of paying commissions, salaries and other expenses of operation, and the
surplus and legal reserves shall constitute the benefit account of
the society and shall be
retained in cash or be invested in accordance with Article VIII.
(2) No society shall invest in or loan upon any bond or note secured
by mortgage or trust deed on real estate if an officer or director of
such society has any financial interest in the real estate upon which
the loan is made.
(Source: P.A. 86-753.)
|
(215 ILCS 5/347) (from Ch. 73, par. 959)
Sec. 347.
Failure to
maintain deposit-Payment of claims.
All claims filed with a society shall be approved or disapproved within
sixty days after receipt of due proof of death and, if approved, shall be
paid within thirty days after such approval. The Director shall proceed
under Article XIII to liquidate any society which shall fail to maintain
the deposit required by this article, or shall conduct its business
fraudulently, or is not carrying out its contracts in good faith, or shall
be thirty days or more in arrears in payment of death claims after the same
have been allowed by the board of directors, or has violated any of the
provisions of this article.
(Source: Laws 1937, p. 696.)
|
(215 ILCS 5/348) (from Ch. 73, par. 960)
Sec. 348.
Amendment
of articles.
The articles of incorporation of any society, subject to the provisions
of this article, may be amended by proper resolutions adopted by the Board
of Directors.
(Source: Laws 1937, p. 696.)
|
(215 ILCS 5/349) (from Ch. 73, par. 961)
Sec. 349.
Penalties.
Any society or any officer or agent of any society who violates any of
the provisions of this article shall be guilty of a petty offense.
(Source: P.A. 77-2699.)
|
(215 ILCS 5/351) (from Ch. 73, par. 963)
Sec. 351.
Application of article and other code provisions.
(1) This article shall not apply to fraternal or fraternal benefit
societies, assessment life and accident associations existing or
operating under or by virtue of any statute of this State, societies
that pay sick or disability benefits and limit their membership to a
particular class of persons or to the employees of a designated person,
firm or corporation nor shall this article apply to any burial insurance
society composed exclusively of the employees of any department of any
municipal, county, state or national government.
(2) Unless otherwise provided in this article every burial society
shall be subject to other applicable provisions of this Code.
Unless specifically exempted by the Director of Insurance every
society not operating on the true assessment plan shall adopt a
standard of valuation approved by the Director.
(Source: P.A. 80-624.)
|
(215 ILCS 5/Art. XIXA heading) ARTICLE XIXA.
LONG-TERM CARE INSURANCE
|
(215 ILCS 5/351A-1) (from Ch. 73, par. 963A-1)
Sec. 351A-1.
Definitions.
Unless the context requires otherwise, in this
Article:
(a) "Long-term care insurance" means any accident and health insurance
policy or rider advertised, marketed, offered or designed to provide
coverage for not less than 12 consecutive months for each covered person on
an expense incurred, indemnity, prepaid or other basis, for one or more
necessary or medically necessary diagnostic, preventive, therapeutic,
rehabilitative, maintenance, or personal care services, provided in a
setting other than an acute care unit of a hospital. Such term includes
group and individual annuities and life insurance policies or riders which
provide directly or which supplement long-term care insurance. The term also
includes a policy or rider that provides for payment of benefits based upon
cognitive impairment or the loss of functional capacity. The term shall also
include qualified long-term care insurance contracts. Long-term
care insurance may be issued by insurers, fraternal benefit societies,
nonprofit health, hospital, and medical service corporations, prepaid
health plans, health maintenance organizations or any similar organization
to the extent they are otherwise authorized to issue life or health
insurance. Long-term care insurance shall not include any insurance policy
which is offered primarily to provide basic Medicare supplement coverage,
basic hospital expense coverage, basic medical-surgical expense coverage,
hospital confinement indemnity coverage, major medical expense coverage,
disability income protection coverage, accident only coverage, specified
disease or specified accident coverage, or limited benefit health coverage.
Long-term care insurance may include benefits for care and treatment in
accordance with the tenets and practices of any established church or
religious denomination which teaches reliance on spiritual treatment
through prayer for healing.
(b) "Applicant" means:
(1) In the case of an individual long-term care | ||
| ||
(2) In the case of a group long-term care insurance | ||
| ||
(c) "Certificate" means, for the purposes of this Article, any
certificate issued under a group long-term care insurance policy, which
policy has been delivered or issued for delivery in this State.
(d) "Director" means the Director of Insurance of this State.
(e) "Group long-term care insurance" means a long-term care insurance
policy which is delivered or issued for delivery in this State and issued
to one of the following:
(1) One or more employers or labor organizations, or | ||
| ||
(2) Any professional, trade or occupational | ||
| ||
(A) is composed of individuals all of whom are or | ||
| ||
(B) has been maintained in good faith for | ||
| ||
(3) An association or a trust or the trustee or | ||
| ||
(A) the association or associations hold regular | ||
| ||
(B) except for credit unions, the association or | ||
| ||
(C) the members have voting privileges and | ||
| ||
Thirty days after such filing the association or | ||
| ||
(4) A group other than as described in paragraph (1), | ||
| ||
(A) the issuance of the group policy is not | ||
| ||
(B) the issuance of the group policy would result | ||
| ||
(C) the benefits are reasonable in relation to | ||
| ||
(f) "Policy" means, for the purposes of this Article, any policy, contract,
subscriber agreement, rider or endorsement delivered or issued for delivery
in this State by an insurer, fraternal benefit society, nonprofit health,
hospital, or medical service corporation, prepaid health plan, health
maintenance organization or any similar organization.
(g) "Qualified long-term care insurance contract" or "federally
tax-qualified long-term care insurance contract" means an individual or group
insurance contract that meets the requirements of Section 7702B(b) of the
Internal Revenue Code of 1986, as amended, as follows:
(1) The only insurance protection provided under the | ||
| ||
(2) The contract does not pay or reimburse expenses | ||
| ||
(3) The contract is guaranteed renewable within the | ||
| ||
(4) The contract does not provide for a cash | ||
| ||
(5) All refunds of premiums and all policyholder | ||
| ||
(6) The contract meets the consumer protection | ||
| ||
"Qualified long-term care insurance contract" or "federally tax-qualified
long-term care insurance contract" also means the portion of a life insurance
contract that provides long-term care insurance
coverage by rider or as part of the contract and that satisfies the
requirements of Sections 7702B(b) and 7702B(e) of the Internal Revenue Code of
1986,
as amended.
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-2) (from Ch. 73, par. 963A-2)
Sec. 351A-2.
Group policy issued in another state.
No group long-term
care insurance coverage may be offered to a resident of this State under a
group policy issued in another state to a group described in paragraph (4)
of subsection (e) of Section 351A-1, unless the Director determines that
this State or another state having statutory and regulatory long-term care
insurance requirements substantially similar to those adopted in this State
has made a determination that such requirements have been met.
(Source: P.A. 85-1172; 85-1174; 85-1440.)
|
(215 ILCS 5/351A-3) (from Ch. 73, par. 963A-3)
Sec. 351A-3.
Disclosures.
The Director may adopt rules that include
standards for full and fair disclosure setting forth the manner, content,
and required disclosures for the sale of long-term care insurance policies,
terms of renewability, initial and subsequent conditions of eligibility,
nonduplication of coverage provisions, coverage of dependents, preexisting
conditions, termination of insurance, continuation or conversion,
probationary periods, limitations, exceptions, reductions, elimination
periods, requirements for replacement, recurrent conditions, and
definitions of terms.
(Source: P.A. 85-1172; 85-1174; 85-1440.)
|
(215 ILCS 5/351A-4) (from Ch. 73, par. 963A-4)
Sec. 351A-4.
Limitation.
No long-term care insurance policy may:
(1) Be cancelled, nonrenewed or otherwise terminated | ||
| ||
(2) Contain a provision establishing a new waiting | ||
| ||
(3) Provide coverage for skilled nursing care only or | ||
| ||
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-4.5)
Sec. 351A-4.5.
Long-term care; coverages.
Nothing in this Code prohibits
an insurance company from offering a long-term care insurance
policy that provides for (1) reimbursement
of paid premiums in the event of cancellation or (2) reduced benefits in the
event the policyholder discontinues premium payments.
(Source: P.A. 88-290.)
|
(215 ILCS 5/351A-5) (from Ch. 73, par. 963A-5)
Sec. 351A-5.
Preexisting condition.
(a) No long-term care insurance
policy or certificate other than a policy or certificate thereunder issued
to a group as defined in paragraph (1) of subsection (e) of Section 351A-1
shall use a definition of "preexisting condition" which is more restrictive
than the following: Preexisting condition means the existence of symptoms
which would cause an ordinarily prudent person to seek diagnosis, care or
treatment, or a condition for which medical advice or treatment was
recommended by, or received from a provider of health care services, within
6 months preceding the effective date of coverage for an insured person.
(b) No long-term care insurance policy or certificate other than a
policy or certificate thereunder issued to a group as defined in paragraph
(1) subsection (e) of Section 351A-1 may exclude coverage for a loss or
confinement which is the result of a preexisting condition unless such loss
or confinement begins within 6 months following the effective date of
coverage of an insured person.
(c) The Director may extend the limitation periods set forth in
subsections (a) and (b) of this Section as to specific age group categories
in specific policy forms upon finding that the extension is in the best
interest of the public.
(d) The definition of "preexisting condition" does not prohibit an
insurer from using an application form designed to elicit the complete
health history of an applicant, and, on the basis of the answers on that
application, from underwriting in accordance with that insurer's
established underwriting standards. Unless otherwise provided in the
policy or certificate, a preexisting condition, regardless of whether it is
disclosed on the application, need not be covered until the waiting period
described in subsection (b) of this Section expires. No long-term care
insurance policy or certificate may exclude or use waivers or riders of any
kind to exclude, limit or reduce coverage or benefits for specifically
named or described preexisting diseases or physical conditions beyond the
waiting period described in subsection (b) of this Section.
(Source: P.A. 85-1172; 85-1174; 85-1440.)
|
(215 ILCS 5/351A-6) (from Ch. 73, par. 963A-6)
Sec. 351A-6.
Prior hospitalization; institutionalizations.
(a) On and after the effective date of this amendatory Act of 1989, no
long-term care insurance policy may be delivered or issued for delivery in
this State if such policy:
(1) conditions eligibility for any benefits on a | ||
| ||
(2) conditions eligibility for benefits provided in | ||
| ||
(b) Beginning one year after the effective date of this amendatory Act
of 1989, a long-term care insurance policy containing any limitations or
conditions for eligibility other than those prohibited above in subsection
(a) shall clearly label in a separate paragraph of the policy or
certificate entitled "Limitations or Conditions on Eligibility for
Benefits" such limitations or conditions, including any required number of
days of confinement.
(1) A long-term care insurance policy containing a | ||
| ||
(2) A long-term care insurance policy which | ||
| ||
(Source: P.A. 85-1440; 86-384.)
|
(215 ILCS 5/351A-7) (from Ch. 73, par. 963A-7)
Sec. 351A-7.
Right to return.
(a) An individual long-term care
insurance policyholder shall have the right to return the policy within 30
days of its delivery and to have the premium refunded directly to him or
her if, after examination of the policy, the policyholder is not satisfied
for any reason. Long-term care insurance 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 30 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) A person insured under a long-term care insurance policy or
certificate issued pursuant to a direct response solicitation 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 if, after
examination, the insured person is not satisfied for any reason. Long-term
care insurance policies or certificates issued pursuant to a direct
response solicitation shall have a notice prominently printed on the first
page of the policy or certificate attached thereto stating in substance
that the insured person shall have the right to return the policy or
certificate within 30 days of its delivery and to have the premium refunded
if, after examination of the policy or certificate, the insured person is
not satisfied for any reason. This subsection also applies to denials of
applications, and any refund must be made within 30 days of the return or
denial.
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-8) (from Ch. 73, par. 963A-8)
Sec. 351A-8.
Outline of coverage.
(a) An outline of coverage shall be delivered to a prospective applicant
for long-term care insurance at the time of initial solicitation through
means which prominently direct the attention of the recipient to the
document and its purpose.
(1) The Director shall prescribe a standard format | ||
| ||
(2) In the case of agent solicitations, an agent must | ||
| ||
(3) In the case of direct response solicitations, the | ||
| ||
(b) The outline of coverage shall include:
(1) A description of the principal benefits and | ||
| ||
(2) A statement of the principal exclusions, | ||
| ||
(3) A statement of the terms under which the policy | ||
| ||
(4) A statement that the outline of coverage is a | ||
| ||
(5) A description of the terms under which the policy | ||
| ||
(6) A brief description of the relationship of cost | ||
| ||
(7) A statement that discloses to the policyholder or | ||
| ||
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-9) (from Ch. 73, par. 963A-9)
Sec. 351A-9.
Disclosure in certificate.
A certificate issued pursuant
to a group long-term care insurance policy, which policy is delivered or
issued for delivery in this State, shall include each of the following:
(1) A description of the principal benefits and coverage provided in
the policy.
(2) A statement of the principal exclusions, reductions and limitations
contained in the policy.
(3) A statement that the group master policy determines governing
contractual provisions.
(Source: P.A. 85-1172; 85-1174; 85-1440.)
|
(215 ILCS 5/351A-9.1) (from Ch. 73, par. 963A-9.1)
Sec. 351A-9.1.
Policy summary and benefit reports.
(a) At the time of policy delivery, a policy summary shall be delivered
for an individual life insurance policy which provides long-term care
benefits within the policy or by rider. In the case of direct response
solicitations, the insurer shall deliver the policy summary upon the
applicant's request, but regardless of request shall make such delivery no
later than at the time of policy delivery. In addition to complying with
all applicable requirements, the summary shall also include:
(1) an explanation of how the long-term care benefit | ||
| ||
(2) an illustration of the amount of benefits, the | ||
| ||
(3) any exclusions, reductions and limitations on | ||
| ||
(4) if applicable to the policy type, the summary | ||
| ||
(A) disclosure of the effects of exercising other | ||
| ||
(B) disclosure of guarantees related to long-term | ||
| ||
(C) current and projected maximum lifetime | ||
| ||
(b) Any time a long-term care benefit, funded through a life insurance
vehicle by the acceleration of the death benefit, is in benefit payment
status, a monthly report shall be provided to the policyholder. Such
report shall include:
(1) any long-term care benefits paid during the month;
(2) an explanation of any changes in the policy, | ||
| ||
(3) the amount of long-term care benefits existing or | ||
| ||
(Source: P.A. 86-384.)
|
(215 ILCS 5/351A-9.2)
Sec. 351A-9.2.
Delivery of policy.
If an applicant for a long-term care
insurance contract or certificate is approved, the issuer shall deliver the
contract or certificate of insurance to the applicant no later than 30 days
after the date of approval.
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-9.3)
Sec. 351A-9.3.
Claim denial; explanation.
If a claim under a long-term
care insurance contract is denied, the issuer, within 60 days after
receipt of a written request by a policyholder or certificate holder or a
policyholder's or certificate holder's representative shall:
(1) provide a written explanation of the reasons for | ||
| ||
(2) make available all information directly related | ||
| ||
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-10) (from Ch. 73, par. 963A-10)
Sec. 351A-10.
Any policy or rider advertised, marketed or offered as
long-term care or nursing home insurance shall comply with the provisions
of this Article.
(Source: P.A. 85-1440; 86-384.)
|
(215 ILCS 5/351A-11) (from Ch. 73, par. 963A-11)
Sec. 351A-11.
Rules and regulations.
The Director may adopt rules and
regulations establishing minimum standards for marketing practices and
reporting practices, penalties for violating those standards, and loss
ratio standards for long-term care insurance policies, provided that a
specific reference to long-term care insurance policies is contained in the
regulation. Rules adopted pursuant to this Article shall be in accordance
with the provisions of the Illinois Administrative Procedure Act.
(Source: P.A. 87-601.)
|
(215 ILCS 5/Art. XIXB heading) ARTICLE XIXB
SMALL EMPLOYER GROUP HEALTH INSURANCE LAW
(Repealed by P.A. 98-692, eff. 7-1-14; 98-969, eff. 1-1-15)
|
(215 ILCS 5/Art. XX heading) ARTICLE XX.
ACCIDENT AND HEALTH INSURANCE
|
(215 ILCS 5/352) (from Ch. 73, par. 964) Sec. 352. Scope of Article. (a) Except as provided in subsections (b), (c), (d), (e), and (g), this Article shall apply to all companies transacting in this State the kinds of business enumerated in clause (b) of Class 1 and clause (a) of Class 2 of Section 4 and to all policies, contracts, and certificates of insurance issued in connection therewith that are not otherwise excluded under Article VII of this Code. Nothing in this Article shall apply to, or in any way affect policies or contracts described in clause (a) of Class 1 of Section 4; however, this Article shall apply to policies and contracts which contain benefits providing reimbursement for the expenses of long term health care which are certified or ordered by a physician including but not limited to professional nursing care, custodial nursing care, and non-nursing custodial care provided in a nursing home or at a residence of the insured. (b) (Blank). (c) A policy issued and delivered in this State that provides coverage under that policy for certificate holders who are neither residents of nor employed in this State does not need to provide to those nonresident certificate holders who are not employed in this State the coverages or services mandated by this Article. (d) Stop-loss insurance, as defined in clause (b) of Class 1 or clause (a) of Class 2 of Section 4, is exempt from all Sections of this Article, except this Section and Sections 353a, 354, 357.30, and 370. (e) A policy issued or delivered in this State to the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) and providing coverage, under clause (b) of Class 1 or clause (a) of Class 2 as described in Section 4, to persons who are enrolled under Article V of the Illinois Public Aid Code or under the Children's Health Insurance Program Act is exempt from all restrictions, limitations, standards, rules, or regulations respecting benefits imposed by or under authority of this Code, except those specified by subsection (1) of Section 143, Section 370c, and Section 370c.1. Nothing in this subsection, however, affects the total medical services available to persons eligible for medical assistance under the Illinois Public Aid Code. (f) An in-office membership care agreement provided under the In-Office Membership Care Act is not insurance for the purposes of this Code. (g) The provisions of Sections 356a through 359a, both inclusive, shall not apply to or affect: (1) any policy or contract of reinsurance; or (2) life insurance, endowment or annuity contracts, | ||
| ||
(Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/352a) (from Ch. 73, par. 964a)
Sec. 352a.
