Health Insurance Benefit Coverage Law Summaries
Illinois, Health Insurance Benefit Coverage Law Summaries
Illinois' mandated health care law is codified in the Illinois Compiled Statutes Annotated at Chapter 215. Some of the coordination of benefits provisions and preexisting conditions provisions are located in the state's administrative rules and insurance code.
DEFINITIONS
“Serious mental illness” means the following psychiatric illnesses as defined in the most current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association (215 ILCS 5/370c(b), as amended by H. 953 and H. 1432, L. 2007, enacted September 22, 2008):
schizophrenia;
paranoid and other psychotic disorders;
bipolar disorders;
major depressive disorders;
schizoaffective disorders;
pervasive developmental disorders;
obsessive-compulsive disorders;
depression in childhood and adolescence;
panic disorder;
post-traumatic stress disorders; and
anorexia nervosa and bulimia nervosa.
“Small employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least two but not more than 50 employees on business days during the preceding calendar year and who employs at least two employees on the first day of the plan year (Sec. 5, S. 802, L. 1997, effective July 1, 1997).
“Preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date (Sec. 5, S. 802, L. 1997, effective July 1, 1997).
Autism spectrum disorder 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 (215 ILCS 5/356z.14, added by Public Act 95-1005 (S. 934), L. 2007, effective December 12, 2008).
WHAT THE EMPLOYER MUST DO
Illinois does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.
Mental health coverage.- Every insurer that delivers, issues for delivery or renews or modifies group accident and health policies providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis must offer to the applicant or group policyholder subject to the insurer's standards of insurability coverage for reasonable and necessary treatment and services for mental, emotional or nervous disorders or conditions, other than serious mental illnesses as defined above (see DEFINITIONS), up to the limits provided in the policy for other disorders or conditions. The insured may be required to pay up to 50 percent of expenses incurred as a result of the treatment or services, and the annual benefit limit may be limited to the lesser of $10,000 or 25 percent of the lifetime policy limit (215 ILCS 5/370c, as amended by H. 953, L. 2007, enacted and effective September 22, 2008).
An insurer that provides coverage for hospital or medical expenses under a group policy of accident and health insurance or health care plan amended, delivered, issued, or renewed after September 22, 2008, must provide coverage under the policy for treatment of serious mental illness under the same terms and conditions as coverage for hospital or medical expenses related to other illnesses and diseases. The coverage required by this section must provide for same durational limits, amount limits, deductibles, and coinsurance requirements for serious mental illness as are provided for other illnesses and diseases. This subsection does not apply to coverage provided to employees by employers who have 50 or fewer employees (215 ILCS 5/370c(b), as amended by H. 953, L. 2007, enacted and effective September 22, 2008).
Upon request of the reimbursing insurer, a provider of treatment of serious mental illness must furnish medical records or other necessary data that substantiate that initial or continued treatment is at all times medically necessary. An insurer must provide a mechanism for the timely review by a provider holding the same license and practicing in the same specialty as the patient's provider, who is unaffiliated with the insurer, jointly selected by the patient (or the patient's next of kin or legal representative if the patient is unable to act for himself or herself), the patient's provider, and the insurer in the event of a dispute between the insurer and patient's provider regarding the medical necessity of a treatment proposed by a patient's provider. If the reviewing provider determines the treatment is medically necessary, the insurer must provide reimbursement for the treatment. Future contractual or employment actions by the insurer regarding the patient's provider may not be based on the provider's participation in this procedure. Nothing prevents the insured from agreeing in writing to continue treatment at his or her expense. When making a determination of the medical necessity for a treatment modality for serious mental illness, 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 (215 ILCS 5/370c(b), as amended by H. 953, L. 2007, enacted and effective September 22, 2008).
A group health benefit plan (215 ILCS 5/370c(b), as amended by H. 953 and H. 1432, L. 2007, enacted September 22, 2008):
must provide coverage based upon medical necessity for the following treatment of mental illness in each calendar year: (a) 45 days of inpatient treatment; and (b) beginning on June 26, 2006, 60 visits for outpatient treatment including group and individual outpatient treatment; and (c) for plans or policies delivered, issued for delivery, renewed, or modified after January 1, 2007, additional outpatient visits for speech therapy for treatment of pervasive developmental disorders that will be in addition to speech therapy provided pursuant to item (b) just above;
may not include a lifetime limit on the number of days of inpatient treatment or the number of outpatient visits covered under the plan; and
must include the same amount limits, deductibles, copayments, and coinsurance factors for serious mental illness as for physical illness.
