Section 2210.110  Governing Authority

 

The Program will be governed by the State Employees Group Insurance Act of 1971 [5 ILCS 375] and this Part.

 

Section 2210.120  Purpose and Application

 

The purpose of this Part is to give full effect to the purposes of the Act by providing for administration of a program of health benefits for persons in the service of the State of Illinois and their eligible dependents.

 

Section 2210.130  Definitions

 

Whenever used in this Part, the following terms shall have the meanings set forth in this Section, unless otherwise expressly provided:

 

“Act” means the State Employees Group Insurance Act of 1971.  [5 ILCS 375/1]

 

“Agency” means the Illinois Department of Central Management Services, or any successor agency responsible for administration of the Program.

 

“Annuitant” means an individual as defined by Section 3(b) of the Act. [5 ILCS 375/3(b)]

 

“Basic Program” or “Basic Health Plan” means the default health benefits plan, as determined by the Agency, offered to Employees, Annuitants, Retirees, and Survivors.

 

“Benefit Choice Period” means the annual open enrollment period, during which time members may elect to add or change benefits coverage options.

 

“COBRA” means the federal Consolidated Omnibus Budget Reconciliation Act [29 U.S.C. 1161] as amended.

 

“Commission” means the Commission on Government Forecasting and Accountability (COGFA).

 

“Compensation” means salary or wages payable as defined by Section 3(d) of the Act. [5 ILCS 375/3(d)]

 

“Department” means any department, institution, board, commission, officer, court or agency of the State government as defined by Section 3(g) of the Act. [5 ILCS 375/3(g)]

 

“Dependent” means an individual as defined in Section 3(h) of the Act. [5 ILCS 375/3(h)]

 

“Director” means the Director of the Agency.

 

“Employee” means an individual as defined by Section 3(k) of the Act. [5 ILCS 375/3(k)]

 

“HIRF” means the Health Insurance Reserve Fund.

 

“Member” means an individual as defined by Section 3(l) of the Act. [5 ILCS 375/3(l)]

 

“Normal Work Period” means a specified number of hours worked on a weekly or monthly basis, as established by the Director in cooperation with each Department.

 

“Optional Program” or “Optional Health Plan” means any health benefits plan, other than the Basic Program, offered to Employees, Annuitants, Retirees and Survivors.

 

“Part-time Employee” means an Employee who works in a position normally requiring actual performance of duty during 50% to 99% of a Normal Work Period.

 

“Plan Administrator” means a third party organization, company, or other entity responsible for performing duties related to the administration of a specific benefit option in accordance with the terms of a contract between such entity and Agency.

 

“Plan Participant” means a Member or Dependent properly enrolled and participating in the Program.

 

“Plan Year” means a period of time, typically 12 months in duration, on which the operation of the Program is based.

 

“Program” means the program of group health benefits, including the Basic Program and any Optional Programs, designed and/or contracted for by the Agency in accordance with the Act and this Part.

 

“Qualifying Change in Status” means an event recognized under Section 125 of the Internal Revenue Code (26 U.S.C. 125) for which the Program may permit changes in coverage elections outside of an Initial Enrollment Period or Annual Open Enrollment Period.

 

“Retired Employee” means an individual as defined in Section 3(p) of the Act. [5 ILCS 375/3(p)]

 

“Survivor” means an individual as defined in Section 3(q) of the Act. [5 ILCS 375/3(q)]

 

“TRAIL Program” means the program of group health benefits designed and/or contracted for by the Agency and made available for Medicare-primary members and their Medicare-primary dependents.

 

Section 2210.140  Records and Certifications

 

Each affected department of the State shall furnish records and other necessary certifications to the Director as necessary for the administration of the Program. These records and certifications shall be retained and provided as necessary by each Department (Section 15(e) of the Act).

 

Section 2210.150  Severability

 

If any provision of the Act or this Part, or application of the Act or this Part to any person or circumstance, is held invalid, that invalidity shall not affect other provisions or applications of the Act or this Part that can be given effect without the invalid application or provision. (Section 16 of the Act) To this end, the provisions of the Act and this Part are declared to be severable.

 

Section 2210.160  Conflicting Provisions

 

If any provision of this Part conflicts with a provision of the Act, the terms of the Act shall control. If any provision of this Part conflicts with a provision of the Benefits Handbook or other publication issued by the Agency, the terms of this Part shall control.

SUBPART B: ELIGIBILITY

 

Section 2210.210  Member Eligibility

 

a)         The following individuals are eligible to enroll in the Program as a Member:

 

1)         Employees

 

A)        Newly-hired Employees will be eligible as of the first day of active State service, and

 

B)        An Employee who would also otherwise be eligible as a Dependent must be enrolled as a Member.

