(215 ILCS 125/4-2) (from Ch. 111 1/2, par. 1408.2)

Sec. 4-2. Medical assistance; coverage of child.

(a) In this Section, "Medicaid" means medical assistance authorized under Section 1902 of the Social Security Act.

(b) A contract or evidence of coverage delivered, issued for delivery, renewed, or amended by a Health Maintenance Organization may not contain any provision which limits or excludes payments of health care services to or on behalf of the enrollee because the enrollee or any covered dependent is eligible for or is receiving Medicaid benefits in this or any other state.

(c) To the extent that payment for covered expenses has been made under Article V, VI, or VII of the Illinois Public Aid Code for health care services provided to an individual, if a third party has a legal liability to make payments for those health care services, the State is considered to have acquired the rights of the individual to payment.

(d) If a child is covered under a health care plan of a Health Maintenance Organization in which the child's noncustodial parent is an enrollee, the Health Maintenance Organization shall:

(1) Provide necessary information to the child's custodial parent to enable the child to obtain benefits under that health care plan.

(2) Permit the child's custodial parent (or the provider, with the custodial parent's approval) to submit claims for payment for covered services without the approval of the noncustodial parent.

(3) Make payments on claims submitted in accordance with paragraph (2) directly to the custodial parent, the provider of health care services, or the state Medicaid agency.

(e) A Health Maintenance Organization may not deny enrollment of a child under the health care plan in which the child's parent is an enrollee on any of the following grounds:

(1) The child was born out of wedlock.

(2) The child is not claimed as a dependent on the parent's federal income tax return.

(3) The child does not reside with the parent or in the service area covered by the health care plan.

(f) If a parent is required by a court or administrative order to provide coverage for a child under a health care plan in which the parent is enrolled, and that offers coverage for eligible dependents, the Health Maintenance Organization, upon receiving a copy of the order, shall:

(1) Upon application, permit the parent to enroll in the health care plan a child who is otherwise eligible for that coverage, without regard to any enrollment season restrictions that might otherwise be applicable as to the time period within which a person may enroll in the plan.

(2) Enroll the child in the health care plan upon application of the child's other parent, the state agency administering the Medicaid program, or the state agency administering a program for enforcing child support and establishing paternity under 42 U.S.C. 651 through 669 (or another child support enforcement program), if the parent is enrolled in the health care plan but fails to apply for enrollment of the child.

(g) A Health Maintenance Organization may not impose, on a state agency that has been assigned the rights of an enrollee in a health care plan who receives Medicaid benefits, requirements that are different from requirements applicable to an assignee of any other enrollee in that health care plan.

(h) Nothing in subsections (e) and (f) prevents a Health Maintenance Organization from denying any such application if the child is not eligible for coverage according to the Health Maintenance Organization's medical underwriting standards.

(i) The Health Maintenance Organization may not disenroll (or otherwise eliminate coverage of) the child from the health care plan unless the Health Maintenance Organization is provided satisfactory written evidence of either of the following:

(1) The court or administrative order is no longer in effect.

(2) The child is or will be enrolled in a comparable health care plan obtained by the parent under such order and that enrollment is currently in effect or will take effect not later than the date the prior coverage is terminated.

(Source: P.A. 89-183, eff. 1-1-96.)