Mandated Coverages.
No legislation enacted after the
effective date of this Amendatory Act of 1990 which mandates or requires
the offering of health care coverages or services shall apply to any
insurer unless the legislation applies equally to employee welfare benefit
plans described in 29 U.S.C. 1001 et seq.
(Source: P.A. 86-1365.)
|
(215 ILCS 5/352b) Sec. 352b. Excepted benefits exempted. (a) Unless specified otherwise and when used in context of accident and health insurance policy benefits, coverage, terms, or conditions required to be provided under this Article, references to any policy of individual or group accident and health insurance, or both, as used in this Article, do not include any coverage or policy that provides an excepted benefit, as that term is defined in Section 2791(c) of the federal Public Health Service Act (42 U.S.C. 300gg-91). Nothing in this subsection applies to a policy of limited scope dental or vision benefits insurance issued under this Code. Nothing in this subsection shall be construed to subject excepted benefits outside the scope of Section 352 to any requirements of this Article. (b) Nothing in this Article shall require a policy of excepted benefits to provide benefits, coverage, terms, or conditions in such a manner as to disqualify it from being classified under federal law as the type of excepted benefit for which its policy forms are filed under Sections 143 and 355 of this Code. (Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/352c) (This Section may contain text from a Public Act with a delayed effective date) Sec. 352c. Short-term, limited-duration insurance prohibited. (a) In this Section: "Excepted benefits" has the meaning given to that term in 42 U.S.C. 300gg-91 and implementing regulations. "Excepted benefits" includes individual, group, or blanket coverage. "Short-term, limited-duration insurance" means any type of accident and health insurance offered or provided within this State pursuant to a group or individual policy or individual certificate by a company, regardless of the situs state of the delivery of the policy, that has an expiration date specified in the contract that is fewer than 365 days after the original effective date. Regardless of the duration of coverage, "short-term, limited-duration insurance" does not include excepted benefits or any student health insurance coverage. (b) On and after January 1, 2025, no company shall issue, deliver, amend, or renew short-term, limited-duration insurance to any natural or legal person that is a resident or domiciled in this State.
(Source: P.A. 103-649, eff. 1-1-25.) |
(215 ILCS 5/353) (from Ch. 73, par. 965)
Sec. 353.
Non-cancellable accident and health insurance reserves.
(1) The legal minimum standard for computing the active life reserve,
including the unearned premium reserve, of non-cancellable accident and
health policies issued on and after January 1 of the year following that
during which this Code becomes effective shall be based on Class III
Disability Experience with interest at not to exceed three and one-half per
centum per annum on the full preliminary term basis; and the minimum
standard for computing the active life reserve of such policies issued
prior to January 1 of the year following that during which this Code
becomes effective shall be such as to place an adequate value, as
determined by sound insurance practices, on the liabilities thereunder.
(2) For policies with a waiting period of less than three (3) months, or
providing benefits at ages beyond the limits of Class III Disability
Experience, such tables shall be extended to cover the provisions of such
policies on such basis as may be approved by the Director.
(3) The reserve for losses under non-cancellable accident and health
policies issued on and after January 1 of the year following that during
which this Code becomes effective shall be based on Class III Disability
Experience, except that for claims of less than twenty-seven months
duration the reserve may be taken as equivalent to the prospective claim
payments for three and one-half times the elapsed period of disability,
provided, that in no case shall the reserve be less than the equivalent of
seven weeks' claim payments; and the minimum standard for computing the
reserve for losses under such policies issued prior to January 1 of the
year following that during which the Code becomes effective shall be such
as to place an adequate value, as determined by sound insurance practices,
on such losses.
(4) The Director shall modify the application of the tables and
requirements prescribed in this section to policies or to claims arising
under policies in accordance with the waiting period contained in such
policies and in accordance with any limitation as to the time for which
indemnity is payable. The company shall give the notice required in section
234 on all non-cancellable accident and health policies.
This section shall apply only to accident and health policies issued
prior to the operative date under section 353a as defined therein.
(Source: Laws 1965, p. 740.)
|
(215 ILCS 5/353a) (from Ch. 73, par. 965a)
Sec. 353a. Accident
and health reserves.
The reserves for all accident and health policies issued after the
operative date of this section shall be computed and maintained on a basis
which shall place an actuarially sound value on the liabilities under such
policies. To provide a basis for the determination of such actuarially
sound value, the Director from time to time shall adopt rules requiring the
use of appropriate tables of morbidity, mortality, interest rates and
valuation methods for such reserves for policies issued before January 1, 2017. For policies issued on or after January 1, 2017, Section 223 shall govern the basis for determining such actuarially sound value. In no event shall such reserves be
less than the pro rata gross unearned premium reserve for such policies.
The company shall give the notice required in section 234 on all
non-cancellable accident and health policies.
After this section becomes effective, any company may file with the
Director written notice of its election to comply with the provisions of
this section after a specified date before January 1, 1967. After the
filing of such notice, then upon such specified date (which shall be the
operative date of this section for such company), this section shall become
operative with respect to the accident and health policies thereafter
issued by such company. If a company makes no such election, the operative
date of this section for such company shall be January 1, 1967.
After this section becomes effective, any company may file with the
Director written notice of its election to establish and maintain reserves
upon its accident and health policies issued prior to the operative date of
this section in accordance with the standards for reserves established by
this section, and thereafter the reserve standards prescribed pursuant to
this section shall be effective with respect to said accident and health
policies issued prior to the operative date of this section.
(Source: P.A. 102-775, eff. 5-13-22.)
|
(215 ILCS 5/354) (from Ch. 73, par. 966)
Sec. 354.
Accident
and health loss reserves.
The loss reserves of all accident and health policies other than
non-cancellable accident and health policies shall be computed and
maintained in accordance with the applicable provisions of Article XXII.
The unearned premium reserve of all accident and health policies other than
non-cancellable accident and health policies shall be computed and
maintained on the monthly pro rata basis.
This Section shall apply only to accident and health policies issued
prior to the operative date under section 353a as defined therein.
(Source: P.A. 83-584.)
|
(215 ILCS 5/355) (from Ch. 73, par. 967) (Text of Section from P.A. 103-106) Sec. 355. Accident and health policies; provisions. (a) As used in this Section: "Inadequate rate" means a rate: (1) that is insufficient to sustain projected losses | ||
| ||
(2) the continued use of which endangers the solvency | ||
| ||
"Large employer" has the meaning provided in the Illinois Health Insurance Portability and Accountability Act. "Plain language" has the meaning provided in the federal Plain Writing Act of 2010 and subsequent guidance documents, including the Federal Plain Language Guidelines. "Unreasonable rate increase" means a rate increase that the Director determines to be excessive, unjustified, or unfairly discriminatory in accordance with 45 CFR 154.205. (b) No policy of insurance against loss or damage from the sickness, or from the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining thereto have been filed with the Director; nor shall it be so issued or delivered until the Director shall have approved such policy pursuant to the provisions of Section 143. If the Director disapproves the policy form, he or she shall make a written decision stating the respects in which such form does not comply with the requirements of law and shall deliver a copy thereof to the company and it shall be unlawful thereafter for any such company to issue any policy in such form. On and after January 1, 2025, any form filing submitted for large employer group accident and health insurance shall be automatically deemed approved within 90 days of the submission date unless the Director extends by not more than an additional 30 days the period within which the form shall be approved or disapproved by giving written notice to the insurer of such extension before the expiration of the 90 days. Any form in receipt of such an extension shall be automatically deemed approved within 120 days of the submission date. The Director may toll the filing due to a conflict in legal interpretation of federal or State law as long as the tolling is applied uniformly to all applicable forms, written notification is provided to the insurer prior to the tolling, the duration of the tolling is provided within the notice to the insurer, and justification for the tolling is posted to the Department's website. The Director may disapprove the filing if the insurer fails to respond to an objection or request for additional information within the timeframe identified for response. As used in this subsection, "large employer" has the meaning given in Section 5 of the federal Health Insurance Portability and Accountability Act. (c) For plan year 2026 and thereafter, premium rates for all individual and small group accident and health insurance policies must be filed with the Department for approval. Unreasonable rate increases or inadequate rates shall be modified or disapproved. For any plan year during which the Illinois Health Benefits Exchange operates as a full State-based exchange, the Department shall provide insurers at least 30 days' notice of the deadline to submit rate filings. (d) For plan year 2025 and thereafter, the Department shall post all insurers' rate filings and summaries on the Department's website 5 business days after the rate filing deadline set by the Department in annual guidance. The rate filings and summaries posted to the Department's website shall exclude information that is proprietary or trade secret information protected under paragraph (g) of subsection (1) of Section 7 of the Freedom of Information Act or confidential or privileged under any applicable insurance law or rule. All summaries shall include a brief justification of any rate increase or decrease requested, including the number of individual members, the medical loss ratio, medical trend, administrative costs, and any other information required by rule. The plain writing summary shall include notification of the public comment period established in subsection (e). (e) The Department shall open a 30-day public comment period on the rate filings beginning on the date that all of the rate filings are posted on the Department's website. The Department shall post all of the comments received to the Department's website within 5 business days after the comment period ends. (f) After the close of the public comment period described in subsection (e), the Department, beginning for plan year 2026, shall issue a decision to approve, disapprove, or modify a rate filing within 60 days. Any rate filing or any rates within a filing on which the Director does not issue a decision within 60 days shall automatically be deemed approved. The Director's decision shall take into account the actuarial justifications and public comments. The Department shall notify the insurer of the decision, make the decision available to the public by posting it on the Department's website, and include an explanation of the findings, actuarial justifications, and rationale that are the basis for the decision. Any company whose rate has been modified or disapproved shall be allowed to request a hearing within 10 days after the action taken. The action of the Director in disapproving a rate shall be subject to judicial review under the Administrative Review Law. (g) If, following the issuance of a decision but before the effective date of the premium rates approved by the decision, an event occurs that materially affects the Director's decision to approve, deny, or modify the rates, the Director may consider supplemental facts or data reasonably related to the event. (h) The Department shall adopt rules implementing the procedures described in subsections (d) through (g) by March 31, 2024. (i) Subsection (a) and subsections (c) through (h) of this Section do not apply to grandfathered health plans as defined in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. 300gg-91; student health insurance coverage as defined in 45 CFR 147.145; the large group market as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act; or short-term, limited-duration health insurance coverage as defined in Section 5 of the Short-Term, Limited-Duration Health Insurance Coverage Act. For a filing of premium rates or classifications of risk for any of these types of coverage, the Director's initial review period shall not exceed 60 days to issue informal objections to the company that request additional clarification, explanation, substantiating documentation, or correction of concerns identified in the filing before the company implements the premium rates, classifications, or related rate-setting methodologies described in the filing, except that the Director may extend by not more than an additional 30 days the period of initial review by giving written notice to the company of such extension before the expiration of the initial 60-day period. Nothing in this subsection shall confer authority upon the Director to approve, modify, or disapprove rates where that authority is not provided by other law. Nothing in this subsection shall prohibit the Director from conducting any investigation, examination, hearing, or other formal administrative or enforcement proceeding with respect to a company's rate filing or implementation thereof under applicable law at any time, including after the period of initial review. (Source: P.A. 103-106, eff. 1-1-24.) (Text of Section from P.A. 103-650, Article 3, Section 3-5) Sec. 355. Accident and health policies; provisions. (a) As used in this Section: "Inadequate rate" means a rate: (1) that is insufficient to sustain projected losses | ||
| ||
(2) the continued use of which endangers the solvency | ||
| ||
"Large employer" has the meaning provided in the Illinois Health Insurance Portability and Accountability Act. "Plain language" has the meaning provided in the federal Plain Writing Act of 2010 and subsequent guidance documents, including the Federal Plain Language Guidelines. "Unreasonable rate increase" means a rate increase that the Director determines to be excessive, unjustified, or unfairly discriminatory in accordance with 45 CFR 154.205. (b) No policy of insurance against loss or damage from the sickness, or from the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining thereto have been filed with the Director; nor shall it be so issued or delivered until the Director shall have approved such policy pursuant to the provisions of Section 143. If the Director disapproves the policy form, he or she shall make a written decision stating the respects in which such form does not comply with the requirements of law and shall deliver a copy thereof to the company and it shall be unlawful thereafter for any such company to issue any policy in such form. On and after January 1, 2025, any form filing submitted for large employer group accident and health insurance shall be automatically deemed approved within 90 days of the submission date unless the Director extends by not more than an additional 30 days the period within which the form shall be approved or disapproved by giving written notice to the insurer of such extension before the expiration of the 90 days. Any form in receipt of such an extension shall be automatically deemed approved within 120 days of the submission date. The Director may toll the filing due to a conflict in legal interpretation of federal or State law as long as the tolling is applied uniformly to all applicable forms, written notification is provided to the insurer prior to the tolling, the duration of the tolling is provided within the notice to the insurer, and justification for the tolling is posted to the Department's website. The Director may disapprove the filing if the insurer fails to respond to an objection or request for additional information within the timeframe identified for response. As used in this subsection, "large employer" has the meaning given in Section 5 of the federal Health Insurance Portability and Accountability Act. (c) For plan year 2026 and thereafter, premium rates for all individual and small group accident and health insurance policies must be filed with the Department for approval. Unreasonable rate increases or inadequate rates shall be modified or disapproved. For any plan year during which the Illinois Health Benefits Exchange operates as a full State-based exchange, the Department shall provide insurers at least 30 days' notice of the deadline to submit rate filings. (c-5) Unless prohibited under federal law, for plan year 2026 and thereafter, each insurer proposing to offer a qualified health plan issued in the individual market through the Illinois Health Benefits Exchange must incorporate the following approach in its rate filing under this Section: (1) The rate filing must apply a cost-sharing | ||
| ||
(A) is uniform across all insurers; (B) is consistent with the total adjustment | ||
| ||
(C) assumes that the only on-Exchange silver | ||
| ||
(2) The rate filing must apply an induced demand | ||
| ||
In the annual notice to insurers described in subsection (c), the Department must include the specific numerical range calculated for the applicable plan year under paragraph (1) of this subsection (c-5) and the formula in paragraph (2) of this subsection (c-5). (d) For plan year 2025 and thereafter, the Department shall post all insurers' rate filings and summaries on the Department's website 5 business days after the rate filing deadline set by the Department in annual guidance. The rate filings and summaries posted to the Department's website shall exclude information that is proprietary or trade secret information protected under paragraph (g) of subsection (1) of Section 7 of the Freedom of Information Act or confidential or privileged under any applicable insurance law or rule. All summaries shall include a brief justification of any rate increase or decrease requested, including the number of individual members, the medical loss ratio, medical trend, administrative costs, and any other information required by rule. The plain writing summary shall include notification of the public comment period established in subsection (e). (e) The Department shall open a 30-day public comment period on the rate filings beginning on the date that all of the rate filings are posted on the Department's website. The Department shall post all of the comments received to the Department's website within 5 business days after the comment period ends. (f) After the close of the public comment period described in subsection (e), the Department, beginning for plan year 2026, shall issue a decision to approve, disapprove, or modify a rate filing within 60 days. Any rate filing or any rates within a filing on which the Director does not issue a decision within 60 days shall automatically be deemed approved. The Director's decision shall take into account the actuarial justifications and public comments. The Department shall notify the insurer of the decision, make the decision available to the public by posting it on the Department's website, and include an explanation of the findings, actuarial justifications, and rationale that are the basis for the decision. Any company whose rate has been modified or disapproved shall be allowed to request a hearing within 10 days after the action taken. The action of the Director in disapproving a rate shall be subject to judicial review under the Administrative Review Law. (g) If, following the issuance of a decision but before the effective date of the premium rates approved by the decision, an event occurs that materially affects the Director's decision to approve, deny, or modify the rates, the Director may consider supplemental facts or data reasonably related to the event. (h) The Department shall adopt rules implementing the procedures described in subsections (d) through (g) by March 31, 2024. (i) Subsection (a) and subsections (c) through (h) of this Section do not apply to grandfathered health plans as defined in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. 300gg-91; student health insurance coverage as defined in 45 CFR 147.145; the large group market as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act; or short-term, limited-duration health insurance coverage as defined in Section 5 of the Short-Term, Limited-Duration Health Insurance Coverage Act. For a filing of premium rates or classifications of risk for any of these types of coverage, the Director's initial review period shall not exceed 60 days to issue informal objections to the company that request additional clarification, explanation, substantiating documentation, or correction of concerns identified in the filing before the company implements the premium rates, classifications, or related rate-setting methodologies described in the filing, except that the Director may extend by not more than an additional 30 days the period of initial review by giving written notice to the company of such extension before the expiration of the initial 60-day period. Nothing in this subsection shall confer authority upon the Director to approve, modify, or disapprove rates where that authority is not provided by other law. Nothing in this subsection shall prohibit the Director from conducting any investigation, examination, hearing, or other formal administrative or enforcement proceeding with respect to a company's rate filing or implementation thereof under applicable law at any time, including after the period of initial review. (Source: P.A. 103-106, eff. 1-1-24; 103-650, Article 3, Section 3-5, eff. 1-1-25.) (Text of Section from P.A. 103-650, Article 4, Section 4-5) Sec. 355. Accident and health policies; provisions. (a) As used in this Section: "Inadequate rate" means a rate: (1) that is insufficient to sustain projected losses | ||
| ||
(2) the continued use of which endangers the solvency | ||
| ||
"Large employer" has the meaning provided in the Illinois Health Insurance Portability and Accountability Act. "Plain language" has the meaning provided in the federal Plain Writing Act of 2010 and subsequent guidance documents, including the Federal Plain Language Guidelines. "Unreasonable rate increase" means a rate increase that the Director determines to be excessive, unjustified, or unfairly discriminatory in accordance with 45 CFR 154.205. (b) No policy of insurance against loss or damage from the sickness, or from the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining thereto have been filed with the Director; nor shall it be so issued or delivered until the Director shall have approved such policy pursuant to the provisions of Section 143. If the Director disapproves the policy form, he or she shall make a written decision stating the respects in which such form does not comply with the requirements of law and shall deliver a copy thereof to the company and it shall be unlawful thereafter for any such company to issue any policy in such form. On and after January 1, 2025, any form filing submitted for large employer group accident and health insurance shall be automatically deemed approved within 90 days of the submission date unless the Director extends by not more than an additional 30 days the period within which the form shall be approved or disapproved by giving written notice to the insurer of such extension before the expiration of the 90 days. Any form in receipt of such an extension shall be automatically deemed approved within 120 days of the submission date. The Director may toll the filing due to a conflict in legal interpretation of federal or State law as long as the tolling is applied uniformly to all applicable forms, written notification is provided to the insurer prior to the tolling, the duration of the tolling is provided within the notice to the insurer, and justification for the tolling is posted to the Department's website. The Director may disapprove the filing if the insurer fails to respond to an objection or request for additional information within the timeframe identified for response. As used in this subsection, "large employer" has the meaning given in Section 5 of the federal Health Insurance Portability and Accountability Act. (c) For plan year 2026 and thereafter, premium rates for all individual and small group accident and health insurance policies must be filed with the Department for approval. Unreasonable rate increases or inadequate rates shall be modified or disapproved. For any plan year during which the Illinois Health Benefits Exchange operates as a full State-based exchange, the Department shall provide insurers at least 30 days' notice of the deadline to submit rate filings. (d) For plan year 2025 and thereafter, the Department shall post all insurers' rate filings and summaries on the Department's website 5 business days after the rate filing deadline set by the Department in annual guidance. The rate filings and summaries posted to the Department's website shall exclude information that is proprietary or trade secret information protected under paragraph (g) of subsection (1) of Section 7 of the Freedom of Information Act or confidential or privileged under any applicable insurance law or rule. All summaries shall include a brief justification of any rate increase or decrease requested, including the number of individual members, the medical loss ratio, medical trend, administrative costs, and any other information required by rule. The plain writing summary shall include notification of the public comment period established in subsection (e). (e) The Department shall open a 30-day public comment period on the rate filings beginning on the date that all of the rate filings are posted on the Department's website. The Department shall post all of the comments received to the Department's website within 5 business days after the comment period ends. (f) After the close of the public comment period described in subsection (e), the Department, beginning for plan year 2026, shall issue a decision to approve, disapprove, or modify a rate filing within 60 days. Any rate filing or any rates within a filing on which the Director does not issue a decision within 60 days shall automatically be deemed approved. The Director's decision shall take into account the actuarial justifications and public comments. The Department shall notify the insurer of the decision, make the decision available to the public by posting it on the Department's website, and include an explanation of the findings, actuarial justifications, and rationale that are the basis for the decision. Any company whose rate has been modified or disapproved shall be allowed to request a hearing within 10 days after the action taken. The action of the Director in disapproving a rate shall be subject to judicial review under the Administrative Review Law. (g) If, following the issuance of a decision but before the effective date of the premium rates approved by the decision, an event occurs that materially affects the Director's decision to approve, deny, or modify the rates, the Director may consider supplemental facts or data reasonably related to the event. (h) The Department shall adopt rules implementing the procedures described in subsections (d) through (g) by March 31, 2024. (i) Subsection (a), subsections (c) through (h), and subsection (j) of this Section do not apply to grandfathered health plans as defined in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. 300gg-91; or student health insurance coverage as defined in 45 CFR 147.145. For a filing of premium rates or classifications of risk for any of these types of coverage, the Director's initial review period shall not exceed 60 days to issue informal objections to the company that request additional clarification, explanation, substantiating documentation, or correction of concerns identified in the filing before the company implements the premium rates, classifications, or related rate-setting methodologies described in the filing, except that the Director may extend by not more than an additional 30 days the period of initial review by giving written notice to the company of such extension before the expiration of the initial 60-day period. Nothing in this subsection shall confer authority upon the Director to approve, modify, or disapprove rates where that authority is not provided by other law. Nothing in this subsection shall prohibit the Director from conducting any investigation, examination, hearing, or other formal administrative or enforcement proceeding with respect to a company's rate filing or implementation thereof under applicable law at any time, including after the period of initial review. (j) Subsection (a) and subsections (c) through (h) do not apply to group policies issued in the large group market as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act. For large group policies issued, delivered, amended, or renewed on or after January 1, 2026 that are not described in subsection (i), the premium rates and risk classifications, including any rate manuals and rules used to arrive at the rates, must be filed with the Department annually for approval at least 120 days before the rates are intended to take effect. (1) A rate filing shall be modified or disapproved if | ||
| ||
(2) Within 60 days of receipt of the rate filing, the | ||
| ||
(3) Any company whose rate or rate filing has been | ||
| ||
(4) Nothing in this subsection requires a company to | ||
| ||
In this subsection, "administrator" and "plan sponsor" have the meaning given to those terms in 29 U.S.C. 1002(16). (Source: P.A. 103-106, eff. 1-1-24; 103-650, Article 4, Section 4-5, eff. 1-1-25.) |
(215 ILCS 5/355.1) (from Ch. 73, par. 967.1)
Sec. 355.1.
