(215 ILCS 5/351A-1) (from Ch. 73, par. 963A-1)
Sec. 351A-1.
Definitions.
Unless the context requires otherwise, in this
Article:
(a) "Long-term care insurance" means any accident and health insurance
policy or rider advertised, marketed, offered or designed to provide
coverage for not less than 12 consecutive months for each covered person on
an expense incurred, indemnity, prepaid or other basis, for one or more
necessary or medically necessary diagnostic, preventive, therapeutic,
rehabilitative, maintenance, or personal care services, provided in a
setting other than an acute care unit of a hospital. Such term includes
group and individual annuities and life insurance policies or riders which
provide directly or which supplement long-term care insurance. The term also
includes a policy or rider that provides for payment of benefits based upon
cognitive impairment or the loss of functional capacity. The term shall also
include qualified long-term care insurance contracts. Long-term
care insurance may be issued by insurers, fraternal benefit societies,
nonprofit health, hospital, and medical service corporations, prepaid
health plans, health maintenance organizations or any similar organization
to the extent they are otherwise authorized to issue life or health
insurance. Long-term care insurance shall not include any insurance policy
which is offered primarily to provide basic Medicare supplement coverage,
basic hospital expense coverage, basic medical-surgical expense coverage,
hospital confinement indemnity coverage, major medical expense coverage,
disability income protection coverage, accident only coverage, specified
disease or specified accident coverage, or limited benefit health coverage.
Long-term care insurance may include benefits for care and treatment in
accordance with the tenets and practices of any established church or
religious denomination which teaches reliance on spiritual treatment
through prayer for healing.
(b) "Applicant" means:
(1) In the case of an individual long-term care |
| insurance policy, the person who seeks to contract for benefits.
|
|
(2) In the case of a group long-term care insurance
|
| policy, the proposed certificate holder.
|
|
(c) "Certificate" means, for the purposes of this Article, any
certificate issued under a group long-term care insurance policy, which
policy has been delivered or issued for delivery in this State.
(d) "Director" means the Director of Insurance of this State.
(e) "Group long-term care insurance" means a long-term care insurance
policy which is delivered or issued for delivery in this State and issued
to one of the following:
(1) One or more employers or labor organizations, or
|
| to a trust or to the trustee or trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
|
|
(2) Any professional, trade or occupational
|
| association for its members or former or retired members, or combination thereof, if such association:
|
|
(A) is composed of individuals all of whom are or
|
| were actively engaged in the same profession, trade or occupation; and
|
|
(B) has been maintained in good faith for
|
| purposes other than obtaining insurance.
|
|
(3) An association or a trust or the trustee or
|
| trustees of a fund established, created or maintained for the benefit of members of one or more associations. Prior to advertising, marketing or offering such policy within this State, the association or associations, or the insurer of the association or associations, shall file evidence with the Director that the association or associations have at the outset a minimum of 100 members and have been organized and maintained in good faith for purposes other than that of obtaining insurance, have been in active existence for at least one year, and have a constitution and by-laws which provide that:
|
|
(A) the association or associations hold regular
|
| meetings not less than annually to further the purposes of the members;
|
|
(B) except for credit unions, the association or
|
| associations collect dues or solicit contributions from members; and
|
|
(C) the members have voting privileges and
|
| representation on the governing board and committees.
|
|
Thirty days after such filing the association or
|
| associations will be deemed to satisfy such organizational requirements, unless the Director makes a finding that the association or associations do not satisfy those organizational requirements.
|
|
(4) A group other than as described in paragraph (1),
|
| (2) or (3) of this subsection (e), subject to a finding by the Director that:
|
|
(A) the issuance of the group policy is not
|
| contrary to the best interest of the public;
|
|
(B) the issuance of the group policy would result
|
| in economies of acquisition or administration; and
|
|
(C) the benefits are reasonable in relation to
|
|
(f) "Policy" means, for the purposes of this Article, any policy, contract,
subscriber agreement, rider or endorsement delivered or issued for delivery
in this State by an insurer, fraternal benefit society, nonprofit health,
hospital, or medical service corporation, prepaid health plan, health
maintenance organization or any similar organization.
(g) "Qualified long-term care insurance contract" or "federally
tax-qualified long-term care insurance contract" means an individual or group
insurance contract that meets the requirements of Section 7702B(b) of the
Internal Revenue Code of 1986, as amended, as follows:
(1) The only insurance protection provided under the
|
| contract is coverage of qualified long-term care services. A contract shall not fail to satisfy the requirements of this subparagraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.
|
|
(2) The contract does not pay or reimburse expenses
|
| incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act, as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount. The requirements of this subparagraph do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor. A contract shall not fail to satisfy the requirements of this subparagraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.
|
|
(3) The contract is guaranteed renewable within the
|
| meaning of Section 7702(B)(b)(1)(C) of the Internal Revenue Code of 1986, as amended.
|
|
(4) The contract does not provide for a cash
|
| surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in subparagraph (5).
|
|
(5) All refunds of premiums and all policyholder
|
| dividends or similar amounts under the contract are to be applied as a reduction in future premiums or to increase future benefits, except that a refund on the event of death of the insured or a complete surrender or cancellation of the contract cannot exceed the aggregate premiums paid under the contract.
|
|
(6) The contract meets the consumer protection
|
| provisions set forth in Section 7702B(g) of the Internal Revenue Code of 1986, as amended.
|
|
"Qualified long-term care insurance contract" or "federally tax-qualified
long-term care insurance contract" also means the portion of a life insurance
contract that provides long-term care insurance
coverage by rider or as part of the contract and that satisfies the
requirements of Sections 7702B(b) and 7702B(e) of the Internal Revenue Code of
1986,
as amended.
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-8) (from Ch. 73, par. 963A-8)
Sec. 351A-8.
Outline of coverage.
(a) An outline of coverage shall be delivered to a prospective applicant
for long-term care insurance at the time of initial solicitation through
means which prominently direct the attention of the recipient to the
document and its purpose.
(1) The Director shall prescribe a standard format |
| including style, arrangement and overall appearance and the content of an outline of coverage.
|
|
(2) In the case of agent solicitations, an agent must
|
| deliver the outline of coverage prior to the presentation of an application or enrollment form.
|
|
(3) In the case of direct response solicitations, the
|
| outline of coverage must be presented in conjunction with any application or enrollment form.
|
|
(b) The outline of coverage shall include:
(1) A description of the principal benefits and
|
| coverage provided in the policy.
|
|
(2) A statement of the principal exclusions,
|
| reductions and limitations contained in the policy.
|
|
(3) A statement of the terms under which the policy
|
| or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described.
|
|
(4) A statement that the outline of coverage is a
|
| summary only, not a contract of insurance, and that the policy or group master policy contain governing contractual provisions.
|
|
(5) A description of the terms under which the policy
|
| or certificate may be returned and premium refunded.
|
|
(6) A brief description of the relationship of cost
|
|
(7) A statement that discloses to the policyholder or
|
| certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract under 7702B(b) of the Internal Revenue Code of 1986, as amended.
|
|
(Source: P.A. 92-148, eff. 7-24-01.)
|
(215 ILCS 5/351A-9.1) (from Ch. 73, par. 963A-9.1)
Sec. 351A-9.1.
Policy summary and benefit reports.
(a) At the time of policy delivery, a policy summary shall be delivered
for an individual life insurance policy which provides long-term care
benefits within the policy or by rider. In the case of direct response
solicitations, the insurer shall deliver the policy summary upon the
applicant's request, but regardless of request shall make such delivery no
later than at the time of policy delivery. In addition to complying with
all applicable requirements, the summary shall also include:
(1) an explanation of how the long-term care benefit |
| interacts with other components of the policy, including deductions from death benefits;
|
|
(2) an illustration of the amount of benefits, the
|
| length of benefit, and the guaranteed lifetime benefits if any, for each covered person;
|
|
(3) any exclusions, reductions and limitations on
|
| benefits of long-term care; and
|
|
(4) if applicable to the policy type, the summary
|
|
(A) disclosure of the effects of exercising other
|
|
(B) disclosure of guarantees related to long-term
|
| care costs of insurance charges; and
|
|
(C) current and projected maximum lifetime
|
|
(b) Any time a long-term care benefit, funded through a life insurance
vehicle by the acceleration of the death benefit, is in benefit payment
status, a monthly report shall be provided to the policyholder. Such
report shall include:
(1) any long-term care benefits paid during the month;
(2) an explanation of any changes in the policy,
|
| including changes in death benefits or cash values, due to long-term care benefits being paid out; and
|
|
(3) the amount of long-term care benefits existing or
|
|
(Source: P.A. 86-384.)
|
(215 ILCS 5/355) (from Ch. 73, par. 967) (Text of Section from P.A. 103-106) Sec. 355. Accident and health policies; provisions. (a) As used in this Section: "Inadequate rate" means a rate: (1) that is insufficient to sustain projected losses |
| and expenses to which the rate applies; and
|
|
(2) the continued use of which endangers the solvency
|
| of an insurer using that rate.
|
|
"Large employer" has the meaning provided in the Illinois Health Insurance Portability and Accountability Act.
"Plain language" has the meaning provided in the federal Plain Writing Act of 2010 and subsequent guidance documents, including the Federal Plain Language Guidelines.
"Unreasonable rate increase" means a rate increase that the Director determines to be excessive, unjustified, or unfairly discriminatory in accordance with 45 CFR 154.205.
(b) No policy of insurance against loss or damage from the sickness, or from the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining thereto have been filed with the Director; nor shall it be so issued or delivered until the Director shall have approved such policy pursuant to the provisions of Section 143. If the Director disapproves the policy form, he or she shall make a written decision stating the respects in which such form does not comply with the requirements of law and shall deliver a copy thereof to the company and it shall be unlawful thereafter for any such company to issue any policy in such form. On and after January 1, 2025, any form filing submitted for large employer group accident and health insurance shall be automatically deemed approved within 90 days of the submission date unless the Director extends by not more than an additional 30 days the period within which the form shall be approved or disapproved by giving written notice to the insurer of such extension before the expiration of the 90 days. Any form in receipt of such an extension shall be automatically deemed approved within 120 days of the submission date. The Director may toll the filing due to a conflict in legal interpretation of federal or State law as long as the tolling is applied uniformly to all applicable forms, written notification is provided to the insurer prior to the tolling, the duration of the tolling is provided within the notice to the insurer, and justification for the tolling is posted to the Department's website. The Director may disapprove the filing if the insurer fails to respond to an objection or request for additional information within the timeframe identified for response. As used in this subsection, "large employer" has the meaning given in Section 5 of the federal Health Insurance Portability and Accountability Act.
(c) For plan year 2026 and thereafter, premium rates for all individual and small group accident and health insurance policies must be filed with the Department for approval. Unreasonable rate increases or inadequate rates shall be modified or disapproved. For any plan year during which the Illinois Health Benefits Exchange operates as a full State-based exchange, the Department shall provide insurers at least 30 days' notice of the deadline to submit rate filings.
(d) For plan year 2025 and thereafter, the Department shall post all insurers' rate filings and summaries on the Department's website 5 business days after the rate filing deadline set by the Department in annual guidance. The rate filings and summaries posted to the Department's website shall exclude information that is proprietary or trade secret information protected under paragraph (g) of subsection (1) of Section 7 of the Freedom of Information Act or confidential or privileged under any applicable insurance law or rule. All summaries shall include a brief justification of any rate increase or decrease requested, including the number of individual members, the medical loss ratio, medical trend, administrative costs, and any other information required by rule. The plain writing summary shall include notification of the public comment period established in subsection (e).
(e) The Department shall open a 30-day public comment period on the rate filings beginning on the date that all of the rate filings are posted on the Department's website. The Department shall post all of the comments received to the Department's website within 5 business days after the comment period ends.
(f) After the close of the public comment period described in subsection (e), the Department, beginning for plan year 2026, shall issue a decision to approve, disapprove, or modify a rate filing within 60 days. Any rate filing or any rates within a filing on which the Director does not issue a decision within 60 days shall automatically be deemed approved. The Director's decision shall take into account the actuarial justifications and public comments. The Department shall notify the insurer of the decision, make the decision available to the public by posting it on the Department's website, and include an explanation of the findings, actuarial justifications, and rationale that are the basis for the decision. Any company whose rate has been modified or disapproved shall be allowed to request a hearing within 10 days after the action taken. The action of the Director in disapproving a rate shall be subject to judicial review under the Administrative Review Law.
(g) If, following the issuance of a decision but before the effective date of the premium rates approved by the decision, an event occurs that materially affects the Director's decision to approve, deny, or modify the rates, the Director may consider supplemental facts or data reasonably related to the event.
(h) The Department shall adopt rules implementing the procedures described in subsections (d) through (g) by March 31, 2024.
(i) Subsection (a) and subsections (c) through (h) of this Section do not apply to grandfathered health plans as defined in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. 300gg-91; student health insurance coverage as defined in 45 CFR 147.145; the large group market as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act; or short-term, limited-duration health insurance coverage as defined in Section 5 of the Short-Term, Limited-Duration Health Insurance Coverage Act. For a filing of premium rates or classifications of risk for any of these types of coverage, the Director's initial review period shall not exceed 60 days to issue informal objections to the company that request additional clarification, explanation, substantiating documentation, or correction of concerns identified in the filing before the company implements the premium rates, classifications, or related rate-setting methodologies described in the filing, except that the Director may extend by not more than an additional 30 days the period of initial review by giving written notice to the company of such extension before the expiration of the initial 60-day period. Nothing in this subsection shall confer authority upon the Director to approve, modify, or disapprove rates where that authority is not provided by other law. Nothing in this subsection shall prohibit the Director from conducting any investigation, examination, hearing, or other formal administrative or enforcement proceeding with respect to a company's rate filing or implementation thereof under applicable law at any time, including after the period of initial review.
(Source: P.A. 103-106, eff. 1-1-24 .)
(Text of Section from P.A. 103-650, Article 3, Section 3-5)
Sec. 355. Accident and health policies; provisions.
(a) As used in this Section:
"Inadequate rate" means a rate:
(1) that is insufficient to sustain projected losses
|
| and expenses to which the rate applies; and
|
|
(2) the continued use of which endangers the solvency
|
| of an insurer using that rate.
|
|
"Large employer" has the meaning provided in the Illinois Health Insurance Portability and Accountability Act.
"Plain language" has the meaning provided in the federal Plain Writing Act of 2010 and subsequent guidance documents, including the Federal Plain Language Guidelines.
"Unreasonable rate increase" means a rate increase that the Director determines to be excessive, unjustified, or unfairly discriminatory in accordance with 45 CFR 154.205.
