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Illinois Compiled Statutes

Information maintained by the Legislative Reference Bureau
Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process. Recent laws may not yet be included in the ILCS database, but they are found on this site as Public Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the Guide.

Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If the source note at the end of a Section of the statutes includes a Public Act that has not yet taken effect, the version of the law that is currently in effect may have already been removed from the database and you should refer to that Public Act to see the changes made to the current law.

INSURANCE
(215 ILCS 5/) Illinois Insurance Code.

215 ILCS 5/Art. XX

 
    (215 ILCS 5/Art. XX heading)
ARTICLE XX. ACCIDENT AND HEALTH INSURANCE

215 ILCS 5/352

    (215 ILCS 5/352) (from Ch. 73, par. 964)
    Sec. 352. Scope of Article.
    (a) Except as provided in subsections (b), (c), (d), and (e), this Article shall apply to all companies transacting in this State the kinds of business enumerated in clause (b) of Class 1 and clause (a) of Class 2 of Section 4. Nothing in this Article shall apply to, or in any way affect policies or contracts described in clause (a) of Class 1 of Section 4; however, this Article shall apply to policies and contracts which contain benefits providing reimbursement for the expenses of long term health care which are certified or ordered by a physician including but not limited to professional nursing care, custodial nursing care, and non-nursing custodial care provided in a nursing home or at a residence of the insured.
    (b) (Blank).
    (c) A policy issued and delivered in this State that provides coverage under that policy for certificate holders who are neither residents of nor employed in this State does not need to provide to those nonresident certificate holders who are not employed in this State the coverages or services mandated by this Article.
    (d) Stop-loss insurance is exempt from all Sections of this Article, except this Section and Sections 353a, 354, 357.30, and 370. For purposes of this exemption, stop-loss insurance is further defined as follows:
        (1) The policy must be issued to and insure an
    
employer, trustee, or other sponsor of the plan, or the plan itself, but not employees, members, or participants.
        (2) Payments by the insurer must be made to the
    
employer, trustee, or other sponsors of the plan, or the plan itself, but not to the employees, members, participants, or health care providers.
    (e) A policy issued or delivered in this State to the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) and providing coverage, under clause (b) of Class 1 or clause (a) of Class 2 as described in Section 4, to persons who are enrolled under Article V of the Illinois Public Aid Code or under the Children's Health Insurance Program Act is exempt from all restrictions, limitations, standards, rules, or regulations respecting benefits imposed by or under authority of this Code, except those specified by subsection (1) of Section 143, Section 370c, and Section 370c.1. Nothing in this subsection, however, affects the total medical services available to persons eligible for medical assistance under the Illinois Public Aid Code.
    (f) An in-office membership care agreement provided under the In-Office Membership Care Act is not insurance for the purposes of this Code.
(Source: P.A. 101-190, eff. 8-2-19.)

215 ILCS 5/352a

    (215 ILCS 5/352a) (from Ch. 73, par. 964a)
    Sec. 352a. Mandated Coverages. No legislation enacted after the effective date of this Amendatory Act of 1990 which mandates or requires the offering of health care coverages or services shall apply to any insurer unless the legislation applies equally to employee welfare benefit plans described in 29 U.S.C. 1001 et seq.
(Source: P.A. 86-1365.)

215 ILCS 5/352b

    (215 ILCS 5/352b)
    Sec. 352b. Policy of individual or group accident and health insurance. Unless specified otherwise and when used in context of accident and health insurance policy benefits, coverage, terms, or conditions required to be provided under this Article, "policy of individual or group accident and health insurance", as used in this Article, does not include any coverage or policy that provides an excepted benefit, as that term is defined in Section 2791(c) of the federal Public Health Service Act (42 U.S.C. 300gg-91). Nothing in this amendatory Act of the 101st General Assembly applies to a policy of liability, workers' compensation, automobile medical payment, or limited scope dental or vision benefits insurance issued under this Code.
(Source: P.A. 101-456, eff. 8-23-19.)

215 ILCS 5/353

    (215 ILCS 5/353) (from Ch. 73, par. 965)
    Sec. 353. Non-cancellable accident and health insurance reserves.
    (1) The legal minimum standard for computing the active life reserve, including the unearned premium reserve, of non-cancellable accident and health policies issued on and after January 1 of the year following that during which this Code becomes effective shall be based on Class III Disability Experience with interest at not to exceed three and one-half per centum per annum on the full preliminary term basis; and the minimum standard for computing the active life reserve of such policies issued prior to January 1 of the year following that during which this Code becomes effective shall be such as to place an adequate value, as determined by sound insurance practices, on the liabilities thereunder.
    (2) For policies with a waiting period of less than three (3) months, or providing benefits at ages beyond the limits of Class III Disability Experience, such tables shall be extended to cover the provisions of such policies on such basis as may be approved by the Director.
    (3) The reserve for losses under non-cancellable accident and health policies issued on and after January 1 of the year following that during which this Code becomes effective shall be based on Class III Disability Experience, except that for claims of less than twenty-seven months duration the reserve may be taken as equivalent to the prospective claim payments for three and one-half times the elapsed period of disability, provided, that in no case shall the reserve be less than the equivalent of seven weeks' claim payments; and the minimum standard for computing the reserve for losses under such policies issued prior to January 1 of the year following that during which the Code becomes effective shall be such as to place an adequate value, as determined by sound insurance practices, on such losses.
    (4) The Director shall modify the application of the tables and requirements prescribed in this section to policies or to claims arising under policies in accordance with the waiting period contained in such policies and in accordance with any limitation as to the time for which indemnity is payable. The company shall give the notice required in section 234 on all non-cancellable accident and health policies.
    This section shall apply only to accident and health policies issued prior to the operative date under section 353a as defined therein.
(Source: Laws 1965, p. 740.)

215 ILCS 5/353a

    (215 ILCS 5/353a) (from Ch. 73, par. 965a)
    Sec. 353a. Accident and health reserves. The reserves for all accident and health policies issued after the operative date of this section shall be computed and maintained on a basis which shall place an actuarially sound value on the liabilities under such policies. To provide a basis for the determination of such actuarially sound value, the Director from time to time shall adopt rules requiring the use of appropriate tables of morbidity, mortality, interest rates and valuation methods for such reserves for policies issued before January 1, 2017. For policies issued on or after January 1, 2017, Section 223 shall govern the basis for determining such actuarially sound value. In no event shall such reserves be less than the pro rata gross unearned premium reserve for such policies.
    The company shall give the notice required in section 234 on all non-cancellable accident and health policies.
    After this section becomes effective, any company may file with the Director written notice of its election to comply with the provisions of this section after a specified date before January 1, 1967. After the filing of such notice, then upon such specified date (which shall be the operative date of this section for such company), this section shall become operative with respect to the accident and health policies thereafter issued by such company. If a company makes no such election, the operative date of this section for such company shall be January 1, 1967.
    After this section becomes effective, any company may file with the Director written notice of its election to establish and maintain reserves upon its accident and health policies issued prior to the operative date of this section in accordance with the standards for reserves established by this section, and thereafter the reserve standards prescribed pursuant to this section shall be effective with respect to said accident and health policies issued prior to the operative date of this section.
(Source: P.A. 102-775, eff. 5-13-22.)

215 ILCS 5/354

    (215 ILCS 5/354) (from Ch. 73, par. 966)
    Sec. 354. Accident and health loss reserves.
    The loss reserves of all accident and health policies other than non-cancellable accident and health policies shall be computed and maintained in accordance with the applicable provisions of Article XXII. The unearned premium reserve of all accident and health policies other than non-cancellable accident and health policies shall be computed and maintained on the monthly pro rata basis.
    This Section shall apply only to accident and health policies issued prior to the operative date under section 353a as defined therein.
(Source: P.A. 83-584.)

215 ILCS 5/355

    (215 ILCS 5/355) (from Ch. 73, par. 967)
    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.)

215 ILCS 5/355.1

    (215 ILCS 5/355.1) (from Ch. 73, par. 967.1)
    Sec. 355.1. No claim for benefits for loss of time from the insured person's occupation, under a group or individual accident and health insurance policy delivered in this State more than 120 days after the effective date of this Section, shall be reduced by reason of any cost-of-living increase, designated as such under the Federal Social Security Act, if such cost-of-living increase occurs while the policy's benefits are payable for that claim.
(Source: P.A. 78-603.)

215 ILCS 5/355.2

    (215 ILCS 5/355.2) (from Ch. 73, par. 967.2)
    Sec. 355.2. Dental coverage reimbursement rates.
    (a) Every company that issues, delivers, amends, or renews any individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of 1991 that provides dental insurance and bases payment for those benefits upon a usual and customary fee charged by licensed dentists must disclose all of the following:
        (1) The frequency of the determination of the usual
    
and customary fee.
        (2) A general description of the methodology used to
    
determine usual and customary fees.
        (3) The percentile that determines the maximum
    
benefit that the company will pay for any dental procedure, if the usual and customary fee is determined by taking a sample of fees submitted on actual claims from licensed dentists and then determining the benefit by selecting a percentile of those fees.
    (b) The disclosure must be provided upon request to all group and individual policy holders and group certificate holders. All proposals for dental insurance must notify the prospective policy holder that information regarding usual and customary fee determinations is available from the insurer. All employee benefit descriptions or supplemental documents must notify the employee that information regarding reimbursement rates is available from the employer.
(Source: P.A. 87-587.)

215 ILCS 5/355.3

    (215 ILCS 5/355.3)
    Sec. 355.3. Noncovered dental services.
    (a) In this Section:
    "Covered services" means dental care services for which a reimbursement is available under an enrollee's plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
    "Dental insurance" means any policy of insurance that is issued by a company that provides coverage for dental services not covered by a medical plan.
    (b) No company that issues, delivers, amends, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 97th General Assembly that provides dental insurance shall issue a service provider contract that requires a dentist to provide services to the insurer's policyholders at a fee set by the insurer unless the services are covered services under the applicable policyholder agreement.
(Source: P.A. 97-805, eff. 1-1-13.)

215 ILCS 5/355.4

    (215 ILCS 5/355.4)
    Sec. 355.4. Provider notification of network plan changes.
    (a) As used in this Section:
    "Contracting entity" means any person or company that enters into direct contracts with providers for the delivery of dental services in the ordinary course of business, including a third-party administrator and a dental carrier.
    "Dental carrier" means a dental insurance company, dental service corporation, dental plan organization authorized to provide dental benefits, or a health insurance plan that includes coverage for dental services.
    (b) No dental carrier may automatically enroll a provider in a leased network without allowing any provider that is part of the dental carrier's provider network to choose to not participate by opting out.
    (c) Any contract entered into or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly that allows the rights and obligations of the contract to be assigned or leased to another insurer shall provide for notice that informs each provider in writing via certified mail 60 days before any scheduled assignment or lease of the network to which the provider is a contracted provider. To be in compliance with this Section, the notification must include all contract terms, a policy manual, a fee schedule, and a statement that the provider has the right to choose not to participate in third-party access.
    (d) A dental carrier that leases or assigns its network shall not cancel a network participating dentist's contractual relationship or otherwise penalize a network participating dentist in any way based on whether or not the dentist accepts the terms of the assignment or lease. Before accepting the terms of an assignment or lease agreement as described in this Section, any provider who receives notification of an impending assignment or lease must be given the option to contract directly with the entities proposing to gain access to the provider's network.
    (e) The provisions of this Section do not apply:
        (1) if access to a provider network contract is
    
granted to a dental carrier or an entity operating in accordance with the same brand licensee program as the contracting entity; or
        (2) to a provider network contract for dental
    
services provided to beneficiaries of the State employee group health insurance program or the medical assistance program under the Illinois Public Aid Code.
(Source: P.A. 103-24, eff. 1-1-24.)

215 ILCS 5/355.5

    (215 ILCS 5/355.5)
    Sec. 355.5. Dental coverage reimbursement; prohibitions. No insurer, dental service plan corporation, professional service corporation, insurance network leasing company, or any company that amends, delivers, issues, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 103rd General Assembly shall require a dental care provider to incur a fee to access and obtain payment or reimbursement for services provided. A dental plan carrier shall provide a dental care provider with 100% of the contracted amount of the payment or reimbursement. Fees incurred directly by a dental care provider from third parties related to transmitting an automated clearing house network claim, transaction management, data management, or portal services and other fees charged by third parties that are not in the control of the dental plan carrier shall not be prohibited by this Section.
(Source: P.A. 103-24, eff. 1-1-24.)

215 ILCS 5/355a

    (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 5/355b

    (215 ILCS 5/355b)
    Sec. 355b. Claim-related information; alternative means of communication.
    (a) For the purposes of this Section, "claim-related information" means all claim or billing information relating specifically to an insured, subscriber, or person covered by an individual or group policy of accident and health insurance issued, delivered, amended, or renewed by a company doing business in this State.
    (b) A company that issues, delivers, amends, or renews an individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 98th General Assembly shall accommodate a reasonable request by a person covered by a policy issued by the company to receive communications of claim-related information from the company by alternative means or at alternative locations if the person clearly states that disclosure of all or part of the information could endanger the person.
    (c) If a child is covered by a policy issued by a company, then the child's parent or guardian may make a request to the company pursuant to subsection (b) of this Section.
    (d) A company may require (1) a person making a request pursuant to subsection (b) of this Section to do so in writing, (2) the request to contain a statement that disclosure of all or part of the claim-related information to which the request pertains could endanger the person or child, and (3) the specification of an alternative address, telephone number, or other method of contact.
    (e) Except with the express consent of the person making a request pursuant to subsection (b) of this Section, a company may not disclose to the policyholder (1) the address, telephone number, or any other personally identifying information of the person who made the request or child for whose benefit a request was made, (2) the nature of the health care services provided, or (3) the name or address of the provider of the health care services.
    (f) A company that makes reasonable and good faith efforts to comply with this Section shall not be subject to civil or criminal liability on the grounds of noncompliance with this Section.
    (g) The Director shall adopt rules to guide companies in guarding against the disclosure of the information protected pursuant to this Section.
    (h) Nothing in this Section shall prevent, hinder, or otherwise affect the entry of an appropriate order made in the best interests of a child by a court of competent jurisdiction adjudicating disputed issues of child welfare or custody.
(Source: P.A. 98-189, eff. 1-1-14.)

215 ILCS 5/355c

    (215 ILCS 5/355c)
    Sec. 355c. Availability of information on qualified health plans.
    (a) Without limiting the generality of paragraph (b) of subsection (5) of Section 355a, no qualified health plans shall be offered for sale directly to consumers through the health insurance marketplace operating in this State in accordance with Sections 1311 and 1321 of the federal Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments thereto, or regulations or guidance issued thereunder (collectively, "the Federal Act"), unless the following information is made available to the consumer at the time he or she is comparing policies and their premiums:
        (1) With respect to prescription drug benefits,
    
the most recently published formulary where a consumer can view in one location covered prescription drugs; information on tiering and the cost-sharing structure for each tier; and information about how a consumer can obtain specific copayment amounts or coinsurance percentages for a specific qualified health plan before enrolling in that plan. This information shall clearly identify the qualified health plan to which it applies.
        (2) The most recently published provider directory
    
where a consumer can view the provider network that applies to each qualified health plan and information about each provider, including location, contact information, specialty, medical group, if any, any institutional affiliation, and whether the provider is accepting new patients at each of the specific locations listing the provider. Dental providers shall notify qualified health plans electronically or in writing of any changes to their information as listed in the provider directory. Qualified health plans shall update their directories in a manner consistent with the information provided by the provider or dental management service organization within 10 business days after being notified of the change by the provider. Nothing in this paragraph (2) shall void any contractual relationship between the provider and the plan. The information shall clearly identify the qualified health plan to which it applies.
    (b) Each company that offers qualified health plans for sale directly to consumers through the health insurance marketplace operating in this State shall make the information in subsection (a), for each qualified health plan that it offers, available and accessible to the general public on the company's website and through other means for individuals without access to the Internet.
    (c) The Department shall ensure that State-operated websites, in addition to the website for the health insurance marketplace established in this State in accordance with the Federal Act, prominently provide links to Internet-based materials and tools to help consumers be informed purchasers of health insurance.
    (d) Nothing in this Section shall be interpreted or implemented in a manner not consistent with the Federal Act. This Section shall apply to all qualified health plans offered for sale directly to consumers through the health insurance marketplace operating in this State for any coverage year beginning on or after January 1, 2015.
(Source: P.A. 102-775, eff. 5-13-22.)

215 ILCS 5/356a

    (215 ILCS 5/356a) (from Ch. 73, par. 968a)
    Sec. 356a. Form of policy.
    (1) No 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 two 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. 76-860.)

215 ILCS 5/356b

    (215 ILCS 5/356b) (from Ch. 73, par. 968b)
    Sec. 356b. (a) This Section applies to the hospital and medical expense provisions of an accident or health insurance policy.
    (b) If a policy provides that coverage of a dependent person terminates upon attainment of the limiting age for dependent persons specified in the policy, the attainment of such limiting age does not operate to terminate the hospital and medical coverage of a person who, because of a disabling condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment and is dependent on his or her parents or other care providers for lifetime care and supervision.
    (c) For purposes of subsection (b), "dependent on other care providers" is defined as requiring a Community Integrated Living Arrangement, group home, supervised apartment, or other residential services licensed or certified by the Department of Human Services (as successor to the Department of Mental Health and Developmental Disabilities), the Department of Public Health, or the Department of Healthcare and Family Services (formerly Department of Public Aid).
    (d) The insurer may inquire of the policyholder 2 months prior to attainment by a dependent of the limiting age set forth in the policy, or at any reasonable time thereafter, whether such dependent is in fact a person who has a disability and is dependent and, in the absence of proof submitted within 60 days of such inquiry that such dependent is a person who has a disability and is dependent may terminate coverage of such person at or after attainment of the limiting age. In the absence of such inquiry, coverage of any person who has a disability and is dependent shall continue through the term of such policy or any extension or renewal thereof.
    (e) This amendatory Act of 1969 is applicable to policies issued or renewed more than 60 days after the effective date of this amendatory Act of 1969.
(Source: P.A. 99-143, eff. 7-27-15.)

215 ILCS 5/356c

    (215 ILCS 5/356c) (from Ch. 73, par. 968c)
    Sec. 356c. (1) No policy of accident and health insurance providing coverage of hospital expenses or medical expenses or both on an expense incurred basis which in addition to covering the insured, also covers members of the insured's immediate family, shall contain any disclaimer, waiver or other limitation of coverage relative to the hospital or medical coverage or insurability of newborn infants from and after the moment of birth.
    (2) Each such policy of accident and health insurance shall contain a provision stating that the accident and health insurance benefits applicable for children shall be granted immediately with respect to a newly born child from the moment of birth. The coverage for newly born children shall include coverage of illness, injury, congenital defects (including the treatment of cleft lip and cleft palate), birth abnormalities and premature birth.
    (3) If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of a newly born child must be furnished to the insurer within 31 days after the date of birth in order to have the coverage continue beyond such 31 day period and may require payment of the appropriate premium.
    (4) In the event that no other members of the insured's immediate family are covered, immediate coverage for the first newborn infant shall be provided if the insured applies for dependent's coverage within 31 days of the newborn's birth. Such coverage shall be contingent upon payment of the additional premium.
    (5) The requirements of this Section shall apply, on or after the sixtieth day following the effective date of this Section, (a) to all such non-group policies delivered or issued for delivery, and (b) to all such group policies delivered, issued for delivery, renewed or amended. The insurers of such non-group policies in effect on the sixtieth day following the effective date of this Section shall extend to owners of said policies, on or before the first policy anniversary following such date, the opportunity to apply for the addition to their policies of a provision as set forth in paragraph (2) above, with, at the option of the insurer, payment of a premium appropriate thereto.
(Source: P.A. 102-768, eff. 1-1-24.)

215 ILCS 5/356d

    (215 ILCS 5/356d) (from Ch. 73, par. 968d)
    Sec. 356d. Conversion privileges for insured former spouses. (1) No policy of accident and health insurance providing coverage of hospital and/or medical expense on either an expense incurred basis or other than an expense incurred basis, which in addition to covering the insured also provides coverage to the spouse of the insured shall contain a provision for termination of coverage for a spouse covered under the policy solely as a result of a break in the marital relationship except by reason of an entry of a valid judgment of dissolution of marriage between the parties.
    (2) Every policy which contains a provision for termination of coverage of the spouse upon dissolution of marriage shall contain a provision to the effect that upon the entry of a valid judgment of dissolution of marriage between the insured parties the spouse whose marriage was dissolved shall be entitled to have issued to him or her, without evidence of insurability, upon application made to the company within 60 days following the entry of such judgment, and upon the payment of the appropriate premium, an individual policy of accident and health insurance. Such policy shall provide the coverage then being issued by the insurer which is most nearly similar to, but not greater than, such terminated coverages. Any and all probationary and/or waiting periods set forth in such policy shall be considered as being met to the extent coverage was in force under the prior policy.
    (3) The requirements of this Section shall apply to all policies delivered or issued for delivery on or after the 60th day following the effective date of this Section.
(Source: P.A. 84-545.)

215 ILCS 5/356e

    (215 ILCS 5/356e) (from Ch. 73, par. 968e)
    Sec. 356e. Victims of certain offenses.
    (1) No policy of accident and health insurance, which provides benefits for hospital or medical expenses based upon the actual expenses incurred, delivered or issued for delivery to any person in this State shall contain any specific exception to coverage which would preclude the payment under that policy of actual expenses incurred in the examination and testing of a victim of an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such offense to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense arising out of the offense. Every policy of accident and health insurance which specifically provides benefits for routine physical examinations shall provide full coverage for expenses incurred in the examination and testing of a victim of an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such offense as set forth in this Section. This Section shall not apply to a policy which covers hospital and medical expenses for specified illnesses or injuries only.
    (2) For purposes of enabling the recovery of State funds, any insurance carrier subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its insureds entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay, hospital or medical expenses for which an insurance carrier is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section.
    (3) Whenever the Department of Public Health finds that it has paid all or part of any hospital or medical expenses which an insurance carrier is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such insurance carrier provided that the Department of Public Health has notified the insurance carrier of its claims before the carrier has paid such benefits to its insureds or in behalf of its insureds.
(Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13.)

215 ILCS 5/356f

    (215 ILCS 5/356f) (from Ch. 73, par. 968f)
    Sec. 356f. No policy of accident or health insurance or any renewal thereof shall be denied or cancelled by the insurer, nor shall any such policy contain any exception or exclusion of benefits, solely because the mother of the insured has taken diethylstilbestrol, commonly referred to as DES.
(Source: P.A. 81-656.)

215 ILCS 5/356g

    (215 ILCS 5/356g) (from Ch. 73, par. 968g)
    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
    
age.
         (2) An annual mammogram for women 40 years of age or
    
older.
         (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.)

215 ILCS 5/356g.5

    (215 ILCS 5/356g.5)
    Sec. 356g.5. Clinical breast exam.
    (a) The General Assembly finds that clinical breast examinations are a critical tool in the early detection of breast cancer, while the disease is in its earlier and potentially more treatable stages. Insurer reimbursement of clinical breast examinations is essential to the effort to reduce breast cancer deaths in Illinois.
    (b) Every insurer shall provide, in each group or individual policy, contract, or certificate of accident or health insurance issued or renewed for persons who are residents of Illinois, coverage for complete and thorough clinical breast examinations as indicated by guidelines of practice, performed by a physician licensed to practice medicine in all its branches, a licensed advanced practice registered nurse, or a licensed physician assistant, to check for lumps and other changes for the purpose of early detection and prevention of breast cancer as follows:
        (1) at least every 3 years for women at least 20
    
years of age but less than 40 years of age; and
        (2) annually for women 40 years of age or older.
    (c) Upon approval of a nationally recognized separate and distinct clinical breast exam code that is compliant with all State and federal laws, rules, and regulations, public and private insurance plans shall take action to cover clinical breast exams on a separate and distinct basis.
(Source: P.A. 99-173, eff. 7-29-15; 100-513, eff. 1-1-18.)

215 ILCS 5/356g.5-1

    (215 ILCS 5/356g.5-1)
    Sec. 356g.5-1. Breast cancer pain medication and therapy. A group or individual 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 95th General Assembly must provide coverage for all medically necessary pain medication and pain therapy related to the treatment of breast cancer on the same terms and conditions that are generally applicable to coverage for other conditions. For purposes of this Section, "pain therapy" means pain therapy that is medically based and includes reasonably defined goals, including, but not limited to, stabilizing or reducing pain, with periodic evaluations of the efficacy of the pain therapy against these goals. The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified-disease policies, or 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.
    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. 95-1045, eff. 3-27-09.)

215 ILCS 5/356h

    (215 ILCS 5/356h) (from Ch. 73, par. 968h)
    Sec. 356h. No individual or group policy of accident and health insurance which covers the insured's immediate family or children, as well as covering the insured, shall exclude a child from coverage or limit coverage for a child solely because the child is an adopted child, or solely because the child does not reside with the insured. For purposes of this Section, a child who is in the custody of the insured, pursuant to an interim court order of adoption or, in the case of group insurance, placement of adoption, whichever comes first, vesting temporary care of the child in the insured, is an adopted child, regardless of whether a final order granting adoption is ultimately issued.
(Source: P.A. 91-549, eff. 8-14-99.)

215 ILCS 5/356i

    (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
    
effect.
        (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 5/356j

    (215 ILCS 5/356j) (from Ch. 73, par. 968j)
    Sec. 356j. (Repealed).
(Source: Repealed by P.A. 89-183, eff. 1-1-96.)

215 ILCS 5/356K

    (215 ILCS 5/356K) (from Ch. 73, par. 968K)
    Sec. 356K. Coverage for Organ Transplantation Procedures. No accident and health insurer providing coverage under this Act for hospital or medical expenses shall deny reimbursement for an otherwise covered expense incurred for any organ transplantation procedure solely on the basis that such procedure is deemed experimental or investigational unless supported by the determination of the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services that such procedure is either experimental or investigational or that there is insufficient data or experience to determine whether an organ transplantation procedure is clinically acceptable. If an accident and health insurer has made written request, or had one made on its behalf by a national organization, for determination by the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services as to whether a specific organ transplantation procedure is clinically acceptable and said organization fails to respond to such a request within a period of 90 days, the failure to act may be deemed a determination that the procedure is deemed to be experimental or investigational.
(Source: P.A. 87-218.)

215 ILCS 5/356L

    (215 ILCS 5/356L) (from Ch. 73, par. 968L)
    Sec. 356L. No policy of accident or health insurance shall include any provision which shall have the effect of denying coverage to or on behalf of an insured under such policy on the basis of a failure by the insured to file a notice of claim within the time period required by the policy, provided such failure is caused solely by the physical inability or mental incapacity of the insured to file such notice of claim because of a period of emergency hospitalization.
(Source: P.A. 86-784.)

215 ILCS 5/356m

    (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 the effective date of this amendatory Act of the 99th General Assembly 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.
    (b) The coverage required under subsection (a) is subject to the following conditions:
        (1) Coverage for procedures for in vitro
    
fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if:
            (A) 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;
            (B) 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
            (C) 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.
        (2) 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.
    (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.
(Source: P.A. 102-170, eff. 1-1-22.)

215 ILCS 5/356n

    (215 ILCS 5/356n) (from Ch. 73, par. 968n)
    Sec. 356n. Fibrocystic condition; denial of coverage. No group or individual policy of accident or health insurance or any renewal thereof shall be denied by the insurer, nor shall any policy contain any exception or exclusion of benefits, solely because the insured has been diagnosed as having a fibrocystic breast condition, unless the condition is diagnosed by a breast biopsy that demonstrates an increased disposition to the development of breast cancer or unless the insured's medical history confirms a chronic, relapsing, symptomatic breast condition.
(Source: P.A. 87-519; 87-895; 87-1066.)

215 ILCS 5/356p

    (215 ILCS 5/356p) (from Ch. 73, par. 968p)
    Sec. 356p. Breast implant removal. No individual or group policy of accident and health insurance shall deny coverage for the removal of breast implants when the removal of the implants is medically necessary treatment for a sickness or injury. This Section does not apply to surgery performed for removal of breast implants that were implanted solely for cosmetic reasons. For the purpose of this Section, cosmetic reasons does not include cosmetic surgery performed as reconstruction resulting from sickness or injury.
(Source: P.A. 87-938.)

