DOI Pat Quinn Governor Andrew Boron, Director

Mandated Benefits, Offers, and Coverages for Accident & Health Insurance and HMOs

Revised January 2012

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Note: This information was developed to provide consumers with general information and guidance about insurance coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy. For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact the Department.

The following is a list of Mandated Benefits, Mandated Coverages and Mandated Offers required by Illinois health insurance and HMO laws and regulations. This list includes the basic mandates; it is not an all-inclusive or comprehensive description of requirements for insurance companies and HMOs. Effective dates have been included for mandates passed recently. State laws do not apply to self-insured private employer health plans or to self-insured health and welfare benefit plans.

The Department provides informational fact sheets regarding many of the mandates listed below. Those fact sheets are available at http://insurance.illinois.gov/Main/Consumer_Facts.asp.

For more information regarding Illinois health insurance and HMO requirements, whether listed or not, please contact our Office of Consumer Health Insurance toll-free at (877) 527-9431 or visit us on our website at http://insurance.illinois.gov.

Mandated Benefits

Alcoholism

[215 ILCS 5/367(7)]

Requires coverage for the inpatient treatment of alcoholism.

For group policies of 51 or more employees, benefits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Effective October 3, 2009).* and with the illinois Mental Health Parity Public Act 97-0437 (Effective August 18, 2011).

Applies to group accident and health insurance policies that provide inpatient hospital coverage.  Does not apply to specified disease policies.

Alcoholism and Substance Abuse

[50 Ill. Admin. Code 5421.130(i)]

Requires coverage of diagnosis, detoxification, and treatment of medical complications of alcoholism to be the same as for any other illness. Alcohol rehabilitation must be covered but may be limited as specified in the Rule.

For group contracts of 51 or more employees, benefits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Effective October 3, 2009).* and with Illinois Mental Health Parity Public Act 97-0437 (Effective August 18, 2011).

Applies to individual and group HMO contracts.

Amino Acid-Based Elemental Formulas

Public Act 95-520 [215 ILCS 5/356z.10]
[215 ILCS 125/5-3]

Requires coverage of non-prescription and specialized amino acid-based elemental formulas administered either by feeding tube or orally when prescribed by a physician as medically necessary for treatment of eosinophilic disorders and short bowel syndrome.  The law does not designate a benefit level. Applies to all individual and group health insurance and all individual and group HMO contracts.

Autism Spectrum Disorders

P.A. 95-1005
[215 ILCS 5/356z.14]

Requires coverage for diagnosis and treatment of autism spectrum disorders for individuals under age 21. 

Effective December 12, 2008, group policies and contracts of 51 or more employees, benefits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Effective October 3, 2009).*

Effective August 18, 2011, group policies and contracts of 51 or more employees, benefits must comply with the Illinois Mental Health Parity Public Act 97-0437.

Applies to all individual and group health insurance policies and individual and group HMO contracts.

Breast Cancer Pain

P.A. 95-1045
[215 ILCS 5/356g.5-1]
[215 ILCS 125/5-3]

Requires coverage for all medically necessary pain medication and pain therapy related to breast cancer on the same terms and conditions generally applicable to coverage for other conditions.

Applies to all individual and group health insurance policies and all individual and group HMO contracts.

Effective March 27, 2009

Breast Exam

P.A. 95-189
[215 ILCS 5/356g.5]
[215 ILCS 125/5-3]

Requires coverage of a complete and thorough physical examination of the breast at least every 3 years for women age between ages of 20 and 40; then annually for women age 40 and older. The law does not specify a benefit level. Coverage is required once a nationally recognized exam code is approved. Applies to all individual and group health insurance policies and all individual and group HMO contracts.

Breast Ultrasound Screening

P.A. 95-431
[215 ILCS 5/356g ]
[215 ILCS 125/4-6.1]

Requires coverage for a comprehensive ultrasound screening when a mammogram demonstrates heterogeneous or dense breast tissue when found to be medically necessary by a physician. Benefits must be at least as favorable as for other radiological exams and subject to same dollar limits, deductibles and co-insurance amounts. Applies to all group and individual insurance policies and all individual and group HMO contracts.