(b) No policy of insurance against loss or damage from the sickness, or from the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining thereto have been filed with the Director; nor shall it be so issued or delivered until the Director shall have approved such policy pursuant to the provisions of Section 143. If the Director disapproves the policy form, he or she shall make a written decision stating the respects in which such form does not comply with the requirements of law and shall deliver a copy thereof to the company and it shall be unlawful thereafter for any such company to issue any policy in such form. On and after January 1, 2025, any form filing submitted for large employer group accident and health insurance shall be automatically deemed approved within 90 days of the submission date unless the Director extends by not more than an additional 30 days the period within which the form shall be approved or disapproved by giving written notice to the insurer of such extension before the expiration of the 90 days. Any form in receipt of such an extension shall be automatically deemed approved within 120 days of the submission date. The Director may toll the filing due to a conflict in legal interpretation of federal or State law as long as the tolling is applied uniformly to all applicable forms, written notification is provided to the insurer prior to the tolling, the duration of the tolling is provided within the notice to the insurer, and justification for the tolling is posted to the Department's website. The Director may disapprove the filing if the insurer fails to respond to an objection or request for additional information within the timeframe identified for response. As used in this subsection, "large employer" has the meaning given in Section 5 of the federal Health Insurance Portability and Accountability Act.
(c) For plan year 2026 and thereafter, premium rates for all individual and small group accident and health insurance policies must be filed with the Department for approval. Unreasonable rate increases or inadequate rates shall be modified or disapproved. For any plan year during which the Illinois Health Benefits Exchange operates as a full State-based exchange, the Department shall provide insurers at least 30 days' notice of the deadline to submit rate filings.
(c-5) Unless prohibited under federal law, for plan year 2026 and thereafter, each insurer proposing to offer a qualified health plan issued in the individual market through the Illinois Health Benefits Exchange must incorporate the following approach in its rate filing under this Section:
(1) The rate filing must apply a cost-sharing
|
| reduction defunding adjustment factor within a range that:
|
|
(A) is uniform across all insurers;
(B) is consistent with the total adjustment
|
| expected to be needed to cover actual cost-sharing reduction costs across all silver plans on the Illinois Health Benefits Exchange statewide, provided that such costs are calculated assuming utilization by the State's full individual-market risk pool; and
|
|
(C) assumes that the only on-Exchange silver
|
| plans that will be purchased are the 87% and 94% cost-sharing reduction variations.
|
|
(2) The rate filing must apply an induced demand
|
| factor based on the following formula: (Plan Actuarial Value) 2 - (Plan Actuarial Value) + 1.24.
|
|
In the annual notice to insurers described in subsection (c), the Department must include the specific numerical range calculated for the applicable plan year under paragraph (1) of this subsection (c-5) and the formula in paragraph (2) of this subsection (c-5).
(d) For plan year 2025 and thereafter, the Department shall post all insurers' rate filings and summaries on the Department's website 5 business days after the rate filing deadline set by the Department in annual guidance. The rate filings and summaries posted to the Department's website shall exclude information that is proprietary or trade secret information protected under paragraph (g) of subsection (1) of Section 7 of the Freedom of Information Act or confidential or privileged under any applicable insurance law or rule. All summaries shall include a brief justification of any rate increase or decrease requested, including the number of individual members, the medical loss ratio, medical trend, administrative costs, and any other information required by rule. The plain writing summary shall include notification of the public comment period established in subsection (e).
(e) The Department shall open a 30-day public comment period on the rate filings beginning on the date that all of the rate filings are posted on the Department's website. The Department shall post all of the comments received to the Department's website within 5 business days after the comment period ends.
(f) After the close of the public comment period described in subsection (e), the Department, beginning for plan year 2026, shall issue a decision to approve, disapprove, or modify a rate filing within 60 days. Any rate filing or any rates within a filing on which the Director does not issue a decision within 60 days shall automatically be deemed approved. The Director's decision shall take into account the actuarial justifications and public comments. The Department shall notify the insurer of the decision, make the decision available to the public by posting it on the Department's website, and include an explanation of the findings, actuarial justifications, and rationale that are the basis for the decision. Any company whose rate has been modified or disapproved shall be allowed to request a hearing within 10 days after the action taken. The action of the Director in disapproving a rate shall be subject to judicial review under the Administrative Review Law.
(g) If, following the issuance of a decision but before the effective date of the premium rates approved by the decision, an event occurs that materially affects the Director's decision to approve, deny, or modify the rates, the Director may consider supplemental facts or data reasonably related to the event.
(h) The Department shall adopt rules implementing the procedures described in subsections (d) through (g) by March 31, 2024.
(i) Subsection (a) and subsections (c) through (h) of this Section do not apply to grandfathered health plans as defined in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. 300gg-91; student health insurance coverage as defined in 45 CFR 147.145; the large group market as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act; or short-term, limited-duration health insurance coverage as defined in Section 5 of the Short-Term, Limited-Duration Health Insurance Coverage Act. For a filing of premium rates or classifications of risk for any of these types of coverage, the Director's initial review period shall not exceed 60 days to issue informal objections to the company that request additional clarification, explanation, substantiating documentation, or correction of concerns identified in the filing before the company implements the premium rates, classifications, or related rate-setting methodologies described in the filing, except that the Director may extend by not more than an additional 30 days the period of initial review by giving written notice to the company of such extension before the expiration of the initial 60-day period. Nothing in this subsection shall confer authority upon the Director to approve, modify, or disapprove rates where that authority is not provided by other law. Nothing in this subsection shall prohibit the Director from conducting any investigation, examination, hearing, or other formal administrative or enforcement proceeding with respect to a company's rate filing or implementation thereof under applicable law at any time, including after the period of initial review.
(Source: P.A. 103-106, eff. 1-1-24; 103-650, Article 3, Section 3-5, eff. 1-1-25.)
(Text of Section from P.A. 103-650, Article 4, Section 4-5)
Sec. 355. Accident and health policies; provisions.
(a) As used in this Section:
"Inadequate rate" means a rate:
(1) that is insufficient to sustain projected losses
|
| and expenses to which the rate applies; and
|
|
(2) the continued use of which endangers the solvency
|
| of an insurer using that rate.
|
|
"Large employer" has the meaning provided in the Illinois Health Insurance Portability and Accountability Act.
"Plain language" has the meaning provided in the federal Plain Writing Act of 2010 and subsequent guidance documents, including the Federal Plain Language Guidelines.
"Unreasonable rate increase" means a rate increase that the Director determines to be excessive, unjustified, or unfairly discriminatory in accordance with 45 CFR 154.205.
(b) No policy of insurance against loss or damage from the sickness, or from the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining thereto have been filed with the Director; nor shall it be so issued or delivered until the Director shall have approved such policy pursuant to the provisions of Section 143. If the Director disapproves the policy form, he or she shall make a written decision stating the respects in which such form does not comply with the requirements of law and shall deliver a copy thereof to the company and it shall be unlawful thereafter for any such company to issue any policy in such form. On and after January 1, 2025, any form filing submitted for large employer group accident and health insurance shall be automatically deemed approved within 90 days of the submission date unless the Director extends by not more than an additional 30 days the period within which the form shall be approved or disapproved by giving written notice to the insurer of such extension before the expiration of the 90 days. Any form in receipt of such an extension shall be automatically deemed approved within 120 days of the submission date. The Director may toll the filing due to a conflict in legal interpretation of federal or State law as long as the tolling is applied uniformly to all applicable forms, written notification is provided to the insurer prior to the tolling, the duration of the tolling is provided within the notice to the insurer, and justification for the tolling is posted to the Department's website. The Director may disapprove the filing if the insurer fails to respond to an objection or request for additional information within the timeframe identified for response. As used in this subsection, "large employer" has the meaning given in Section 5 of the federal Health Insurance Portability and Accountability Act.
(c) For plan year 2026 and thereafter, premium rates for all individual and small group accident and health insurance policies must be filed with the Department for approval. Unreasonable rate increases or inadequate rates shall be modified or disapproved. For any plan year during which the Illinois Health Benefits Exchange operates as a full State-based exchange, the Department shall provide insurers at least 30 days' notice of the deadline to submit rate filings.
(d) For plan year 2025 and thereafter, the Department shall post all insurers' rate filings and summaries on the Department's website 5 business days after the rate filing deadline set by the Department in annual guidance. The rate filings and summaries posted to the Department's website shall exclude information that is proprietary or trade secret information protected under paragraph (g) of subsection (1) of Section 7 of the Freedom of Information Act or confidential or privileged under any applicable insurance law or rule. All summaries shall include a brief justification of any rate increase or decrease requested, including the number of individual members, the medical loss ratio, medical trend, administrative costs, and any other information required by rule. The plain writing summary shall include notification of the public comment period established in subsection (e).
(e) The Department shall open a 30-day public comment period on the rate filings beginning on the date that all of the rate filings are posted on the Department's website. The Department shall post all of the comments received to the Department's website within 5 business days after the comment period ends.
(f) After the close of the public comment period described in subsection (e), the Department, beginning for plan year 2026, shall issue a decision to approve, disapprove, or modify a rate filing within 60 days. Any rate filing or any rates within a filing on which the Director does not issue a decision within 60 days shall automatically be deemed approved. The Director's decision shall take into account the actuarial justifications and public comments. The Department shall notify the insurer of the decision, make the decision available to the public by posting it on the Department's website, and include an explanation of the findings, actuarial justifications, and rationale that are the basis for the decision. Any company whose rate has been modified or disapproved shall be allowed to request a hearing within 10 days after the action taken. The action of the Director in disapproving a rate shall be subject to judicial review under the Administrative Review Law.
(g) If, following the issuance of a decision but before the effective date of the premium rates approved by the decision, an event occurs that materially affects the Director's decision to approve, deny, or modify the rates, the Director may consider supplemental facts or data reasonably related to the event.
(h) The Department shall adopt rules implementing the procedures described in subsections (d) through (g) by March 31, 2024.
(i) Subsection (a), subsections (c) through (h), and subsection (j) of this Section do not apply to grandfathered health plans as defined in 45 CFR 147.140; excepted benefits as defined in 42 U.S.C. 300gg-91; or student health insurance coverage as defined in 45 CFR 147.145. For a filing of premium rates or classifications of risk for any of these types of coverage, the Director's initial review period shall not exceed 60 days to issue informal objections to the company that request additional clarification, explanation, substantiating documentation, or correction of concerns identified in the filing before the company implements the premium rates, classifications, or related rate-setting methodologies described in the filing, except that the Director may extend by not more than an additional 30 days the period of initial review by giving written notice to the company of such extension before the expiration of the initial 60-day period. Nothing in this subsection shall confer authority upon the Director to approve, modify, or disapprove rates where that authority is not provided by other law. Nothing in this subsection shall prohibit the Director from conducting any investigation, examination, hearing, or other formal administrative or enforcement proceeding with respect to a company's rate filing or implementation thereof under applicable law at any time, including after the period of initial review.
(j) Subsection (a) and subsections (c) through (h) do not apply to group policies issued in the large group market as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act. For large group policies issued, delivered, amended, or renewed on or after January 1, 2026 that are not described in subsection (i), the premium rates and risk classifications, including any rate manuals and rules used to arrive at the rates, must be filed with the Department annually for approval at least 120 days before the rates are intended to take effect.
(1) A rate filing shall be modified or disapproved if
|
| the premiums are unreasonable in relation to the benefits because the rates were not calculated in accordance with sound actuarial principles.
|
|
(2) Within 60 days of receipt of the rate filing, the
|
| Director shall issue a decision to approve, disapprove, or modify the filing along with the reasons and actuarial justification for the decision. Any rate filing or rates within a filing on which the Director does not issue a decision within 60 days shall be automatically deemed approved.
|
|
(3) Any company whose rate or rate filing has been
|
| modified or disapproved shall be allowed to request a hearing within 10 days after the action taken. The action of the Director in disapproving a rate or rate filing shall be subject to judicial review under the Administrative Review Law.
|
|
(4) Nothing in this subsection requires a company to
|
| file a large group policy's final premium rates for prior approval if the company negotiates the final rates or rate adjustments with the plan sponsor or its administrator in accordance with the rate manual and rules of the currently approved rate filing for the policy.
|
|
In this subsection, "administrator" and "plan sponsor" have the meaning given to those terms in 29 U.S.C. 1002(16).
(Source: P.A. 103-106, eff. 1-1-24; 103-650, Article 4, Section 4-5, eff. 1-1-25.)
|
(215 ILCS 5/355a) (from Ch. 73, par. 967a)
Sec. 355a. Standardization of terms and coverage.
(1) The purposes of this Section shall be (a) to provide
reasonable standardization and simplification of terms and coverages of
individual accident and health insurance policies to facilitate public
understanding and comparisons; (b) to eliminate provisions contained in
individual accident and health insurance policies which may be
misleading or unreasonably confusing in connection either with the
purchase of such coverages or with the settlement of claims; and (c) to
provide for reasonable disclosure in the sale of accident and health
coverages.
(2) Definitions applicable to this Section are as follows:
(a) "Policy" means all or any part of the forms |
| constituting the contract between the insurer and the insured, including the policy, certificate, subscriber contract, riders, endorsements, and the application if attached, which are subject to filing with and approval by the Director.
|
|
(b) "Service corporations" means voluntary health and
|
| dental corporations organized and operating respectively under the Voluntary Health Services Plans Act and the Dental Service Plan Act.
|
|
(c) "Accident and health insurance" means insurance
|
| written under Article XX of this Code, other than credit accident and health insurance, and coverages provided in subscriber contracts issued by service corporations. For purposes of this Section such service corporations shall be deemed to be insurers engaged in the business of insurance.
|
|
(3) The Director shall issue such rules as he shall deem necessary
or desirable to establish specific standards, including standards of
full and fair disclosure that set forth the form and content and
required disclosure for sale, of individual policies of accident and
health insurance, which rules and regulations shall be in addition to
and in accordance with the applicable laws of this State, and which may
cover but shall not be limited to: (a) terms of renewability; (b)
initial and subsequent conditions of eligibility; (c) non-duplication of
coverage provisions; (d) coverage of dependents; (e) pre-existing
conditions; (f) termination of insurance; (g) probationary periods; (h)
limitation, exceptions, and reductions; (i) elimination periods; (j)
requirements regarding replacements; (k) recurrent conditions; and (l)
the definition of terms, including, but not limited to, the following:
hospital, accident, sickness, injury, physician, accidental means, total
disability, partial disability, nervous disorder, guaranteed renewable,
and non-cancellable.
The Director may issue rules that specify prohibited policy
provisions not otherwise specifically authorized by statute which in the
opinion of the Director are unjust, unfair or unfairly discriminatory to
the policyholder, any person insured under the policy, or beneficiary.
(4) The Director shall issue such rules as he shall deem necessary
or desirable to establish minimum standards for benefits under each
category of coverage in individual accident and health policies, other
than conversion policies issued pursuant to a contractual conversion
privilege under a group policy, including but not limited to the
following categories: (a) basic hospital expense coverage; (b) basic
medical-surgical expense coverage; (c) hospital confinement indemnity
coverage; (d) major medical expense coverage; (e) disability income
protection coverage; (f) accident only coverage; and (g) specified
disease or specified accident coverage.
Nothing in this subsection (4) shall preclude the issuance of any
policy which combines two or more of the categories of coverage
enumerated in subparagraphs (a) through (f) of this subsection.
