215 ILCS 5/ Illinois Insurance Code.

(215 ILCS 5/356z.45)

Sec. 356z.45. Coverage for patient care services provided by a pharmacist. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2023 shall provide coverage for health care or patient care services provided by a pharmacist if:

(1) the pharmacist meets the requirements and scope of practice as set forth in Section 43 or Section 43.5 of the Pharmacy Practice Act;

(2) the health plan provides coverage for the same service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;

(3) the pharmacist is included in the health benefit plan's network of participating providers; and

(4) a reimbursement has been successfully negotiated in good faith between the pharmacist and the health plan.

(Source: P.A. 102-103, eff. 1-1-23; 102-813, eff. 5-13-22; 102-1051, eff. 1-1-23.)

(215 ILCS 5/356z.46)

Sec. 356z.46. Biomarker testing.

(a) As used in this Section:

"Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention. "Biomarker" includes, but is not limited to, gene mutations or protein expression.

"Biomarker testing" means the analysis of a patient's tissue, blood, or fluid biospecimen for the presence of a biomarker. "Biomarker testing" includes, but is not limited to, single-analyte tests, multi-plex panel tests, and partial or whole genome sequencing.

(b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2022 shall include coverage for biomarker testing as defined in this Section pursuant to criteria established under subsection (d).

(c) Biomarker testing shall be covered and conducted in an efficient manner to provide the most complete range of results to the patient's health care provider without requiring multiple biopsies, biospecimen samples, or other delays or disruptions in patient care.

(d) Biomarker testing must be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence, including, but not limited to:

(1) labeled indications for an FDA-approved test or indicated tests for an FDA-approved drug;

(2) federal Centers for Medicare and Medicaid Services National Coverage Determinations;

(3) nationally recognized clinical practice guidelines;

(4) consensus statements;

(5) professional society recommendations;

(6) peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medicus, Medline, and MEDLARS database of Health Services Technology Assessment Research; and

(7) peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.

(e) When coverage of biomarker testing for the purpose of diagnosis, treatment, or ongoing monitoring of any medical condition is restricted for use by a group or individual policy of accident and health insurance or managed care plan, the patient and prescribing practitioner shall have access to a clear, readily accessible, and convenient processes to request an exception. The process shall be made readily accessible on the insurer's website.

(Source: P.A. 102-203, eff. 1-1-22; 102-813, eff. 5-13-22.)

(215 ILCS 5/356z.47)

Sec. 356z.47. Coverage for pancreatic cancer screening. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for medically necessary pancreatic cancer screening.

(Source: P.A. 102-306, eff. 1-1-22; 102-813, eff. 5-13-22.)

(215 ILCS 5/356z.48)

Sec. 356z.48. Colonoscopy coverage.

(a) A group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for a colonoscopy that is a follow-up exam based on an initial screen where the colonoscopy was determined to be medically necessary by a physician licensed to practice medicine in all its branches, an advanced practice registered nurse, or a physician assistant.

(b) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this subsection does not apply to coverage of colonoscopies to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.

(Source: P.A. 102-443, eff. 1-1-22; 102-813, eff. 5-13-22.)

(215 ILCS 5/356z.49)

Sec. 356z.49. A1C testing.

(a) As used in this Section, "A1C testing" means blood sugar level testing used to diagnose prediabetes, type 1 diabetes, and type 2 diabetes and to monitor management of blood sugar levels.

(b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2022 (the effective date of Public Act 102-530) shall provide coverage for A1C testing recommended by a health care provider for prediabetes, type 1 diabetes, and type 2 diabetes in accordance with prediabetes and diabetes risk factors identified by the United States Centers for Disease Control and Prevention.

(1) Risk factors for prediabetes may include, but are not limited to, being overweight or obese, being aged 35 or older, having an immediate family member with type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.

(2) Risk factors for type 1 diabetes may include, but are not limited to, family history of diabetes.

(3) Risk factors for type 2 diabetes may include, but are not limited to, having prediabetes, being overweight or obese, being aged 35 or older, having an immediate family member with type 1 or type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.

(Source: P.A. 102-530, eff. 1-1-22; 102-813, eff. 5-13-22.)

(215 ILCS 5/356z.50)

Sec. 356z.50. Comprehensive cancer testing.

(a) As used in this Section:

"Comprehensive cancer testing" includes, but is not limited to, the following forms of testing:

(1) Targeted cancer gene panels.

(2) Whole-exome genome testing.

(3) Whole-genome sequencing.

(4) RNA sequencing.

(5) Tumor mutation burden.