An issuer of a group health benefit plan may not count toward the number of outpatient visits required to be covered under this section an outpatient visit for the purpose of medication management and must cover the outpatient visits under the same terms and conditions as it covers outpatient visits for the treatment of physical illness (215 ILCS 5/370c(b), as amended by H. 953, L. 2007, enacted and effective September 22, 2008).
An issuer of a group health benefit plan may provide or offer coverage required under this section through a managed care plan (215 ILCS 5/370c(b), as amended by H. 953, L. 2007, enacted and effective September 22, 2008).
This section shall not be interpreted to require a group health benefit plan to provide coverage for treatment of (215 ILCS 5/370c(b), as amended by H. 953, L. 2007, enacted and effective September 22, 2008):
an addiction to a controlled substance or cannabis that is used unlawfully; or
mental illness resulting from the use of a controlled substance or cannabis unlawfully.
Facilities.- No claim may be denied, under any group accident and health policy delivered or renewed in Illinois for treatment or services for mental illness or rehabilitation following mental illness rendered in a hospital solely because such hospital lacks surgical facilities (Secs. 5/367c and 5/367d).
Dependent care coverage.- No contract or policy issued by a health maintenance organization that provides for coverage of dependents of the principal enrollee may contain any disclaimer, waiver or other limitation relative to the eligibility or coverage of newborn infants of a principal enrollee from and after the moment of birth (Sec. 125/4-8).
Similarly, no policy of accident and health insurance providing coverage of hospital expenses or medical expenses or both on an expense-incurred basis that, in addition to covering the insured, also covers members of the insured's immediate family may 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 (Sec. 5/356c).
Each such contract, evidence of coverage, or policy of accident and health insurance must contain a provision stating that benefits must be granted immediately with respect to a newly born child from the moment of birth. The coverage for newly born children must include coverage of illness, injury, congenital defects, birth abnormalities and premature birth (Secs. 5/356c and 125/4-8).
Adoption.- No contract or evidence of coverage issued by a health maintenance organization that provides for coverage of dependents of the principal enrollees may exclude a child from coverage or eligibility for coverage or limit coverage for a child solely on the basis that he or she is an adopted child (Sec. 125/4-9, as amended by H. 1348, L. 1999, effective August 14, 1999).
Likewise, no group policy of accident and health insurance that covers the insured's immediate family or children, as well as covering the insured, may 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 (Sec. 5/356h, as amended by H. 1348, L. 1999, effective August 14, 1999).
Autism spectrum disorder. -A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued or renewed after December 12, 2008, 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 such diagnosis and treatment is not already covered by the policy or plan. Coverage of autism diagnosis and treatment is subject to a maximum benefit of $36,000 per year, which, after December 30, 2009, is to be adjusted annually for inflation. However, such coverage is not to be subject to any limits on the number of visits to an autism service provider. Coverage is subject to the same copayments, deductibles, and coinsurance provisions of a plan or policy as other covered medical services (215 ILCS 5/356z.14, added by Public Act 95-1005 (S. 934), L. 2007, effective December 12, 2008).
Habilitative services.- Group and individual accident and health insurance policies, as well as managed care plans, must provide coverage for habilitative services (such as occupational therapy, physical therapy and speech therapy) for children under 19 with a congenital, genetic or early acquired disorder. A licensed physician must have diagnosed the disorder; the treatment must be administered by a licensed practitioner upon referral of the physician; and initial or continued treatment must be medically necessary and therapeutic, not experimental or investigational (215 ILCS 5/356z.14 as added by Public Act 1049 (S. 101), L. 2007, enacted April 7, 2009, effective January 1, 2010).
Disabilities.- The attainment of a limiting age under a group contract or evidence of coverage that provides that coverage of a dependent person of an enrollee terminates upon attainment of the limiting age for dependent persons does not operate to terminate the coverage of a person who, because of a handicapped 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 (Sec. 125/4-9.1). This also applies to accident and health insurance polices (Secs. 5/356b and 5/367b).
Extension of age of covered dependents.- Effective June 1, 2009, a group policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after June 1, 2009, 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 (215 ILCS 5/356z.11, as added by P.A. 958 (H. 5285), L. 2007, enacted September 12, 2008).