No policy shall be delivered or issued for delivery in this State
which does not meet the prescribed minimum standards for the categories
of coverage listed in this subsection unless the Director finds that
such policy is necessary to meet specific needs of individuals or groups
and such individuals or groups will be adequately informed that such
policy does not meet the prescribed minimum standards, and such policy
meets the requirement that the benefits provided therein are reasonable
in relation to the premium charged. The standards and criteria to be
used by the Director in approving such policies shall be included in the
rules required under this Section with as much specificity as
practicable.
The Director shall prescribe by rule the method of identification of
policies based upon coverages provided.
(5) (a) In order to provide for full and fair disclosure in the
sale of individual accident and health insurance policies, no such
policy shall be delivered or issued for delivery in this State unless
the outline of coverage described in paragraph (b) of this subsection
either accompanies the policy, or is delivered to the applicant at the
time the application is made, and an acknowledgment signed by the
insured, of receipt of delivery of such outline, is provided to the
insurer. In the event the policy is issued on a basis other than that
applied for, the outline of coverage properly describing the policy must
accompany the policy when it is delivered and such outline shall clearly
state that the policy differs, and to what extent, from that for which
application was originally made. All policies, except single premium
nonrenewal policies, shall have a notice prominently printed on the
first page of the policy or attached thereto stating in substance, that
the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if after
examination of the policy the policyholder is not satisfied for any
reason.
(b) The Director shall issue such rules as he shall deem necessary
or desirable to prescribe the format and content of the outline of
coverage required by paragraph (a) of this subsection. "Format" means
style, arrangement, and overall appearance, including such items as the
size, color, and prominence of type and the arrangement of text and
captions. "Content" shall include without limitation thereto,
statements relating to the particular policy as to the applicable
category of coverage prescribed under subsection (4); principal benefits;
exceptions, reductions and limitations; and renewal provisions,
including any reservation by the insurer of a right to change premiums.
Such outline of coverage shall clearly state that it constitutes a
summary of the policy issued or applied for and that the policy should
be consulted to determine governing contractual provisions.
(c) (Blank).
(d) (Blank).
(e) (Blank).
(f) (Blank).
(6) Prior to the issuance of rules pursuant to this Section, the
Director shall afford the public, including the companies affected
thereby, reasonable opportunity for comment. Such rulemaking is subject
to the provisions of the Illinois Administrative Procedure Act.
(7) When a rule has been adopted, pursuant to this Section, all
policies of insurance or subscriber contracts which are not in
compliance with such rule shall, when so provided in such rule, be
deemed to be disapproved as of a date specified in such rule not less
than 120 days following its effective date, without any further or
additional notice other than the adoption of the rule.
(8) When a rule adopted pursuant to this Section so provides, a
policy of insurance or subscriber contract which does not comply with
the rule shall, not less than 120 days from the effective date of such
rule, be construed, and the insurer or service corporation shall be
liable, as if the policy or contract did comply with the rule.
(9) Violation of any rule adopted pursuant to this Section shall be
a violation of the insurance law for purposes of Sections 370 and 446 of this
Code.
(Source: P.A. 102-775, eff. 5-13-22.)
|
(215 ILCS 5/356a) (from Ch. 73, par. 968a) Sec. 356a. Form of policy. (1) No individual policy of accident and health insurance shall be delivered or issued for delivery to any person in this State unless: (a) the entire money and other considerations |
| therefor are expressed therein; and
|
|
(b) the time at which the insurance takes effect and
|
| terminates is expressed therein; and
|
|
(c) it purports to insure only one person, except
|
| that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, any 2 or more eligible members of that family, including husband, wife, dependent children or any children under a specified age which shall not exceed 19 years and any other person dependent upon the policyholder; and
|
|
(d) the style, arrangement and over-all appearance of
|
| the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than ten-point with a lower-case unspaced alphabet length not less than one hundred and twenty-point (the "text" shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and captions and subcaptions); and
|
|
(e) the exceptions and reductions of indemnity are
|
| set forth in the policy and, except those which are set forth in Sections 357.1 through 357.30 of this Act, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and
|
|
(f) each such form, including riders and
|
| endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and
|
|
(g) it contains no provision purporting to make any
|
| portion of the charter, rules, constitution, or by-laws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the Director.
|
|
(2) If any policy is issued by an insurer domiciled in this State for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the Director that any such policy is not subject to approval or disapproval by such official, the Director may by ruling require that such policy meet the standards set forth in subsection (1) of this Section and in Sections 357.1 through 357.30.
(Source: P.A. 103-718, eff. 7-19-24.)
|
(215 ILCS 5/356g) (from Ch. 73, par. 968g) (Text of Section before amendment by P.A. 103-808 ) Sec. 356g. Mammograms; mastectomies. (a) Every insurer shall provide in each group or individual
policy, contract, or certificate of insurance issued or renewed for persons
who are residents of this State, coverage for screening by low-dose
mammography for all women 35 years of age or older for the presence of
occult breast cancer within the provisions of the policy, contract, or
certificate. The coverage shall be as follows: (1) A baseline mammogram for women 35 to 39 years of |
|
(2) An annual mammogram for women 40 years of age or
|
|
(3) A mammogram at the age and intervals considered
|
| medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
|
|
(4) For an individual or group policy of accident and
|
| health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
|
|
(5) A screening MRI when medically necessary, as
|
| determined by a physician licensed to practice medicine in all of its branches.
|
|
(6) For an individual or group policy of accident and
|
| health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly, a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.
|
|
A policy subject to this subsection shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this sentence does not apply to coverage of diagnostic mammograms 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 (26 U.S.C. 223).
For purposes of this Section:
"Diagnostic
mammogram" means a mammogram obtained using diagnostic mammography.
"Diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.
"Low-dose mammography"
means the x-ray examination of the breast using equipment dedicated
specifically for mammography, including the x-ray tube, filter, compression
device, and image receptor, with radiation exposure delivery of less than
1 rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. As used in this Section, the term "breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this subsection, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this subsection.
(a-5) Coverage as described by subsection (a) shall be provided at no cost to the insured and shall not be applied to an annual or lifetime maximum benefit.
(a-10) When health care services are available through contracted providers and a person does not comply with plan provisions specific to the use of contracted providers, the requirements of subsection (a-5) are not applicable. When a person does not comply with plan provisions specific to the use of contracted providers, plan provisions specific to the use of non-contracted providers must be applied without distinction for coverage required by this Section and shall be at least as favorable as for other radiological examinations covered by the policy or contract.
(b) No policy of accident or health insurance that provides for
the surgical procedure known as a mastectomy shall be issued, amended,
delivered, or renewed in this State unless
that coverage also provides for prosthetic devices
or reconstructive surgery
incident to the mastectomy.
Coverage for breast reconstruction in connection with a mastectomy shall
include:
(1) reconstruction of the breast upon which the
|
| mastectomy has been performed;
|
|
(2) surgery and reconstruction of the other breast to
|
| produce a symmetrical appearance; and
|
|
(3) prostheses and treatment for physical
|
| complications at all stages of mastectomy, including lymphedemas.
|
|
Care shall be determined in consultation with the attending physician and the
patient.
The offered coverage for prosthetic devices and
reconstructive surgery shall be subject to the deductible and coinsurance
conditions applied to the mastectomy, and all other terms and conditions
applicable to other benefits. When a mastectomy is performed and there is
no evidence of malignancy then the offered coverage may be limited to the
provision of prosthetic devices and reconstructive surgery to within 2
years after the date of the mastectomy. As used in this Section,
"mastectomy" means the removal of all or part of the breast for medically
necessary reasons, as determined by a licensed physician.
Written notice of the availability of coverage under this Section shall be
delivered to the insured upon enrollment and annually thereafter. An insurer
may not deny to an insured eligibility, or continued eligibility, to enroll or
to renew coverage under the terms of the plan solely for the purpose of
avoiding the requirements of this Section. An insurer may not penalize or
reduce or
limit the reimbursement of an attending provider or provide incentives
(monetary or otherwise) to an attending provider to induce the provider to
provide care to an insured in a manner inconsistent with this Section.
(c) Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20 .)
(Text of Section after amendment by P.A. 103-808 )
Sec. 356g. Mammograms; mastectomies.
(a) Every insurer shall provide in each group or individual policy, contract, or certificate of insurance issued or renewed for persons who are residents of this State, coverage for screening by low-dose mammography for all patients 35 years of age or older for the presence of occult breast cancer within the provisions of the policy, contract, or certificate. The coverage shall be as follows:
(1) A baseline mammogram for patients 35 to 39 years
|
|
(2) An annual mammogram for patients 40 years of age
|
|
(3) A mammogram at the age and intervals considered
|
| medically necessary by the patient's health care provider for patients under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
|
|
(4) For an individual or group policy of accident and
|
| health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-580) and before the effective date of this amendatory Act of the 103rd General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
|
|
(4.3) For an individual or group policy of accident
|
| and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches, advanced practice registered nurse, or physician assistant.
|
|
(4.5) For a group policy of accident and health
|
| insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly, molecular breast imaging (MBI) of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches, advanced practice registered nurse, or physician assistant.
|
|
(5) A screening MRI when medically necessary, as
|
| determined by a physician licensed to practice medicine in all of its branches.
|
|
(6) For an individual or group policy of accident and
|
| health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-580), a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.
|
|
A policy subject to this subsection shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this sentence does not apply to coverage of diagnostic mammograms 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 (26 U.S.C. 223).
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using diagnostic mammography.
"Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast.
"Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with radiation exposure delivery of less than 1 rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. As used in this Section, the term "breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this subsection, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this subsection.
(a-5) Coverage as described by subsection (a) shall be provided at no cost to the insured and shall not be applied to an annual or lifetime maximum benefit.
(a-10) When health care services are available through contracted providers and a person does not comply with plan provisions specific to the use of contracted providers, the requirements of subsection (a-5) are not applicable. When a person does not comply with plan provisions specific to the use of contracted providers, plan provisions specific to the use of non-contracted providers must be applied without distinction for coverage required by this Section and shall be at least as favorable as for other radiological examinations covered by the policy or contract.
(b) No policy of accident or health insurance that provides for the surgical procedure known as a mastectomy shall be issued, amended, delivered, or renewed in this State unless that coverage also provides for prosthetic devices or reconstructive surgery incident to the mastectomy. Coverage for breast reconstruction in connection with a mastectomy shall include:
(1) reconstruction of the breast upon which the
|
| mastectomy has been performed;
|
|
(2) surgery and reconstruction of the other breast to
|
| produce a symmetrical appearance; and
|
|
(3) prostheses and treatment for physical
|
| complications at all stages of mastectomy, including lymphedemas.
|
|
Care shall be determined in consultation with the attending physician and the patient. The offered coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy, and all other terms and conditions applicable to other benefits. When a mastectomy is performed and there is no evidence of malignancy then the offered coverage may be limited to the provision of prosthetic devices and reconstructive surgery to within 2 years after the date of the mastectomy. As used in this Section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician.
Written notice of the availability of coverage under this Section shall be delivered to the insured upon enrollment and annually thereafter. An insurer may not deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Section. An insurer may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives (monetary or otherwise) to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with this Section.
(c) Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 103-808, eff. 1-1-26.)
|
(215 ILCS 5/356i) (from Ch. 73, par. 968i)
Sec. 356i.
Medical assistance; coverage of child.
(a) In this Section, "Medicaid" means medical assistance authorized under
Section 1902 of the Social Security Act.
(b) An individual or group
policy of accident and health insurance that is delivered or issued for
delivery to any person in this State or renewed or amended may not contain
any provision which limits or excludes payments of hospital or
medical
benefits coverage to or on behalf of the insured because the insured or
any covered dependent is eligible for or 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 an accident and health insurance policy
issued to the child's noncustodial parent, the issuer of the policy shall do
all of the following:
(1) Provide necessary information to the child's |
| custodial parent to enable the child to obtain benefits under that coverage.
|
|
(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) An insurer may not deny enrollment of a child under the accident and
health insurance coverage of the child's parent 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 insurer's service area.
|
|
(f) If a parent is required by a court or administrative order to provide
accident and health insurance coverage for a child and the parent is insured
under a plan that offers coverage
for eligible dependents, the insurer, upon receiving a copy of the order,
shall:
(1) Upon application, permit the parent to add to the
|
| parent's coverage such a child who is otherwise eligible for that coverage, without regard to any enrollment season restrictions.
|
|
(2) Add the child to the parent's coverage 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 covered but fails to apply for coverage for the child.
|
|
(g) An insurer may not impose, on a state agency that has been assigned the
rights of a covered individual who
receives Medicaid benefits, requirements that are different from requirements
applicable to an assignee of any other individual covered under the same
insurance policy.
(h) Nothing in subsections (e) and (f) prevents an
insurer from denying any such application if the child is not eligible for
coverage according to the insurer's medical underwriting standards.
(i) The insurer may not eliminate coverage of such a child unless the
insurer
is provided
satisfactory written evidence of either of the following:
(1) The court or administrative order is no longer in
|
|
(2) The child is or will be covered under a
|
| comparable health care plan obtained by the parent under such order and that coverage 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.)
|
(215 ILCS 5/356m) (from Ch. 73, par. 968m) Sec. 356m. Infertility coverage. (a) No group policy of accident and health insurance providing coverage for more than 25 employees that provides pregnancy-related benefits may be issued, amended, delivered, or renewed in this State after January 1, 2016 and through December 31, 2025 unless the policy contains coverage for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer. (a-5) No group policy of accident and health insurance that provides pregnancy-related benefits may be issued, amended, delivered, or renewed in this State on or after January 1, 2026 unless the policy contains coverage for the diagnosis and treatment of infertility, including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, surgical sperm extraction procedures, and low tubal ovum transfer. The coverage required shall include procedures necessary to screen or diagnose a fertilized egg before implantation, including, but not limited to, preimplantation genetic testing for aneuploidy, preimplantation genetic testing for chromosome structural rearrangements, and preimplantation genetic testing for monogenic or single gene disorders. Coverage under this subsection for the diagnosis and treatment of infertility shall be required only if the procedures: (1) are considered medically appropriate by the |
| patient's medical provider based on clinical guidelines or standards developed by the American Society for Reproductive Medicine, the American College of Obstetricians and Gynecologists, or the Society for Assisted Reproductive Technology; and
|
|
(2) are performed at medical facilities or clinics
|
| that are members in good standing of the Society for Assisted Reproductive Technology.
|
|
(b) The coverage required under subsection (a) for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if:
(1) the covered individual has been unable to attain
|
| a viable pregnancy, maintain a viable pregnancy, or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract;
|
|
(2) the covered individual has not undergone 4
|
| completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and
|
|
(3) the procedures are performed at medical
|
| facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.
|
|
(c) As used in this Section, "infertility" means a disease, condition, or status characterized by:
(1) a failure to establish a pregnancy or to carry a
|
| pregnancy to live birth after 12 months of regular, unprotected sexual intercourse if the woman is 35 years of age or younger, or after 6 months of regular, unprotected sexual intercourse if the woman is over 35 years of age; conceiving but having a miscarriage does not restart the 12-month or 6-month term for determining infertility;
|
|
(2) a person's inability to reproduce either as a
|
| single individual or with a partner without medical intervention; or
|
|
(3) a licensed physician's findings based on a
|
| patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.
|
|
(d) A policy, contract, or certificate may not impose any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on any other prescription medications, nor may it impose any exclusions, limitations, or other restrictions on coverage of any fertility services based on a covered individual's participation in fertility services provided by or to a third party, nor may it impose deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for the diagnosis of infertility, treatment for infertility, and standard fertility preservation services, except as provided in this Section, that are different from those imposed upon benefits for services not related to infertility.