215 ILCS 5/356q

    (215 ILCS 5/356q)
    Sec. 356q. On or after the effective date of this Section, every insurer which delivers or issues for delivery in this State a group accident and health policy providing coverage for hospital, medical, or surgical treatment on an expense-incurred basis shall offer, for an additional premium and subject to the insurer's standard of insurability, optional coverage for the reasonable and necessary medical treatment of temporomandibular joint disorder and craniomandibular disorder. The group policyholder shall accept or reject the coverage in writing on the application or an amendment thereto for the master group policy. Benefits may be subject to the same pre-existing conditions, limitations, deductibles, co-payments and co-insurance that generally apply to any other sickness. The maximum lifetime benefits for temporomandibular joint disorder and craniomandibular treatment shall be no less than $2,500. Nothing herein shall prevent an insurer from including such coverage for temporomandibular joint disorder and craniomandibular disorder as part of a policy's basic coverage, in lieu of offering optional coverage.
(Source: P.A. 88-592, eff. 1-1-95.)

215 ILCS 5/356r

    (215 ILCS 5/356r)
    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.)

215 ILCS 5/356s

    (215 ILCS 5/356s)
    Sec. 356s. Post-parturition care. An individual or group policy of accident and health insurance that provides maternity coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1996 shall provide coverage for the following:
        (1) a minimum of 48 hours of inpatient care following
    
a vaginal delivery for the mother and the newborn, except as otherwise provided in this Section; or
        (2) a minimum of 96 hours of inpatient care following
    
a delivery by caesarian section for the mother and newborn, except as otherwise provided in this Section.
    A shorter length of hospital inpatient stay for services related to maternity and newborn care may be provided if the attending physician licensed to practice medicine in all of its branches determines, in accordance with the protocols and guidelines developed by the American College of Obstetricians and Gynecologists or the American Academy of Pediatrics, that the mother and the newborn meet the appropriate guidelines for that length of stay based upon evaluation of the mother and newborn and the coverage and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the infant in the first 48 hours after discharge.
(Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)

215 ILCS 5/356t

    (215 ILCS 5/356t)
    Sec. 356t. Post-mastectomy care. An individual or group policy of accident and health insurance or managed care plan that provides surgical coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1997 shall provide inpatient coverage following a mastectomy for a length of time determined by the attending physician to be medically necessary and in accordance with protocols and guidelines based on sound scientific evidence and upon evaluation of the patient and the coverage for and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the patient in the first 48 hours after discharge.
(Source: P.A. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98.)

215 ILCS 5/356u

    (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
    
female insureds.
        (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
        
prostate cancer.
        (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
    
all insureds.
        (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;
        
and
            (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 5/356u.5

    (215 ILCS 5/356u.5)
    Sec. 356u.5. Coverage for genetic testing for breast and ovarian cancer susceptibility. A group or individual policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for the cost of the genetic testing of the BRCA1 and BRCA2 genes to detect an increased risk for breast and ovarian cancer if recommended by a health care provider in accordance with the United States Preventive Services Task Force's recommendations for testing.
(Source: P.A. 102-979, eff. 1-1-23.)

215 ILCS 5/356v

    (215 ILCS 5/356v)
    Sec. 356v. Use of information derived from genetic testing. After the effective date of this amendatory Act of 1997, an insurer must comply with the provisions of the Genetic Information Privacy Act in connection with the amendment, delivery, issuance, or renewal of, or claims for or denial of coverage under, an individual or group policy of accident and health insurance. Additionally, genetic information shall not be treated as a condition described in item (1) of subsection (A) of Section 20 of the Illinois Health Insurance Portability and Accountability Act in the absence of a diagnosis of the condition related to that genetic information.
(Source: P.A. 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 91-549, eff. 8-14-99.)

215 ILCS 5/356w

    (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
    
sugar; and
        (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 5/356x

    (215 ILCS 5/356x)
    Sec. 356x. Coverage for colorectal cancer examination and screening.
    (a) 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 93rd General Assembly that provides coverage to a resident of this State must provide benefits or coverage for all colorectal cancer examinations and laboratory tests for colorectal cancer as prescribed by a physician, in accordance with the published American Cancer Society guidelines on colorectal cancer screening or other existing colorectal cancer screening guidelines issued by nationally recognized professional medical societies or federal government agencies, including the National Cancer Institute, the Centers for Disease Control and Prevention, and the American College of Gastroenterology.
    (b) Coverage required under this Section may not impose any deductible, coinsurance, waiting period, or other cost-sharing limitation that is greater than that required for other coverage under the policy.
(Source: P.A. 93-568, eff. 1-1-04.)

215 ILCS 5/356y

    (215 ILCS 5/356y)
    Sec. 356y. (Repealed).
(Source: P.A. 91-406, eff. 1-1-00. Repealed internally, eff. 1-1-03.)

215 ILCS 5/356z.1

    (215 ILCS 5/356z.1)
    Sec. 356z.1. Prenatal HIV testing. An individual or group policy of accident and health insurance that provides maternity coverage and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 92nd General Assembly must provide coverage for prenatal HIV testing ordered by an attending physician licensed to practice medicine in all its branches, or by a physician assistant or advanced practice registered nurse, including but not limited to orders consistent with the recommendations of the American College of Obstetricians and Gynecologists or the American Academy of Pediatrics.
(Source: P.A. 99-173, eff. 7-29-15.)

215 ILCS 5/356z.2

    (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.3

    (215 ILCS 5/356z.3)
    Sec. 356z.3. Disclosure of limited benefit. An insurer that issues, delivers, amends, or renews an individual or group policy of accident and health insurance in this State after the effective date of this amendatory Act of the 92nd General Assembly and arranges, contracts with, or administers contracts with a provider whereby beneficiaries are provided an incentive to use the services of such provider must include the following disclosure on its contracts and evidences of coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a non-participating provider for a covered service in non-emergency situations, benefit payments to such non-participating provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy's fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-participating providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill, except as provided in Section 356z.3a of the Illinois Insurance Code for covered services received at a participating health care facility from a nonparticipating provider that are: (a) ancillary services, (b) items or services furnished as a result of unforeseen, urgent medical needs that arise at the time the item or service is furnished, or (c) items or services received when the facility or the non-participating provider fails to satisfy the notice and consent criteria specified under Section 356z.3a. Participating providers have agreed to accept discounted payments for services with no additional billing to the member other than co-insurance and deductible amounts. You may obtain further information about the participating status of professional providers and information on out-of-pocket expenses by calling the toll free telephone number on your identification card.".
(Source: P.A. 102-901, eff. 1-1-23.)

215 ILCS 5/356z.3a

    (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
    
U.S.C. 1395i-4(e);
        (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

    (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.4a

    (215 ILCS 5/356z.4a)
    Sec. 356z.4a. Coverage for abortion.
    (a) Except as otherwise provided in this Section, no individual or group policy of accident and health insurance that provides pregnancy-related benefits may be issued, amended, delivered, or renewed in this State after the effective date of this amendatory Act of the 101st General Assembly unless the policy provides a covered person with coverage for abortion care. Regardless of whether the policy otherwise provides prescription drug benefits, abortion care coverage must include medications that are obtained through a prescription and used to terminate a pregnancy, regardless of whether there is proof of a pregnancy.
    (b) Coverage for abortion care may not impose any deductible, coinsurance, waiting period, or other cost-sharing limitation that is greater than that required for other pregnancy-related benefits covered by the policy.
    (c) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section.
    (d) This Section does not, pursuant to 42 U.S.C. 18054(a)(6), apply to a multistate plan that does not provide coverage for abortion.
    (e) If the Department concludes that enforcement of this Section may adversely affect the allocation of federal funds to this State, the Department may grant an exemption to the requirements, but only to the minimum extent necessary to ensure the continued receipt of federal funds.
(Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.)

215 ILCS 5/356z.4b

    (215 ILCS 5/356z.4b)
    Sec. 356z.4b. Billing for long-acting reversible contraceptives.
    (a) In this Section, "long-acting reversible contraceptive device" means any intrauterine device or contraceptive implant.
    (b) Any individual or group policy of accident and health insurance or qualified health plan that is offered through the health insurance marketplace that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall allow hospitals separate reimbursement for a long-acting reversible contraceptive device provided immediately postpartum in the inpatient hospital setting before hospital discharge. The payment shall be made in addition to a bundled or Diagnostic Related Group reimbursement for labor and delivery.
(Source: P.A. 102-665, eff. 10-8-21.)

215 ILCS 5/356z.5

    (215 ILCS 5/356z.5)
    Sec. 356z.5. Prescription inhalants. 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 93rd General Assembly that provides coverage for prescription drugs may not deny or limit coverage for prescription inhalants to enable persons to breathe when suffering from asthma or other life-threatening bronchial ailments based upon any restriction on the number of days before an inhaler refill may be obtained if, contrary to those restrictions, the inhalants have been ordered or prescribed by the treating physician and are medically appropriate.
(Source: P.A. 95-331, eff. 8-21-07.)

215 ILCS 5/356z.6

    (215 ILCS 5/356z.6)
    Sec. 356z.6. Bone mass measurement; osteoporosis. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 93rd General Assembly must provide coverage for medically necessary bone mass measurement and for the diagnosis and treatment of osteoporosis on the same terms and conditions that are generally applicable to coverage for other medical conditions.
(Source: P.A. 93-853, eff. 1-1-05.)

215 ILCS 5/356z.7

    (215 ILCS 5/356z.7) (was 215 ILCS 5/370r)
    Sec. 356z.7. Prescription drugs; cancer treatment. No group policy of accident or health insurance that provides coverage for prescribed drugs approved by the federal Food and Drug Administration for the treatment of certain types of cancer shall exclude coverage of any drug on the basis that the drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the federal Food and Drug Administration. The drug, however, must be approved by the federal Food and Drug Administration and must be recognized for the treatment of the specific type of cancer for which the drug has been prescribed in any one of the following established reference compendia:
        (a) the American Hospital Formulary Service Drug
    
Information;
        (b) National Comprehensive Cancer Network's Drugs &
    
Biologics Compendium;
        (c) Thomson Micromedex's Drug Dex;
        (d) Elsevier Gold Standard's Clinical Pharmacology; or
        (e) other authoritative compendia as identified from
    
time to time by the Federal Secretary of Health and Human Services;
or if not in the compendia, recommended for that particular type of cancer in formal clinical studies, the results of which have been published in at least two peer reviewed professional medical journals published in the United States or Great Britain.
    Any coverage required by this Section shall also include those medically necessary services associated with the administration of a drug.
    Despite the provisions of this Section, coverage shall not be required for any experimental or investigational drugs or any drug that the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed. This Section shall apply only to cancer drugs. Nothing in this Section shall be construed, expressly or by implication, to create, impair, alter, limit, notify, enlarge, abrogate or prohibit reimbursement for drugs used in the treatment of any other disease or condition.
(Source: P.A. 95-331, eff. 8-21-07; 96-457, eff. 8-14-09.)

215 ILCS 5/356z.8

    (215 ILCS 5/356z.8)
    Sec. 356z.8. Multiple sclerosis preventative physical therapy. 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 94th General Assembly must provide coverage for medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis. For the purposes of this Section, "preventative physical therapy" means physical therapy that is prescribed by a physician licensed to practice medicine in all of its branches for the purpose of treating parts of the body affected by multiple sclerosis, but only where the physical therapy includes reasonably defined goals, including, but not limited to, sustaining the level of function the person has achieved, with periodic evaluation of the efficacy of the physical therapy against those goals. The coverage required under this Section shall be subject to the same deductible, coinsurance, waiting period, cost sharing limitation, treatment limitation, calendar year maximum, or other limitations as provided for other physical or rehabilitative therapy benefits covered by the policy.
(Source: P.A. 94-1076, eff. 12-29-06.)

215 ILCS 5/356z.9

    (215 ILCS 5/356z.9)
    Sec. 356z.9. Human papillomavirus vaccine. 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 a human papillomavirus vaccine (HPV) that is approved for marketing by the federal Food and Drug Administration.
(Source: P.A. 95-422, eff. 8-24-07; 95-876, eff. 8-21-08.)

215 ILCS 5/356z.10

    (215 ILCS 5/356z.10)
    Sec. 356z.10. Amino acid-based elemental formulas. A group or individual major medical accident and health insurance policy 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 and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
(Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)

215 ILCS 5/356z.11

    (215 ILCS 5/356z.11)
    Sec. 356z.11. Dependent students; medical leave of absence. 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 continue to provide coverage for a dependent college student who takes a medical leave of absence or reduces his or her course load to part-time status because of a catastrophic illness or injury.
    Continuation of coverage under this Section is subject to all of the policy's terms and conditions applicable to those forms of insurance. Continuation of insurance under the policy shall terminate 12 months after notice of the illness or injury or until the coverage would have otherwise lapsed pursuant to the terms and conditions of the policy, whichever comes first, provided the need for part-time status or medical leave of absence is supported by a clinical certification of need from a physician licensed to practice medicine in all its branches.
    The provisions of this Section do not apply to short-term travel, accident-only, limited, or specified disease policies or 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. 95-958, eff. 6-1-09; 96-328, eff. 8-11-09.)

215 ILCS 5/356z.12

    (215 ILCS 5/356z.12)
    Sec. 356z.12. Dependent coverage.
    (a) A group or individual policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly shall not terminate coverage or deny the election of coverage for an unmarried dependent by reason of the dependent's age before the dependent's 26th birthday.
    (b) A policy or plan subject to this Section shall, upon amendment, delivery, issuance, or renewal, establish an initial enrollment period of not less than 90 days during which an insured may make a written election for coverage of an unmarried person as a dependent under this Section. After the initial enrollment period, enrollment by a dependent pursuant to this Section shall be consistent with the enrollment terms of the plan or policy.
    (c) A policy or plan subject to this Section shall allow for dependent coverage during the annual open enrollment date or the annual renewal date if the dependent, as of the date on which the insured elects dependent coverage under this subsection, has:
        (1) a period of continuous creditable coverage of 90
    
days or more; and
        (2) not been without creditable coverage for more
    
than 63 days.
An insured may elect coverage for a dependent who does not meet the continuous creditable coverage requirements of this subsection (c) and that dependent shall not be denied coverage due to age.
    For purposes of this subsection (c), "creditable coverage" shall have the meaning provided under subsection (C)(1) of Section 20 of the Illinois Health Insurance Portability and Accountability Act.
    (d) Military personnel. A group or individual policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly shall not terminate coverage or deny the election of coverage for an unmarried dependent by reason of the dependent's age before the dependent's 30th birthday if the dependent (i) is an Illinois resident, (ii) served as a member of the active or reserve components of any of the branches of the Armed Forces of the United States, and (iii) has received a release or discharge other than a dishonorable discharge. To be eligible for coverage under this subsection (d), the eligible dependent shall submit to the insurer a form approved by the Illinois Department of Veterans' Affairs stating the date on which the dependent was released from service.
    (e) Calculation of the cost of coverage provided to an unmarried dependent under this Section shall be identical.
    (f) Nothing in this Section shall prohibit an employer from requiring an employee to pay all or part of the cost of coverage provided under this Section.
    (g) No exclusions or limitations may be applied to coverage elected pursuant to this Section that do not apply to all dependents covered under the policy.
    (h) A policy or plan subject to this Section shall not condition eligibility for dependent coverage provided pursuant to this Section on enrollment in any educational institution.
    (i) Notice regarding coverage for a dependent as provided pursuant to this Section shall be provided to an insured by the insurer:
        (1) upon application or enrollment;
        (2) in the certificate of coverage or equivalent
    
document prepared for an insured and delivered on or about the date on which the coverage commences; and
        (3) (blank).
(Source: P.A. 98-226, eff. 1-1-14.)

215 ILCS 5/356z.13

    (215 ILCS 5/356z.13)
    Sec. 356z.13. Shingles vaccine. A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of the amendatory Act of this 95th General Assembly must provide coverage for a vaccine for shingles that is approved for marketing by the federal Food and Drug Administration if the vaccine is ordered by a physician licensed to practice medicine in all its branches and the enrollee is 60 years of age or older.
(Source: P.A. 95-978, eff. 1-1-09; 96-328, eff. 8-11-09.)

215 ILCS 5/356z.14

    (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

    (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.16

    (215 ILCS 5/356z.16)
    Sec. 356z.16. (Repealed).
(Source: P.A. 100-386, eff. 1-1-18. Repealed by P.A. 101-456, eff. 8-23-19.)

215 ILCS 5/356z.17

    (215 ILCS 5/356z.17)
    Sec. 356z.17. Wellness coverage.
    (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after January 1, 2010 (the effective date of Public Act 96-639) that provides coverage for hospital or medical treatment on an expense incurred basis may offer a reasonably designed program for wellness coverage that allows for a reward, a contribution, a reduction in premiums or reduced medical, prescription drug, or equipment copayments, coinsurance, or deductibles, or a combination of these incentives, for participation in any health behavior wellness, maintenance, or improvement program approved or offered by the insurer or managed care plan. The insured or enrollee may be required to provide evidence of participation in a program. Individuals unable to participate in these incentives due to an adverse health factor shall not be penalized based upon an adverse health status.
    (b) For purposes of this Section, "wellness coverage" means health care coverage with the primary purpose to engage and motivate the insured or enrollee through: incentives; provision of health education, counseling, and self-management skills; identification of modifiable health risks; and other activities to influence health behavior changes.
    For the purposes of this Section, "reasonably designed program" means a program of wellness coverage that has a reasonable chance of improving health or preventing disease; is not overly burdensome; does not discriminate based upon factors of health; and is not otherwise contrary to law.
    (c) Incentives as outlined in this Section are specific and unique to the offering of wellness coverage and have no application to any other required or optional health care benefit.
    (d) Such wellness coverage must satisfy the requirements for an exception from the general prohibition against discrimination based on a health factor under the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191; 110 Stat. 1936), including any federal regulations that are adopted pursuant to that Act.
    (e) A plan offering wellness coverage must do the following:
        (i) give participants the opportunity to qualify for
    
offered incentives at least once a year;
        (ii) allow a reasonable alternative to any individual
    
for whom it is unreasonably difficult, due to a medical condition, to satisfy otherwise applicable wellness program standards. Plans may seek physician verification that health factors make it unreasonably difficult or medically inadvisable for the participant to satisfy the standards; and
        (iii) not provide a total incentive that exceeds 30%
    
of the cost of self-only or employee-only coverage, except that the incentive may be increased by up to an additional 20%, for a total incentive of 50%, to the extent that the additional percentage is in connection with a program designed to prevent or reduce tobacco use. The cost of employee-only or family coverage provided through group health insurance coverage includes both employer and employee contributions. For group or individual plans offering family coverage, the limitation applies to cost of family coverage and applies to the entire family.
    (f) A reward, contribution, or reduction established under this Section and included in the policy or certificate does not violate Section 151 of this Code.
(Source: P.A. 102-462, eff. 8-20-21.)

215 ILCS 5/356z.18

    (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 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. 103-512, eff. 1-1-25.)

215 ILCS 5/356z.19

    (215 ILCS 5/356z.19)
    Sec. 356z.19. Cardiovascular disease. Because cardiovascular disease is a leading cause of death and disability, an insurer providing group or individual policies of accident and health insurance or a managed care plan shall develop and implement a process to communicate with their adult enrollees on an annual basis regarding the importance and value of early detection and proactive management of cardiovascular disease. Nothing in this Section affects any change in the terms, conditions, or benefits of the policies and plans, nor the criteria, standards, and procedures related to the application for, enrollment in, or renewal of coverage or conditions of participation of enrollees in the health plans or policies subject to this Code.
(Source: P.A. 97-282, eff. 8-9-11; 97-813, eff. 7-13-12.)

215 ILCS 5/356z.20

    (215 ILCS 5/356z.20)
    Sec. 356z.20. Cancer drug parity.
    (a) As used in this Section:
    "Financial requirement" means deductibles, copayments, coinsurance, out-of-pocket expenses, aggregate lifetime limits, and annual limits.
    "Treatment limitation" means limits on the frequency of treatment, days of coverage, or other similar limits on the scope or duration of treatment.
    (b) On and after the effective date of this amendatory Act of the 97th General Assembly, every insurer that amends, delivers, issues, or renews an individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 97th General Assembly that provides coverage for prescribed orally-administered cancer medications and intravenously administered or injected cancer medications shall ensure that:
        (1) the financial requirements applicable to such
    
prescribed orally-administered cancer medications are no more restrictive than the financial requirements applied to intravenously administered or injected cancer medications that are covered by the policy and that there are no separate cost-sharing requirements that are applicable only with respect to such prescribed orally-administered cancer medications; and
        (2) the treatment limitations applicable to such
    
prescribed orally-administered cancer medications are no more restrictive than the treatment limitations applied to intravenously administered or injected cancer medications that are covered by the policy and that there are no separate treatment limitations that are applicable only with respect to such prescribed orally-administered cancer medications.
    (c) An insurer cannot achieve compliance with this Section by increasing financial requirements or imposing more restrictive treatment limitations on prescribed orally-administered cancer medications or intravenously administered or injected cancer medications covered under the policy on the effective date of this amendatory Act of the 97th General Assembly.
(Source: P.A. 97-198, eff. 1-1-12; 97-813, eff. 7-13-12.)

215 ILCS 5/356z.21

    (215 ILCS 5/356z.21)
    Sec. 356z.21. Tobacco use cessation programs; coverage offer.
    (a) Tobacco use is the number one cause of preventable disease and death in Illinois, costing $4.1 billion annually in direct health care costs and an additional $4.35 billion in lost productivity. In Illinois, the smoking rates are highest among African Americans (25.8%). Smoking rates among lesbian, gay, and bisexual adults range from 25% to 44%. The U.S. Public Health Service Clinical Practice Guideline 2008 Update found that tobacco dependence treatments are both clinically effective and highly cost effective. A study in the Journal of Preventive Medicine concluded that comprehensive smoking cessation treatment is one of the 3 most important and cost effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.
    (b) In this Section, "tobacco use cessation program" means a program recommended by a physician that follows evidence-based treatment, such as is outlined in the United States Public Health Service guidelines for tobacco use cessation. "Tobacco use cessation program" includes education and medical treatment components designed to assist a person in ceasing the use of tobacco products. "Tobacco use cessation program" includes education and counseling by physicians or associated medical personnel and all FDA approved medications for the treatment of tobacco dependence irrespective of whether they are available only over the counter, only by prescription, or both over the counter and by prescription.
    (c) On or after the effective date of this amendatory Act of the 97th General Assembly, every insurer that amends, delivers, issues, or renews group accident and health policies providing coverage for hospital or medical treatment or services on an expense-incurred basis shall offer, for an additional premium and subject to the insurer's standard of insurability, optional coverage or optional reimbursement of up to $500 annually for a tobacco use cessation program for a person enrolled in the plan who is 18 years of age or older.
    (d) 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.
    (e) For the coverage provided under 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 the coverage under this Section.
(Source: P.A. 97-592, eff. 1-1-12; 97-813, eff. 7-13-12.)

215 ILCS 5/356z.22

    (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.23

    (215 ILCS 5/356z.23)
    Sec. 356z.23. Coverage for opioid antagonists.
    (a) 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 that provides coverage for prescription drugs must provide coverage for at least one opioid antagonist, including the medication product, administration devices, and any pharmacy administration fees related to the dispensing of the opioid antagonist. This coverage must include refills for expired or utilized opioid antagonists.
    (a-5) Notwithstanding subsection (a), no individual or group policy of accident and health insurance amended, delivered, issued, or renewed after January 1, 2024 that provides coverage for naloxone hydrochloride shall impose a copayment on the coverage provided, except that this subsection does not apply to coverage of naloxone hydrochloride to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account under Section 223 of the Internal Revenue Code.
    (b) As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration.
(Source: P.A. 102-1038, eff. 1-1-23.)

215 ILCS 5/356z.24

    (215 ILCS 5/356z.24)
    Sec. 356z.24. Immune gamma globulin therapy.
    (a) 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 99th General Assembly may not allow for the delay, discontinuation, or interruption of immune gamma globulin therapy for persons who are diagnosed with a primary immunodeficiency when prescribed as medically necessary by a physician licensed to practice medicine in all of its branches and if provided as a covered benefit under the plan. Nothing in this Section shall prevent an insurer from applying appropriate utilization review standards to the ongoing coverage of immune gamma globulin therapy for persons diagnosed with a primary immunodeficiency by a physician licensed to practice medicine in all of its branches.
    (b) Upon diagnosis of primary immunodeficiency by the prescribing physician, determination of an initial authorization for immune gamma globulin therapy shall be no less than 3 months. Reauthorization for immune gamma globulin therapy for patients with a primary immunodeficiency diagnosis may occur every 6 months thereafter. For patients with a diagnosis of primary immunodeficiency who have been receiving immune gamma globulin therapy for at least 2 years with sustained beneficial response based on the treatment notes or clinical narrative detailing progress to date, reauthorization shall be no less than 12 months unless a more frequent duration has been indicated by the prescribing physician.
    (c) 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 subsections (a) and (b), then subsections (a) and (b) are inoperative with respect to all coverage outlined in subsections (a) and (b) 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 subsections (a) and (b).
(Source: P.A. 99-788, eff. 8-12-16.)

215 ILCS 5/356z.25

    (215 ILCS 5/356z.25)
    Sec. 356z.25. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after July 18, 2017 (the effective date of Public Act 100-24) shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome, including, but not limited to, the use of intravenous immunoglobulin therapy.
    No group or individual policy of accident and health insurance or managed care plan shall deny or delay coverage for medically necessary treatment under this Section solely because the insured, enrollee, or beneficiary previously received any treatment, including the same or similar treatment, for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or pediatric acute onset neuropsychiatric syndrome, or because the insured, enrollee, or beneficiary has been diagnosed with or receives treatment for an otherwise diagnosed condition.
    For the purposes of this Section, coverage of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome shall adhere to the treatment recommendations developed by a medical professional consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of such disorders or syndrome that are accessible for medical professionals and are based on evidence of positive patient outcomes. Coverage for any form of medically necessary treatment shall not be limited over a lifetime of an insured, enrollee, or beneficiary, unless the patient is no longer benefiting from the treatment, or by policy period. Nothing in this Section prevents insurers from requesting treatment notes and anticipated duration of treatment and outcomes.
    For billing and diagnosis purposes, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome shall be coded as autoimmune encephalitis until the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. Thereafter, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome may be coded as autoimmune encephalitis, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or pediatric acute onset neuropsychiatric syndrome.
    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 pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome outlined in this Section, then the requirement that an insurer cover pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome 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 pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.
(Source: P.A. 103-59, eff. 6-9-23.)

215 ILCS 5/356z.26

    (215 ILCS 5/356z.26)
    Sec. 356z.26. Synchronization.
    (a) As used in this Section, "synchronization" means the coordination of medication refills for a patient taking 2 or more medications for one or more chronic conditions such that the patient's medications are refilled on the same schedule for a given time period.
    (b) Every policy of health and accident insurance amended, delivered, issued, or renewed after August 18, 2017 (the effective date of Public Act 100-138) that provides coverage for prescription drugs shall provide for synchronization of prescription drug refills on at least one occasion per insured per year, provided all of the following conditions are met:
        (1) the prescription drugs are covered by the
    
policy's clinical coverage policy or have been approved by a formulary exceptions process;
        (2) the prescription drugs are maintenance
    
medications as defined by the policy and have available refill quantities at the time of synchronization;
        (3) the medications are not Schedule II, III, or IV
    
controlled substances;
        (4) the insured meets all utilization management
    
criteria specific to the prescription drugs at the time of synchronization;
        (5) the prescription drugs are of a formulation that
    
can be safely split into short-fill periods to achieve synchronization; and
        (6) the prescription drugs do not have special
    
handling or sourcing needs as determined by the policy, contract, or agreement that require a single, designated pharmacy to fill or refill the prescription.
    (c) When necessary to permit synchronization, the policy shall apply a prorated daily cost-sharing rate to any medication dispensed by a network pharmacy pursuant to this Section. No dispensing fees shall be prorated, and all dispensing fees shall be based on the number of prescriptions filled or refilled.
(Source: P.A. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18.)

215 ILCS 5/356z.27

    (215 ILCS 5/356z.27)
    Sec. 356z.27. (Repealed).
(Source: P.A. 100-863, eff. 8-14-18. Repealed by P.A. 102-775, eff. 5-13-22.)