Effective June 1, 2009, 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 (215 ILCS 5/356z.11, as added by P.A. 958 (H. 5285), L. 2007, enacted September 12, 2008).
Effective June 1, 2009, a group policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after June 1, 2009, 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 (215 ILCS 5/356z.12(a), as added by P.A. 958 (H. 5285), L. 2007, enacted September 12, 2008).
Effective June 1, 2009, 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 (215 ILCS 5/356z.12(b), as added by P.A. 958 (H. 5285), L. 2007, enacted September 12, 2008).
Effective June 1, 2009, 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 (215 ILCS 5/356z.12(c), as added by P.A. 958 (H. 5285), L. 2007, enacted September 12, 2008):
a period of continuous creditable coverage of 90 days or more; and
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 and that dependent shall not be denied coverage due to age.
Effective June 1, 2009, a group policy of accident and health insurance or managed care plan that provides coverage for dependents and that is amended, delivered, issued, or renewed after June 1, 2009, 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, 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 (215 ILCS 5/356z.12(d), as added by P.A. 958 (H. 5285), L. 2007, enacted September 12, 2008).
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 (215 ILCS 5/356z.12(f), as added by P.A. 958 (H. 5285), L. 2007, enacted September 12, 2008).
Substance abuse coverage.- No policy of group accident and health insurance delivered in Illinois that provides inpatient hospital coverage for sicknesses, other than a policy that covers only specified sicknesses, may exclude from such coverage the treatment of alcoholism (Sec. 5/367, as amended by H. 1348, L. 1999, effective August 14, 1999).
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 Illinois if it excludes from coverage services provided by persons or entities licensed by the Department of Alcoholism and Substance Abuse to provide alcoholism or drug abuse or dependency services. Charges must otherwise be eligible for reimbursement under the policy, however, and the services provided must be medically necessary and within the scope of the licensure of the provider (Sec. 5/367d.1).
Exceptions.- The substance abuse provision outlined above does not apply to arrangements, agreements or policies authorized under the following Illinois laws: Health Care Reimbursement Reform Act of 1985; Limited Health Service Organization Act; or the Health Maintenance Organization Act (Sec. 5/367d.1).
Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, health maintenance organizations, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.
Group accident and health insurance plans must specify how benefits will be coordinated (Sec. 5/367, as amended by H. 1348, L. 1999, effective August 14, 1999; and Sec. 401; 12 Ill. Adm. Code 17346; and 15 Ill. Adm. Code 15061). Small employer plans must follow the birthday rule when coordinating benefits for dependent children (Sec. 5/367, as amended by H. 1348, L. 1999, effective August 14, 1999).
Order of benefits.- The following priority applies when coordinating health benefit payments (Illinois Administrative Rules, Title 50, Chapter 1, Subchapter Z, Part 2009 (50 Ill. Adm. Code 2009.40)):
Employee/Dependent: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent. A primary plan must pay benefits as if the secondary plan does not exist unless the secondary plan is designed to provide benefits that supplement the basic or primary plan;
Dependent Child/Birthday Rule: For a dependent child covered by two health benefit plans, health maintenance organizations, or health insurance policies whose parents are not separated or divorced, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time;
Dependent Child/Divorced or Separated Parents: For a dependent child covered by two health benefit plans, health maintenance organizations, or health insurance policies whose parents are separated or divorced, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent. If a court decree states that the parents will share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child should follow the order of benefit determination rules outlined in the birthday rule. If only one plan specifies the birthday rule and the other plan pays benefits according to the gender of the parent, benefits will be paid first according to the gender rule;
Active/Inactive Employee: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored;
Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time; and
Continuation Coverage: For an individual covered by two health benefit plans, health maintenance organizations, or health insurance policies one of which is a COBRA continuation plan, benefits will be paid first by the plan that covers the individual as an employee, member, or subscriber or as the employee's dependent and second under the COBRA continuation coverage. If only one of the two plans specifies this rule, this standard is ignored.
Maintenance of benefits.- A plan that pays benefits on a secondary basis may reduce benefits as long as the total benefits paid do not exceed allowable expenses (Sec. 5/367, as amended by H. 1348, L. 1999).