Breast Implant Removal

[215 ILCS 5/356p]
[215 ILCS 125/4-6.2]

Prohibits the denial of coverage for the removal of breast implants when such removal is medically necessary treatment for sickness or injury.  This provision does not apply for implants implanted solely for cosmetic reasons. Applies to all individual and group health insurance and all individual and group HMO contracts.Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Cancer Clinical Trial PA 97-0091 215 ILCS 5/364.01(c)

Prohibits group policies of accident and health insurance from excluding coverage for any routine patient care for insured who is participating in a qualified clinical cancer trial if the policy covers that care for patient not enrolled in a clinical cancer trial. Applies to group accident and health policies. Effective January 1, 2012.

Cancer Drug parity PA 97-0198 215 ILCS 5/356z.19

Requires that orally-administered cancer medications be covered at same benefit as injected cancer medications to the extent coverage is provided by the policy. Applies to individual and group accident and health insurance policies amended, delivered, issued or renewed on or after January 1, 2012.
Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Cancer Treatment – Prescription Drugs

[215 ILCS 5/356z.7]
[215 ILCS 125/4-6.3]
Amended by P.A. 96-457

If a policy provides prescription drug benefits, it must also provide benefits for any drug that has been prescribed for the treatment of a type of cancer, even if the drug has not been approved for that specific cancer by the FDA.  The drug must be approved by the FDA and must be recognized for treatment of the specific cancer for which it has been prescribed.  The amendment effective August 14, 2009 provided current reference compendia that may be used.

Applies to group insurance policies (PPO) and individual and group HMO contracts.

Amendment effective August 14, 2009

Colorectal Cancer Screening

P.A. 93-568
[215 ILCS 5/356x]
[215 ILCS 125/5-3]

Requires coverage for all colorectal cancer examinations and laboratory tests for colorectal cancer, in accordance with professional organizations and the federal government as specified in the law.

September 23, 2010- Under the federal Affordable Care Act, coverage for colorectal cancer screening using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults beginning at age 50 and continuing until age 75 must be provided without any cost-sharing for the enrollee when delivered by in-network providers if the enrollee is covered by a non-grandfathered plan.

Applies to individual and group insurance policies and to individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Affordable Care Act Preventive Services (Section 2713) applies to non-grandfathered health insurance policies and HMO contracts issued on or after September 23, 2010.

Contraceptives

P.A. 93-102
[215 ILCS 5/356z.4]
[215 ILCS 125/5-3]

Requires coverage for all outpatient contraceptive services and all outpatient contraceptive drugs and devices approved by the Food and Drug Administration.

Applies to individual and group insurance policies and individual and group HMO contracts that provide coverage for outpatient services and outpatient prescription drugs.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Dental Adjunctive Services

P.A. 92-764
[215 ILCS 5/356z.2]
[215 ILCS 125/5-3]

Requires coverage for anesthesia and other charges incurred in conjunction with  dental care provided in a hospital or ambulatory surgical treatment center to:
  • a young child (6 or under);
  • a person with a medical condition that requires hospitalization for the procedure; or
  • a disabled individual.
Does not require coverage of dental services.

Applies to individual and group insurance policies and individual and group HMO contracts. 

Does not apply to short-term travel, accident only, limited, or specified disease policies or to policies designed for Medicare beneficiaries.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Diabetes Self Management

P.A. 90-741
[215 ILCS 5/356w]
[215 ILCS 125/5-3]

Amended by P.A. 97-281

Requires coverage for outpatient self-management training and education, and specified equipment and supplies for Type 1 diabetes, Type 2 diabetes and gestational diabetes mellitus.  Equipment must be covered to the extent durable medical equipment is covered by the policy.  Pharmaceuticals and supplies must be covered to the extent there is coverage for pharmaceuticals and supplies in the policy or in an attached rider.  See the law for list of covered supplies and equipment.

Law was amended by P.A. 97-281 to expand definition of diabetes self-management training to include services that allow the patient to maintain A1c level within the range of nationally recognized standards of care.

