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INSURANCE
(215 ILCS 5/) Illinois Insurance Code.

215 ILCS 5/351A-4

    (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
    
on grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder.
        (2) Contain a provision establishing a new waiting
    
period in the event existing coverage is converted to or replaced by a new or other form, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder.
        (3) Provide coverage for skilled nursing care only or
    
provide significantly more coverage for skilled care in a facility than coverage for lower levels of care.
(Source: P.A. 92-148, eff. 7-24-01.)

215 ILCS 5/351A-4.5

    (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

    (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

    (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
    
prior hospitalization requirement; or
        (2) conditions eligibility for benefits provided in
    
an institutional care setting on the receipt of a higher level of institutional care.
    (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
    
benefit advertised, marketed or offered as a home health care or home care benefit may not condition receipt of benefits on a prior institutionalization requirement.
        (2) A long-term care insurance policy which
    
conditions eligibility of non-institutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than 30 days for which benefits are paid.
(Source: P.A. 85-1440; 86-384.)

215 ILCS 5/351A-7

    (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

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

215 ILCS 5/351A-9

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

215 ILCS 5/351A-9.1

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

215 ILCS 5/351A-9.2

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

215 ILCS 5/351A-9.3

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

215 ILCS 5/351A-10

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

215 ILCS 5/351A-11

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

215 ILCS 5/Art. XIXB

 
    (215 ILCS 5/Art. XIXB heading)
ARTICLE XIXB SMALL EMPLOYER GROUP HEALTH INSURANCE LAW
(Repealed by P.A. 98-692, eff. 7-1-14; 98-969, eff. 1-1-15)

215 ILCS 5/Art. XX

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

215 ILCS 5/352

    (215 ILCS 5/352) (from Ch. 73, par. 964)
    Sec. 352. Scope of Article.
    (a) Except as provided in subsections (b), (c), (d), (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,
    
or contracts supplemental thereto that contain only such provisions relating to accident and sickness insurance that (A) provide additional benefits in case of death or dismemberment or loss of sight by accident, or (B) operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity if the insured or annuitant becomes a person with a total and permanent disability, as defined by the contract or supplemental contract.
(Source: P.A. 103-718, eff. 7-19-24.)

215 ILCS 5/352a

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

215 ILCS 5/352b

    (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

    (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

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

215 ILCS 5/353a

    (215 ILCS 5/353a) (from Ch. 73, par. 965a)
    Sec. 353a. Accident and health reserves. The reserves for all accident and health policies issued after the operative date of this section shall be computed and maintained on a basis which shall place an actuarially sound value on the liabilities under such policies. To provide a basis for the determination of such actuarially sound value, the Director from time to time shall adopt rules requiring the use of appropriate tables of morbidity, mortality, interest rates and valuation methods for such reserves 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

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

215 ILCS 5/355

    (215 ILCS 5/355) (from Ch. 73, par. 967)
    (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
    
and expenses to which the rate applies; and
        (2) the continued use of which endangers the solvency
    
of an insurer using that rate.
    "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
    
and expenses to which the rate applies; and
        (2) the continued use of which endangers the solvency
    
of an insurer using that rate.
    "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
    
reduction defunding adjustment factor within a range that:
            (A) is uniform across all insurers;
            (B) is consistent with the total adjustment
        
expected to be needed to cover actual cost-sharing reduction costs across all silver plans on the Illinois Health Benefits Exchange statewide, provided that such costs are calculated assuming utilization by the State's full individual-market risk pool; and
            (C) assumes that the only on-Exchange silver
        
plans that will be purchased are the 87% and 94% cost-sharing reduction variations.
        (2) The rate filing must apply an induced demand
    
factor based on the following formula: (Plan Actuarial Value)2 - (Plan Actuarial Value) + 1.24.
    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
    
and expenses to which the rate applies; and
        (2) the continued use of which endangers the solvency
    
of an insurer using that rate.
    "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
    
the premiums are unreasonable in relation to the benefits because the rates were not calculated in accordance with sound actuarial principles.
        (2) Within 60 days of receipt of the rate filing, the
    
Director shall issue a decision to approve, disapprove, or modify the filing along with the reasons and actuarial justification for the decision. Any rate filing or rates within a filing on which the Director does not issue a decision within 60 days shall be automatically deemed approved.
        (3) Any company whose rate or rate filing 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 or rate filing shall be subject to judicial review under the Administrative Review Law.
        (4) Nothing in this subsection requires a company to
    
file a large group policy's final premium rates for prior approval if the company negotiates the final rates or rate adjustments with the plan sponsor or its administrator in accordance with the rate manual and rules of the currently approved rate filing for the policy.
    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

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

215 ILCS 5/355.2

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

215 ILCS 5/355.3

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

215 ILCS 5/355.4

    (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
    
granted to a dental carrier or an entity operating in accordance with the same brand licensee program as the contracting entity; or
        (2) to a provider network contract for dental
    
services provided to beneficiaries of the State employee group health insurance program or the medical assistance program under the Illinois Public Aid Code.
(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
    
granted to a dental carrier or an entity operating in accordance with the same brand licensee program as the contracting entity; or
        (2) to a provider network contract for dental
    
services provided to beneficiaries of the State employee group health insurance program or the medical assistance program under the Illinois Public Aid Code.
(Source: P.A. 103-24, eff. 1-1-24; 103-832, eff. 1-1-25.)

215 ILCS 5/355.5

    (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

    (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
    
fees associated with a particular payment method and that the insurer or managed care plan, or its contracted vendor, shall disclose any fees beyond what the health care provider would normally pay to process a payment using that payment method; and
        (2) provide the health care provider with clear
    
instructions on the insurer's or managed care plan's, or its contracted vendor's, website or through means other than the contract offered to the health care provider as to how to select each method.
    (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

    (215 ILCS 5/355a) (from Ch. 73, par. 967a)
    Sec. 355a. Standardization of terms and coverage.
    (1) The purposes of this Section shall be (a) to provide reasonable standardization and simplification of terms and coverages of individual accident and health insurance policies to facilitate public understanding and comparisons; (b) to eliminate provisions contained in individual accident and health insurance policies which may be misleading or unreasonably confusing in connection either with the purchase of such coverages or with the settlement of claims; and (c) to provide for reasonable disclosure in the sale of accident and health coverages.
    (2) Definitions applicable to this Section are as follows:
        (a) "Policy" means all or any part of the forms
    
constituting the contract between the insurer and the insured, including the policy, certificate, subscriber contract, riders, endorsements, and the application if attached, which are subject to filing with and approval by the Director.
        (b) "Service corporations" means voluntary health and
    
dental corporations organized and operating respectively under the Voluntary Health Services Plans Act and the Dental Service Plan Act.
        (c) "Accident and health insurance" means insurance
    
written under Article XX of this Code, other than credit accident and health insurance, and coverages provided in subscriber contracts issued by service corporations. For purposes of this Section such service corporations shall be deemed to be insurers engaged in the business of insurance.
    (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

    (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

    (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,
    
the most recently published formulary where a consumer can view in one location covered prescription drugs; information on tiering and the cost-sharing structure for each tier; and information about how a consumer can obtain specific copayment amounts or coinsurance percentages for a specific qualified health plan before enrolling in that plan. This information shall clearly identify the qualified health plan to which it applies.
        (2) The most recently published provider directory
    
where a consumer can view the provider network that applies to each qualified health plan and information about each provider, including location, contact information, specialty, medical group, if any, any institutional affiliation, and whether the provider is accepting new patients at each of the specific locations listing the provider. Dental providers shall notify qualified health plans electronically or in writing of any changes to their information as listed in the provider directory. Qualified health plans shall update their directories in a manner consistent with the information provided by the provider or dental management service organization within 10 business days after being notified of the change by the provider. Nothing in this paragraph (2) shall void any contractual relationship between the provider and the plan. The information shall clearly identify the qualified health plan to which it applies.
    (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

    (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
    
frequency limitations, that were not applicable at the time of the prior authorization are reached due to utilization after issuance of the prior authorization;
        (2) the documentation for the claim provided by the
    
person submitting the claim clearly fails to support the claim as originally authorized;
        (3) if, after the issuance of the prior
    
authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary based on the prevailing standard of care;
        (4) if, after the issuance of the prior
    
authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would, at that time, require disapproval pursuant to the terms and conditions for coverage under the plan for the patient in effect at the time the prior authorization was used; or
        (5) the claim was denied by a dental carrier due to
    
one of the following reasons:
            (A) another payor is responsible for the payment;
            (B) the dentist has already been paid for the
        
procedures identified on the claim;
            (C) the claim was submitted fraudulently or the
        
prior authorization was based in whole or material part on erroneous information provided to the dental carrier; or
            (D) the person receiving the procedure was not
        
eligible for the procedure on the date of service and the dental carrier did not know, and with the exercise of reasonable care could not have known, that person's eligibility status.
    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

    (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
    
therefor are expressed therein; and
        (b) the time at which the insurance takes effect and
    
terminates is expressed therein; and
        (c) it purports to insure only one person, except
    
that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, any 2 or more eligible members of that family, including husband, wife, dependent children or any children under a specified age which shall not exceed 19 years and any other person dependent upon the policyholder; and
        (d) the style, arrangement and over-all appearance of
    
the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than ten-point with a lower-case unspaced alphabet length not less than one hundred and twenty-point (the "text" shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and captions and subcaptions); and
        (e) the exceptions and reductions of indemnity are
    
set forth in the policy and, except those which are set forth in Sections 357.1 through 357.30 of this Act, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and
        (f) each such form, including riders and
    
endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and
        (g) it contains no provision purporting to make any
    
portion of the charter, rules, constitution, or by-laws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the Director.
    (2) If any policy is issued by an insurer domiciled in this State for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the Director that any such policy is not subject to approval or disapproval by such official, the Director may by ruling require that such policy meet the standards set forth in subsection (1) of this Section and in Sections 357.1 through 357.30.
(Source: P.A. 103-718, eff. 7-19-24.)