(e) The procedures required to be covered under this Section are not required to be contained in any policy or plan issued to or by a religious institution or organization or to or by an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this Section to violate its religious and moral teachings and beliefs.
(Source: P.A. 102-170, eff. 1-1-22; 103-751, eff. 8-2-24.)
|
(215 ILCS 5/356r)
(Text of Section before amendment by P.A. 103-718 )
Sec. 356r. Woman's principal health care provider.
(a) An individual or group policy of accident and health insurance or a
managed care plan amended, delivered, issued, or renewed in this State after
November 14, 1996 that
requires an insured or enrollee to designate an individual to coordinate care
or to control access to health care services shall also permit a female insured
or enrollee to designate a participating woman's principal health care
provider,
and the insurer or managed care plan shall provide the following written
notice to all female insureds or enrollees no later than 120 days after the
effective date of this amendatory Act of 1998; to all new enrollees at the
time of enrollment;
and thereafter to all existing enrollees at least annually, as a part of a
regular publication or informational mailing:
"NOTICE TO ALL FEMALE PLAN MEMBERS:
YOUR RIGHT TO SELECT A WOMAN'S PRINCIPAL
HEALTH CARE PROVIDER.
Illinois law allows you to select "a woman's |
| principal health care provider" in addition to your selection of a primary care physician. A woman's principal health care provider is a physician licensed to practice medicine in all its branches specializing in obstetrics or gynecology or specializing in family practice. A woman's principal health care provider may be seen for care without referrals from your primary care physician. If you have not already selected a woman's principal health care provider, you may do so now or at any other time. You are not required to have or to select a woman's principal health care provider.
|
|
Your woman's principal health care provider must be a
|
| part of your plan. You may get the list of participating obstetricians, gynecologists, and family practice specialists from your employer's employee benefits coordinator, or for your own copy of the current list, you may call [insert plan's toll free number]. The list will be sent to you within 10 days after your call. To designate a woman's principal health care provider from the list, call [insert plan's toll free number] and tell our staff the name of the physician you have selected.".
|
|
If the insurer or managed care plan exercises the option set forth in
subsection
(a-5), the notice shall also state:
"Your plan requires that your primary care physician
|
| and your woman's principal health care provider have a referral arrangement with one another. If the woman's principal health care provider that you select does not have a referral arrangement with your primary care physician, you will have to select a new primary care physician who has a referral arrangement with your woman's principal health care provider or you may select a woman's principal health care provider who has a referral arrangement with your primary care physician. The list of woman's principal health care providers will also have the names of the primary care physicians and their referral arrangements.".
|
|
No later than 120 days after the effective date of this amendatory Act of
1998, the insurer or managed
care plan shall provide each employer who has a policy of insurance or a
managed
care plan with the insurer or managed care plan with a list of physicians
licensed to practice medicine in all its branches specializing in obstetrics or
gynecology or specializing in family practice who have contracted with the
plan. At the time of enrollment and thereafter within 10 days after a request
by an insured or enrollee, the insurer or managed care plan also shall provide
this list directly to the insured or enrollee.
The list shall include each physician's address, telephone
number, and specialty. No insurer or plan formal or informal
policy may restrict a female insured's or enrollee's right to designate a
woman's
principal health care provider, except as set forth in subsection (a-5).
If the
female enrollee is an enrollee of a managed care plan under contract with the
Department of Healthcare and Family Services, the physician chosen by the enrollee as her woman's
principal health care provider must be a Medicaid-enrolled provider.
This requirement does not require a female insured or enrollee to make a
selection of a woman's principal health care provider.
The female insured or enrollee may designate a physician licensed to practice
medicine in
all its branches specializing in family practice as her woman's principal
health care provider.
(a-5) The insured or enrollee may be required by the insurer or managed care
plan to select a woman's principal health care provider who has a
referral
arrangement with the insured's or enrollee's individual who coordinates care or
controls access to health care services
if such referral arrangement exists
or to
select a new individual to coordinate care or to control access to health care
services who has a referral arrangement with the
woman's principal health care provider chosen by the insured or enrollee, if
such referral arrangement exists. If an
insurer or a managed care plan requires an insured or enrollee to select a new
physician under this subsection (a-5), the insurer or managed care plan must
provide the insured or enrollee with both options to select a new physician
provided in this subsection
(a-5).
Notwithstanding a plan's restrictions of the frequency or timing of making
designations of primary care providers, a female enrollee or insured who is
subject to the selection requirements of this subsection, may, at any time,
effect a change in primary care physicians in order to make a
selection of a woman's principal health care provider.
(a-6) If an insurer or managed care plan exercises the option in
subsection (a-5), the list to be provided under subsection (a) shall identify
the referral arrangements that exist between the individual who
coordinates
care or controls access to health care services and the woman's principal
health care provider in order to assist the female insured or enrollee to make
a selection within the insurer's or managed care plan's requirement.
(b) If a female insured or enrollee has designated a woman's principal
health care provider, then the insured or enrollee must be given direct access
to the woman's principal health care provider for services covered by the
policy or plan without the need
for a referral or prior approval. Nothing shall prohibit the insurer or
managed care plan from requiring prior authorization or approval from either a
primary care provider or the woman's principal health care provider for
referrals for additional care or services.
(c) For the purposes of this Section the following terms are defined:
(1) "Woman's principal health care provider" means a
|
| physician licensed to practice medicine in all of its branches specializing in obstetrics or gynecology or specializing in family practice.
|
|
(2) "Managed care entity" means any entity including
|
| a licensed insurance company, hospital or medical service plan, health maintenance organization, limited health service organization, preferred provider organization, third party administrator, an employer or employee organization, or any person or entity that establishes, operates, or maintains a network of participating providers.
|
|
(3) "Managed care plan" means a plan operated by a
|
| managed care entity that provides for the financing of health care services to persons enrolled in the plan through:
|
|
(A) organizational arrangements for ongoing
|
| quality assurance, utilization review programs, or dispute resolution; or
|
|
(B) financial incentives for persons enrolled in
|
| the plan to use the participating providers and procedures covered by the plan.
|
|
(4) "Participating provider" means a physician who
|
| has contracted with an insurer or managed care plan to provide services to insureds or enrollees as defined by the contract.
|
|
(d) The original provisions of this Section became law on July 17,
1996 and took effect November 14, 1996, which is 120 days after
becoming law.
(Source: P.A. 95-331, eff. 8-21-07.)
(Text of Section after amendment by P.A. 103-718 )
Sec. 356r. Access to obstetrical and gynecological care.
(a) An individual or group policy of accident and health insurance or a managed care plan amended, delivered, issued, or renewed in this State must not require authorization or referral by the plan, issuer, or any person, including a primary care provider, for any covered individual who seeks coverage for obstetrical or gynecological care provided by any licensed or certified participating health care professional who specializes in obstetrics or gynecology.
(a-5) If a policy, contract, or certificate requires or allows a covered individual to designate a primary care provider and provides coverage for any obstetrical or gynecological care, the insurer shall provide the notice required under 45 CFR 147.138(a)(4) and 149.310(a)(4) in all circumstances required under that provision.
(a-6) The requirements of this Section shall be construed in a manner consistent with the requirements for access to and notice of obstetrical and gynecological care in 45 CFR 147.138 and 45 CFR 149.310.
(b) Nothing in this Section prevents a health insurance issuer from requiring a participating obstetrical or gynecological health care professional to agree, with respect to individuals covered under a policy of accident and health insurance, to otherwise adhere to the health insurance issuer's policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan, if any, approved by the issuer.
(c) (Blank).
(d) Nothing in this Section shall be construed to preclude a health insurance issuer from requiring that a participating obstetrical or gynecological health care professional notify the covered individual's primary care physician or the issuer of treatment decisions or update centralized medical records.
(Source: P.A. 103-718, eff. 1-1-25.)
|
(215 ILCS 5/356u)
(Text of Section before amendment by P.A. 103-30 )
Sec. 356u. Pap tests and prostate cancer screenings.
(a) A group policy of accident and health insurance that provides coverage
for hospital or medical treatment or services for illness on an
expense-incurred basis and is amended, delivered, issued, or renewed after January 1, 2024 shall provide coverage, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement, for all of
the
following:
(1) An annual cervical smear or Pap smear test for |
|
(2) An annual prostate cancer screening for male
|
| insureds upon the recommendation of a physician licensed to practice medicine in all its branches for:
|
|
(A) asymptomatic men age 50 and over;
(B) African-American men age 40 and over; and
(C) men age 40 and over with a family history of
|
|
(3) Surveillance tests for ovarian cancer for female
|
| insureds who are at risk for ovarian cancer.
|
|
(b) This Section shall not apply to agreements, contracts, or policies that
provide coverage for a specified disease or other limited benefit coverage.
(c) This Section does not apply to coverage of prostate cancer 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.
(d) For the purposes of this Section:
"At risk for ovarian cancer" means:
(1) having a family history (i) with one or more
|
| first-degree relatives with ovarian cancer, (ii) of clusters of women relatives with breast cancer, or (iii) of nonpolyposis colorectal cancer; or
|
|
(2) testing positive for BRCA1 or BRCA2 mutations.
"Prostate cancer screening" means medically viable methods for the detection and diagnosis of prostate cancer, including a digital rectal exam and the prostate-specific antigen test and associated laboratory work. "Prostate cancer screening" includes medically necessary subsequent follow-up testing as directed by a health care provider, including, but not limited to:
(1) urinary analysis;
(2) serum biomarkers; and
(3) medical imaging, including, but not limited to,
|
| magnetic resonance imaging.
|
|
"Surveillance tests for ovarian cancer" means annual screening using (i) CA-125 serum tumor marker testing, (ii) transvaginal ultrasound, (iii) pelvic examination.
(Source: P.A. 102-1073, eff. 1-1-23 .)
(Text of Section after amendment by P.A. 103-30 )
Sec. 356u. Pap tests and prostate cancer screenings.
(a) A group policy of accident and health insurance that provides coverage
for hospital or medical treatment or services for illness on an
expense-incurred basis and is amended, delivered, issued, or renewed after January 1, 2024 shall provide coverage, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement, for all of
the
following:
(1) An annual cervical smear or Pap smear test for
|
|
(2) An annual prostate cancer screening for insureds
|
| upon the recommendation of a physician licensed to practice medicine in all its branches for:
|
|
(A) asymptomatic individuals age 50 and over;
(B) African-American individuals age 40 and over;
|
|
(C) individuals age 40 and over with a family
|
| history of or genetic predisposition to prostate cancer.
|
|
(3) Surveillance tests for ovarian cancer for
|
| insureds who are at risk for ovarian cancer.
|
|
(b) This Section shall not apply to agreements, contracts, or policies that
provide coverage for a specified disease or other limited benefit coverage.
(c) This Section does not apply to coverage of prostate cancer 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.
(d) For the purposes of this Section:
"At risk for ovarian cancer" means:
(1) having a family history (i) with one or more
|
| first-degree relatives with ovarian cancer, (ii) of clusters of relatives with breast cancer, or (iii) of nonpolyposis colorectal cancer; or
|
|
(2) testing positive for BRCA1 or BRCA2 mutations.
"Prostate cancer screening" means medically viable methods for the detection and diagnosis of prostate cancer, including a digital rectal exam and the prostate-specific antigen test and associated laboratory work. "Prostate cancer screening" includes medically necessary subsequent follow-up testing as directed by a health care provider, including, but not limited to:
(1) urinary analysis;
(2) serum biomarkers; and
(3) medical imaging, including, but not limited to,
|
| magnetic resonance imaging.
|
|
"Surveillance tests for ovarian cancer" means annual screening using (i) CA-125 serum tumor marker testing, (ii) transvaginal ultrasound, (iii) pelvic examination.
(Source: P.A. 102-1073, eff. 1-1-23; 103-30, eff. 1-1-25.)
|
(215 ILCS 5/356w)
Sec. 356w. Diabetes self-management training and education.
(a) A group policy of accident and health insurance that is amended,
delivered,
issued, or renewed after the
effective date of this amendatory Act of 1998 shall provide coverage for
outpatient self-management
training and education, equipment, and supplies, as set forth in this Section,
for the treatment of type 1 diabetes, type 2 diabetes, and gestational diabetes
mellitus.
(b) As used in this Section:
"Diabetes self-management training"
means instruction in an outpatient setting
which enables a diabetic patient to understand the diabetic management process
and daily management of
diabetic therapy as a means of avoiding frequent hospitalization and
complications. Diabetes self-management training shall include
the content areas listed in the National Standards for Diabetes Self-Management
Education Programs as published by the American Diabetes Association, including
medical nutrition therapy and education programs, as defined by the contract of insurance, that allow the patient to maintain an A1c level within the range identified in nationally recognized standards of care.
"Medical nutrition therapy" shall have the meaning
ascribed to that term in the Dietitian Nutritionist
Practice Act.
"Physician" means a
physician licensed to practice medicine in all of
its branches providing care to the individual.
"Qualified provider" for an
individual that is enrolled in:
(1) a health maintenance organization that uses a |
| primary care physician to control access to specialty care means (A) the individual's primary care physician licensed to practice medicine in all of its branches, (B) a physician licensed to practice medicine in all of its branches to whom the individual has been referred by the primary care physician, or (C) a certified, registered, or licensed network health care professional with expertise in diabetes management to whom the individual has been referred by the primary care physician.
|
|
(2) an insurance plan means (A) a physician licensed
|
| to practice medicine in all of its branches or (B) a certified, registered, or licensed health care professional with expertise in diabetes management to whom the individual has been referred by a physician.
|
|
(c) Coverage under this Section for diabetes self-management training,
including medical nutrition
education, shall be limited to the following:
(1) Up to 3 medically necessary visits to a qualified
|
| provider upon initial diagnosis of diabetes by the patient's physician or, if diagnosis of diabetes was made within one year prior to the effective date of this amendatory Act of 1998 where the insured was a covered individual, up to 3 medically necessary visits to a qualified provider within one year after that effective date.
|
|
(2) Up to 2 medically necessary visits to a qualified
|
| provider upon a determination by a patient's physician that a significant change in the patient's symptoms or medical condition has occurred. A "significant change" in condition means symptomatic hyperglycemia (greater than 250 mg/dl on repeated occasions), severe hypoglycemia (requiring the assistance of another person), onset or progression of diabetes, or a significant change in medical condition that would require a significantly different treatment regimen.
|
|
Payment by the insurer or health maintenance organization for the coverage
required for diabetes self-management training pursuant to the provisions of
this Section is only required to be made for services provided.
No coverage is required for additional visits beyond those specified in items
(1) and (2) of this subsection.
Coverage under this subsection (c) for diabetes self-management training
shall
be subject to the same
deductible, co-payment, and co-insurance provisions that apply to coverage
under
the policy for other
services provided by the same type of provider.
