Section 2603.25  Definitions

 

"ACA" means the Patient Protection and Affordable Care Act (42 USC 18001 et seq.).

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Director" means the Director of the Illinois Department of Insurance.

 

"Department" means the Illinois Department of Insurance.

 

"Excepted Benefits", for purposes of this Part, means benefits under one or more (or any combination) of the following:

 

Benefits not subject to requirements under this Part:

 

Coverage only for accident or disability income insurance, or any combination of that insurance;

 

Coverage issued as a supplement to liability insurance;

 

Liability insurance, including general liability insurance and automobile liability insurance;

 

Workers' compensation or similar insurance;

 

Automobile medical payment insurance;

 

Credit-only insurance;

 

Coverage for on-site medical clinics; or

 

Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits.

 

Benefits not subject to requirements if offered separately:

 

Limited scope dental or vision benefits; and

 

Benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits.

 

Benefits not subject to requirements if offered as independent, noncoordinated benefits:

 

Coverage only for a specified disease or illness; or

 

Hospital indemnity or other fixed indemnity insurance paid as a fixed dollar amount per day or other period, or per event or upon benefits paid upon a basis other than period of time, regardless of the amount of expenses incurred.

 

Benefits not subject to requirements if offered as a separate insurance policy:

 

Medicare supplemental health insurance (as defined under section 1882(g)(1) of the Social Security Act (42 USC 1395ss(g)(1))), coverage supplemental to the coverage provided under 10 USC 55, and similar supplemental coverage provided to coverage under a group health plan.  (See 26 USC 9832.)

 

"Gender Transition" means the process of changing one's outward appearance, including physical sex characteristics, to accord with his or her actual gender identity.

 

"Grandfathered Health Plan" means any group health plan or health insurance coverage in which an individual was enrolled on the date of the enactment of the ACA and shall have the same meaning as set forth in section 18011 of the Public Health and Welfare Act (42 USC 18011).

 

"Perceived Gender Identity" means an observer's impression of another's internal sense of being:  male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female. The term also includes an observer's impression that another is:  male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.

 

"Transgender Person" means a person who has, or has been diagnosed with, gender identity disorder or gender dysphoria; who has received health care services, including counseling, related to gender transition; who adopts the dress, appearance, or behavior of the opposite sex; or who otherwise identifies himself or herself as a gender different from the gender assigned to that person at birth.

 

(Source:  Added at 39 Ill. Reg. 409, effective July 1, 2015)

 

Section 2603.30  Prohibited Practices

 

No company shall refuse to issue any contract of insurance, certificate of insurance, notices of proposed insurance, policies, endorsements or riders or decline to renew a contract, certificate, notice, policy, endorsement or rider because of the sex, sexual orientation or marital status of the insured or prospective insured.  The amount of benefits payable or any term, condition or type of coverage shall not be restricted, modified, excluded or reduced on the basis of the sex, sexual orientation or marital status of the insured or prospective insured.  All underwriting criteria shall be applied in all instances of similar circumstances without regard to the sex, sexual orientation or marital status of the insured or prospective insured. When benefits for elective procedures are offered, they must be offered equally.

 

a)         Examples of the practices prohibited by this Section include, but are not limited to:

 

1)         Offering coverage to males gainfully employed at home, employed part-time or employed by relatives, while denying or offering reduced coverage to females similarly employed;

 

2)         Denying policy riders because of an individual's sex, sexual orientation or marital status;

 

3)         Denying, cancelling or refusing to renew coverage, or providing coverage on different terms, because the insured or prospective insured is residing with another person or persons of either sex not related by blood or marriage;

 

4)         Reducing disability benefits for women who become disabled while not gainfully employed full-time outside the home when a similar reduction is not applied to men;

 

5)         Restricting availability of maternity coverages or benefits based upon marital status;

 

6)         Offering dependent coverage to wives of male employees while denying dependent coverage to husbands of female employees;

 

7)         Establishment of different conditions or benefit options based on an individual's sex, sexual orientation or marital status.  This includes more restrictive benefit periods and more restrictive definitions of disability to women than to men, except as permitted by this Part;

 

8)         Requiring an applicant to submit to a medical examination because of the applicant's sex, sexual orientation or marital status;

 

9)         Denying to divorced or single persons coverage available to married persons;

 

10)         Denying disability income contracts of insurance, certificates of insurance, notices, policies, riders or endorsements to those in similar occupational classifications because of an individual's sex, sexual orientation or marital status;

 

11)         Considering that portion of treatment attributed to complications of pregnancy in a manner different than any other illness or sickness covered by the contract, certificate, notice, policy, endorsement or rider;

 

12)         Limiting the amount of coverage an insured or prospective insured may purchase based upon the sex, sexual orientation or marital status of the insured or prospective insured;

 

13)         Denying maternity coverage to an individual who has not purchased dependent or family coverage when maternity coverage is otherwise available.