 

2)         Retired Employees.  A Retired Employee who: 

 

A)        Is not Medicare-primary due to age or disability, and resides within the United States or a U.S. Territory, shall be eligible.

 

B)        Is Medicare-primary due to age or disability, and resides within the United States or a U.S. Territory, shall be eligible only for the TRAIL Program regardless of the Medicare eligibility status of an enrolled Dependent.

 

3)         Annuitants.  An Annuitant who: 

 

A)        Is not Medicare-primary due to age or disability, and resides within the United States or a U.S. Territory, shall be eligible.

 

B)        Is Medicare-primary due to age or disability, and resides within the United States or a U.S. Territory, shall be eligible only for the TRAIL Program regardless of the Medicare eligibility status of an enrolled Dependent.

 

4)         Survivors.  A Survivor who:  

 

A)        Is not Medicare-primary due to age or disability, and resides within the United States or a U.S. Territory, shall be eligible.

 

B)        Is Medicare-primary due to age or disability, and resides within the United States or a U.S. Territory, shall be eligible only for the TRAIL Program, regardless of the Medicare eligibility status of an enrolled Dependent.

 

(Source:  Amended at 48 Ill. Reg. 9547, effective June 20, 2024)

 

Section 2210.220  Dependent Eligibility

 

a)         Except as limited in this Section, the following categories of individuals are eligible to be covered as Dependents under the Program:

 

1)         A Member’s spouse

 

A)        Common law spouses, ex-spouses, and persons not legally married are not eligible to be covered under the Program; and

 

B)        A new spouse of a Survivor is not eligible to be covered under the Program.

 

2)         A Member’s civil union partner enrolled on or after June 1, 2011. However, a new civil union partner of a Survivor is not eligible to be covered under the Program.

 

3)         A Member’s child from birth to age 26. For purposes of this Section, a child includes:

 

A)        A biological child;

 

B)        A step-child or child of a civil union partner;

 

C)        A legally adopted child or a child who lives with the Member from the time of placement for adoption until entry of an Order of Adoption;

 

D)        A child for whom the Member is a court-appointed permanent legal guardian; and

 

E)        An adjudicated child for whom a U.S. court decree has established the Member’s financial responsibility to provide the child’s medical, dental, or other healthcare.

 

4)         A Member’s child over the age of 26 who meets one of the following conditions:

 

A)        An unmarried child from age 26 up to, but not including, age 30 who is an Illinois resident and has served as a member of the active or reserve components of any of the branches of the United States Armed Forces and received a release or discharge other than a dishonorable discharge; or

 

B)        A child age 26 or older who is mentally or physically disabled from a cause originating prior to the child reaching age 26.

 

5)         A Member’s domestic partner who was enrolled in the Program as a Dependent prior to June 1, 2011, and has remained continuously enrolled in the Program.

 

6)         Any person who has received after June 30, 2000, an organ transplant and is financially dependent on the Member and eligible to be claimed as the Member’s dependent for income tax purposes.

 

7)         Any person who was enrolled in the Program as a Dependent prior to February 11, 1983 and has remained continuously enrolled in the Program and is dependent upon the Member to the extent that the Member may claim such person as a dependent for income tax deduction purposes.

 

b)         Ex-spouses and ex-civil union partners are not eligible for enrollment in the Program except to the extent to which such ex-spouse or ex-civil union partner may qualify for continuation coverage as described in Section 2210.430 of this Part. A divorce decree, dissolution decree, legal separation order, settlement agreement or other document requiring a Member to provide coverage for an ex-spouse or ex-civil union partner does not grant eligibility to such ex-spouse or ex-civil union partner.

SUBPART C: ENROLLMENT

 

Section 2210.310  Initial Enrollment for New Employees

 

a)         A New Employee will have an initial enrollment period lasting 30 calendar days from the first date of employment.

 

b)         The following elections may be made by a New Employee during the initial enrollment period:

 

1)         Enroll in either the Basic Health Plan or any available Optional Health Plan;

 

2)         Elect not to participate in the Program;

 

3)         Enroll eligible Dependents, or

 

4)         Enroll in the dental plan administered by the Agency.

 

c)         A New Employee who fails to either submit an enrollment form or elect not to participate in the Program during the Initial Enrollment Period will be automatically enrolled for self-only coverage in the Basic Health Plan. An Employee who is automatically enrolled pursuant to this subsection will also be enrolled for self-only coverage in the dental plan administered by the Agency.

 

d)         An Employee must provide a social security number, and the social security number of any Dependents being enrolled, at the time of enrollment.

 

e)         Enrolled Dependents designated by the Employee, who receive coverage based on the Employee's designation and timely complete and submit the necessary enrollment paperwork, will have the same effective date of coverage as the Employee.