No claim for benefits for loss of time from the insured person's
occupation, under a group or individual accident and health insurance
policy delivered in this State more than 120 days after the effective date
of this Section, shall be reduced by reason of any cost-of-living increase,
designated as such under the Federal Social Security Act, if such
cost-of-living increase occurs while the policy's benefits are payable for
that claim.
(Source: P.A. 78-603.)
|
(215 ILCS 5/355.2) (from Ch. 73, par. 967.2)
Sec. 355.2.
Dental coverage reimbursement rates.
(a) Every company that issues, delivers, amends, or renews any
individual or group policy of accident and health insurance on or after the
effective date of this amendatory Act of 1991 that provides
dental insurance and bases payment for those benefits upon a
usual and customary fee charged by licensed dentists
must disclose all of the following:
(1) The frequency of the determination of the usual | ||
| ||
(2) A general description of the methodology used to | ||
| ||
(3) The percentile that determines the maximum | ||
| ||
(b) The disclosure must be provided upon request to all group and
individual policy holders and group certificate holders. All proposals for
dental insurance must notify the prospective policy holder that information
regarding usual and customary fee determinations is available from the
insurer. All employee benefit descriptions or supplemental documents must
notify the employee that information regarding reimbursement rates is
available from the employer.
(Source: P.A. 87-587.)
|
(215 ILCS 5/355.3) Sec. 355.3. Noncovered dental services. (a) In this Section: "Covered services" means dental care services for which a reimbursement is available under an
enrollee's plan contract, or for which a reimbursement would be available but for the application of
contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or
lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation. "Dental insurance" means any policy of insurance that is issued by a company that provides coverage for dental services not covered by a medical plan. (b) No company that issues, delivers, amends, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 97th General Assembly that provides dental insurance shall issue a service provider contract that requires a dentist to provide services to the insurer's policyholders at a fee set by the insurer unless the services are covered services under the applicable policyholder agreement.
(Source: P.A. 97-805, eff. 1-1-13.) |
(215 ILCS 5/355.4) (Text of Section before amendment by P.A. 103-832) Sec. 355.4. Provider notification of network plan changes. (a) As used in this Section: "Contracting entity" means any person or company that enters into direct contracts with providers for the delivery of dental services in the ordinary course of business, including a third-party administrator and a dental carrier. "Dental carrier" means a dental insurance company, dental service corporation, dental plan organization authorized to provide dental benefits, or a health insurance plan that includes coverage for dental services. (b) No dental carrier may automatically enroll a provider in a leased network without allowing any provider that is part of the dental carrier's provider network to choose to not participate by opting out. (c) Any contract entered into or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly that allows the rights and obligations of the contract to be assigned or leased to another insurer shall provide for notice that informs each provider in writing via certified mail 60 days before any scheduled assignment or lease of the network to which the provider is a contracted provider. To be in compliance with this Section, the notification must include all contract terms, a policy manual, a fee schedule, and a statement that the provider has the right to choose not to participate in third-party access. (d) A dental carrier that leases or assigns its network shall not cancel a network participating dentist's contractual relationship or otherwise penalize a network participating dentist in any way based on whether or not the dentist accepts the terms of the assignment or lease. Before accepting the terms of an assignment or lease agreement as described in this Section, any provider who receives notification of an impending assignment or lease must be given the option to contract directly with the entities proposing to gain access to the provider's network. (e) The provisions of this Section do not apply: (1) if access to a provider network contract is | ||
| ||
(2) to a provider network contract for dental | ||
| ||
(Source: P.A. 103-24, eff. 1-1-24.) (Text of Section after amendment by P.A. 103-832) Sec. 355.4. Provider notification of network plan changes. (a) As used in this Section: "Contracting entity" means any person or company that enters into direct contracts with providers for the delivery of dental services in the ordinary course of business, including a third-party administrator and a dental carrier. "Dental carrier" means a dental insurance company, dental service corporation, dental plan organization authorized to provide dental benefits, or a health insurance plan that includes coverage for dental services. (b) No dental carrier may automatically enroll a provider in a leased network without allowing any provider that is part of the dental carrier's provider network to choose to not participate by opting out. (c) Any contract entered into or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly that allows the rights and obligations of the contract to be assigned or leased to another insurer shall provide for notice that informs each provider in writing via mail 60 days before any scheduled assignment or lease of the network to which the provider is a contracted provider. To be in compliance with this Section, the notification must provide the specific URL address where the following are located: all contract terms, a policy manual, a fee schedule, and a statement that the provider has the right to choose not to participate in third-party access. The notification must also provide instructions for how the provider may obtain a copy of those materials. (d) A dental carrier that leases or assigns its network shall not cancel a network participating dentist's contractual relationship or otherwise penalize a network participating dentist in any way based on whether or not the dentist accepts the terms of the assignment or lease. Before accepting the terms of an assignment or lease agreement as described in this Section, any provider who receives notification of an impending assignment or lease must be given the option to contract directly with the entities proposing to gain access to the provider's network. (e) The provisions of this Section do not apply: (1) if access to a provider network contract is | ||
| ||
(2) to a provider network contract for dental | ||
| ||
(Source: P.A. 103-24, eff. 1-1-24; 103-832, eff. 1-1-25.) |
(215 ILCS 5/355.5) Sec. 355.5. Dental coverage reimbursement; prohibitions. No insurer, dental service plan corporation, professional service corporation, insurance network leasing company, or any company that amends, delivers, issues, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 103rd General Assembly shall require a dental care provider to incur a fee to access and obtain payment or reimbursement for services provided. A dental plan carrier shall provide a dental care provider with 100% of the contracted amount of the payment or reimbursement. Fees incurred directly by a dental care provider from third parties related to transmitting an automated clearing house network claim, transaction management, data management, or portal services and other fees charged by third parties that are not in the control of the dental plan carrier shall not be prohibited by this Section.(Source: P.A. 103-24, eff. 1-1-24.) |
(215 ILCS 5/355.6) (This Section may contain text from a Public Act with a delayed effective date) Sec. 355.6. Health care provider reimbursement. (a) In this Section, "health care provider" has the meaning given to the term "provider" in Section 370g. (b) Any group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2026 shall offer all reasonably available methods of payment from the insurer or managed care plan, or its contracted vendor, to the contracted health care provider, which shall include, but not be limited to, payment by check and electronic funds transfer. An insurer or managed care plan shall not mandate payment by credit card. For purposes of this subsection, "credit card" means a single-use or virtual credit card provided in an electronic, digital, facsimile, physical, or paper format. (c) If one of the available payment methods has a fee associated with it, the insurer or managed care plan, or its contracted vendor, shall, prior to initiating the first payment to an in-network health care provider or upon changing the payment methods available to a health care provider: (1) notify the health care provider that there may be | ||
| ||
(2) provide the health care provider with clear | ||
| ||
(d) If a health care provider requests a change in the available payment method, the insurer or managed care plan, or its contracted vendor, shall implement the change to the payment method selected by the health care provider within 30 business days, subject to federal and State verification measures to prevent fraud and abuse. (e) An insurer or managed care plan shall not use a health care provider's preferred method of payment as a factor when deciding whether to provide credentials to a health care provider.
(Source: P.A. 103-618, eff. 1-1-25.) |
(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 | ||
| ||
(b) "Service corporations" means voluntary health and | ||
| ||
(c) "Accident and health insurance" means insurance | ||
| ||
(3) The Director shall issue such rules as he shall deem necessary
or desirable to establish specific standards, including standards of
full and fair disclosure that set forth the form and content and
required disclosure for sale, of individual policies of accident and
health insurance, which rules and regulations shall be in addition to
and in accordance with the applicable laws of this State, and which may
cover but shall not be limited to: (a) terms of renewability; (b)
initial and subsequent conditions of eligibility; (c) non-duplication of
coverage provisions; (d) coverage of dependents; (e) pre-existing
conditions; (f) termination of insurance; (g) probationary periods; (h)
limitation, exceptions, and reductions; (i) elimination periods; (j)
requirements regarding replacements; (k) recurrent conditions; and (l)
the definition of terms, including, but not limited to, the following:
hospital, accident, sickness, injury, physician, accidental means, total
disability, partial disability, nervous disorder, guaranteed renewable,
and non-cancellable.
The Director may issue rules that specify prohibited policy
provisions not otherwise specifically authorized by statute which in the
opinion of the Director are unjust, unfair or unfairly discriminatory to
the policyholder, any person insured under the policy, or beneficiary.
(4) The Director shall issue such rules as he shall deem necessary
or desirable to establish minimum standards for benefits under each
category of coverage in individual accident and health policies, other
than conversion policies issued pursuant to a contractual conversion
privilege under a group policy, including but not limited to the
following categories: (a) basic hospital expense coverage; (b) basic
medical-surgical expense coverage; (c) hospital confinement indemnity
coverage; (d) major medical expense coverage; (e) disability income
protection coverage; (f) accident only coverage; and (g) specified
disease or specified accident coverage.
Nothing in this subsection (4) shall preclude the issuance of any
policy which combines two or more of the categories of coverage
enumerated in subparagraphs (a) through (f) of this subsection.
No policy shall be delivered or issued for delivery in this State
which does not meet the prescribed minimum standards for the categories
of coverage listed in this subsection unless the Director finds that
such policy is necessary to meet specific needs of individuals or groups
and such individuals or groups will be adequately informed that such
policy does not meet the prescribed minimum standards, and such policy
meets the requirement that the benefits provided therein are reasonable
in relation to the premium charged. The standards and criteria to be
used by the Director in approving such policies shall be included in the
rules required under this Section with as much specificity as
practicable.
The Director shall prescribe by rule the method of identification of
policies based upon coverages provided.
(5) (a) In order to provide for full and fair disclosure in the
sale of individual accident and health insurance policies, no such
policy shall be delivered or issued for delivery in this State unless
the outline of coverage described in paragraph (b) of this subsection
either accompanies the policy, or is delivered to the applicant at the
time the application is made, and an acknowledgment signed by the
insured, of receipt of delivery of such outline, is provided to the
insurer. In the event the policy is issued on a basis other than that
applied for, the outline of coverage properly describing the policy must
accompany the policy when it is delivered and such outline shall clearly
state that the policy differs, and to what extent, from that for which
application was originally made. All policies, except single premium
nonrenewal policies, shall have a notice prominently printed on the
first page of the policy or attached thereto stating in substance, that
the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if after
examination of the policy the policyholder is not satisfied for any
reason.
(b) The Director shall issue such rules as he shall deem necessary
or desirable to prescribe the format and content of the outline of
coverage required by paragraph (a) of this subsection. "Format" means
style, arrangement, and overall appearance, including such items as the
size, color, and prominence of type and the arrangement of text and
captions. "Content" shall include without limitation thereto,
statements relating to the particular policy as to the applicable
category of coverage prescribed under subsection (4); principal benefits;
exceptions, reductions and limitations; and renewal provisions,
including any reservation by the insurer of a right to change premiums.
Such outline of coverage shall clearly state that it constitutes a
summary of the policy issued or applied for and that the policy should
be consulted to determine governing contractual provisions.
(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.)
|
(215 ILCS 5/355b) Sec. 355b. Claim-related information; alternative means of communication. (a) For the purposes of this Section, "claim-related information" means all claim or billing information relating specifically to an insured, subscriber, or person covered by an individual or group policy of accident and health insurance issued, delivered, amended, or renewed by a company doing business in this State. (b) A company that issues, delivers, amends, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 98th General Assembly shall accommodate a reasonable request by a person covered by a policy issued by the company to receive communications of claim-related information from the company by alternative means or at alternative locations if the person clearly states that disclosure of all or part of the information could endanger the person. (c) If a child is covered by a policy issued by a company, then the child's parent or guardian may make a request to the company pursuant to subsection (b) of this Section. (d) A company may require (1) a person making a request pursuant to subsection (b) of this Section to do so in writing, (2) the request to contain a statement that disclosure of all or part of the claim-related information to which the request pertains could endanger the person or child, and (3) the specification of an alternative address, telephone number, or other method of contact. (e) Except with the express consent of the person making a request pursuant to subsection (b) of this Section, a company may not disclose to the policyholder (1) the address, telephone number, or any other personally identifying information of the person who made the request or child for whose benefit a request was made, (2) the nature of the health care services provided, or (3) the name or address of the provider of the health care services. (f) A company that makes reasonable and good faith efforts to comply with this Section shall not be subject to civil or criminal liability on the grounds of noncompliance with this Section. (g) The Director shall adopt rules to guide companies in guarding against the disclosure of the information protected pursuant to this Section. (h) Nothing in this Section shall prevent, hinder, or otherwise affect the entry of an appropriate order made in the best interests of a child by a court of competent jurisdiction adjudicating disputed issues of child welfare or custody.