215 ILCS 5/356b

    (215 ILCS 5/356b) (from Ch. 73, par. 968b)
    Sec. 356b. (a) This Section applies to the hospital and medical expense provisions of an 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

    (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

    (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

    (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

    (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

    (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
    
age.
        (2) An annual mammogram for women 40 years of age or
    
older.
        (3) A mammogram at the age and intervals considered
    
medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
        (4) For 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 101st General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
        (5) A screening MRI when medically necessary, as
    
determined by a physician licensed to practice medicine in all of its branches.
        (6) For 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 101st General Assembly, a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.
    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
    
mastectomy has been performed;
        (2) surgery and reconstruction of the other breast to
    
produce a symmetrical appearance; and
        (3) prostheses and treatment for physical
    
complications at all stages of mastectomy, including lymphedemas.
Care shall be determined in consultation with the attending physician and the patient. The offered coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy, and all other terms and conditions applicable to other benefits. When a mastectomy is performed and there is no evidence of malignancy then the offered coverage may be limited to the provision of prosthetic devices and reconstructive surgery to within 2 years after the date of the mastectomy. As used in this Section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician.
    Written notice of the availability of coverage under this Section shall be delivered to the insured upon enrollment and annually thereafter. An insurer may not deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Section. An insurer may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives (monetary or otherwise) to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with this Section.
    (c) Rulemaking authority to implement 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
    
of age.
        (2) An annual mammogram for patients 40 years of age
    
or older.
        (3) A mammogram at the age and intervals considered
    
medically necessary by the patient's health care provider for patients under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
        (4) For 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 January 1, 2020 (the effective date of Public Act 101-580) and before the effective date of this amendatory Act of the 103rd General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
        (4.3) For 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 103rd General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches, advanced practice registered nurse, or physician assistant.
        (4.5) For a group policy of accident and health
    
insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly, molecular breast imaging (MBI) of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches, advanced practice registered nurse, or physician assistant.
        (5) A screening MRI when medically necessary, as
    
determined by a physician licensed to practice medicine in all of its branches.
        (6) For 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 January 1, 2020 (the effective date of Public Act 101-580), a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.
    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
    
mastectomy has been performed;
        (2) surgery and reconstruction of the other breast to
    
produce a symmetrical appearance; and
        (3) prostheses and treatment for physical
    
complications at all stages of mastectomy, including lymphedemas.
Care shall be determined in consultation with the attending physician and the patient. The offered coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy, and all other terms and conditions applicable to other benefits. When a mastectomy is performed and there is no evidence of malignancy then the offered coverage may be limited to the provision of prosthetic devices and reconstructive surgery to within 2 years after the date of the mastectomy. As used in this Section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician.
    Written notice of the availability of coverage under this Section shall be delivered to the insured upon enrollment and annually thereafter. An insurer may not deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Section. An insurer may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives (monetary or otherwise) to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with this Section.
    (c) Rulemaking authority to implement 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

    (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
    
years of age but less than 40 years of age; and
        (2) annually for women 40 years of age or older.
    (c) Upon approval of a nationally recognized separate and distinct clinical breast exam code that is compliant with all State and federal laws, rules, and regulations, public and private insurance plans shall take action to cover clinical breast exams on a separate and distinct basis.
(Source: P.A. 99-173, eff. 7-29-15; 100-513, eff. 1-1-18.)

215 ILCS 5/356g.5-1

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

215 ILCS 5/356h

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

215 ILCS 5/356i

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

215 ILCS 5/356j

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

215 ILCS 5/356K

    (215 ILCS 5/356K) (from Ch. 73, par. 968K)
    Sec. 356K. Coverage for Organ Transplantation Procedures. No 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

    (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

    (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
    
patient's medical provider based on clinical guidelines or standards developed by the American Society for Reproductive Medicine, the American College of Obstetricians and Gynecologists, or the Society for Assisted Reproductive Technology; and
        (2) are performed at medical facilities or clinics
    
that are members in good standing of the Society for Assisted Reproductive Technology.
    (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
    
a viable pregnancy, maintain a viable pregnancy, or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract;
        (2) the covered individual has not undergone 4
    
completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and
        (3) the procedures are performed at medical
    
facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.
    (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
    
pregnancy to live birth after 12 months of regular, unprotected sexual intercourse if the woman is 35 years of age or younger, or after 6 months of regular, unprotected sexual intercourse if the woman is over 35 years of age; conceiving but having a miscarriage does not restart the 12-month or 6-month term for determining infertility;
        (2) a person's inability to reproduce either as a
    
single individual or with a partner without medical intervention; or
        (3) a licensed physician's findings based on a
    
patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.
    (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

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

215 ILCS 5/356p

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

215 ILCS 5/356q

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

215 ILCS 5/356r

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

    (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
    
a vaginal delivery for the mother and the newborn, except as otherwise provided in this Section; or
        (2) a minimum of 96 hours of inpatient care following
    
a delivery by caesarian section for the mother and newborn, except as otherwise provided in this Section.
    A shorter length of hospital inpatient stay for services related to maternity and newborn care may be provided if the attending physician licensed to practice medicine in all of its branches determines, in accordance with the protocols and guidelines developed by the American College of Obstetricians and Gynecologists or the American Academy of Pediatrics, that the mother and the newborn meet the appropriate guidelines for that length of stay based upon evaluation of the mother and newborn and the coverage and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the infant in the first 48 hours after discharge.
(Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)
 
    (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
    
a vaginal delivery for the mother and the newborn, except as otherwise provided in this Section; or
        (2) a minimum of 96 hours of inpatient care following
    
a delivery by caesarian section for the mother and newborn, except as otherwise provided in this Section.
    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

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

215 ILCS 5/356u

    (215 ILCS 5/356u)
    (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
    
female insureds.
        (2) An annual prostate cancer screening for male
    
insureds upon the recommendation of a physician licensed to practice medicine in all its branches for:
            (A) asymptomatic men age 50 and over;
            (B) African-American men age 40 and over; and
            (C) men age 40 and over with a family history of
        
prostate cancer.
        (3) Surveillance tests for ovarian cancer for female
    
insureds who are at risk for ovarian cancer.
    (b) This Section shall not apply to agreements, contracts, or policies that provide coverage for a specified disease or other limited benefit coverage.
    (c) 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
    
first-degree relatives with ovarian cancer, (ii) of clusters of women relatives with breast cancer, or (iii) of nonpolyposis colorectal cancer; or
        (2) testing positive for BRCA1 or BRCA2 mutations.
    "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,
    
magnetic resonance imaging.
    "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
    
all insureds.
        (2) An annual prostate cancer screening for insureds
    
upon the recommendation of a physician licensed to practice medicine in all its branches for:
            (A) asymptomatic individuals age 50 and over;
            (B) African-American individuals age 40 and over;
        
and
            (C) individuals age 40 and over with a family
        
history of or genetic predisposition to prostate cancer.
        (3) Surveillance tests for ovarian cancer for
    
insureds who are at risk for ovarian cancer.
    (b) This Section shall not apply to agreements, contracts, or policies that provide coverage for a specified disease or other limited benefit coverage.
    (c) 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
    
first-degree relatives with ovarian cancer, (ii) of clusters of relatives with breast cancer, or (iii) of nonpolyposis colorectal cancer; or
        (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,
    
magnetic resonance imaging.
    "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

    (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

    (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

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

215 ILCS 5/356w

    (215 ILCS 5/356w)
    Sec. 356w. Diabetes self-management training and education.
    (a) A group policy of accident and health insurance that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1998 shall provide coverage for outpatient self-management training and education, equipment, and supplies, as set forth in this Section, for the treatment of type 1 diabetes, type 2 diabetes, and gestational diabetes mellitus.
    (b) As used in this Section:
    "Diabetes self-management training" means instruction in an outpatient setting which enables a diabetic patient to understand the diabetic management process and daily management of diabetic therapy as a means of avoiding frequent hospitalization and complications. Diabetes self-management training shall include the content areas listed in the National Standards for Diabetes Self-Management Education Programs as published by the American Diabetes Association, including medical nutrition therapy and education programs, as defined by the contract of insurance, that allow the patient to maintain an A1c level within the range identified in nationally recognized standards of care.
    "Medical nutrition therapy" shall have the meaning ascribed to that term in the Dietitian Nutritionist Practice Act.
    "Physician" means a physician licensed to practice medicine in all of its branches providing care to the individual.
    "Qualified provider" for an individual that is enrolled in:
        (1) a health maintenance organization that uses a
    
primary care physician to control access to specialty care means (A) the individual's primary care physician licensed to practice medicine in all of its branches, (B) a physician licensed to practice medicine in all of its branches to whom the individual has been referred by the primary care physician, or (C) a certified, registered, or licensed network health care professional with expertise in diabetes management to whom the individual has been referred by the primary care physician.
        (2) an insurance plan means (A) a physician licensed
    
to practice medicine in all of its branches or (B) a certified, registered, or licensed health care professional with expertise in diabetes management to whom the individual has been referred by a physician.
    (c) Coverage under this Section for diabetes self-management training, including medical nutrition education, shall be limited to the following:
        (1) Up to 3 medically necessary visits to a qualified
    
provider upon initial diagnosis of diabetes by the patient's physician or, if diagnosis of diabetes was made within one year prior to the effective date of this amendatory Act of 1998 where the insured was a covered individual, up to 3 medically necessary visits to a qualified provider within one year after that effective date.
        (2) Up to 2 medically necessary visits to a qualified
    
provider upon a determination by a patient's physician that a significant change in the patient's symptoms or medical condition has occurred. A "significant change" in condition means symptomatic hyperglycemia (greater than 250 mg/dl on repeated occasions), severe hypoglycemia (requiring the assistance of another person), onset or progression of diabetes, or a significant change in medical condition that would require a significantly different treatment regimen.
    Payment by the insurer or health maintenance organization for the coverage required for diabetes self-management training pursuant to the provisions of this Section is only required to be made for services provided. No coverage is required for additional visits beyond those specified in items (1) and (2) of this subsection.
    Coverage under this subsection (c) for diabetes self-management training shall be subject to the same deductible, co-payment, and co-insurance provisions that apply to coverage under the policy for other services provided by the same type of provider.
    (d) Coverage shall be provided for the following equipment when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items shall be subject to deductible, co-payment and co-insurance provisions provided for under the policy or a durable medical equipment rider to the policy:
        (1) blood glucose monitors;
        (2) blood glucose monitors for the legally blind;
        (3) cartridges for the legally blind; and
        (4) lancets and lancing devices.
    This subsection does not apply to a group policy of accident and health insurance that does not provide a durable medical equipment benefit.
    (e) Coverage shall be provided for the following pharmaceuticals and supplies when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items shall be subject to the same coverage, deductible, co-payment, and co-insurance provisions under the policy or a drug rider to the policy, 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
    
sugar; and
        (5) glucagon emergency kits.
    This subsection does not apply to a group policy of accident and health insurance that does not provide a drug benefit.
    (f) Coverage shall be provided for regular foot care exams by a physician or by a physician to whom a physician has referred the patient. Coverage for regular foot care exams shall be subject to the same deductible, co-payment, and co-insurance provisions that apply under the policy for other services provided by the same type of provider.
    (g) If authorized by a physician, diabetes self-management training may be provided as a part of an office visit, group setting, or home visit.
    (h) This Section shall not apply to agreements, contracts, or policies that provide coverage for a specified diagnosis or other limited benefit coverage.
(Source: P.A. 101-625, eff. 1-1-21.)

215 ILCS 5/356x

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

215 ILCS 5/356y

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

215 ILCS 5/356z.1

    (215 ILCS 5/356z.1)
    Sec. 356z.1. Prenatal HIV testing. An individual or group policy of accident and health insurance that provides maternity coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 92nd General Assembly must provide coverage for prenatal HIV testing ordered by an attending physician licensed to practice medicine in all its branches, or by a physician assistant or advanced practice registered nurse, 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

    (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
    
requires hospitalization or general anesthesia for dental care; or
        (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
    
impairment or combination of mental and physical impairments.
        (2) It is likely to continue.
        (3) It results in substantial functional limitations
    
in one or more of the following areas of major life activity:
            (A) self-care;
            (B) receptive and expressive language;
            (C) learning;
            (D) mobility;
            (E) capacity for independent living; or
            (F) economic self-sufficiency.
    (c) The coverage required under this Section may be subject to any limitations, exclusions, or cost-sharing provisions that apply generally under the insurance policy.
    (d) This Section does not apply to a policy that covers only dental care.
    (e) Nothing in this Section requires that the dental services be covered.
    (f) The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified disease policies, nor to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under State or federal governmental plans.
(Source: P.A. 101-525, eff. 1-1-20; 102-972, eff. 1-1-23.)