 

Section 2210.320  Initial Enrollment for New Annuitants and New Survivors Who Are Not Medicare Eligible

 

a)         A new Annuitant has an initial enrollment period lasting 60 days from the date of retirement from State employment.

 

b)         A new Survivor has an initial enrollment period lasting 60 days from the date the Survivor first becomes eligible to receive an annuity as the result of the death of an Employee, Retiree, or Annuitant.

 

c)         The following elections may be made by a new Annuitant or new Survivor during the initial enrollment period:

 

1)         Enroll in either the Basic Health Plan or any available Optional Health Plan;

 

2)         Elect not to participate in the Program;

 

3)         Enroll eligible Dependents, or

 

4)         Enroll in the dental plan administered by the Agency.

 

d)         A new Annuitant or new Survivor who fails to submit the forms required by the Agency for enrollment during the initial enrollment period will not be covered by the Program.

 

e)         Coverage for a new Annuitant will be effective on the latest of:

 

1)         Date of commencement of the individual's retirement/annuity benefit; or

 

2)         The first day of the month following the month in which the individual's application for retirement is received by the appropriate retirement system. However, at no time will the effective date of coverage be retroactive greater than six months from the date the Agency is notified of the individual's retirement.

 

f)         If a new Survivor was enrolled as a Dependent of a deceased Member at the time of the deceased Member's death, elected coverage as a Survivor will be effective on the day after the Member's death.

 

g)         If a new Survivor was not enrolled as a Dependent of a deceased Member at the time of the deceased Member's death, elected coverage as a Survivor will be effective on the first day of the month following the date the Agency is notified of the approved application.

 

h)         Enrolled Dependents designated by the Annuitant or Survivor, who receive coverage based on that designation and timely complete and submit the necessary enrollment paperwork, will have the same effective date of coverage as the new Annuitant or new Survivor.  Notwithstanding the new Annuitant or new Survivor's non-Medicare eligibility status, if a Dependent is Medicare eligible, the Dependent must enroll in Medicare Part A and Part B coverage and the TRAIL Program for their health benefits.

 

i)          A new Annuitant or new Survivor must provide a social security number, and the social security number of any Dependents being enrolled, at the time of initial enrollment.

 

j)          A full-time Employee who would otherwise be eligible as a new Annuitant or new Survivor must make an election to either enroll in coverage or opt out of coverage as an employee.  A full-time Employee opting out of coverage must provide proof of other major medical insurance administered by an entity other than Agency.

 

k)         A Part-time Employee who would otherwise be eligible as a new Annuitant or new Survivor must make an election to either enroll in coverage or waive coverage.

 

(Source:  Amended at 48 Ill. Reg. 9547, effective June 20, 2024)

 

Section 2210.330  Initial Enrollment for New Annuitants and New Survivors Who Are Medicare Eligible

 

a)         If a new Annuitant or new Survivor is already a Medicare eligible beneficiary at the time they first become eligible for coverage, the new Annuitant or new Survivor will be required to enroll into the TRAIL Program within 60 days after retirement, regardless of the Medicare eligibility status of any enrolled Dependents.

 

b)         The following elections may be made by a new Annuitant or new Survivor during the initial enrollment period:

 

1)         Enroll in the TRAIL program, failure to enroll in coverage will result in the new Annuitant's or Survivor's health coverage being defaulted to a waive status;

 

2)         Elect any available Optional Health Plan;

 

3)         Elect not to participate in the Program;

 

4)         Enroll eligible Dependents, or

 

5)         Enroll in the dental plan administered by the Agency.

 

c)         Enrolled Dependents will have the same effective date of coverage as the new Annuitant or new Survivor.

 

d)         A new Annuitant or new Survivor must provide a social security number, and the social security number of any Dependents being enrolled, at the time of initial enrollment.

 

(Source:  Amended at 48 Ill. Reg. 9547, effective June 20, 2024)

 

Section 2210.340  Annual Open Enrollment Period for Non-TRAIL Program Members

 

a)         The Agency shall conduct an annual open enrollment period during which all eligible Employees, Retired Employees, Annuitants, and Survivors may make changes to their benefit elections under the Program.

 

b)         The Agency shall annually determine the beginning date and ending date of the annual open enrollment period. The enrollment period must last at least 30 calendar days.

 

c)         All annual open enrollment period elections will be effective as of the beginning of the next Plan Year.