(d) Coverage shall be provided for the following
equipment when medically necessary
and prescribed by a physician licensed to practice medicine in all
of its branches.
Coverage for the following items shall be subject to deductible, co-payment
and co-insurance provisions
provided for under the policy or a durable medical equipment rider to the
policy:
(1) blood glucose monitors;
(2) blood glucose monitors for the legally blind;
(3) cartridges for the legally blind; and
(4) lancets and lancing devices.
This subsection does not apply to a group policy of accident and health
insurance that does not provide a durable medical equipment benefit.
(e) Coverage shall be provided for the following pharmaceuticals and
supplies when
medically necessary and prescribed by a physician licensed to
practice medicine in all of its
branches.
Coverage for the following items shall be subject to the same coverage,
deductible,
co-payment, and co-insurance
provisions under the policy or a drug rider to the policy, except as otherwise provided for under Section 356z.41:
(1) insulin;
(2) syringes and needles;
(3) test strips for glucose monitors;
(4) FDA approved oral agents used to control blood
|
|
(5) glucagon emergency kits.
This subsection does not apply to a group policy of accident and health
insurance that does not provide a drug benefit.
(f) Coverage shall be provided for regular foot care exams by a
physician or by a
physician to whom a physician has referred the patient. Coverage
for regular foot care exams
shall be subject to the same deductible, co-payment, and co-insurance
provisions
that apply under the policy for
other services provided by the same type of provider.
(g) If authorized by a physician, diabetes self-management
training may be provided as a part of an office visit, group setting, or home
visit.
(h) This Section shall not apply to agreements, contracts, or policies that
provide coverage for a specified diagnosis or other limited benefit coverage.
(Source: P.A. 101-625, eff. 1-1-21 .)
|
(215 ILCS 5/356z.2)
Sec. 356z.2. Coverage for adjunctive services in dental care.
(a) An individual or group policy of accident and health insurance
amended, delivered, issued, or renewed after January 1, 2003 (the effective date of Public Act 92-764) shall cover
charges incurred, and anesthetics provided, in
conjunction with dental care that is provided to a covered individual in a
hospital or
an ambulatory surgical treatment center
if any of the
following
applies:
(1) the individual is a child age 6 or under;
(2) the individual has a medical condition that |
| requires hospitalization or general anesthesia for dental care; or
|
|
(3) the individual is a person with a disability.
(a-5) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed after January 1, 2016 (the effective date of Public Act 99-141) shall cover charges incurred, and anesthetics provided by a dentist with a permit provided under Section 8.1 of the Illinois Dental Practice Act, in conjunction with dental care that is provided to a covered individual in a dental office, oral surgeon's office, hospital, or ambulatory surgical treatment center if the individual is under age 26 and has been diagnosed with an autism spectrum disorder as defined in Section 10 of the Autism Spectrum Disorders Reporting Act or a developmental disability. A covered individual shall be required to make 2 visits to the dental care provider prior to accessing other coverage under this subsection.
For purposes of this subsection, "developmental disability" means "developmental disability" as defined in Section 1-106 of the Mental Health and Developmental Disabilities Code.
(b) For purposes of this Section, "ambulatory surgical treatment center"
has the meaning given to that term in Section 3 of the Ambulatory
Surgical Treatment Center Act.
For purposes of this Section, "person with a disability" means a person, regardless of age,
with a chronic
disability if the chronic disability meets all of the following conditions:
(1) It is attributable to a mental or physical
|
| impairment or combination of mental and physical impairments.
|
|
(2) It is likely to continue.
(3) It results in substantial functional limitations
|
| in one or more of the following areas of major life activity:
|
|
(A) self-care;
(B) receptive and expressive language;
(C) learning;
(D) mobility;
(E) capacity for independent living; or
(F) economic self-sufficiency.
(c) The coverage required under this Section may be subject to any
limitations, exclusions, or cost-sharing provisions that apply generally under
the insurance policy.
(d) This Section does not apply to a policy that covers only dental care.
(e) Nothing in this Section requires that the dental services be
covered.
(f) The provisions of this Section do not apply to short-term travel,
accident-only, limited, or specified disease policies, nor to policies or
contracts designed for issuance to persons eligible for coverage under Title
XVIII of the Social Security Act, known as Medicare, or any other similar
coverage under State or federal governmental plans.
(Source: P.A. 101-525, eff. 1-1-20; 102-972, eff. 1-1-23 .)
|
(215 ILCS 5/356z.3a) Sec. 356z.3a. Billing; emergency services; nonparticipating providers. (a) As used in this Section: "Ancillary services" means: (1) items and services related to emergency |
| medicine, anesthesiology, pathology, radiology, and neonatology that are provided by any health care provider;
|
|
(2) items and services provided by assistant
|
| surgeons, hospitalists, and intensivists;
|
|
(3) diagnostic services, including radiology and
|
| laboratory services, except for advanced diagnostic laboratory tests identified on the most current list published by the United States Secretary of Health and Human Services under 42 U.S.C. 300gg-132(b)(3);
|
|
(4) items and services provided by other specialty
|
| practitioners as the United States Secretary of Health and Human Services specifies through rulemaking under 42 U.S.C. 300gg-132(b)(3);
|
|
(5) items and services provided by a
|
| nonparticipating provider if there is no participating provider who can furnish the item or service at the facility; and
|
|
(6) items and services provided by a
|
| nonparticipating provider if there is no participating provider who will furnish the item or service because a participating provider has asserted the participating provider's rights under the Health Care Right of Conscience Act.
|
|
"Cost sharing" means the amount an insured, beneficiary, or enrollee is responsible for paying for a covered item or service under the terms of the policy or certificate. "Cost sharing" includes copayments, coinsurance, and amounts paid toward deductibles, but does not include amounts paid towards premiums, balance billing by out-of-network providers, or the cost of items or services that are not covered under the policy or certificate.
"Emergency department of a hospital" means any hospital department that provides emergency services, including a hospital outpatient department.
"Emergency medical condition" has the meaning ascribed to that term in Section 10 of the Managed Care Reform and Patient Rights Act.
"Emergency medical screening examination" has the meaning ascribed to that term in Section 10 of the Managed Care Reform and Patient Rights Act.
"Emergency services" means, with respect to an emergency medical condition:
(1) in general, an emergency medical screening
|
| examination, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and such further medical examination and treatment as would be required to stabilize the patient regardless of the department of the hospital or other facility in which such further examination or treatment is furnished; or
|
|
(2) additional items and services for which
|
| benefits are provided or covered under the coverage and that are furnished by a nonparticipating provider or nonparticipating emergency facility regardless of the department of the hospital or other facility in which such items are furnished after the insured, beneficiary, or enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in paragraph (1) are furnished. Services after stabilization cease to be emergency services only when all the conditions of 42 U.S.C. 300gg-111(a)(3)(C)(ii)(II) and regulations thereunder are met.
|
|
"Freestanding Emergency Center" means a facility licensed under Section 32.5 of the Emergency Medical Services (EMS) Systems Act.
"Health care facility" means, in the context of non-emergency services, any of the following:
(1) a hospital as defined in 42 U.S.C. 1395x(e);
(2) a hospital outpatient department;
(3) a critical access hospital certified under 42
|
|
(4) an ambulatory surgical treatment center as
|
| defined in the Ambulatory Surgical Treatment Center Act; or
|
|
(5) any recipient of a license under the Hospital
|
| Licensing Act that is not otherwise described in this definition.
|
|
"Health care provider" means a provider as defined in subsection (d) of Section 370g. "Health care provider" does not include a provider of air ambulance or ground ambulance services.
"Health care services" has the meaning ascribed to that term in subsection (a) of Section 370g.
"Health insurance issuer" has the meaning ascribed to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act.
"Nonparticipating emergency facility" means, with respect to the furnishing of an item or service under a policy of group or individual health insurance coverage, any of the following facilities that does not have a contractual relationship directly or indirectly with a health insurance issuer in relation to the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as
|
| defined in the Ambulatory Surgical Treatment Center Act; or
|
|
(4) with respect to emergency services described in
|
| paragraph (2) of the definition of "emergency services", a hospital.
|
|
"Nonparticipating provider" means, with respect to the furnishing of an item or service under a policy of group or individual health insurance coverage, any health care provider who does not have a contractual relationship directly or indirectly with a health insurance issuer in relation to the coverage.
"Participating emergency facility" means any of the following facilities that has a contractual relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage:
(1) an emergency department of a hospital;
(2) a Freestanding Emergency Center;
(3) an ambulatory surgical treatment center as
|
| defined in the Ambulatory Surgical Treatment Center Act; or
|
|
(4) with respect to emergency services described in
|
| paragraph (2) of the definition of "emergency services", a hospital.
|
|
For purposes of this definition, a single case agreement between an emergency facility and an issuer that is used to address unique situations in which an insured, beneficiary, or enrollee requires services that typically occur out-of-network constitutes a contractual relationship and is limited to the parties to the agreement.
"Participating health care facility" means any health care facility that has a contractual
relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage. A single case agreement between an emergency facility and an issuer that is used to address unique situations in which an insured, beneficiary, or enrollee requires services that typically occur out-of-network constitutes a contractual relationship for purposes of this definition and is limited to the parties to the agreement.
"Participating provider" means any health care provider that has a
contractual relationship directly or indirectly with a health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant health care service is provided to an insured, beneficiary, or enrollee under the coverage.
"Qualifying payment amount" has the meaning given to that term in 42 U.S.C. 300gg-111(a)(3)(E) and the regulations promulgated thereunder.
"Recognized amount" means the lesser of the amount initially billed by the provider or the qualifying payment amount.
"Stabilize" means "stabilization" as defined in Section 10 of the Managed Care Reform and Patient Rights Act.
"Treating provider" means a health care provider who has evaluated the individual.
"Visit" means, with respect to health care services furnished to an individual at a health care facility, health care services furnished by a provider at the facility, as well as equipment, devices, telehealth services, imaging services, laboratory services, and preoperative and postoperative services regardless of whether the provider furnishing such services is at the facility.
(b) Emergency services. When a beneficiary, insured, or enrollee receives emergency services from a nonparticipating provider or a nonparticipating emergency facility, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider or a participating emergency facility. Any cost-sharing requirements shall be applied as though the emergency services had been received from a participating provider or a participating facility. Cost sharing shall be calculated based on the recognized amount for the emergency services. If the cost sharing for the same item or service furnished by a participating provider would have been a flat-dollar copayment, that amount shall be the cost-sharing amount unless the provider has billed a lesser total amount. In no event shall the beneficiary, insured, enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the nonparticipating emergency facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the emergency services delivered. Administrative requirements or limitations shall be no greater than those applicable to emergency services received from a participating provider or a participating emergency facility.
(b-5) Non-emergency services at participating health care facilities.
(1) When a beneficiary, insured, or enrollee utilizes
|
| a participating health care facility and, due to any reason, covered ancillary services are provided by a nonparticipating provider during or resulting from the visit, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider for the ancillary services. Any cost-sharing requirements shall be applied as though the ancillary services had been received from a participating provider. Cost sharing shall be calculated based on the recognized amount for the ancillary services. If the cost sharing for the same item or service furnished by a participating provider would have been a flat-dollar copayment, that amount shall be the cost-sharing amount unless the provider has billed a lesser total amount. In no event shall the beneficiary, insured, enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the participating health care facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the ancillary services delivered. In addition to ancillary services, the requirements of this paragraph shall also apply with respect to covered items or services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the nonparticipating provider satisfied the notice and consent criteria under paragraph (2) of this subsection.
|
|
(2) When a beneficiary, insured, or enrollee utilizes
|
| a participating health care facility and receives non-emergency covered health care services other than those described in paragraph (1) of this subsection from a nonparticipating provider during or resulting from the visit, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee incurs no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider unless the nonparticipating provider or the participating health care facility on behalf of the nonparticipating provider satisfies the notice and consent criteria provided in 42 U.S.C. 300gg-132 and regulations promulgated thereunder. If the notice and consent criteria are not satisfied, then:
|
|
(A) any cost-sharing requirements shall be
|
| applied as though the health care services had been received from a participating provider;
|
|
(B) cost sharing shall be calculated based on
|
| the recognized amount for the health care services; and
|
|
(C) in no event shall the beneficiary, insured,
|
| enrollee, or any group policyholder or plan sponsor be liable to or billed by the health insurance issuer, the nonparticipating provider, or the participating health care facility for any amount beyond the cost sharing calculated in accordance with this subsection with respect to the health care services delivered.
|
|
(c) Notwithstanding any other provision of this Code, except when the notice and consent criteria are satisfied for the situation in paragraph (2) of subsection (b-5), any benefits a beneficiary, insured, or enrollee receives for services under the situations in subsection (b) or (b-5) are assigned to the nonparticipating providers or the facility acting on their behalf. Upon receipt of the provider's bill or facility's bill, the health insurance issuer shall provide the nonparticipating provider or the facility with a written explanation of benefits that specifies the proposed reimbursement and the applicable deductible, copayment, or coinsurance amounts owed by the insured, beneficiary, or enrollee. The health insurance issuer shall pay any reimbursement subject to this Section directly to the nonparticipating provider or the facility.
(d) For bills assigned under subsection (c), the nonparticipating provider or the facility may bill the health insurance issuer for the services rendered, and the health insurance issuer may pay the billed amount or attempt to negotiate reimbursement with the nonparticipating provider or the facility. Within 30 calendar days after the provider or facility transmits the bill to the health insurance issuer, the issuer shall send an initial payment or notice of denial of payment with the written explanation of benefits to the provider or facility. If attempts to negotiate reimbursement for services provided by a nonparticipating provider do not result in a resolution of the payment dispute within 30 days after receipt of written explanation of benefits by the health insurance issuer, then the health insurance issuer or nonparticipating provider or the facility may initiate binding arbitration to determine payment for services provided on a per-bill or batched-bill basis, in accordance with Section 300gg-111 of the Public Health Service Act and the regulations promulgated thereunder. The party requesting arbitration shall notify the other party arbitration has been initiated and state its final offer before arbitration. In response to this notice, the nonrequesting party shall inform the requesting party of its final offer before the arbitration occurs. Arbitration shall be initiated by filing a request with the Department of Insurance.
(e) The Department of Insurance shall publish a list of approved arbitrators or entities that shall provide binding arbitration. These arbitrators shall be American Arbitration Association or American Health Lawyers Association trained arbitrators. Both parties must agree on an arbitrator from the Department of Insurance's or its approved entity's list of arbitrators. If no agreement can be reached, then a list of 5 arbitrators shall be provided by the Department of Insurance or the approved entity. From the list of 5 arbitrators, the health insurance issuer can veto 2 arbitrators and the provider or facility can veto 2 arbitrators. The remaining arbitrator shall be the chosen arbitrator. This arbitration shall consist of a review of the written submissions by both parties. The arbitrator shall not establish a rebuttable presumption that the qualifying payment amount should be the total amount owed to the provider or facility by the combination of the issuer and the insured, beneficiary, or enrollee. Binding arbitration shall provide for a written decision within 45 days after the request is filed with the Department of Insurance. Both parties shall be bound by the arbitrator's decision. The arbitrator's expenses and fees, together with other expenses, not including attorney's fees, incurred in the conduct of the arbitration, shall be paid as provided in the decision.