215 ILCS 5/356z.3

    (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

    (215 ILCS 5/356z.3a)
    Sec. 356z.3a. Billing; emergency services; nonparticipating providers.
    (a) As used in this Section:
    "Ancillary services" means:
        (1) items and services related to emergency
    
medicine, anesthesiology, pathology, radiology, and neonatology that are provided by any health care provider;
        (2) items and services provided by assistant
    
surgeons, hospitalists, and intensivists;
        (3) diagnostic services, including radiology and
    
laboratory services, except for advanced diagnostic laboratory tests identified on the most current list published by the United States Secretary of Health and Human Services under 42 U.S.C. 300gg-132(b)(3);
        (4) items and services provided by other specialty
    
practitioners as the United States Secretary of Health and Human Services specifies through rulemaking under 42 U.S.C. 300gg-132(b)(3);
        (5) items and services provided by a
    
nonparticipating provider if there is no participating provider who can furnish the item or service at the facility; and
        (6) items and services provided by a
    
nonparticipating provider if there is no participating provider who will furnish the item or service because a participating provider has asserted the participating provider's rights under the Health Care Right of Conscience Act.
    "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
    
examination, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and such further medical examination and treatment as would be required to stabilize the patient regardless of the department of the hospital or other facility in which such further examination or treatment is furnished; or
        (2) additional items and services for which
    
benefits are provided or covered under the coverage and that are furnished by a nonparticipating provider or nonparticipating emergency facility regardless of the department of the hospital or other facility in which such items are furnished after the insured, beneficiary, or enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in paragraph (1) are furnished. Services after stabilization cease to be emergency services only when all the conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and regulations thereunder are met.
    "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
    
U.S.C. 1395i-4(e);
        (4) an ambulatory surgical treatment center as
    
defined in the Ambulatory Surgical Treatment Center Act; or
        (5) any recipient of a license under the Hospital
    
Licensing Act that is not otherwise described in this definition.
    "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
    
defined in the Ambulatory Surgical Treatment Center Act; or
        (4) with respect to emergency services described in
    
paragraph (2) of the definition of "emergency services", a hospital.
    "Nonparticipating provider" means, with respect to the furnishing of an item or service under a policy of group or individual health insurance coverage, any health care provider who does not have a contractual relationship directly or indirectly with a health insurance issuer in relation to the coverage.
    "Participating emergency facility" means any of the following facilities that has a contractual relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage:
        (1) an emergency department of a hospital;
        (2) a Freestanding Emergency Center;
        (3) an ambulatory surgical treatment center as
    
defined in the Ambulatory Surgical Treatment Center Act; or
        (4) with respect to emergency services described in
    
paragraph (2) of the definition of "emergency services", a hospital.
    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
    
a participating health care facility and, due to any reason, covered ancillary services are provided by a nonparticipating provider during or resulting from the visit, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider for the ancillary services. Any cost-sharing requirements shall be applied as though the ancillary services had been received from a participating provider. Cost sharing shall be calculated based on the recognized amount for the ancillary services. If the cost sharing for the same item or service furnished by a participating provider would have been a flat-dollar copayment, that amount shall be the cost-sharing amount unless the provider has billed a lesser total amount. In no event shall the beneficiary, insured, enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the participating health care facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the ancillary services delivered. In addition to ancillary services, the requirements of this paragraph shall also apply with respect to covered items or services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the nonparticipating provider satisfied the notice and consent criteria under paragraph (2) of this subsection.
        (2) When a beneficiary, insured, or enrollee utilizes
    
a participating health care facility and receives non-emergency covered health care services other than those described in paragraph (1) of this subsection from a nonparticipating provider during or resulting from the visit, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee incurs no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider unless the nonparticipating provider or the participating health care facility on behalf of the nonparticipating provider satisfies the notice and consent criteria provided in 42 U.S.C. 300gg-132 and regulations promulgated thereunder. If the notice and consent criteria are not satisfied, then:
            (A) any cost-sharing requirements shall be
        
applied as though the health care services had been received from a participating provider;
            (B) cost sharing shall be calculated based on
        
the recognized amount for the health care services; and
            (C) in no event shall the beneficiary, insured,
        
enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the participating health care facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the health care services delivered.
    (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

    (215 ILCS 5/356z.4)
    Sec. 356z.4. Coverage for contraceptives.
    (a)(1) The General Assembly hereby finds and declares all of the following:
        (A) Illinois has a long history of expanding
    
timely access to birth control to prevent unintended pregnancy.
        (B) The federal Patient Protection and Affordable
    
Care Act includes a contraceptive coverage guarantee as part of a broader requirement for health insurance to cover key preventive care services without out-of-pocket costs for patients.
        (C) The General Assembly intends to build on
    
existing State and federal law to promote gender equity and women's health and to ensure greater contraceptive coverage equity and timely access to all federal Food and Drug Administration approved methods of birth control for all individuals covered by an individual or group health insurance policy in Illinois.
        (D) Medical management techniques such as denials,
    
step therapy, or prior authorization in public and private health care coverage can impede access to the most effective contraceptive methods.
    (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
    
(A) contain identical amounts of the same active drug ingredient in the same dosage form and route of administration and (B) meet compendial or other applicable standards of strength, quality, purity, and identity;
        (iii) they are bioequivalent in that (A) they do not
    
present a known or potential bioequivalence problem and they meet an acceptable in vitro standard or (B) if they do present such a known or potential problem, they are shown to meet an appropriate bioequivalence standard;
        (iv) they are adequately labeled; and
        (v) they are manufactured in compliance with Current
    
Good Manufacturing Practice regulations.
    (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
    
products approved by the United States Food and Drug Administration. This includes all over-the-counter contraceptive drugs, devices, and products approved by the United States Food and Drug Administration, excluding male condoms, except as provided in the current comprehensive guidelines supported by the Health Resources and Services Administration. The following apply:
            (i) If the United States Food and Drug
        
Administration has approved one or more therapeutic equivalent versions of a contraceptive drug, device, or product, a policy is not required to include all such therapeutic equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing and in accordance with this Section.
            (ii) If an individual's attending provider
        
recommends a particular service or item approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. The plan or issuer must defer to the determination of the attending provider.
            (iii) If a drug, device, or product is not
        
covered, plans and issuers must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or other individual acting as a patient's authorized representative to ensure coverage without cost sharing.
            (iv) This coverage must provide for the
        
dispensing of 12 months' worth of contraception at one time.
        (B) Voluntary sterilization procedures.
        (C) Contraceptive services, patient education, and
    
counseling on contraception.
        (D) Follow-up services related to the drugs,
    
devices, products, and procedures covered under this Section, including, but not limited to, management of side effects, counseling for continued adherence, and device insertion and removal.
    (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

    (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

    (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

    (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

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

215 ILCS 5/356z.7

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

215 ILCS 5/356z.8

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

215 ILCS 5/356z.9

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

215 ILCS 5/356z.10

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

215 ILCS 5/356z.11

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

215 ILCS 5/356z.12

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

215 ILCS 5/356z.13

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

215 ILCS 5/356z.14

    (215 ILCS 5/356z.14)
    Sec. 356z.14. Autism spectrum disorders.
    (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after December 12, 2008 (the effective date of Public Act 95-1005) must provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the policy of accident and health insurance or managed care plan.
    (b) Coverage provided under this Section shall be subject to a maximum benefit of $36,000 per year, but shall not be subject to any limits on the number of visits to a service provider. After December 30, 2009, the Director of the Division of Insurance shall, on an annual basis, adjust the maximum benefit for inflation using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition not diagnosed as an autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.
    (c) Coverage under this Section shall be subject to copayment, deductible, and coinsurance provisions of a policy of accident and health insurance or managed care plan to the extent that other medical services covered by the policy of accident and health insurance or managed care plan are subject to these provisions.
    (d) This Section shall not be construed as limiting benefits that are otherwise available to an individual under a policy of accident and health insurance or managed care plan and benefits provided under this Section may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally.
    (e) An insurer may not deny or refuse to provide otherwise covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract to provide services to an individual because the individual or their dependent is diagnosed with an autism spectrum disorder or due to the individual utilizing benefits in this Section.
    (e-5) An insurer may not deny or refuse to provide otherwise covered services under a group or individual policy of accident and health insurance or a managed care plan solely because of the location wherein the clinically appropriate services are provided.
    (f) Upon request of the reimbursing insurer, a provider of treatment for autism spectrum disorders shall furnish medical records, clinical notes, or other necessary data that substantiate that initial or continued medical treatment is medically necessary and is resulting in improved clinical status. When treatment is anticipated to require continued services to achieve demonstrable progress, the insurer may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated outcomes stated as goals, and the frequency by which the treatment plan will be updated.
    (g) When making a determination of medical necessity for a treatment modality for autism spectrum disorders, an insurer must make the determination in a manner that is consistent with the manner used to make that determination with respect to other diseases or illnesses covered under the policy, including an appeals process. During the appeals process, any challenge to medical necessity must be viewed as reasonable only if the review includes a physician with expertise in the most current and effective treatment modalities for autism spectrum disorders.
    (h) Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists, as defined in 89 Ill. Adm. Code 500 and any subsequent amendments thereto.
    (h-5) If an individual has been diagnosed as having an autism spectrum disorder, meeting the diagnostic criteria in place at the time of diagnosis, and treatment is determined medically necessary, then that individual shall remain eligible for coverage under this Section even if subsequent changes to the diagnostic criteria are adopted by the American Psychiatric Association. If no changes to the diagnostic criteria are adopted after April 1, 2012, and before December 31, 2014, then this subsection (h-5) shall be of no further force and effect.
    (h-10) An insurer may not deny or refuse to provide covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract, for a person diagnosed with an autism spectrum disorder on the basis that the individual declined an alternative medication or covered service when the individual's health care provider has determined that such medication or covered service may exacerbate clinical symptomatology and is medically contraindicated for the individual and the individual has requested and received a medical exception as provided for under Section 45.1 of the Managed Care Reform and Patient Rights Act. For the purposes of this subsection (h-10), "clinical symptomatology" means any indication of disorder or disease when experienced by an individual as a change from normal function, sensation, or appearance.
    (h-15) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage outlined in subsection (h-10), then subsection (h-10) is inoperative with respect to all coverage outlined in subsection (h-10) other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage set forth in subsection (h-10).
    (i) As used in this Section:
    "Autism spectrum disorders" means pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autism, Asperger's disorder, and pervasive developmental disorder not otherwise specified.
    "Diagnosis of autism spectrum disorders" means one or more tests, evaluations, or assessments to diagnose whether an individual has autism spectrum disorder that is prescribed, performed, or ordered by (A) a physician licensed to practice medicine in all its branches or (B) a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders.
    "Medically necessary" means any care, treatment, intervention, service or item which will or is reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, disease, or disability; (ii) reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury, disease, or disability; or (iii) assist to achieve or maintain maximum functional activity in performing daily activities.
    "Treatment for autism spectrum disorders" shall include the following care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder by (A) a physician licensed to practice medicine in all its branches or (B) a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches:
        (1) Psychiatric care, meaning direct, consultative,
    
or diagnostic services provided by a licensed psychiatrist.
        (2) Psychological care, meaning direct or
    
consultative services provided by a licensed psychologist.
        (3) Habilitative or rehabilitative care, meaning
    
professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are intended to develop, maintain, and restore the functioning of an individual. As used in this subsection (i), "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
        (4) Therapeutic care, including behavioral, speech,
    
occupational, and physical therapies that provide treatment in the following areas: (i) self care and feeding, (ii) pragmatic, receptive, and expressive language, (iii) cognitive functioning, (iv) applied behavior analysis, intervention, and modification, (v) motor planning, and (vi) sensory processing.
    (j) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 102-322, eff. 1-1-22; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.15