 

d)         Members may make the following elections during an annual open enrollment period:

 

1)         Change health plans, if more than one health plan option is available to the Member;

 

2)         Enroll or re-enroll in the Program if the Member had previously elected not to participate in the Program;

 

3)         Re-enroll in the Program if coverage is currently terminated due to non-payment of premiums. Such re-enrollment will be permitted and coverage reinstated only if the Member makes payment at the time of enrollment of all outstanding past-due premiums plus the premium payment for the first month of the Plan Year for which the Member is attempting to enroll. This election option is available only to Employees and Annuitants, Retired Employees, and Survivors terminated due to non-payment of premiums incurred as an Employee.  Annuitant, Retired Employee, or Survivors terminated due to unpaid premiums as an Annuitant, Retired Employee, or Survivor will not be permitted to re-enroll in the Program;

 

4)         Elect not to participate in the Program;

 

5)         Add or drop coverage for eligible Dependents; or

 

6)         Add or drop dental coverage.

 

Section 2210.350  Annual Open Enrollment Period for Medicare-primary Members eligible for the TRAIL Program

 

a)         To be eligible for the TRAIL Program the Member, and all covered Dependents, must be enrolled in Medicare Parts A and B and be a resident of the United Sates or a U.S. Territory.

 

b)         The Agency shall conduct an annual open enrollment period during which all eligible Retired Employees, Annuitants, and Survivors may make changes to their benefit elections under the TRAIL Program.

 

c)         The Agency shall annually determine the beginning date and ending date of the TRAIL annual open enrollment period. The enrollment period must last at least 30 calendar days.

 

d)         All annual open enrollment period elections will be effective as of the beginning of the next Plan Year.

 

e)         All newly eligible members may enroll into the TRAIL Program during the annual open enrollment period.  Failure to make an election to enroll into the TRIAL Program will result in termination of coverage.

 

f)         Eligible individuals may make the following elections during the open enrollment period:

 

1)         Elect not to participate in the program;

 

2)         Enroll or re-enroll in the program if the Member had previously elected not to participate;

 

3)         Add or drop dental coverage; or

 

4)         Add or drop coverage for eligible Dependents.

 

Section 2210.360  Special Enrollment Periods

 

a)         Eligible Members may change their elections under the Program outside of the initial enrollment period or an annual open enrollment period only upon experiencing a qualifying change in status as defined by the Internal Revenue Service Code.

 

b)         Election changes made by a Member due to a qualifying change in status must be consistent with the qualifying event the Member has experienced and completed within 60 days of the qualifying event. The Agency shall determine whether a requested election is consistent with the qualifying event.

 

c)         The Agency shall determine the qualifying changes in status for which a special enrollment period may be granted to Members.

 

Section 2210.370  Dependent Enrollment

 

a)         All non-Medicare eligible Dependents of a non-Medicare eligible, Annuitant, Retired Employee, or Survivor must be enrolled in the same health plan and, if applicable, dental plan as the Employee, Annuitant, Retired Employee, or Survivor.

 

b)         If both parents of a child are Employees, either Employee may elect to cover the child as a Dependent. Such child may not be covered as a Dependent under both Employees for the same type of coverage. A Dependent whose coverage was terminated for nonpayment of premium under one parent may not be enrolled under the other parent until all premiums due are paid.

 

c)         Employees, Annuitants, Retired Employees, and Survivors must complete the enrollment and submit any and all documentation required by the Agency in order to enroll Dependents. Failure to submit required documentation within the time frame specified by the Agency will result in denial of coverage for the Dependent.

 

(Source:  Amended at 48 Ill. Reg. 9547, effective June 20, 2024)

 

Section 2210.380  Time Away From Work

 

a)         An Employee who is not in active service may continue to participate in the Program as authorized by the Act and this Part.

 

b)         The State shall continue to contribute toward the cost of an Employee’s elected coverage, at the same rate as if the Employee were in active service, if the Employee is not in active service due to one of the following reasons:

 

1)         Nonoccupational disability leave of absence

 

A)        An Employee on a nonoccupational disability leave and is receiving ordinary or accidental disability benefits or retirement benefits through the appropriate retirement system will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service.

 

B)        An Employee on a nonoccupational disability leave but is not receiving ordinary or accidental disability benefits or retirement benefits through the appropriate retirement system will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service, subject to a maximum period of 24 months.

 

2)         Occupational disability leave of absence.  An Employee on an occupational disability leave of absence who is receiving benefits under the Workers’ Compensation Act [820 ILCS 305] or Workers' Occupational Disease Act [820 ILCS 310] will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service.

 

3)         Authorized educational leave of absence.  An Employee on an authorized educational leave of absence will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service, subject to a lifetime maximum period of 24 months.

 

4)         Sabbatical leave of absence.  An Employee on an authorized sabbatical leave of absence will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service, subject to a lifetime maximum period of 24 months.

 

5)         Military leave of absence.  An Employee on a military leave of absence will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service.