 

b)         Examples of practices not prohibited by this Section include, but are not limited to:

 

1)         Offering annuity benefit amounts that differ (such as through the election of a settlement option in a life insurance policy) based upon the individual's sex;

 

2)         Taking marital status into account for the purpose of determining a spouse eligible for dependent benefits under a group or family policy; marital status of the named insured or certificate holder shall not be taken into account for the purpose of determining eligibility for dependent benefits with regard to natural or adopted children and to obligations as required by the courts.  When maternity benefits are provided, those benefits shall be applied to natural or adopted children who are covered as dependents.

 

(Source:  Amended at 39 Ill. Reg. 409, effective July 1, 2015)

 

Section 2603.35  Prohibited Gender Identity Discrimination

 

a)         A company that offers or provides group or individual health insurance coverage that is neither a grandfathered plan nor a plan offering excepted benefits shall not discriminate on the basis of an insured's or prospective insured's actual or perceived gender identity, or on the basis that the insured or prospective insured is a transgender person. The discrimination prohibited by this Section includes any of the following:

 

1)         discriminatory exclusionary clauses;

 

2)         provisions that exclude from, limit, charge a higher rate for, or deny a claim for coverage of hospital and medical benefits for gender dysphoria if benefits covered by the policy are provided for other medical conditions;

 

3)         cancelling, limiting or refusing to issue or renew an insurance policy on the basis of an insured's or prospective insured's actual or perceived gender identity, or for the reason that the insured or prospective insured is a transgender person, or because the insured or prospective insured has undergone, or is in the process of undergoing, gender transition;

 

4)         designating an insured's or prospective insured's actual or perceived gender identity, or the fact that an insured or prospective insured is a transgender person, as a preexisting condition for which coverage will be denied or limited;

 

5)         provisions that exclude from, limit, charge a higher rate for, or deny a claim for coverage for the surgical treatments for gender dysphoria;

 

6)         denying or limiting coverage, or denying a claim, for services due to an insured's actual or perceived gender identity, or for the reason that the insured is a transgender person or has undergone, or is in the process of undergoing, gender transition, including, but not limited to, denials or limitations relating to health care services that are ordinarily available to individuals of one sex based on the fact that an individual's sex assigned at birth, actual or perceived gender identity, or gender otherwise recorded is different from the one to which such services are ordinarily available; or

 

7)         denying or limiting coverage, or denying a claim, for a covered service relating to gender transition based on a categorical age limitation.

 

b)         Temporary Exemption for Transitional Small Group Plans. A group plan having fewer than 51 members that was sold before January 1, 2014 and renewed between January 1, 2015 and October 1, 2015 will not be required to comply with the requirements of this Section until after the expiration of the 2015 plan year.

 

c)         Nothing in this Section is intended to determine, or restrict a company from determining, whether a particular health care service is medically necessary.

 

(Source:  Amended at 44 Ill. Reg. 13352, effective July 31, 2020)

 

Section 2603.40  Rates

 

a)         No insurance company shall place a risk in a rating classification on the basis of sex, sexual orientation or marital status or otherwise differentiate in rates on the basis of sex, sexual orientation or marital status unless that classification or differentiation is based upon expected claim costs and expenses derived by applying sound actuarial principles to relevant and reasonably current company or intercompany studies, claim costs, and expense experience.  After July 1, 1979, no company shall charge a differential by sex, sexual orientation or marital status larger than the differential indicated by the criterion stated in this Section.

 

b)         No insurance company shall use separate rating classifications or otherwise differentiate in rates on the basis of actual or perceived gender identity, or on the basis that the insured or prospective insured is a transgender person, or on the basis that the insured or prospective insured has undergone, or is in the process of undergoing, gender transition, unless the classification or differentiation is based upon expected claim costs and expenses derived by applying sound actuarial principles to relevant and reasonably current company or intercompany studies, claim costs, and expense experience.  After August 1, 2020, no company shall charge a differential by actual or perceived gender identity, or by the fact that the insured or prospective insured is a transgender person, or on the basis that the insured or prospective insured has undergone, or is in the process of undergoing, gender transition, that is larger than the differential indicated by the criterion stated in this Section.  Nothing in this Section otherwise prohibits a company from recognizing an individual's gender identity to the extent requested by the individual.

 

c)         An insurer shall, upon request of the Director, justify that any classification or differentiation described in this Section equitably and reasonably reflects differences in expected claim costs and expenses.

 

(Source:  Amended at 44 Ill. Reg. 13352, effective July 31, 2020)

 

Section 2603.50  Severability Provision

 

If any Section or portion of a Section of this Part, or the applicability thereof to any person or circumstance is held invalid by a court,  the remainder of the Part, or the applicability of such provision or circumstance, shall not be affected thereby.

 

Section 2603.60  Effective Date (Repealed)

 

(Source:  Repealed at 39 Ill. Reg. 409, effective July 1, 2015)