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

    (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

    (215 ILCS 5/356z.17)
    Sec. 356z.17. Wellness coverage.
    (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after January 1, 2010 (the effective date of Public Act 96-639) that provides coverage for hospital or medical treatment on an expense incurred basis may offer a reasonably designed program for wellness coverage that allows for a reward, a contribution, a reduction in premiums or reduced medical, prescription drug, or equipment copayments, coinsurance, or deductibles, or a combination of these incentives, for participation in any health behavior wellness, maintenance, or improvement program approved or offered by the insurer or managed care plan. The insured or enrollee may be required to provide evidence of participation in a program. Individuals unable to participate in these incentives due to an adverse health factor shall not be penalized based upon an adverse health status.
    (b) For purposes of this Section, "wellness coverage" means health care coverage with the primary purpose to engage and motivate the insured or enrollee through: incentives; provision of health education, counseling, and self-management skills; identification of modifiable health risks; and other activities to influence health behavior changes.
    For the purposes of this Section, "reasonably designed program" means a program of wellness coverage that has a reasonable chance of improving health or preventing disease; is not overly burdensome; does not discriminate based upon factors of health; and is not otherwise contrary to law.
    (c) Incentives as outlined in this Section are specific and unique to the offering of wellness coverage and have no application to any other required or optional health care benefit.
    (d) Such wellness coverage must satisfy the requirements for an exception from the general prohibition against discrimination based on a health factor under the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191; 110 Stat. 1936), including any federal regulations that are adopted pursuant to that Act.
    (e) A plan offering wellness coverage must do the following:
        (i) give participants the opportunity to qualify for
    
offered incentives at least once a year;
        (ii) allow a reasonable alternative to any individual
    
for whom it is unreasonably difficult, due to a medical condition, to satisfy otherwise applicable wellness program standards. Plans may seek physician verification that health factors make it unreasonably difficult or medically inadvisable for the participant to satisfy the standards; and
        (iii) not provide a total incentive that exceeds 30%
    
of the cost of self-only or employee-only coverage, except that the incentive may be increased by up to an additional 20%, for a total incentive of 50%, to the extent that the additional percentage is in connection with a program designed to prevent or reduce tobacco use. The cost of employee-only or family coverage provided through group health insurance coverage includes both employer and employee contributions. For group or individual plans offering family coverage, the limitation applies to cost of family coverage and applies to the entire family.
    (f) A reward, contribution, or reduction established under this Section and included in the policy or certificate does not violate Section 151 of this Code.
(Source: P.A. 102-462, eff. 8-20-21.)

215 ILCS 5/356z.18

    (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

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

215 ILCS 5/356z.20

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

215 ILCS 5/356z.21

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

215 ILCS 5/356z.22

    (215 ILCS 5/356z.22)
    Sec. 356z.22. Coverage for telehealth services.
    (a) For purposes of this Section:
    "Asynchronous store and forward system" has the meaning given to that term in Section 5 of the Telehealth Act.
    "Distant site" has the meaning given to that term in Section 5 of the Telehealth Act.
    "E-visits" has the meaning given to that term in Section 5 of the Telehealth Act.
    "Facility" means any hospital facility licensed under the Hospital Licensing Act or the University of Illinois Hospital Act, a federally qualified health center, a community mental health center, a behavioral health clinic, a substance use disorder treatment program licensed by the Division of Substance Use Prevention and Recovery of the Department of Human Services, or other building, place, or institution that is owned or operated by a person that is licensed or otherwise authorized to deliver health care services.
    "Health care professional" has the meaning given to that term in Section 5 of the Telehealth Act.
    "Interactive telecommunications system" has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, "interactive telecommunications system" does not include virtual check-ins.
    "Originating site" has the meaning given to that term in Section 5 of the Telehealth Act.
    "Telehealth services" has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, "telehealth services" do not include asynchronous store and forward systems, remote patient monitoring technologies, e-visits, or virtual check-ins.
    "Virtual check-in" has the meaning given to that term in Section 5 of the Telehealth Act.
    (b) An individual or group policy of accident or health insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall cover telehealth services, e-visits, and virtual check-ins rendered by a health care professional when clinically appropriate and medically necessary to insureds, enrollees, and members in the same manner as any other benefits covered under the policy. An individual or group policy of accident or health insurance may provide reimbursement to a facility that serves as the originating site at the time a telehealth service is rendered.
    (c) To ensure telehealth service, e-visit, and virtual check-in access is equitable for all patients in receipt of health care services under this Section and health care professionals and facilities are able to deliver medically necessary services that can be appropriately delivered via telehealth within the scope of their licensure or certification, coverage required under this Section shall comply with all of the following:
        (1) An individual or group policy of accident or
    
health insurance shall not:
            (A) require that in-person contact occur between
        
a health care professional and a patient before the provision of a telehealth service;
            (B) require patients, health care professionals,
        
or facilities to prove or document a hardship or access barrier to an in-person consultation for coverage and reimbursement of telehealth services, e-visits, or virtual check-ins;
            (C) require the use of telehealth services,
        
e-visits, or virtual check-ins when the health care professional has determined that it is not appropriate;
            (D) require the use of telehealth services when
        
a patient chooses an in-person consultation;
            (E) require a health care professional to be
        
physically present in the same room as the patient at the originating site, unless deemed medically necessary by the health care professional providing the telehealth service;
            (F) create geographic or facility restrictions
        
or requirements for telehealth services, e-visits, or virtual check-ins;
            (G) require health care professionals or
        
facilities to offer or provide telehealth services, e-visits, or virtual check-ins;
            (H) require patients to use telehealth
        
services, e-visits, or virtual check-ins, or require patients to use a separate panel of health care professionals or facilities to receive telehealth service, e-visit, or virtual check-in coverage and reimbursement; or
            (I) impose upon telehealth services, e-visits,
        
or virtual check-ins utilization review requirements that are unnecessary, duplicative, or unwarranted or impose any treatment limitations, prior authorization, documentation, or recordkeeping requirements that are more stringent than the requirements applicable to the same health care service when rendered in-person, except procedure code modifiers may be required to document telehealth.
        (2) Deductibles, copayments, coinsurance, or any
    
other cost-sharing applicable to services provided through telehealth shall not exceed the deductibles, copayments, coinsurance, or any other cost-sharing required by the individual or group policy of accident or health insurance for the same services provided through in-person consultation.
        (3) An individual or group policy of accident or
    
health insurance shall notify health care professionals and facilities of any instructions necessary to facilitate billing for telehealth services, e-visits, and virtual check-ins.
    (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

    (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

    (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

    (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

    (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
    
policy's clinical coverage policy or have been approved by a formulary exceptions process;
        (2) the prescription drugs are maintenance
    
medications as defined by the policy and have available refill quantities at the time of synchronization;
        (3) the medications are not Schedule II, III, or IV
    
controlled substances;
        (4) the insured meets all utilization management
    
criteria specific to the prescription drugs at the time of synchronization;
        (5) the prescription drugs are of a formulation that
    
can be safely split into short-fill periods to achieve synchronization; and
        (6) the prescription drugs do not have special
    
handling or sourcing needs as determined by the policy, contract, or agreement that require a single, designated pharmacy to fill or refill the prescription.
    (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

    (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

    (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

    (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

    (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
    
ear every 36 months;
        (2) related services, such as audiological exams and
    
selection, fitting, and adjustment of ear molds to maintain optimal fit shall be covered when deemed medically necessary by a hearing care professional; and
        (3) hearing instrument repairs may be covered when
    
deemed medically necessary.
    (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
    
ear every 36 months;
        (2) related services, such as audiological exams and
    
selection, fitting, and adjustment of ear molds to maintain optimal fit shall be covered when deemed medically necessary by a hearing care professional; and
        (3) hearing instrument repairs may be covered when
    
deemed medically necessary.
    (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

    (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

    (215 ILCS 5/356z.31)
    Sec. 356z.31. Recovery housing for persons with substance use disorders.
    (a) Definitions. As used in this Section:
    "Substance use disorder" and "case management" have the meanings ascribed to those terms in Section 1-10 of the Substance Use Disorder Act.
    "Hospital" means a facility licensed by the Department of Public Health under the Hospital Licensing Act.
    "Federally qualified health center" means a facility as defined in Section 1905(l)(2)(B) of the federal Social Security Act.
    "Recovery housing" means a residential extended care treatment facility or a recovery home as defined and licensed in 77 Illinois Administrative Code, Part 2060, by the Illinois Department of Human Services, Division of Substance Use Prevention and Recovery.
    (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2019 (the effective date of Public Act 100-1065) may provide coverage for residential extended care services and supports for persons recovery housing for persons with substance use disorders who are at risk of a relapse following discharge from a health care clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department so long as all of the following conditions are met:
        (1) A health care clinic, federally qualified health
    
center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department has conducted an individualized assessment, using criteria established by the American Society of Addiction Medicine, of the person's condition prior to discharge and has identified the person as being at risk of a relapse and in need of supportive services, including employment and training and case management, to maintain long-term recovery. A determination of whether a person is in need of supportive services shall also be based on whether the person has a history of poverty, job insecurity, and lack of a safe and sober living environment.
        (2) The recovery housing is administered by a
    
community-based agency that is licensed by or under contract with the Department of Human Services, Division of Substance Use Prevention and Recovery.
        (3) The recovery housing is administered by a
    
community-based agency as described in paragraph (2) upon the referral of a health care clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department.
    (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
    
are in accordance with licensure standards promulgated by the Department of Human Services, Division of Substance Use Prevention and Recovery.
        (2) Transitional housing services, including food or
    
meal plans.
        (3) Individualized case management and referral
    
services, including case management and social services for the families of persons who are seeking treatment for a substance use disorder.
        (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
    
from a substance use disorder;
        (3) improve outcomes;
        (4) track persons with substance use disorders; and
        (5) improve the quality of life of persons with
    
substance use disorders through the utilization of sustainable recovery, education, employment, and housing services.
    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

    (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
    
fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.
        "May directly or indirectly cause" means the likely
    
possibility that treatment will cause a side effect of infertility, based upon current evidence-based standards of care established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other national medical associations that follow current evidence-based standards of care.
        "Standard fertility preservation services" means
    
procedures based upon current evidence-based standards of care established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other national medical associations that follow current evidence-based standards of care.
    (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

    (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

    (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

    (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
    
complications related to such an infection;
        (3) an infection with other strains of borrelia or a
    
tick-borne disease that is recognized by the United States Centers for Disease Control and Prevention; and
        (4) the presence of signs or symptoms compatible with
    
acute infection of borrelia or other tick-borne diseases.
    (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

    (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
    
psychosis treatment, covering the elements of the treatment model included in the most recent national research trials conducted by the National Institute of Mental Health in the Recovery After an Initial Schizophrenia Episode (RAISE) trials for psychosis resulting from a serious mental illness, but excluding the components of the treatment model related to education and employment support.
        (2) Assertive community treatment (ACT) and community
    
support team (CST) treatment. The elements of ACT and CST to be covered shall include those covered under Article V of the Illinois Public Aid Code, through 89 Ill. Adm. Code 140.453(d)(4).
    (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

    (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

    (215 ILCS 5/356z.38)
    Sec. 356z.38. Human breast milk coverage.
    (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under an individual or group health insurance for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
        (1) the milk is obtained from a human milk bank that
    
meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
        (2) the infant's mother is medically or physically
    
unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the infant's needs or the maternal breast milk is contraindicated;
        (3) the milk has been determined to be medically
    
necessary for the infant; and
        (4) one or more of the following applies:
            (A) the infant's birth weight is below 1,500
        
grams;
            (B) the infant has a congenital or acquired
        
condition that places the infant at a high risk for development of necrotizing enterocolitis;
            (C) the infant has infant hypoglycemia;
            (D) the infant has congenital heart disease;
            (E) the infant has had or will have an organ
        
transplant;
            (F) the infant has sepsis; or
            (G) the infant has any other serious congenital
        
or acquired condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the infant.
    (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
    
meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
        (2) the child's mother is medically or physically
    
unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
        (3) the milk has been determined to be medically
    
necessary for the child; and
        (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
        
grams and he or she has long-term feeding or gastrointestinal complications related to prematurity;
            (C) the child has had or will have an organ
        
transplant; or
            (D) the child has a congenital or acquired
        
condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the child.
(Source: P.A. 101-511, eff. 1-1-20; 102-558, eff. 8-20-21.)