(Source: P.A. 98-189, eff. 1-1-14.) |
(215 ILCS 5/355c) Sec. 355c. Availability of information on qualified health plans. (a) Without limiting the generality of paragraph (b) of subsection (5) of Section 355a, no qualified health plans shall be offered for sale directly to consumers through the health insurance marketplace operating in this State in accordance with Sections 1311 and 1321 of the federal Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments thereto, or regulations or guidance issued thereunder (collectively, "the Federal Act"), unless the following information is made available to the consumer at the time he or she is comparing policies and their premiums: (1) With respect to prescription drug benefits, | ||
| ||
(2) The most recently published provider directory | ||
| ||
(b) Each company that offers qualified health plans for sale directly to consumers through the health insurance marketplace operating in this State shall make the information in subsection (a), for each qualified health plan that it offers, available and accessible to the general public on the company's website and through other means for individuals without access to the Internet. (c) The Department shall ensure that State-operated websites, in addition to the website for the health insurance marketplace established in this State in accordance with the Federal Act, prominently provide links to Internet-based materials and tools to help consumers be informed purchasers of health insurance. (d) Nothing in this Section shall be interpreted or implemented in a manner not consistent with the Federal Act. This Section shall apply to all qualified health plans offered for sale directly to consumers through the health insurance marketplace operating in this State for any coverage year beginning on or after January 1, 2015.
(Source: P.A. 102-775, eff. 5-13-22.) |
(215 ILCS 5/355d) (This Section may contain text from a Public Act with a delayed effective date) Sec. 355d. Denials of claims submitted after prior authorization. (a) In this Section: "Dental carrier" means an insurer, dental service corporation, insurance network leasing company, or any company that offers individual or group policies of accident and health insurance that provide coverage for dental services. "Prior authorization" means any written communication that is verifiable, whether through issuance or letter, facsimile, email, or similar means, indicating that a specific procedure is, or multiple procedures are, covered under the patient's dental plan and reimbursable at a specific amount, subject to applicable coinsurance and deductibles, and issued in response to a request submitted by a dentist using a format prescribed by the dental carrier. (b) Beginning on the effective date of this amendatory Act of the 103rd General Assembly, a dental carrier shall not deny any claim subsequently submitted for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied: (1) benefit limitations, such as annual maximums and | ||
| ||
(2) the documentation for the claim provided by the | ||
| ||
(3) if, after the issuance of the prior | ||
| ||
(4) if, after the issuance of the prior | ||
| ||
(5) the claim was denied by a dental carrier due to | ||
| ||
(A) another payor is responsible for the payment; (B) the dentist has already been paid for the | ||
| ||
(C) the claim was submitted fraudulently or the | ||
| ||
(D) the person receiving the procedure was not | ||
| ||
A dental carrier shall not recoup a claim solely due to a loss of coverage of a patient or ineligibility if, at the time of treatment, the dental carrier erroneously confirmed coverage and eligibility, but had sufficient information available to the dental carrier indicating that the patient was no longer covered or was ineligible for coverage. (c) The provisions of this Section may not be waived by contract. Any contractual agreement entered into or amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly that is in conflict with this Section or that purports to waive any requirement of this Section is null and void.(Source: P.A. 103-832, eff. 1-1-25.) |
(215 ILCS 5/356a) (from Ch. 73, par. 968a) Sec. 356a. Form of policy. (1) No individual policy of accident and health insurance shall be delivered or issued for delivery to any person in this State unless: (a) the entire money and other considerations | ||
| ||
(b) the time at which the insurance takes effect and | ||
| ||
(c) it purports to insure only one person, except | ||
| ||
(d) the style, arrangement and over-all appearance of | ||
| ||
(e) the exceptions and reductions of indemnity are | ||
| ||
(f) each such form, including riders and | ||
| ||
(g) it contains no provision purporting to make any | ||
| ||
(2) If any policy is issued by an insurer domiciled in this State for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the Director that any such policy is not subject to approval or disapproval by such official, the Director may by ruling require that such policy meet the standards set forth in subsection (1) of this Section and in Sections 357.1 through 357.30.(Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/356b) (from Ch. 73, par. 968b) Sec. 356b. (a) This Section applies to the hospital and medical expense provisions of an individual accident or health insurance policy. (b) If a policy provides that coverage of a dependent person terminates upon attainment of the limiting age for dependent persons specified in the policy, the attainment of such limiting age does not operate to terminate the hospital and medical coverage of a person who, because of a disabling condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment and is dependent on his or her parents or other care providers for lifetime care and supervision. (c) For purposes of subsection (b), "dependent on other care providers" is defined as requiring a Community Integrated Living Arrangement, group home, supervised apartment, or other residential services licensed or certified by the Department of Human Services (as successor to the Department of Mental Health and Developmental Disabilities), the Department of Public Health, or the Department of Healthcare and Family Services (formerly Department of Public Aid). (d) The insurer may inquire of the policyholder 2 months prior to attainment by a dependent of the limiting age set forth in the policy, or at any reasonable time thereafter, whether such dependent is in fact a person who has a disability and is dependent and, in the absence of proof submitted within 60 days of such inquiry that such dependent is a person who has a disability and is dependent may terminate coverage of such person at or after attainment of the limiting age. In the absence of such inquiry, coverage of any person who has a disability and is dependent shall continue through the term of such policy or any extension or renewal thereof. (e) This amendatory Act of 1969 is applicable to policies issued or renewed more than 60 days after the effective date of this amendatory Act of 1969.(Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/356c) (from Ch. 73, par. 968c)
Sec. 356c.
(1) No policy of accident and health insurance providing
coverage of hospital expenses or medical expenses or
both on an expense incurred basis which in addition to covering the
insured, also covers members of the insured's immediate family, shall
contain any disclaimer, waiver or other limitation of coverage relative to
the hospital or medical
coverage or insurability of newborn infants from and after
the moment of birth.
(2) Each such policy of accident and health insurance shall contain
a provision stating that the accident and health insurance benefits
applicable for children shall be granted immediately with respect to a
newly born child from the moment of birth. The coverage for newly born
children shall include coverage of illness, injury, congenital defects (including the treatment of cleft lip and cleft palate),
birth abnormalities and premature birth.
(3) If payment of a specific premium is required to provide coverage
for a child, the policy may require that notification of birth of a
newly born child must be furnished to the insurer within 31 days after
the date of birth in order to have the coverage continue beyond such 31
day period and may require payment of the appropriate premium.
(4) In the event that no other members of the insured's immediate
family are covered, immediate coverage for the first newborn infant shall
be provided if the insured applies for dependent's coverage
within 31 days of the newborn's birth.
Such coverage shall be contingent upon payment of the additional premium.
(5) The requirements of this Section shall apply, on or after the
sixtieth day following the effective date of this Section, (a) to all
such non-group policies delivered or issued for delivery, and (b) to all
such group policies delivered, issued for delivery, renewed or amended.
The insurers of such non-group policies in effect on the sixtieth day
following the effective date of this Section shall extend to owners of
said policies, on or before the first policy anniversary following such
date, the opportunity to apply for the addition to their policies of a
provision as set forth in paragraph (2) above, with, at the option of
the insurer, payment of a premium appropriate thereto.
(Source: P.A. 102-768, eff. 1-1-24.)
|
(215 ILCS 5/356d) (from Ch. 73, par. 968d) Sec. 356d. Conversion privileges for insured former spouses. (1) No individual policy of accident and health insurance providing coverage of hospital and/or medical expense on either an expense incurred basis or other than an expense incurred basis, which in addition to covering the insured also provides coverage to the spouse of the insured shall contain a provision for termination of coverage for a spouse covered under the policy solely as a result of a break in the marital relationship except by reason of an entry of a valid judgment of dissolution of marriage between the parties. (2) Every policy which contains a provision for termination of coverage of the spouse upon dissolution of marriage shall contain a provision to the effect that upon the entry of a valid judgment of dissolution of marriage between the insured parties the spouse whose marriage was dissolved shall be entitled to have issued to him or her, without evidence of insurability, upon application made to the company within 60 days following the entry of such judgment, and upon the payment of the appropriate premium, an individual policy of accident and health insurance. Such policy shall provide the coverage then being issued by the insurer which is most nearly similar to, but not greater than, such terminated coverages. Any and all probationary and/or waiting periods set forth in such policy shall be considered as being met to the extent coverage was in force under the prior policy. (3) The requirements of this Section shall apply to all policies delivered or issued for delivery on or after the 60th day following the effective date of this Section.(Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/356e) (from Ch. 73, par. 968e) Sec. 356e. Victims of certain offenses. (1) No individual policy of accident and health insurance, which provides benefits for hospital or medical expenses based upon the actual expenses incurred, delivered or issued for delivery to any person in this State shall contain any specific exception to coverage which would preclude the payment under that policy of actual expenses incurred in the examination and testing of a victim of an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such offense to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense arising out of the offense. Every policy of accident and health insurance which specifically provides benefits for routine physical examinations shall provide full coverage for expenses incurred in the examination and testing of a victim of an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such offense as set forth in this Section. This Section shall not apply to a policy which covers hospital and medical expenses for specified illnesses or injuries only. (2) For purposes of enabling the recovery of State funds, any insurance carrier subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its insureds entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay, hospital or medical expenses for which an insurance carrier is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section. (3) Whenever the Department of Public Health finds that it has paid all or part of any hospital or medical expenses which an insurance carrier is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such insurance carrier provided that the Department of Public Health has notified the insurance carrier of its claims before the carrier has paid such benefits to its insureds or in behalf of its insureds.(Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/356f) (from Ch. 73, par. 968f) Sec. 356f. No individual policy of accident or health insurance or any renewal thereof shall be denied or cancelled by the insurer, nor shall any such policy contain any exception or exclusion of benefits, solely because the mother of the insured has taken diethylstilbestrol, commonly referred to as DES.(Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/356g) (from Ch. 73, par. 968g) (Text of Section before amendment by P.A. 103-808) 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 | ||
| ||
(2) An annual mammogram for women 40 years of age or | ||
| ||
(3) A mammogram at the age and intervals considered | ||
| ||
(4) For an individual or group policy of accident and | ||
| ||
(5) A screening MRI when medically necessary, as | ||
| ||
(6) For an individual or group policy of accident and | ||
| ||
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 | ||
| ||
(2) surgery and reconstruction of the other breast to | ||
| ||
(3) prostheses and treatment for physical | ||
| ||
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.) (Text of Section after amendment by P.A. 103-808) 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 patients 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 patients 35 to 39 years | ||
| ||
(2) An annual mammogram for patients 40 years of age | ||
| ||
(3) A mammogram at the age and intervals considered | ||
| ||
(4) For an individual or group policy of accident and | ||
| ||
(4.3) For an individual or group policy of accident | ||
| ||
(4.5) For a group policy of accident and health | ||
| ||
(5) A screening MRI when medically necessary, as | ||
| ||
(6) For an individual or group policy of accident and | ||
| ||
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 | ||
| ||
(2) surgery and reconstruction of the other breast to | ||
| ||
(3) prostheses and treatment for physical | ||
| ||
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. 103-808, eff. 1-1-26.) |
(215 ILCS 5/356g.5) Sec. 356g.5. Clinical breast exam. (a) The General Assembly finds that clinical breast examinations are a critical tool in the early detection of breast cancer, while the disease is in its earlier and potentially more treatable stages. Insurer reimbursement of clinical breast examinations is essential to the effort to reduce breast cancer deaths in Illinois. (b) Every insurer shall provide, in each group or individual policy, contract, or certificate of accident or health insurance issued or renewed for persons who are residents of Illinois, coverage for complete and thorough clinical breast examinations as indicated by guidelines of practice, performed by a physician licensed to practice medicine in all its branches, a licensed advanced practice registered nurse, or a licensed physician assistant, to check for lumps and other changes for the purpose of early detection and prevention of breast cancer as follows: (1) at least every 3 years for women at least 20 | ||
| ||
(2) annually for women 40 years of age or older. (c) Upon approval of a nationally recognized separate and distinct clinical breast exam code that is compliant with all State and federal laws, rules, and regulations, public and private insurance plans shall take action to cover clinical breast exams on a separate and distinct basis.
(Source: P.A. 99-173, eff. 7-29-15; 100-513, eff. 1-1-18.) |
(215 ILCS 5/356g.5-1) Sec. 356g.5-1. Breast cancer pain medication and therapy. A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage for all medically necessary pain medication and pain therapy related to the treatment of breast cancer on the same terms and conditions that are generally applicable to coverage for other conditions. For purposes of this Section, "pain therapy" means pain therapy that is medically based and includes reasonably defined goals, including, but not limited to, stabilizing or reducing pain, with periodic evaluations of the efficacy of the pain therapy against these goals. The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified-disease policies, or to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under State or federal governmental plans. Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 95-1045, eff. 3-27-09.) |
(215 ILCS 5/356h) (from Ch. 73, par. 968h)
Sec. 356h.
No individual or group policy of accident and health
insurance which covers the insured's immediate family or children, as well
as covering the insured, shall exclude a child from coverage or limit
coverage for a child solely because the child is an adopted child, or
solely because the child does not reside with the insured. For purposes of
this Section, a child who is in the custody of the insured, pursuant to an
interim court order of adoption or, in the case of group insurance, placement
of adoption, whichever comes first, vesting temporary care of the child in
the
insured, is an adopted child, regardless of whether a final order granting
adoption is ultimately issued.
(Source: P.A. 91-549, eff. 8-14-99.)
|
(215 ILCS 5/356i) (from Ch. 73, par. 968i)
Sec. 356i.
Medical assistance; coverage of child.
(a) In this Section, "Medicaid" means medical assistance authorized under
Section 1902 of the Social Security Act.
(b) An individual or group
policy of accident and health insurance that is delivered or issued for
delivery to any person in this State or renewed or amended may not contain
any provision which limits or excludes payments of hospital or
medical
benefits coverage to or on behalf of the insured because the insured or
any covered dependent is eligible for or receiving Medicaid benefits in this or any other state.
(c) To the extent that payment for covered expenses has been made under
Article V, VI, or VII of the Illinois Public Aid Code for health care services
provided to an individual, if a third party has a legal liability to make
payments for those health care services, the State is considered to have
acquired the rights of the individual to payment.
(d) If a child is covered under an accident and health insurance policy
issued to the child's noncustodial parent, the issuer of the policy shall do
all of the following:
(1) Provide necessary information to the child's | ||
| ||
(2) Permit the child's custodial parent (or the | ||
| ||
(3) Make payments on claims submitted in accordance | ||
| ||
(e) An insurer may not deny enrollment of a child under the accident and
health insurance coverage of the child's parent on any of the following
grounds:
(1) The child was born out of wedlock.
(2) The child is not claimed as a dependent on the | ||
| ||
(3) The child does not reside with the parent or in | ||
| ||
(f) If a parent is required by a court or administrative order to provide
accident and health insurance coverage for a child and the parent is insured
under a plan that offers coverage
for eligible dependents, the insurer, upon receiving a copy of the order,
shall:
(1) Upon application, permit the parent to add to the | ||
| ||
(2) Add the child to the parent's coverage upon | ||
| ||
(g) An insurer may not impose, on a state agency that has been assigned the
rights of a covered individual who
receives Medicaid benefits, requirements that are different from requirements
applicable to an assignee of any other individual covered under the same
insurance policy.
(h) Nothing in subsections (e) and (f) prevents an
insurer from denying any such application if the child is not eligible for
coverage according to the insurer's medical underwriting standards.
(i) The insurer may not eliminate coverage of such a child unless the
insurer
is provided
satisfactory written evidence of either of the following:
(1) The court or administrative order is no longer in | ||
| ||
(2) The child is or will be covered under a | ||
| ||
(Source: P.A. 89-183, eff. 1-1-96.)
|
(215 ILCS 5/356j) (from Ch. 73, par. 968j)
Sec. 356j.
(Repealed).
(Source: Repealed by P.A. 89-183, eff. 1-1-96.)
|
(215 ILCS 5/356K) (from Ch. 73, par. 968K) Sec. 356K. Coverage for Organ Transplantation Procedures. No insurer providing individual accident and health insurance coverage under this Act for hospital or medical expenses shall deny reimbursement for an otherwise covered expense incurred for any organ transplantation procedure solely on the basis that such procedure is deemed experimental or investigational unless supported by the determination of the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services that such procedure is either experimental or investigational or that there is insufficient data or experience to determine whether an organ transplantation procedure is clinically acceptable. If an accident and health insurer has made written request, or had one made on its behalf by a national organization, for determination by the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services as to whether a specific organ transplantation procedure is clinically acceptable and said organization fails to respond to such a request within a period of 90 days, the failure to act may be deemed a determination that the procedure is deemed to be experimental or investigational.(Source: P.A. 103-718, eff. 7-19-24.) |
(215 ILCS 5/356L) (from Ch. 73, par. 968L) Sec. 356L. No individual policy of accident or health insurance shall include any provision which shall have the effect of denying coverage to or on behalf of an insured under such policy on the basis of a failure by the insured to file a notice of claim within the time period required by the policy, provided such failure is caused solely by the physical inability or mental incapacity of the insured to file such notice of claim because of a period of emergency hospitalization.(Source: P.A. 103-718, eff. 7-19-24.) |
(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 January 1, 2016 and through December 31, 2025 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. (a-5) No group policy of accident and health insurance that provides pregnancy-related benefits may be issued, amended, delivered, or renewed in this State on or after January 1, 2026 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, surgical sperm extraction procedures, and low tubal ovum transfer. The coverage required shall include procedures necessary to screen or diagnose a fertilized egg before implantation, including, but not limited to, preimplantation genetic testing for aneuploidy, preimplantation genetic testing for chromosome structural rearrangements, and preimplantation genetic testing for monogenic or single gene disorders. Coverage under this subsection for the diagnosis and treatment of infertility shall be required only if the procedures: (1) are considered medically appropriate by the | ||
| ||
(2) are performed at medical facilities or clinics | ||
| ||
(b) The coverage required under subsection (a) for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if: (1) the covered individual has been unable to attain | ||
| ||
(2) the covered individual has not undergone 4 | ||
| ||
(3) the procedures are performed at medical | ||
| ||
(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 | ||
| ||
(2) a person's inability to reproduce either as a | ||
| ||
(3) a licensed physician's findings based on a | ||
| ||
(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. (e) The procedures required to be covered under this Section are not required to be contained in any policy or plan issued to or by a religious institution or organization or to or by an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this Section to violate its religious and moral teachings and beliefs. (Source: P.A. 102-170, eff. 1-1-22; 103-751, eff. 8-2-24.) |
(215 ILCS 5/356n) (from Ch. 73, par. 968n)
Sec. 356n.