Applies to group insurance policies and group HMO contracts. Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

P.A. 97-281 Effective January 1, 2012.

External Review PA 96-0857 215 ILCS 180 Effective January 5, 2010

Amended by P.A. 97-0574

Requires health insurers and HMOs to provide (1) an internal appeals process for all denied claims and (2) external independent review for claims or pre-authorization requests denied due to medical necessity, appropriateness, health care setting, level of care, or effectiveness.

P.A. 97-0574 expanded External Review Law to include review of claims denied due to pre-existing condition or rescission of health policy. The amended law requires that the Illinois Department of Insurance assign the independent review organization (IRO) for each external review request.

Applies to individual and group insurance policies and individual and group HMO contracts on July 1, 2010 for any adverse determination dated within four months prior.

P.A. 97-0574 Effective August 26, 2011.

HPV Vaccine

P.A. 95-422
[215 ILCS 5/356z.9]
[215 ILCS 125/5-3]

Requires coverage for the human papillomavirus vaccine.  The law does not specify the benefit.

September 23, 2010- Under the federal Affordable Care Act, coverage must be provided for HPV vaccine without any cost-sharing for the enrollee when delivered by in-network providers if the enrollee is covered by a non-grandfathered plan.

Applies to all individual and group health insurance and all individual and group HMO contracts.

Affordable Care Act Preventive Services (Section 2713) applies to non-grandfathered health insurance policies and HMO contracts issued on or after September 23, 2010.

Habilitative Services for children

P.A. 95-1049 (SB 101)
[215 ILCS 5/356z.15]
[215 ILCS 125/5-3]
[215 ILCS 165/10]

Requires coverage for medically necessary habilitative services for children under age 19 who have a congenital, genetic or early acquired disorder diagnosed by a physician licensed to practice medicine in all its branches.  The law specifies types of health care providers whose services must be covered.  Denials based on medical necessity are subject to independent external review.

For group policies and contracts of 51 or more employees, benefits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Effective October 3, 2009)*  and with the Illinois Mental Health Parity Public Act 97-0437 (Effective August 18, 2011).*

Applies to all individual and group health insurance policies and all individual and group HMO contracts.  Also applies to all individual and group Voluntary Health Services Plans contracts.

Effective January 1, 2010

Infertility

215 ILCS 5/356m
215 ILCS 125/5-3

Requires coverage for the diagnosis and treatment of infertility, including coverage for IVF, GIFT, ZIFT.

Applies to group insurance policies and group HMO contracts that provide coverage for more than 25 full-time employees.  (See law for exceptions relating to religious organizations or institutions.)

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Mammograms

[215 ILCS 5/356g]
[215 ILCS 125/4-6.1]Amended by P.A. 95-1045

Requires coverage for (1) a baseline mammogram for women ages 35 to 39 and (2) an annual mammogram for women age 40 or older.  Requires coverage for medically necessary mammograms for women under age 40 who have a family history of breast cancer or other risk factors.

Effective March 27, 2009 - includes digital mammography and requires coverage be provided at no cost to the insured. Cost of mammograms shall not be applied to an annual or lifetime maximum benefit.

September 23, 2010- Under the federal Affordable Care Act, coverage for screening mammography for women, with or without clinical breast examination must be provided every 1-2 years for women aged 40 and older without any cost-sharing for the enrollee when delivered by in-network providers if the enrollee is covered by a non-grandfathered plan.

Applies to individual and group insurance policies and individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Effective March 27, 2009

Affordable Care Act Preventive Services (Section 2713) applies to non-grandfathered health insurance policies and HMO contracts issued on or after September 23, 2010.

Mastectomy – Post Mastectomy Care

[215 ILCS 5/356t]
[215 ILCS 125/4-6.5]

Requires coverage for inpatient hospital stay following a mastectomy for a length of time the attending physician determines is medically necessary in accordance with protocols and guidelines based on sound scientific evidence and upon evaluation of the patient.  If the patient is discharged early, a post-discharge physician office visit must be available to her within 48 hours and must be covered by the policy.