Medicare coordination.- The benefits of the plan that covers the person as an employee, member or subscriber (or other than as a dependent) are determined before those of the plan that covers the person as a dependent; except that if the person is also a Medicare beneficiary, Medicare is secondary to the plan covering the person as a dependent and primary to the plan covering the person as other than a dependent (for example, a retired employee) (Illinois Administrative Rules, Title 50, Chapter 1, Subchapter Z, Part 2009 (50 Ill. Adm. Code 2009.40)).
Providers.-Podiatrists.- The person entitled to benefits or person performing services under an individual or group policy of accident and health insurance, or a policy, contract, plan or agreement for hospital or medical service or indemnity, wherever such policy, contract, plan or agreement provides for reimbursement for any service provided by persons licensed under the Illinois Medical Practice Act of 1987, is entitled to reimbursement on an equal basis for such service when the said service is performed by a person licensed under the Illinois Medical Practice Act of 1987 or the Podiatric Medical Practice Act of 1987. This provision does not apply to any policy, contract, plan or agreement in effect prior to September 19, 1969, or to preferred provider arrangements or benefit agreements (Sec. 5/370b).
Psychologists/social workers.- Each insured that is covered for mental, emotional or nervous disorders or conditions is free to select the physician licensed to practice medicine in all its branches, licensed clinical psychologist, licensed clinical social worker, licensed clinical professional counselor, or licensed marriage and family therapist of his or her choice to treat such disorders (215 ILCS 5/370c(a), as amended by H. 953, L. 2007, enacted and effective September 22, 2008).
Preexisting conditions.- A group health plan and a health insurance issuer offering group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if (Sec. 20, S. 802, L. 1997, effective July 1, 1997):
the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment date;
the exclusion extends for a period of not more than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and
the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the participant or beneficiary as of the enrollment date.
A group health plan or health insurance issuer offering group health insurance coverage may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition. Genetic information may not be treated as a preexisting condition in the absence of a diagnosis of the condition related to such information (Sec. 20, S. 802, L. 1997, effective July 1, 1997).
HMOs that offer health insurance coverage in connection with a group health plan and that do not impose any allowable preexisting condition exclusion may impose an “affiliation period” if the period is applied uniformly without regard to health status-related factors and does not exceed two months (three months in the case of a late enrollee) (Sec. 20, S. 802, L. 1997, effective July 1, 1997).
State employees.- State employees transferred from previous coverage will be transferred regardless of preexisting conditions or waiting periods (Illinois Compiled Statutes Annotated, Chapter 5, Sec. 375/8).
Prescription drugs.- No HMO that provides coverage for prescribed drugs approved by the federal Food and Drug Administration for the treatment of certain types of cancer may 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 FDA. The drug, however, must be approved by the FDA 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 (Sec. 125/4-6.3):
the American Medical Association Drug Evaluations;
the American Hospital Formulary Service Drug Information; or
the United States Pharmacopeia Drug Information.
If not so recognized in the compendia, the drug must be 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 (Sec. 125/4-6.3).
Any coverage required by this provision must also include those medically necessary services associated with the administration of a drug (Sec. 125/4-6.3).
Despite the provisions outlined above regarding cancer treatment drugs, coverage is not required for any experimental or investigational drugs or any drug that the FDA has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed (Sec. 125/4-6.3).
Formularies.- Accident and health insurers that provide coverage for prescription drugs through the use of a drug formulary must notify insureds of any change in the formulary. A company may comply with this requirement by posting changes in the formulary on its websites (215 ILCS 5/155.37, as added by S. 935, L. 2001, effective August 17, 2001).
Inhalants.- A group policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after August 14, 2003, 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. HMOs are also subject to this provision (215 ILCS 5/356z.4, as added by S. 467, L. 2003; 215 ILCS 125/5-3, as amended by S. 467, L. 2003).
Intoxication and narcotics; exclusion of coverage prohibited.- 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 (215 ILCS 5/367k, as added by S. 21, L. 2007, enacted August 16, 2007).
Contraceptives.- A group policy of accident and health insurance amended, delivered, issued or renewed in Illinois after January 1, 2004, 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 FDA. Nothing in this section shall be construed to require an insurance company to cover services related to an abortion or permanent sterilization that requires a surgical procedure. HMOs must also provide this coverage (215 ILCS 5/356z.4, as added by H. 211, L. 2003, effective January 1, 2004; 215 ILCS 125/5-3, as amended by H. 211, L. 2003, effective January 1, 2004).