215 ILCS 5/356z.28

    (215 ILCS 5/356z.28)
    Sec. 356z.28. Dry needling by a physical therapist. A group or individual policy of accident and health insurance or a qualified health plan offered through the health insurance market place is not required to provide coverage for dry needling performed by a physical therapist as described in Section 1.5 of the Illinois Physical Therapy Act.
(Source: P.A. 100-418, eff. 8-25-17; 100-863, eff. 8-14-18.)

215 ILCS 5/356z.29

    (215 ILCS 5/356z.29)
    Sec. 356z.29. Stage 4 advanced, metastatic cancer.
    (a) As used in this Section, "stage 4 advanced, metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.
    (b) No individual or group policy of accident and health insurance amended, issued, delivered, or renewed in this State after January 1, 2019 (the effective date of Public Act 100-1057) that, as a provision of hospital, medical, or surgical services, directly or indirectly covers the treatment of stage 4 advanced, metastatic cancer shall limit or exclude coverage for a drug approved by the United States Food and Drug Administration by mandating that the insured shall first be required to fail to successfully respond to a different drug or prove a history of failure of the drug as long as the use of the drug is consistent with best practices for the treatment of stage 4 advanced, metastatic cancer and is supported by peer-reviewed medical literature.
    (c) If, at any time before or after January 1, 2019 (the effective date of Public Act 100-1057), 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 the prohibition of coverage restrictions or exclusions contained in subsection (b) of this Section for the treatment of stage 4 advanced, metastatic cancer, 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 the prohibition of coverage restrictions or exclusions contained in subsection (b) of this Section for the treatment of stage 4 advanced, metastatic cancer.
(Source: P.A. 100-1057, eff. 1-1-19; 101-81, eff. 7-12-19.)

215 ILCS 5/356z.30

    (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
    
ear every 36 months;
        (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
    
ear every 36 months;
        (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.30a

    (215 ILCS 5/356z.30a)
    Sec. 356z.30a. Coverage for hearing instruments.
    (a) As used in this Section:
    "Hearing care professional" means a person who is a licensed hearing instrument dispenser, licensed audiologist, or a licensed physician.
    "Hearing instrument" means any wearable non-disposable 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.
    "Related services" means those services necessary to assess, select, and adjust or fit the hearing instrument to ensure optimal performance, including, but not limited to: audiological exams, replacement ear molds, and repairs to the hearing instrument.
    (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 101st General Assembly shall offer, for an additional premium and subject to the insurer's standard of insurability, optional coverage or optional reimbursement for hearing instruments and related services for all individuals when a hearing care professional prescribes a hearing instrument to augment communication.
    (c) This optional coverage shall be subject to all applicable copayments, coinsurance, deductibles, and out-of-pocket limits for the cost of a hearing instrument for each ear, as needed, as well as related services, with a maximum for the hearing instrument and related services of no more than $2,500 per hearing instrument every 24 months.
    (d) Nothing in this Section precludes an insured from selecting a hearing instrument that costs more than the amount covered by a plan of accident and health insurance or a managed care plan and paying the uncovered cost at his or her own expense.
    (e) Nothing in this Section shall be construed to require a group policy of accident and health insurance to provide coverage if the group is unable to meet mandatory minimum participation requirements set by the insurer.
(Source: P.A. 101-393, eff. 1-1-20.)

215 ILCS 5/356z.31

    (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
    
meal plans.
        (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

    (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.33

    (215 ILCS 5/356z.33)
    (Text of Section before amendment by P.A. 103-454)
    Sec. 356z.33. Coverage for epinephrine injectors. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-281) shall provide coverage for medically necessary epinephrine injectors for persons 18 years of age or under. As used in this Section, "epinephrine injector" has the meaning given to that term in Section 5 of the Epinephrine Injector Act.
(Source: P.A. 101-281, eff. 1-1-20; 102-558, eff. 8-20-21.)
 
    (Text of Section after amendment by P.A. 103-454)
    Sec. 356z.33. Coverage for epinephrine injectors.
    (a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-281) shall provide coverage for medically necessary epinephrine injectors for persons 18 years of age or under. As used in this Section, "epinephrine injector" has the meaning given to that term in Section 5 of the Epinephrine Injector Act.
    (b) An insurer that provides coverage for medically necessary epinephrine injectors shall limit the total amount that an insured is required to pay for a twin-pack of medically necessary epinephrine injectors at an amount not to exceed $60, regardless of the type of epinephrine injector.
    (c) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (b).
    (d) The Department may adopt rules as necessary to implement and administer this Section.
(Source: P.A. 102-558, eff. 8-20-21; 103-454, eff. 1-1-25.)

215 ILCS 5/356z.34

    (215 ILCS 5/356z.34)
    Sec. 356z.34. Coverage for cardiopulmonary monitors. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed after January 1, 2020 (the effective date of Public Act 101-218) shall provide coverage for cardiopulmonary monitors determined to be medically necessary for a person 18 years old or younger who has had a cardiopulmonary event.
(Source: P.A. 101-218, eff. 1-1-20; 102-558, eff. 8-20-21.)

215 ILCS 5/356z.35

    (215 ILCS 5/356z.35)
    Sec. 356z.35. Long-term antibiotic therapy for tick-borne diseases.
    (a) As used in this Section:
    "Long-term antibiotic therapy" means the administration of oral, intramuscular, or intravenous antibiotics singly or in combination for periods of time in excess of 4 weeks.
    "Tick-borne disease" means a disease caused when an infected tick bites a person and the tick's saliva transmits an infectious agent (bacteria, viruses, or parasites) that can cause illness, including, but not limited to, the following:
        (1) a severe infection with borrelia burgdorferi;
        (2) a late stage, persistent, or chronic infection or
    
complications related to such an infection;
        (3) an infection with other strains of borrelia or a
    
tick-borne disease that is recognized by the United States Centers for Disease Control and Prevention; and
        (4) the presence of signs or symptoms compatible with
    
acute infection of borrelia or other tick-borne diseases.
    (b) An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-371) shall provide coverage for long-term antibiotic therapy, including necessary office visits and ongoing testing, for a person with a tick-borne disease when determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches after making a thorough evaluation of the person's symptoms, diagnostic test results, or response to treatment. An experimental drug shall be covered as a long-term antibiotic therapy if it is approved for an indication by the United States Food and Drug Administration. A drug, including an experimental drug, shall be covered for an off-label use in the treatment of a tick-borne disease if the drug has been approved by the United States Food and Drug Administration.
(Source: P.A. 101-371, eff. 1-1-20; 102-558, eff. 8-20-21.)

215 ILCS 5/356z.36

    (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.37

    (215 ILCS 5/356z.37)
    Sec. 356z.37. Whole body skin examination. An individual or group policy of accident and health insurance shall cover, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement upon the insured patient, one annual office visit, using appropriate routine evaluation and management Current Procedural Terminology codes or any successor codes, for a whole body skin examination for lesions suspicious for skin cancer. The whole body skin examination shall be indicated using an appropriate International Statistical Classification of Diseases and Related Health Problems code or any successor codes. The provisions of this Section do not apply to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to 26 U.S.C. 223.
(Source: P.A. 101-500, eff. 1-1-20; 102-558, eff. 8-20-21.)

215 ILCS 5/356z.38

    (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
        
grams;
            (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
        
transplant;
            (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
        
transplant; or
            (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.39

    (215 ILCS 5/356z.39)
    Sec. 356z.39. Coverage of the psychiatric Collaborative Care Model.
    (a) As used in this Section, "psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method, which includes a formal collaborative arrangement among a primary care team consisting of a primary care provider, a care manager, and a psychiatric consultant, and includes, but is not limited to, the following elements:
        (1) care directed by the primary care team;
        (2) structured care management;
        (3) regular assessments of clinical status using
    
validated tools; and
        (4) modification of treatment as appropriate.
    (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-574) or managed care organization that provides mental health benefits shall provide reimbursement for benefits that are delivered through the psychiatric Collaborative Care Model. The following American Medical Association 2018 current procedural terminology codes and Healthcare Common Procedure Coding System code shall be used to bill for benefits delivered through the psychiatric Collaborative Care Model:
        (1) 99492;
        (2) 99493;
        (3) 99494; and
        (4) G0512.
    (c) The Director of Insurance shall update the billing codes in subsection (b) if there are any alterations or additions to the billing codes for the psychiatric Collaborative Care Model.
    (d) An individual or group policy or managed care organization that provides benefits under this Section may deny reimbursement of any billing code listed in this Section on the grounds of medical necessity if such medical necessity determinations are in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and its implementing and related regulations and that such determinations are made in accordance with the utilization review requirements under Section 85 of the Managed Care Reform and Patient Rights Act.
(Source: P.A. 101-574, eff. 1-1-20; 102-558, eff. 8-20-21.)

215 ILCS 5/356z.40

    (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.41

    (215 ILCS 5/356z.41)
    (Text of Section before amendment by P.A. 103-429)
    Sec. 356z.41. Cost sharing in prescription insulin drugs; limits; confidentiality of rebate information.
    (a) As used in this Section, "prescription insulin drug" means a prescription drug that contains insulin and is used to control blood glucose levels to treat diabetes but does not include an insulin drug that is administered to a patient intravenously.
    (b) This Section applies to a group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly.
    (c) An insurer that provides coverage for prescription insulin drugs pursuant to the terms of a health coverage plan the insurer offers shall limit the total amount that an insured is required to pay for a 30-day supply of covered prescription insulin drugs at an amount not to exceed $100, regardless of the quantity or type of covered prescription insulin drug used to fill the insured's prescription.
    (d) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (c).
    (e) The Director may use any of the Director's enforcement powers to obtain an insurer's compliance with this Section.
    (f) The Department may adopt rules as necessary to implement and administer this Section and to align it with federal requirements.
    (g) On January 1 of each year, the limit on the amount that an insured is required to pay for a 30-day supply of a covered prescription insulin drug shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the Consumer Price Index of the Bureau of Labor Statistics of the United States Department of Labor.
(Source: P.A. 101-625, eff. 1-1-21.)
 
    (Text of Section after amendment by P.A. 103-429)
    Sec. 356z.41. Cost sharing in prescription insulin drugs; limits; confidentiality of rebate information.
    (a) As used in this Section, "prescription insulin drug" means a prescription drug that contains insulin and is used to control blood glucose levels to treat diabetes but does not include an insulin drug that is administered to a patient intravenously.
    (b) This Section applies to a group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly.
    (c) An insurer that provides coverage for prescription insulin drugs pursuant to the terms of a health coverage plan the insurer offers shall limit the total amount that an insured is required to pay for a 30-day supply of covered prescription insulin drugs at an amount not to exceed $35, regardless of the quantity or type of covered prescription insulin drug used to fill the insured's prescription.
    (d) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (c).
    (e) The Director may use any of the Director's enforcement powers to obtain an insurer's compliance with this Section.
    (f) The Department may adopt rules as necessary to implement and administer this Section and to align it with federal requirements.
    (g) On January 1 of each year, the limit on the amount that an insured is required to pay for a 30-day supply of a covered prescription insulin drug shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the Consumer Price Index of the Bureau of Labor Statistics of the United States Department of Labor.
(Source: P.A. 103-429, eff. 7-1-25.)

215 ILCS 5/356z.42

    (215 ILCS 5/356z.42)
    Sec. 356z.42. (Repealed).
(Source: P.A. 101-625, eff. 1-24-20. Repealed internally, eff. 12-31-20.)

215 ILCS 5/356z.43

    (215 ILCS 5/356z.43)
    Sec. 356z.43. (Repealed).
(Source: P.A. 102-813, eff. 5-13-22. Repealed internally, eff. 1-1-22.)

215 ILCS 5/356z.44

    (215 ILCS 5/356z.44)
    Sec. 356z.44. Vitamin D testing.
    (a) As used in this Section, "vitamin D testing" means vitamin D blood testing that measures the level of vitamin D in an individual's blood.
    (b) A group or individual 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 vitamin D testing recommended by a health care provider in accordance with vitamin D deficiency risk factors identified by the United States Centers for Disease Control and Prevention. Risk factors for vitamin D deficiency include, but are not limited to:
        (1) having osteoporosis or other bone-health
    
problems;
        (2) having conditions that affect fat absorption,
    
including celiac disease or weight loss surgery;
        (3) routinely taking medications that interfere
    
with vitamin D activity, including anticonvulsants and glucocorticoids;
        (4) beneficiaries aged 55 and older;
        (5) having a darker skin color;
        (6) inadequate sunlight exposure;
        (7) being obese;
        (8) previous diagnosis of diabetes or kidney
    
disease; and
        (9) exhibiting poor muscle strength or constant
    
tiredness.
(Source: P.A. 102-530, eff. 1-1-22.)

215 ILCS 5/356z.45

    (215 ILCS 5/356z.45)
    Sec. 356z.45. Coverage for patient care services provided by a pharmacist. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2023 shall provide coverage for health care or patient care services provided by a pharmacist if:
        (1) the pharmacist meets the requirements and scope
    
of practice as set forth in Section 43 or Section 43.5 of the Pharmacy Practice Act;
        (2) the health plan provides coverage for the same
    
service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;
        (3) the pharmacist is included in the health
    
benefit plan's network of participating providers; and
        (4) a reimbursement has been successfully
    
negotiated in good faith between the pharmacist and the health plan.
(Source: P.A. 102-103, eff. 1-1-23; 102-813, eff. 5-13-22; 102-1051, eff. 1-1-23.)

215 ILCS 5/356z.46

    (215 ILCS 5/356z.46)
    Sec. 356z.46. Biomarker testing.
    (a) As used in this Section:
    "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention. "Biomarker" includes, but is not limited to, gene mutations or protein expression.
    "Biomarker testing" means the analysis of a patient's tissue, blood, or fluid biospecimen for the presence of a biomarker. "Biomarker testing" includes, but is not limited to, single-analyte tests, multi-plex panel tests, and partial or whole genome sequencing.
    (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2022 shall include coverage for biomarker testing as defined in this Section pursuant to criteria established under subsection (d).
    (c) Biomarker testing shall be covered and conducted in an efficient manner to provide the most complete range of results to the patient's health care provider without requiring multiple biopsies, biospecimen samples, or other delays or disruptions in patient care.
    (d) Biomarker testing must be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence, including, but not limited to:
        (1) labeled indications for an FDA-approved test or
    
indicated tests for an FDA-approved drug;
        (2) federal Centers for Medicare and Medicaid
    
Services National Coverage Determinations;
        (3) nationally recognized clinical practice
    
guidelines;
        (4) consensus statements;
        (5) professional society recommendations;
        (6) peer-reviewed literature, biomedical compendia,
    
and other medical literature that meet the criteria of the National Institutes of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medicus, Medline, and MEDLARS database of Health Services Technology Assessment Research; and
        (7) peer-reviewed scientific studies published in
    
or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.
    (e) When coverage of biomarker testing for the purpose of diagnosis, treatment, or ongoing monitoring of any medical condition is restricted for use by a group or individual policy of accident and health insurance or managed care plan, the patient and prescribing practitioner shall have access to a clear, readily accessible, and convenient processes to request an exception. The process shall be made readily accessible on the insurer's website.
(Source: P.A. 102-203, eff. 1-1-22; 102-813, eff. 5-13-22.)

215 ILCS 5/356z.47

    (215 ILCS 5/356z.47)
    Sec. 356z.47. Coverage for pancreatic cancer screening. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for medically necessary pancreatic cancer screening.
(Source: P.A. 102-306, eff. 1-1-22; 102-813, eff. 5-13-22.)

215 ILCS 5/356z.48

    (215 ILCS 5/356z.48)
    Sec. 356z.48. Colonoscopy coverage.
    (a) A group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for a colonoscopy that is a follow-up exam based on an initial screen where the colonoscopy was determined to be medically necessary by a physician licensed to practice medicine in all its branches, an advanced practice registered nurse, or a physician assistant.
    (b) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this subsection does not apply to coverage of colonoscopies to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(Source: P.A. 102-443, eff. 1-1-22; 102-813, eff. 5-13-22.)

215 ILCS 5/356z.49

    (215 ILCS 5/356z.49)
    Sec. 356z.49. A1C testing.
    (a) As used in this Section, "A1C testing" means blood sugar level testing used to diagnose prediabetes, type 1 diabetes, and type 2 diabetes and to monitor management of blood sugar levels.
    (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2022 (the effective date of Public Act 102-530) shall provide coverage for A1C testing recommended by a health care provider for prediabetes, type 1 diabetes, and type 2 diabetes in accordance with prediabetes and diabetes risk factors identified by the United States Centers for Disease Control and Prevention.
        (1) Risk factors for prediabetes may include, but
    
are not limited to, being overweight or obese, being aged 35 or older, having an immediate family member with type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.
        (2) Risk factors for type 1 diabetes may include,
    
but are not limited to, family history of diabetes.
        (3) Risk factors for type 2 diabetes may include,
    
but are not limited to, having prediabetes, being overweight or obese, being aged 35 or older, having an immediate family member with type 1 or type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.
(Source: P.A. 102-530, eff. 1-1-22; 102-813, eff. 5-13-22.)

215 ILCS 5/356z.50

    (215 ILCS 5/356z.50)
    Sec. 356z.50. Comprehensive cancer testing.
    (a) As used in this Section:
    "Comprehensive cancer testing" includes, but is not limited to, the following forms of testing:
        (1) Targeted cancer gene panels.
        (2) Whole-exome genome testing.
        (3) Whole-genome sequencing.
        (4) RNA sequencing.
        (5) Tumor mutation burden.
    "Testing of blood or constitutional tissue for cancer predisposition testing" includes, but is not limited to, the following forms of testing:
        (1) Targeted cancer gene panels.
        (2) Whole-exome genome testing.
        (3) Whole-genome sequencing.
    (b) An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2022 (the effective date of Public Act 102-589) shall provide coverage for medically necessary comprehensive cancer testing and testing of blood or constitutional tissue for cancer predisposition testing as determined by a physician licensed to practice medicine in all of its branches.
(Source: P.A. 102-589, eff. 1-1-22; 102-813, eff. 5-13-22.)

215 ILCS 5/356z.51

    (215 ILCS 5/356z.51)
    Sec. 356z.51. Coverage for port-wine stain treatment.
    (a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for treatment to eliminate or provide maximum feasible treatment of nevus flammeus, also known as port-wine stains, including, but not limited to, port-wine stains caused by Sturge-Weber syndrome. For purposes of this Section, treatment or maximum feasible treatment shall include early intervention treatment, including topical, intralesional, or systemic medical therapy and surgery, and laser treatments approved by the U.S. Food and Drug Administration in children aged 18 years and younger that are intended to prevent functional impairment related to vision function, oral function, inflammation, bleeding, infection, and other medical complications associated with port-wine stains.
    (b) Coverage for treatment required under this Section shall not include treatment solely for cosmetic purposes.
(Source: P.A. 102-642, eff. 1-1-22; 102-813, eff. 5-13-22.)

215 ILCS 5/356z.53

    (215 ILCS 5/356z.53)
    Sec. 356z.53. Coverage for home health services. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for access to home health services for the duration of medically necessary care.
(Source: P.A. 102-816, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.54

    (215 ILCS 5/356z.54)
    Sec. 356z.54. Coverage for breast reduction surgery. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for medically necessary breast reduction surgery.
(Source: P.A. 102-731, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.55

    (215 ILCS 5/356z.55)
    Sec. 356z.55. Coverage for cleft lip and cleft palate.
    (a) As used in this Section, "medically necessary care and treatment" to address congenital anomalies associated with a cleft lip or palate, or both, includes:
        (1) oral and facial surgery, including reconstructive
    
services and procedures necessary to improve and restore and maintain vital functions;
        (2) prosthetic treatment such as obturators, speech
    
appliances, and feeding appliances;
        (3) orthodontic treatment and management;
        (4) prosthodontic treatment and management; and
        (5) otolaryngology treatment and management.
    "Medically necessary care and treatment" does not include cosmetic surgery performed to reshape normal structures of the lip, jaw, palate, or other facial structures to improve appearance.
    (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2024 (the effective date of Public Act 102-768) shall provide coverage for the medically necessary care and treatment of cleft lip and palate for children under the age of 19. Coverage for cleft lip and palate care and treatment may impose the same deductible, coinsurance, or other cost-sharing limitation that is imposed on other related surgical benefits under the policy.
    (c) This Section does not apply to a policy that covers only dental care.
(Source: P.A. 102-768, eff. 1-1-24; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.56

    (215 ILCS 5/356z.56)
    Sec. 356z.56. Coverage for hormone therapy to treat menopause. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy.
(Source: P.A. 102-804, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.57

    (215 ILCS 5/356z.57)
    Sec. 356z.57. Pediatric palliative care.
    (a) A group or individual policy of accident and health insurance or a managed care plan amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for community-based pediatric palliative care and hospice care. This care shall be delivered to any qualifying child with a serious illness by a trained interdisciplinary team that allows a child to receive community-based pediatric palliative care and hospice care while continuing to pursue curative treatment and disease-directed therapies for the qualifying illness.
    (b) As used in this Section, "palliative care" and "serious illness" have the same meaning as set forth in the Pediatric Palliative Care Act.
(Source: P.A. 102-860, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.58

    (215 ILCS 5/356z.58)
    Sec. 356z.58. Prenatal vitamins coverage. A group or individual policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 that provides coverage for prescription drugs shall provide coverage for prenatal vitamins when prescribed by a physician licensed to practice medicine in all of its branches or an advanced practice registered nurse licensed under the Nurse Practice Act.
(Source: P.A. 102-930, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.59

    (215 ILCS 5/356z.59)
    Sec. 356z.59. Coverage for continuous glucose monitors. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2024 shall provide coverage for medically necessary continuous glucose monitors for individuals who are diagnosed with type 1 or type 2 diabetes and require insulin for the management of their diabetes.
(Source: P.A. 102-1093, eff. 1-1-23; 103-154, eff. 6-30-23.)

215 ILCS 5/356z.60

    (215 ILCS 5/356z.60)
    Sec. 356z.60. Coverage for abortifacients, hormonal therapy, and human immunodeficiency virus pre-exposure prophylaxis and post-exposure prophylaxis.
    (a) As used in this Section:
    "Abortifacients" means any medication administered to terminate a pregnancy as prescribed or ordered by a health care professional.
    "Health care professional" means a physician licensed to practice medicine in all of its branches, licensed advanced practice registered nurse, or physician assistant.
    "Hormonal therapy medication" means hormonal treatment administered to treat gender dysphoria.
    "Therapeutic equivalent version" means drugs, devices, or products that can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling and that satisfy the following general criteria:
        (1) it is approved as safe and effective;
        (2) it is a pharmaceutical equivalent in that it:
            (A) contains identical amounts of the same
        
active drug ingredient in the same dosage form and route of administration; and
            (B) meets compendial or other applicable
        
standards of strength, quality, purity, and identity;
        (3) it is bioequivalent in that:
            (A) it does not present a known or potential
        
bioequivalence problem and it meets an acceptable in vitro standard; or
            (B) if it does present such a known or
        
potential problem, it is shown to meet an appropriate bioequivalence standard;
        (4) it is adequately labeled; and
        (5) it is manufactured in compliance with Current
    
Good Manufacturing Practice regulations adopted by the United States Food and Drug Administration.
    (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2024 shall provide coverage for all abortifacients, hormonal therapy medication, human immunodeficiency virus pre-exposure prophylaxis, and post-exposure prophylaxis drugs approved by the United States Food and Drug Administration, and follow-up services related to that coverage, including, but not limited to, management of side effects, medication self-management or adherence counseling, risk reduction strategies, and mental health counseling. This coverage shall include drugs approved by the United States Food and Drug Administration that are prescribed or ordered for off-label use for the purposes described in this Section.
    (c) The coverage required under subsection (b) is subject to the following conditions:
        (1) If the United States Food and Drug
    
Administration has approved one or more therapeutic equivalent versions of an abortifacient drug, a policy is not required to include all such therapeutic equivalent versions in its formulary so long as at least one is included and covered without cost sharing and in accordance with this Section.
        (2) If an individual's attending provider
    
recommends a particular drug approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must defer to the determination of the attending provider and must cover that service or item without cost sharing.
        (3) If a drug is not covered, plans and issuers
    
must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or other individual acting as a patient's authorized representative to ensure coverage without cost sharing.
    The conditions listed under this subsection (c) also apply to drugs prescribed for off-label use as abortifacients.
    (d) Except as otherwise provided in this Section, a policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided. The provisions of this subsection do not apply to coverage of procedures to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 223.
    (e) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section.
    (f) The coverage requirements in this Section for abortifacients do not, pursuant to 42 U.S.C. 18054(a)(6), apply to a multistate plan that does not provide coverage for abortion.
    (g) If the Department concludes that enforcement of any coverage requirement of this Section for abortifacients may adversely affect the allocation of federal funds to this State, the Department may grant an exemption to that requirement, but only to the minimum extent necessary to ensure the continued receipt of federal funds.
(Source: P.A. 102-1117, eff. 1-13-23; 103-462, eff. 8-4-23.)

215 ILCS 5/356z.61

    (215 ILCS 5/356z.61)
    (Text of Section from P.A. 103-1)
    Sec. 356z.61. Coverage of pharmacy testing, screening, vaccinations, and treatment. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for health care or patient care services provided by a pharmacist if:
        (1) the pharmacist meets the requirements and scope
    
of practice described in paragraph (15), (16), or (17) of subsection (d) of Section 3 of the Pharmacy Practice Act;
        (2) the health plan provides coverage for the same
    
service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;
        (3) the pharmacist is included in the health benefit
    
plan's network of participating providers; and
        (4) reimbursement has been successfully negotiated in
    
good faith between the pharmacist and the health plan.
(Source: P.A. 103-1, eff. 4-27-23.)
 
    (Text of Section from P.A. 103-84)
    Sec. 356z.61. Coverage for liver disease screening. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for preventative liver disease screenings for individuals 35 years of age or older and under the age of 65 at high risk for liver disease, including liver ultrasounds and alpha-fetoprotein blood tests every 6 months, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this Section does not apply to coverage of liver disease screenings to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
(Source: P.A. 103-84, eff. 1-1-24.)
 
    (Text of Section from P.A. 103-91)
    Sec. 356z.61. Coverage for compression sleeves. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for compression sleeves that is medically necessary for the enrollee to prevent or mitigate lymphedema.
(Source: P.A. 103-91, eff. 1-1-24.)
 
    (Text of Section from P.A. 103-123)
    Sec. 356z.61. Coverage for reconstructive services.
    (a) As used in this Section, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance.
    (b) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 may not deny coverage for medically necessary reconstructive services that are intended to restore physical appearance.
(Source: P.A. 103-123, eff. 1-1-24.)
 
    (Text of Section from P.A. 103-325)
    Sec. 356z.61. Proton beam therapy.
    (a) As used in this Section:
    "Medically necessary" has the meaning given to that term in the Prior Authorization Reform Act.
    "Proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells.
    "Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.
    (b) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage for the treatment of cancer shall not apply a higher standard of clinical evidence for the coverage of proton beam therapy than the insurer applies for the coverage of any other form of radiation therapy treatment.
    (c) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 that provides coverage or benefits to any resident of this State for radiation oncology shall include coverage or benefits for medically necessary proton beam therapy for the treatment of cancer.
(Source: P.A. 103-325, eff. 1-1-24.)
 
    (Text of Section from P.A. 103-420)
    Sec. 356z.61. Coverage of prescription estrogen.
    (a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 and that provides coverage for prescription drugs shall include coverage for one or more therapeutic equivalent versions of vaginal estrogen in its formulary.
    (b) If a particular vaginal estrogen product or its therapeutic equivalent version approved by the United States Food and Drug Administration is determined to be medically necessary, the issuer must cover that service or item pursuant to the cost-sharing requirement contained in subsection (c).
    (c) A policy subject to this Section shall not impose a deductible, copayment, or any other cost sharing requirement that exceeds any deductible, coinsurance, copayment, or any other cost-sharing requirement imposed on any prescription drug authorized for the treatment of erectile dysfunction covered by the policy; except that this subsection does not apply to coverage of vaginal estrogen to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
    (d) As used in this Section, "therapeutic equivalent version" has the meaning given to that term in paragraph (2) of subsection (a) of Section 356z.4.
(Source: P.A. 103-420, eff. 1-1-24.)
 
    (Text of Section from P.A. 103-445)
    Sec. 356z.61. Home saliva cancer screening.
    (a) As used in this Section, "home saliva cancer screening" means an outpatient test that utilizes an individual's saliva to detect biomarkers for early-stage cancer.
    (b) An individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2025 shall cover a medically necessary home saliva cancer screening every 24 months if the patient:
        (1) is asymptomatic and at high risk for the disease
    
being tested for; or
        (2) demonstrates symptoms of the disease being tested
    
for at a physical exam.
(Source: P.A. 103-445, eff. 1-1-24.)
 