"Testing of blood or constitutional tissue for cancer predisposition testing" includes, but is not limited to, the following forms of testing:

(1) Targeted cancer gene panels.

(2) Whole-exome genome testing.

(3) Whole-genome sequencing.

(b) An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2022 (the effective date of Public Act 102-589) shall provide coverage for medically necessary comprehensive cancer testing and testing of blood or constitutional tissue for cancer predisposition testing as determined by a physician licensed to practice medicine in all of its branches.

(Source: P.A. 102-589, eff. 1-1-22; 102-813, eff. 5-13-22.)

(215 ILCS 5/356z.51)

Sec. 356z.51. Coverage for port-wine stain treatment.

(a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for treatment to eliminate or provide maximum feasible treatment of nevus flammeus, also known as port-wine stains, including, but not limited to, port-wine stains caused by Sturge-Weber syndrome. For purposes of this Section, treatment or maximum feasible treatment shall include early intervention treatment, including topical, intralesional, or systemic medical therapy and surgery, and laser treatments approved by the U.S. Food and Drug Administration in children aged 18 years and younger that are intended to prevent functional impairment related to vision function, oral function, inflammation, bleeding, infection, and other medical complications associated with port-wine stains.

(b) Coverage for treatment required under this Section shall not include treatment solely for cosmetic purposes.

(Source: P.A. 102-642, eff. 1-1-22; 102-813, eff. 5-13-22.)

(215 ILCS 5/356z.53)

Sec. 356z.53. Coverage for home health services. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for access to home health services for the duration of medically necessary care.

(Source: P.A. 102-816, eff. 1-1-23; 103-154, eff. 6-30-23.)

(215 ILCS 5/356z.54)

Sec. 356z.54. Coverage for breast reduction surgery. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for medically necessary breast reduction surgery.

(Source: P.A. 102-731, eff. 1-1-23; 103-154, eff. 6-30-23.)

(215 ILCS 5/356z.55)

Sec. 356z.55. Coverage for cleft lip and cleft palate.

(a) As used in this Section, "medically necessary care and treatment" to address congenital anomalies associated with a cleft lip or palate, or both, includes:

(1) oral and facial surgery, including reconstructive services and procedures necessary to improve and restore and maintain vital functions;

(2) prosthetic treatment such as obturators, speech appliances, and feeding appliances;

(3) orthodontic treatment and management;

(4) prosthodontic treatment and management; and

(5) otolaryngology treatment and management.

"Medically necessary care and treatment" does not include cosmetic surgery performed to reshape normal structures of the lip, jaw, palate, or other facial structures to improve appearance.

(b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2024 (the effective date of Public Act 102-768) shall provide coverage for the medically necessary care and treatment of cleft lip and palate for children under the age of 19. Coverage for cleft lip and palate care and treatment may impose the same deductible, coinsurance, or other cost-sharing limitation that is imposed on other related surgical benefits under the policy.

(c) This Section does not apply to a policy that covers only dental care.

(Source: P.A. 102-768, eff. 1-1-24; 103-154, eff. 6-30-23.)

(215 ILCS 5/356z.56)

Sec. 356z.56. Coverage for hormone therapy to treat menopause. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy.

(Source: P.A. 102-804, eff. 1-1-23; 103-154, eff. 6-30-23.)

(215 ILCS 5/356z.57)

Sec. 356z.57. Pediatric palliative care.

(a) A group or individual policy of accident and health insurance or a managed care plan amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for community-based pediatric palliative care and hospice care. This care shall be delivered to any qualifying child with a serious illness by a trained interdisciplinary team that allows a child to receive community-based pediatric palliative care and hospice care while continuing to pursue curative treatment and disease-directed therapies for the qualifying illness.

(b) As used in this Section, "palliative care" and "serious illness" have the same meaning as set forth in the Pediatric Palliative Care Act.

(Source: P.A. 102-860, eff. 1-1-23; 103-154, eff. 6-30-23.)

(215 ILCS 5/356z.58)

Sec. 356z.58. Prenatal vitamins coverage. A group or individual policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 that provides coverage for prescription drugs shall provide coverage for prenatal vitamins when prescribed by a physician licensed to practice medicine in all of its branches or an advanced practice registered nurse licensed under the Nurse Practice Act.

(Source: P.A. 102-930, eff. 1-1-23; 103-154, eff. 6-30-23.)

(215 ILCS 5/356z.59)

Sec. 356z.59. Coverage for continuous glucose monitors. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for medically necessary continuous glucose monitors for individuals who are diagnosed with type 1 or type 2 diabetes and require insulin for the management of their diabetes.