Fibrocystic condition; denial of coverage.
No
group or individual policy of accident or health insurance or
any renewal thereof shall be denied by the insurer, nor shall any policy
contain any exception or exclusion of benefits, solely because the insured
has been diagnosed as having a fibrocystic breast condition, unless the
condition is diagnosed by a breast biopsy that demonstrates an increased
disposition to the development of breast cancer or unless the insured's medical
history confirms a chronic, relapsing, symptomatic breast condition.
(Source: P.A. 87-519; 87-895; 87-1066.)
|
(215 ILCS 5/356p) (from Ch. 73, par. 968p)
Sec. 356p.
Breast implant removal.
No individual or group policy of
accident and health insurance shall deny coverage for the removal of breast
implants when the removal of the implants is medically necessary treatment
for a sickness or injury. This Section does not apply to surgery performed
for removal of breast implants that were implanted solely for cosmetic
reasons. For the purpose of this Section, cosmetic reasons does not include
cosmetic surgery performed as reconstruction resulting from sickness or
injury.
(Source: P.A. 87-938.)
|
(215 ILCS 5/356q)
Sec. 356q.
On or after the effective date of this Section, every insurer
which delivers or issues for delivery in this State a group accident and health
policy providing coverage for hospital, medical, or surgical treatment on an
expense-incurred basis shall offer, for an additional premium and subject to
the insurer's standard of insurability, optional coverage for the reasonable
and necessary medical treatment of temporomandibular joint disorder and
craniomandibular disorder. The group policyholder shall accept or reject the
coverage in writing on the application or an amendment thereto for the master
group policy. Benefits may be subject to the same pre-existing
conditions, limitations, deductibles, co-payments and co-insurance that
generally apply to any other sickness. The maximum lifetime benefits for
temporomandibular joint disorder and craniomandibular treatment shall be no
less than $2,500. Nothing herein shall prevent an insurer from including such
coverage for temporomandibular joint disorder and craniomandibular disorder as
part of a policy's basic coverage, in lieu of offering optional coverage.
(Source: P.A. 88-592, eff. 1-1-95.)
|
(215 ILCS 5/356r)
(Text of Section before amendment by P.A. 103-718)
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 | ||
| ||
Your woman's principal health care provider must be a | ||
| ||
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 | ||
| ||
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 | ||
| ||
(2) "Managed care entity" means any entity including | ||
| ||
(3) "Managed care plan" means a plan operated by a | ||
| ||
(A) organizational arrangements for ongoing | ||
| ||
(B) financial incentives for persons enrolled in | ||
| ||
(4) "Participating provider" means a physician who | ||
| ||
(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.)
(Text of Section after amendment by P.A. 103-718) Sec. 356r. Access to obstetrical and gynecological care. (a) An individual or group policy of accident and health insurance or a managed care plan amended, delivered, issued, or renewed in this State must not require authorization or referral by the plan, issuer, or any person, including a primary care provider, for any covered individual who seeks coverage for obstetrical or gynecological care provided by any licensed or certified participating health care professional who specializes in obstetrics or gynecology. (a-5) If a policy, contract, or certificate requires or allows a covered individual to designate a primary care provider and provides coverage for any obstetrical or gynecological care, the insurer shall provide the notice required under 45 CFR 147.138(a)(4) and 149.310(a)(4) in all circumstances required under that provision. (a-6) The requirements of this Section shall be construed in a manner consistent with the requirements for access to and notice of obstetrical and gynecological care in 45 CFR 147.138 and 45 CFR 149.310. (b) Nothing in this Section prevents a health insurance issuer from requiring a participating obstetrical or gynecological health care professional to agree, with respect to individuals covered under a policy of accident and health insurance, to otherwise adhere to the health insurance issuer's policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan, if any, approved by the issuer. (c) (Blank). (d) Nothing in this Section shall be construed to preclude a health insurance issuer from requiring that a participating obstetrical or gynecological health care professional notify the covered individual's primary care physician or the issuer of treatment decisions or update centralized medical records.(Source: P.A. 103-718, eff. 1-1-25.) |
(215 ILCS 5/356s)
(Text of Section before amendment by P.A. 103-718)
Sec. 356s.
Post-parturition care.
An individual or group
policy of accident and health insurance that provides maternity coverage and is
amended, delivered, issued, or renewed after the effective date of this
amendatory Act of 1996 shall provide coverage for the following:
(1) a minimum of 48 hours of inpatient care following | ||
| ||
(2) a minimum of 96 hours of inpatient care following | ||
| ||
A shorter length of hospital inpatient stay for services related to maternity
and newborn care may be provided if the attending physician licensed to
practice medicine in all of its branches determines, in accordance with the
protocols and guidelines developed by the American College of Obstetricians and
Gynecologists or the American Academy of Pediatrics, that the mother and the
newborn meet the appropriate guidelines for that length of stay based upon
evaluation of the mother and newborn and the coverage and availability of a
post-discharge physician office visit or in-home nurse visit to verify the
condition of the infant in the first 48 hours after discharge.
(Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)
(Text of Section after amendment by P.A. 103-718) Sec. 356s. Post-parturition care. An individual or group policy of accident and health insurance that provides maternity coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1996 shall provide coverage for the following: (1) a minimum of 48 hours of inpatient care following | ||
| ||
(2) a minimum of 96 hours of inpatient care following | ||
| ||
Coverage may be limited to a shorter length of inpatient care for services related to maternity and newborn care if the attending physician licensed to practice medicine in all of its branches determines, in accordance with the protocols and guidelines developed by the American College of Obstetricians and Gynecologists or the American Academy of Pediatrics, that the mother and the newborn meet the appropriate guidelines for that length of stay based upon evaluation of the mother and newborn and the coverage and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the infant in the first 48 hours after discharge.(Source: P.A. 103-718, eff. 1-1-25.)
|
(215 ILCS 5/356t)
Sec. 356t.
Post-mastectomy care.
An individual or group policy of accident
and health insurance or managed care plan that provides surgical coverage and
is amended, delivered, issued, or renewed after the effective date of this
amendatory Act of 1997 shall provide inpatient coverage following a mastectomy
for a length of time determined by the attending physician to be medically
necessary and in accordance with protocols and guidelines based on sound
scientific evidence and upon evaluation of the patient and the coverage for and
availability of a post-discharge physician office visit or in-home nurse visit
to verify the condition of the patient in the first 48 hours after discharge.
(Source: P.A. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98.)
|
(215 ILCS 5/356u)
(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 | ||
| ||
(2) An annual prostate cancer screening for male | ||
| ||
(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 | ||
| ||
(3) Surveillance tests for ovarian cancer for female | ||
| ||
(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 | ||
| ||
(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, | ||
| ||
"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 | ||
| ||
(2) An annual prostate cancer screening for insureds | ||
| ||
(A) asymptomatic individuals age 50 and over;
(B) African-American individuals age 40 and over; | ||
| ||
(C) individuals age 40 and over with a family | ||
| ||
(3) Surveillance tests for ovarian cancer for | ||
| ||
(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 | ||
| ||
(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, | ||
| ||
"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.)
|
(215 ILCS 5/356u.5) Sec. 356u.5. Coverage for genetic testing for breast and ovarian cancer susceptibility. A group or individual policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for the cost of the genetic testing of the BRCA1 and BRCA2 genes to detect an increased risk for breast and ovarian cancer if recommended by a health care provider in accordance with the United States Preventive Services Task Force's recommendations for testing.
(Source: P.A. 102-979, eff. 1-1-23.) |
(215 ILCS 5/356u.10) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356u.10. Genetic testing and evidence-based screenings for an inherited gene mutation. (a) In this Section, "genetic testing for an inherited mutation" means germline multi-gene testing for an inherited mutation associated with an increased risk of cancer in accordance with evidence-based, clinical practice guidelines. (b) A group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after January 1, 2026 shall provide coverage for clinical genetic testing for an inherited gene mutation for individuals with a personal or family history of cancer, as recommended by a health care professional in accordance with current evidence-based clinical practice guidelines, including, but not limited to, the current version of the National Comprehensive Cancer Network clinical practice guidelines. The coverage shall limit the total amount that a covered person is required to pay for a clinical genetic test under this subsection to an amount not to exceed $50, except for services for which cost sharing is prohibited under 42 U.S.C. 300gg-13. This subsection (b) shall not apply to coverage of genetic testing 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. (c) For individuals with a genetic test that is positive for an inherited mutation associated with an increased risk of cancer, coverage required under this Section shall include any evidence-based screenings, as recommended by a health care professional in accordance with current evidence-based clinical practice guidelines, to the extent that the management recommendation is not already covered by the policy, except that coverage for evidence-based screenings under this subsection (c) may be subject to a deductible, coinsurance, or other cost-sharing limitation so long as the limitation is not greater than that required for other related cancer risk management benefits covered under the policy. In this subsection, "evidence-based cancer screenings" means medically recommended evidence-based screening modalities in accordance with current clinical practice guidelines.(Source: P.A. 103-914, eff. 1-1-25.) |
(215 ILCS 5/356v)
Sec. 356v.
Use of information derived from genetic testing.
After the effective date of this amendatory Act of 1997, an insurer must comply
with the provisions of the Genetic Information Privacy Act in connection with
the amendment, delivery, issuance, or renewal of, or claims for or denial of
coverage under, an individual or group policy of accident and health insurance.
Additionally, genetic information shall not be treated as a condition
described in item (1) of subsection (A) of Section 20 of the Illinois Health
Insurance Portability and Accountability Act in the absence of a diagnosis of
the condition related to that genetic information.
(Source: P.A. 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 91-549, eff. 8-14-99.)
|
(215 ILCS 5/356w)
Sec. 356w. Diabetes self-management training and education.
(a) A group policy of accident and health insurance that is amended,
delivered,
issued, or renewed after the
effective date of this amendatory Act of 1998 shall provide coverage for
outpatient self-management
training and education, equipment, and supplies, as set forth in this Section,
for the treatment of type 1 diabetes, type 2 diabetes, and gestational diabetes
mellitus.
(b) As used in this Section:
"Diabetes self-management training"
means instruction in an outpatient setting
which enables a diabetic patient to understand the diabetic management process
and daily management of
diabetic therapy as a means of avoiding frequent hospitalization and
complications. Diabetes self-management training shall include
the content areas listed in the National Standards for Diabetes Self-Management
Education Programs as published by the American Diabetes Association, including
medical nutrition therapy and education programs, as defined by the contract of insurance, that allow the patient to maintain an A1c level within the range identified in nationally recognized standards of care.
"Medical nutrition therapy" shall have the meaning
ascribed to that term in the Dietitian Nutritionist
Practice Act.
"Physician" means a
physician licensed to practice medicine in all of
its branches providing care to the individual.
"Qualified provider" for an
individual that is enrolled in:
(1) a health maintenance organization that uses a | ||
| ||
(2) an insurance plan means (A) a physician licensed | ||
| ||
(c) Coverage under this Section for diabetes self-management training,
including medical nutrition
education, shall be limited to the following:
(1) Up to 3 medically necessary visits to a qualified | ||
| ||
(2) Up to 2 medically necessary visits to a qualified | ||
| ||
Payment by the insurer or health maintenance organization for the coverage
required for diabetes self-management training pursuant to the provisions of
this Section is only required to be made for services provided.
No coverage is required for additional visits beyond those specified in items
(1) and (2) of this subsection.
Coverage under this subsection (c) for diabetes self-management training
shall
be subject to the same
deductible, co-payment, and co-insurance provisions that apply to coverage
under
the policy for other
services provided by the same type of provider.
(d) Coverage shall be provided for the following
equipment when medically necessary
and prescribed by a physician licensed to practice medicine in all
of its branches.
Coverage for the following items shall be subject to deductible, co-payment
and co-insurance provisions
provided for under the policy or a durable medical equipment rider to the
policy:
(1) blood glucose monitors;
(2) blood glucose monitors for the legally blind;
(3) cartridges for the legally blind; and
(4) lancets and lancing devices.
This subsection does not apply to a group policy of accident and health
insurance that does not provide a durable medical equipment benefit.
(e) Coverage shall be provided for the following pharmaceuticals and
supplies when
medically necessary and prescribed by a physician licensed to
practice medicine in all of its
branches.
Coverage for the following items shall be subject to the same coverage,
deductible,
co-payment, and co-insurance
provisions under the policy or a drug rider to the policy, except as otherwise provided for under Section 356z.41:
(1) insulin;
(2) syringes and needles;
(3) test strips for glucose monitors;
(4) FDA approved oral agents used to control blood | ||
| ||
(5) glucagon emergency kits.
This subsection does not apply to a group policy of accident and health
insurance that does not provide a drug benefit.
(f) Coverage shall be provided for regular foot care exams by a
physician or by a
physician to whom a physician has referred the patient. Coverage
for regular foot care exams
shall be subject to the same deductible, co-payment, and co-insurance
provisions
that apply under the policy for
other services provided by the same type of provider.
(g) If authorized by a physician, diabetes self-management
training may be provided as a part of an office visit, group setting, or home
visit.
(h) This Section shall not apply to agreements, contracts, or policies that
provide coverage for a specified diagnosis or other limited benefit coverage.
(Source: P.A. 101-625, eff. 1-1-21.)
|
(215 ILCS 5/356x)
Sec. 356x.
Coverage for colorectal cancer examination and screening.
(a) An individual or group policy of accident and health insurance or a
managed care plan that is amended, delivered, issued,
or
renewed on or after the effective date of this amendatory Act of the 93rd
General Assembly that provides coverage to a resident of this State must
provide benefits or coverage for all colorectal cancer examinations and
laboratory
tests for colorectal cancer
as prescribed by a physician, in
accordance with the
published American Cancer Society guidelines on colorectal cancer
screening or
other existing colorectal cancer screening guidelines issued by nationally
recognized professional medical
societies or federal government agencies, including the
National Cancer Institute, the Centers for Disease
Control and Prevention, and the
American College of Gastroenterology.
(b) Coverage required under this Section may not impose any deductible,
coinsurance, waiting
period, or other cost-sharing limitation that is greater than that
required for other coverage under the policy.
(Source: P.A. 93-568, eff. 1-1-04.)
|
(215 ILCS 5/356y)
Sec. 356y.
(Repealed).
(Source: P.A. 91-406, eff. 1-1-00. Repealed internally, eff. 1-1-03.)
|
(215 ILCS 5/356z.1)
Sec. 356z.1. Prenatal HIV testing. An individual or group policy of
accident and health insurance that provides maternity coverage and is amended,
delivered, issued, or renewed after the effective date of this amendatory Act
of the 92nd General Assembly must provide coverage for prenatal HIV testing
ordered by an attending physician licensed to practice medicine in all its
branches, or by a physician assistant or advanced practice registered nurse, including but not limited to orders consistent with
the recommendations of the American College of Obstetricians and Gynecologists
or the American Academy of Pediatrics.
(Source: P.A. 99-173, eff. 7-29-15.)
|
(215 ILCS 5/356z.2)
Sec. 356z.2. Coverage for adjunctive services in dental care.
(a) An individual or group policy of accident and health insurance
amended, delivered, issued, or renewed after January 1, 2003 (the effective date of Public Act 92-764) shall cover
charges incurred, and anesthetics provided, in
conjunction with dental care that is provided to a covered individual in a
hospital or
an ambulatory surgical treatment center
if any of the
following
applies:
(1) the individual is a child age 6 or under;
(2) the individual has a medical condition that | ||
| ||
(3) the individual is a person with a disability.
(a-5) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed after January 1, 2016 (the effective date of Public Act 99-141) shall cover charges incurred, and anesthetics provided by a dentist with a permit provided under Section 8.1 of the Illinois Dental Practice Act, in conjunction with dental care that is provided to a covered individual in a dental office, oral surgeon's office, hospital, or ambulatory surgical treatment center if the individual is under age 26 and has been diagnosed with an autism spectrum disorder as defined in Section 10 of the Autism Spectrum Disorders Reporting Act or a developmental disability. A covered individual shall be required to make 2 visits to the dental care provider prior to accessing other coverage under this subsection. For purposes of this subsection, "developmental disability" means "developmental disability" as defined in Section 1-106 of the Mental Health and Developmental Disabilities Code. (b) For purposes of this Section, "ambulatory surgical treatment center"
has the meaning given to that term in Section 3 of the Ambulatory
Surgical Treatment Center Act.
For purposes of this Section, "person with a disability" means a person, regardless of age,
with a chronic
disability if the chronic disability meets all of the following conditions:
(1) It is attributable to a mental or physical | ||
| ||
(2) It is likely to continue.
(3) It results in substantial functional limitations | ||
| ||
(A) self-care;
(B) receptive and expressive language;
(C) learning;
(D) mobility;
(E) capacity for independent living; or
(F) economic self-sufficiency.
(c) The coverage required under this Section may be subject to any
limitations, exclusions, or cost-sharing provisions that apply generally under
the insurance policy.
(d) This Section does not apply to a policy that covers only dental care.
(e) Nothing in this Section requires that the dental services be
covered.
(f) The provisions of this Section do not apply to short-term travel,
accident-only, limited, or specified disease policies, nor to policies or
contracts designed for issuance to persons eligible for coverage under Title
XVIII of the Social Security Act, known as Medicare, or any other similar
coverage under State or federal governmental plans.