    (Text of Section from P.A. 103-458)
    Sec. 356z.61. Coverage for children with neuromuscular, neurological, or cognitive impairment. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for therapy, diagnostic testing, and equipment necessary to increase quality of life for children who have been clinically or genetically diagnosed with any disease, syndrome, or disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.
(Source: P.A. 103-458, eff. 1-1-24.)
 
    (Text of Section from P.A. 103-535)
    Sec. 356z.61. Coverage of no-cost mental health prevention and wellness visits.
    (a) A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025 shall provide coverage for one annual mental health prevention and wellness visit for children and for adults.
    (b) Mental health prevention and wellness visits shall include any age-appropriate screening recommended by the United States Preventive Services Task Force or by the American Academy of Pediatrics' Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents for purposes of identifying a mental health issue, condition, or disorder; discussing mental health symptoms that might be present, including symptoms of a previously diagnosed mental health condition or disorder; performing an evaluation of adverse childhood experiences; and discussing mental health and wellness.
    (c) A mental health prevention and wellness visit shall be covered for up to 60 minutes and may be performed by a physician licensed to practice medicine in all of its branches, a licensed clinical psychologist, a licensed clinical social worker, a licensed clinical professional counselor, a licensed marriage and family therapist, a licensed social worker, or a licensed professional counselor.
    (d) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement for mental health prevention and wellness visits. The cost-sharing prohibition in this subsection (d) does not apply to coverage of mental health prevention and wellness visits to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.
    (e) A mental health prevention and wellness visit shall be in addition to an annual physical examination and shall not replace a well-child visit or a general health or medical visit.
    (f) A mental health prevention and wellness visit shall be reimbursed through the following American Medical Association current procedural terminology codes and at the same rate that current procedural terminology codes are reimbursed for the provision of other medical care: 99381-99387 and 99391-99397. The Department shall update the current procedural terminology codes through adoption of rules if the codes listed in this subsection are altered, amended, changed, deleted, or supplemented.
    (g) Reimbursement of any of the current procedural terminology codes listed in this Section shall comply with the following:
        (1) reimbursement may be adjusted for payment of
    
claims that are billed by a nonphysician clinician so long as the methodology to determine the adjustments are comparable to and applied no more stringently than the methodology for adjustments made for reimbursement of claims billed by nonphysician clinicians for other medical care, in accordance with 45 CFR 146.136(c)(4); and
        (2) for a mental health prevention and wellness visit
    
and for a service other than a mental health prevention and wellness visit, reimbursement shall not be denied if they occur on the same date by the same provider and the provider is a primary care provider.
    (h) A mental health prevention and wellness visit may be incorporated into and reimbursed within any type of integrated primary care service delivery method, including, but not limited to, a psychiatric collaborative care model as provided for under this Code.
    (i) The Department shall adopt any rules necessary to implement this Section by no later than October 31, 2024.
(Source: P.A. 103-535, eff. 8-11-23.)

215 ILCS 5/356z.62

    (215 ILCS 5/356z.62)
    Sec. 356z.62. Coverage of preventive health services.
    (a) A policy of group health insurance coverage or individual health insurance coverage as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act shall, at a minimum, provide coverage for and shall not impose any cost-sharing requirements, including a copayment, coinsurance, or deductible, for:
        (1) evidence-based items or services that have in
    
effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;
        (2) immunizations that have in effect a
    
recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;
        (3) with respect to infants, children, and
    
adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
        (4) with respect to women, such additional preventive
    
care and screenings not described in paragraph (1) of this subsection (a) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.
    (b) For purposes of this Section, and for purposes of any other provision of State law, recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current.
    (c) For office visits:
        (1) if an item or service described in subsection (a)
    
is billed separately or is tracked as individual encounter data separately from an office visit, then a policy may impose cost-sharing requirements with respect to the office visit;
        (2) if an item or service described in subsection (a)
    
is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a policy may not impose cost-sharing requirements with respect to the office visit; and
        (3) if an item or service described in subsection (a)
    
is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a policy may impose cost-sharing requirements with respect to the office visit.
    (d) A policy must provide coverage pursuant to subsection (a) for plan or policy years that begin on or after the date that is one year after the date the recommendation or guideline is issued. If a recommendation or guideline is in effect on the first day of the plan or policy year, the policy shall cover the items and services specified in the recommendation or guideline through the last day of the plan or policy year unless either:
        (1) a recommendation under paragraph (1) of
    
subsection (a) is downgraded to a "D" rating; or
        (2) the item or service is subject to a safety recall
    
or is otherwise determined to pose a significant safety concern by a federal agency authorized to regulate the item or service during the plan or policy year.
    (e) Network limitations.
        (1) Subject to paragraph (3) of this subsection,
    
nothing in this Section requires coverage for items or services described in subsection (a) that are delivered by an out-of-network provider under a health maintenance organization health care plan, other than a point-of-service contract, or under a voluntary health services plan that generally excludes coverage for out-of-network services except as otherwise required by law.
        (2) Subject to paragraph (3) of this subsection,
    
nothing in this Section precludes a policy with a preferred provider program under Article XX-1/2 of this Code, a health maintenance organization point-of-service contract, or a similarly designed voluntary health services plan from imposing cost-sharing requirements for items or services described in subsection (a) that are delivered by an out-of-network provider.
        (3) If a policy does not have in its network a
    
provider who can provide an item or service described in subsection (a), then the policy must cover the item or service when performed by an out-of-network provider and it may not impose cost-sharing with respect to the item or service.
    (f) Nothing in this Section prevents a company from using reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in subsection (a) to the extent not specified in the recommendation or guideline.
    (g) Nothing in this Section shall be construed to prohibit a policy from providing coverage for items or services in addition to those required under subsection (a) or from denying coverage for items or services that are not required under subsection (a). Unless prohibited by other law, a policy may impose cost-sharing requirements for a treatment not described in subsection (a) even if the treatment results from an item or service described in subsection (a). Nothing in this Section shall be construed to limit coverage requirements provided under other law.
    (h) The Director may develop guidelines to permit a company to utilize value-based insurance designs. In the absence of guidelines developed by the Director, any such guidelines developed by the Secretary of the U.S. Department of Health and Human Services that are in force under 42 U.S.C. 300gg-13 shall apply.
    (i) For student health insurance coverage as defined at 45 CFR 147.145, student administrative health fees are not considered cost-sharing requirements with respect to preventive services specified under subsection (a). As used in this subsection, "student administrative health fee" means a fee charged by an institution of higher education on a periodic basis to its students to offset the cost of providing health care through health clinics regardless of whether the students utilize the health clinics or enroll in student health insurance coverage.
    (j) For any recommendation or guideline specifically referring to women or men, a company shall not deny or limit the coverage required or a claim made under subsection (a) based solely on the individual's recorded sex or actual or perceived gender identity, or for the reason that the individual is gender nonconforming, intersex, transgender, or has undergone, or is in the process of undergoing, gender transition, if, notwithstanding the sex or gender assigned at birth, the covered individual meets the conditions for the recommendation or guideline at the time the item or service is furnished.
    (k) This Section does not apply to grandfathered health plans, excepted benefits, or short-term, limited-duration health insurance coverage.
(Source: P.A. 103-551, eff. 8-11-23.)

215 ILCS 5/357.1

    (215 ILCS 5/357.1) (from Ch. 73, par. 969.1)
    Sec. 357.1. Accident and health policy provisions required.
    Except as provided in section 357.26 of this article each accident and health policy delivered or issued for delivery to any person in this State shall contain the provisions set forth in sections 357.2 through 357.13 in the words in which the same appear in the specified sections; provided, however, that the company may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the Director which are in each instance not less favorable in any respect to the insured or the beneficiary. Such provisions shall be preceded individually by the caption appearing at the beginning of each such section or, at the option of the company, by such appropriate individual or group captions or subcaptions as the Director may approve.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.2

    (215 ILCS 5/357.2) (from Ch. 73, par. 969.2)
    Sec. 357.2. "ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the company and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions."
    (1) Premium Notice Required. No policy of accident and health insurance, as enumerated in class 1(b) or 2(a) of Section 4, shall be declared forfeited or lapsed within 6 months after default in payment of any premium installment or interest or any portion thereof, nor shall any such policy be forfeited or lapsed by reason of nonpayment when due of any premium, installment or interest, or any portion thereof, required by the terms of the policy to be paid, within 6 months from the default in payment of such premium, installment or interest, unless a written or printed notice stating the amount of such premium, installment, interest or portion thereof due on such policy, the place where it shall be paid and the person to whom the same is payable, shall have been duly addressed and mailed with the required postage affixed, to the person insured or to the premium payor if other than the insured at the last known post office address of the insured or premium payor, at least 15 days and not more than 45 days prior to the day when same is due and payable before the beginning of the grace period.
    Such notice shall also state that unless such premium or other sum due shall be paid to the company or its agent the policy and all payments thereon will become forfeited and void, except as to any right to a surrender value or paid up policy as provided for by the policy. The affidavit of any officer, clerk or agent of the company or of anyone authorized to mail such notice that the notice required by this Section bearing the required postage has been duly addressed and mailed shall be presumptive evidence that such notice has been duly given.
    If the notice is given in a manner other than mailing, then physical proof of the receipt of such notice by the proper recipient shall be maintained by the insurer.
    (2) Paragraph (1) of this Section shall not apply to cancellable policies which are renewable at the option of the company nor shall it apply to group policies, industrial policies, or any policies upon which premiums are payable monthly or at shorter intervals.
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.3

    (215 ILCS 5/357.3) (from Ch. 73, par. 969.3)
    Sec. 357.3. "TIME LIMIT ON CERTAIN DEFENSES:
    (1) After 2 years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such 2 year period."
    (The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial 2 year period, nor to limit the application of section 357.15 through section 357.19 in the event of misstatement with respect to age or occupation or other insurance.)
    A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue, may contain in lieu of the foregoing the following provisions (from which the clause in parentheses may be omitted at the company's option) under the caption "INCONTESTABLE":
    "After this policy has been in force for a period of 2 years during the lifetime of the insured (excluding any period during which the insured is a person with a disability), it shall become incontestable as to the statements contained in the application."
    (2) "No claim for loss incurred or disability (as defined in the policy) commencing after 2 years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy."
(Source: P.A. 99-143, eff. 7-27-15.)

215 ILCS 5/357.4

    (215 ILCS 5/357.4) (from Ch. 73, par. 969.4)
    Sec. 357.4. "GRACE PERIOD: A grace period of ....(insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force."
    (A policy which contains a cancellation provision may add, at the end of the above provision: "Subject to the right of the company to cancel in accordance with the cancellation provision hereof."
    A policy in which the company reserves the right to refuse any renewal shall have, at the beginning of the above provision:
    "Unless not less than 30 days prior to the premium due date the company has delivered to the insured or has mailed to his last address as shown by the records of the company written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.")
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.5

    (215 ILCS 5/357.5) (from Ch. 73, par. 969.5)
    Sec. 357.5. "REINSTATEMENT: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the company or by any agent duly authorized by the company to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the company or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the company or, lacking such approval, upon the 45th day following the date of such conditional receipt unless the company has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date. In all other respects the insured and company shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement."
    The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue.
    For the purpose of this Section, the phrase "loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date" shall mean that the reinstated policy shall not cover a loss resulting from accidental injury sustained after the date of lapse of the policy and prior to the date of reinstatement or a loss resulting from sickness which is first manifested after the date of lapse of the policy but not after a date more than 10 days after the date of reinstatement. An accidental injury and a sickness as described in this Section shall be subject to the requirements of Section 357.3 with the exception that references to date of issue and application shall mean date of reinstatement and reinstatement application. All other accidental injuries and sicknesses will be subject to the requirements of 357.3. Provisions endorsed or attached to the policy in connection with the reinstatement shall relate to a disease or physical condition of an insured under the policy.
(Source: P.A. 84-1308.)

215 ILCS 5/357.6

    (215 ILCS 5/357.6) (from Ch. 73, par. 969.6)
    Sec. 357.6. "NOTICE OF CLAIM: Written notice of claim must be given to the company within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the company at ....(insert the location of such office as the company may designate for the purpose), or to any authorized agent of the company, with information sufficient to identify the insured, shall be deemed notice to the company."
    In a policy providing a loss-of-time benefit which may be payable for at least 2 years, a company may at its option insert the following between the first and second sentences of the above provision:
    "Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least 2 years, he shall, at least once in every 6 months after having given notice of claim, give to the company notice of continuance of said disability, except in the event of legal incapacity. The period of 6 months following any filing of proof by the insured or any payment by the company on account of such claim or any denial of liability in whole or in part by the company shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of 6 months preceding the date on which such notice is actually given."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.7

    (215 ILCS 5/357.7) (from Ch. 73, par. 969.7)
    Sec. 357.7. "CLAIM FORMS: The company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.8

    (215 ILCS 5/357.8) (from Ch. 73, par. 969.8)
    Sec. 357.8. "PROOFS OF LOSS: Written proof of loss must be furnished to the company at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the company is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.9

    (215 ILCS 5/357.9) (from Ch. 73, par. 969.9)
    Sec. 357.9. "TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid .... (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability, will be paid immediately upon receipt of due written proof."
    All claims and indemnities payable under the terms of a policy of accident and health insurance shall be paid within 30 days following receipt by the insurer of due proof of loss. Failure to pay within such period shall entitle the insured to interest at the rate of 9 per cent per annum from the 30th day after receipt of such proof of loss to the date of late payment, provided that interest amounting to less than one dollar need not be paid. An insured or an insured's assignee shall be notified by the insurer, health maintenance organization, managed care plan, health care plan, preferred provider organization, or third party administrator of any known failure to provide sufficient documentation for a due proof of loss within 30 days after receipt of the claim. Any required interest payments shall be made within 30 days after the payment.
    The requirements of this Section shall apply to any policy of accident and health insurance delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this amendatory Act of 1985. The requirements of this Section also shall specifically apply to any group policy of dental insurance only, delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this amendatory Act of 1987.
(Source: P.A. 91-605, eff. 12-14-99.)

215 ILCS 5/357.9a

    (215 ILCS 5/357.9a) (from Ch. 73, par. 969.9a)
    Sec. 357.9a. Delay in payment of claims. Periodic payments of accrued indemnities for loss-of-time coverage under accident and health policies shall commence not later than 30 days after the receipt by the company of the required written proofs of loss. An insurer which violates this Section if liable under said policy, shall pay to the insured, in addition to any other penalty provided for in this Code, interest at the rate of 9% per annum from the 30th day after receipt of such proofs of loss to the date of late payment of the accrued indemnities, provided that interest amounting to less than one dollar need not be paid.
(Source: P.A. 92-139, eff. 7-24-01.)

215 ILCS 5/357.10

    (215 ILCS 5/357.10) (from Ch. 73, par. 969.10)
    Sec. 357.10. "PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the company, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured."
    The following provisions, or either of them, may be included with the foregoing provision at the option of the company:
    "If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the company may pay such indemnity, up to an amount not exceeding $....(insert an amount which shall not exceed $1000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the company to be equitably entitled thereto. Any payment made by the company in good faith pursuant to this provision shall fully discharge the company to the extent of such payment.
    "Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the company's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person. Nothing in this provision shall prohibit an insurer from providing incentives for insureds to utilize the services of a particular hospital or person."
(Source: P.A. 84-618.)

215 ILCS 5/357.11

    (215 ILCS 5/357.11) (from Ch. 73, par. 969.11)
    Sec. 357.11. "PHYSICAL EXAMINATIONS AND AUTOPSY: The company at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.12

    (215 ILCS 5/357.12) (from Ch. 73, par. 969.12)
    Sec. 357.12. "LEGAL ACTIONS: No civil action shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished."
(Source: P.A. 79-1362.)

215 ILCS 5/357.13

    (215 ILCS 5/357.13) (from Ch. 73, par. 969.13)
    Sec. 357.13. "CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy."
    (The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the company's option.)
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.14

    (215 ILCS 5/357.14) (from Ch. 73, par. 969.14)
    Sec. 357.14. Except as provided in section 357.26, no such policy delivered or issued for delivery to any person in this State shall contain provisions respecting the matters set forth in sections 357.15 through 357.24 unless such provisions are in the words in which the same appear in this article; provided, however, that the company may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the Director which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in the following sections or, at the option of the company, by such appropriate individual or group captions or subcaptions as the Director may approve.
(Source: P.A. 95-230, eff. 1-1-08.)

215 ILCS 5/357.15

    (215 ILCS 5/357.15) (from Ch. 73, par. 969.15)
    Sec. 357.15. "CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having changed his occupation to one classified by the company as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the company will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the company for such more hazardous occupation. If the insured changes his occupation to one classified by the company as less hazardous than that stated in this policy, the company, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the company prior to the occurrence of the loss for which the company is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the company in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.16

    (215 ILCS 5/357.16) (from Ch. 73, par. 969.16)
    Sec. 357.16. "MISSTATEMENT OF AGE: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.17

    (215 ILCS 5/357.17) (from Ch. 73, par. 969.17)
    Sec. 357.17. "OTHER INSURANCE IN THIS COMPANY: If an accident or health or accident and health policy or policies previously issued by the company to the insured be in force concurrently herewith, making the aggregate indemnity for ....(insert type of coverage or coverages) in excess of $....(insert maximum limit of indemnity or indemnities) the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate." or, in lieu thereof:
    "Insurance effective at any one time on the insured under a like policy or policies in this company is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the company will return all premiums paid for all other such policies."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.18

    (215 ILCS 5/357.18) (from Ch. 73, par. 969.18)
    Sec. 357.18. "INSURANCE WITH OTHER COMPANIES: If there be other valid coverage, not with this company, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this company has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this company had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the "like amount" of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage."
    (If the foregoing policy provision is included in a policy which also contains the next following policy provision there shall be added to the caption of the foregoing provision the phrase "--EXPENSE INCURRED BENEFITS". The company may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the Director, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the Director. In the absence of such definition such term does not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute) whether provided by a governmental agency or otherwise is "other valid coverage" of which the company has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage".)
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.19

    (215 ILCS 5/357.19) (from Ch. 73, par. 969.19)
    Sec. 357.19. "INSURANCE WITH OTHER COMPANIES: If there be other valid coverage, not with this company, providing benefits for the same loss on other than an expense incurred basis and of which this company has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the company had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined."
    (If the foregoing policy provision is included in a policy which also contains the next preceding policy provision there shall be added to the caption of the foregoing provision the phrase "--OTHER BENEFITS". The company may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the Director, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the Director. In the absence of such definition such term does not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute) whether provided by a governmental agency or otherwise is "other valid coverage" of which the company has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage".)
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.20

    (215 ILCS 5/357.20) (from Ch. 73, par. 969.20)
    Sec. 357.20. "RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of 2 years immediately preceding a disability for which claim is made, whichever is the greater, the company will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such 2 years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of $200.00 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time."
    (The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue. The company may, at its option, include in this provision a definition of "valid loss of time coverage", approved as to form by the Director, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the Director or any combination of such coverages. In the absence of such definition such term does not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute), or benefits provided by union welfare plans or by employer or employee benefit organizations.)
(Source: P.A. 91-357, eff. 7-29-99.)

215 ILCS 5/357.21

    (215 ILCS 5/357.21) (from Ch. 73, par. 969.21)
    Sec. 357.21. "UNPAID PREMIUM: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.22

    (215 ILCS 5/357.22) (from Ch. 73, par. 969.22)
    Sec. 357.22. "CANCELLATION: The company may cancel this policy at any time by written notice delivered to the insured, or mailed to his last address as shown by the records of the company, stating when, not less than 30 days thereafter, such cancellation shall be effective; and after the policy has been continued beyond its original term the insured may cancel this policy at any time by written notice delivered or mailed to the company, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the company will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the company cancels, the earned premium shall be computed pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation." (Notice to the policy holder of the cancellable nature of his policy shall be set forth on the face of the policy.)
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.23

    (215 ILCS 5/357.23) (from Ch. 73, par. 969.23)
    Sec. 357.23. "CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.24

    (215 ILCS 5/357.24) (from Ch. 73, par. 969.24)
    Sec. 357.24. "ILLEGAL OCCUPATION: The company shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation."
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.25

    (215 ILCS 5/357.25)
    Sec. 357.25. (Repealed).
(Source: Laws 1967, p. 1735. Repealed by P.A. 95-230, eff. 1-1-08.)

215 ILCS 5/357.26

    (215 ILCS 5/357.26) (from Ch. 73, par. 969.26)
    Sec. 357.26. If any provision of the preceding sections is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy the company, with the approval of the Director, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.27

    (215 ILCS 5/357.27) (from Ch. 73, par. 969.27)
    Sec. 357.27. The provisions which are the subject of Sections 357.2 through 357.25, or any corresponding provisions which are used in lieu thereof in accordance with such sections, shall be printed in the consecutive order of the provisions in such sections or, at the option of the company, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.28

    (215 ILCS 5/357.28) (from Ch. 73, par. 969.28)
    Sec. 357.28. The word "insured", as used in this article, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.29

    (215 ILCS 5/357.29) (from Ch. 73, par. 969.29)
    Sec. 357.29. Any policy of a foreign or alien company, when delivered or issued for delivery to any person in this State, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of this article and which is prescribed or required by the law of the state under which the company is organized.
    Any policy of a domestic company may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.30

    (215 ILCS 5/357.30) (from Ch. 73, par. 969.30)
    Sec. 357.30. The Director may make such reasonable rules and regulations concerning the procedure for the filing or submission of policies subject to this article as are necessary, proper or advisable to the administration of this article. This provision shall not abridge any other authority granted the Director by law. The effective date of the new provisions added by this amendatory Act shall be January 1, 1968.
(Source: Laws 1967, p. 1735.)

215 ILCS 5/357.31

    (215 ILCS 5/357.31) (from Ch. 73, par. 969.31)
    Sec. 357.31. In the event of the death of a policyholder of an individual accident and health insurance policy, the insurance company, upon receipt of notice of the policyholder's death and a request for a pro-rata refund, supported by a valid death certificate supplied by a party entitled to claim such refund, shall refund the unearned premium pro-rated to the month of the policyholder's death. In no event shall such refund of premium be computed by the use of a short-rate table. Refund of the premium and termination of the coverage shall be without prejudice to any claim originating prior to the date of the policyholder's death. Coverage of persons insured under the same policy other than the policyholder shall not be affected by the premium refund provided for in this Section nor shall the obligation of such other insureds to pay required premiums be diminished pursuant to this Section.
(Source: P.A. 86-665.)

215 ILCS 5/358a

    (215 ILCS 5/358a) (from Ch. 73, par. 970a)
    Sec. 358a. Conforming to statute.
    (1) Other Policy Provisions
    No policy provision which is not subject to section 357a of this act shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to this act.
    (2) Policy Conflicting with this Article
    A policy delivered or issued for delivery to any person in this state in violation of this article shall be held valid but shall be construed as provided in this article. When any provision in a policy subject to this article is in conflict with any provision of this article, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of this article.
    (3) Operating under Old Provisions
    Subsection (3) of Section 356a of this Act is hereby incorporated into and made a part of this section by express reference.
(Source: Laws 1951, p. 611.)

215 ILCS 5/359a

    (215 ILCS 5/359a) (from Ch. 73, par. 971a)
    Sec. 359a. Application.
    (1) No policy of insurance except an Industrial Accident and Health Policy provided for by this article shall be issued, except upon the signed application of the person or persons sought to be insured. Any information or statement of the applicant shall plainly appear upon such application in the form of interrogatories by the insurer and answers by the applicant. The insured shall not be bound by any statement made in an application for any policy, including an Industrial Accident and Health Policy, unless a copy of such application is attached to or endorsed on the policy when issued as a part thereof. If any such policy delivered or issued for delivery to any person in this state shall be reinstated or renewed, and the insured or the beneficiary or assignee of such policy shall make written request to the insurer for a copy of the application, if any, for such reinstatement or renewal, the insurer shall within fifteen days after the receipt of such request at its home office or any branch office of the insurer, deliver or mail to the person making such request, a copy of such application. If such copy shall not be so delivered or mailed, the insurer shall be precluded from introducing such application as evidence in any action or proceeding based upon or involving such policy or its reinstatement or renewal.
    (2) No alteration of any written application for any such policy shall be made by any person other than the applicant without his written consent, except that insertions may be made by the insurer, for administrative purposes only, in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant.
    (3) The falsity of any statement in the application for any policy covered by this act may not bar the right to recovery thereunder unless such false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer.
(Source: Laws 1951, p. 611.)

215 ILCS 5/359b

    (215 ILCS 5/359b)
    Sec. 359b. (Repealed).
(Source: P.A. 96-857, eff. 1-5-10. Repealed by P.A. 98-969, eff. 1-1-15.)

215 ILCS 5/359c

    (215 ILCS 5/359c)
    Sec. 359c. (Repealed).
(Source: P.A. 97-524, eff. 1-1-12. Repealed by P.A. 98-969, eff. 1-1-15.)

215 ILCS 5/360a

    (215 ILCS 5/360a) (from Ch. 73, par. 972a)
    Sec. 360a. Notice, waiver.
    The acknowledgement by any insurer of the receipt of notice given under any policy covered by this article, or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.
(Source: Laws 1951, p. 611.)

215 ILCS 5/361a

    (215 ILCS 5/361a) (from Ch. 73, par. 973a)
    Sec. 361a. Age limit.
    If any such policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.
(Source: Laws 1951, p. 611.)

215 ILCS 5/362a

    (215 ILCS 5/362a) (from Ch. 73, par. 974a)
    Sec. 362a. Non-application to certain policies. The provisions of sections 356a to 359a, both inclusive, shall not apply to or affect (1) any policy of workers' compensation insurance or any policy of liability insurance with or without supplementary expense coverage therein; or (2) any policy or contract of reinsurance; or (3) any group policy of insurance (unless otherwise specifically provided); or (4) life insurance, endowment or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to accident and sickness insurance as (a) provide additional benefits in case of death or dismemberment or loss of sight by accident, or as (b) operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant shall become a person with a total and permanent disability, as defined by the contract or supplemental contract.
(Source: P.A. 99-143, eff. 7-27-15.)