 

6)         Approved leaves of absence covered by the Family Medical Leave Act of 1993 (29 U.S.C. 2601 through 2654), including medical or bonding family leave, and military caregiver or military qualifying exigency family leave.

 

7)         Seasonal leave of absence.  An Employee on an authorized seasonal leave of absence will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service, subject to a maximum period of six months.

 

8)         University annual break.  An Employee on an authorized leave of absence due to a University annual break will remain eligible for State contributions toward the cost of coverage until expiration of authorized leave or return to active service, subject to a maximum period of three months.

 

9)         Dock or suspension status up to 30 calendar days per fiscal year.

 

c)         The State will not contribute toward the cost of an Employee’s elected coverage, when the Employee is not in active service due to one of the following reasons. An Employee not in active service due to one of these reasons may continue participation in the Program only by making personal payment equal to the total cost of the Employee’s elected coverage.

 

1)         Dock or suspension status greater than 30 days per fiscal year;

 

2)         Personal or general leave of absence;

 

3)         Family Responsibility Leave of absence that is not covered under the Family and Medical Leave Act of 1993;

 

4)         Military Family Leave; and

 

5)         Military Leave after the Employee has been released from covered active duty.

 

d)         An Employee who is not in active State service due to a reason identified in subsection (c) will remain eligible to continue participation in the Program until such time as the Employee returns to a status eligible for contributions by the State or until the Employee’s employment or annuitant status with the State is terminated, subject to a maximum period of 24 months per occurrence.

 

Section 2210.390  Opt Out or Waiver of Coverage

 

An Employee who elects not to participate in the Program may not be enrolled as a Dependent in the Program, the Teachers’ Retirement Insurance Program, the College Insurance Program, or the Local Government Health Plan.

SUBPART D: TERMINATION

 

Section 2210.410  Effective Date of Termination

 

a)         Termination of Member Coverage Other Than For Non-Payment.

 

1)         An Employee’s coverage will terminate on the date of termination of State employment, regardless of whether the termination of employment was voluntary or involuntary;

 

2)         An Employee’s coverage will terminate on the date on which the Employee’s employment status changes to a part-time status in which the Employee is not normally required to work at least fifty percent (50%) of a Normal Work Period;

 

3)         An Employee’s coverage will terminate on the date that the maximum period allowed for a leave of absence (see Section 10(a-10)(c) of the Act) is reached;

 

4)         An Employee’s coverage will terminate on the date that the maximum period allowed for premium-free permanent layoff benefits, if any, (see Section 10(a-10)(e) of the Act) is reached;

 

5)         A Member’s coverage will terminate on the date of the Member’s death, and

 

6)         Coverage for a Member who makes an election during an annual open enrollment period not to participate in the Program will terminate on the date immediately preceding the beginning of the Plan Year for which the open enrollment period was held.

 

b)         Termination of Dependent Coverage.

 

1)         Notwithstanding any other provision within this subsection, an enrolled Dependent’s coverage will terminate simultaneous with termination of coverage for the Member;

 

2)         Coverage for an enrolled spouse, civil union partner, or domestic partner, and all applicable stepchildren or children of the civil union partner or domestic partner, will terminate on the date preceding a divorce, dissolution of partnership, or legal separation from the primary Member;

 

3)         Coverage for an enrolled Dependent who becomes ineligible to participate in the Program, other than by reason of a divorce or dissolution of a civil union partnership or domestic partnership (e.g., a child who reaches age 26 or another limiting age), will terminate on the last day of the month in which the Dependent loses eligibility;

 

4)         Coverage for an enrolled Dependent will terminate on the date of the Dependent’s death;

 

5)         Coverage for an enrolled Dependent will terminate on the date immediately preceding the date on which the Dependent becomes eligible to participate in the Program as a Member;

 

6)         Coverage for an enrolled Dependent whose enrollment is voluntarily terminated by the primary Member during the annual open enrollment period will terminate on the date immediately preceding the beginning of the Plan Year for which the open enrollment period was held;

 

7)         Coverage for an enrolled Dependent whose enrollment is voluntarily terminated by the Member due to a Qualifying Change in Status will terminate on the later of the date the voluntary termination is requested by the Member or the date of the qualifying event; and

 

8)         In the event that an Employee, Annuitant, or Survivor is requested to provide certification of continued eligibility for a Dependent and the Member fails to provide such certification, coverage for the Dependent will terminate on the last day of the month in which the Member fails to certify continued eligibility.

 

c)         When coverage is terminated due to the reasons identified in subsections (a) and (b), coverage will no longer be effective as of 12:00 a.m. on the date immediately following the applicable date of termination.  For example, if an Employee terminates State employment on June 15, coverage for the Employee will terminate at 11:59:59 p.m. on June 15 and will no longer be effective as of 12:00 a.m. on June 16.