(Source: P.A. 101-525, eff. 1-1-20; 102-972, eff. 1-1-23.)
|
(215 ILCS 5/356z.3) (Text of Section before amendment by P.A. 103-718) Sec. 356z.3. Disclosure of limited benefit. An insurer that
issues,
delivers,
amends, or
renews an individual or group policy of accident and health insurance in this
State after the
effective date of this amendatory Act of the 92nd General Assembly and
arranges, contracts
with, or administers contracts with a provider whereby beneficiaries are
provided an incentive to
use the services of such provider must include the following disclosure on its
contracts and
evidences of coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect
to
utilize the services of a non-participating provider for a covered service in non-emergency
situations, benefit payments to such non-participating provider are not based upon the amount
billed. The basis of your benefit payment will be determined according to your policy's fee
schedule, usual and customary charge (which is determined by comparing charges for similar
services adjusted to the geographical area where the services are performed), or other method as
defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE
AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED
PORTION. Non-participating providers may bill members for any amount up to the
billed
charge after the plan has paid its portion of the bill, except as provided in Section 356z.3a of the Illinois Insurance Code for covered services received at a participating health care facility from a nonparticipating provider that are: (a) ancillary services, (b) items or services furnished as a result of unforeseen, urgent medical needs that arise at the time the item or service is furnished, or (c) items or services received when the facility or the non-participating provider fails to satisfy the notice and consent criteria specified under Section 356z.3a. Participating providers
have agreed to accept
discounted payments for services with no additional billing to the member other
than co-insurance and deductible amounts. You may obtain further information
about the
participating
status of professional providers and information on out-of-pocket expenses by
calling the toll
free telephone number on your identification card.".(Source: P.A. 102-901, eff. 1-1-23.) (Text of Section after amendment by P.A. 103-718) Sec. 356z.3. Disclosure of limited benefit. An insurer that issues, delivers, amends, or renews an individual or group policy of accident and health insurance in this State after the effective date of this amendatory Act of the 92nd General Assembly and arranges, contracts with, or administers contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider must include the following disclosure on its contracts and evidences of coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED. YOU CAN EXPECT TO PAY MORE THAN THE COST-SHARING AMOUNT DEFINED IN THE POLICY IN NON-EMERGENCY SITUATIONS. Except in limited situations governed by the federal No Surprises Act or Section 356z.3a of the Illinois Insurance Code (215 ILCS 5/356z.3a), non-participating providers furnishing non-emergency services may bill members for any amount up to the billed charge after the plan has paid its portion of the bill. If you elect to use a non-participating provider, plan benefit payments will be determined according to your policy's fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the policy. Participating providers have agreed to ONLY bill members the cost-sharing amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll-free telephone number on your identification card.".(Source: P.A. 102-901, eff. 1-1-23; 103-718, eff. 1-1-25.) |
(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 | ||
| ||
(2) items and services provided by assistant | ||
| ||
(3) diagnostic services, including radiology and | ||
| ||
(4) items and services provided by other specialty | ||
| ||
(5) items and services provided by a | ||
| ||
(6) items and services provided by a | ||
| ||
"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 | ||
| ||
(2) additional items and services for which | ||
| ||
"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 | ||
| ||
(4) an ambulatory surgical treatment center as | ||
| ||
(5) any recipient of a license under the Hospital | ||
| ||
"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 | ||
| ||
(4) with respect to emergency services described in | ||
| ||
"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 | ||
| ||
(4) with respect to emergency services described in | ||
| ||
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 | ||
| ||
(2) When a beneficiary, insured, or enrollee utilizes | ||
| ||
(A) any cost-sharing requirements shall be | ||
| ||
(B) cost sharing shall be calculated based on | ||
| ||
(C) in no event shall the beneficiary, insured, | ||
| ||
(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.) |
(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 | ||
| ||
(B) The federal Patient Protection and Affordable | ||
| ||
(C) The General Assembly intends to build on | ||
| ||
(D) Medical management techniques such as denials, | ||
| ||
(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 | ||
| ||
(iii) they are bioequivalent in that (A) they do not | ||
| ||
(iv) they are adequately labeled; and (v) they are manufactured in compliance with Current | ||
| ||
(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 | ||
| ||
(i) If the United States Food and Drug | ||
| ||
(ii) If an individual's attending provider | ||
| ||
(iii) If a drug, device, or product is not | ||
| ||
(iv) This coverage must provide for the | ||
| ||
(B) Voluntary sterilization procedures. (C) Contraceptive services, patient education, and | ||
| ||
(D) Follow-up services related to the drugs, | ||
| ||
(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.)
|
(215 ILCS 5/356z.4a) (Text of Section before amendment by P.A. 103-720) Sec. 356z.4a. Coverage for abortion. (a) Except as otherwise provided in this Section, no individual or group policy of accident and health insurance 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 101st General Assembly unless the policy provides a covered person with coverage for abortion care. Regardless of whether the policy otherwise provides prescription drug benefits, abortion care coverage must include medications that are obtained through a prescription and used to terminate a pregnancy, regardless of whether there is proof of a pregnancy. (b) Coverage for abortion care may not impose any deductible, coinsurance, waiting period, or other cost-sharing limitation that is greater than that required for other pregnancy-related benefits covered by the policy. (c) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section. (d) This Section does not, pursuant to 42 U.S.C. 18054(a)(6), apply to a multistate plan that does not provide coverage for abortion. (e) If the Department concludes that enforcement of this Section may adversely affect the allocation of federal funds to this State, the Department may grant an exemption to the requirements, but only to the minimum extent necessary to ensure the continued receipt of federal funds.
(Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.) (Text of Section after amendment by P.A. 103-720) Sec. 356z.4a. Coverage for abortion. (a) Except as otherwise provided in this Section, no individual or group policy of accident and health insurance 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 101st General Assembly unless the policy provides a covered person with coverage for abortion care. Regardless of whether the policy otherwise provides prescription drug benefits, abortion care coverage must include medications that are obtained through a prescription and used to terminate a pregnancy, regardless of whether there is proof of a pregnancy. (b) Coverage for abortion care may not impose any deductible, coinsurance, waiting period, or other cost-sharing limitation. This subsection does not apply to the extent that 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. (c) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section. (d) This Section does not, pursuant to 42 U.S.C. 18054(a)(6), apply to a multistate plan that does not provide coverage for abortion. (e) If the Department concludes that enforcement of this Section may adversely affect the allocation of federal funds to this State, the Department may grant an exemption to the requirements, but only to the minimum extent necessary to ensure the continued receipt of federal funds. (Source: P.A. 102-1117, eff. 1-13-23; 103-720, eff. 1-1-26.) |
(215 ILCS 5/356z.4b) Sec. 356z.4b. Billing for long-acting reversible contraceptives. (a) In this Section, "long-acting reversible contraceptive device" means any intrauterine device or contraceptive implant. (b) Any individual or group policy of accident and health insurance or qualified health plan that is offered through the health insurance marketplace that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall allow hospitals separate reimbursement for a long-acting reversible contraceptive device provided immediately postpartum in the inpatient hospital setting before hospital discharge. The payment shall be made in addition to a bundled or Diagnostic Related Group reimbursement for labor and delivery.
(Source: P.A. 102-665, eff. 10-8-21.) |
(215 ILCS 5/356z.5) (Text of Section before amendment by P.A. 103-951) Sec. 356z.5. Prescription inhalants. A group or individual
policy of
accident and health insurance or managed care plan amended, delivered, issued,
or renewed
after the effective date of this amendatory Act of the 93rd General Assembly
that provides
coverage for prescription drugs may not deny or limit coverage
for prescription inhalants to enable persons to breathe when suffering from
asthma or other life-threatening bronchial ailments based upon any restriction
on the number of days before an inhaler refill may be obtained if, contrary to
those restrictions, the inhalants have been ordered or prescribed by the
treating physician and are medically appropriate.(Source: P.A. 95-331, eff. 8-21-07.) (Text of Section after amendment by P.A. 103-951) Sec. 356z.5. Prescription inhalants. (a) In this Section, "prescription inhaler" means a prescribed medical device that delivers inhaled medications used to treat breathing for persons suffering from asthma or other life-threatening bronchial ailments. "Prescription inhaler" includes metered-dose inhalers, nebulizers, and dry powder inhalers. "Prescription inhaler" does not include inhalers available over the counter without a prescription to provide temporary relief from respiratory symptoms. (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed through December 31, 2025 that provides coverage for prescription drugs may not deny or limit coverage for prescription inhalers to enable persons to breathe when suffering from asthma or other life-threatening bronchial ailments based upon any restriction on the number of days before an inhaler refill may be obtained if, contrary to those restrictions, the inhalants have been ordered or prescribed by the treating physician and are medically appropriate. (c) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2026 that provides coverage for prescription drugs may not deny or limit, except as otherwise provided in this subsection, coverage for prescription inhalers to enable persons to breathe when suffering from asthma or other life-threatening bronchial ailments based upon any restriction on the number of days before an inhaler refill may be obtained if, contrary to those restrictions, the inhalants have been ordered or prescribed by the treating physician and are medically appropriate. A group or individual policy of accident and health insurance or managed care plan subject to this subsection shall limit the total amount that a covered person is required to pay for a covered prescription inhaler to an amount not to exceed $25 per 30-day supply. (d) Nothing in this Section prevents a group or individual policy of accident and health insurance or managed care plan from reducing a covered person's cost sharing to an amount less than the amount specified in subsection (c). (e) Coverage for prescription inhalers shall not be subject to any deductible; except that this provision does not apply 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). (f) The Department may adopt rules necessary to implement and administer this Section and to align with federal requirements. The Department may use any of its enforcement powers to obtain a group or individual policy of accident and health insurance's or managed care plan's compliance with this Section. (Source: P.A. 103-951, eff. 1-1-25.) |
(215 ILCS 5/356z.6)
Sec. 356z.6. Bone mass measurement; osteoporosis. A group or individual
policy of
accident and health insurance amended, delivered, issued,
or renewed after the effective date of this amendatory Act of the 93rd General
Assembly must
provide coverage for
medically necessary bone mass measurement and for the diagnosis and treatment
of osteoporosis on
the
same terms and conditions that are generally
applicable
to coverage for other
medical conditions.
(Source: P.A. 93-853, eff. 1-1-05.) |
(215 ILCS 5/356z.7) (was 215 ILCS 5/370r)
Sec. 356z.7. Prescription drugs; cancer treatment. No group policy of
accident or health insurance that provides coverage for prescribed
drugs approved by the federal Food and Drug Administration for the
treatment of certain types of cancer shall exclude coverage of any drug on
the basis that the drug has been prescribed for the treatment of a type of
cancer for which the drug has not been approved by the federal Food and
Drug Administration. The drug, however, must be approved by the federal
Food and Drug Administration and must be recognized for the treatment of the
specific type of cancer for which the drug has been prescribed in any
one of the following established reference compendia:
(a) the American Hospital Formulary Service Drug | ||
| ||
(b) National Comprehensive Cancer Network's Drugs & | ||
| ||
(c) Thomson Micromedex's Drug Dex; (d) Elsevier Gold Standard's Clinical Pharmacology; or (e) other authoritative compendia as identified from | ||
| ||
or if not in the compendia, recommended for that particular type of cancer
in formal clinical studies, the results of which have been published in at
least two peer reviewed professional medical journals published in the
United States or Great Britain.
Any coverage required by this Section shall also include those medically
necessary services associated with the administration of a drug.
Despite the provisions of this Section, coverage shall
not be required for any experimental or investigational drugs or any drug
that the federal Food and Drug Administration has determined to be
contraindicated for treatment of the specific type of cancer for which the
drug has been prescribed. This Section shall apply only to cancer drugs.
Nothing in this Section shall be construed, expressly or by implication, to
create, impair, alter, limit, notify, enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any other disease or
condition.
(Source: P.A. 95-331, eff. 8-21-07; 96-457, eff. 8-14-09.)
|
(215 ILCS 5/356z.8)
Sec. 356z.8. Multiple sclerosis preventative physical therapy. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 94th General Assembly must provide coverage for medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis. For the purposes of this Section, "preventative physical therapy" means physical therapy that is prescribed by a physician licensed to practice medicine in all of its branches for the purpose of treating parts of the body affected by multiple sclerosis, but only where the physical therapy includes reasonably defined goals, including, but not limited to, sustaining the level of function the person has achieved, with periodic evaluation of the efficacy of the physical therapy against those goals. The coverage required under this Section shall be subject to the same deductible, coinsurance, waiting period, cost sharing limitation, treatment limitation, calendar year maximum, or other limitations as provided for
other physical or rehabilitative therapy benefits covered by the policy.
(Source: P.A. 94-1076, eff. 12-29-06.) |
(215 ILCS 5/356z.9)
Sec. 356z.9. Human papillomavirus vaccine. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage for a human papillomavirus vaccine (HPV) that is approved for marketing by the federal Food and Drug Administration.
(Source: P.A. 95-422, eff. 8-24-07; 95-876, eff. 8-21-08.) |
(215 ILCS 5/356z.10) Sec. 356z.10. Amino acid-based elemental formulas. A group or individual major medical accident and health insurance policy or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
(Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.) |
(215 ILCS 5/356z.11) Sec. 356z.11. Dependent students; medical leave of absence. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must continue to provide coverage for a dependent college student who takes a medical leave of absence or reduces his or her course load to part-time status because of a catastrophic illness or injury. Continuation of coverage under this Section is subject to all of the policy's terms and
conditions applicable to those forms of insurance. Continuation of insurance under the policy shall terminate 12 months after notice of the illness or injury or until the coverage would have otherwise lapsed pursuant to the terms and conditions of the policy, whichever comes first, provided the need for part-time status or medical leave of absence is supported by a clinical certification of need from a physician licensed to practice medicine in all its branches. The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified disease policies or to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under State or federal governmental plans.
(Source: P.A. 95-958, eff. 6-1-09; 96-328, eff. 8-11-09.) |
(215 ILCS 5/356z.12) Sec. 356z.12. Dependent coverage. (a) A group or individual policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly shall not terminate coverage or deny the election of coverage for an unmarried dependent by reason of the dependent's age before the dependent's 26th birthday. (b) A policy or plan subject to this Section shall, upon amendment, delivery, issuance, or renewal, establish an initial enrollment period of not less than 90 days during which an insured may make a written election for coverage of an unmarried person as a dependent under this Section. After the initial enrollment period, enrollment by a dependent pursuant to this Section shall be consistent with the enrollment terms of the plan or policy. (c) A policy or plan subject to this Section shall allow for dependent coverage during the annual open enrollment date or the annual renewal date if the dependent, as of the date on which the insured elects dependent coverage under this subsection, has: (1) a period of continuous creditable coverage of 90 | ||
| ||
(2) not been without creditable coverage for more | ||
| ||
An insured may elect coverage for a dependent who does not meet the continuous creditable coverage requirements of this subsection (c) and that dependent shall not be denied coverage due to age. For purposes of this subsection (c), "creditable coverage" shall have the meaning provided under subsection (C)(1) of Section 20 of the Illinois Health Insurance Portability and Accountability Act. (d) Military personnel. A group or individual policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly shall not terminate coverage or deny the election of coverage for an unmarried dependent by reason of the dependent's age before the dependent's 30th birthday if the dependent (i) is an Illinois resident, (ii) served as a member of the active or reserve components of any of the branches of the Armed Forces of the United States, and (iii) has received a release or discharge other than a dishonorable discharge. To be eligible for coverage under this subsection (d), the eligible dependent shall submit to the insurer a form approved by the Illinois Department of Veterans' Affairs stating the date on which the dependent was released from service. (e) Calculation of the cost of coverage provided to an unmarried dependent under this Section shall be identical. (f) Nothing in this Section shall prohibit an employer from requiring an employee to pay all or part of the cost of coverage provided under this Section. (g) No exclusions or limitations may be applied to coverage elected pursuant to this Section that do not apply to all dependents covered under the policy. (h) A policy or plan subject to this Section shall not condition eligibility for dependent coverage provided pursuant to this Section on enrollment in any educational institution. (i) Notice regarding coverage for a dependent as provided pursuant to this Section shall be provided to an insured by the insurer: (1) upon application or enrollment; (2) in the certificate of coverage or equivalent | ||
| ||
(3) (blank).
(Source: P.A. 98-226, eff. 1-1-14.) |
(215 ILCS 5/356z.13) Sec. 356z.13. Shingles vaccine. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of the amendatory Act of this 95th General Assembly must provide coverage for a vaccine for shingles that is approved for marketing by the federal Food and Drug Administration if the vaccine is ordered by a physician licensed to practice medicine in all its branches and the enrollee is 60 years of age or older.
(Source: P.A. 95-978, eff. 1-1-09; 96-328, eff. 8-11-09.) |
(215 ILCS 5/356z.14) 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, | ||
| ||
(2) Psychological care, meaning direct or | ||
| ||
(3) Habilitative or rehabilitative care, meaning | ||
| ||
(4) Therapeutic care, including behavioral, speech, | ||
| ||
(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.) |
(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 | ||
| ||
(2) The treatment is administered by a licensed | ||
| ||
(3) The initial or continued treatment must be | ||
| ||
(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.) |
(215 ILCS 5/356z.16)
Sec. 356z.16. (Repealed).
(Source: P.A. 100-386, eff. 1-1-18. Repealed by P.A. 101-456, eff. 8-23-19.)
|
(215 ILCS 5/356z.17) Sec. 356z.17. Wellness coverage. (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after January 1, 2010 (the effective date of Public Act 96-639) that provides coverage for hospital or medical treatment on an expense incurred basis may offer a reasonably designed program for wellness coverage that allows for a reward, a contribution, a reduction in premiums or reduced medical, prescription drug, or equipment copayments, coinsurance, or deductibles, or a combination of these incentives, for participation in any health behavior wellness, maintenance, or improvement program approved or offered by the insurer or managed care plan. The insured or enrollee may be required to provide evidence of participation in a program. Individuals unable to participate in these incentives due to an adverse health factor shall not be penalized based upon an adverse health status. (b) For purposes of this Section, "wellness coverage" means health care coverage with the primary purpose to engage and motivate the insured or enrollee through: incentives; provision of health education, counseling, and self-management skills; identification of modifiable health risks; and other activities to influence health behavior changes. For the purposes of this Section, "reasonably designed program" means a program of wellness coverage that has a reasonable chance of improving health or preventing disease; is not overly burdensome; does not discriminate based upon factors of health; and is not otherwise contrary to law. (c) Incentives as outlined in this Section are specific and unique to the offering of wellness coverage and have no application to any other required or optional health care benefit. (d) Such wellness coverage must satisfy the requirements for an exception from the general prohibition against discrimination based on a health factor under the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191; 110 Stat. 1936), including any federal regulations that are adopted pursuant to that Act. (e) A plan offering wellness coverage must do the following: (i) give participants the opportunity to qualify for | ||
| ||
(ii) allow a reasonable alternative to any individual | ||
| ||
(iii) not provide a total incentive that exceeds 30% | ||
| ||
(f) A reward, contribution, or reduction established under this Section and included in the policy or certificate does not violate Section 151 of this Code.