215 ILCS 5/363

    (215 ILCS 5/363) (from Ch. 73, par. 975)
    Sec. 363. Medicare supplement policies; minimum standards.
    (1) Except as otherwise specifically provided therein, this Section and Section 363a of this Code shall apply to:
        (a) all Medicare supplement policies and subscriber
    
contracts delivered or issued for delivery in this State on and after January 1, 1989; and
        (b) all certificates issued under group Medicare
    
supplement policies or subscriber contracts, which certificates are issued or issued for delivery in this State on and after January 1, 1989.
    This Section shall not apply to "Accident Only" or "Specified Disease" types of policies. The provisions of this Section are not intended to prohibit or apply to policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons, which policies or plans are not marketed or purported or held to be Medicare supplement policies or benefit plans.
    (2) For the purposes of this Section and Section 363a, the following terms have the following meanings:
        (a) "Applicant" means:
            (i) in the case of individual Medicare supplement
        
policy, the person who seeks to contract for insurance benefits, and
            (ii) in the case of a group Medicare policy or
        
subscriber contract, the proposed certificate holder.
        (b) "Certificate" means any certificate delivered or
    
issued for delivery in this State under a group Medicare supplement policy.
        (c) "Medicare supplement policy" means an individual
    
policy of accident and health insurance, as defined in paragraph (a) of subsection (2) of Section 355a of this Code, or a group policy or certificate delivered or issued for delivery in this State by an insurer, fraternal benefit society, voluntary health service plan, or health maintenance organization, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.) or a policy issued under a demonstration project specified in 42 U.S.C. Section 1395ss(g)(1), or any similar organization, that is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of persons eligible for Medicare.
        (d) "Issuer" includes insurance companies, fraternal
    
benefit societies, voluntary health service plans, health maintenance organizations, or any other entity providing Medicare supplement insurance, unless the context clearly indicates otherwise.
        (e) "Medicare" means the Health Insurance for the
    
Aged Act, Title XVIII of the Social Security Amendments of 1965.
    (3) No Medicare supplement insurance policy, contract, or certificate, that provides benefits that duplicate benefits provided by Medicare, shall be issued or issued for delivery in this State after December 31, 1988. No such policy, contract, or certificate shall provide lesser benefits than those required under this Section or the existing Medicare Supplement Minimum Standards Regulation, except where duplication of Medicare benefits would result.
    (4) Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded directly to him or her in a timely manner if, after examination of the policy or certificate, the insured person is not satisfied for any reason.
    (5) A Medicare supplement policy or certificate may not deny a claim for losses incurred more than 6 months from the effective date of coverage for a preexisting condition. The policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
    (6) An issuer of a Medicare supplement policy shall:
        (a) not deny coverage to an applicant under 65 years
    
of age who meets any of the following criteria:
            (i) becomes eligible for Medicare by reason of
        
disability if the person makes application for a Medicare supplement policy within 6 months of the first day on which the person enrolls for benefits under Medicare Part B; for a person who is retroactively enrolled in Medicare Part B due to a retroactive eligibility decision made by the Social Security Administration, the application must be submitted within a 6-month period beginning with the month in which the person received notice of retroactive eligibility to enroll;
            (ii) has Medicare and an employer group health
        
plan (either primary or secondary to Medicare) that terminates or ceases to provide all such supplemental health benefits;
            (iii) is insured by a Medicare Advantage plan
        
that includes a Health Maintenance Organization, a Preferred Provider Organization, and a Private Fee-For-Service or Medicare Select plan and the applicant moves out of the plan's service area; the insurer goes out of business, withdraws from the market, or has its Medicare contract terminated; or the plan violates its contract provisions or is misrepresented in its marketing; or
            (iv) is insured by a Medicare supplement policy
        
and the insurer goes out of business, withdraws from the market, or the insurance company or agents misrepresent the plan and the applicant is without coverage;
        (b) make available to persons eligible for Medicare
    
by reason of disability each type of Medicare supplement policy the issuer makes available to persons eligible for Medicare by reason of age;
        (c) not charge individuals who become eligible for
    
Medicare by reason of disability and who are under the age of 65 premium rates for any medical supplemental insurance benefit plan offered by the issuer that exceed the issuer's highest rate on the current rate schedule filed with the Division of Insurance for that plan to individuals who are age 65 or older; and
        (d) provide the rights granted by items (a) through
    
(d), for 6 months after the effective date of this amendatory Act of the 95th General Assembly, to any person who had enrolled for benefits under Medicare Part B prior to this amendatory Act of the 95th General Assembly who otherwise would have been eligible for coverage under item (a).
    (7) The Director shall issue reasonable rules and regulations for the following purposes:
        (a) To establish specific standards for policy
    
provisions of Medicare policies and certificates. The standards shall be in accordance with the requirements of this Code. No requirement of this Code relating to minimum required policy benefits, other than the minimum standards contained in this Section and Section 363a, shall apply to Medicare supplement policies and certificates. The standards may cover, but are not limited to the following:
            (A) Terms of renewability.
            (B) Initial and subsequent terms of eligibility.
            (C) Non-duplication of coverage.
            (D) Probationary and elimination periods.
            (E) Benefit limitations, exceptions and
        
reductions.
            (F) Requirements for replacement.
            (G) Recurrent conditions.
            (H) Definition of terms.
            (I) Requirements for issuing rebates or credits
        
to policyholders if the policy's loss ratio does not comply with subsection (7) of Section 363a.
            (J) Uniform methodology for the calculating and
        
reporting of loss ratio information.
            (K) Assuring public access to loss ratio
        
information of an issuer of Medicare supplement insurance.
            (L) Establishing a process for approving or
        
disapproving proposed premium increases.
            (M) Establishing a policy for holding public
        
hearings prior to approval of premium increases.
            (N) Establishing standards for Medicare Select
        
policies.
            (O) Prohibited policy provisions not otherwise
        
specifically authorized by statute that, in the opinion of the Director, are unjust, unfair, or unfairly discriminatory to any person insured or proposed for coverage under a medicare supplement policy or certificate.
        (b) To establish minimum standards for benefits and
    
claims payments, marketing practices, compensation arrangements, and reporting practices for Medicare supplement policies.
        (c) To implement transitional requirements of
    
Medicare supplement insurance benefits and premiums of Medicare supplement policies and certificates to conform to Medicare program revisions.
    (8) If an individual is at least 65 years of age but no more than 75 years of age and has an existing Medicare supplement policy, the individual is entitled to an annual open enrollment period lasting 45 days, commencing with the individual's birthday, and the individual may purchase any Medicare supplement policy with the same issuer that offers benefits equal to or lesser than those provided by the previous coverage. During this open enrollment period, an issuer of a Medicare supplement policy shall not deny or condition the issuance or effectiveness of Medicare supplemental coverage, nor discriminate in the pricing of coverage, because of health status, claims experience, receipt of health care, or a medical condition of the individual. An issuer shall provide notice of this annual open enrollment period for eligible Medicare supplement policyholders at the time that the application is made for a Medicare supplement policy or certificate. The notice shall be in a form that may be prescribed by the Department.
    (9) Without limiting an individual's eligibility under Department rules implementing 42 U.S.C. 1395ss(s)(2)(A), for at least 63 days after the later of the applicant's loss of benefits or the notice of termination of benefits, including a notice of claim denial due to termination of benefits, under the State's medical assistance program under Article V of the Illinois Public Aid Code, an issuer shall not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate that is offered and is available for issuance to new enrollees by the issuer; shall not discriminate in the pricing of such a Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition; and shall not include a policy provision that imposes an exclusion of benefits based on a preexisting condition under such a Medicare supplement policy if the individual:
        (a) is enrolled for Medicare Part B;
        (b) was enrolled in the State's medical assistance
    
program during the COVID-19 Public Health Emergency described in Section 5-1.5 of the Illinois Public Aid Code;
        (c) was terminated or disenrolled from the State's
    
medical assistance program after the COVID-19 Public Health Emergency and the later of the date of termination of benefits or the date of the notice of termination, including a notice of a claim denial due to termination, occurred on, after, or no more than 63 days before the end of either, as applicable:
            (A) the individual's Medicare supplement open
        
enrollment period described in Department rules implementing 42 U.S.C. 1395ss(s)(2)(A); or
            (B) the 6-month period described in Section
        
363(6)(a)(i) of this Code; and
        (d) submits evidence of the date of termination of
    
benefits or notice of termination under the State's medical assistance program with the application for a Medicare supplement policy or certificate.
    (10) Each Medicare supplement policy and certificate available from an insurer on and after the effective date of this amendatory Act of the 103rd General Assembly shall be made available to all applicants who qualify under subparagraph (i) of paragraph (a) of subsection (6) or Department rules implementing 42 U.S.C. 1395ss(s)(2)(A) without regard to age or applicability of a Medicare Part B late enrollment penalty.
(Source: P.A. 102-142, eff. 1-1-22; 103-102, eff. 6-16-23.)

215 ILCS 5/363a

    (215 ILCS 5/363a) (from Ch. 73, par. 975a)
    Sec. 363a. Medicare supplement policies; disclosure, advertising, loss ratio standards.
    (1) Scope. This Section pertains to disclosure requirements of companies and agents and mandatory and prohibited practices of agents when selling a policy to supplement the Medicare program or any other health insurance policy sold to individuals eligible for Medicare. No policy shall be referred to or labeled as a Medicare supplement policy if it does not comply with the minimum standards required by regulation pursuant to Section 363 of this Code. Except as otherwise specifically provided in paragraph (d) of subsection (6), this Section shall not apply to accident only or specified disease type of policies or hospital confinement indemnity or other type policies clearly unrelated to Medicare.
    (2) Advertising. An advertisement that describes or offers to provide information concerning the federal Medicare program shall comply with all of the following:
        (a) It may not include any reference to that program
    
on the envelope, the reply envelope, or the address side of the reply postal card, if any, nor use any language to imply that failure to respond to the advertisement might result in loss of Medicare benefits.
        (b) It must include a prominent statement to the
    
effect that in providing supplemental coverage the insurer and agent involved in the solicitation are not in any manner connected with that program.
        (c) It must prominently disclose that it is an
    
advertisement for insurance or is intended to obtain insurance prospects.
        (d) It must prominently identify and set forth the
    
actual address of the insurer or insurers that issue the coverage.
        (e) It must prominently state that any material or
    
information offered will be delivered in person by a representative of the insurer, if that is the case.
    The Director may issue reasonable rules and regulations for the purpose of establishing criteria and guidelines for the advertising of Medicare supplement insurance.
    (3) Mandatory agent practices. For the purpose of this Act, "home solicitation sale by an agent" means a sale or attempted sale of an insurance policy at the purchaser's residence, agent's transient quarters, or away from the agent's home office when the initial contact is personally solicited by the agent or insurer. Any agent involved in any home solicitation sale of a Medicare supplement policy or other policy of accident and health insurance, subject to subsection (1) of this Section, sold to individuals eligible for Medicare shall promptly do the following:
        (a) Identify himself as an insurance agent.
        (b) Identify the insurer or insurers for which he is
    
a licensed agent.
        (c) Provide the purchaser with a clearly printed or
    
typed identification of his name, address, telephone number, and the name of the insurer in which the insurance is to be written.
        (d) Determine what, if any, policy is appropriate,
    
suitable, and nonduplicative for the purchaser considering existing coverage and be able to provide proof to the company that such a determination has been made.
        (e) Fully and completely disclose the purchaser's
    
medical history on the application if required for issue.
        (f) Complete a Policy Check List in duplicate as
    
follows:
POLICY CHECK LIST
    Applicant's Name:
    Policy Number:
    Name of Existing Insurer:
    Expiration Date of Existing Insurance:
MedicareExistingSupplementInsured's
PaysCoveragePaysResponsibility
    Service
    Hospital
    Skilled
    Nursing
    Home Care
    Prescription
    Drugs
        This policy does/does not (circle one) comply with
    
the minimum standards for Medicare supplements set forth in Section 363 of the Illinois Insurance Code.
                                        Signature of Applicant
                                            Signature of Agent
        This Policy Check List is to be completed in the
    
presence of the purchaser at the point of sale, and copies of it, completed and duly signed, are to be provided to the purchaser and to the company.
        (g) Except in the case of refunds of premium made
    
pursuant to subsection (5) of Section 363 of this Code, send by mail to an insured or an applicant for insurance, when the insurer follows a practice of having agents return premium refund drafts issued by the insurer, a premium refund draft within 2 weeks of its receipt by the agent from the insurer making such refund.
        (h) Deliver to the purchaser, along with every policy
    
issued pursuant to Section 363 of this Code, an Outline of Coverage as described in paragraph (b) of subsection (6) of this Section.
    (4) Prohibited agent practices.
        (a) No insurance agent engaged in a home solicitation
    
sale of a Medicare supplement policy or other policy of accident and health insurance, subject to subsection (1) of this Section, sold to individuals eligible for Medicare shall use any false, deceptive, or misleading representation to induce a sale, or use any plan, scheme, or ruse, that misrepresents the true status or mission of the person making the call, or represent directly or by implication that the agent:
            (i) Is offering insurance that is approved or
        
recommended by the State or federal government to supplement Medicare.
            (ii) Is in any way representing, working for, or
        
compensated by a local, State, or federal government agency.
            (iii) Is engaged in an advisory business in which
        
his compensation is unrelated to the sale of insurance by the use of terms such as Medicare consultant, Medicare advisor, Medicare Bureau, disability insurance consultant, or similar expression in a letter, envelope, reply card, or other.
            (iv) Will provide a continuing service to the
        
purchaser of the policy unless he does provide services to the purchaser beyond the sale and renewal of policies.
        (b) No agent engaged in a home solicitation sale of a
    
Medicare supplement policy or other policy of accident and health insurance sold to individuals eligible for Medicare shall misrepresent, directly or by implication, any of the following:
            (i) The identity of the insurance company or
        
companies he represents.
            (ii) That the assistance programs of the State or
        
county or the federal Medicare programs for medical insurance are to be discontinued or are increasing in cost to the prospective buyer or are in any way endangered.
            (iii) That an insurance company in which the
        
prospective purchaser is insured is financially unstable, cancelling its outstanding policies, merging, or withdrawing from the State.
            (iv) The coverage of the policy being sold.
            (v) The effective date of coverage under the
        
policy.
            (vi) That any pre-existing health condition of
        
the purchaser is irrelevant.
            (vii) The right of the purchaser to cancel the
        
policy within 30 days after receiving it.
    (5) Mandatory company practices. Any company involved in the sale of Medicare supplement policies or any policies of accident and health insurance (subject to subsection (1) of this Section) sold to individuals eligible for Medicare shall do the following:
        (a) Be able to readily determine the number of
    
accident and health policies in force with the company on each insured eligible for Medicare.
        (b) Make certain that policies of Medicare supplement
    
insurance are not issued, and any premium collected for those policies is refunded, when they are deemed duplicative, inappropriate, or not suitable considering existing coverage with the company.
        (c) Maintain copies of the Policy Check List as
    
completed by the agent at the point of sale of a Medicare supplement policy or any policy of accident and health insurance (subject to subsection (1) of this Section) sold to individuals eligible for Medicare on file at the company's regional or other administrative office.
    (6) Disclosures. In order to provide for full and fair disclosure in the sale of Medicare supplement policies, there must be compliance with the following:
        (a) No Medicare supplement policy or certificate
    
shall be delivered in this State unless an outline of coverage is delivered to the applicant at the time application is made and, except for direct response policies, an acknowledgement from the applicant of receipt of the outline is obtained.
        (b) Outline of coverage requirements for Medicare
    
supplement policies.
            (i) Insurers issuing Medicare supplement policies
        
or certificates for delivery in this State shall provide an outline of coverage to all applicants at the time application is made and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant.
            (ii) If an outline of coverage is provided at the
        
time of application and the Medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and shall contain immediately above the company name, in no less than 12 point type, the following statement:
            "NOTICE: Read this outline of coverage carefully.
        
It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.".
            (iii) The outline of coverage provided to
        
applicants shall be in the form prescribed by rule by the Department.
        (c) Insurers issuing policies that provide hospital
    
or medical expense coverage on an expense incurred or indemnity basis, other than incidentally, to a person or persons eligible for Medicare shall provide to the policyholder a buyer's guide approved by the Director. Delivery of the buyer's guide shall be made whether or not the policy qualifies as a "Medicare Supplement Coverage" in accordance with Section 363 of this Code. Except in the case of direct response insurers, delivery of the buyer's guide shall be made at the time of application, and acknowledgement of receipt of certification of delivery of the buyer's guide shall be provided to the insurer. Direct response insurers shall deliver the buyer's guide upon request, but not later than at the time the policy is delivered.
        (d) Outlines of coverage delivered in connection with
    
policies defined in subsection (4) of Section 355a of this Code as Hospital confinement Indemnity (Section 4c), Accident Only Coverage (Section 4f), Specified Disease (Section 4g) or Limited Benefit Health Insurance Coverage to persons eligible for Medicare shall contain, in addition to other requirements for those outlines, the following language that shall be printed on or attached to the first page of the outline of coverage:
        "This policy, certificate or subscriber contract IS
    
NOT A MEDICARE SUPPLEMENT policy or certificate. It does not fully supplement your federal Medicare health insurance. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.".
        (e) In the case wherein a policy, as defined in
    
paragraph (a) of subsection (2) of Section 355a of this Code, being sold to a person eligible for Medicare provides one or more but not all of the minimum standards for Medicare supplements set forth in Section 363 of this Code, disclosure must be provided that the policy is not a Medicare supplement and does not meet the minimum benefit standards set for those policies in this State.
    (7) Loss ratio standards.
        (a) Every issuer of Medicare supplement policies or
    
certificates in this State, as defined in Section 363 of this Code, shall file annually its rates, rating schedule, and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall demonstrate that the actual and anticipated losses in relation to premiums comply with the requirements of this Code.
        (b) Medicare supplement policies shall, for the
    
entire period for which rates are computed to provide coverage, on the basis of incurred claims experience and earned premiums for the period and in accordance with accepted actuarial principles and practices, return to policyholders in the form of aggregate benefits the following:
            (i) In the case of group policies, at least 75%
        
of the aggregate amount of premiums earned.
            (ii) In the case of individual policies, at least
        
60% of the aggregate amount of premiums earned; and beginning November 5, 1991, at least 65% of the aggregate amount of premiums earned.
            (iii) In the case of sponsored group policies in
        
which coverage is marketed on an individual basis by direct response to eligible individuals in that group only, at least 65% of the aggregate amount of premiums earned.
        (c) For the purposes of this Section, the insurer
    
shall be deemed to comply with the loss ratio standards if: (i) for the most recent year, the ratio of the incurred losses to earned premiums for policies or certificates that have been in force for 3 years or more is greater than or equal to the applicable percentages contained in this Section; and (ii) the anticipated losses in relation to premiums over the entire period for which the policy is rated comply with the requirements of this Section. An anticipated third-year loss ratio that is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years.
    (8) Applicability. This Section shall apply to those companies writing the kind or kinds of business enumerated in Classes 1(b) and 2(a) of Section 4 of this Code and to those entities organized and operating under the Voluntary Health Services Plans Act and the Health Maintenance Organization Act.
    (9) Penalties.
        (a) Any company or agent who is found to have
    
violated any of the provisions of this Section may be required by order of the Director of Insurance to forfeit by civil penalty not less than $500 nor more than $5,000 for each offense. Written notice will be issued and an opportunity for a hearing will be granted pursuant to subsection (2) of Section 403A of this Code.
        (b) In addition to any other applicable penalties for
    
violations of this Code, the Director may require insurers violating any provision of this Code or regulations promulgated pursuant to this Code to cease marketing in this State any Medicare supplement policy or certificate that is related directly or indirectly to a violation and may require the insurer to take actions as are necessary to comply with the provisions of Sections 363 and 363a of this Code.
        (c) After June 30, 1991, no person may advertise,
    
solicit for the sale or purchase of, offer for sale, or deliver a Medicare supplement policy that has not been approved by the Director. A person who knowingly violates, directly or through an agent, the provisions of this paragraph commits a Class 3 felony. Any person who violates the provisions of this paragraph may be subjected to a civil penalty not to exceed $10,000. The civil penalty authorized in this paragraph shall be enforced in the manner provided in Section 403A of this Code.
    (10) Replacement. Application forms shall include a question designed to elicit information as to whether a Medicare supplement policy or certificate is intended to replace any similar accident and sickness policy or certificate presently in force. A supplementary application or other form to be signed by the applicant containing the question may be used. Upon determining that a sale of Medicare supplement coverage will involve replacement, an insurer, other than a direct response insurer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of the notice shall be provided to the applicant, and an additional copy signed by the applicant shall be retained by the insurer. A direct response insurer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement coverage.
(Source: P.A. 93-32, eff. 7-1-03.)

215 ILCS 5/364

    (215 ILCS 5/364) (from Ch. 73, par. 976)
    Sec. 364. Discrimination prohibited. Discrimination between individuals of the same class of risk in the issuance of its policies or in the amount of premiums or rates charged for any insurance covered by this article, or in the benefits payable thereon, or in any of the terms or conditions of such policy, or in any other manner whatsoever is prohibited. Nothing in this provision shall prohibit an insurer from providing incentives for insureds to utilize the services of a particular hospital or person. It is hereby expressly provided that whenever the terms "physician" or "doctor" appear or are used in any way in any policy of accident or health insurance issued in this state, said terms shall include within their meaning persons licensed to practice dentistry under the Illinois Dental Practice Act with regard to benefits payable for services performed by a person so licensed, which such services are within the coverage provided by the particular policy or contract of insurance and are within the professional services authorized to be performed by such person under and in accordance with the said Act.
    No company, in any policy of accident or health insurance issued in this State, shall make or permit any distinction or discrimination against individuals solely because of the individuals' disabilities in the amount of payment of premiums or rates charged for policies of insurance, in the amount of any dividends or other benefits payable thereon, or in any other terms and conditions of the contract it makes, except where the distinction or discrimination is based on sound actuarial principles or is related to actual or reasonably anticipated experience.
    No company shall refuse to insure, or refuse to continue to insure, or limit the amount or extent or kind of coverage available to an individual, or charge an individual a different rate for the same coverage solely because of blindness or partial blindness. With respect to all other conditions, including the underlying cause of the blindness or partial blindness, persons who are blind or partially blind shall be subject to the same standards of sound actuarial principles or actual or reasonably anticipated experience as are sighted persons. Refusal to insure includes denial by an insurer of disability insurance coverage on the grounds that the policy defines "disability" as being presumed in the event that the insured loses his or her eyesight.
(Source: P.A. 99-143, eff. 7-27-15.)

215 ILCS 5/364.01

    (215 ILCS 5/364.01)
    Sec. 364.01. Qualified clinical cancer trials.
    (a) No individual or group policy of accident and health insurance issued or renewed in this State may be cancelled or non-renewed for any individual based on that individual's participation in a qualified clinical cancer trial.
    (b) Qualified clinical cancer trials must meet the following criteria:
        (1) the effectiveness of the treatment has not been
    
determined relative to established therapies;
        (2) the trial is under clinical investigation as part
    
of an approved cancer research trial in Phase II, Phase III, or Phase IV of investigation;
        (3) the trial is:
            (A) approved by the Food and Drug Administration;
        
or
            (B) approved and funded by the National
        
Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the United States Department of Defense, the United States Department of Veterans Affairs, or the United States Department of Energy in the form of an investigational new drug application, or a cooperative group or center of any entity described in this subdivision (B); and
        (4) the patient's primary care physician, if any, is
    
involved in the coordination of care.
    (c) No group policy of accident and health insurance shall exclude coverage for any routine patient care administered to an insured who is a qualified individual participating in a qualified clinical cancer trial, if the policy covers that same routine patient care of insureds not enrolled in a qualified clinical cancer trial.
    (d) The coverage that may not be excluded under subsection (c) of this Section is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to the same routine patient care received by an insured not enrolled in a qualified clinical cancer trial, including the application of any authorization requirement, utilization review, or medical management practices. The insured or enrollee shall incur no greater out-of-pocket liability than had the insured or enrollee not enrolled in a qualified clinical cancer trial.
    (e) If the group policy of accident and health insurance uses a preferred provider program and a preferred provider provides routine patient care in connection with a qualified clinical cancer trial, then the insurer may require the insured to use the preferred provider if the preferred provider agrees to provide to the insured that routine patient care.
    (f) A qualified clinical cancer trial may not pay or refuse to pay for routine patient care of an individual participating in the trial, based in whole or in part on the person's having or not having coverage for routine patient care under a group policy of accident and health insurance.
    (g) Nothing in this Section shall be construed to limit an insurer's coverage with respect to clinical trials.
    (h) Nothing in this Section shall require coverage for out-of-network services where the underlying health benefit plan does not provide coverage for out-of-network services.
    (i) As used in this Section, "routine patient care" means all health care services provided in the qualified clinical cancer trial that are otherwise generally covered under the policy if those items or services were not provided in connection with a qualified clinical cancer trial consistent with the standard of care for the treatment of cancer, including the type and frequency of any diagnostic modality, that a provider typically provides to a cancer patient who is not enrolled in a qualified clinical cancer trial. "Routine patient care" does not include, and a group policy of accident and health insurance may exclude, coverage for:
        (1) a health care service, item, or drug that is the
    
subject of the cancer clinical trial;
        (2) a health care service, item, or drug provided
    
solely to satisfy data collection and analysis needs for the qualified clinical cancer trial that is not used in the direct clinical management of the patient;
        (3) an investigational drug or device that has not
    
been approved for market by the United States Food and Drug Administration;
        (4) transportation, lodging, food, or other expenses
    
for the patient or a family member or companion of the patient that are associated with the travel to or from a facility providing the qualified clinical cancer trial, unless the policy covers these expenses for a cancer patient who is not enrolled in a qualified clinical cancer trial;
        (5) a health care service, item, or drug customarily
    
provided by the qualified clinical cancer trial sponsors free of charge for any patient;
        (6) a health care service or item, which except for
    
the fact that it is being provided in a qualified clinical cancer trial, is otherwise specifically excluded from coverage under the insured's policy, including:
            (A) costs of extra treatments, services,
        
procedures, tests, or drugs that would not be performed or administered except for the fact that the insured is participating in the cancer clinical trial; and
            (B) costs of nonhealth care services that the
        
patient is required to receive as a result of participation in the approved cancer clinical trial;
        (7) costs for services, items, or drugs that are
    
eligible for reimbursement from a source other than a patient's contract or policy providing for third-party payment or prepayment of health or medical expenses, including the sponsor of the approved cancer clinical trial;
        (8) costs associated with approved cancer clinical
    
trials designed exclusively to test toxicity or disease pathophysiology, unless the policy covers these expenses for a cancer patient who is not enrolled in a qualified clinical cancer trial; or
        (9) a health care service or item that is eligible
    
for reimbursement by a source other than the insured's policy, including the sponsor of the qualified clinical cancer trial.
    The definitions of the terms "health care services", "Non-Preferred Provider", "Preferred Provider", and "Preferred Provider Program", stated in 50 Ill. Adm. Code Part 2051 Preferred Provider Programs apply to these terms in this Section.
    (j) The external review procedures established under the Health Carrier External Review Act shall apply to the provisions under this Section.
(Source: P.A. 103-154, eff. 6-30-23.)

215 ILCS 5/364.1

    (215 ILCS 5/364.1) (from Ch. 73, par. 976.1)
    Sec. 364.1. Every policy of accident and health insurance delivered or issued for delivery to any person in this State after the effective date of this amendatory Act of 1979 which provides coverage for services coming within the practice of optometry as defined in the Illinois Optometric Practice Act of 1987, as now or hereafter amended shall, upon issuance or delivery, be accompanied by a written notice to the policyholder that such policyholder may elect for optometric services received to be reimbursed to either a physician licensed to practice medicine in all its branches or to an optometrist licensed in this State.
(Source: P.A. 85-1209.)

215 ILCS 5/364.2

    (215 ILCS 5/364.2)
    Sec. 364.2. Purchase of ophthalmic goods or services. An insurer may not require a provider, as a condition of participation by the provider, to purchase ophthalmic goods or services, including but not limited to eyeglass frames, in a quantity or dollar amount in excess of the quantity or dollar amount an enrollee purchases under the terms of the policy.
(Source: P.A. 93-1077, eff. 1-18-05.)

215 ILCS 5/364.3

    (215 ILCS 5/364.3)
    Sec. 364.3. Insurer uniform electronic prior authorization form; prescription benefits.
    (a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.
    (b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, an insurer that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits.
    (c) On or before July 1, 2020, the Department shall develop a uniform electronic prior authorization form that shall be used by commercial insurers. Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits and every insurer shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits.
    (d) The Department shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents commercial insurers, from at least one public meeting.
    (e) The Department, in development of the uniform electronic prior authorization form, shall take into consideration the following:
        (1) existing prior authorization forms established by
    
the federal Centers for Medicare and Medicaid Services and the Department; and
        (2) national standards pertaining to electronic prior
    
authorization.
    (f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, an insurer fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours (if the patient has urgent medication needs) or within 72 hours (if the patient has regular medication needs), then the prior authorization request shall be deemed to have been granted.
(Source: P.A. 101-463, eff. 1-1-20.)