 

Section 2210.420  Termination of Coverage for Non-Payment

 

a)         Coverage for a Member who fails to pay the required monthly premium due will be terminated on the last day of the month in which payment is due, as identified in a final notice of premium due issued by the Agency.

 

b)         A Member whose coverage is terminated due to non-payment of premium will not be eligible to be covered as a Dependent of another Member.

 

c)         A Dependent whose coverage is terminated due to non-payment of premium will not be eligible to be covered by any other Member until all outstanding premiums are paid.

 

d)         Any Member whose coverage is terminated due to non-payment of premium will not be eligible to elect continuation of coverage described in Section 2210.430.

 

Section 2210.430  Continuation of Coverage

 

a)         Election of Continuation Coverage.

 

1)         Eligible Members who lose coverage due an event identified in subsection (b) may elect to continue coverage for a specified period of time in accordance with the requirements of federal law and sections 367.2, 367e, and 367e.1 of the Illinois Insurance Code [215 ILCS 5].

 

2)         A Member electing continuation coverage must make a written election to continue coverage within 60 calendar days after the later of the date coverage is terminated due to a qualifying event or the date the Member or Dependent is sent notice of the right to elect continuation coverage.

 

3)         A Member electing to enroll in continuation coverage must submit payment of all premiums due for such coverage within 45 calendar days of the date of election.

 

4)         A Member who timely elects continuation coverage and submits payment of all premiums due will not have a gap in coverage and will have coverage reinstated retroactive to the date of termination.

 

5)         The Agency shall establish the monthly premium rates to be paid by Members for continuation coverage. These rates are published in the CMS Benefit Program Books available at https://cms.illinois.gov/benefits/stateemployee/benefitsbooks.html

 

b)         Qualifying Events for Continuation Coverage.

 

1)         An Employee may elect continuation coverage under the Program upon the occurrence of any of the following events:

 

A)        Termination of Employee’s employment with the State for any reason other than gross misconduct;

 

B)        Termination of Employee’s disability benefits;

 

C)        Expiration of Employee’s maximum leave of absence period; or

 

D)        Loss of eligibility to participate in the Program due to a reduction in work hours.

 

2)         A Dependent will be eligible to elect continuation coverage under the Program upon the occurrence of any of the following events:

 

A)        Employee’s termination of employment with the State;

 

B)        Employee’s termination of disability benefits;

 

C)        Expiration of the Employee’s maximum leave of absence period;

 

D)        Employee’s loss of eligibility to participate in the Program due to a reduction in work hours;

 

E)        Divorce, annulment, dissolution of civil union partnership, or legal separation from the Employee;

 

F)         Loss of eligibility as a dependent child or domestic partner; or

 

G)        Death of the Employee.

 

3)         A Dependent whose coverage is voluntarily dropped by an Employee shall not be eligible to elect continuation coverage.

SUBPART E: PROGRAM OF BENEFITS FOR EMPLOYEES AND NON-MEDICARE PRIMARY ANNUITANTS/SURVIVORS

 

Section 2210.510  Program Requirements

 

a)         The Program shall be designed by the Director and administered by the Agency to provide benefits on an equitable basis, to the extent possible, to all Members throughout the State.

 

b)         The Program may include reasonable controls, including but not limited to Member copayments, coinsurance, and deductibles, to prevent or minimize unnecessary utilization of covered services and to ensure continued stability of the Program.

 

c)         The Director shall, in accordance with statutory requirements, determine the level of benefits to be provided by the Program and each health plan offered through the Program.

 

d)         The Program, in accordance with Section 6(a) of the Act, shall provide for basic hospital and medical/surgical coverage.  The Program may also include, but is not limited to, benefits such as behavioral health coverage, prescription drug coverage, dental coverage, vision coverage, and other group benefits that are now or may become available.

 

e)         The Program and any health plan offered under the Program may be modified or amended at any time by the Director. Modifications or amendments to any material provision of the Program or any health plan shall become effective no earlier than 60 days following notice of such modification or amendment being issued by the Agency.

 

Section 2210.520  Covered Services

 

a)         Covered and optional services of the Program include services provided within the scope of their licenses by practitioners in all categories licensed under the Illinois Medical Practice Act of 1987 [225 ILCS 60].

 

b)         The Director shall determine the type of services (e.g., office visits, inpatient, outpatient, diagnostic) to be covered by the Basic Health Plan and any Optional Health Plans offered under the Program.

 

c)         The Director shall determine the amount of coverage available and any applicable Member cost-sharing for each service covered by the Basic Health Plan or any Optional Health Plan.

