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INSURANCE
(215 ILCS 5/) Illinois Insurance Code.

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 hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers' compensation insurance, or automobile medical payment insurance.
(Source: P.A. 103-512, eff. 1-1-25.)

215 ILCS 5/356z.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. 111148), 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.)