(Source: P.A. 102-462, eff. 8-20-21.) |
(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 travel, hospital confinement indemnity or other fixed 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; 103-649, eff. 1-1-25.) |
(215 ILCS 5/356z.19) Sec. 356z.19. Cardiovascular disease. Because cardiovascular disease is a leading cause of death and disability, an insurer providing group or individual policies of accident and health insurance or a managed care plan shall develop and implement a process to communicate with their adult enrollees on an annual basis regarding the importance and value of early detection and proactive management of cardiovascular disease. Nothing in this Section affects any change in the terms, conditions, or benefits of the policies and plans, nor the criteria, standards, and procedures related to the application for, enrollment in, or renewal of coverage or conditions of participation of enrollees in the health plans or policies subject to this Code.
(Source: P.A. 97-282, eff. 8-9-11; 97-813, eff. 7-13-12.) |
(215 ILCS 5/356z.20) Sec. 356z.20. Cancer drug parity. (a) As used in this Section: "Financial requirement" means deductibles, copayments,
coinsurance, out-of-pocket expenses, aggregate lifetime
limits, and annual limits. "Treatment limitation" means limits on the frequency of
treatment, days of coverage, or other similar limits on the
scope or duration of treatment. (b) On and after the effective date of this amendatory Act
of the 97th General Assembly, every insurer that amends,
delivers, issues, or renews an individual or group policy of
accident and health insurance amended, delivered, issued, or
renewed on or after the effective date of this amendatory Act
of the 97th General Assembly that provides coverage for
prescribed orally-administered cancer medications and
intravenously administered or injected cancer medications
shall ensure that: (1) the financial requirements applicable to such | ||
| ||
(2) the treatment limitations applicable to such | ||
| ||
(c) An insurer cannot achieve compliance with this Section
by increasing financial requirements or imposing more
restrictive treatment limitations on prescribed orally-administered cancer medications or intravenously
administered or injected cancer medications covered under the
policy on the effective date of this amendatory Act of the 97th
General Assembly.
(Source: P.A. 97-198, eff. 1-1-12; 97-813, eff. 7-13-12.) |
(215 ILCS 5/356z.21) Sec. 356z.21. Tobacco use cessation programs; coverage offer. (a) Tobacco use is the number one cause of preventable disease and death in Illinois, costing $4.1 billion annually in direct health care costs and an additional $4.35 billion in lost productivity. In Illinois, the smoking rates are highest among African Americans (25.8%). Smoking rates among lesbian, gay, and bisexual adults range from 25% to 44%. The U.S. Public Health Service Clinical Practice Guideline 2008 Update found that tobacco dependence treatments are both clinically effective and highly cost effective. A study in the Journal of Preventive Medicine concluded that comprehensive smoking cessation treatment is one of the 3 most important and cost effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low
levels of performance. (b) In this Section, "tobacco use cessation program" means a program recommended by a physician that follows evidence-based treatment, such as is outlined in the United States Public Health Service guidelines for tobacco use cessation. "Tobacco use cessation program" includes education and medical treatment components designed to assist a person in ceasing the use of tobacco products. "Tobacco use cessation program" includes education and counseling by physicians or associated medical personnel and all FDA approved medications for the treatment of tobacco dependence irrespective of whether they are available only over the counter, only by prescription, or both over the counter and by prescription. (c) On or after the effective date of this amendatory Act of the 97th General Assembly, every
insurer that amends, delivers, issues, or renews group accident and health policies providing coverage for hospital or medical treatment or services on an expense-incurred basis shall offer, for an additional premium and subject to the insurer's standard of insurability, optional coverage or optional reimbursement of up to $500 annually for a tobacco use cessation program for a person enrolled in the plan who is 18 years of age or older. (d) The coverage required by this Section shall be subject
to other general exclusions and limitations of the policy,
including coordination of benefits, participating provider
requirements, restrictions on services provided by family or household members, utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, and other managed care provisions. (e) For the coverage provided under this Section, an insurer may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives, monetary or otherwise, to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with the coverage under this Section.
(Source: P.A. 97-592, eff. 1-1-12; 97-813, eff. 7-13-12.) |
(215 ILCS 5/356z.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 | ||
| ||
(A) require that in-person contact occur between | ||
| ||
(B) require patients, health care professionals, | ||
| ||
(C) require the use of telehealth services, | ||
| ||
(D) require the use of telehealth services when | ||
| ||
(E) require a health care professional to be | ||
| ||
(F) create geographic or facility restrictions | ||
| ||
(G) require health care professionals or | ||
| ||
(H) require patients to use telehealth | ||
| ||
(I) impose upon telehealth services, e-visits, | ||
| ||
(2) Deductibles, copayments, coinsurance, or any | ||
| ||
(3) An individual or group policy of accident or | ||
| ||
(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.) |
(215 ILCS 5/356z.23) Sec. 356z.23. Coverage for opioid antagonists. (a) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State after the effective date of this amendatory Act of the 99th General Assembly that provides coverage for prescription drugs must provide coverage for at least one opioid antagonist, including the medication product, administration devices, and any pharmacy administration fees related to the dispensing of the opioid antagonist. This coverage must include refills for expired or utilized opioid antagonists. (a-5) Notwithstanding subsection (a), no individual or group policy of accident and health insurance amended, delivered, issued, or renewed after January 1, 2024 that provides coverage for naloxone hydrochloride shall impose a copayment on the coverage provided, except that this subsection does not apply to coverage of naloxone hydrochloride to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account under Section 223 of the Internal Revenue Code. (b) As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration.
(Source: P.A. 102-1038, eff. 1-1-23.) |
(215 ILCS 5/356z.24) Sec. 356z.24. Immune gamma globulin therapy. (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 99th General Assembly may not allow for the delay, discontinuation, or interruption of immune gamma globulin therapy for persons who are diagnosed with a primary immunodeficiency when prescribed as medically necessary by a physician licensed to practice medicine in all of its branches and if provided as a covered benefit under the plan. Nothing in this Section shall prevent an insurer from applying appropriate utilization review standards to the ongoing coverage of immune gamma globulin therapy for persons diagnosed with a primary immunodeficiency by a physician licensed to practice medicine in all of its branches. (b) Upon diagnosis of primary immunodeficiency by the prescribing physician, determination of an initial authorization for immune gamma globulin therapy shall be no less than 3 months. Reauthorization for immune gamma globulin therapy for patients with a primary immunodeficiency diagnosis may occur every 6 months thereafter. For patients with a diagnosis of primary immunodeficiency who have been receiving immune gamma globulin therapy for at least 2 years with sustained beneficial response based on the treatment notes or clinical narrative detailing progress to date, reauthorization shall be no less than 12 months unless a more frequent duration has been indicated by the prescribing physician. (c) 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 subsections (a) and (b), then subsections (a) and (b) are inoperative with respect to all coverage outlined in subsections (a) and (b) 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 subsections (a) and (b).
(Source: P.A. 99-788, eff. 8-12-16.) |
(215 ILCS 5/356z.25) Sec. 356z.25. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after July 18, 2017 (the effective date of Public Act 100-24) shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome, including, but not limited to, the use of intravenous immunoglobulin therapy. No group or individual policy of accident and health insurance or managed care plan shall deny or delay coverage for medically necessary treatment under this Section solely because the insured, enrollee, or beneficiary previously received any treatment, including the same or similar treatment, for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or pediatric acute onset neuropsychiatric syndrome, or because the insured, enrollee, or beneficiary has been diagnosed with or receives treatment for an otherwise diagnosed condition. For the purposes of this Section, coverage of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome shall adhere to the treatment recommendations developed by a medical professional consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of such disorders or syndrome that are accessible for medical professionals and are based on evidence of positive patient outcomes. Coverage for any form of medically necessary treatment shall not be limited over a lifetime of an insured, enrollee, or beneficiary, unless the patient is no longer benefiting from the treatment, or by policy period. Nothing in this Section prevents insurers from requesting treatment notes and anticipated duration of treatment and outcomes. For billing and diagnosis purposes, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome shall be coded as autoimmune encephalitis until the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. Thereafter, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome may be coded as autoimmune encephalitis, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or pediatric acute onset neuropsychiatric syndrome. 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 pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome outlined in this Section, then the requirement that an insurer cover pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome 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 pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.
(Source: P.A. 103-59, eff. 6-9-23.) |
(215 ILCS 5/356z.26) Sec. 356z.26. Synchronization. (a) As used in this Section, "synchronization" means the coordination of medication refills for a patient taking 2 or more medications for one or more chronic conditions such that the patient's medications are refilled on the same schedule for a given time period. (b) Every policy of health and accident insurance amended, delivered, issued, or renewed after August 18, 2017 (the effective date of Public Act 100-138) that provides coverage for prescription drugs shall provide for synchronization of prescription drug refills on at least one occasion per insured per year, provided all of the following conditions are met: (1) the prescription drugs are covered by the | ||
| ||
(2) the prescription drugs are maintenance | ||
| ||
(3) the medications are not Schedule II, III, or IV | ||
| ||
(4) the insured meets all utilization management | ||
| ||
(5) the prescription drugs are of a formulation that | ||
| ||
(6) the prescription drugs do not have special | ||
| ||
(c) When necessary to permit synchronization, the policy shall apply a prorated daily cost-sharing rate to any medication dispensed by a network pharmacy pursuant to this Section. No dispensing fees shall be prorated, and all dispensing fees shall be based on the number of prescriptions filled or refilled.
(Source: P.A. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18.) |
(215 ILCS 5/356z.27)
Sec. 356z.27. (Repealed).
(Source: P.A. 100-863, eff. 8-14-18. Repealed by P.A. 102-775, eff. 5-13-22.)
|
(215 ILCS 5/356z.28) Sec. 356z.28. Dry needling by a physical therapist. A group or individual policy of accident and health insurance or a qualified health plan offered through the health insurance market place is not required to provide coverage for dry needling performed by a physical therapist as described in Section 1.5 of the Illinois Physical Therapy Act.
(Source: P.A. 100-418, eff. 8-25-17; 100-863, eff. 8-14-18.) |
(215 ILCS 5/356z.29) Sec. 356z.29. Stage 4 advanced, metastatic cancer. (a) As used in this Section, "stage 4 advanced, metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body. (b) No individual or group policy of accident and health insurance amended, issued, delivered, or renewed in this State after January 1, 2019 (the effective date of Public Act 100-1057) that, as a provision of hospital, medical, or surgical services, directly or indirectly covers the treatment of stage 4 advanced, metastatic cancer shall limit or exclude coverage for a drug approved by the United States Food and Drug Administration by mandating that the insured shall first be required to fail to successfully respond to a different drug or prove a history of failure of the drug as long as the use of the drug is consistent with best practices for the treatment of stage 4 advanced, metastatic cancer and is supported by peer-reviewed medical literature. (c) If, at any time before or after January 1, 2019 (the effective date of Public Act 100-1057), 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 the prohibition of coverage restrictions or exclusions contained in subsection (b) of this Section for the treatment of stage 4 advanced, metastatic cancer, 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 the prohibition of coverage restrictions or exclusions contained in subsection (b) of this Section for the treatment of stage 4 advanced, metastatic cancer.
(Source: P.A. 100-1057, eff. 1-1-19; 101-81, eff. 7-12-19.) |
(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 | ||
| ||
(2) related services, such as audiological exams and | ||
| ||
(3) hearing instrument repairs may be covered when | ||
| ||
(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 | ||
| ||
(2) related services, such as audiological exams and | ||
| ||
(3) hearing instrument repairs may be covered when | ||
| ||
(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.) |
(215 ILCS 5/356z.30a) Sec. 356z.30a. (Repealed).(Source: P.A. 101-393, eff. 1-1-20. Repealed by P.A. 103-718, eff. 7-19-24.) |
(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 | ||
| ||
(2) The recovery housing is administered by a | ||
| ||
(3) The recovery housing is administered by a | ||
| ||
(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 | ||
| ||
(2) Transitional housing services, including food or | ||
| ||
(3) Individualized case management and referral | ||
| ||
(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 | ||
| ||
(3) improve outcomes; (4) track persons with substance use disorders; and (5) improve the quality of life of persons with | ||
| ||
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.) |
(215 ILCS 5/356z.32) Sec. 356z.32. Coverage for fertility preservation services. (a) As used in this Section: "Iatrogenic infertility" means an impairment of | ||
| ||
"May directly or indirectly cause" means the likely | ||
| ||
"Standard fertility preservation services" means | ||
| ||
(b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State after January 1, 2019 (the effective date of Public Act 100-1102) must provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee. (c) In determining coverage pursuant to this Section, an insurer shall not discriminate based on an individual's expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions, nor based on personal characteristics, including age, sex, sexual orientation, or marital status. (d) If, at any time before or after January 1, 2019 (the effective date of Public Act 100-1102), 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 fertility preservation services, 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 fertility preservation services.
(Source: P.A. 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19.) |
(215 ILCS 5/356z.33) (Text of Section before amendment by P.A. 103-454) Sec. 356z.33. Coverage for epinephrine injectors. 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, 2020 (the effective date of Public Act 101-281) shall provide coverage for medically necessary epinephrine injectors for persons 18 years of age or under. As used in this Section, "epinephrine injector" has the meaning given to that term in Section 5 of the Epinephrine Injector Act.(Source: P.A. 101-281, eff. 1-1-20; 102-558, eff. 8-20-21; 103-718, eff. 7-19-24.) (Text of Section after amendment by P.A. 103-454) Sec. 356z.33. Coverage for epinephrine injectors. (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, 2020 (the effective date of Public Act 101-281) shall provide coverage for medically necessary epinephrine injectors for persons 18 years of age or under. As used in this Section, "epinephrine injector" has the meaning given to that term in Section 5 of the Epinephrine Injector Act. (b) An insurer that provides coverage for medically necessary epinephrine injectors shall limit the total amount that an insured is required to pay for a twin-pack of medically necessary epinephrine injectors at an amount not to exceed $60, regardless of the type of epinephrine injector; except that this provision does not apply 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). (c) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (b). (d) The Department may adopt rules as necessary to implement and administer this Section. (Source: P.A. 102-558, eff. 8-20-21; 103-454, eff. 1-1-25; 103-718, eff. 7-19-24.) |
(215 ILCS 5/356z.34) Sec. 356z.34. Coverage for cardiopulmonary monitors. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed after January 1, 2020 (the effective date of Public Act 101-218) shall provide coverage for cardiopulmonary monitors determined to be medically necessary for a person 18 years old or younger who has had a cardiopulmonary event.
(Source: P.A. 101-218, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.35) Sec. 356z.35. Long-term antibiotic therapy for tick-borne diseases. (a) As used in this Section: "Long-term antibiotic therapy" means the administration of oral, intramuscular, or intravenous antibiotics singly or in combination for periods of time in excess of 4 weeks. "Tick-borne disease" means a disease caused when an infected tick bites a person and the tick's saliva transmits an infectious agent (bacteria, viruses, or parasites) that can cause illness, including, but not limited to, the following: (1) a severe infection with borrelia burgdorferi; (2) a late stage, persistent, or chronic infection or | ||
| ||
(3) an infection with other strains of borrelia or a | ||
| ||
(4) the presence of signs or symptoms compatible with | ||
| ||
(b) An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-371) shall provide coverage for long-term antibiotic therapy, including necessary office visits and ongoing testing, for a person with a tick-borne disease when determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches after making a thorough evaluation of the person's symptoms, diagnostic test results, or response to treatment. An experimental drug shall be covered as a long-term antibiotic therapy if it is approved for an indication by the United States Food and Drug Administration. A drug, including an experimental drug, shall be covered for an off-label use in the treatment of a tick-borne disease if the drug has been approved by the United States Food and Drug Administration.