Applies to individual and group insurance policies that provide benefits for surgical coverage. Also applies to individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Mastectomy - Reconstruction

P.A. 92-0048
[215 ILCS 5/356g(b)]
[215 ILCS 125/4-6.1]

Requires coverage for prosthetic devices or reconstructive surgery incident to a mastectomy.  When a mastectomy is performed and no evidence of malignancy is found, the offered coverage is limited to prosthetic devices and reconstructive surgery within two years of the mastectomy date.

In addition to reconstruction on the affected breast, this law requires surgery and reconstruction of the other breast (the one the mastectomy was not performed on) to produce a symmetrical appearance.  Also requires coverage for prostheses and treatment for physical complications at all stages of mastectomy, including lymphedemas.
Applies to individual and group health policies and to individual and group HMO contracts that provide coverage for mastectomies.

Maternity

[50 Ill. Admin. Code 5421.130(e)]

Requires coverage for maternity care including prenatal and post-natal care and care for complication of pregnancy. Applies to individual and group HMO contracts.

Maternity – Complications of Pregnancy

[50 Ill. Admin. Code 2603.30(11)]

Requires coverage for treatment of complications of pregnancy. Applies to individual and group insurance policies.

Maternity – Post Parturition Care

[215 ILCS 5/356s]
[215 ILCS 125/4-6.4]

Requires coverage for a minimum of 48 hours inpatient hospital stay following a vaginal delivery and 96 hours following a caesarian section for both mother and newborn.  A shorter length of stay may be provided under certain conditions and if a post-discharge office visit or in-home nurse visit is provided and covered. Applies to individual and group insurance policies that provide maternity coverage.  Also applies to individual and group HMO contracts.

Maternity – Prenatal HIV Testing

P.A. 92-130
[215 ILCS 5/356z.l]
[215 ILCS 125/4-6.5]

Requires coverage for prenatal HIV testing ordered by an attending physician licensed to practice medicine in all branches, physician assistant or advanced practice registered nurse.

Applies to individual and group insurance policies and individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Mental Health – “Serious Mental Illness”

[215 ILCS 5/370c(b)(1)]
[215 ILCS 125/5-3]

Amended by PA 97-0437

Requires coverage of serious mental illness under the same terms and conditions as coverage for other illnesses and diseases.  The law defines “serious mental illnesses” to include the following: schizophrenia; paranoid and other psychotic disorders; bipolar disorders (hypomanic, manic, depressive, and mixed); major depressive disorders (single episode or recurrent); schizoaffective disorders (bipolar or depressive); pervasive developmental disorders; obsessive-compulsive disorders; depression in childhood and adolescence; panic disorder; post-traumatic stress disorders (acute, chronic, or with delayed onset); and anorexia nervosa and bulimia nervosa.

For group policies and contracts of 51 or more employees, benefits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Effective October 3, 2009).*

P.A. 97-0437 adds substance use disorder as required coverage. Adds parity provisions which prohibit more restrictive financial requirements, treatment limitations, annual limits and lifetime limits for mental illness or substance use disorder than those applied to substantially all other hospital and medical benefits covered under the policy thereby removing previously allowed limits.

Applies to group insurance policies and group HMO contracts that provide coverage for hospital or medical expenses.

Does not apply to employer groups with 50 or fewer employees or to individual policies.  Note: See Mandated Offers for other Mental Health related requirements.

P.A. 97-0437 Effective for policies issued, delivered or amended on or after August 18, 2011.

Mental Health – HMOs

50 Ill. Adm. Code 5421.130(h)

Amended by PA 97-0437

Requires coverage for ten (10) days inpatient mental health care per year.  Also requires coverage of twenty (20) individual outpatient mental health care visits per enrollee per year, as appropriate for evaluation, short-term treatment and crisis intervention services. Care in a day hospital, residential non-hospital or intensive outpatient mode may be substituted on a two-to-one basis for inpatient hospital services as deemed appropriate by the primary care physician.  Group outpatient mental health care visits may be substituted on a two-to-one basis for individual mental health care visits as deemed appropriate by the primary care physician.