(Source: P.A. 102-1093, eff. 1-1-23; 103-154, eff. 6-30-23.)

(215 ILCS 5/356z.60)

Sec. 356z.60. Coverage for abortifacients, hormonal therapy, and human immunodeficiency virus pre-exposure prophylaxis and post-exposure prophylaxis.

(a) As used in this Section:

"Abortifacients" means any medication administered to terminate a pregnancy as prescribed or ordered by a health care professional.

"Health care professional" means a physician licensed to practice medicine in all of its branches, licensed advanced practice registered nurse, or physician assistant.

"Hormonal therapy medication" means hormonal treatment administered to treat gender dysphoria.

"Therapeutic equivalent version" means drugs, devices, or products that can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling and that satisfy the following general criteria:

(1) it is approved as safe and effective;

(2) it is a pharmaceutical equivalent in that it:

(A) contains identical amounts of the same active drug ingredient in the same dosage form and route of administration; and

(B) meets compendial or other applicable standards of strength, quality, purity, and identity;

(3) it is bioequivalent in that:

(A) it does not present a known or potential bioequivalence problem and it meets an acceptable in vitro standard; or

(B) if it does present such a known or potential problem, it is shown to meet an appropriate bioequivalence standard;

(4) it is adequately labeled; and

(5) it is manufactured in compliance with Current Good Manufacturing Practice regulations adopted by the United States Food and Drug Administration.

(b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2024 shall provide coverage for all abortifacients, hormonal therapy medication, human immunodeficiency virus pre-exposure prophylaxis, and post-exposure prophylaxis drugs approved by the United States Food and Drug Administration, and follow-up services related to that coverage, including, but not limited to, management of side effects, medication self-management or adherence counseling, risk reduction strategies, and mental health counseling. This coverage shall include drugs approved by the United States Food and Drug Administration that are prescribed or ordered for off-label use for the purposes described in this Section.

(c) The coverage required under subsection (b) is subject to the following conditions:

(1) If the United States Food and Drug Administration has approved one or more therapeutic equivalent versions of an abortifacient drug, a policy is not required to include all such therapeutic equivalent versions in its formulary so long as at least one is included and covered without cost sharing and in accordance with this Section.

(2) If an individual's attending provider recommends a particular drug approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must defer to the determination of the attending provider and must cover that service or item without cost sharing.

(3) If a drug is not covered, plans and issuers must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or other individual acting as a patient's authorized representative to ensure coverage without cost sharing.

The conditions listed under this subsection (c) also apply to drugs prescribed for off-label use as abortifacients.

(d) Except as otherwise provided in this Section, a policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided. The provisions of this subsection do not apply to coverage of procedures to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 223.

(e) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section.

(f) The coverage requirements in this Section for abortifacients do not, pursuant to 42 U.S.C. 18054(a)(6), apply to a multistate plan that does not provide coverage for abortion.

(g) If the Department concludes that enforcement of any coverage requirement of this Section for abortifacients may adversely affect the allocation of federal funds to this State, the Department may grant an exemption to that requirement, but only to the minimum extent necessary to ensure the continued receipt of federal funds.

(Source: P.A. 102-1117, eff. 1-13-23; 103-462, eff. 8-4-23.)

(215 ILCS 5/356z.61)

(Text of Section from P.A. 103-1)

Sec. 356z.61. Coverage of pharmacy testing, screening, vaccinations, and treatment. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for health care or patient care services provided by a pharmacist if:

(1) the pharmacist meets the requirements and scope of practice described in paragraph (15), (16), or (17) of subsection (d) of Section 3 of the Pharmacy Practice Act;

(2) the health plan provides coverage for the same service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;

(3) the pharmacist is included in the health benefit plan's network of participating providers; and

(4) reimbursement has been successfully negotiated in good faith between the pharmacist and the health plan.

(Source: P.A. 103-1, eff. 4-27-23.)

(Text of Section from P.A. 103-84)

Sec. 356z.61. Coverage for liver disease screening. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for preventative liver disease screenings for individuals 35 years of age or older and under the age of 65 at high risk for liver disease, including liver ultrasounds and alpha-fetoprotein blood tests every 6 months, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this Section does not apply to coverage of liver disease screenings to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.

(Source: P.A. 103-84, eff. 1-1-24.)

(Text of Section from P.A. 103-91)

Sec. 356z.61. Coverage for compression sleeves. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for compression sleeves that is medically necessary for the enrollee to prevent or mitigate lymphedema.

(Source: P.A. 103-91, eff. 1-1-24.)

(Text of Section from P.A. 103-123)

Sec. 356z.61. Coverage for reconstructive services.