Amino acid-based elemental formulas.- A group 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 (215 ILCS 5/356z.9, as added by S. 935, L. 2007).
Clinical breast exams.- Group insurers and HMOs shall provide 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, an advanced practice nurse who has a collaborative agreement with a collaborating physician that authorizes breast examinations, or a physician assistant who has been delegated authority to provide breast examinations, to check for lumps and other changes for the purpose of early detection and prevention of breast cancer as follows (215 ILCS 5/356g.5, as added by H. 147, L. 2007; and 215 ILCS 125/4-6.5, as amended by H. 147, L. 2007):
at least every three years for women at least 20 years of age but less than 40 years of age; and
annually for women 40 years of age or older.
Mammograms.- Group insurers and HMOs must cover screening by low-dose mammography for all women 35 years of age or older for the presence of occult breast cancer. The coverage must be as follows (215 ILCS 5/356g and 215 ILCS 125/4-6.1, as amended by S. 1174, L. 2007, effective March 27, 2009):
a baseline mammogram for women 35 to 39 years of age;
an annual mammogram for women 40 years of age or older;
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;
a comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
Coverage must be provided at no cost to the insured and may not be applied to an annual or lifetime maximum benefit, unless a person does not comply with plan provisions regarding the use of contracted providers. In that case, plan provisions regarding non-contracted providers must be applied (without distinction for mammography) and must be at least as favorable as those for other radiological examinations covered by the policy or contract (215 ILCS 5/356g and 215 ILCS 125/4-6.1, as amended by Public Act 1045 (S. 1174), L. 2007, effective March 27, 2009).
Mastectomies.- No policy of accident or health insurance that provides for the surgical procedure known as a mastectomy may be issued, amended, delivered, or renewed in Illinois unless that coverage also provides for prosthetic devices or reconstructive surgery incident to the mastectomy. Coverage for breast reconstruction in connection with a mastectomy must 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 must be determined in consultation with the attending physician and the patient. The offered coverage for prosthetic devices and reconstructive surgery is subject to the deductible and coinsurance conditions applied to the mastectomy and to 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 two years after the date of the mastectomy (215 ILCS 5/356g, as amended by S. 866, L. 2001, effective July 3, 2001). HMOs must also provide this coverage (215 ILCS 125/4-6.1, as amended by S. 866, L. 2001, effective July 3, 2001).
Breast cancer pain medication and therapy.- Group and individual accident and health insurance policies, as well as managed care plans, must provide coverage for all medically necessary pain medication and pain therapy related to the treatment of breast cancer. Coverage must be provided on the same terms that are generally applicable to coverage for other conditions (215 ILCS 5/356g.5-1, as added by Public Act 1045 (S. 1174), L. 2007, effective March 27, 2009).
Fibrocystic conditions.- No contract or evidence of coverage issued by a health maintenance organization may be denied by the organization, nor may any contract or evidence of coverage contain any exception or exclusion of benefits, solely because the enrollee 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 enrollee's medical history confirms a chronic, relapsing, symptomatic breast condition (Sec. 125/4-16). This also applies to group or individual policies of accident or health insurance or any renewal of such policies (Sec. 5/356n).
Bone mass measurement.- Group or individual policies of accident and health insurance amended, delivered, issued or renewed on or after June 1, 2005, 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 (Sec. 356z.6, as added by S. 2744, L. 2004).
Maternity benefits.- A group policy of accident and health insurance that provides maternity coverage must provide coverage for the following (Sec. 5/356s):
a minimum of 48 hours of inpatient care following a vaginal delivery for the mother and the newborn; or
a minimum of 96 hours of inpatient care following a delivery by caesarian section for the mother and newborn.
A shorter length of hospital inpatient stay for services related to maternity and newborn care may be provided if the attending physician 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 (Sec. 5/356s).
Prenatal HIV testing.- A group policy of accident and health insurance that provides maternity coverage and is amended, delivered, issued, or renewed after July 20, 2001, 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 who has a written collaborative agreement with a collaborating physician that authorizes these services (215 ILCS 5/356z.1, as added by S. 1254, L. 2001, effective July 20, 2001). HMOs must also provide this coverage (215 ILCS 125/4-6.5, as amended by S. 1254, L. 2001, effective July 20, 2001).
Infertility.- 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 Illinois 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 (Sec. 5/356m).