215 ILCS 5/356z.39

    (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
    
validated tools; and
        (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

    (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
    
experiencing a high-risk pregnancy by the individual's treating provider shall have access to clinically appropriate case management programs. As used in this subsection, "case management" means a mechanism to coordinate and assure continuity of services, including, but not limited to, health services, social services, and educational services necessary for the individual. "Case management" involves individualized assessment of needs, planning of services, referral, monitoring, and advocacy to assist an individual in gaining access to appropriate services and closure when services are no longer required. "Case management" is an active and collaborative process involving a single qualified case manager, the individual, the individual's family, the providers, and the community. This includes close coordination and involvement with all service providers in the management plan for that individual or family, including assuring that the individual receives the services. As used in this subsection, "high-risk pregnancy" means a pregnancy in which the pregnant or postpartum individual or baby is at an increased risk for poor health or complications during pregnancy or childbirth, including, but not limited to, hypertension disorders, gestational diabetes, and hemorrhage.
        (2) An individual shall have access to medically
    
necessary treatment of a mental, emotional, nervous, or substance use disorder or condition consistent with the requirements set forth in this Section and in Sections 370c and 370c.1 of this Code.
        (3) The benefits provided for inpatient and
    
outpatient services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided if determined to be medically necessary, consistent with the requirements of Sections 370c and 370c.1 of this Code. The facility or provider shall notify the insurer of both the admission and the initial treatment plan within 48 hours after admission or initiation of treatment. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy.
        (4) The benefits for the first 48 hours of initiation
    
of services for an inpatient admission, detoxification or withdrawal management program, or partial hospitalization admission for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided without post-service or concurrent review of medical necessity, as the medical necessity for the first 48 hours of such services shall be determined solely by the covered pregnant or postpartum individual's provider. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review, including the review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy, of any inpatient admission, detoxification or withdrawal management program admission, or partial hospitalization admission services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications received 48 hours after the initiation of such services. If an insurer determines that the services are no longer medically necessary, then the covered person shall have the right to external review pursuant to the requirements of the Health Carrier External Review Act.
        (5) If an insurer determines that continued inpatient
    
care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment in a facility is no longer medically necessary, the insurer shall, within 24 hours, provide written notice to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider of its decision and the right to file an expedited internal appeal of the determination. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider. If the determination is to uphold the denial, the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider have the right to file an expedited external appeal. An independent utilization review organization shall make a determination within 72 hours. If the insurer's determination is upheld and it is determined that continued inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment is not medically necessary, the insurer shall remain responsible for providing benefits for the inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment through the day following the date the determination is made, and the covered pregnant or postpartum individual shall only be responsible for any applicable copayment, deductible, and coinsurance for the stay through that date as applicable under the policy. The covered pregnant or postpartum individual shall not be discharged or released from the inpatient facility, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment until all internal appeals and independent utilization review organization appeals are exhausted. A decision to reverse an adverse determination shall comply with the Health Carrier External Review Act.
        (6) Except as otherwise stated in this subsection
    
(b), the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.
        (7) The benefits required by paragraphs (2) and (6)
    
of this subsection (b) are to be provided to all covered pregnant or postpartum individuals with a diagnosis of a mental, emotional, nervous, or substance use disorder or condition. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this subsection (b).
(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
    
experiencing a high-risk pregnancy by the individual's treating provider shall have access to clinically appropriate case management programs. As used in this subsection, "case management" means a mechanism to coordinate and assure continuity of services, including, but not limited to, health services, social services, and educational services necessary for the individual. "Case management" involves individualized assessment of needs, planning of services, referral, monitoring, and advocacy to assist an individual in gaining access to appropriate services and closure when services are no longer required. "Case management" is an active and collaborative process involving a single qualified case manager, the individual, the individual's family, the providers, and the community. This includes close coordination and involvement with all service providers in the management plan for that individual or family, including assuring that the individual receives the services. As used in this subsection, "high-risk pregnancy" means a pregnancy in which the pregnant or postpartum individual or baby is at an increased risk for poor health or complications during pregnancy or childbirth, including, but not limited to, hypertension disorders, gestational diabetes, and hemorrhage.
        (2) An individual shall have access to medically
    
necessary treatment of a mental, emotional, nervous, or substance use disorder or condition consistent with the requirements set forth in this Section and in Sections 370c and 370c.1 of this Code.
        (3) The benefits provided for inpatient and
    
outpatient services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided if determined to be medically necessary, consistent with the requirements of Sections 370c and 370c.1 of this Code. The facility or provider shall notify the insurer of both the admission and the initial treatment plan within 48 hours after admission or initiation of treatment. Subject to the requirements of Sections 370c and 370c.1 of this Code, nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy.
        (4) The benefits for the first 48 hours of initiation
    
of services for an inpatient admission, detoxification or withdrawal management program, or partial hospitalization admission for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided without post-service or concurrent review of medical necessity, as the medical necessity for the first 48 hours of such services shall be determined solely by the covered pregnant or postpartum individual's provider. Subject to Section 370c and 370c.1 of this Code, nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review, including the review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy, of any inpatient admission, detoxification or withdrawal management program admission, or partial hospitalization admission services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications received 48 hours after the initiation of such services. If an insurer determines that the services are no longer medically necessary, then the covered person shall have the right to external review pursuant to the requirements of the Health Carrier External Review Act.
        (5) If an insurer determines that continued inpatient
    
care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment in a facility is no longer medically necessary, the insurer shall, within 24 hours, provide written notice to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider of its decision and the right to file an expedited internal appeal of the determination. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider. If the determination is to uphold the denial, the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider have the right to file an expedited external appeal. An independent review organization shall make a determination within 72 hours. If the insurer's determination is upheld and it is determined that continued inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment is not medically necessary, the insurer shall remain responsible for providing benefits for the inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment through the day following the date the determination is made, and the covered pregnant or postpartum individual shall only be responsible for any applicable copayment, deductible, and coinsurance for the stay through that date as applicable under the policy. The covered pregnant or postpartum individual shall not be discharged or released from the inpatient facility, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment until all internal appeals and independent utilization review organization appeals are exhausted. A decision to reverse an adverse determination shall comply with the Health Carrier External Review Act.
        (6) Except as otherwise stated in this subsection
    
(b), the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.
        (7) The benefits required by paragraphs (2) and (6)
    
of this subsection (b) are to be provided to all covered pregnant or postpartum individuals with a diagnosis of a mental, emotional, nervous, or substance use disorder or condition. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this subsection (b).
(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
    
experiencing a high-risk pregnancy by the individual's treating provider shall have access to clinically appropriate case management programs. As used in this subsection, "case management" means a mechanism to coordinate and assure continuity of services, including, but not limited to, health services, social services, and educational services necessary for the individual. "Case management" involves individualized assessment of needs, planning of services, referral, monitoring, and advocacy to assist an individual in gaining access to appropriate services and closure when services are no longer required. "Case management" is an active and collaborative process involving a single qualified case manager, the individual, the individual's family, the providers, and the community. This includes close coordination and involvement with all service providers in the management plan for that individual or family, including assuring that the individual receives the services. As used in this subsection, "high-risk pregnancy" means a pregnancy in which the pregnant or postpartum individual or baby is at an increased risk for poor health or complications during pregnancy or childbirth, including, but not limited to, hypertension disorders, gestational diabetes, and hemorrhage.
        (2) An individual shall have access to medically
    
necessary treatment of a mental, emotional, nervous, or substance use disorder or condition consistent with the requirements set forth in this Section and in Sections 370c and 370c.1 of this Code.
        (3) The benefits provided for inpatient and
    
outpatient services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided if determined to be medically necessary, consistent with the requirements of Sections 370c and 370c.1 of this Code. The facility or provider shall notify the insurer of both the admission and the initial treatment plan within 48 hours after admission or initiation of treatment. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy.
        (4) The benefits for the first 48 hours of initiation
    
of services for an inpatient admission, detoxification or withdrawal management program, or partial hospitalization admission for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided without post-service or concurrent review of medical necessity, as the medical necessity for the first 48 hours of such services shall be determined solely by the covered pregnant or postpartum individual's provider. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review, including the review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy, of any inpatient admission, detoxification or withdrawal management program admission, or partial hospitalization admission services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications received 48 hours after the initiation of such services. If an insurer determines that the services are no longer medically necessary, then the covered person shall have the right to external review pursuant to the requirements of the Health Carrier External Review Act.
        (5) If an insurer determines that continued inpatient
    
care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment in a facility is no longer medically necessary, the insurer shall, within 24 hours, provide written notice to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider of its decision and the right to file an expedited internal appeal of the determination. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider. If the determination is to uphold the denial, the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider have the right to file an expedited external appeal. An independent utilization review organization shall make a determination within 72 hours. If the insurer's determination is upheld and it is determined that continued inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment is not medically necessary, the insurer shall remain responsible for providing benefits for the inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment through the day following the date the determination is made, and the covered pregnant or postpartum individual shall only be responsible for any applicable copayment, deductible, and coinsurance for the stay through that date as applicable under the policy. The covered pregnant or postpartum individual shall not be discharged or released from the inpatient facility, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment until all internal appeals and independent utilization review organization appeals are exhausted. A decision to reverse an adverse determination shall comply with the Health Carrier External Review Act.
        (6) Except as otherwise stated in this subsection
    