(a) As used in this Section, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance.

(b) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 may not deny coverage for medically necessary reconstructive services that are intended to restore physical appearance.

(Source: P.A. 103-123, eff. 1-1-24.)

(Text of Section from P.A. 103-325)

Sec. 356z.61. Proton beam therapy.

(a) As used in this Section:

"Medically necessary" has the meaning given to that term in the Prior Authorization Reform Act.

"Proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells.

"Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.

(b) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage for the treatment of cancer shall not apply a higher standard of clinical evidence for the coverage of proton beam therapy than the insurer applies for the coverage of any other form of radiation therapy treatment.

(c) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage or benefits to any resident of this State for radiation oncology shall include coverage or benefits for medically necessary proton beam therapy for the treatment of cancer.

(Source: P.A. 103-325, eff. 1-1-24.)

(Text of Section from P.A. 103-420)

Sec. 356z.61. Coverage of prescription estrogen.

(a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 and that provides coverage for prescription drugs shall include coverage for one or more therapeutic equivalent versions of vaginal estrogen in its formulary.

(b) If a particular vaginal estrogen product or its therapeutic equivalent version approved by the United States Food and Drug Administration is determined to be medically necessary, the issuer must cover that service or item pursuant to the cost-sharing requirement contained in subsection (c).

(c) A policy subject to this Section shall not impose a deductible, copayment, or any other cost sharing requirement that exceeds any deductible, coinsurance, copayment, or any other cost-sharing requirement imposed on any prescription drug authorized for the treatment of erectile dysfunction covered by the policy; except that this subsection does not apply to coverage of vaginal estrogen to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.

(d) As used in this Section, "therapeutic equivalent version" has the meaning given to that term in paragraph (2) of subsection (a) of Section 356z.4.

(Source: P.A. 103-420, eff. 1-1-24.)

(Text of Section from P.A. 103-445)

Sec. 356z.61. Home saliva cancer screening.

(a) As used in this Section, "home saliva cancer screening" means an outpatient test that utilizes an individual's saliva to detect biomarkers for early-stage cancer.

(b) An individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2025 shall cover a medically necessary home saliva cancer screening every 24 months if the patient:

(1) is asymptomatic and at high risk for the disease being tested for; or

(2) demonstrates symptoms of the disease being tested for at a physical exam.

(Source: P.A. 103-445, eff. 1-1-24.)

(Text of Section from P.A. 103-458)

Sec. 356z.61. Coverage for children with neuromuscular, neurological, or cognitive impairment. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for therapy, diagnostic testing, and equipment necessary to increase quality of life for children who have been clinically or genetically diagnosed with any disease, syndrome, or disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.

(Source: P.A. 103-458, eff. 1-1-24.)

(Text of Section from P.A. 103-535)

Sec. 356z.61. Coverage of no-cost mental health prevention and wellness visits.

(a) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for one annual mental health prevention and wellness visit for children and for adults.

(b) Mental health prevention and wellness visits shall include any age-appropriate screening recommended by the United States Preventive Services Task Force or by the American Academy of Pediatrics' Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents for purposes of identifying a mental health issue, condition, or disorder; discussing mental health symptoms that might be present, including symptoms of a previously diagnosed mental health condition or disorder; performing an evaluation of adverse childhood experiences; and discussing mental health and wellness.

(c) A mental health prevention and wellness visit shall be covered for up to 60 minutes and may be performed by a physician licensed to practice medicine in all of its branches, a licensed clinical psychologist, a licensed clinical social worker, a licensed clinical professional counselor, a licensed marriage and family therapist, a licensed social worker, or a licensed professional counselor.

(d) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement for mental health prevention and wellness visits. The cost-sharing prohibition in this subsection (d) does not apply to coverage of mental health prevention and wellness visits to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.

(e) A mental health prevention and wellness visit shall be in addition to an annual physical examination and shall not replace a well-child visit or a general health or medical visit.

(f) A mental health prevention and wellness visit shall be reimbursed through the following American Medical Association current procedural terminology codes and at the same rate that current procedural terminology codes are reimbursed for the provision of other medical care: 99381-99387 and 99391-99397. The Department shall update the current procedural terminology codes through adoption of rules if the codes listed in this subsection are altered, amended, changed, deleted, or supplemented.

(g) Reimbursement of any of the current procedural terminology codes listed in this Section shall comply with the following:

(1) reimbursement may be adjusted for payment of claims that are billed by a nonphysician clinician so long as the methodology to determine the adjustments are comparable to and applied no more stringently than the methodology for adjustments made for reimbursement of claims billed by nonphysician clinicians for other medical care, in accordance with 45 CFR 146.136(c)(4); and

(2) for a mental health prevention and wellness visit and for a service other than a mental health prevention and wellness visit, reimbursement shall not be denied if they occur on the same date by the same provider and the provider is a primary care provider.