215 ILCS 5/367

    (215 ILCS 5/367) (from Ch. 73, par. 979)
    Sec. 367. Group accident and health insurance.
    (1) Group accident and health insurance is hereby declared to be that form of accident and health insurance covering not less than 2 employees, members, or employees of members, written under a master policy issued to any governmental corporation, unit, agency or department thereof, or to any corporation, copartnership, individual employer, or to any association upon application of an executive officer or trustee of such association having a constitution or bylaws and formed in good faith for purposes other than that of obtaining insurance, where officers, members, employees, employees of members or classes or department thereof, may be insured for their individual benefit. In addition a group accident and health policy may be written to insure any group which may be insured under a group life insurance policy. The term "employees" shall include the officers, managers and employees of subsidiary or affiliated corporations, and the individual proprietors, partners and employees of affiliated individuals and firms, when the business of such subsidiary or affiliated corporations, firms or individuals, is controlled by a common employer through stock ownership, contract or otherwise.
    (2) Any insurance company authorized to write accident and health insurance in this State shall have power to issue group accident and health policies. No policy of group accident and health insurance may be issued or delivered in this State unless a copy of the form thereof shall have been filed with the department and approved by it in accordance with Section 355, and it contains in substance those provisions contained in Sections 357.1 through 357.30 as may be applicable to group accident and health insurance and the following provisions:
        (a) A provision that the policy, the application of
    
the employer, or executive officer or trustee of any association, and the individual applications, if any, of the employees, members or employees of members insured shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer or trustee, or by the individual employees, members or employees of members shall (in the absence of fraud) be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the policy, unless it is contained in a written application.
        (b) A provision that the insurer will issue to the
    
employer, or to the executive officer or trustee of the association, for delivery to the employee, member or employee of a member, who is insured under such policy, an individual certificate setting forth a statement as to the insurance protection to which he is entitled and to whom payable.
        (c) A provision that to the group or class thereof
    
originally insured shall be added from time to time all new employees of the employer, members of the association or employees of members eligible to and applying for insurance in such group or class.
    (3) Anything in this code to the contrary notwithstanding, any group accident and health policy may provide that all or any portion of any indemnities provided by any such policy on account of hospital, nursing, medical or surgical services, may, at the insurer's option, be paid directly to the hospital or person rendering such services; but the policy may not require that the service be rendered by a particular hospital or person. Payment so made shall discharge the insurer's obligation with respect to the amount of insurance so paid. Nothing in this subsection (3) shall prohibit an insurer from providing incentives for insureds to utilize the services of a particular hospital or person.
    (4) Special group policies may be issued to school districts providing medical or hospital service, or both, for pupils of the district injured while participating in any athletic activity under the jurisdiction of or sponsored or controlled by the district or the authorities of any school thereof. The provisions of this Section governing the issuance of group accident and health insurance shall, insofar as applicable, control the issuance of such policies issued to schools.
    (5) No policy of group accident and health insurance may be issued or delivered in this State unless it provides that upon the death of the insured employee or group member the dependents' coverage, if any, continues for a period of at least 90 days subject to any other policy provisions relating to termination of dependents' coverage.
    (6) No group hospital policy covering miscellaneous hospital expenses issued or delivered in this State shall contain any exception or exclusion from coverage which would preclude the payment of expenses incurred for the processing and administration of blood and its components.
    (7) No policy of group accident and health insurance, delivered in this State more than 120 days after the effective day of the Section, which provides inpatient hospital coverage for sicknesses shall exclude from such coverage the treatment of alcoholism. This subsection shall not apply to a policy which covers only specified sicknesses.
    (8) No policy of group accident and health insurance, which provides benefits for hospital or medical expenses based upon the actual expenses incurred, issued or delivered in this State shall contain any specific exception to coverage which would preclude the payment of actual expenses incurred in the examination and testing of a victim of an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such offense, to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by the victim of such offense, arising out of the offense. Every group policy of accident and health insurance which specifically provides benefits for routine physical examinations shall provide full coverage for expenses incurred in the examination and testing of a victim of an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such offense, as set forth in this Section. This subsection shall not apply to a policy which covers hospital and medical expenses for specified illnesses and injuries only.
    (9) For purposes of enabling the recovery of State funds, any insurance carrier subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its insureds entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay, hospital or medical expenses for which an insurance carrier is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section.
    (10) Whenever the Department of Public Health finds that it has paid all or part of any hospital or medical expenses which an insurance carrier is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such insurance carrier provided that the Department of Public Health has notified the insurance carrier of its claim before the carrier has paid the benefits to its insureds or the insureds' assignees.
    (11) (a) No group hospital, medical or surgical expense
    
policy shall contain any provision whereby benefits otherwise payable thereunder are subject to reduction solely on account of the existence of similar benefits provided under other group or group-type accident and sickness insurance policies where such reduction would operate to reduce total benefits payable under these policies below an amount equal to 100% of total allowable expenses provided under these policies.
        (b) When dependents of insureds are covered under 2
    
policies, both of which contain coordination of benefits provisions, benefits of the policy of the insured whose birthday falls earlier in the year are determined before those of the policy of the insured whose birthday falls later in the year. Birthday, as used herein, refers only to the month and day in a calendar year, not the year in which the person was born. The Department of Insurance shall promulgate rules defining the order of benefit determination pursuant to this paragraph (b).
    (12) Every group policy under this Section shall be subject to the provisions of Sections 356g and 356n of this Code.
    (13) No accident and health insurer providing coverage for hospital or medical expenses on an expense incurred basis shall deny reimbursement for an otherwise covered expense incurred for any organ transplantation procedure solely on the basis that such procedure is deemed experimental or investigational unless supported by the determination of the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services that such procedure is either experimental or investigational or that there is insufficient data or experience to determine whether an organ transplantation procedure is clinically acceptable. If an accident and health insurer has made written request, or had one made on its behalf by a national organization, for determination by the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services as to whether a specific organ transplantation procedure is clinically acceptable and said organization fails to respond to such a request within a period of 90 days, the failure to act may be deemed a determination that the procedure is deemed to be experimental or investigational.
    (14) Whenever a claim for benefits by an insured under a dental prepayment program is denied or reduced, based on the review of x-ray films, such review must be performed by a dentist.
(Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13.)

215 ILCS 5/367.2

    (215 ILCS 5/367.2) (from Ch. 73, par. 979.2)
    Sec. 367.2. Spousal continuation privilege; group contracts.
    A. No policy of group accident or health insurance, nor any certificate thereunder shall be delivered or issued for delivery in this State after December 1, 1985, unless the policy provides for a continuation of the existing insurance benefits for an employee's spouse and dependent children who are insured under the provisions of that group policy or certificate thereunder, notwithstanding that the marriage is dissolved by judgment or terminated by the death of the employee or, after the effective date of this amendatory Act of the 93rd General Assembly, notwithstanding the retirement of the employee provided that the employee's spouse is at least 55 years of age, in each case without any other eligibility requirements. The provisions of this amendatory Act of the 93rd General Assembly apply to every group policy of accident or health insurance and every certificate issued thereunder delivered or issued for delivery after the effective date of this amendatory Act of the 93rd General Assembly.
    B. Within 30 days of the entry of judgment or the death or retirement of the employee, the spouse of an employee insured under the policy who seeks a continuation of coverage thereunder shall give the employer or the insurer written notice of the dissolution of the marriage or the death or retirement of the employee. The employer, within 15 days of receipt of the notice shall give written notice of the dissolution of the employee's marriage or the death or retirement of the employee and that former spouse's or retired employee's spouse's residence to the insurance company issuing the policy.
    The employer shall immediately send a copy of the notice to the former spouse of the employee or the spouse of the retired employee at the retired employee's spouse's residence or at the former spouse's residence. For purposes of this Act, the term "former spouse" includes "widow" or "widower".
    C. Within 30 days after the date of receipt of a notice from the employer, retired employee's spouse or former spouse or of the initiation of a new group policy, the insurance company, by certified mail, return receipt requested, shall notify the retired employee's spouse or former spouse at his or her residence that the policy may be continued for that retired employee's spouse or former spouse and covered dependents, and the notice shall include:
        (i) a form for election to continue the insurance
    
coverage;
        (ii) the amount of periodic premiums to be charged
    
for continuation coverage and the method and place of payment; and
        (iii) instructions for returning the election form
    
within 30 days after the date it is received from the insurance company.
    Failure of the retired employee's spouse or former spouse to exercise the election to continue insurance coverage by notifying the insurance company in writing within such 30 day period shall terminate the continuation of benefits and the right to continuation.
    If the insurance company fails to notify the retired employee's spouse or former spouse as provided for in subsection C hereof, all premiums shall be waived from the date the notice was required until notice is sent, and the benefits shall continue under the terms and provisions of the policy, from the date the notice was required until the notice is sent, notwithstanding any other provision hereof, except where the benefits in existence at the time the company's notice was to be sent pursuant to subsection C are terminated as to all employees.
    D. With respect to a former spouse who has not attained the age of 55 at the time continuation coverage begins, the monthly premium for continuation shall be computed as follows:
        (i) an amount, if any, that would be charged an
    
employee if the former spouse were a current employee of the employer, plus;
        (ii) an amount, if any, that the employer would
    
contribute toward the premium if the former spouse were a current employee.
    Failure to pay the initial monthly premium within 30 days after the date of receipt of notice required in subsection C of this Section terminates the continuation benefits and the right to continuation benefits.
    The continuation coverage for former spouses who have not attained the age of 55 at the time coverage begins shall terminate upon the earliest to happen of the following:
        (i) The failure to pay premiums when due, including
    
any grace period allowed by the policy; or
        (ii) When coverage would terminate under the terms of
    
the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
        (iii) the date on which the former spouse first
    
becomes, after the date of election, an insured employee under any other group health plan; or
        (iv) the date on which the former spouse remarries; or
        (v) the expiration of 2 years from the date
    
continuation coverage began.
    Upon the termination of continuation coverage, the former spouse shall be entitled to convert the coverage to an individual policy.
    The continuation rights granted to former spouses who have not attained age 55 shall also include eligible dependents insured prior to the dissolution of marriage or the death of the employee.
    E. With respect to a retired employee's spouse or former spouse who has attained the age of 55 at the time continuation coverage begins, the monthly premium for the continuation shall be computed as follows:
        (i) an amount, if any, that would be charged an
    
employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
        (ii) an amount, if any, that the employer would
    
contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
    Beginning 2 years after coverage begins under this paragraph, the monthly premium shall be computed as follows:
        (i) an amount, if any, that would be charged an
    
employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
        (ii) an amount, if any, that the employer would
    
contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
        (iii) an additional amount, not to exceed 20% of (i)
    
and (ii) above, for costs of administration.
    Failure to pay the initial monthly premium within 30 days after the date of receipt of the notice required in subsection C of this Section terminates the continuation benefits and the right to continuation benefits.
    The continuation coverage for retired employees' spouses and former spouses who have attained the age of 55 at the time coverage begins shall terminate upon the earliest to happen of the following:
        (i) The failure to pay premiums when due, including
    
any grace period allowed by the policy; or
        (ii) When coverage would terminate, except due to the
    
retirement of an employee, under the terms of the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or retirement to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
        (iii) the date on which the retired employee's spouse
    
or former spouse first becomes, after the date of election, an insured employee under any other group health plan; or
        (iv) the date on which the former spouse remarries; or
        (v) the date that person reaches the qualifying age
    
or otherwise establishes eligibility under the Medicare Program pursuant to Title XVIII of the federal Social Security Act.
    Upon the termination of continuation coverage, the former spouse shall be entitled to convert the coverage to an individual policy.
    The continuation rights granted to former spouses who have attained age 55 shall also include eligible dependents insured prior to the dissolution of marriage, the death of the employee, or the retirement of the employee.
    F. The renewal, amendment, or extension of any group policy affected by this Section shall be deemed to be delivery or issuance for delivery of a new policy or contract of insurance in this State.
    G. If (i) the policy is canceled, and (ii) another insurance company contracts to provide group health and accident insurance to the employer, and (iii) continuation coverage is in effect for the retired employee's spouse or former spouse at the time of cancellation and (iv) the employee is or would have been included under the new group policy, then the new insurer must also offer continuation coverage to the retired employee's spouse and to an employee's former spouse under the same terms and conditions as contained in this Section.
    H. This Section shall not limit the right of the retired employee's spouse or any former spouse to exercise the privilege to convert to an individual policy as contained in this Code.
    I. No person who obtains coverage under this Section shall be required to pay a rate greater than that applicable to any employee or member covered under that group except as provided in clause (iii) of the second paragraph of subsection E.
(Source: P.A. 93-477, eff. 1-1-04.)

215 ILCS 5/367.2-5

    (215 ILCS 5/367.2-5)
    Sec. 367.2-5. Dependent child continuation privilege; group contracts.
    (a) No policy of group accident or health insurance, nor any certificate thereunder shall be amended, renewed, delivered, or issued for delivery in this State after July 1, 2004, unless the policy provides for a continuation of the existing insurance benefits for an employee's dependent child who is insured under the provisions of that group policy or certificate in the event of the death of the employee and the child is not eligible for coverage as a dependent under the provisions of Section 367.2 or the dependent child has attained the limiting age under the policy.
    (b) In the event of the death of the employee, if continuation coverage is desired, the dependent child or a responsible adult acting on behalf of the dependent child shall give the employer or the insurer written notice of the death of employee within 30 days of the date the coverage terminates. The employer, within 15 days of receipt of the notice, shall give written notice to the insurance company issuing the policy of the death of the employee and the dependent child's residence. The employer shall immediately send a copy of the notice to the dependent child or responsible adult at the dependent child's residence.
    (c) In the event of the dependent child attaining the limiting age under the policy, if continuation coverage is desired, the dependent child shall give the employer or the insurer written notice of the attainment of the limiting age within 30 days of the date the coverage terminates. The employer, within 15 days of receipt of the notice, shall give written notice to the insurance company issuing the policy of the attainment of the limiting age by the dependent child and of the dependent child's residence.
    (d) Within 30 days after the date of receipt of a notice from the employer, dependent child, or responsible adult acting on behalf of the dependent child, or of the initiation of a new group policy, the insurance company, by certified mail, return receipt requested, shall notify the dependent child or responsible adult at the dependent child's residence that the policy may be continued for the dependent child. The notice shall include:
        (1) a form for election to continue the insurance
    
coverage;
        (2) the amount of periodic premiums to be charged for
    
continuation coverage and the method and place of payment; and
        (3) instructions for returning the election form
    
within 30 days after the date it is received from the insurance company.
    Failure of the dependent child or the responsible adult acting on behalf of the dependent child to exercise the election to continue insurance coverage by notifying the insurance company in writing within such 30 day period shall terminate the continuation of benefits and the right to continuation.
    If the insurance company fails to notify the dependent child or responsible adult acting on behalf of the dependent child as provided for in this subsection (d), all premiums shall be waived from the date the notice was required until notice was sent, and the benefits shall continue under the terms and provisions of the policy, from the date the notice was required until the notice was sent, notwithstanding any other provision hereof, except where the benefits in existence at the time the company's notice was to be sent pursuant to this subsection (d) are terminated as to all employees.
    (e) The monthly premium for continuation shall be computed as follows:
        (1) an amount, if any, that would be charged an
    
employee if the dependent child were a current employee of the employer, plus;
        (2) an amount, if any, that the employer would
    
contribute toward the premium if the dependent child were a current employee.
    Failure to pay the initial monthly premium within 30 days after the date of receipt of notice required in subsection (d) of this Section terminates the continuation benefits and the right to continuation benefits.
    Continuation coverage provided under this Act shall terminate upon the earliest to happen of the following:
        (1) the failure to pay premiums when due, including
    
any grace period allowed by the policy;
        (2) when coverage would terminate under the terms of
    
the existing policy if the dependent child was still an eligible dependent of the employee;
        (3) the date on which the dependent child first
    
becomes, after the date of election, an insured employee under any other group health plan; or
        (4) the expiration of 2 years from the date
    
continuation coverage began.
    Upon the termination of continuation coverage, the dependent child shall be entitled to convert the coverage to an individual policy.
    (f) The renewal, amendment, or extension of any group policy affected by this Section shall be deemed to be delivery or issuance for delivery of a new policy or contract of insurance in this State.
    (g) If (1) the policy is cancelled, and (2) another insurance company contracts to provide group health and accident insurance to the employer, and (3) continuation coverage is in effect for the dependent child at the time of cancellation, and (4) the employee is or would have been included under the new group policy, then the new insurer must also offer continuation coverage to the dependent child under the same terms and conditions as contained in this Section.
    (h) This Section shall not limit the right of any dependent child to exercise the privilege to convert to an individual policy as contained in this Code.
    (i) No person who obtains coverage under this Section shall be required to pay a rate greater than that applicable to any employee or member covered under that group.
(Source: P.A. 93-477, eff. 1-1-04.)

215 ILCS 5/367.3

    (215 ILCS 5/367.3) (from Ch. 73, par. 979.3)
    Sec. 367.3. Group accident and health insurance; discretionary groups.
    (a) No group health insurance offered to a resident of this State under a policy issued to a group, other than one specifically described in Section 367(1), shall be delivered or issued for delivery in this State unless the Director determines that:
        (1) the issuance of the policy is not contrary to the
    
public interest;
        (2) the issuance of the policy will result in
    
economies of acquisition and administration; and
        (3) the benefits under the policy are reasonable in
    
relation to the premium charged.
    (b) No such group health insurance may be offered in this State under a policy issued in another state unless this State or the state in which the group policy is issued has made a determination that the requirements of subsection (a) have been met.
    Where insurance is to be offered in this State under a policy described in this subsection, the insurer shall file for informational review purposes:
        (1) a copy of the group master contract;
        (2) a copy of the statute authorizing the issuance of
    
the group policy in the state of situs, which statute has the same or similar requirements as this State, or in the absence of such statute, a certification by an officer of the company that the policy meets the Illinois minimum standards required for individual accident and health policies under authority of Section 401 of this Code, as now or hereafter amended, as promulgated by rule at 50 Illinois Administrative Code, Ch. I, Sec. 2007, et seq., as now or hereafter amended, or by a successor rule;
        (3) evidence of approval by the state of situs of the
    
group master policy; and
        (4) copies of all supportive material furnished to
    
the state of situs to satisfy the criteria for approval.
    (c) The Director may, at any time after receipt of the information required under subsection (b) and after finding that the standards of subsection (a) have not been met, order the insurer to cease the issuance or marketing of that coverage in this State.
    (d) Group accident and health insurance subject to the provisions of this Section is also subject to the provisions of Section 367i of this Code.
(Source: P.A. 90-655, eff. 7-30-98.)

215 ILCS 5/367a

    (215 ILCS 5/367a) (from Ch. 73, par. 979a)
    Sec. 367a. Blanket accident and health insurance.
    (1) Blanket accident and health insurance is that form of accident and health insurance covering special groups of persons as enumerated in one of the following paragraphs (a) to (g), inclusive:
    (a) Under a policy or contract issued to any carrier for hire, which shall be deemed the policyholder, covering a group defined as all persons who may become passengers on such carrier.
    (b) Under a policy or contract issued to an employer, who shall be deemed the policyholder, covering all employees or any group of employees defined by reference to exceptional hazards incident to such employment.
    (c) Under a policy or contract issued to a college, school, or other institution of learning or to the head or principal thereof, who or which shall be deemed the policyholder, covering students or teachers.
    (d) Under a policy or contract issued in the name of any volunteer fire department, first aid, or other such volunteer group, which shall be deemed the policyholder, covering all of the members of such department or group.
    (e) Under a policy or contract issued to a creditor, who shall be deemed the policyholder, to insure debtors of the creditors; Provided, however, that in the case of a loan which is subject to the Small Loans Act, no insurance premium or other cost shall be directly or indirectly charged or assessed against, or collected or received from the borrower.
    (f) Under a policy or contract issued to a sports team or to a camp, which team or camp sponsor shall be deemed the policyholder, covering members or campers.
    (g) Under a policy or contract issued to any other substantially similar group which, in the discretion of the Director, may be subject to the issuance of a blanket accident and health policy or contract.
    (2) Any insurance company authorized to write accident and health insurance in this state shall have the power to issue blanket accident and health insurance. No such blanket policy may be issued or delivered in this State unless a copy of the form thereof shall have been filed in accordance with Section 355, and it contains in substance such of those provisions contained in Sections 357.1 through 357.30 as may be applicable to blanket accident and health insurance and the following provisions:
    (a) A provision that the policy and the application shall constitute the entire contract between the parties, and that all statements made by the policyholder shall, in absence of fraud, be deemed representations and not warranties, and that no such statements shall be used in defense to a claim under the policy, unless it is contained in a written application.
    (b) A provision that to the group or class thereof originally insured shall be added from time to time all new persons or individuals eligible for coverage.
    (3) An individual application shall not be required from a person covered under a blanket accident or health policy or contract, nor shall it be necessary for the insurer to furnish each person a certificate.
    (4) All benefits under any blanket accident and health policy shall be payable to the person insured, or to his designated beneficiary or beneficiaries, or to his or her estate, except that if the person insured be a minor or person under legal disability, such benefits may be made payable to his or her parent, guardian, or other person actually supporting him or her. Provided further, however, that the policy may provide that all or any portion of any indemnities provided by any such policy on account of hospital, nursing, medical or surgical services may, at the insurer's option, be paid directly to the hospital or person rendering such services; but the policy may not require that the service be rendered by a particular hospital or person. Payment so made shall discharge the insurer's obligation with respect to the amount of insurance so paid.
    (5) Nothing contained in this section shall be deemed to affect the legal liability of policyholders for the death of or injury to, any such member of such group.
(Source: P.A. 83-1362.)

215 ILCS 5/367b

    (215 ILCS 5/367b) (from Ch. 73, par. 979b)
    Sec. 367b. (a) This Section applies to the hospital and medical expense provisions of a group accident or health insurance policy.
    (b) If a policy provides that coverage of a dependent of an employee or other member of the covered group terminates upon attainment of the limiting age for dependent persons specified in the policy, the attainment of such limiting age does not operate to terminate the hospital and medical coverage of a person who, because of a disabling condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment and is dependent on his or her parents or other care providers for lifetime care and supervision.
    (c) For purposes of subsection (b), "dependent on other care providers" is defined as requiring a Community Integrated Living Arrangement, group home, supervised apartment, or other residential services licensed or certified by the Department of Human Services (as successor to the Department of Mental Health and Developmental Disabilities), the Department of Public Health, or the Department of Healthcare and Family Services (formerly Department of Public Aid).
    (d) The insurer may inquire of the person insured 2 months prior to attainment by a dependent of the limiting age set forth in the policy, or at any reasonable time thereafter, whether such dependent is in fact a person who has a disability and is dependent and, in the absence of proof submitted within 31 days of such inquiry that such dependent is a person who has a disability and is dependent may terminate coverage of such person at or after attainment of the limiting age. In the absence of such inquiry, coverage of any person who has a disability and is dependent shall continue through the term of such policy or any extension or renewal.
    (e) This amendatory Act of 1969 is applicable to policies issued or renewed more than 60 days after the effective date of this amendatory Act of 1969.
(Source: P.A. 99-143, eff. 7-27-15.)

215 ILCS 5/367c

    (215 ILCS 5/367c) (from Ch. 73, par. 979c)
    Sec. 367c.
    No claim shall be denied, under any group accident and health policy delivered or renewed in this State after the effective date of this Amendatory Act, for treatment or services for mental illness rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P.A. 78-708.)

215 ILCS 5/367d

    (215 ILCS 5/367d) (from Ch. 73, par. 979d)
    Sec. 367d. No claim shall be denied, under any group accident and health policy delivered or renewed in this State after the effective date of this amendatory Act, for treatment or services for rehabilitation following either a physical or mental illness, rendered in a hospital solely because such hospital lacks surgical facilities.
(Source: P.A. 79-303.)

215 ILCS 5/367d.1

    (215 ILCS 5/367d.1) (from Ch. 73, par. 979d.1)
    Sec. 367d.1. After the effective date of this amendatory Act of 1992, no group policy of accident and health insurance that provides coverage for the treatment of alcoholism or other drug abuse or dependency on both an inpatient and outpatient basis may be issued, delivered or amended in this State if it excludes from coverage services provided by persons or entities licensed by the Department of Human Services to provide substance use disorder treatment, provided however that (a) the charges are otherwise eligible for reimbursement under the policy and (b) the services provided are medically necessary and within the scope of the licensure of the provider. This Section shall not apply to arrangements, agreements or policies authorized under the Health Care Reimbursement Reform Act of 1985; the Limited Health Service Organization Act; or the Health Maintenance Organization Act.
(Source: P.A. 100-759, eff. 1-1-19.)

215 ILCS 5/367e

    (215 ILCS 5/367e) (from Ch. 73, par. 979e)
    Sec. 367e. Continuation of Group Hospital, Surgical and Major Medical Coverage After Termination of Employment or Membership. A group policy delivered, issued for delivery, renewed or amended in this state which insures employees or members for hospital, surgical or major medical insurance on an expense incurred or service basis, other than for specific diseases or for accidental injuries only, shall provide that employees or members whose insurance under the group policy would otherwise terminate because of termination of employment or membership or because of a reduction in hours below the minimum required by the group plan shall be entitled to continue their hospital, surgical and major medical insurance under that group policy, for themselves and their eligible dependents, subject to all of the group policy's terms and conditions applicable to those forms of insurance and to the following conditions:
        1. Continuation shall only be available to an
    
employee or member who has been continuously insured under the group policy (and for similar benefits under any group policy which it replaced) during the entire 3 months period ending with such termination or reduction in hours below the minimum required by the group plan. With respect to an employee or member who is involuntarily terminated between September 1, 2008 and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, continuation shall be available if the employee or member was insured under the group policy on the day prior to the termination.
        2. Continuation shall not be available for any person
    
who is covered by Medicare, except for those individuals who have been covered under a group Medicare supplement policy. Neither shall continuation be available for any person who is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan or who exercises his conversion privilege under the group policy.
        3. Continuation need not include dental, vision care,
    
prescription drug benefits, disability income, specified disease, or similar supplementary benefits which are provided under the group policy in addition to its hospital, surgical or major medical benefits.
        4. Within 10 days after the employee's or member's
    
termination or reduction in hours below the minimum required by the group plan written notice of continuation shall be presented to the employee or member by the employer. If the employee or member is unavailable, written notice shall be mailed by the employer to the last known address of the employee or member within 10 days after the employee's or member's termination or reduction in hours below the minimum required by the group plan. The employer shall also send a copy of the notice to the insurer. An employee or member who wishes continuation of coverage must request such continuation in writing within the 30 day period following the later of: (i) the date of such termination or reduction in hours below the minimum required by the group plan, or (ii) the date the employee is presented or mailed written notice of the right of continuation by either the employer or the group policyholder. In no event, however, may the employee or member elect continuation more than 60 days after the date of such termination or reduction in hours below the minimum required by the group plan. Written notice of continuation presented to the employee or member by the policyholder, or mailed by the policyholder to the last known address of the employee, shall constitute the giving of notice for the purpose of this provision.
        The insurer shall not deny coverage to the employee
    
or member due to the employer's failure to provide notice pursuant to this Section to the employee or member. Until the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, in the event the employee or member contacts the insurer regarding continuation rights and advises that notice has not been provided by the employer or group policyholder, the insurer shall provide a written explanation to the employee or member of the employee's or member's continuation rights pursuant to this Section.
        4a. Unless contrary to the provisions of, or any
    
rules promulgated pursuant to, the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage and who are terminated or whose reduction in hours below the minimum required by the group occurs between the effective date of this amendatory Act of the 96th General Assembly and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, the notice requirements of this Section are not satisfied unless notice is presented or mailed to the employee or member by the insurer informing the employee or member of the availability of premium reduction with respect to such coverage under the American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 4a.
        4b. Unless contrary to the provisions of, or any
    
rules promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage who were terminated or whose reduction in hours below the minimum required by the group occurred between September 1, 2008 and the effective date of this amendatory Act of the 96th General Assembly and who have an election of continuation of coverage pursuant to this Section in effect, notice shall be presented or mailed to the employee or member by the insurer informing the employee or member of the availability of premium reduction with respect to such coverage under the federal American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009 and shall be presented or mailed to the employee or member within 14 days of the effective date of this amendatory Act of the 96th General Assembly. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 4b.
        5. An employee or member electing continuation must
    
pay to the group policyholder or his employer, on a monthly basis in advance, the total amount of premium required by the insurer, including that portion of the premium contributed by the policyholder or employer, if any, but not more than the group rate for the insurance being continued with appropriate reduction in premium for any supplementary benefits which have been discontinued under paragraph (3) of this Section. The premium rate required by the insurer shall be the applicable premium required on the due date of each payment.
        6. Continuation of insurance under the group policy
    
for any person shall terminate when he becomes eligible for Medicare or is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan as provided in condition 2 above or, if earlier, at the first to occur of the following:
            (a) The date 12 months after the date the
        
employee's or member's insurance under the policy would otherwise have terminated because of termination of employment or membership or reduction in hours below the minimum required by the group plan or, with respect to an employee or member who is an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, the date that the individual ceases to be eligible for premium assistance under Section 3001(a)(2)(A)(ii)(I) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended.
            (b) If the employee or member fails to make
        
timely payment of a required contribution, the end of the period for which contributions were made.
            (c) The date on which the group policy is
        
terminated or, in the case of an employee, the date his employer terminates participation under the group policy. However, if this (c) applies and the coverage ceasing by reason of such termination is replaced by similar coverage under another group policy, the following shall apply:
                (i) The employee or member shall have the
            
right to become covered under that other group policy, for the balance of the period that he would have remained covered under the prior group policy in accordance with condition 6 had a termination described in this (c) not occurred.
                (ii) The prior group policy shall continue to
            
provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.
        7. A notification of the continuation privilege shall
    
be included in each certificate of coverage.
        8. Continuation shall not be available for any
    
employee who was discharged because of the commission of a felony in connection with his work, or because of theft in connection with his work, for which the employer was in no way responsible; provided the employee admitted his commission of the felony or theft or such act has resulted in a conviction or order of supervision by a court of competent jurisdiction.
        9. An employee or member without an election of
    
continuation of coverage pursuant to this Section in effect on the effective date of this amendatory Act of the 96th General Assembly may elect continuation pursuant to this paragraph 9 if the employee or member: (i) would be an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, if such an election were in effect and (ii) at the time of termination was eligible for continuation pursuant to paragraphs 1 and 2 of this Section.
        Unless contrary to the provisions of, or any rules
    
promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, written notice of continuation pursuant to this paragraph 9 shall be presented to the employee or member by the insurer or mailed by the insurer to the last known address of the employee or member within 30 days after the effective date of this amendatory Act of the 96th General Assembly. Such written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by insurers pursuant to this paragraph 9.
        An employee or member electing continuation of
    
coverage under this paragraph 9 must request such continuation in writing within 60 days after the date the employee or member receives written notice of the right of continuation by the insurer.
        Continuation of coverage elected pursuant to this
    
paragraph 9 shall commence with the first period of coverage beginning on or after February 17, 2009, the effective date of the federal American Recovery and Reinvestment Act of 2009, and shall not extend beyond the period of continuation that would have been required if the coverage had been elected pursuant to paragraph 4 of this Section.
        With respect to an employee or member who elects
    
continuation of coverage under this paragraph 9, the period beginning on the date of the employee's or member's involuntary termination of employment and ending on the date of the first period of coverage on or after February 17, 2009 shall be disregarded for purposes of determining the 63-day period referred to in Section 20 of the Illinois Health Insurance Portability and Accountability Act.
    The requirements of this amendatory Act of 1983 shall apply to any group policy as defined in this Section, delivered or issued for delivery on or after 180 days following the effective date of this amendatory Act of 1983.
    The requirements of this amendatory Act of 1985 shall apply to any group policy as defined in this Section, delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this amendatory Act of 1985.
(Source: P.A. 96-13, eff. 6-18-09; 96-894, eff. 5-17-10.)