For group policies and contracts of 51 or more employees, benefits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Effective October 3, 2009).*

P.A. 97-0437 adds substance use disorder as required coverage. Adds parity provisions which prohibit more restrictive financial requirements, treatment limitations, annual limits and lifetime limits for mental illness or substance use disorder than those applied to substantially all other hospital and medical benefits covered under the policy thereby removing previous allowed limits.

Previously applied to all group and individual HMO contracts.

Federal standards for large group policies effective October 3, 2009.

P.A. 97-0437 effective for group policies issued, delivered or amended on or after August 18, 2011.

Multiple Sclerosis Preventative Physical Therapy

P.A. 94-1076  [215 ILCS 5/356z.8]
[215 ILCS 125/5-3]

Requires coverage for medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis if prescribed by a physician and if the physical therapy includes reasonably defined goals.  Coverage must be the same as physical therapy under the policy for other conditions.

Applies to individual and group insurance policies and HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Organ Transplants

[215 ILCS 5/367(13)]
[215 ILCS 5/356k]
[215 ILCS 125/4-5]

Sets forth guidelines under which experimental or investigational organ transplantation procedures can be denied.

Applies to individual and group insurance policies and to individual and group HMO and Voluntary Health Services Plans.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Organ Transplants – Immunosuppressive Drugs

P.A. 96-766 (HB 152)

A policy that covers immunosuppressant drugs may not limit, reduce, or deny coverage of those drugs if, prior to the limitation, reduction or denial of coverage:
  1. the insured was using the drug;
  2. the insured was covered under the policy; and
  3. the drug was covered under the policy.

Applies to individual and group health and accident insurance, HMOs and Voluntary Health Services Plans.

Effective January 1, 2010

Osteoporosis

[215 ILCS 5/356z.6]
[215 ILCS 125/5-3]

Requires coverage for medically necessary bone mass measurement and the diagnosis and treatment of osteoporosis on the same terms and conditions that generally apply to other medical conditions.

September 23, 2010- Under the federal Affordable Care Act, coverage for routine screening for women age 65 and older (or beginning at age 60 for women at increased risk for osteoporotic fractures) must be provided without any cost-sharing for the enrollee when delivered by in-network providers if the enrollee is covered by a non-grandfathered plan.

Applies to individual and group insurance policies, and to individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Affordable Care Act Preventive Services (Section 2713) applies to non-grandfathered health insurance policies and HMO contracts issued on or after September 23, 2010.

Ovarian Cancer Testing

P.A. 94-122
[215 ILCS 5/356u]
[215 ILCS 125/5-3]

Requires coverage for surveillance tests for ovarian cancer for female insureds who are at risk for ovarian cancer. 

Applies to group insurance policies, except specified disease policies or other limited benefit policies, and to individual and group HMO contracts.

Pap Smears

[215 ILCS 5/356u]
[215 ILCS 125/4-6.5]
[50 Ill. Adm. Code 5421.130g]

Requires coverage for an annual cervical smear or pap smear for females.

September 23, 2010- Under the federal Affordable Care Act, coverage for cervical cancer screening for women who have been sexually active and have a cervix must be provided without any cost-sharing for the enrollee when delivered by in-network providers if the enrollee is covered by a non-grandfathered plan.

Applies to group insurance policies, except specified disease policies, and limited benefit policies and to individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Affordable Care Act Preventive Services (Section 2713) applies to non-grandfathered health insurance policies and HMO contracts issued on or after September 23, 2010.

Prescription Inhalants

P.A. 93-529
[215 ILCS 5/356z.5]
[215 ILCS 125/5-3]

Requires coverage of prescription inhalants for persons with asthma or other life-threatening bronchial ailments, as often as needed, if medically appropriate and prescribed by the attending physician.  Policy restrictions, placed on refill limitations, do not apply.

Applies to individual and group insurance policies and HMO contracts that provide coverage for prescription drugs.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Preventive Health Services(Including Well Child Care)

[50 Ill. Adm. Code 5421.130g]

Requires coverage of preventive health services as appropriate for the patient population, including a health evaluation program and immunizations to prevent or arrest the further manifestation of human illness or injury.