(h) A mental health prevention and wellness visit may be incorporated into and reimbursed within any type of integrated primary care service delivery method, including, but not limited to, a psychiatric collaborative care model as provided for under this Code.

(i) The Department shall adopt any rules necessary to implement this Section by no later than October 31, 2024.

(Source: P.A. 103-535, eff. 8-11-23.)

(215 ILCS 5/356z.62)

Sec. 356z.62. Coverage of preventive health services.

(a) A policy of group health insurance coverage or individual health insurance coverage as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act shall, at a minimum, provide coverage for and shall not impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for:

(1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;

(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) of this subsection (a) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.

(b) For purposes of this Section, and for purposes of any other provision of State law, recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current.

(c) For office visits:

(1) if an item or service described in subsection (a) is billed separately or is tracked as individual encounter data separately from an office visit, then a policy may impose cost-sharing requirements with respect to the office visit;

(2) if an item or service described in subsection (a) is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a policy may not impose cost-sharing requirements with respect to the office visit; and

(3) if an item or service described in subsection (a) is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a policy may impose cost-sharing requirements with respect to the office visit.

(d) A policy must provide coverage pursuant to subsection (a) for plan or policy years that begin on or after the date that is one year after the date the recommendation or guideline is issued. If a recommendation or guideline is in effect on the first day of the plan or policy year, the policy shall cover the items and services specified in the recommendation or guideline through the last day of the plan or policy year unless either:

(1) a recommendation under paragraph (1) of subsection (a) is downgraded to a "D" rating; or

(2) the item or service is subject to a safety recall or is otherwise determined to pose a significant safety concern by a federal agency authorized to regulate the item or service during the plan or policy year.

(e) Network limitations.

(1) Subject to paragraph (3) of this subsection, nothing in this Section requires coverage for items or services described in subsection (a) that are delivered by an out-of-network provider under a health maintenance organization health care plan, other than a point-of-service contract, or under a voluntary health services plan that generally excludes coverage for out-of-network services except as otherwise required by law.

(2) Subject to paragraph (3) of this subsection, nothing in this Section precludes a policy with a preferred provider program under Article XX-1/2 of this Code, a health maintenance organization point-of-service contract, or a similarly designed voluntary health services plan from imposing cost-sharing requirements for items or services described in subsection (a) that are delivered by an out-of-network provider.

(3) If a policy does not have in its network a provider who can provide an item or service described in subsection (a), then the policy must cover the item or service when performed by an out-of-network provider and it may not impose cost-sharing with respect to the item or service.

(f) Nothing in this Section prevents a company from using reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in subsection (a) to the extent not specified in the recommendation or guideline.

(g) Nothing in this Section shall be construed to prohibit a policy from providing coverage for items or services in addition to those required under subsection (a) or from denying coverage for items or services that are not required under subsection (a). Unless prohibited by other law, a policy may impose cost-sharing requirements for a treatment not described in subsection (a) even if the treatment results from an item or service described in subsection (a). Nothing in this Section shall be construed to limit coverage requirements provided under other law.

(h) The Director may develop guidelines to permit a company to utilize value-based insurance designs. In the absence of guidelines developed by the Director, any such guidelines developed by the Secretary of the U.S. Department of Health and Human Services that are in force under 42 U.S.C. 300gg-13 shall apply.

(i) For student health insurance coverage as defined at 45 CFR 147.145, student administrative health fees are not considered cost-sharing requirements with respect to preventive services specified under subsection (a). As used in this subsection, "student administrative health fee" means a fee charged by an institution of higher education on a periodic basis to its students to offset the cost of providing health care through health clinics regardless of whether the students utilize the health clinics or enroll in student health insurance coverage.

(j) For any recommendation or guideline specifically referring to women or men, a company shall not deny or limit the coverage required or a claim made under subsection (a) based solely on the individual's recorded sex or actual or perceived gender identity, or for the reason that the individual is gender nonconforming, intersex, transgender, or has undergone, or is in the process of undergoing, gender transition, if, notwithstanding the sex or gender assigned at birth, the covered individual meets the conditions for the recommendation or guideline at the time the item or service is furnished.

(k) This Section does not apply to grandfathered health plans, excepted benefits, or short-term, limited-duration health insurance coverage.

(Source: P.A. 103-551, eff. 8-11-23.)