(f) (Blank).
(g) Section 368a of this Act shall not apply during the pendency of a decision under subsection (d). Upon the issuance of the arbitrator's decision, Section 368a applies with respect to the amount, if any, by which the arbitrator's determination exceeds the issuer's initial payment under subsection (c), or the entire amount of the arbitrator's determination if initial payment was denied. Any interest required to be paid to a provider under Section 368a shall not accrue until after 30 days of an arbitrator's decision as provided in subsection (d), but in no circumstances longer than 150 days from the date the nonparticipating facility-based provider billed for services rendered.
(h) Nothing in this Section shall be interpreted to change the prudent layperson provisions with respect to emergency services under the Managed Care Reform and Patient Rights Act.
(i) Nothing in this Section shall preclude a health care provider from billing a beneficiary, insured, or enrollee for reasonable administrative fees, such as service fees for checks returned for nonsufficient funds and missed appointments.
(j) Nothing in this Section shall preclude a beneficiary, insured, or enrollee from assigning benefits to a nonparticipating provider when the notice and consent criteria are satisfied under paragraph (2) of subsection (b-5) or in any other situation not described in subsection (b) or (b-5).
(k) Except when the notice and consent criteria are satisfied under paragraph (2) of subsection (b-5), if an individual receives health care services under the situations described in subsection (b) or (b-5), no referral requirement or any other provision contained in the policy or certificate of coverage shall deny coverage, reduce benefits, or otherwise defeat the requirements of this Section for services that would have been covered with a participating provider. However, this subsection shall not be construed to preclude a provider contract with a health insurance issuer, or with an administrator or similar entity acting on the issuer's behalf, from imposing requirements on the participating provider, participating emergency facility, or participating health care facility relating to the referral of covered individuals to nonparticipating providers.
(l) Except if the notice and consent criteria are satisfied under paragraph (2) of subsection (b-5), cost-sharing amounts calculated in conformity with this Section shall count toward any deductible or out-of-pocket maximum applicable to in-network coverage.
(m) The Department has the authority to enforce the requirements of this Section in the situations described in subsections (b) and (b-5), and in any other situation for which 42 U.S.C. Chapter 6A, Subchapter XXV, Parts D or E and regulations promulgated thereunder would prohibit an individual from being billed or liable for emergency services furnished by a nonparticipating provider or nonparticipating emergency facility or for non-emergency health care services furnished by a nonparticipating provider at a participating health care facility.
(n) This Section does not apply with respect to air ambulance or ground ambulance services. This Section does not apply to any policy of excepted benefits or to short-term, limited-duration health insurance coverage.
(Source: P.A. 102-901, eff. 7-1-22; 102-1117, eff. 1-13-23; 103-440, eff. 1-1-24 .)
|
(215 ILCS 5/356z.4)
Sec. 356z.4. Coverage for contraceptives. (a)(1) The General Assembly hereby finds and declares all of the following: (A) Illinois has a long history of expanding |
| timely access to birth control to prevent unintended pregnancy.
|
|
(B) The federal Patient Protection and Affordable
|
| Care Act includes a contraceptive coverage guarantee as part of a broader requirement for health insurance to cover key preventive care services without out-of-pocket costs for patients.
|
|
(C) The General Assembly intends to build on
|
| existing State and federal law to promote gender equity and women's health and to ensure greater contraceptive coverage equity and timely access to all federal Food and Drug Administration approved methods of birth control for all individuals covered by an individual or group health insurance policy in Illinois.
|
|
(D) Medical management techniques such as denials,
|
| step therapy, or prior authorization in public and private health care coverage can impede access to the most effective contraceptive methods.
|
|
(2) As used in this subsection (a):
"Contraceptive services" includes consultations, examinations, procedures, and medical services related to the use of contraceptive methods (including natural family planning) to prevent an unintended pregnancy.
"Medical necessity", for the purposes of this subsection (a), includes, but is not limited to, considerations such as severity of side effects, differences in permanence and reversibility of contraceptive, and ability to adhere to the appropriate use of the item or service, as determined by the attending provider.
"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 satisfy the following general criteria:
(i) they are approved as safe and effective;
(ii) they are pharmaceutical equivalents in that they
|
| (A) contain identical amounts of the same active drug ingredient in the same dosage form and route of administration and (B) meet compendial or other applicable standards of strength, quality, purity, and identity;
|
|
(iii) they are bioequivalent in that (A) they do not
|
| present a known or potential bioequivalence problem and they meet an acceptable in vitro standard or (B) if they do present such a known or potential problem, they are shown to meet an appropriate bioequivalence standard;
|
|
(iv) they are adequately labeled; and
(v) they are manufactured in compliance with Current
|
| Good Manufacturing Practice regulations.
|
|
(3) An individual or group policy of accident and health insurance amended,
delivered, issued, or renewed in this State after the effective date of this amendatory Act of the 99th General Assembly shall provide coverage for all of the following services and contraceptive methods:
(A) All contraceptive drugs, devices, and other
|
| products approved by the United States Food and Drug Administration. This includes all over-the-counter contraceptive drugs, devices, and products approved by the United States Food and Drug Administration, excluding male condoms, except as provided in the current comprehensive guidelines supported by the Health Resources and Services Administration. The following apply:
|
|
(i) If the United States Food and Drug
|
| Administration has approved one or more therapeutic equivalent versions of a contraceptive drug, device, or product, 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.
|
|
(ii) If an individual's attending provider
|
| recommends a particular service or item 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 cover that service or item without cost sharing. The plan or issuer must defer to the determination of the attending provider.
|
|
(iii) If a drug, device, or product 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.
|
|
(iv) This coverage must provide for the
|
| dispensing of 12 months' worth of contraception at one time.
|
|
(B) Voluntary sterilization procedures.
(C) Contraceptive services, patient education, and
|
| counseling on contraception.
|
|
(D) Follow-up services related to the drugs,
|
| devices, products, and procedures covered under this Section, including, but not limited to, management of side effects, counseling for continued adherence, and device insertion and removal.
|
|
(4) Except as otherwise provided in this subsection (a), a policy subject to this subsection (a) shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided. The provisions of this paragraph do not apply to coverage of voluntary male sterilization 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.
(5) Except as otherwise authorized under this subsection (a), a policy shall not impose any restrictions or delays on the coverage required under this subsection (a).
(6) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage outlined in this subsection (a), then this subsection (a) is inoperative with respect to all coverage outlined in this subsection (a) other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage set forth in this subsection (a).
(b) This subsection (b) shall become operative if and only if subsection (a) becomes inoperative.
An individual or group policy of accident and health insurance amended,
delivered, issued, or renewed in this State after the date this subsection (b) becomes operative that provides coverage for
outpatient services and outpatient prescription drugs or devices must provide
coverage for the insured and any
dependent of the
insured covered by the policy for all outpatient contraceptive services and
all outpatient contraceptive drugs and devices approved by the Food and
Drug Administration. Coverage required under this Section may not impose any
deductible, coinsurance, waiting period, or other cost-sharing or limitation
that is greater than that required for any outpatient service or outpatient
prescription drug or device otherwise covered by the policy.
Nothing in this subsection (b) shall be construed to require an insurance
company to cover services related to permanent sterilization that requires a
surgical procedure.
As used in this subsection (b), "outpatient contraceptive service" means
consultations, examinations, procedures, and medical services, provided on an
outpatient basis and related to the use of contraceptive methods (including
natural family planning) to prevent an unintended pregnancy.
(c) (Blank).
(d) If a plan or issuer utilizes a network of providers, nothing in this Section shall be construed to require coverage or to prohibit the plan or issuer from imposing cost-sharing for items or services described in this Section that are provided or delivered by an out-of-network provider, unless the plan or issuer does not have in its network a provider who is able to or is willing to provide the applicable items or services.
(Source: P.A. 103-551, eff. 8-11-23.)
|
(215 ILCS 5/356z.14) Sec. 356z.14. Autism spectrum disorders. (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after December 12, 2008 (the effective date of Public Act 95-1005) must provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the policy of accident and health insurance or managed care plan. (b) Coverage provided under this Section shall be subject to a maximum benefit of $36,000 per year, but shall not be subject to any limits on the number of visits to a service provider. After December 30, 2009, the Director of the Division of Insurance shall, on an annual basis, adjust the maximum benefit for inflation using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition not diagnosed as an autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection. (c) Coverage under this Section shall be subject to copayment, deductible, and coinsurance provisions of a policy of accident and health insurance or managed care plan to the extent that other medical services covered by the policy of accident and health insurance or managed care plan are subject to these provisions. (d) This Section shall not be construed as limiting benefits that are otherwise available to an individual under a policy of accident and health insurance or managed care plan and benefits provided under this Section may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally. (e) An insurer may not deny or refuse to provide otherwise covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract to provide services to an individual because the individual or their dependent is diagnosed with an autism spectrum disorder or due to the individual utilizing benefits in this Section. (e-5) An insurer may not deny or refuse to provide otherwise covered services under a group or individual policy of accident and health insurance or a managed care plan solely because of the location wherein the clinically appropriate services are provided. (f) Upon request of the reimbursing insurer, a provider of treatment for autism spectrum disorders shall furnish medical records, clinical notes, or other necessary data that substantiate that initial or continued medical treatment is medically necessary and is resulting in improved clinical status. When treatment is anticipated to require continued services to achieve demonstrable progress, the insurer may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated outcomes stated as goals, and the frequency by which the treatment plan will be updated. (g) When making a determination of medical necessity for a treatment modality for autism spectrum disorders, an insurer must make the determination in a manner that is consistent with the manner used to make that determination with respect to other diseases or illnesses covered under the policy, including an appeals process. During the appeals process, any challenge to medical necessity must be viewed as reasonable only if the review includes a physician with expertise in the most current and effective treatment modalities for autism spectrum disorders. (h) Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists, as defined in 89 Ill. Adm. Code 500 and any subsequent amendments thereto. (h-5) If an individual has been diagnosed as having an autism spectrum disorder, meeting the diagnostic criteria in place at the time of diagnosis, and treatment is determined medically necessary, then that individual shall remain eligible for coverage under this Section even if subsequent changes to the diagnostic criteria are adopted by the American Psychiatric Association. If no changes to the diagnostic criteria are adopted after April 1, 2012, and before December 31, 2014, then this subsection (h-5) shall be of no further force and effect. (h-10) An insurer may not deny or refuse to provide covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract, for a person diagnosed with an autism spectrum disorder on the basis that the individual declined an alternative medication or covered service when the individual's health care provider has determined that such medication or covered service may exacerbate clinical symptomatology and is medically contraindicated for the individual and the individual has requested and received a medical exception as provided for under Section 45.1 of the Managed Care Reform and Patient Rights Act. For the purposes of this subsection (h-10), "clinical symptomatology" means any indication of disorder or disease when experienced by an individual as a change from normal function, sensation, or appearance. (h-15) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage outlined in subsection (h-10), then subsection (h-10) is inoperative with respect to all coverage outlined in subsection (h-10) other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage set forth in subsection (h-10). (i) As used in this Section: "Autism spectrum disorders" means pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autism, Asperger's disorder, and pervasive developmental disorder not otherwise specified. "Diagnosis of autism spectrum disorders" means one or more tests, evaluations, or assessments to diagnose whether an individual has autism spectrum disorder that is prescribed, performed, or ordered by (A) a physician licensed to practice medicine in all its branches or (B) a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders. "Medically necessary" means any care, treatment, intervention, service or item which will or is reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, disease, or disability; (ii) reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury, disease, or disability; or (iii) assist to achieve or maintain maximum functional activity in performing daily activities. "Treatment for autism spectrum disorders" shall include the following care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder by (A) a physician licensed to practice medicine in all its branches or (B) a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches: (1) Psychiatric care, meaning direct, consultative, |
| or diagnostic services provided by a licensed psychiatrist.
|
|
(2) Psychological care, meaning direct or
|
| consultative services provided by a licensed psychologist.
|
|
(3) Habilitative or rehabilitative care, meaning
|
| professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are intended to develop, maintain, and restore the functioning of an individual. As used in this subsection (i), "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
|
|
(4) Therapeutic care, including behavioral, speech,
|
| occupational, and physical therapies that provide treatment in the following areas: (i) self care and feeding, (ii) pragmatic, receptive, and expressive language, (iii) cognitive functioning, (iv) applied behavior analysis, intervention, and modification, (v) motor planning, and (vi) sensory processing.
|
|
(j) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 102-322, eff. 1-1-22; 103-154, eff. 6-30-23.)
|
(215 ILCS 5/356z.15) Sec. 356z.15. Habilitative services for children. (a) As used in this Section, "habilitative services" means occupational therapy, physical therapy, speech therapy, and other services prescribed by the insured's treating physician pursuant to a treatment plan to enhance the ability of a child to function with a congenital, genetic, or early acquired disorder. A congenital or genetic disorder includes, but is not limited to, hereditary disorders. An early acquired disorder refers to a disorder resulting from illness, trauma, injury, or some other event or condition suffered by a child prior to that child developing functional life skills such as, but not limited to, walking, talking, or self-help skills. Congenital, genetic, and early acquired disorders may include, but are not limited to, autism or an autism spectrum disorder, cerebral palsy, and other disorders resulting from early childhood illness, trauma, or injury. (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage for habilitative services for children under 19 years of age with a congenital, genetic, or early acquired disorder so long as all of the following conditions are met: (1) A physician licensed to practice medicine in all |
| its branches has diagnosed the child's congenital, genetic, or early acquired disorder.
|
|
(2) The treatment is administered by a licensed
|
| speech-language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, licensed physician, licensed nurse, licensed optometrist, licensed nutritionist, licensed social worker, or licensed psychologist upon the referral of a physician licensed to practice medicine in all its branches.
|
|
(3) The initial or continued treatment must be
|
| medically necessary and therapeutic and not experimental or investigational.
|
|
(c) The coverage required by this Section shall be subject to other general exclusions and limitations of the policy, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, utilization review of health care services, including review of medical necessity, case management, experimental, and investigational treatments, and other managed care provisions.
(d) Coverage under this Section does not apply to those services that are solely educational in nature or otherwise paid under State or federal law for purely educational services. Nothing in this subsection (d) relieves an insurer or similar third party from an otherwise valid obligation to provide or to pay for services provided to a child with a disability.
(e) Coverage under this Section for children under age 19 shall not apply to treatment of mental or emotional disorders or illnesses as covered under Section 370 of this Code as well as any other benefit based upon a specific diagnosis that may be otherwise required by law.
(f) The provisions of this Section do not apply to short-term travel, accident-only, limited, or specific disease policies.
(g) Any denial of care for habilitative services shall be subject to appeal and external independent review procedures as provided by Section 45 of the Managed Care Reform and Patient Rights Act.
(h) Upon request of the reimbursing insurer, the provider under whose supervision the habilitative services are being provided shall furnish medical records, clinical notes, or other necessary data to allow the insurer to substantiate that initial or continued medical treatment is medically necessary and that the patient's condition is clinically improving. When the treating provider anticipates that continued treatment is or will be required to permit the patient to achieve demonstrable progress, the insurer may request that the provider furnish a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated goals of treatment, and how frequently the treatment plan will be updated.