 

d)         The Agency, either directly or through its contracted Plan Administrators, shall make information regarding covered services available to all Members and Dependents.

 

Section 2210.530  Coordination of Benefits

 

a)         If a Member or Dependent is entitled to receive primary benefits through a group medical, dental, or vision plan other than the Program, the benefits payable by the Program may be reduced to the extent that the total payment provided by all plans does not exceed the total allowable expense incurred for the service.

 

b)         The Program shall coordinate benefits with the following types of coverage:

 

1)         Any group insurance plan;

 

2)         Medicare;

 

3)         Any Veterans’ Administration plan; and

 

4)         A motor vehicle plan required by law which provides medical or dental payments, in whole or in part, without regard to fault.

 

c)         The Program will not coordinate benefits with the following types of coverage:

 

1)         Private individual insurance plans;

 

2)         Any student insurance policy;

 

3)         Medicaid, or any other State-sponsored insurance program; and

 

4)         TRICARE.

 

d)         Members and Dependents must notify the Agency of enrollment in Medicare insurance benefits.

 

e)         Members and Dependents shall promptly report to the Agency any changes to other insurance coverage.

 

f)         Order of Benefit Determination.

 

1)         The Program shall coordinate benefits with other available insurance in accordance with model regulations issued by the National Association of Insurance Commissioners (available at https://content.naic.org/sites/default/files/model-law-120.pdf). Coordination of benefits with Medicare shall be in accordance with Medicare Secondary Payer guidelines issued by the federal Centers for Medicare & Medicaid Services (available at https://www.medicare.gov/sites/default/files/2021-10/02179-Medicare-and-other-health-benefits-your-guide-to-who-pays-first.pdf).

 

2)         The Agency shall provide notice of the methodology for coordination of benefits through incorporation into the Benefits Handbook available to Members.

 

Section 2210.540  Determining Rates and Premiums

 

a)         The Agency shall annually determine the premium rates, including rates for Dependent coverage, for each health plan offered through the Program and the amount of contributions toward the premium rate that shall be made by Members.

 

b)         Actively working Employees shall pay the required premium contribution by automatic pre-tax payroll deduction.

 

c)         An Employee who is in non-pay status as of the first work day of a pay period, or an Employee whose paycheck is not sufficient to deduct the amount of premium contribution owed to the Agency, will be billed by the Agency for the amount of the required premium contribution. Such employee must make personal payment of the amount owed within the timeframe specified by the Agency.

 

Section 2210.550  Appeals

 

a)         Members may request an appeal of a decision by a Plan Administrator relating to a claim for benefits under the Program.

 

b)         The Agency shall provide a description of the applicable appeals process in the Benefits Handbook made available to Members.

 

c)         The Program’s appeals process shall comply with applicable federal laws and regulations, including, but not limited to, the Affordable Care Act and its implementing regulations (45 CFR 147.136).

 

Section 2210.560  Requirements to Enroll in Medicare

 

a)         Members and Dependents must contact the Social Security Administration to apply for Medicare benefits at least three months prior to turning age 65.

 

1)         Members and Dependents who are determined by the Social Security Administration to be eligible for premium-free Medicare Part A must accept the Medicare Part A coverage and submit a copy of the Medicare identification card to the Agency upon receipt.

 

2)         Members and Dependents who are determined by the Social Security Administration to not be eligible for premium-free Medicare Part A will not be required to enroll in Medicare Part A coverage. Such members must provide a written statement of ineligibility from the Social Security Administration to the Agency.

 

b)         Actively working Employees will not be required to enroll in Medicare Part B coverage until such time as the Employee retires or otherwise loses active employment status.

 

c)         Members and Dependents who fail to enroll in Medicare Parts A and B are responsible for the portion of healthcare costs that would have been covered by Medicare.

 

d)         Failure to enroll or remain enrolled in Medicare will result in a reduction of eligible benefit payments when Medicare is determined to be the primary payor.

 

e)         When any Member or Dependent becomes Medicare eligible, they must enroll in Medicare Part A and Part B coverage and the TRAIL Program, regardless of the Medicare eligibility status of any other family or household member covered under the State Employee Group Health Insurance Program.

 

(Source:  Amended at 48 Ill. Reg. 9547, effective June 20, 2024)

 

Section 2210.570  Member Responsibilities

 

a)         Members are responsible for verifying that payroll deductions for the payment of premiums are accurate, or paying the required premiums for all elected coverages, as applicable.

 

b)         Members must report, within 60 days of the event, information pertaining to any event which would result in the loss of a Dependent’s eligibility under the Program. Failure to report a loss of eligibility, or the falsifying of information in order to obtain or continue coverage under the Program, will be considered a fraudulent act by the Member.