September 23, 2010- Under the federal Affordable Care Act, coverage for (1) preventive health services with rating of A or B in current recommendations of the United State Preventive Service Task Force; (2)immunizations for routine use as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and (3) preventive care and screening for infants, children and adolescents as recommended by the Health Resources and Services Administration must be provided without any cost-sharing for the enrollee when delivered by in-network providers if the enrollee is covered by a non-grandfathered plan.

Applies to individual and group HMO contracts.

Affordable Care Act Preventive Services (Section 2713) applies to non-grandfathered health insurance policies and HMO contracts issued on or after September 23, 2010.

Prostate Specific Antigen Testing

[215 ILCS 5/356u]
[215 ILCS 125/4-6.5]

Requires coverage for an annual digital rectal examination and a prostate specific antigen test for male insureds upon recommendation of a physician for asymptomatic men age 50 and over, African American men age 40 and over, men age 40 and over with family history.

Applies to group insurance policies, except specified disease and limited benefit policies, and to group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Prosthetic and Orthotic Devices

P.A. 96-833 (HB 2652)
[215 ILCS 356z.18]

For policies issued or renewed on or after December 1, 2010, requires coverage for prosthetic and customized orthotic devices that is no less favorable than the terms and conditions applicable to substantially all medical and surgical benefits provided under the plan or coverage.

Applies to group and individual insurance policies and group and individual HMO and Voluntary Health Services Plans contracts.

Effective June 1, 2010

Shingles Vaccine

P.A. 95-978 (HB 4602)
[215 ILCS 5/356z.13]
[215 ILCS 125/5-3]

Requires coverage for federally approved shingles vaccine when ordered by a physician for an enrollee who is age 60 or older.

September 23, 2010- Under the federal Affordable Care Act, coverage for shingles vaccine for people age 60 years and older must be provided without any cost-sharing for the enrollee when delivered by in-network providers if the enrollee is covered by a non-grandfathered plan.

Applies to group and individual insurance policies and individual and group HMO contracts.

Effective January 1, 2009

Affordable Care Act Preventive Services (Section 2713) applies to non-grandfathered health insurance policies and HMO contracts issued on or after September 23, 2010.

Under the Influence

P.A. 95-230
[215 ILCS 5/367K]

Prohibits exclusion or coverage for emergency or other medical, hospital or surgical expenses incurred as a result of and related to an injury acquired while the individual is intoxicated or under the influence of a narcotic.

Applies to group and individual major medical insurance and managed care plans.

Effective January 1, 2008

* Group policies subject to the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 may not impose financial requirements (e.g., deductibles, co-payments, or coinsurance) or treatment limitations (e.g., limits on the frequency of treatment, number of visits, or days of coverage) for the treatment of mental health or substance use disorders that are more restrictive than those applied to medical and surgical benefits. For example, a group policy that did not contain a limit on the number of outpatient visits for medical/surgical benefits could not limit the number of outpatient visits for mental health or substance use disorder benefits.

For more information on federal mental health parity laws, please see the fact sheet prepared by the U.S. Department of Labor (http://www.dol.gov/ebsa/newsroom/fsmhparity.html).

Mandated Coverages

Adopted Children

[215 ILCS 5/356h]
[215 ILCS 125/4-9]

Prohibits denial or limitation of coverage to an adopted child solely because the child is adopted.

Applies to individual and group insurance policies and individual and group HMO contracts.

 

Continuation

[215 ILCS 5/367e]
[215 ILCS 125/4-9.2]

Amended by P.A. 96-13

Employees or members whose group health insurance terminates due to termination of employment or membership or reduction in hours must be offered continuation of coverage for themselves and their dependents for a period of 12 months. (Amendment of June 18, 2009 increased length of continuation coverage from 9 to 12 months for policies issued, amended, delivered or renewed after that date)

Group insurance policies that insure employees or members for hospital, surgical, or major medical insurance on an expense incurred basis and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Amendment effective June 18, 2009

Continuation for Spouse

[215 ILCS 5/367.2]

An employees’ spouse and dependent children who are insured under the policy must be offered continuation of coverage if group coverage is terminated for the spouse and dependents due to the dissolution the marriage or death of the employee (for any age spouse), or due to retirement of the employee (for a spouse age 55 or older).