(Source: P.A. 101-371, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.36) Sec. 356z.36. Coverage of treatment models for early treatment of serious mental illnesses. (a) For purposes of early treatment of a serious mental illness in a child or young adult under age 26, a group or individual policy of accident and health insurance, or managed care plan, that is amended, delivered, issued, or renewed after December 31, 2020 shall provide coverage of the following bundled, evidence-based treatment: (1) Coordinated specialty care for first episode | ||
| ||
(2) Assertive community treatment (ACT) and community | ||
| ||
(b) Adherence to the clinical models. For purposes of ensuring adherence to the coordinated specialty care for first episode psychosis treatment model, only providers contracted with the Department of Human Services' Division of Mental Health to be FIRST.IL providers to deliver coordinated specialty care for first episode psychosis treatment shall be permitted to provide such treatment in accordance with this Section and such providers must adhere to the fidelity of the treatment model. For purposes of ensuring fidelity to ACT and CST, only providers certified to provide ACT and CST by the Department of Human Services' Division of Mental Health and approved to provide ACT and CST by the Department of Healthcare and Family Services, or its designee, in accordance with 89 Ill. Adm. Code 140, shall be permitted to provide such services under this Section and such providers shall be required to adhere to the fidelity of the models. (c) Development of medical necessity criteria for coverage. Within 6 months after January 1, 2020 (the effective date of Public Act 101-461), the Department of Insurance shall lead and convene a workgroup that includes the Department of Human Services' Division of Mental Health, the Department of Healthcare and Family Services, providers of the treatment models listed in this Section, and insurers operating in Illinois to develop medical necessity criteria for such treatment models for purposes of coverage under this Section. The workgroup shall use the medical necessity criteria the State and other states use as guidance for establishing medical necessity for insurance coverage. The Department of Insurance shall adopt a rule that defines medical necessity for each of the 3 treatment models listed in this Section by no later than June 30, 2020 based on the workgroup's recommendations. (d) For purposes of credentialing the mental health professionals and other medical professionals that are part of a coordinated specialty care for first episode psychosis treatment team, an ACT team, or a CST team, the credentialing of the psychiatrist or the licensed clinical leader of the treatment team shall qualify all members of the treatment team to be credentialed with the insurer. (e) Payment for the services performed under the treatment models listed in this Section shall be based on a bundled treatment model or payment, rather than payment for each separate service delivered by a treatment team member. By no later than 6 months after January 1, 2020 (the effective date of Public Act 101-461), the Department of Insurance shall convene a workgroup of Illinois insurance companies and Illinois mental health treatment providers that deliver the bundled treatment approaches listed in this Section to determine a coding solution that allows for these bundled treatment models to be coded and paid for as a bundle of services, similar to intensive outpatient treatment where multiple services are covered under one billing code or a bundled set of billing codes. The coding solution shall ensure that services delivered using coordinated specialty care for first episode psychosis treatment, ACT, or CST are provided and billed as a bundled service, rather than for each individual service provided by a treatment team member, which would deconstruct the evidence-based practice. The coding solution shall be reached prior to coverage, which shall begin for plans amended, delivered, issued, or renewed after December 31, 2020, to ensure coverage of the treatment team approaches as intended by this Section. (f) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, adopts 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, under any provision of the Patient Protection and Affordable Care Act (P.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 any coverage for serious mental illnesses or serious emotional disturbances outlined in this Section, then the requirement that a group or individual policy of accident and health insurance or managed care plan cover the bundled treatment approaches listed in this Section 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 the coverage. (g) After 5 years following full implementation of this Section, if requested by an insurer, the Department of Insurance shall contract with an independent third party with expertise in analyzing health insurance premiums and costs to perform an independent analysis of the impact coverage of the team-based treatment models listed in this Section has had on insurance premiums in Illinois. If premiums increased by more than 1% annually solely due to coverage of these treatment models, coverage of these models shall no longer be required. (h) The Department of Insurance shall adopt any rules necessary to implement the provisions of this Section by no later than June 30, 2020.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.37) Sec. 356z.37. Whole body skin examination. An individual or group policy of accident and health insurance shall cover, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement upon the insured patient, one annual office visit, using appropriate routine evaluation and management Current Procedural Terminology codes or any successor codes, for a whole body skin examination for lesions suspicious for skin cancer. The whole body skin examination shall be indicated using an appropriate International Statistical Classification of Diseases and Related Health Problems code or any successor codes. The provisions of this Section do not apply to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to 26 U.S.C. 223.
(Source: P.A. 101-500, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(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 | ||
| ||
(2) the infant's mother is medically or physically | ||
| ||
(3) the milk has been determined to be medically | ||
| ||
(4) one or more of the following applies: (A) the infant's birth weight is below 1,500 | ||
| ||
(B) the infant has a congenital or acquired | ||
| ||
(C) the infant has infant hypoglycemia; (D) the infant has congenital heart disease; (E) the infant has had or will have an organ | ||
| ||
(F) the infant has sepsis; or (G) the infant has any other serious congenital | ||
| ||
(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 | ||
| ||
(2) the child's mother is medically or physically | ||
| ||
(3) the milk has been determined to be medically | ||
| ||
(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 | ||
| ||
(C) the child has had or will have an organ | ||
| ||
(D) the child has a congenital or acquired | ||
| ||
(Source: P.A. 101-511, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.39) Sec. 356z.39. Coverage of the psychiatric Collaborative Care Model. (a) As used in this Section, "psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method, which includes a formal collaborative arrangement among a primary care team consisting of a primary care provider, a care manager, and a psychiatric consultant, and includes, but is not limited to, the following elements: (1) care directed by the primary care team; (2) structured care management; (3) regular assessments of clinical status using | ||
| ||
(4) modification of treatment as appropriate. (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-574) or managed care organization that provides mental health benefits shall provide reimbursement for benefits that are delivered through the psychiatric Collaborative Care Model. The following American Medical Association 2018 current procedural terminology codes and Healthcare Common Procedure Coding System code shall be used to bill for benefits delivered through the psychiatric Collaborative Care Model: (1) 99492; (2) 99493; (3) 99494; and (4) G0512. (c) The Director of Insurance shall update the billing codes in subsection (b) if there are any alterations or additions to the billing codes for the psychiatric Collaborative Care Model. (d) An individual or group policy or managed care organization that provides benefits under this Section may deny reimbursement of any billing code listed in this Section on the grounds of medical necessity if such medical necessity determinations are in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and its implementing and related regulations and that such determinations are made in accordance with the utilization review requirements under Section 85 of the Managed Care Reform and Patient Rights Act.
(Source: P.A. 101-574, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.40) (Text of Section from P.A. 102-665) 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 | ||
| ||
(2) An individual shall have access to medically | ||
| ||
(3) The benefits provided for inpatient and | ||
| ||
(4) The benefits for the first 48 hours of initiation | ||
| ||
(5) If an insurer determines that continued inpatient | ||
| ||
(6) Except as otherwise stated in this subsection | ||
| ||
(7) The benefits required by paragraphs (2) and (6) | ||
| ||
(Source: P.A. 102-665, eff. 10-8-21.) (Text of Section from P.A. 103-650) 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 | ||
| ||
(2) An individual shall have access to medically | ||
| ||
(3) The benefits provided for inpatient and | ||
| ||
(4) The benefits for the first 48 hours of initiation | ||
| ||
(5) If an insurer determines that continued inpatient | ||
| ||
(6) Except as otherwise stated in this subsection | ||
| ||
(7) The benefits required by paragraphs (2) and (6) | ||
| ||
(Source: P.A. 102-665, eff. 10-8-21; 103-650, eff. 1-1-25.) (Text of Section from P.A. 103-701) 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 | ||
| ||
(2) An individual shall have access to medically | ||
| ||
(3) The benefits provided for inpatient and | ||
| ||
(4) The benefits for the first 48 hours of initiation | ||
| ||
(5) If an insurer determines that continued inpatient | ||
| ||
(6) Except as otherwise stated in this subsection | ||
| ||
(7) The benefits required by paragraphs (2) and (6) | ||
| ||
(Source: P.A. 102-665, eff. 10-8-21; 103-701, eff. 1-1-26.) (Text of Section from P.A. 103-720) 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 October 8, 2021 (the effective date of Public Act 102-665) shall provide coverage for pregnancy and newborn care in accordance with 42 U.S.C. 18022(b) regarding essential health benefits. For policies amended, delivered, issued, or renewed on or after January 1, 2026, this subsection also applies to coverage for postpartum care. (b) Benefits under this Section shall be as follows: (1) An individual who has been identified as | ||
| ||
(2) An individual shall have access to medically | ||
| ||
(3) The benefits provided for inpatient and | ||
| ||
(4) The benefits for the first 48 hours of initiation | ||
| ||
(5) If an insurer determines that continued inpatient | ||
| ||
(6) Except as otherwise stated in this subsection (b) | ||
| ||
(7) The benefits required by paragraphs (2) and (6) | ||
| ||
(8) Insurers shall cover all services for pregnancy, | ||
| ||
(9) Coverage for pregnancy, postpartum, and newborn | ||
| ||
(10) Coverage for postpartum services shall apply for | ||
| ||
(c) All coverage described in subsection (b), other than health care services for home births, shall be provided without cost-sharing, except that, for mental health services, the cost-sharing prohibition does not apply to inpatient or residential services, and, for substance use disorder services, the cost-sharing prohibition applies only to levels of treatment below and not including Level 3.1 (Clinically Managed Low-Intensity Residential), as established by the American Society for Addiction Medicine. This subsection does not apply 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. 102-665, eff. 10-8-21; 103-720, eff. 1-1-26.) |
(215 ILCS 5/356z.40a) Sec. 356z.40a. Pregnancy as a qualifying life event for qualified health plans. Beginning with the operation of a State-based exchange in plan year 2026, a pregnant individual has the right to enroll in a qualified health plan through a special enrollment period within 60 days after any qualified health care professional, including a licensed certified professional midwife, licensed or certified under the laws of this State or any other state to provide pregnancy-related health care services certifies that the individual is pregnant. Upon enrollment, coverage shall be effective on and after the first day of the month in which the qualified health care professional certifies that the individual is pregnant, unless the individual elects to have coverage effective on the first day of the month following the date that the individual received certification of the pregnancy.
(Source: P.A. 103-777, eff. 8-2-24.) |
(215 ILCS 5/356z.41) (Text of Section before amendment by P.A. 103-429) Sec. 356z.41. Cost sharing in prescription insulin drugs; limits; confidentiality of rebate information. (a) As used in this Section, "prescription insulin drug" means a prescription drug that contains insulin and is used to control blood glucose levels to treat diabetes but does not include an insulin drug that is
administered to a patient intravenously. (b) This Section applies to a group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly. (c) An insurer that provides coverage for prescription insulin drugs pursuant to the terms of a health coverage plan the insurer offers shall limit the total amount that an insured is required to pay for a 30-day supply of covered prescription insulin drugs at an amount not to exceed $100, regardless of the quantity or type of covered prescription insulin drug used to fill the insured's prescription. (d) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (c). (e) The Director may use any of the Director's enforcement powers to obtain an insurer's compliance with this Section. (f) The Department may adopt rules as necessary to implement and administer this Section and to align it with federal requirements. (g) On January 1 of each year, the limit on the amount that an insured is required to pay for a 30-day supply of a covered prescription insulin drug shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the Consumer Price Index of the Bureau of Labor Statistics of the United States Department of Labor.
(Source: P.A. 101-625, eff. 1-1-21.) (Text of Section after amendment by P.A. 103-429) Sec. 356z.41. Cost sharing in prescription insulin drugs; limits; confidentiality of rebate information. (a) As used in this Section, "prescription insulin drug" means a prescription drug that contains insulin and is used to control blood glucose levels to treat diabetes but does not include an insulin drug that is
administered to a patient intravenously. (b) This Section applies to a group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly. (c) An insurer that provides coverage for prescription insulin drugs pursuant to the terms of a health coverage plan the insurer offers shall limit the total amount that an insured is required to pay for a 30-day supply of covered prescription insulin drugs at an amount not to exceed $35, regardless of the quantity or type of covered prescription insulin drug used to fill the insured's prescription. (d) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (c). (e) The Director may use any of the Director's enforcement powers to obtain an insurer's compliance with this Section. (f) The Department may adopt rules as necessary to implement and administer this Section and to align it with federal requirements. (g) On January 1 of each year, the limit on the amount that an insured is required to pay for a 30-day supply of a covered prescription insulin drug shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the Consumer Price Index of the Bureau of Labor Statistics of the United States Department of Labor.
(Source: P.A. 103-429, eff. 7-1-25.) |
(215 ILCS 5/356z.42) Sec. 356z.42. (Repealed).
(Source: P.A. 101-625, eff. 1-24-20. Repealed internally, eff. 12-31-20.) |
(215 ILCS 5/356z.43) Sec. 356z.43. (Repealed).
(Source: P.A. 102-813, eff. 5-13-22. Repealed internally, eff. 1-1-22.) |
(215 ILCS 5/356z.44) Sec. 356z.44. Vitamin D testing. (a) As used in this Section, "vitamin D testing" means vitamin D blood testing that measures the level of vitamin D in an individual's blood. (b) A group or individual 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 vitamin D testing recommended by a health care provider in accordance with vitamin D deficiency risk factors identified by the United States Centers for Disease Control and Prevention. Risk factors for vitamin D deficiency include, but are not limited to: (1) having osteoporosis or other bone-health | ||
| ||
(2) having conditions that affect fat absorption, | ||
| ||
(3) routinely taking medications that interfere | ||
| ||
(4) beneficiaries aged 55 and older; (5) having a darker skin color; (6) inadequate sunlight exposure; (7) being obese; (8) previous diagnosis of diabetes or kidney | ||
| ||
(9) exhibiting poor muscle strength or constant | ||
| ||
(Source: P.A. 102-530, eff. 1-1-22.) |
(215 ILCS 5/356z.45)
Sec. 356z.45. Coverage for patient care services provided by a pharmacist. 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, 2023 shall provide coverage for health care or patient care services provided by a pharmacist if: (1) the pharmacist meets the requirements and scope | ||
| ||
(2) the health plan provides coverage for the same | ||
| ||
(3) the pharmacist is included in the health | ||
| ||
(4) a reimbursement has been successfully | ||
| ||
(Source: P.A. 102-103, eff. 1-1-23; 102-813, eff. 5-13-22; 102-1051, eff. 1-1-23.)
|
(215 ILCS 5/356z.46)
Sec. 356z.46. Biomarker testing. (a) As used in this Section: "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention. "Biomarker" includes, but is not limited to, gene mutations or protein expression. "Biomarker testing" means the analysis of a patient's tissue, blood, or fluid biospecimen for the presence of a biomarker. "Biomarker testing" includes, but is not limited to, single-analyte tests, multi-plex panel tests, and partial or whole genome sequencing. (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, 2022 shall include coverage for biomarker testing as defined in this Section pursuant to criteria established under subsection (d). (c) Biomarker testing shall be covered and conducted in an efficient manner to provide the most complete range of results to the patient's health care provider without requiring multiple biopsies, biospecimen samples, or other delays or disruptions in patient care. (d) Biomarker testing must be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence, including, but not limited to: (1) labeled indications for an FDA-approved test or | ||
| ||
(2) federal Centers for Medicare and Medicaid | ||
| ||
(3) nationally recognized clinical practice | ||
| ||
(4) consensus statements; (5) professional society recommendations; (6) peer-reviewed literature, biomedical compendia, | ||
| ||
(7) peer-reviewed scientific studies published in | ||
| ||
(e) When coverage of biomarker testing for the purpose of diagnosis, treatment, or ongoing monitoring of any medical condition is restricted for use by a group or individual policy of accident and health insurance or managed care plan, the patient and prescribing practitioner shall have access to a clear, readily accessible, and convenient processes to request an exception. The process shall be made readily accessible on the insurer's website.
(Source: P.A. 102-203, eff. 1-1-22; 102-813, eff. 5-13-22.)
|
(215 ILCS 5/356z.47)
Sec. 356z.47. Coverage for pancreatic cancer 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, 2022 shall provide coverage for medically necessary pancreatic cancer screening.
(Source: P.A. 102-306, eff. 1-1-22; 102-813, eff. 5-13-22.)
|
(215 ILCS 5/356z.48) (Text of Section before amendment by P.A. 103-800) Sec. 356z.48. Colonoscopy coverage. (a) A group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for a colonoscopy that is a follow-up exam based on an initial screen where the colonoscopy was determined to be medically necessary by a physician licensed to practice medicine in all its branches, an advanced practice registered nurse, or a physician assistant. (b) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this subsection does not apply to coverage of colonoscopies 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. 102-443, eff. 1-1-22; 102-813, eff. 5-13-22.) (Text of Section after amendment by P.A. 103-800) Sec. 356z.48. Colonoscopy coverage. (a) A group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for a colonoscopy that is a follow-up exam based on an initial screen where the colonoscopy was determined to be medically necessary by a physician licensed to practice medicine in all its branches, an advanced practice registered nurse, or a physician assistant. (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, 2026 shall provide coverage for a colonoscopy determined to be medically necessary. (c) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this subsection does not apply to coverage of colonoscopies 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. 102-443, eff. 1-1-22; 102-813, eff. 5-13-22; 103-800, eff. 1-1-25.) |
(215 ILCS 5/356z.49)
Sec. 356z.49. A1C testing. (a) As used in this Section, "A1C testing" means blood sugar level testing used to diagnose prediabetes, type 1 diabetes, and type 2 diabetes and to monitor management of blood sugar levels. (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, 2022 (the effective date of Public Act 102-530) shall provide coverage for A1C testing recommended by a health care provider for prediabetes, type 1 diabetes, and type 2 diabetes in accordance with prediabetes and diabetes risk factors identified by the United States Centers for Disease Control and Prevention. (1) Risk factors for prediabetes may include, but | ||
| ||
(2) Risk factors for type 1 diabetes may include, | ||
| ||
(3) Risk factors for type 2 diabetes may include, | ||
| ||
(Source: P.A. 102-530, eff. 1-1-22; 102-813, eff. 5-13-22.)
|
(215 ILCS 5/356z.50)
Sec. 356z.50. Comprehensive cancer testing. (a) As used in this Section: "Comprehensive cancer testing" includes, but is not limited to, the following forms of testing: (1) Targeted cancer gene panels. (2) Whole-exome genome testing. (3) Whole-genome sequencing. (4) RNA sequencing. (5) Tumor mutation burden. "Testing of blood or constitutional tissue for cancer predisposition testing" includes, but is not limited to, the following forms of testing: (1) Targeted cancer gene panels. (2) Whole-exome genome testing. (3) Whole-genome sequencing. (b) An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2022 (the effective date of Public Act 102-589) shall provide coverage for medically necessary comprehensive cancer testing and testing of blood or constitutional tissue for cancer predisposition testing as determined by a physician licensed to practice medicine in all of its branches.
(Source: P.A. 102-589, eff. 1-1-22; 102-813, eff. 5-13-22.)
|
(215 ILCS 5/356z.51)
Sec. 356z.51. Coverage for port-wine stain treatment. (a) A group or individual policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed on or after January 1, 2022 shall provide coverage for
treatment to eliminate or provide maximum
feasible treatment of nevus flammeus, also known as port-wine
stains, including, but not limited to, port-wine stains caused
by Sturge-Weber syndrome. For purposes of this Section, treatment or maximum feasible treatment shall include early intervention treatment, including topical, intralesional, or systemic medical therapy and surgery, and laser treatments approved by the U.S. Food and Drug Administration in children aged 18 years and younger that are intended to prevent functional impairment related to vision function, oral function, inflammation, bleeding, infection, and other medical complications associated with port-wine stains. (b) Coverage for treatment required under this Section shall not include treatment solely for cosmetic purposes.
(Source: P.A. 102-642, eff. 1-1-22; 102-813, eff. 5-13-22.)
|
(215 ILCS 5/356z.53) Sec. 356z.53. Coverage for home health services. 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, 2024 shall provide coverage for access to home health services for the duration of medically necessary care.
(Source: P.A. 102-816, eff. 1-1-23; 103-154, eff. 6-30-23.) |