Coverage for infertility is subject to the following conditions (Sec. 5/356m):
Coverage for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer is required only if (a) the covered individual has been unable to attain 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 four completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then two more completed oocyte retrievals must 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.
The procedures required to be covered are not required to be contained in any policy or plan issued to a religious institution or organization or to an entity sponsored by a religious institution or organization that finds such procedures to be in violation of its religious and moral teachings and beliefs.
Sexual assault/abuse victims.- Contracts or evidences of coverage issued by a health maintenance organization that provide benefits for health care services must, to the full extent of coverage provided for any other emergency or accident care, provide for the payment of actual expenses incurred, without offset or reduction for benefit deductibles or coinsurance amounts, in the examination and testing of a victim of sexual assault or abuse 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 venereal disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense (Sec. 125/4-4).
Similarly, no policy of accident and health insurance delivered or issued for delivery to any person in Illinois that provides benefits for hospital or medical expenses based upon the actual expenses incurred, other than a policy that covers hospital and medical expenses for specified illnesses or injuries only, may contain any specific exception to coverage that would preclude the payment under that policy of actual expenses incurred in the examination and testing of a victim of a sexual offense or of 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 venereal 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 that specifically provides benefits for routine physical examinations must provide full coverage for expenses incurred in the examination and testing of such victims (Sec. 5/356e; and Sec. 5/367, as amended by H. 1348, L. 1999, effective August 14, 1999).
No company authorized to transact health insurance in Illinois may deny, refuse to issue, refuse to renew, refuse to reissue, cancel or otherwise terminate an insurance policy or restrict coverage on an individual because that individual is or has been the subject of domestic abuse or because that individual seeks or has sought medical or psychological treatment for domestic abuse or protection or shelter from domestic abuse (Sec. 5/155.22a, as added by S. 490, L. 1997, effective January 1, 1998).
Breast implant removal.- No contract offered by health maintenance organizations nor any individual or group policy of accident and health insurance may deny coverage for the removal of breast implants when the removal of the implants is medically necessary treatment for a sickness or injury. This provision does not apply to surgery performed for removal of breast implants that were implanted solely for cosmetic reasons (Secs. 5/356p and 125/4-6.2).
Blood processing.- No group hospital policy covering miscellaneous hospital expenses issued or delivered in Illinois may contain any exception or exclusion from coverage that would preclude the payment of expenses incurred for the processing and administration of blood and its components (Sec. 5/367, as amended by H. 1348, L. 1999, effective August 14, 1999).
Diethylstilbestrol (DES).- No policy of accident or health insurance or any renewal thereof may be denied or canceled by the insurer, nor may any such policy contain any exception or exclusion of benefits, solely because the mother of the insured has taken diethylstilbestrol (DES) (Sec. 5/356f).
New cancer therapies.- An insurer that issues, delivers, amends or renews a group policy of accident and health insurance in Illinois after April 29, 2000, must offer coverage for routine patient care of insureds, when medically appropriate and the insured has a terminal condition related to cancer that, according to the diagnosis of the treating physician, is considered life-threatening, to participate in an approved cancer research trial, and must provide coverage for the patient care provided pursuant to investigational cancer treatments (Sec. 5/356y, as added by H. 1622, L. 1999, effective until January 1, 2003).
HMOs must also provide this coverage (Sec. 125/5-3, as amended by H. 1348 and H. 1622, L. 1999).
Qualified cancer trials.- No individual or group policy of accident and health insurance issued or renewed in Illinois may be cancelled or non-renewed for any individual based on that individual's participation in a qualified clinical trial. Qualified cancer trials are those in which the effectiveness of the treatment has not been determined relative to established therapies; they are under clinical investigation as part of an approved cancer research trial in Phase II, Phase III, or Phase IV of investigation; and are approved by the Food and Drug Administration, or 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; and the patient's primary care physician, if any, is involved in the coordination of care (Sec. 5/364.01, as added by S. 2339, L. 2004, effective January 1, 2005).
HMOs must also provide this coverage (Sec. 125/5-3, as amended by S. 2339, L. 2004, effective January 1, 2005).
Diabetes.- A group policy of accident and health insurance that is amended, delivered, issued or renewed after January 1, 1999, must provide coverage for outpatient self-management training and education, equipment and supplies for the treatment of type 1 diabetes and gestational diabetes mellitus (Sec. 5/356w, as added by Act 90-741 (H. 3427), L. 1997, effective January 1, 1999).