(i) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(j) An insurer may not deny or refuse to provide
otherwise covered services under a group or individual policy
of accident and health insurance or a managed care plan solely
because of the location wherein the clinically appropriate
services are provided.
(Source: P.A. 102-322, eff. 1-1-22 .)
|
(215 ILCS 5/356z.18) (Text of Section before amendment by P.A. 103-512 ) Sec. 356z.18. Prosthetic and customized orthotic devices. (a) For the purposes of this Section: "Customized orthotic device" means a supportive device for the body or a part of the body, the head, neck, or extremities, and includes the replacement or repair of the device based on the patient's physical condition as medically necessary, excluding foot orthotics defined as an in-shoe device designed to support the structural components of the foot during weight-bearing activities. "Licensed provider" means a prosthetist, orthotist, or pedorthist licensed to practice in this State. "Prosthetic device" means an artificial device to replace, in whole or in part, an arm or leg and includes accessories essential to the effective use of the device and the replacement or repair of the device based on the patient's physical condition as medically necessary. (b) This amendatory Act of the 96th General Assembly shall provide benefits to any person covered thereunder for expenses incurred in obtaining a prosthetic or custom orthotic device from any Illinois licensed prosthetist, licensed orthotist, or licensed pedorthist as required under the Orthotics, Prosthetics, and Pedorthics Practice Act. (c) A group or individual major medical policy of accident or health insurance or managed care plan or medical, health, or hospital service corporation contract that provides coverage for prosthetic or custom orthotic care and is amended, delivered, issued, or renewed 6 months after the effective date of this amendatory Act of the 96th General Assembly must provide coverage for prosthetic and orthotic devices in accordance with this subsection (c). The coverage required under this Section shall be subject to the other general exclusions, limitations, and financial requirements of the policy, including coordination of benefits, participating provider requirements, utilization review of health care services, including review of medical necessity, case management, and experimental and investigational treatments, and other managed care provisions under terms and conditions that are no less favorable than the terms and conditions that apply to substantially all medical and surgical benefits provided under the plan or coverage. (d) The policy or plan or contract may require prior authorization for the prosthetic or orthotic devices in the same manner that prior authorization is required for any other covered benefit. (e) Repairs and replacements of prosthetic and orthotic devices are also covered, subject to the co-payments and deductibles, unless necessitated by misuse or loss. (f) A policy or plan or contract may require that, if coverage is provided through a managed care plan, the benefits mandated pursuant to this Section shall be covered benefits only if the prosthetic or orthotic devices are provided by a licensed provider employed by a provider service who contracts with or is designated by the carrier, to the extent that the carrier provides in-network and out-of-network service, the coverage for the prosthetic or orthotic device shall be offered no less extensively. (g) The policy or plan or contract shall also meet adequacy requirements as established by the Health Care Reimbursement Reform Act of 1985 of the Illinois Insurance Code. (h) This Section shall not apply to accident only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers' compensation insurance, or automobile medical payment insurance. (Source: P.A. 96-833, eff. 6-1-10 .) (Text of Section after amendment by P.A. 103-512 ) Sec. 356z.18. Prosthetic and customized orthotic devices. (a) For the purposes of this Section: "Customized orthotic device" means a supportive device for the body or a part of the body, the head, neck, or extremities, and includes the replacement or repair of the device based on the patient's physical condition as medically necessary, excluding foot orthotics defined as an in-shoe device designed to support the structural components of the foot during weight-bearing activities. "Licensed provider" means a prosthetist, orthotist, or pedorthist licensed to practice in this State. "Prosthetic device" means an artificial device to replace, in whole or in part, an arm or leg and includes accessories essential to the effective use of the device and the replacement or repair of the device based on the patient's physical condition as medically necessary. (b) This amendatory Act of the 96th General Assembly shall provide benefits to any person covered thereunder for expenses incurred in obtaining a prosthetic or custom orthotic device from any Illinois licensed prosthetist, licensed orthotist, or licensed pedorthist as required under the Orthotics, Prosthetics, and Pedorthics Practice Act. (c) A group or individual major medical policy of accident or health insurance or managed care plan or medical, health, or hospital service corporation contract that provides coverage for prosthetic or custom orthotic care and is amended, delivered, issued, or renewed 6 months after the effective date of this amendatory Act of the 96th General Assembly must provide coverage for prosthetic and orthotic devices in accordance with this subsection (c). The coverage required under this Section shall be subject to the other general exclusions, limitations, and financial requirements of the policy, including coordination of benefits, participating provider requirements, utilization review of health care services, including review of medical necessity, case management, and experimental and investigational treatments, and other managed care provisions under terms and conditions that are no less favorable than the terms and conditions that apply to substantially all medical and surgical benefits provided under the plan or coverage. (d) With respect to an enrollee at any age, in addition to coverage of a prosthetic or custom orthotic device required by this Section, benefits shall be provided for a prosthetic or custom orthotic device determined by the enrollee's provider to be the most appropriate model that is medically necessary for the enrollee to perform physical activities, as applicable, such as running, biking, swimming, and lifting weights, and to maximize the enrollee's whole body health and strengthen the lower and upper limb function. (e) The requirements of this Section do not constitute an addition to this State's essential health benefits that requires defrayal of costs by this State pursuant to 42 U.S.C. 18031(d)(3)(B). (f) The policy or plan or contract may require prior authorization for the prosthetic or orthotic devices in the same manner that prior authorization is required for any other covered benefit. (g) Repairs and replacements of prosthetic and orthotic devices are also covered, subject to the co-payments and deductibles, unless necessitated by misuse or loss. (h) A policy or plan or contract may require that, if coverage is provided through a managed care plan, the benefits mandated pursuant to this Section shall be covered benefits only if the prosthetic or orthotic devices are provided by a licensed provider employed by a provider service who contracts with or is designated by the carrier, to the extent that the carrier provides in-network and out-of-network service, the coverage for the prosthetic or orthotic device shall be offered no less extensively. (i) The policy or plan or contract shall also meet adequacy requirements as established by the Health Care Reimbursement Reform Act of 1985 of the Illinois Insurance Code. (j) This Section shall not apply to accident only, specified disease, short-term travel, hospital confinement indemnity or other fixed indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers' compensation insurance, or automobile medical payment insurance. (Source: P.A. 103-512, eff. 1-1-25; 103-649, eff. 1-1-25.) |
(215 ILCS 5/356z.22) Sec. 356z.22. Coverage for telehealth services. (a) For purposes of this Section: "Asynchronous store and forward system" has the meaning given to that term in Section 5 of the Telehealth Act. "Distant site" has the meaning given to that term in Section 5 of the Telehealth Act. "E-visits" has the meaning given to that term in Section 5 of the Telehealth Act. "Facility" means any hospital facility licensed under the Hospital Licensing Act or the University of Illinois Hospital Act, a federally qualified health center, a community mental health center, a behavioral health clinic, a substance use disorder treatment program licensed by the Division of Substance Use Prevention and Recovery of the Department of Human Services, or other building, place, or institution that is owned or operated by a person that is licensed or otherwise authorized to deliver health care services. "Health care professional" has the meaning given to that term in Section 5 of the Telehealth Act. "Interactive telecommunications system" has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, "interactive telecommunications system" does not include virtual check-ins. "Originating site" has the meaning given to that term in Section 5 of the Telehealth Act. "Telehealth services" has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, "telehealth services" do not include asynchronous store and forward systems, remote patient monitoring technologies, e-visits, or virtual check-ins. "Virtual check-in" has the meaning given to that term in Section 5 of the Telehealth Act. (b) An individual or group policy of accident or health insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall cover telehealth services, e-visits, and virtual check-ins rendered by a health care professional when clinically appropriate and medically necessary to insureds, enrollees, and members in the same manner as any other benefits covered under the policy. An individual or group policy of accident or health insurance may provide reimbursement to a facility that serves as the originating site at the time a telehealth service is rendered. (c) To ensure telehealth service, e-visit, and virtual check-in access is equitable for all patients in receipt of health care services under this Section and health care professionals and facilities are able to deliver medically necessary services that can be appropriately delivered via telehealth within the scope of their licensure or certification, coverage required under this Section shall comply with all of the following: (1) An individual or group policy of accident or |
| health insurance shall not:
|
|
(A) require that in-person contact occur between
|
| a health care professional and a patient before the provision of a telehealth service;
|
|
(B) require patients, health care professionals,
|
| or facilities to prove or document a hardship or access barrier to an in-person consultation for coverage and reimbursement of telehealth services, e-visits, or virtual check-ins;
|
|
(C) require the use of telehealth services,
|
| e-visits, or virtual check-ins when the health care professional has determined that it is not appropriate;
|
|
(D) require the use of telehealth services when
|
| a patient chooses an in-person consultation;
|
|
(E) require a health care professional to be
|
| physically present in the same room as the patient at the originating site, unless deemed medically necessary by the health care professional providing the telehealth service;
|
|
(F) create geographic or facility restrictions
|
| or requirements for telehealth services, e-visits, or virtual check-ins;
|
|
(G) require health care professionals or
|
| facilities to offer or provide telehealth services, e-visits, or virtual check-ins;
|
|
(H) require patients to use telehealth
|
| services, e-visits, or virtual check-ins, or require patients to use a separate panel of health care professionals or facilities to receive telehealth service, e-visit, or virtual check-in coverage and reimbursement; or
|
|
(I) impose upon telehealth services, e-visits,
|
| or virtual check-ins utilization review requirements that are unnecessary, duplicative, or unwarranted or impose any treatment limitations, prior authorization, documentation, or recordkeeping requirements that are more stringent than the requirements applicable to the same health care service when rendered in-person, except procedure code modifiers may be required to document telehealth.
|
|
(2) Deductibles, copayments, coinsurance, or any
|
| other cost-sharing applicable to services provided through telehealth shall not exceed the deductibles, copayments, coinsurance, or any other cost-sharing required by the individual or group policy of accident or health insurance for the same services provided through in-person consultation.
|
|
(3) An individual or group policy of accident or
|
| health insurance shall notify health care professionals and facilities of any instructions necessary to facilitate billing for telehealth services, e-visits, and virtual check-ins.
|
|
(d) For purposes of reimbursement, an individual or group policy of accident or health insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall reimburse an in-network health care professional or facility, including a health care professional or facility in a tiered network, for telehealth services provided through an interactive telecommunications system on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by an in-network or tiered network health care professional or facility. This subsection applies only to those services provided by telehealth that may otherwise be billed as an in-person service. This subsection is inoperative on and after January 1, 2028, except that this subsection is operative after that date with respect to mental health and substance use disorder telehealth services.
(e) The Department and the Department of Public Health shall commission a report to the General Assembly administered by an established medical college in this State wherein supervised clinical training takes place at an affiliated institution that uses telehealth services, subject to appropriation. The report shall study the telehealth coverage and reimbursement policies established in subsections (b) and (d) of this Section, to determine if the policies improve access to care, reduce health disparities, promote health equity, have an impact on utilization and cost-avoidance, including direct or indirect cost savings to the patient, and to provide any recommendations for telehealth access expansion in the future. An individual or group policy of accident or health insurance shall provide data necessary to carry out the requirements of this subsection upon request of the Department. The Department and the Department of Public Health shall submit the report by December 31, 2026. The established medical college may utilize subject matter expertise to complete any necessary actuarial analysis.
(f) Nothing in this Section is intended to limit the ability of an individual or group policy of accident or health insurance and a health care professional or facility to voluntarily negotiate alternate reimbursement rates for telehealth services. Such voluntary negotiations shall take into consideration the ongoing investment necessary to ensure these telehealth platforms may be continuously maintained, seamlessly updated, and integrated with a patient's electronic medical records.
(g) An individual or group policy of accident or health insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall provide coverage for telehealth services for licensed dietitian nutritionists and certified diabetes educators who counsel diabetes patients in the diabetes patients' homes to remove the hurdle of transportation for diabetes patients to receive treatment, in accordance with the Dietitian Nutritionist Practice Act.
(h) Any policy, contract, or certificate of health insurance coverage that does not distinguish between in-network and out-of-network health care professionals and facilities shall be subject to this Section as though all health care professionals and facilities were in-network.
(i) Health care professionals and facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 and the Mental Health and Developmental Disabilities Confidentiality Act.
(j) Nothing in this Section shall be deemed as precluding a health insurer from providing benefits for other telehealth services, including, but not limited to, services not required for coverage provided through an asynchronous store and forward system, remote patient monitoring services, other monitoring services, or oral communications otherwise covered under the policy.
(k) There shall be no restrictions on originating site requirements for telehealth coverage or reimbursement to the distant site under this Section other than requiring the telehealth services to be medically necessary and clinically appropriate.
(l) The Department may adopt rules, including emergency rules subject to the provisions of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(Source: P.A. 102-104, eff. 7-22-21.)
|
(215 ILCS 5/356z.30) (Text of Section before amendment by P.A. 103-530 ) Sec. 356z.30. Coverage for hearing aids for individuals under the age of 18. (a) As used in this Section: "Hearing care professional" means a person who is a
licensed hearing instrument dispenser, licensed audiologist, or licensed physician. "Hearing instrument" or "hearing aid" means any wearable
non-disposable, non-experimental instrument or device designed to aid or
compensate for impaired human hearing and any parts, attachments, or accessories for the instrument or device, including
an ear mold but excluding batteries and cords. (b) An individual or group policy of accident and health
insurance or managed care plan that is amended, delivered,
issued, or renewed after August 22, 2018 (the effective date of Public Act 100-1026) must provide coverage for
medically necessary hearing instruments and related services for all individuals under the age of 18
when a hearing care professional prescribes a hearing instrument to augment communication. (c) An insurer shall provide coverage, subject to all applicable co-payments, co-insurance, deductibles, and out-of-pocket limits, subject to the following restrictions: (1) one hearing instrument shall be covered for each |
|
(2) related services, such as audiological exams and
|
| selection, fitting, and adjustment of ear molds to maintain optimal fit shall be covered when deemed medically necessary by a hearing care professional; and
|
|
(3) hearing instrument repairs may be covered when
|
| deemed medically necessary.
|
|
(d) If, at any time before or after August 22, 2018 (the effective date of Public Act 100-1026), the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register, publishes a comment in the Federal Register, or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Pub. L. 111–148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of coverage for medically necessary hearing instruments and related services for individuals under the age of 18, then this Section is inoperative with respect to all such coverage other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for medically necessary hearing instruments and related services for individuals under the age of 18.
(Source: P.A. 100-1026, eff. 8-22-18; 101-81, eff. 7-12-19.)
(Text of Section after amendment by P.A. 103-530 )
Sec. 356z.30. Coverage for hearing aids.
(a) As used in this Section:
"Hearing care professional" means a person who is a
licensed hearing instrument dispenser, licensed audiologist, or licensed physician.
"Hearing instrument" or "hearing aid" means any wearable
non-disposable, non-experimental instrument or device designed to aid or
compensate for impaired human hearing and any parts, attachments, or accessories for the instrument or device, including
an ear mold but excluding batteries and cords.