215 ILCS 5/367e.1

    (215 ILCS 5/367e.1)
    Sec. 367e.1. Group Accident and Health Insurance Conversion Privilege.
    (A) A group policy which provides hospital, medical, or major medical expense insurance, or any combination of these coverages, on an expense-incurred basis, but not including a policy which provides benefits for specific diseases or for accidental injuries only, shall provide that an employee or member (i) whose insurance under the group policy has been terminated for any reason other than discontinuance of the group policy in its entirety where there is a succeeding carrier, or failure of the employee or member to pay any required contribution; and (ii) who has been continuously insured under the group policy (and under any group policy providing similar benefits which it replaces) for at least three months immediately prior to termination, shall be entitled to have issued to him by the insurer a policy of health insurance (hereafter referred to as the converted policy), subject to the following conditions:
        (1) Written application for the converted policy
    
shall be made and the first premium paid to the insurer not later than the latter of (i) thirty-one days after such termination or (ii) 15 days after the employee or member has been given written notice of the existence of the conversion privilege, but in no event later than 60 days after such termination.
     Written notice presented to the employee or member by
    
the policyholder, or mailed by the policyholder to the last known address of the employee or member, shall constitute the giving of notice for the purpose of this provision.
        (2) The converted policy shall be issued without
    
evidence of insurability.
        (3) The initial premium for the converted policy
    
shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of each person to be covered under the converted policy and to the type and amount of the insurance provided. Conditions pertaining to health shall not be an acceptable basis of classification for the purposes of this subsection. The frequency of premium payment shall be the frequency customarily required by the insurer for the policy form and plan selected, provided that the insurer shall not require premium payments less frequently than quarterly without the consent of the insured.
        (4) The effective date of the converted policy shall
    
be the day following the termination of insurance under the group policy.
        (5) The converted policy shall cover the employee or
    
member and his dependents who were covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.
        (6) The insurer shall not be required to issue a
    
converted policy covering any person if such person is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded). Furthermore, the insurer shall not be required to issue a converted policy covering any person if (i) such person is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) such person is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any statute, and the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person together with the converted policy would result in overinsurance according to the insurer's standards.
        (7) In the event that coverage would be continued
    
under the group policy on an employee following his retirement prior to the time he is or could be covered by Medicare, he may elect, in lieu of such continuation of such group insurance, to have the same conversion rights as would apply had his insurance terminated at retirement by reason of termination of employment or membership.
        (8) Subject to the conditions set forth above, the
    
conversion privilege shall also be available (i) to the surviving spouse, if any, at the death of the employee or member, with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death, otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or, if the group policy provides for continuation of dependents' coverage following the employee's or member's death, at the end of such continuation; (ii) to the spouse of the employee or member upon termination of coverage of the spouse, while the employee or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time; or (iii) to a child solely with respect to himself upon termination of his coverage by reason of ceasing to be a qualified family member under the group policy, if a conversion privilege is not otherwise provided above with respect to such termination.
        (9) A notification of the conversion privilege shall
    
be included in each certificate.
        (10) The insurer may elect to provide group insurance
    
coverage in lieu of the issuance of a converted policy.
    (B) A converted policy issued upon the exercise of the conversion privilege required by subsection (A) of this Section shall conform to the following minimum standards:
        (1) If the group policy provided hospital, surgical,
    
or medical expense insurance, or a combination thereof, the converted policy shall provide benefits on an expense-incurred basis equal to the lesser of (i) the hospital room and board, miscellaneous hospital, surgical and medical benefits provided under the group policy; and (ii) the corresponding benefits described below:
            (a) Hospital room and board benefits in an amount
        
per day elected by the group policyholder, but in no event less than 60% of the then average semi-private hospital room and board charge in the State, such benefits to be payable for a maximum of not less than 70 days for any period of hospital confinement, as defined in the converted policy.
            (b) Miscellaneous hospital benefits for any one
        
period of hospital confinement in an amount up to twenty times the hospital room and board daily benefit provided under the converted policy.
            (c) Surgical benefits according to a surgical
        
schedule providing a benefit amount elected by the group policy holder, but in no event less than 60% of the then average surgical charge in the State and with a maximum amount appropriate thereto. The maximum surgical benefit shall be applicable to all surgical operations of an individual resulting from or contributed to by the same and all related causes occurring in one period of disability. Two or more surgical procedures performed in the course of a single operation through the same incision, or in the same natural body orifice, may be treated as one surgical procedure with the payment determined by the scheduled benefit for the most expensive procedure performed. The surgical schedule shall be consistent with the schedule of operations customarily offered by the insurer under group or individual health insurance policies.
            (d) Non-surgical medical attendance benefits for
        
in-hospital services in an amount elected by the group policyholder, but in no event less than 60% of the then average in-hospital physician's visit charge in the State, such benefits may be limited to one visit per day of hospitalization and a maximum number of visits numbering not less than seventy for any period of hospital confinement as defined in the converted policy.
        (2) If the group policy provided major medical
    
insurance, the insurer may offer the insurance described in (1) above only, major medical insurance only, or a combination of the insurance described in (1) above and major medical insurance. If the insurer elects to provide major medical insurance, the converted policy shall provide:
            (a) A maximum benefit at least equal to (i) or
        
(ii) below:
                (i) A maximum payment of twenty-five thousand
            
dollars for all covered medical expenses incurred during the covered person's lifetime with an annual restoration of the lesser of, while coverage is in force, one thousand dollars and the amount counted against the maximum benefit which was not previously restored; or
                (ii) A maximum payment of twenty-five
            
thousand dollars for each unrelated injury or illness.
            (b) Payment of benefits for covered medical
        
expenses, in excess of the deductible, at a rate not less than 80% except as otherwise permitted below.
            (c) A deductible for each benefit period which,
        
at the option of the insurer, shall be (i) the greater of $500 and the benefits deductible; (ii) the sum of the benefits deductible and $100; or (iii) the corresponding deductible in the group policy. The term "benefit period," as used herein, means, when the maximum payment is determined by (a) (i) above, either a calendar year or a period of twelve consecutive months; and, when the maximum payment is determined by (a) (ii) above, a period of twenty-four consecutive months. The term "benefits deductible," as used herein, means the value of any benefits provided on an expense-incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical, or medical insurance policy or hospital or medical service subscriber contract of medical practice or other prepayment plan, or any other plans or program whether on an insured or uninsured basis, or of any similar benefits which are provided or made available pursuant to or in accordance with the requirements of any statute and, if, pursuant to the provisions of this subsection, the converted policy provides both the coverage described in (1) above and major medical insurance, the value of the coverage described in (1) above. The insurer may require that the deductible be satisfied during a period of not less than three months. If the maximum payment is determined by (a) (i) above, and if no benefits become payable during the preceding benefit period due to the cash deductible not being satisfied; credit shall be given, in the succeeding benefit period, to any expense applied toward the cash deductible of the preceding benefit period and incurred during the last three months of such preceding benefit period, subject to any requirement that the deductible be satisfied during a specified period of time.
            (d) The term "covered medical expenses," as used
        
above, may be limited (i) in the case of hospital room and board benefits, maximum surgical schedule, and non-surgical medical attendance benefits to amounts not less than the amounts provided in (1) (a), (1) (c) and (1) (d) above; and (ii) in the case of mental and nervous condition treatments while the patient is not a hospital in-patient, to co-insurance of 50%, a maximum benefit of $500 per calendar year or twelve consecutive month periods subject to the inclusion by the insurer of reasonable limits on the number of visits and the maximum permissible expense per visit.
        (3) The converted policy may contain any exclusion,
    
reduction, or limitation contained in the group policy and any exclusion, reduction, or limitation customarily used in individual accident and health policies delivered or issued for delivery in this state. It is not required that the converted policy contain all of the covered medical expenses or the same level of benefits as provided in the group policy.
        (4) The insurer may, at its option, also offer
    
alternative plans for group accident and health conversion.
        (5) The converted policy may only exclude a
    
pre-existing condition excluded by the group policy. Any hospital, surgical, medical or major medical benefits payable under the converted policy may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder and, during the first policy year of such converted policy, the benefits payable under the converted policy may be so reduced so that they are not in excess of the benefits that would have been payable had the individual's insurance under the group policy remained in force and effect.
        (6) The converted policy may provide for the
    
termination of coverage thereunder of any person when he is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded).
        (7) The converted policy may provide that the insurer
    
may request information from the converted policyholder, in advance of any premium due date of the converted policy, to determine whether any person covered thereunder (i) is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) has similar benefits provided for or available to such person, pursuant to or in accordance with the requirements of any statute. The converted policy may also provide that the insurer need not renew the converted policy or the coverage of any person insured thereunder if either the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person, together with the converted policy, would result in overinsurance according to the insurer's standards, or if the converted policyholder refuses to provide the requested information.
        (8) The converted policy shall not contain any
    
provision allowing the insurer to non-renew due to a change in the health of an insured.
        (9) The converted policy may contain any provisions
    
permitted herein and may also include any other provisions not expressly prohibited by law. Any provisions required or permitted herein may be made a part of the converted policy by means of an endorsement or rider.
        (10) In the conversion of group health insurance in
    
accordance with the provisions of subsection (A) above, the insurer may, at its option, accomplish the conversion by issuing one or more converted policies.
        (11) With respect to any person who was covered by
    
the group policy, the period specified in the Time Limit on Certain Defenses provisions of the converted policy shall commence with the date the person's insurance became effective under the group policy.
        (12) If the insurer elects to provide group insurance
    
coverage in lieu of a converted policy, the benefit levels required for a converted policy must be applicable to such group insurance coverage.
    (C) The requirements of this Section shall apply to any group policy of accident and health insurance delivered, issued for delivery, renewed or amended on or after 180 days following the effective date of this Section.
(Source: P.A. 93-477, eff. 1-1-04.)

215 ILCS 5/367f

    (215 ILCS 5/367f) (from Ch. 73, par. 979f)
    Sec. 367f. Firefighters' continuance privilege. As used in this Section:
    1. The terms "municipality", "deferred pensioner" and "creditable service" shall have the meaning ascribed to such terms by Sections 4-103, 4-105a and 4-108, respectively, of the Illinois Pension Code, as now or hereafter amended.
    2. "Firefighter" means a person who is a "firefighter" as defined in Section 4-106 of the Illinois Pension Code, a paramedic who is employed by a unit of local government, or an emergency medical technician, emergency medical technician-basic, emergency medical technician-intermediate, or advanced emergency medical technician who is employed by a unit of local government.
    3. The "retirement or disability period" of a firefighter means the period:
        a. which begins on the day the firefighter is
    
removed from a municipality's fire department payroll because of the occurrence of any of the following events, to wit: (i) the firefighter retires as a deferred pensioner under Section 4-105a of the Illinois Pension Code, (ii) the firefighter retires from active service as a firefighter with an attained age and accumulated creditable service which together qualify the firefighter for immediate receipt of retirement pension benefits under Section 4-109 of the Illinois Pension Code, or (iii) the firefighter's disability is established under Section 4-112 of the Illinois Pension Code; and
        b. which ends on the first to occur of any of the
    
following events, to wit: (i) the firefighter's reinstatement or reentry into active service on the municipality's fire department as provided for under Article 4 of the Illinois Pension Code, (ii) the firefighter's exercise of any refund option available under Section 4-116 of the Illinois Pension Code, (iii) the firefighter's loss pursuant to Section 4-138 of the Illinois Pension Code of any benefits provided for in Article 4 of that Code, or (iv) the firefighter's death or -- if at the time of the firefighter's death the firefighter is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 4 of the Illinois Pension Code -- then the death or remarriage of that spouse.
    No policy of group accident and health insurance under which firefighters employed by a municipality are insured for their individual benefit shall be issued or delivered in this State to any municipality unless such group policy provides for the election of continued group insurance coverage for the retirement or disability period of each firefighter who is insured under the provisions of the group policy on the day immediately preceding the day on which the retirement or disability period of such firefighter begins. So long as any required premiums for continued group insurance coverage are paid in accordance with the provisions of the group policy, an election made pursuant to this Section shall provide continued group insurance coverage for a firefighter throughout the retirement or disability period of the firefighter and, unless the firefighter otherwise elects and subject to any other provisions of the group policy which relate either to the provision or to the termination of dependents' coverage and which are not inconsistent with this Section, for any dependents of the firefighter who are insured under the group policy on the day immediately preceding the day on which the retirement or disability period of the firefighter begins; provided, however, that when such continued group insurance coverage is in effect with respect to a firefighter on the date of the firefighter's death but the retirement or disability period of the firefighter does not end with such firefighter's death, then the deceased firefighter's surviving spouse upon whose death or remarriage such retirement or disability period will end shall be entitled, without further election and upon payment of any required premiums in accordance with the provisions of the group policy, to maintain such continued group insurance coverage in effect until the end of such retirement or disability period. Continued group insurance coverage shall be provided in accordance with this Section at the same premium rate from time to time charged for equivalent coverage provided under the group policy with respect to covered firefighters whose retirement or disability period has not begun, and no distinction or discrimination in the amount or rate of premiums or in any waiver of premium or other benefit provision shall be made between continued group insurance coverage elected pursuant to this Section and equivalent coverage provided to firefighters under the group policy other than pursuant to the provisions of this Section; provided that no municipality shall be required by reason of any provision of this Section to pay any group insurance premium other than one that may be negotiated in a collective bargaining agreement. If a person electing continued coverage under this Section becomes eligible for medicare coverage, benefits under the group policy may continue as a supplement to the medicare coverage upon payment of any required premiums to maintain the benefits of the group policy as supplemental coverage.
    Within 15 days of the beginning of the retirement or disability period of any firefighter entitled to elect continued group insurance coverage under any group policy affected by this Section, the municipality last employing such firefighter shall give written notice of such beginning by certified mail, return receipt requested to the insurance company issuing such policy. The notice shall include the firefighter's name and last known place of residence and the beginning date of the firefighter's retirement or disability period.
    Within 15 days of the date of receipt of such notice from the municipality, the insurance company by certified mail, return receipt requested, shall give written notice to the firefighter at the firefighter's last known place of residence that coverage under the group policy may be continued for the retirement or disability period of the firefighter as provided in this Section. Such notice shall set forth: (i) a statement of election to be filed by the firefighter if the firefighter wishes to continue such group insurance coverage, (ii) the amount of monthly premium, including a statement of the portion of such monthly premium attributable to any dependents' coverage which the firefighter may elect, and (iii) instructions as to the return of the election form to the insurance company issuing such policy. Election shall be made, if at all, by returning the statement of election to the insurance company by certified mail, return receipt requested within 15 days after having received it.
    If the firefighter elects to continue coverage, it shall be the obligation of the firefighter to pay the monthly premium directly to the municipality which shall forward it to the insurance company issuing the group insurance policy, or as otherwise directed by the insurance company; provided, however, that the firefighter shall be entitled to designate on the statement of election required to be filed with the insurance company that the total monthly premium, or such portion thereof as is not contributed by a municipality, be deducted by a Firefighter's Pension Fund from any monthly pension payment otherwise payable to or on behalf of the firefighter pursuant to Article 4 of the Illinois Pension Code, and be remitted by such Pension Fund to the insurance company. The portion, if any, of the monthly premium contributed by a municipality for such continued group insurance coverage shall be paid by the municipality directly to the insurance company issuing the group insurance policy, or as otherwise directed by the insurance company. Such continued group insurance coverage shall relate back to the beginning of the firefighter's retirement or disability period.
    The amendment, renewal or extension of any group insurance policy affected by this Section shall be deemed to be the issuance of a new policy of insurance for purposes of this Section.
    In the event that a municipality makes a program of accident, health, hospital or medical benefits available to its firefighters through self-insurance, or by participation in a pool or reciprocal insurer, or by contract in a form other than a policy of group insurance with one or more medical service plans, health care service corporations, health maintenance organizations, or any other professional corporations or plans under which health care or reimbursement for the costs thereof is provided, whether the cost of such benefits is borne by the municipality or the firefighters or both, such firefighters and their surviving spouses shall have the same right to elect continued coverage under such program of benefits as they would have if such benefits were provided by a policy of group accident and health insurance. In such cases, the notice of right to elect continued coverage shall be sent by the municipality; the statement of election shall be sent to the municipality; and references to the required premium shall refer to that portion of the cost of such benefits which is not borne by the municipality, either voluntarily or pursuant to the provisions of a collective bargaining agreement. In the case of a municipality providing such benefits through self-insurance or participation in a pool or reciprocal insurer, the right to elect continued coverage which is provided by this paragraph shall be implemented and made available to the firefighters of the municipality and qualifying surviving spouses not later than July 1, 1985.
    The amendment, renewal or extension of any such contract in a form other than a policy of group insurance policy shall be deemed the formation of a new contract for the purposes of this Section.
    This Section shall not limit the exercise of any conversion privileges available under Section 367e.
    Pursuant to paragraphs (h) and (i) of Section 6 of Article VII of the Illinois Constitution, this Section specifically denies and limits the exercise by a home rule unit of any power which is inconsistent with this Section and all existing laws and ordinances which are inconsistent with this Section are hereby superseded. This Section does not preempt the concurrent exercise by home rule units of powers consistent herewith.
    The Division of Insurance of the Department of Financial and Professional Regulation shall enforce the provisions of this Section, including provisions relating to municipality self-insured benefit plans.
(Source: P.A. 103-52, eff. 1-1-24.)

215 ILCS 5/367g

    (215 ILCS 5/367g) (from Ch. 73, par. 979g)
    Sec. 367g. Police officer's continuance privilege. As used in this Section:
    1. The terms "municipality" and "creditable service" shall have the meaning ascribed to such terms by Sections 3-103 and 3-110, respectively, of the Illinois Pension Code, as now or hereafter amended.
    The term "deferred pensioner" means a police officer who has retired, having accumulated enough creditable service to qualify for a pension, but who has not attained the required age.
    2. The term "police officer" shall have the meaning ascribed to it by Section 3-106 of the Illinois Pension Code, and include those persons under the coverage of Article 3 of that Code, as heretofore or hereafter amended.
    3. The "retirement or disability period" of a police officer means the period:
    a. which begins on the day the police officer is removed from a municipality's police department payroll because of the occurrence of any of the following events, to wit: (i) the police officer retires as a deferred pensioner, (ii) the police officer retires from active service as a police officer with an attained age and accumulated creditable service which together qualify the police officer for immediate receipt of retirement pension benefits under Section 3-111 of the Illinois Pension Code, or (iii) the police officer's disability is established under Section 3-115 of the Illinois Pension Code; and
    b. which ends on the first to occur of any of the following events, to wit: (i) the police officer's reinstatement or reentry into active service on the municipality's police department as provided for under Article 3 of the Illinois Pension Code, (ii) the police officer's exercise of any refund option available under Section 3-124 of the Illinois Pension Code, (iii) the police officer's loss pursuant to Section 3-147 of the Illinois Pension Code of any benefits provided for in Article 3 of that Code, or (iv) the police officer's death or -- if at the time of the police officer's death the police officer is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 3 of the Illinois Pension Code -- the death or remarriage of that spouse.
    No policy of group accident and health insurance under which policemen employed by a municipality are insured for their individual benefit shall be issued or delivered in this State to any municipality unless such group policy provides for the election of continued group insurance coverage for the retirement or disability period of each police officer who is insured under the provisions of the group policy on the day immediately preceding the day on which the retirement or disability period of such police officer begins. So long as any required premiums for continued group insurance coverage are paid in accordance with the provisions of the group policy, an election made pursuant to this Section shall provide continued group insurance coverage for a police officer throughout the retirement or disability period of the police officer and, unless the police officer otherwise elects and subject to any other provisions of the group policy which relate either to the provision or to the termination of dependents' coverage and which are not inconsistent with this Section, for any dependents of the police officer who are insured under the group policy on the day immediately preceding the day on which the retirement or disability period of the police officer begins; provided, however, that when such continued group insurance coverage is in effect with respect to a police officer on the date of the police officer's death but the retirement or disability period of the police officer does not end with such police officer's death, then the deceased police officer's surviving spouse upon whose death or remarriage such retirement or disability period will end shall be entitled, without further election and upon payment of any required premiums in accordance with the provisions of the group policy, to maintain such continued group insurance coverage in effect until the end of such retirement or disability period. Continued group insurance coverage shall be provided in accordance with this Section at the same premium rate from time to time charged for equivalent coverage provided under the group policy with respect to covered policemen whose retirement or disability period has not begun, and no distinction or discrimination in the amount or rate of premiums or in any waiver of premium or other benefit provision shall be made between continued group insurance coverage elected pursuant to this Section and equivalent coverage provided to policemen under the group policy other than pursuant to the provisions of this Section; provided that no municipality shall be required by reason of any provision of this Section to pay any group insurance premium other than one that may be negotiated in a collective bargaining agreement. If the group policy provides for a reduction in benefits and premium for insureds who become eligible for medicare, such provision shall apply to persons electing continued coverage under this Section.
    Within 15 days of the beginning of the retirement or disability period of any police officer entitled to elect continued group insurance coverage under any group policy affected by this Section, the municipality last employing such police officer shall give written notice of such beginning by certified mail, return receipt requested to the insurance company issuing such policy. The notice shall include the police officer's name and last known place of residence and the beginning date of the police officer's retirement or disability period.
    Within 15 days of the date of receipt of such notice from the municipality, the insurance company by certified mail, return receipt requested, shall give written notice to the police officer at the police officer's last known place of residence that coverage under the group policy may be continued for the retirement or disability period of the police officer as provided in this Section. Such notice shall set forth: (i) a statement of election to be filed by the police officer if the police officer wishes to continue such group insurance coverage, (ii) the amount of monthly premium, including a statement of the portion of such monthly premium attributable to any dependents' coverage which the police officer may elect, and (iii) instructions as to the return of the election form to the insurance company issuing such policy. Election shall be made, if at all, by returning the statement of election to the insurance company by certified mail, return receipt requested within 15 days after having received it.
    If the police officer elects to continue coverage, it shall be the obligation of the police officer to pay the monthly premium directly to the municipality which shall forward it to the insurance company issuing the group insurance policy, or as otherwise directed by the insurance company; provided, however, that the police officer shall be entitled to designate on the statement of election required to be filed with the insurance company that the total monthly premium, or such portion thereof as is not contributed by a municipality, be deducted by a Police Pension Fund from any monthly pension payment otherwise payable to or on behalf of the police officer pursuant to Article 3 of the Illinois Pension Code, and be remitted by such Pension Fund to the insurance company. The portion, if any, of the monthly premium contributed by a municipality for such continued group insurance coverage shall be paid by the municipality directly to the insurance company issuing the group insurance policy, or as otherwise directed by the insurance company. Such continued group insurance coverage shall relate back to the beginning of the police officer's retirement or disability period.
    The amendment, renewal or extension of any group insurance policy affected by this Section shall be deemed to be the issuance of a new policy of insurance for purposes of this Section.
    In the event that a municipality makes a program of accident, health, hospital or medical benefits available to its police officers through self-insurance, or by participation in a pool or reciprocal insurer, or by contract in a form other than a policy of group insurance with one or more medical service plans, health care service corporations, health maintenance organizations, or any other professional corporations or plans under which health care or reimbursement for the costs thereof is provided, whether the cost of such benefits is borne by the municipality or the police officers or both, such police officers and their surviving spouses shall have the same right to elect continued coverage under such program of benefits as they would have if such benefits were provided by a policy of group accident and health insurance. In such cases, the notice of right to elect continued coverage shall be sent by the municipality; the statement of election shall be sent to the municipality; and references to the required premium shall refer to that portion of the cost of such benefits which is not borne by the municipality, either voluntarily or pursuant to the provisions of a collective bargaining agreement. In the case of a municipality providing such benefits through self-insurance or participation in a pool or reciprocal insurer, the right to elect continued coverage which is provided by this paragraph shall be implemented and made available to the police officers of the municipality and qualifying surviving spouses not later than July 1, 1986.
    The amendment, renewal or extension of any such contract in a form other than a policy of group insurance policy shall be deemed the formation of a new contract for the purposes of this Section.
    This Section shall not limit the exercise of any conversion privileges available under Section 367e.
(Source: P.A. 84-1010.)