 

c)         Members must timely notify the Agency of any other group health coverage in which the Member or a Dependent is enrolled. Members shall provide copies of all relevant documents relating to the other group health coverage, including, but not limited to, a group health identification card.

SUBPART F: PROGRAM OF BENEFITS FOR MEDICARE PRIMARY ANNUITANTS/SURVIVORS (TRAIL PROGRAM)

 

Section 2210.610  Program Requirements

 

a)         The Director shall design the TRAIL Program to be reasonably comparable in overall stability and continuity of coverage, care, and services to the Basic Health Plan.

 

b)         The Director may make the TRAIL Program available to eligible Medicare-primary Members through a contract or contracts with one or more vendors.

 

(Source:  Amended at 48 Ill. Reg. 9547, effective June 20, 2024)

 

Section 2210.620  Covered Services

 

a)         The TRAIL Program shall provide coverage for services covered by Medicare. Coverage will be provided only for services considered to be medically necessary.

 

b)         The Director may establish reasonable controls, including but not limited to coinsurance, copayments, and deductibles for covered services to the extent permitted by the Centers for Medicare and Medicaid Services.

 

c)         The TRAIL Program shall include coverage for prescription drugs. The Director shall design such coverage to comply with coverage requirements established by the Centers for Medicare and Medicaid Services for Medicare Part D plans (see 42 CFR 423.100).

 

Section 2210.630  Determining Rates and Premiums

 

The Agency shall annually determine the premium rates, including rates for Dependent coverage, for each plan offered through the TRAIL Program. These rates are published at https://cms.illinois.gov/benefits/trail.html

 

Section 2210.640  Premium Contributions

 

a)         Member and State contributions toward the monthly premium cost for elected coverage shall be in accordance with 80 Ill. Adm. Code 2200 (State Employees Group Insurance Program Retiree Premium Contributions).

 

b)         The Agency shall annually determine the amount of monthly contributions to be made by Members toward the cost of Dependent coverage for each plan offered through the TRAIL Program.

 

c)         The Agency shall annually determine the amount of monthly contributions to be made by Members toward the cost of any dental coverage elected by the Member.

 

Section 2210.650  Appeals

 

a)         A Member who is unsatisfied with a coverage decision made by a Plan Administrator may appeal such decision by complying with the appeals process established by the Plan Administrator.

 

b)         Each Plan Administrator's appeals process shall comply with all applicable federal and state laws and regulations.

 

c)         Unless a health plan is maintained on a self-insured basis, the Agency will have no direct involvement in appeals relating to coverage decisions made by a Plan Administrator, since non-self-insured plans are regulated by the Department of Insurance. For any health plan maintained on a self-insured basis, the Agency may permit a Member who has exhausted all available appeal levels through the Plan Administrator to submit a final appeal request to the Agency only if the appeal is based on an administrative denial, not on a medical denial.  The final appeal request will be reviewed by the Agency and granted or denied based on the requirements of the Act or this Part.

 

(Source:  Amended at 48 Ill. Reg. 9547, effective June 20, 2024)

SUBPART G: PROGRAM FUNDING

 

Section 2210.710  Health Insurance Reserve Fund

 

a)         All contributions, appropriations, interest, dividend payments, and all other revenues arising from the administration of the Program shall be deposited into HIRF.

 

b)         The Director shall direct all expenditures from HIRF. Such expenditures shall be only for one or more of the following purposes:

 

1)         Payment of administrative expenses incurred by the Department for the Program;

 

2)         Payment of administrative expenses incurred by a Plan Administrator;

 

3)         Payment of monthly premiums owed to Health Maintenance Organizations or other vendors administering a plan on a fully-insured basis;

 

4)         Payment to claimants or providers for health benefits;

 

5)         Payment of medical expenses incurred by the Agency for the treatment of Employees who suffer accidental injury or death within the scope of their employment;

 

6)         Refunds to Employees for erroneous payment of their elected coverage;

 

7)         Payment of premium for stop-loss or re-insurance;

 

8)         Payment of adoption program benefits, if any; and

 

9)         Payment of other benefits offered to Members and Dependents under the Act.

 

Section 2210.720  Funds Outside the State Treasury

 

a)         Pursuant to Section 13.1(b) of the Act, the Agency may establish funds or separate accounts to be held by the Director outside the State treasury. Such funds or accounts may be utilized for the purpose of receiving the transfer of moneys from HIRF.

 

b)         Interest earned on funds or accounts established pursuant to the Act and this Part shall inure to HIRF.

 

c)         Moneys transferred to any funds or accounts shall be used exclusively for transfers to Plan Administrators of self-insured plans or their financial institutions for payments of claims to claimants and health care providers.