Coverage must be provided for regular foot care exams by a physician or by a physician to whom a physician has referred the patient (Sec. 5/356w, as added by Act 90-741 (H. 3427), L. 1997, effective January 1, 1999).
HMOs are also subject to these requirements (Sec. 125/5-3, as amended by H. 1348 and H. 1622, L. 1999).
Colorectal cancer screenings.- A group policy of accident and health insurance or managed care plan that is amended, delivered, issued or renewed on or after January 1, 2004, that provides coverage to a resident of Illinois must provide benefits or coverage for all colorectal cancer examinations and lab 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 (215 ILCS 5/356x, as amended by S. 1417, L. 2003, effective January 1, 2004).
HMOs are also subject to these requirements (Sec. 125/5-3, as amended by H. 1348 and H. 1622, L. 1999).
Pap tests and prostate-specific antigen tests.- Group insurers must provide coverage for all of the following: (1) an annual cervical smear or Pap smear test for female insureds; (2) an annual digital rectal exam and prostate-specific antigen test, 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 (215 ILCS 5/356u(a), as amended by S. 521, L. 2005, effective January 1, 2006).
Temporomandibular joint disorder.- Every insurer that delivers or issues for delivery in Illinois a group accident and health policy providing coverage for hospital, medical, or surgical treatment on an expense-incurred basis must 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 maximum lifetime benefits for such conditions must be no less than $2,500 (Sec. 5/356q).
Organ transplants.- No contract or evidence of coverage issued by a health maintenance organization that provides coverage for health care services may 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 (Sec. 125/4-5). This also applies to accident and health insurers providing coverage for hospital or medical expenses (Sec. 5/356K; and Sec. 5/367, as amended by H. 1348, L. 1999, effective August 14, 1999).
Genetic information.- An insurer may not seek information derived from genetic testing for use in connection with a policy of accident and health insurance. Except as provided below, an insurer that receives information derived from genetic testing, regardless of the source of that information, may not use the information for a nontherapeutic purpose as it relates to a policy of accident and health insurance (410 ILCS 513/20(a), as amended by S. 42, L. 2001, effective August 17, 2001).
An insurer may consider the results of genetic testing in connection with a policy of accident and health insurance if the individual voluntarily submits the results and the results are favorable to the individual (410 ILCS 513/20(b), as amended by S. 42, L. 2001, effective August 17, 2001).
An insurer that possesses information derived from genetic testing may not release the information to a third party, except as specified in 410 ILCS 513/30 (410 ILCS 513/20(c), as amended by S. 42, L. 2001, effective August 17, 2001).
Ambulance services.- No contract or evidence of coverage for basic health care services delivered, issued for delivery, renewed or amended by a health maintenance organization may exclude coverage for emergency transportation by ambulance (Sec. 125/4-15).
Rehabilitation services.-Facilities.- No claim may be denied, under any group accident and health policy delivered or renewed in Illinois for treatment or services for rehabilitation following either a physical or mental illness rendered in a hospital solely because such hospital lacks surgical facilities (Sec. 5/367d).
Multiple sclerosis preventative physical therapy.- A group policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after December 29, 2006, 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. HMOs must also provide this coverage (215 ILCS 5/356z.8, as added by S. 2917, L. 2005, enacted December 29, 2006; 215 ILCS 125/5-3, as amended by S. 2917, L. 2005, enacted December 29, 2006).
Utilization review.- Any preferred provider program, insurer, or administrator offering medical, dental, or hospital services must include utilization review (Sec. 5/370n).
Shingles vaccine.- A group policy of accident and health insurance or managed care plan 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 (215 ILCS 5/356z.11, as added by H. 4602, L. 2007, enacted September 22, 2008). HMOs must also provide this coverage (215 ILCS 125/5-3, as amended by H. 4602, L. 2007, enacted September 22, 2008).
WHO TO CONTACT
Contact the Director of the Department of Insurance at 320 W. Washington Street, Springfield, IL 62767. Telephone: (217) 782-4515. Fax: (217) 782-5020.
<p>Contact the Director of the Department of Insurance at 320 W. Washington Street, Springfield, IL 62767. Telephone: (217) 782-4515. Fax: (217) 782-5020.</p>
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