(b), the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.
        (7) The benefits required by paragraphs (2) and (6)
    
of this subsection (b) are to be provided to (i) all covered pregnant or postpartum individuals with a diagnosis of a mental, emotional, nervous, or substance use disorder or condition and (ii) all individuals who have experienced a miscarriage or stillbirth. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this subsection (b).
(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
    
experiencing a high-risk pregnancy by the individual's treating provider shall have access to clinically appropriate case management programs. As used in this subsection, "case management" means a mechanism to coordinate and assure continuity of services, including, but not limited to, health services, social services, and educational services necessary for the individual. "Case management" involves individualized assessment of needs, planning of services, referral, monitoring, and advocacy to assist an individual in gaining access to appropriate services and closure when services are no longer required. "Case management" is an active and collaborative process involving a single qualified case manager, the individual, the individual's family, the providers, and the community. This includes close coordination and involvement with all service providers in the management plan for that individual or family, including assuring that the individual receives the services. As used in this subsection, "high-risk pregnancy" means a pregnancy in which the pregnant or postpartum individual or baby is at an increased risk for poor health or complications during pregnancy or childbirth, including, but not limited to, hypertension disorders, gestational diabetes, and hemorrhage.
        (2) An individual shall have access to medically
    
necessary treatment of a mental, emotional, nervous, or substance use disorder or condition consistent with the requirements set forth in this Section and in Sections 370c and 370c.1 of this Code.
        (3) The benefits provided for inpatient and
    
outpatient services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided if determined to be medically necessary, consistent with the requirements of Sections 370c and 370c.1 of this Code. The facility or provider shall notify the insurer of both the admission and the initial treatment plan within 48 hours after admission or initiation of treatment. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy.
        (4) The benefits for the first 48 hours of initiation
    
of services for an inpatient admission, detoxification or withdrawal management program, or partial hospitalization admission for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided without post-service or concurrent review of medical necessity, as the medical necessity for the first 48 hours of such services shall be determined solely by the covered pregnant or postpartum individual's provider. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review, including the review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy, of any inpatient admission, detoxification or withdrawal management program admission, or partial hospitalization admission services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications received 48 hours after the initiation of such services. If an insurer determines that the services are no longer medically necessary, then the covered person shall have the right to external review pursuant to the requirements of the Health Carrier External Review Act.
        (5) If an insurer determines that continued inpatient
    
care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment in a facility is no longer medically necessary, the insurer shall, within 24 hours, provide written notice to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider of its decision and the right to file an expedited internal appeal of the determination. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider. If the determination is to uphold the denial, the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider have the right to file an expedited external appeal. An independent utilization review organization shall make a determination within 72 hours. If the insurer's determination is upheld and it is determined that continued inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment is not medically necessary, the insurer shall remain responsible for providing benefits for the inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment through the day following the date the determination is made, and the covered pregnant or postpartum individual shall only be responsible for any applicable copayment, deductible, and coinsurance for the stay through that date as applicable under the policy. The covered pregnant or postpartum individual shall not be discharged or released from the inpatient facility, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment until all internal appeals and independent utilization review organization appeals are exhausted. A decision to reverse an adverse determination shall comply with the Health Carrier External Review Act.
        (6) Except as otherwise stated in this subsection (b)
    
and subsection (c), the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.
        (7) The benefits required by paragraphs (2) and (6)
    
of this subsection (b) are to be provided to all covered pregnant or postpartum individuals with a diagnosis of a mental, emotional, nervous, or substance use disorder or condition. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this subsection (b).
        (8) Insurers shall cover all services for pregnancy,
    
postpartum, and newborn care that are rendered by perinatal doulas or licensed certified professional midwives, including home births, home visits, and support during labor, abortion, or miscarriage. Coverage shall include the necessary equipment and medical supplies for a home birth. For home visits by a perinatal doula, not counting any home birth, the policy may limit coverage to 16 visits before and 16 visits after a birth, miscarriage, or abortion, provided that the policy shall not be required to cover more than $8,000 for doula visits for each pregnancy and subsequent postpartum period. As used in this paragraph (8), "perinatal doula" has the meaning given in subsection (a) of Section 5-18.5 of the Illinois Public Aid Code.
        (9) Coverage for pregnancy, postpartum, and newborn
    
care shall include home visits by lactation consultants and the purchase of breast pumps and breast pump supplies, including such breast pumps, breast pump supplies, breastfeeding supplies, and feeding aids as recommended by the lactation consultant. As used in this paragraph (9), "lactation consultant" means an International Board-Certified Lactation Consultant, a certified lactation specialist with a certification from Lactation Education Consultants, or a certified lactation counselor as defined in subsection (a) of Section 5-18.10 of the Illinois Public Aid Code.
        (10) Coverage for postpartum services shall apply for
    
all covered services rendered within the first 12 months after the end of pregnancy, subject to any policy limitation on home visits by a perinatal doula allowed under paragraph (8) of this subsection (b). Nothing in this paragraph (10) shall be construed to require a policy to cover services for an individual who is no longer insured or enrolled under the policy. If an individual becomes insured or enrolled under a new policy, the new policy shall cover the individual consistent with the time period and limitations allowed under this paragraph (10). This paragraph (10) is subject to the requirements of Section 25 of the Managed Care Reform and Patient Rights Act, Section 20 of the Network Adequacy and Transparency Act, and 42 U.S.C. 300gg-113.
    (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

    (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

    (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

    (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

    (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

    (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
    
problems;
        (2) having conditions that affect fat absorption,
    
including celiac disease or weight loss surgery;
        (3) routinely taking medications that interfere
    
with vitamin D activity, including anticonvulsants and glucocorticoids;
        (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
    
disease; and
        (9) exhibiting poor muscle strength or constant
    
tiredness.
(Source: P.A. 102-530, eff. 1-1-22.)

215 ILCS 5/356z.45

    (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
    
of practice as set forth in Section 43 or Section 43.5 of the Pharmacy Practice Act;
        (2) the health plan provides coverage for the same
    
service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;
        (3) the pharmacist is included in the health
    
benefit plan's network of participating providers; and
        (4) a reimbursement has been successfully
    
negotiated in good faith between the pharmacist and the health plan.
(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

    (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
    
indicated tests for an FDA-approved drug;
        (2) federal Centers for Medicare and Medicaid
    
Services National Coverage Determinations;
        (3) nationally recognized clinical practice
    
guidelines;
        (4) consensus statements;
        (5) professional society recommendations;
        (6) peer-reviewed literature, biomedical compendia,
    
and other medical literature that meet the criteria of the National Institutes of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medicus, Medline, and MEDLARS database of Health Services Technology Assessment Research; and
        (7) peer-reviewed scientific studies published in
    
or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.
    (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

    (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

    (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

    (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
    
are not limited to, being overweight or obese, being aged 35 or older, having an immediate family member with type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.
        (2) Risk factors for type 1 diabetes may include,
    
but are not limited to, family history of diabetes.
        (3) Risk factors for type 2 diabetes may include,
    
but are not limited to, having prediabetes, being overweight or obese, being aged 35 or older, having an immediate family member with type 1 or type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.
(Source: P.A. 102-530, eff. 1-1-22; 102-813, eff. 5-13-22.)

215 ILCS 5/356z.50

    (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

    (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

    (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.)

215 ILCS 5/356z.54

    (215 ILCS 5/356z.54)
    Sec. 356z.54. Coverage for breast reduction surgery. 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 medically necessary breast reduction surgery.
(Source: P.A. 102-731, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.55

    (215 ILCS 5/356z.55)
    Sec. 356z.55. Coverage for cleft lip and cleft palate.
    (a) As used in this Section, "medically necessary care and treatment" to address congenital anomalies associated with a cleft lip or palate, or both, includes:
        (1) oral and facial surgery, including reconstructive
    
services and procedures necessary to improve and restore and maintain vital functions;
        (2) prosthetic treatment such as obturators, speech
    
appliances, and feeding appliances;
        (3) orthodontic treatment and management;
        (4) prosthodontic treatment and management; and
        (5) otolaryngology treatment and management.
    "Medically necessary care and treatment" does not include cosmetic surgery performed to reshape normal structures of the lip, jaw, palate, or other facial structures to improve appearance.
    (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2024 (the effective date of Public Act 102-768) shall provide coverage for the medically necessary care and treatment of cleft lip and palate for children under the age of 19. Coverage for cleft lip and palate care and treatment may impose the same deductible, coinsurance, or other cost-sharing limitation that is imposed on other related surgical benefits under the policy.
    (c) This Section does not apply to a policy that covers only dental care.
(Source: P.A. 102-768, eff. 1-1-24; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.56

    (215 ILCS 5/356z.56)
    (Text of Section before amendment by P.A. 103-703)
    Sec. 356z.56. Coverage for hormone therapy to treat menopause. 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 medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy.
(Source: P.A. 102-804, eff. 1-1-23; 103-154, eff. 6-30-23.)
 
    (Text of Section after amendment by P.A. 103-703)
    Sec. 356z.56. Coverage for hormonal and non-hormonal therapy to treat menopause. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed in this State shall provide coverage for medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy. This coverage applies only to coverage provided on or after January 1, 2024 and before January 1, 2026.
    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, 2026 shall provide coverage for medically necessary hormonal and non-hormonal therapy to treat menopausal symptoms if the therapy is recommended by a qualified health care provider who is licensed, accredited, or certified under Illinois law and the therapy has been proven safe and effective in peer-reviewed scientific studies. Coverage for therapy to treat menopausal symptoms shall include all federal Food and Drug Administration-approved modalities of hormonal and non-hormonal administration, including, but not limited to, oral, transdermal, topical, and vaginal rings.
(Source: P.A. 102-804, eff. 1-1-23; 103-154, eff. 6-30-23; 103-703, eff. 1-1-26.)

215 ILCS 5/356z.57

    (215 ILCS 5/356z.57)
    Sec. 356z.57. Pediatric palliative care.
    (a) A group or individual policy of accident and health insurance or a managed care plan amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for community-based pediatric palliative care and hospice care. This care shall be delivered to any qualifying child with a serious illness by a trained interdisciplinary team that allows a child to receive community-based pediatric palliative care and hospice care while continuing to pursue curative treatment and disease-directed therapies for the qualifying illness.
    (b) As used in this Section, "palliative care" and "serious illness" have the same meaning as set forth in the Pediatric Palliative Care Act.
(Source: P.A. 102-860, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.58

    (215 ILCS 5/356z.58)
    Sec. 356z.58. Prenatal vitamins coverage. A group or individual policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 that provides coverage for prescription drugs shall provide coverage for prenatal vitamins when prescribed by a physician licensed to practice medicine in all of its branches or an advanced practice registered nurse licensed under the Nurse Practice Act.
(Source: P.A. 102-930, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.59

    (215 ILCS 5/356z.59)
    Sec. 356z.59. Coverage for continuous glucose monitors.
    (a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed before January 1, 2026 shall provide coverage for medically necessary continuous glucose monitors for individuals who are diagnosed with any form of diabetes mellitus and require insulin for the management of their diabetes. 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, 2026 shall provide coverage for continuous glucose monitors, related supplies, and training in the use of continuous glucose monitors for any individual if the following requirements are met:
        (1) the individual is diagnosed with diabetes
    
mellitus;
        (2) the continuous glucose monitor has been
    
prescribed by a physician licensed under the Medical Practice Act of 1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician;
        (3) the continuous glucose monitor has been
    
prescribed in accordance with the Food and Drug Administration's indications for use;
        (4) the prescriber has concluded that the individual
    
or individual's caregiver has sufficient training in using the continuous glucose monitor, which may be evidenced by the prescriber having prescribed a continuous glucose monitor, and has attested that the patient will be provided with that training;
        (5) the individual either:
            (A) uses insulin for treatment via one or more
        
injections or infusions of insulin per day, and only one injection or infusion of one type of insulin shall be sufficient utilization of insulin to qualify for a continuous glucose monitor under this Section; or
            (B) has reported a history of problematic
        
hypoglycemia with documentation to the individual's medical provider showing at least one of the following:
                (i) recurrent hypoglycemic events
            
characterized by an altered mental or physical state, despite multiple attempts to adjust medications or modify the diabetes treatment plan, as documented by a medical provider; or
                (ii) a history of at least one hypoglycemic
            
event characterized by an altered mental or physical state requiring third-party assistance for treatment of hypoglycemia, as documented by the individual's medical provider, which may be self-reported by the individual; third-party assistance shall not, in any event, be deemed to require that the individual had been admitted to a hospital or visited an emergency department; and
        (6) within 6 months prior to prescribing a continuous
    
glucose monitor, the medical provider prescribing the continuous glucose monitor had an in-person or covered telehealth visit with the individual to evaluate the individual's diabetes control and has determined that the criteria of paragraphs (1) through (5) are met.
    Notwithstanding any other provision of this Section, to qualify for a continuous glucose monitor under this Section, an individual is not required to have a diagnosis of uncontrolled diabetes; have a history of emergency room visits or hospitalizations; or show improved glycemic control.
    All continuous glucose monitors covered under this Section shall be approved for use by individuals, and the choice of device shall be made based upon the individual's circumstances and medical needs in consultation with the individual's medical provider, subject to the terms of the policy.
    (b) Any individual who is diagnosed with diabetes mellitus and meets the requirements of this Section shall not be required to obtain prior authorization for coverage for a continuous glucose monitor, and coverage shall be continuous once the continuous glucose monitor is prescribed.
    (c) 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, 2026 shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage of a one-month supply of continuous glucose monitors, including one transmitter if necessary, as provided under this Section. The provisions of this subsection do not apply to coverage under this Section 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. 23.
(Source: P.A. 102-1093, eff. 1-1-23; 103-154, eff. 6-30-23; 103-639, eff. 7-1-24.)