215 ILCS 5/367h

    (215 ILCS 5/367h) (from Ch. 73, par. 979h)
    Sec. 367h. Deputy's continuance privilege. As used in this Section:
    1. The terms "municipality" and "creditable service" shall have the meaning ascribed to such terms by Sections 7-105 and 7-113, respectively, of the Illinois Pension Code, as now or hereafter amended.
    The term "deferred pensioner" means a deputy who has retired, having accumulated enough creditable service to qualify for a pension, but who has not attained the required age.
    2. The term "deputy" shall mean a "sheriff's law enforcement employee" as defined in Section 7-109.3 of the Illinois Pension Code, and include only persons under the coverage of Article 7 of that Code, as heretofore or hereafter amended.
    3. The "retirement or disability period" of a deputy means the period:
        a. which begins on the day the deputy is removed from
    
a sheriff's police department payroll because of the occurrence of any of the following events, to wit: (i) the deputy retires as a deferred pensioner, (ii) the deputy retires from active service as a deputy with an attained age and accumulated creditable service which together qualify the deputy for immediate receipt of retirement pension benefits under Section 7-142.1 of the Illinois Pension Code, or (iii) the deputy's disability is established under Article 7 of the Illinois Pension Code; and
        b. which ends on the first to occur of any of the
    
following events, to wit: (i) the deputy's reinstatement or reentry into active service in the sheriff's police department as provided for under Article 7 of the Illinois Pension Code, (ii) the deputy's exercise of any refund option or acceptance of any separation benefit available under Article 7 of the Illinois Pension Code, (iii) the deputy's loss pursuant to Section 7-219 of the Illinois Pension Code of any benefits provided for in Article 7 of that Code, or (iv) the deputy's death or -- if at the time of the deputy's death the deputy is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 7 of the Illinois Pension Code -- the death or remarriage of that spouse.
    No policy of group accident and health insurance under which deputies employed by a municipality are insured for their individual benefit shall be issued or delivered in this State to any municipality unless such group policy provides for the election of continued group insurance coverage for the retirement or disability period of each deputy who is insured under the provisions of the group policy on the day immediately preceding the day on which the retirement or disability period of such deputy begins. So long as any required premiums for continued group insurance coverage are paid in accordance with the provisions of the group policy, an election made pursuant to this Section shall provide continued group insurance coverage for a deputy throughout the retirement or disability period of the deputy and, unless the deputy otherwise elects and subject to any other provisions of the group policy which relate either to the provision or to the termination of dependents' coverage and which are not inconsistent with this Section, for any dependents of the deputy who are insured under the group policy on the day immediately preceding the day on which the retirement or disability period of the deputy begins; provided, however, that when such continued group insurance coverage is in effect with respect to a deputy on the date of the deputy's death but the retirement or disability period of the deputy does not end with such deputy's death, then the deceased deputy's surviving spouse upon whose death or remarriage such retirement or disability period will end shall be entitled, without further election and upon payment of any required premiums in accordance with the provisions of the group policy, to maintain such continued group insurance coverage in effect until the end of such retirement or disability period. Continued group insurance coverage shall be provided in accordance with this Section at the same premium rate from time to time charged for equivalent coverage provided under the group policy with respect to covered deputies whose retirement or disability period has not begun, and no distinction or discrimination in the amount or rate of premiums or in any waiver of premium or other benefit provision shall be made between continued group insurance coverage elected pursuant to this Section and equivalent coverage provided to deputies under the group policy other than pursuant to the provisions of this Section; provided that no municipality shall be required by reason of any provision of this Section to pay any group insurance premium other than one that may be negotiated in a collective bargaining agreement. If the group policy provides for a reduction in benefits and premium for insureds who become eligible for medicare, such provision shall apply to persons electing continued coverage under this Section.
    Within 15 days of the beginning of the retirement or disability period of any deputy entitled to elect continued group insurance coverage under any group policy affected by this Section, the municipality last employing such deputy shall give written notice of such beginning by certified mail, return receipt requested, to the insurance company issuing such policy. The notice shall include the deputy's name and last known place of residence and the beginning date of the deputy's retirement or disability period.
    Within 15 days of the date of receipt of such notice from the municipality, the insurance company by certified mail, return receipt requested, shall give written notice to the deputy at the deputy's last known place of residence that coverage under the group policy may be continued for the retirement or disability period of the deputy as provided in this Section. Such notice shall set forth: (i) a statement of election to be filed by the deputy if the deputy wishes to continue such group insurance coverage, (ii) the amount of monthly premium, including a statement of the portion of such monthly premium attributable to any dependents' coverage which the deputy may elect, and (iii) instructions as to the return of the election form to the insurance company issuing such policy. Election shall be made, if at all, by returning the statement of election to the insurance company by certified mail, return receipt requested, within 15 days after having received it.
    If the deputy elects to continue coverage, it shall be the obligation of the deputy to pay the monthly premium directly to the municipality which shall forward it to the insurance company issuing the group insurance policy, or as otherwise directed by the insurance company; provided, however, that the deputy shall be entitled to designate on the statement of election required to be filed with the insurance company that the total monthly premium, or such portion thereof as is not contributed by a municipality, be deducted by the Illinois Municipal Retirement Fund from the monthly pension payment otherwise payable to or on behalf of the deputy pursuant to Article 7 of the Illinois Pension Code, and be remitted by such Fund to the insurance company. The portion, if any, of the monthly premium contributed by a municipality for such continued group insurance coverage shall be paid by the directly to the insurance company issuing the group insurance policy, or as directed by the insurance company. Such continued group insurance coverage shall relate back to the beginning of the deputy's retirement or disability period.
    The amendment, renewal or extension of any group insurance policy affected by this Section shall be deemed to be the issuance of a new policy of insurance for purposes of this Section.
    In the event that a municipality makes a program of accident, health, hospital or medical benefits available to its deputies through self-insurance, or by participation in a pool or reciprocal insurer, or by contract in a form other than a policy of group insurance with one or more medical service plans, health care service corporations, health maintenance organizations, or any other professional corporations or plans under which health care or reimbursement for the costs thereof is provided, whether the cost of such benefits is borne by the municipality or the deputies or both, such deputies and their surviving spouses shall have the same right to elect continued coverage under such program of benefits as they would have if such benefits were provided by a policy of group accident and health insurance. In such cases, the notice of right to elect continued coverage shall be sent by the municipality; the statement of election shall be sent to the municipality; and references to the required premium shall refer to that portion of the cost of such benefits which is not borne by the municipality, either voluntarily or pursuant to the provisions of a collective bargaining agreement. In the case of a municipality providing such benefits through self-insurance or participation in a pool or reciprocal insurer, the right to elect continued coverage which is provided by this paragraph shall be implemented and made available to the deputies of the municipality and qualifying surviving spouses not later than July 1, 1986.
    The amendment, renewal or extension of any such contract in a form other than a policy of group insurance policy shall be deemed the formation of a new contract for the purposes of this Section.
    This Section shall not limit the exercise of any conversion privileges available under Section 367e.
(Source: P.A. 90-655, eff. 7-30-98.)

215 ILCS 5/367i

    (215 ILCS 5/367i) (from Ch. 73, par. 979i)
    Sec. 367i. Discontinuance and replacement of coverage. Group health insurance policies issued, amended, delivered or renewed on and after the effective date of this amendatory Act of 1989, shall provide a reasonable extension of benefits in the event of total disability on the date the policy is discontinued for any reason.
    Any applicable extension of benefits or accrued liability shall be described in the policy and group certificate. Benefits payable during any extension of benefits may be subject to the policy's regular benefit limits.
    Any insurer discontinuing a group health insurance policy shall provide to the policyholder for delivery to covered employees or members a notice as to the date such discontinuation is to be effective and urging them to refer to their group certificates to determine what contract rights, if any, are available to them.
    In the event a discontinued policy is replaced by another group policy, the prior insurer or plan shall be liable only to the extent of its accrued liabilities and extension of benefits. Persons eligible for coverage under the succeeding insurer's plan shall include all employees and dependents covered under the prior insurer's plan, including individuals with disabilities covered under the prior plan but absent from work on the effective date and thereafter. The prior insurer shall provide extension of benefits for an insured's disabling condition when no coverage is available under the succeeding insurer's plan whether due to the absence of coverage in the contract or lack of required creditable coverage for a preexisting condition.
    The Director shall promulgate reasonable rules as necessary to carry out this Section.
(Source: P.A. 99-143, eff. 7-27-15.)

215 ILCS 5/367j

    (215 ILCS 5/367j) (from Ch. 73, par. 979j)
    Sec. 367j. Municipal employee's continuance privilege.
    (a) As used in this Section:
        (1) The term "creditable service" shall have the
    
meaning ascribed to it by Section 7-113 of the Illinois Pension Code.
        (2) The term "municipality" means any municipality,
    
instrumentality, or participating instrumentality (as those terms are defined in Sections 7-105, 7-107 and 7-108, respectively, of the Illinois Pension Code) that participates in the Illinois Municipal Retirement Fund pursuant to Section 7-132 of the Illinois Pension Code.
        (3) The term "employee" shall mean an employee as
    
defined in Section 7-109 of the Illinois Pension Code, but does not include any person who is a deputy as defined in Section 367h of this Code.
        (4) The "retirement or disability period" of an
    
employee means the period:
            (A) which begins on the day the employee is
        
removed from the municipality payroll because of the occurrence of either of the following events: (i) the employee retires from active service as an employee with an attained age and accumulated creditable service which together qualify the employee for immediate receipt of retirement pension benefits under Article 7 of the Illinois Pension Code, or (ii) the employee's disability is established under Article 7 of the Illinois Pension Code; and
            (B) which ends on the first to occur of any of
        
the following events: (i) the employee's reinstatement or reentry into active service as provided for under Article 7 of the Illinois Pension Code, (ii) the employee's exercise of any refund option or acceptance of any separation benefit available under Article 7 of the Illinois Pension Code, (iii) the employee's loss pursuant to Section 7-219 of the Illinois Pension Code of any benefits provided for in Article 7 of that Code, or (iv) the employee's death or, if at the time of the employee's death the employee is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 7 of the Illinois Pension Code, the death or remarriage of that spouse.
    (b) No policy of group accident and health insurance under which employees of a municipality are insured for their individual benefit shall be issued or delivered in this State to a municipality unless such group policy provides for the election of continued group insurance coverage for the retirement or disability period of each employee who is insured under the provisions of the group policy on the day immediately preceding the day on which the retirement or disability period of such employee begins. So long as any required premiums for continued group insurance coverage are paid in accordance with the provisions of the group policy, an election made pursuant to this Section shall provide continued group insurance coverage for an employee throughout the retirement or disability period of the employee and, unless the employee otherwise elects and subject to any other provisions of the group policy which relate either to the provision or to the termination of dependents' coverage and which are not inconsistent with this Section, for any dependents of the employee who are insured under the group policy on the day immediately preceding the day on which the retirement or disability period of the employee begins; provided, however, that when such continued group insurance coverage is in effect with respect to an employee on the date of the employee's death but the retirement or disability period of the employee does not end with the employee's death, then the deceased employee's surviving spouse upon whose death or remarriage such retirement or disability period will end shall be entitled, without further election and upon payment of any required premiums in accordance with the provisions of the group policy, to maintain such continued group insurance coverage in effect until the end of the retirement or disability period. Continued group insurance coverage shall be provided in accordance with this Section at the same premium rate from time to time charged for equivalent coverage provided under the group policy with respect to covered employees whose retirement or disability period has not begun, and no distinction or discrimination in the amount or rate of premiums or in any waiver of premium or other benefit provision shall be made between continued group insurance coverage elected pursuant to this Section and equivalent coverage provided to employees under the group policy other than pursuant to the provisions of this Section; provided that no municipality shall be required by reason of any provision of this Section to pay any group insurance premium other than one that may be negotiated in a collective bargaining agreement. If the group policy provides for a reduction in benefits and premium for insureds who become eligible for medicare, such provision shall apply to persons electing continued coverage under this Section.
    Within 15 days of the beginning of the retirement or disability period of any employee entitled to elect continued group insurance coverage under any group policy affected by this Section, the municipality last employing such employee shall give written notice of such beginning by certified mail, return receipt requested, to the insurance company issuing such policy. The notice shall include the employee's name and last known place of residence and the beginning date of the employee's retirement or disability period.
    Within 15 days of the date of receipt of such notice from the municipality, the insurance company by certified mail, return receipt requested, shall give written notice to the employee at the employee's last known place of residence that coverage under the group policy may be continued for the retirement or disability period of the employee as provided in this Section. Such notice shall set forth: (i) a statement of election to be filed by the employee if the employee wishes to continue such group insurance coverage, (ii) the amount of monthly premium, including a statement of the portion of such monthly premium attributable to any dependents' coverage which the employee may elect, and (iii) instructions as to the return of the election form to the insurance company issuing such policy. Election shall be made, if at all, by returning the statement of election to the insurance company by certified mail, return receipt requested, within 15 days after having received it.
    If the employee elects to continue coverage, it shall be the obligation of the employee to pay the monthly premium directly to the municipality which shall forward it to the insurance company issuing the group insurance policy, or as otherwise directed by the insurance company; provided, however, that the employee shall be entitled to designate on the statement of election required to be filed with the insurance company that the total monthly premium, or such portion thereof as is not contributed by a municipality, be deducted by the Illinois Municipal Retirement Fund from the monthly pension payment otherwise payable to or on behalf of the employee pursuant to Article 7 of the Illinois Pension Code, and be remitted by such Fund to the insurance company. The portion, if any, of the monthly premium contributed by a municipality for such continued group insurance coverage shall be paid by the municipality directly to the insurance company issuing the group insurance policy, or as directed by the insurance company. Such continued group insurance coverage shall relate back to the beginning of the employee's retirement or disability period.
    The amendment, renewal or extension of any group insurance policy affected by this Section shall be deemed to be the issuance of a new policy of insurance for purposes of this Section.
    (c) In the event that a municipality makes a program of accident, health, hospital or medical benefits available to its employees through self-insurance, or by participation in a pool or reciprocal insurer, or by contract in a form other than a policy of group insurance with one or more medical service plans, health care service corporations, health maintenance organizations, or any other professional corporations or plans under which health care or reimbursement for the costs thereof is provided, whether the cost of such benefits is borne by the municipality or the employees or both, such employees and their surviving spouses shall have the same right to elect continued coverage under such program of benefits as they would have if such benefits were provided by a policy of group accident and health insurance. In such cases, the notice of right to elect continued coverage shall be sent by the municipality; the statement of election shall be sent to the municipality; and references to the required premium shall refer to that portion of the cost of such benefits which is not borne by the municipality, either voluntarily or pursuant to the provisions of a collective bargaining agreement. In the case of a municipality providing such benefits through self-insurance or participation in a pool or reciprocal insurer, the right to elect continued coverage which is provided by this paragraph shall be implemented and made available to the employees of the municipality and qualifying surviving spouses not later than July 1, 1991.
    The amendment, renewal or extension of any such contract in a form other than a policy of group insurance policy shall be deemed the formation of a new contract for the purposes of this Section.
    (d) This Section shall not limit the exercise of any conversion privileges available under Section 367e.
(Source: P.A. 86-1444; 87-435.)

215 ILCS 5/367k

    (215 ILCS 5/367k)
    Sec. 367k. Intoxication and narcotics; exclusion of coverage prohibited.
    (a) A group or individual major medical policy of accident or health insurance or managed care plan amended, delivered, issued, or renewed after January 1, 2008 shall not, solely on the basis of the insured being intoxicated or under the influence of a narcotic, exclude coverage for any emergency or other medical, hospital, or surgical expenses incurred by an insured as a result of and related to an injury acquired while the insured is intoxicated or under the influence of any narcotic, regardless of whether the intoxicant or narcotic is administered on the advice of a health care practitioner.
    (b) Coverage required under this Section may be subject to deductibles, copayments, coinsurance, or annual or maximum payment limits that are consistent with deductibles, copayments, coinsurance, or annual or maximum payment limits applicable to other similar coverage under the plan.
(Source: P.A. 95-230, eff. 1-1-08.)

215 ILCS 5/367m

    (215 ILCS 5/367m)
    Sec. 367m. Early intervention services. A policy of accident and health insurance that provides coverage for early intervention services must conform to the following criteria:
        (1) The use of private health insurance to pay for
    
early intervention services under Part C of the federal Individuals with Disabilities Education Act may not count towards or result in a loss of benefits due to annual or lifetime insurance caps for an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy.
        (2) The use of private health insurance to pay for
    
early intervention services under Part C of the federal Individuals with Disabilities Education Act may not negatively affect the availability of health insurance to an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy, and health insurance coverage may not be discontinued for these individuals due to the use of the health insurance to pay for services under Part C of the federal Individuals with Disabilities Education Act.
        (3) The use of private health insurance to pay for
    
early intervention services under Part C of the federal Individuals with Disabilities Education Act may not be the basis for increasing the health insurance premiums of an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members covered under that health insurance policy.
    For the purposes of this Section, "early intervention services" has the same meaning as in the Early Intervention Services System Act.
(Source: P.A. 98-41, eff. 6-28-13.)

215 ILCS 5/368

    (215 ILCS 5/368) (from Ch. 73, par. 980)
    Sec. 368. Industrial accident and health insurance.
    (1) Industrial accident and health insurance is hereby declared to be that form of accident and health insurance in which the premium is payable weekly.
    (2) Any insurance company authorized to write accident and health insurance in this State shall have power to issue industrial accident and health policies. No policy of industrial accident and health insurance may be issued or delivered in this State unless it has printed thereon the words "Industrial Policy," a copy of the form thereof shall have been filed with the department and approved by it in accordance with section 355.
(Source: Laws 1951, p. 611.)

215 ILCS 5/368a

    (215 ILCS 5/368a)
    Sec. 368a. Timely payment for health care services.
    (a) This Section applies to insurers, health maintenance organizations, managed care plans, health care plans, preferred provider organizations, third party administrators, independent practice associations, and physician-hospital organizations (hereinafter referred to as "payors") that provide periodic payments, which are payments not requiring a claim, bill, capitation encounter data, or capitation reconciliation reports, such as prospective capitation payments, to health care professionals and health care facilities to provide medical or health care services for insureds or enrollees.
        (1) A payor shall make periodic payments in
    
accordance with item (3). Failure to make periodic payments within the period of time specified in item (3) shall entitle the health care professional or health care facility to interest at the rate of 9% per year from the date payment was required to be made to the date of the late payment, provided that interest amounting to less than $1 need not be paid. Any required interest payments shall be made within 30 days after the payment.
        (2) When a payor requires selection of a health care
    
professional or health care facility, the selection shall be completed by the insured or enrollee no later than 30 days after enrollment. The payor shall provide written notice of this requirement to all insureds and enrollees. Nothing in this Section shall be construed to require a payor to select a health care professional or health care facility for an insured or enrollee.
        (3) A payor shall provide the health care
    
professional or health care facility with notice of the selection as a health care professional or health care facility by an insured or enrollee and the effective date of the selection within 60 calendar days after the selection. No later than the 60th day following the date an insured or enrollee has selected a health care professional or health care facility or the date that selection becomes effective, whichever is later, or in cases of retrospective enrollment only, 30 days after notice by an employer to the payor of the selection, a payor shall begin periodic payment of the required amounts to the insured's or enrollee's health care professional or health care facility, or the designee of either, calculated from the date of selection or the date the selection becomes effective, whichever is later. All subsequent payments shall be made in accordance with a monthly periodic cycle.
    (b) Notwithstanding any other provision of this Section, independent practice associations and physician-hospital organizations shall make periodic payment of the required amounts in accordance with a monthly periodic schedule after an insured or enrollee has selected a health care professional or health care facility or after that selection becomes effective, whichever is later.
    Notwithstanding any other provision of this Section, independent practice associations and physician-hospital organizations shall make all other payments for health services within 30 days after receipt of due proof of loss. Independent practice associations and physician-hospital organizations shall notify the insured, insured's assignee, health care professional, or health care facility of any failure to provide sufficient documentation for a due proof of loss within 30 days after receipt of the claim for health services.
    Failure to pay within the required time period shall entitle the payee to interest at the rate of 9% per year from the date the payment is due to the date of the late payment, provided that interest amounting to less than $1 need not be paid. Any required interest payments shall be made within 30 days after the payment.
    (c) All insurers, health maintenance organizations, managed care plans, health care plans, preferred provider organizations, and third party administrators shall ensure that all claims and indemnities concerning health care services other than for any periodic payment shall be paid within 30 days after receipt of due written proof of such loss. An insured, insured's assignee, health care professional, or health care facility shall be notified of any known failure to provide sufficient documentation for a due proof of loss within 30 days after receipt of the claim for health care services. Failure to pay within such period shall entitle the payee to interest at the rate of 9% per year from the 30th day after receipt of such proof of loss to the date of late payment, provided that interest amounting to less than one dollar need not be paid. Any required interest payments shall be made within 30 days after the payment.
    (d) The Department shall enforce the provisions of this Section pursuant to the enforcement powers granted to it by law.
    (e) The Department is hereby granted specific authority to issue a cease and desist order, fine, or otherwise penalize independent practice associations and physician-hospital organizations that violate this Section. The Department shall adopt reasonable rules to enforce compliance with this Section by independent practice associations and physician-hospital organizations.
(Source: P.A. 97-813, eff. 7-13-12.)

215 ILCS 5/368b

    (215 ILCS 5/368b)
    Sec. 368b. Contracting procedures.
    (a) A health care professional or health care provider offered a contract by an insurer, health maintenance organization, independent practice association, or physician hospital organization for signature after the effective date of this amendatory Act of the 93rd General Assembly shall be provided with a proposed health care professional or health care provider services contract including, if any, exhibits and attachments that the contract indicates are to be attached. Within 35 days after a written request, the health care professional or health care provider offered a contract shall be given the opportunity to review and obtain a copy of the following: a specialty-specific fee schedule sample based on a minimum of the 50 highest volume fee schedule codes with the rates applicable to the health care professional or health care provider to whom the contract is offered, the network provider administration manual, and a summary capitation schedule, if payment is made on a capitation basis. If 50 codes do not exist for a particular specialty, the health care professional or health care provider offered a contract shall be given the opportunity to review or obtain a copy of a fee schedule sample with the codes applicable to that particular specialty. This information may be provided electronically. An insurer, health maintenance organization, independent practice association, or physician hospital organization may substitute the fee schedule sample with a document providing reference to the information needed to calculate the fee schedule that is available to the public at no charge and the percentage or conversion factor at which the insurer, health maintenance organization, preferred provider organization, independent practice association, or physician hospital organization sets its rates.
    (b) The fee schedule, the capitation schedule, and the network provider administration manual constitute confidential, proprietary, and trade secret information and are subject to the provisions of the Illinois Trade Secrets Act. The health care professional or health care provider receiving such protected information may disclose the information on a need to know basis and only to individuals and entities that provide services directly related to the health care professional's or health care provider's decision to enter into the contract or keep the contract in force. Any person or entity receiving or reviewing such protected information pursuant to this Section shall not disclose the information to any other person, organization, or entity, unless the disclosure is requested pursuant to a valid court order or required by a state or federal government agency. Individuals or entities receiving such information from a health care professional or health care provider as delineated in this subsection are subject to the provisions of the Illinois Trade Secrets Act.
    (c) The health care professional or health care provider shall be allowed at least 30 days to review the health care professional or health care provider services contract, including exhibits and attachments, if any, before signing. The 30-day review period begins upon receipt of the health care professional or health care provider services contract, unless the information available upon request in subsection (a) is not included. If information is not included in the professional services contract and is requested pursuant to subsection (a), the 30-day review period begins on the date of receipt of the information. Nothing in this subsection shall prohibit a health care professional or health care provider from signing a contract prior to the expiration of the 30-day review period.
    (d) As used in this subsection:
    "Change" means an increase or decrease in the fee schedule referred to in subsection (a).
    "Nonroutine change" means any proposed change to the fee schedule except a change that is otherwise required by law, regulation, or an applicable regulatory authority or that is required as a result of changes in fee schedules, reimbursement methodology, or payment policies established by a government agency or by the American Medical Association's current procedural terminology codes, reporting guidelines, and conventions, or a change that is expressly provided for under the terms of the contract by the inclusion of or reference to a specific fee or fee schedule, reimbursement methodology, or payment policy indexing mechanism.
    The insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide all contracted health care professionals or health care providers with any changes to the fee schedule provided under subsection (a) not later than 35 days after the effective date of the changes, unless such changes are specified in the contract and the health care professional or health care provider is able to calculate the changed rates based on information in the contract and information available to the public at no charge. Beginning January 1, 2023, with respect to nonroutine changes to the fee schedule, the insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide all contracted health care professionals or health care providers impacted by the nonroutine change with notice of the change at least 60 days before the effective date of the change. The right to advance notice of nonroutine changes to the fee schedule may not be waived by the health care professional or health care provider. For the purposes of this subsection (d), health maintenance organizations that provide or arrange for and pay or reimburse for the cost of any health care services for persons who are enrolled in the medical assistance programs under the Illinois Public Aid Code shall comply with provider notification requirements established by the Department of Healthcare and Family Services.
     This information may be made available by mail, e-mail, newsletter, website listing, or other reasonable method. For nonroutine changes, the information directing the health care professional or health care provider to the information provided by newsletter, website listing, or other reasonable method shall be provided by email or, if requested by the health care professional or health care provider, by mail. Upon request, a health care professional or health care provider may request an updated copy of the fee schedule referred to in subsection (a) every calendar quarter.
    (e) Upon termination of a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization and at the request of the patient, a health care professional or health care provider shall transfer copies of the patient's medical records. Any other provision of law notwithstanding, the costs for copying and transferring copies of medical records shall be assigned per the arrangements agreed upon, if any, in the health care professional or health care provider services contract.
(Source: P.A. 102-957, eff. 1-1-23.)

215 ILCS 5/368c

    (215 ILCS 5/368c)
    Sec. 368c. Remittance advice and procedures.
    (a) A remittance advice shall be furnished to a health care professional or health care provider that identifies the disposition of each claim. The remittance advice shall identify the services billed; the patient responsibility, if any; the actual payment, if any, for the services billed; and the reason for any reduction to the amount for which the claim was submitted. For any reductions to the amount for which the claim was submitted, the remittance shall identify any withholds and the reason for any denial or reduction.
    A remittance advice for capitation or prospective payment arrangements shall be furnished to a health care professional or health care provider pursuant to a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization in accordance with the terms of the contract.
    (b) When health care services are provided by a non-participating health care professional or health care provider, an insurer, health maintenance organization, independent practice association, or physician hospital organization may pay for covered services either to a patient directly or to the non-participating health care professional or health care provider.
    (c) When a person presents a benefits information card, a health care professional or health care provider shall make a good faith effort to inform the person if the health care professional or health care provider has a participation contract with the insurer, health maintenance organization, or other entity identified on the card.
(Source: P.A. 93-261, eff. 1-1-04.)

215 ILCS 5/368d

    (215 ILCS 5/368d)
    Sec. 368d. Recoupments.
    (a) A health care professional or health care provider shall be provided a remittance advice, which must include an explanation of a recoupment or offset taken by an insurer, health maintenance organization, independent practice association, or physician hospital organization, if any. The recoupment explanation shall, at a minimum, include the name of the patient; the date of service; the service code or if no service code is available a service description; the recoupment amount; and the reason for the recoupment or offset. In addition, an insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide with the remittance advice, or with any demand for recoupment or offset, a telephone number or mailing address to initiate an appeal of the recoupment or offset together with the deadline for initiating an appeal. Such information shall be prominently displayed on the remittance advice or written document containing the demand for recoupment or offset. Any appeal of a recoupment or offset by a health care professional or health care provider must be made within 60 days after receipt of the remittance advice.
    (b) It is not a recoupment when a health care professional or health care provider is paid an amount prospectively or concurrently under a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization that requires a retrospective reconciliation based upon specific conditions outlined in the contract.
    (c) No recoupment or offset may be requested or withheld from future payments 12 months or more after the original payment is made, except in cases in which:
        (1) a court, government administrative agency, other
    
tribunal, or independent third-party arbitrator makes or has made a formal finding of fraud or material misrepresentation;
        (2) an insurer is acting as a plan administrator for
    
the Comprehensive Health Insurance Plan under the Comprehensive Health Insurance Plan Act;
        (3) the provider has already been paid in full by any
    
other payer, third party, or workers' compensation insurer; or
        (4) an insurer contracted with the Department of
    
Healthcare and Family Services is required by the Department of Healthcare and Family Services to recoup or offset payments due to a federal Medicaid requirement.
No contract between an insurer and a health care professional or health care provider may provide for recoupments in violation of this Section. Nothing in this Section shall be construed to preclude insurers, health maintenance organizations, independent practice associations, or physician hospital organizations from resolving coordination of benefits between or among each other, including, but not limited to, resolution of workers' compensation and third-party liability cases, without recouping payment from the provider beyond the 18-month time limit provided in this subsection (c).
(Source: P.A. 102-632, eff. 1-1-22.)

215 ILCS 5/368e

    (215 ILCS 5/368e)
    Sec. 368e. Administration and enforcement.
    (a) Other than the duties specifically created in Sections 368b, 368c, and 368d, nothing in those Sections is intended to preclude, prevent, or require the adoption, modification, or termination of any utilization management, quality management, or claims processing methodologies or other provisions of a contract applicable to services provided under a contract between an insurer, health maintenance organization, independent practice association, or physician hospital organization and a health care professional or health care provider.
    (b) Nothing in Sections 368b, 368c, and 368d precludes, prevents, or requires the adoption, modification, or termination of any health plan term, benefit, coverage or eligibility provision, or payment methodology.
    (c) The provisions of Sections 368b, 368c, and 368d are deemed incorporated into health care professional and health care provider service contracts entered into on or before the effective date of this amendatory Act of the 93rd General Assembly and do not require an insurer, health maintenance organization, independent practice association, or physician hospital organization to renew or renegotiate the contracts with a health care professional or health care provider.
    (d) The Department shall enforce the provisions of this Section and Sections 368b, 368c, and 368d pursuant to the enforcement powers granted to it by law.
    (e) The Department is hereby granted specific authority to issue a cease and desist order against, fine, or otherwise penalize independent practice associations and physician-hospital organizations for violations.
    (f) The Department shall adopt reasonable rules to enforce compliance with this Section and Sections 368b, 368c, and 368d.
(Source: P.A. 93-261, eff. 1-1-04.)