(b) An individual or group policy of accident and health
insurance or managed care plan that is amended, delivered,
issued, or renewed after the effective date of this amendatory Act of the 103rd General Assembly must provide coverage for
medically necessary hearing instruments and related services for all individuals
when a hearing care professional prescribes a hearing instrument to augment communication.
(c) An insurer shall provide coverage, subject to all applicable co-payments, co-insurance, deductibles, and out-of-pocket limits, subject to the following restrictions:
(1) one hearing instrument shall be covered for each
|
|
(2) related services, such as audiological exams and
|
| selection, fitting, and adjustment of ear molds to maintain optimal fit shall be covered when deemed medically necessary by a hearing care professional; and
|
|
(3) hearing instrument repairs may be covered when
|
| deemed medically necessary.
|
|
(d) If, at any time before or after the effective date of this amendatory Act of the 103rd General Assembly, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register, publishes a comment in the Federal Register, or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Pub. L. 111–148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of coverage for medically necessary hearing instruments and related services for any individual, then this Section is inoperative with respect to all such coverage other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for medically necessary hearing instruments and related services for any individual subject to federally defrayed cost of coverage.
(Source: P.A. 103-530, eff. 1-1-25.)
|
(215 ILCS 5/356z.31) Sec. 356z.31. Recovery housing for persons with substance use
disorders. (a) Definitions. As used in this Section: "Substance use disorder" and "case management" have the meanings ascribed to those terms in Section 1-10 of the Substance Use Disorder Act. "Hospital" means a facility licensed by the Department of Public Health under the Hospital Licensing Act. "Federally qualified health center" means a facility as defined in Section 1905(l)(2)(B) of the federal Social Security Act. "Recovery housing" means a residential extended care treatment facility or a recovery home as defined and licensed in 77 Illinois Administrative Code, Part 2060, by the Illinois Department of Human Services, Division of Substance Use Prevention and Recovery. (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, 2019 (the effective date of Public Act 100-1065) may provide coverage for residential extended care services and supports for persons recovery housing for persons with substance use disorders who are at risk of a relapse following discharge from a health care clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department so long as all of the following conditions are met: (1) A health care clinic, federally qualified health |
| center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department has conducted an individualized assessment, using criteria established by the American Society of Addiction Medicine, of the person's condition prior to discharge and has identified the person as being at risk of a relapse and in need of supportive services, including employment and training and case management, to maintain long-term recovery. A determination of whether a person is in need of supportive services shall also be based on whether the person has a history of poverty, job insecurity, and lack of a safe and sober living environment.
|
|
(2) The recovery housing is administered by a
|
| community-based agency that is licensed by or under contract with the Department of Human Services, Division of Substance Use Prevention and Recovery.
|
|
(3) The recovery housing is administered by a
|
| community-based agency as described in paragraph (2) upon the referral of a health care clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department.
|
|
(c) Based on the individualized needs assessment, any coverage provided in accordance with this Section may include, but not be limited to, the following:
(1) Substance use disorder treatment services that
|
| are in accordance with licensure standards promulgated by the Department of Human Services, Division of Substance Use Prevention and Recovery.
|
|
(2) Transitional housing services, including food or
|
|
(3) Individualized case management and referral
|
| services, including case management and social services for the families of persons who are seeking treatment for a substance use disorder.
|
|
(4)
Job training or placement services.
(d) The insurer may rate each community-based agency that is licensed by or under contract with the Department of Human Services, Division of Substance Use Prevention and Recovery to provide recovery housing based on an evaluation of each agency's ability to:
(1) reduce health care costs;
(2) reduce recidivism rates for persons suffering
|
| from a substance use disorder;
|
|
(3) improve outcomes;
(4) track persons with substance use disorders; and
(5) improve the quality of life of persons with
|
| substance use disorders through the utilization of sustainable recovery, education, employment, and housing services.
|
|
The insurer may publish the results of the ratings on its official website and shall, on an annual basis, update the posted results.
(e) The Department of Insurance may adopt any rules necessary to implement the provisions of this Section in accordance with the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 100-1065, eff. 1-1-19; 101-81, eff. 7-12-19.)
|
(215 ILCS 5/356z.32) Sec. 356z.32. Coverage for fertility preservation services. (a) As used in this Section: "Iatrogenic infertility" means an impairment of |
| fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.
|
|
"May directly or indirectly cause" means the likely
|
| possibility that treatment will cause a side effect of infertility, based upon current evidence-based standards of care established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other national medical associations that follow current evidence-based standards of care.
|
|
"Standard fertility preservation services" means
|
| procedures based upon current evidence-based standards of care established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other national medical associations that follow current evidence-based standards of care.
|
|
(b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State after January 1, 2019 (the effective date of Public Act 100-1102) must provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee.
(c) In determining coverage pursuant to this Section, an insurer shall not discriminate based on an individual's expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions, nor based on personal characteristics, including age, sex, sexual orientation, or marital status.
(d) If, at any time before or after January 1, 2019 (the effective date of Public Act 100-1102), the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register, publishes a comment in the Federal Register, or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Pub. L. 111–148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of coverage for fertility preservation services, then this Section is inoperative with respect to all such coverage other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for fertility preservation services.
(Source: P.A. 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19.)
|
(215 ILCS 5/356z.36) Sec. 356z.36. Coverage of treatment models for early treatment of serious mental illnesses. (a) For purposes of early treatment of a serious mental illness in a child or young adult under age 26, a group or individual policy of accident and health insurance, or managed care plan, that is amended, delivered, issued, or renewed after December 31, 2020 shall provide coverage of the following bundled, evidence-based treatment: (1) Coordinated specialty care for first episode |
| psychosis treatment, covering the elements of the treatment model included in the most recent national research trials conducted by the National Institute of Mental Health in the Recovery After an Initial Schizophrenia Episode (RAISE) trials for psychosis resulting from a serious mental illness, but excluding the components of the treatment model related to education and employment support.
|
|
(2) Assertive community treatment (ACT) and community
|
| support team (CST) treatment. The elements of ACT and CST to be covered shall include those covered under Article V of the Illinois Public Aid Code, through 89 Ill. Adm. Code 140.453(d)(4).
|
|
(b) Adherence to the clinical models. For purposes of ensuring adherence to the coordinated specialty care for first episode psychosis treatment model, only providers contracted with the Department of Human Services' Division of Mental Health to be FIRST.IL providers to deliver coordinated specialty care for first episode psychosis treatment shall be permitted to provide such treatment in accordance with this Section and such providers must adhere to the fidelity of the treatment model. For purposes of ensuring fidelity to ACT and CST, only providers certified to provide ACT and CST by the Department of Human Services' Division of Mental Health and approved to provide ACT and CST by the Department of Healthcare and Family Services, or its designee, in accordance with 89 Ill. Adm. Code 140, shall be permitted to provide such services under this Section and such providers shall be required to adhere to the fidelity of the models.
(c) Development of medical necessity criteria for coverage. Within 6 months after January 1, 2020 (the effective date of Public Act 101-461), the Department of Insurance shall lead and convene a workgroup that includes the Department of Human Services' Division of Mental Health, the Department of Healthcare and Family Services, providers of the treatment models listed in this Section, and insurers operating in Illinois to develop medical necessity criteria for such treatment models for purposes of coverage under this Section. The workgroup shall use the medical necessity criteria the State and other states use as guidance for establishing medical necessity for insurance coverage. The Department of Insurance shall adopt a rule that defines medical necessity for each of the 3 treatment models listed in this Section by no later than June 30, 2020 based on the workgroup's recommendations.
(d) For purposes of credentialing the mental health professionals and other medical professionals that are part of a coordinated specialty care for first episode psychosis treatment team, an ACT team, or a CST team, the credentialing of the psychiatrist or the licensed clinical leader of the treatment team shall qualify all members of the treatment team to be credentialed with the insurer.
(e) Payment for the services performed under the treatment models listed in this Section shall be based on a bundled treatment model or payment, rather than payment for each separate service delivered by a treatment team member. By no later than 6 months after January 1, 2020 (the effective date of Public Act 101-461), the Department of Insurance shall convene a workgroup of Illinois insurance companies and Illinois mental health treatment providers that deliver the bundled treatment approaches listed in this Section to determine a coding solution that allows for these bundled treatment models to be coded and paid for as a bundle of services, similar to intensive outpatient treatment where multiple services are covered under one billing code or a bundled set of billing codes. The coding solution shall ensure that services delivered using coordinated specialty care for first episode psychosis treatment, ACT, or CST are provided and billed as a bundled service, rather than for each individual service provided by a treatment team member, which would deconstruct the evidence-based practice. The coding solution shall be reached prior to coverage, which shall begin for plans amended, delivered, issued, or renewed after December 31, 2020, to ensure coverage of the treatment team approaches as intended by this Section.
(f) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, adopts rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, under any provision of the Patient Protection and Affordable Care Act (P.L. 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(b), or any successor provision, to defray the cost of any coverage for serious mental illnesses or serious emotional disturbances outlined in this Section, then the requirement that a group or individual policy of accident and health insurance or managed care plan cover the bundled treatment approaches listed in this Section is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage.
(g) After 5 years following full implementation of this Section, if requested by an insurer, the Department of Insurance shall contract with an independent third party with expertise in analyzing health insurance premiums and costs to perform an independent analysis of the impact coverage of the team-based treatment models listed in this Section has had on insurance premiums in Illinois. If premiums increased by more than 1% annually solely due to coverage of these treatment models, coverage of these models shall no longer be required.
(h) The Department of Insurance shall adopt any rules necessary to implement the provisions of this Section by no later than June 30, 2020.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.)
|
(215 ILCS 5/356z.38) Sec. 356z.38. Human breast milk coverage. (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under an individual or group health insurance for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that |
| meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
|
|
(2) the infant's mother is medically or physically
|
| unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the infant's needs or the maternal breast milk is contraindicated;
|
|
(3) the milk has been determined to be medically
|
| necessary for the infant; and
|
|
(4) one or more of the following applies:
(A) the infant's birth weight is below 1,500
|
|
(B) the infant has a congenital or acquired
|
| condition that places the infant at a high risk for development of necrotizing enterocolitis;
|
|
(C) the infant has infant hypoglycemia;
(D) the infant has congenital heart disease;
(E) the infant has had or will have an organ
|
|
(F) the infant has sepsis; or
(G) the infant has any other serious congenital
|
| or acquired condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the infant.
|
|
(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under an individual or group health insurance for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
(1) the milk is obtained from a human milk bank that
|
| meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
|
|
(2) the child's mother is medically or physically
|
| unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
|
|
(3) the milk has been determined to be medically
|
| necessary for the child; and
|
|
(4) one or more of the following applies:
(A) the child has spinal muscular atrophy;
(B) the child's birth weight was below 1,500
|
| grams and he or she has long-term feeding or gastrointestinal complications related to prematurity;
|
|
(C) the child has had or will have an organ
|
|
(D) the child has a congenital or acquired
|
| condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the child.
|
|
(Source: P.A. 101-511, eff. 1-1-20; 102-558, eff. 8-20-21.)
|
(215 ILCS 5/356z.40) Sec. 356z.40. Pregnancy and postpartum coverage. (a) An individual or group policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall provide coverage for pregnancy and newborn care in accordance with 42 U.S.C. 18022(b) regarding essential health benefits. (b) Benefits under this Section shall be as follows: (1) An individual who has been identified as |
| experiencing a high-risk pregnancy by the individual's treating provider shall have access to clinically appropriate case management programs. As used in this subsection, "case management" means a mechanism to coordinate and assure continuity of services, including, but not limited to, health services, social services, and educational services necessary for the individual. "Case management" involves individualized assessment of needs, planning of services, referral, monitoring, and advocacy to assist an individual in gaining access to appropriate services and closure when services are no longer required. "Case management" is an active and collaborative process involving a single qualified case manager, the individual, the individual's family, the providers, and the community. This includes close coordination and involvement with all service providers in the management plan for that individual or family, including assuring that the individual receives the services. As used in this subsection, "high-risk pregnancy" means a pregnancy in which the pregnant or postpartum individual or baby is at an increased risk for poor health or complications during pregnancy or childbirth, including, but not limited to, hypertension disorders, gestational diabetes, and hemorrhage.
|
|
(2) An individual shall have access to medically
|
| necessary treatment of a mental, emotional, nervous, or substance use disorder or condition consistent with the requirements set forth in this Section and in Sections 370c and 370c.1 of this Code.
|
|
(3) The benefits provided for inpatient and
|
| outpatient services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided if determined to be medically necessary, consistent with the requirements of Sections 370c and 370c.1 of this Code. The facility or provider shall notify the insurer of both the admission and the initial treatment plan within 48 hours after admission or initiation of treatment. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review of health care services, including review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy.
|
|
(4) The benefits for the first 48 hours of initiation
|
| of services for an inpatient admission, detoxification or withdrawal management program, or partial hospitalization admission for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications shall be provided without post-service or concurrent review of medical necessity, as the medical necessity for the first 48 hours of such services shall be determined solely by the covered pregnant or postpartum individual's provider. Nothing in this paragraph shall prevent an insurer from applying concurrent and post-service utilization review, including the review of medical necessity, case management, experimental and investigational treatments, managed care provisions, and other terms and conditions of the insurance policy, of any inpatient admission, detoxification or withdrawal management program admission, or partial hospitalization admission services for the treatment of a mental, emotional, nervous, or substance use disorder or condition related to pregnancy or postpartum complications received 48 hours after the initiation of such services. If an insurer determines that the services are no longer medically necessary, then the covered person shall have the right to external review pursuant to the requirements of the Health Carrier External Review Act.
|
|
(5) If an insurer determines that continued inpatient
|
| care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment in a facility is no longer medically necessary, the insurer shall, within 24 hours, provide written notice to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider of its decision and the right to file an expedited internal appeal of the determination. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider. If the determination is to uphold the denial, the covered pregnant or postpartum individual and the covered pregnant or postpartum individual's provider have the right to file an expedited external appeal. An independent utilization review organization shall make a determination within 72 hours. If the insurer's determination is upheld and it is determined that continued inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment is not medically necessary, the insurer shall remain responsible for providing benefits for the inpatient care, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment through the day following the date the determination is made, and the covered pregnant or postpartum individual shall only be responsible for any applicable copayment, deductible, and coinsurance for the stay through that date as applicable under the policy. The covered pregnant or postpartum individual shall not be discharged or released from the inpatient facility, detoxification or withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment until all internal appeals and independent utilization review organization appeals are exhausted. A decision to reverse an adverse determination shall comply with the Health Carrier External Review Act.
|
|
(6) Except as otherwise stated in this subsection
|
| (b), the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.
|
|
(7) The benefits required by paragraphs (2) and (6)
|
| of this subsection (b) are to be provided to all covered pregnant or postpartum individuals with a diagnosis of a mental, emotional, nervous, or substance use disorder or condition. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this subsection (b).
|
|
(Source: P.A. 102-665, eff. 10-8-21.)
|
(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
|
|
(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.)
|