215 ILCS 5/356z.60

    (215 ILCS 5/356z.60)
    Sec. 356z.60. Coverage for abortifacients, hormonal therapy, and human immunodeficiency virus pre-exposure prophylaxis and post-exposure prophylaxis.
    (a) As used in this Section:
    "Abortifacients" means any medication administered to terminate a pregnancy as prescribed or ordered by a health care professional.
    "Health care professional" means a physician licensed to practice medicine in all of its branches, licensed advanced practice registered nurse, or physician assistant.
    "Hormonal therapy medication" means hormonal treatment administered to treat gender dysphoria.
    "Therapeutic equivalent version" means drugs, devices, or products that can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling and that satisfy the following general criteria:
        (1) it is approved as safe and effective;
        (2) it is a pharmaceutical equivalent in that it:
            (A) contains identical amounts of the same
        
active drug ingredient in the same dosage form and route of administration; and
            (B) meets compendial or other applicable
        
standards of strength, quality, purity, and identity;
        (3) it is bioequivalent in that:
            (A) it does not present a known or potential
        
bioequivalence problem and it meets an acceptable in vitro standard; or
            (B) if it does present such a known or
        
potential problem, it is shown to meet an appropriate bioequivalence standard;
        (4) it is adequately labeled; and
        (5) it is manufactured in compliance with Current
    
Good Manufacturing Practice regulations adopted by the United States Food and Drug Administration.
    (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2024 shall provide coverage for all abortifacients, hormonal therapy medication, human immunodeficiency virus pre-exposure prophylaxis, and post-exposure prophylaxis drugs approved by the United States Food and Drug Administration, and follow-up services related to that coverage, including, but not limited to, management of side effects, medication self-management or adherence counseling, risk reduction strategies, and mental health counseling. This coverage shall include drugs approved by the United States Food and Drug Administration that are prescribed or ordered for off-label use for the purposes described in this Section.
    (c) The coverage required under subsection (b) is subject to the following conditions:
        (1) If the United States Food and Drug
    
Administration has approved one or more therapeutic equivalent versions of an abortifacient drug, a policy is not required to include all such therapeutic equivalent versions in its formulary so long as at least one is included and covered without cost sharing and in accordance with this Section.
        (2) If an individual's attending provider
    
recommends a particular drug approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must defer to the determination of the attending provider and must cover that service or item without cost sharing.
        (3) If a drug is not covered, plans and issuers
    
must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or other individual acting as a patient's authorized representative to ensure coverage without cost sharing.
    The conditions listed under this subsection (c) also apply to drugs prescribed for off-label use as abortifacients.
    (d) Except as otherwise provided in this Section, a policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided. The provisions of this subsection do not apply to coverage of procedures to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 223.
    (e) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section.
    (f) The coverage requirements in this Section for abortifacients do not, pursuant to 42 U.S.C. 18054(a)(6), apply to a multistate plan that does not provide coverage for abortion.
    (g) If the Department concludes that enforcement of any coverage requirement of this Section for abortifacients may adversely affect the allocation of federal funds to this State, the Department may grant an exemption to that requirement, but only to the minimum extent necessary to ensure the continued receipt of federal funds.
(Source: P.A. 102-1117, eff. 1-13-23; 103-462, eff. 8-4-23.)

215 ILCS 5/356z.61

    (215 ILCS 5/356z.61)
    (Text of Section from P.A. 103-605)
    Sec. 356z.61. Coverage for liver disease screening. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for preventative liver disease screenings for individuals 35 years of age or older and under the age of 65 at high risk for liver disease, including liver ultrasounds and alpha-fetoprotein blood tests every 6 months, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this Section does not apply to coverage of liver disease screenings to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(Source: P.A. 103-84, eff. 1-1-24; 103-605, eff. 7-1-24.)
 
    (Text of Section from P.A. 103-753)
    Sec. 356z.61. Wigs and hair prostheses. A group or individual plan of accident and health insurance or managed care plan amended, delivered, issued, or renewed after January 1, 2026 must provide coverage, no less than once every 12 months, for one wig or other scalp prosthesis worn for hair loss caused by alopecia, chemotherapy, or radiation treatment for cancer or other conditions.
(Source: P.A. 103-753, eff. 8-2-24.)

215 ILCS 5/356z.62

    (215 ILCS 5/356z.62)
    Sec. 356z.62. Coverage of preventive health services.
    (a) A policy of group health insurance coverage or individual health insurance coverage as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act shall, at a minimum, provide coverage for and shall not impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for:
        (1) evidence-based items or services that have in
    
effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;
        (2) immunizations that have in effect a
    
recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;
        (3) with respect to infants, children, and
    
adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
        (4) with respect to women, such additional preventive
    
care and screenings not described in paragraph (1) of this subsection (a) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.
    (b) For purposes of this Section, and for purposes of any other provision of State law, recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current.
    (c) For office visits:
        (1) if an item or service described in subsection (a)
    
is billed separately or is tracked as individual encounter data separately from an office visit, then a policy may impose cost-sharing requirements with respect to the office visit;
        (2) if an item or service described in subsection (a)
    
is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a policy may not impose cost-sharing requirements with respect to the office visit; and
        (3) if an item or service described in subsection (a)
    
is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a policy may impose cost-sharing requirements with respect to the office visit.
    (d) A policy must provide coverage pursuant to subsection (a) for plan or policy years that begin on or after the date that is one year after the date the recommendation or guideline is issued. If a recommendation or guideline is in effect on the first day of the plan or policy year, the policy shall cover the items and services specified in the recommendation or guideline through the last day of the plan or policy year unless either:
        (1) a recommendation under paragraph (1) of
    
subsection (a) is downgraded to a "D" rating; or
        (2) the item or service is subject to a safety recall
    
or is otherwise determined to pose a significant safety concern by a federal agency authorized to regulate the item or service during the plan or policy year.
    (e) Network limitations.
        (1) Subject to paragraph (3) of this subsection,
    
nothing in this Section requires coverage for items or services described in subsection (a) that are delivered by an out-of-network provider under a health maintenance organization health care plan, other than a point-of-service contract, or under a voluntary health services plan that generally excludes coverage for out-of-network services except as otherwise required by law.
        (2) Subject to paragraph (3) of this subsection,
    
nothing in this Section precludes a policy with a preferred provider program under Article XX-1/2 of this Code, a health maintenance organization point-of-service contract, or a similarly designed voluntary health services plan from imposing cost-sharing requirements for items or services described in subsection (a) that are delivered by an out-of-network provider.
        (3) If a policy does not have in its network a
    
provider who can provide an item or service described in subsection (a), then the policy must cover the item or service when performed by an out-of-network provider and it may not impose cost-sharing with respect to the item or service.
    (f) Nothing in this Section prevents a company from using reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in subsection (a) to the extent not specified in the recommendation or guideline.
    (g) Nothing in this Section shall be construed to prohibit a policy from providing coverage for items or services in addition to those required under subsection (a) or from denying coverage for items or services that are not required under subsection (a). Unless prohibited by other law, a policy may impose cost-sharing requirements for a treatment not described in subsection (a) even if the treatment results from an item or service described in subsection (a). Nothing in this Section shall be construed to limit coverage requirements provided under other law.
    (h) The Director may develop guidelines to permit a company to utilize value-based insurance designs. In the absence of guidelines developed by the Director, any such guidelines developed by the Secretary of the U.S. Department of Health and Human Services that are in force under 42 U.S.C. 300gg-13 shall apply.
    (i) For student health insurance coverage as defined at 45 CFR 147.145, student administrative health fees are not considered cost-sharing requirements with respect to preventive services specified under subsection (a). As used in this subsection, "student administrative health fee" means a fee charged by an institution of higher education on a periodic basis to its students to offset the cost of providing health care through health clinics regardless of whether the students utilize the health clinics or enroll in student health insurance coverage.
    (j) For any recommendation or guideline specifically referring to women or men, a company shall not deny or limit the coverage required or a claim made under subsection (a) based solely on the individual's recorded sex or actual or perceived gender identity, or for the reason that the individual is gender nonconforming, intersex, transgender, or has undergone, or is in the process of undergoing, gender transition, if, notwithstanding the sex or gender assigned at birth, the covered individual meets the conditions for the recommendation or guideline at the time the item or service is furnished.
    (k) This Section does not apply to grandfathered health plans, excepted benefits, or short-term, limited-duration health insurance coverage.
(Source: P.A. 103-551, eff. 8-11-23.)

215 ILCS 5/356z.63

    (215 ILCS 5/356z.63)
    Sec. 356z.63. Coverage of pharmacy testing, screening, vaccinations, and treatment. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for health care or patient care services provided by a pharmacist if:
        (1) the pharmacist meets the requirements and scope
    
of practice described in paragraph (15), (16), or (17) of subsection (d) of Section 3 of the Pharmacy Practice Act;
        (2) the health plan provides coverage for the same
    
service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;
        (3) the pharmacist is included in the health benefit
    
plan's network of participating providers; and
        (4) reimbursement has been successfully negotiated in
    
good faith between the pharmacist and the health plan.
(Source: P.A. 103-1, eff. 4-27-23; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.64

    (215 ILCS 5/356z.64)
    Sec. 356z.64. Coverage for compression sleeves. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for compression sleeves that are medically necessary for the enrollee to prevent or mitigate lymphedema.
(Source: P.A. 103-91, eff. 1-1-24; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.65

    (215 ILCS 5/356z.65)
    Sec. 356z.65. Coverage for reconstructive services.
    (a) As used in this Section, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance.
    (b) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 may not deny coverage for medically necessary reconstructive services that are intended to restore physical appearance.
(Source: P.A. 103-123, eff. 1-1-24; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.66

    (215 ILCS 5/356z.66)
    Sec. 356z.66. Proton beam therapy.
    (a) As used in this Section:
    "Medically necessary" has the meaning given to that term in the Prior Authorization Reform Act.
    "Proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells.
    "Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.
    (b) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage for the treatment of cancer shall not apply a higher standard of clinical evidence for the coverage of proton beam therapy than the insurer applies for the coverage of any other form of radiation therapy treatment.
    (c) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage or benefits to any resident of this State for radiation oncology shall include coverage or benefits for medically necessary proton beam therapy for the treatment of cancer.
(Source: P.A. 103-325, eff. 1-1-24; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.67

    (215 ILCS 5/356z.67)
    Sec. 356z.67. Coverage of prescription estrogen.
    (a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 and that provides coverage for prescription drugs shall include coverage for one or more therapeutic equivalent versions of vaginal estrogen in its formulary.
    (b) If a particular vaginal estrogen product or its therapeutic equivalent version approved by the United States Food and Drug Administration is determined to be medically necessary, the issuer must cover that service or item pursuant to the cost-sharing requirement contained in subsection (c).
    (c) A policy subject to this Section shall not impose a deductible, copayment, or any other cost sharing requirement that exceeds any deductible, coinsurance, copayment, or any other cost-sharing requirement imposed on any prescription drug authorized for the treatment of erectile dysfunction covered by the policy; except that this subsection does not apply to coverage of vaginal estrogen to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
    (d) As used in this Section, "therapeutic equivalent version" has the meaning given to that term in paragraph (2) of subsection (a) of Section 356z.4.
(Source: P.A. 103-420, eff. 1-1-24; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.68

    (215 ILCS 5/356z.68)
    Sec. 356z.68. Home saliva cancer screening.
    (a) As used in this Section, "home saliva cancer screening" means an outpatient test that utilizes an individual's saliva to detect biomarkers for early-stage cancer.
    (b) An individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2025 shall cover a medically necessary home saliva cancer screening every 24 months if the patient:
        (1) is asymptomatic and at high risk for the disease
    
being tested for; or
        (2) demonstrates symptoms of the disease being tested
    
for at a physical exam.
(Source: P.A. 103-445, eff. 1-1-24; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.69

    (215 ILCS 5/356z.69)
    Sec. 356z.69. Coverage for children with neuromuscular, neurological, or cognitive impairment. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for therapy, diagnostic testing, and equipment necessary to increase quality of life for children who have been clinically or genetically diagnosed with any disease, syndrome, or disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.
(Source: P.A. 103-458, eff. 1-1-24; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.70

    (215 ILCS 5/356z.70)
    Sec. 356z.70. Coverage of no-cost mental health prevention and wellness visits.
    (a) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for one annual mental health prevention and wellness visit for children and for adults.
    (b) Mental health prevention and wellness visits shall include any age-appropriate screening recommended by the United States Preventive Services Task Force or by the American Academy of Pediatrics' Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents for purposes of identifying a mental health issue, condition, or disorder; discussing mental health symptoms that might be present, including symptoms of a previously diagnosed mental health condition or disorder; performing an evaluation of adverse childhood experiences; and discussing mental health and wellness.
    (c) A mental health prevention and wellness visit shall be covered for up to 60 minutes and may be performed by a physician licensed to practice medicine in all of its branches, a licensed clinical psychologist, a licensed clinical social worker, a licensed clinical professional counselor, a licensed marriage and family therapist, a licensed social worker, or a licensed professional counselor.
    (d) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement for mental health prevention and wellness visits. The cost-sharing prohibition in this subsection (d) does not apply to coverage of mental health prevention and wellness visits to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
    (e) A mental health prevention and wellness visit shall be in addition to an annual physical examination and shall not replace a well-child visit or a general health or medical visit.
    (f) A mental health prevention and wellness visit shall be reimbursed through the following American Medical Association current procedural terminology codes and at the same rate that current procedural terminology codes are reimbursed for the provision of other medical care: 99381-99387 and 99391-99397. The Department shall update the current procedural terminology codes through adoption of rules if the codes listed in this subsection are altered, amended, changed, deleted, or supplemented.
    (g) Reimbursement of any of the current procedural terminology codes listed in this Section shall comply with the following:
        (1) reimbursement may be adjusted for payment of
    
claims that are billed by a nonphysician clinician so long as the methodology to determine the adjustments are comparable to and applied no more stringently than the methodology for adjustments made for reimbursement of claims billed by nonphysician clinicians for other medical care, in accordance with 45 CFR 146.136(c)(4); and
        (2) for a mental health prevention and wellness visit
    
and for a service other than a mental health prevention and wellness visit, reimbursement shall not be denied if they occur on the same date by the same provider and the provider is a primary care provider.
    (h) A mental health prevention and wellness visit may be incorporated into and reimbursed within any type of integrated primary care service delivery method, including, but not limited to, a psychiatric collaborative care model as provided for under this Code.
    (i) The Department shall adopt any rules necessary to implement this Section by no later than October 31, 2024.
(Source: P.A. 103-535, eff. 8-11-23; 103-605, eff. 7-1-24.)

215 ILCS 5/356z.71

    (215 ILCS 5/356z.71)
    (Text of Section from P.A. 103-700)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 356z.71. Insurance coverage for dependent parents.
    (a) A group or individual policy of accident and health insurance issued, amended, delivered, or renewed after January 1, 2026 that provides dependent coverage shall make that dependent coverage available to the parent or stepparent of the insured if the parent or stepparent meets the definition of a qualifying relative under 26 U.S.C. 152(d) and lives or resides within the accident and health insurance policy's service area.
    (b) This Section does not apply to specialized health care service plans, Medicare supplement insurance, hospital-only policies, accident-only policies, or specified disease insurance policies that reimburse for hospital, medical, or surgical expenses.
(Source: P.A. 103-700, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-751)
    Sec. 356z.71. Coverage for annual menopause health visit. A group or individual policy of accident and health insurance providing coverage for more than 25 employees that is amended, delivered, issued, or renewed on or after January 1, 2026 shall provide, for individuals 45 years of age and older, coverage for an annual menopause health visit. 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 Section does not apply to this coverage to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(Source: P.A. 103-751, eff. 8-2-24.)
 
    (Text of Section from P.A. 103-758)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 356z.71. Coverage during a generic drug shortage.
    (a) As used in this Section:
    "Eligible prescription drug" means a prescription drug approved under 21 U.S.C. 355(c) that is not under patent.
    "Generic drug" means a drug that is approved pursuant to an application referencing an eligible prescription drug that is submitted under subsection (j) of Section 505 of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. 355(j).
    "Unavailable" means being listed as Currently in Shortage or as a Discontinuation in the United States Food and Drug Administration's Drug Shortages Database. "Unavailable" does not include being listed as a Resolved Shortage in the United States Food and Drug Administration's Drug Shortages Database.
    (b) If a generic drug or a therapeutic equivalent is unavailable due to a supply issue and dosage cannot be adjusted, a group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed after January 1, 2026 shall provide coverage for a brand name eligible prescription drug until supply of the generic drug or a therapeutic equivalent is available.
(Source: P.A. 103-758, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-870)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 356z.71. Coverage for at-home pregnancy tests. 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, 2026 shall provide coverage for at-home, urine-based pregnancy tests that are prescribed to the covered person, regardless of whether the tests are otherwise available over-the-counter. The coverage required under this Section is limited to 2 at-home, urine-based pregnancy tests every 30 days.
(Source: P.A. 103-870, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-918)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 356z.71. Coverage of vaccination administration fees.
    (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, 2026 shall provide coverage for vaccinations for COVID-19, influenza, and respiratory syncytial virus, including the administration of the vaccine by a pharmacist or health care provider authorized to administer such a vaccine, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement, if the following conditions are met:
        (1) the vaccine is authorized or licensed by the
    
United States Food and Drug Administration; and
        (2) the vaccine is ordered and administered according
    
to the Advisory Committee on Immunization Practices standard immunization schedule.
    (b) If the vaccinations provided for in subsection (a) are not otherwise available to be administered by a contracted pharmacist or health care provider, the group or individual policy of accident and health insurance or a managed care plan shall cover the vaccination, including administration fees, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement.
    (c) The coverage required in this Section does not apply to the extent that the coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code of 1986.
(Source: P.A. 103-918, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-972)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 356z.71. Coverage for medically necessary care and treatment to address a major injury to the jaw either through an accident or disease.
    (a) In this Section, "medically necessary care and treatment to address a major injury to the jaw either through an accident or disease" includes:
        (1) oral and facial surgery, including reconstructive
    
services and procedures necessary to improve, restore, or maintain vital functions;
        (2) dental implants, crowns, or bridges;
        (3) prosthetic treatment such as obturators, speech
    
appliances, and feeding appliances;
        (4) orthodontic treatment and management;
        (5) prosthodontic treatment and management; and
        (6) otolaryngology treatment and management.
    (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2026 shall provide coverage for medically necessary care and treatment to address a major injury to the jaw either through an accident or disease. Coverage under this Section may impose the same deductibles, coinsurance, or other cost-sharing limitations that are imposed on other related benefits under the policy.
(Source: P.A. 103-972, eff. 1-1-25.)
 
    (Text of Section from P.A. 103-1024)
    (This Section may contain text from a Public Act with a delayed effective date)
    Sec. 356z.71. Coverage for mobile integrated health care services.
    (a) In this Section:
    "Eligible recipient" means an individual who has received hospital emergency department services 3 or more times in a period of 4 consecutive months in the past 12 months or an individual who has been identified by a health care provider as an individual for whom mobile integrated health care services would likely prevent admission or readmission to or would allow discharge from a hospital, behavioral health facility, acute care facility, or nursing facility.
    "Mobile integrated health care services" means medically necessary health services provided on-site by emergency medical services personnel, as defined in Section 5 of the Emergency Medical Services (EMS) Systems Act.
    "Mobile integrated health care services" includes health assessment, chronic disease monitoring and education, medication compliance, immunizations and vaccinations, laboratory specimen collection, hospital discharge follow-up care, and minor medical procedures as approved by the applicable EMS Medical Director.
    "Mobile integrated health care services" does not include nonemergency ambulance transport.
    (b) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026, shall provide coverage to an eligible recipient for medically necessary mobile integrated health care services.
(Source: P.A. 103-1024, eff. 1-1-25.)

215 ILCS 5/357.1

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

215 ILCS 5/357.2

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

215 ILCS 5/357.3

    (215 ILCS 5/357.3) (from Ch. 73, par. 969.3)
    Sec. 357.3. "TIME LIMIT ON CERTAIN DEFENSES:
    (1) After 2 years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such 2 year period."
    (The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial 2 year period, nor to limit the application of section 357.15 through section 357.19 in the event of misstatement with respect to age or occupation or other insurance.)
    A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue, may contain in lieu of the foregoing the following provisions (from which the clause in parentheses may be omitted at the company's option) under the caption "INCONTESTABLE":
    "After this policy has been in force for a period of 2 years during the lifetime of the insured (excluding any period during which the insured is a person with a disability), it shall become incontestable as to the statements contained in the application."
    (2) "No claim for loss incurred or disability (as defined in the policy) commencing after 2 years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy."
(Source: P.A. 99-143, eff. 7-27-15.)

215 ILCS 5/357.4

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

215 ILCS 5/357.5

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

215 ILCS 5/357.6

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

215 ILCS 5/357.7

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

215 ILCS 5/357.8

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

215 ILCS 5/357.9

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

215 ILCS 5/357.9a

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

215 ILCS 5/357.10

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

215 ILCS 5/357.11

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