Applies to group accident and health insurance polices and to group HMO contracts.

Continuation for Dependent Children

P.A. 93-477
[215 ILCS 5/367.2-5]

A dependent child who is insured on the policy must be offered dependent child continuation upon attainment of the limiting age under the policy or upon the death of the employee (if coverage through spousal continuation is not available).

Applies to group accident and health insurance policies and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Conversion

[215 ILCS 5/367e.1]
[50 Ill. Adm. Code 5421.110v]

Employees or members whose coverage under the group plan has terminated, for any reason other than (1) discontinuance of the group policy in its entirety where there is a succeeding carrier or (2) failure of the employee or member to pay premium, are entitled to a conversion policy.

Group insurance policies and group HMO contracts where the insured has been continuously covered for at least three months immediately prior to the termination of coverage.

Should also be offered after COBRA or Illinois Continuation has been exhausted.

Conversion for Spouse

[215 ILCS 5/356d]

Prohibits an individual insurance policy that covers an insured and dependent spouse from terminating the spouse solely because of a break in the marital relationship unless a valid judgment of dissolution of marriage has been entered into.  If the policy is terminated due to a dissolution of marriage, a conversion policy must be offered to the spouse.

Individual insurance policies and HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Dependent Child Coverage

P.A. 95-958 (HB 5285)
[215 ILCS 5/356z.12]

This law gives parents with insurance policies that cover dependents the right to elect coverage for qualifying dependents up to age 26 and up to age 30 for military veteran dependents.

Applies to all individual and group health policies and all individual and group HMOs.

Effective June 1, 2009
Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Dependent Students – Medical Leave of Absence

P.A. 95-958 (HB 5285)
[215 ILCS 5/356z.11]

Requires 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.

Applies to all individual and group health policies and all individual and group HMOs.  Does not apply to short-term travel, accident-only, limited, or specified disease policies.

Effective June 1, 2009

Handicapped Dependents – Attainment of Limiting Age

[215 ILCS 5/356b]
[215 ILCS 5/367(b)]
[215 ILCS 125/4-9.1]

Requires coverage for a child who has attained the limiting age under the policy if the child continues to be incapable of sustaining employment and is dependent on his or her parents or other care providers for lifetime care and supervision.

Applies to individual and group insurance policies and to individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Newborn

[215 ILCS 5/356c]
[215 ILCS 125/4-8]

Requires coverage of newborn children from the moment of birth.  Coverage must include coverage of illness, injury, congenital defects, birth abnormalities and premature birth to the extent the services, supplies or treatments are covered by the policy.  Notification to the company and payment of premium may be required.

Applies to individual and group insurance policies and to individual and group HMO contracts.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Mandated Offers

Mental Health –
“Other Mental Illness”

P.A. 92-185
[215 ILCS 5/370c]

Amended by PA 97-0437

The insurer shall offer optional coverage for mental, emotional or nervous disorders or conditions, other than “serious mental illnesses” (see Mandated Benefits section above for statutory definition) up to the limits provided in the policy.

For employer groups of 50 or fewer employees, insureds may be required to pay 50% coinsurance, and the annual benefit may be limited to the lesser of $10,000 or 25% of the lifetime policy limit.

For employer groups of 51 or more employees, benefits must comply with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Effective October 3, 2009).*

Requires parity of mental health benefits if the small group accepts offer of coverage for non-serious mental illnesses. The 50% coinsurance and annual benefit of $10,000 or 25% of the lifetime policy limit is no longer allowed.

Applies to group insurance policies that provide coverage for hospital or medical expenses.

Effective August 18, 2011.

TMJ

P.A. 88-592
[215 ILCS 5/356q]

The insurer shall offer optional coverage for the reasonable and necessary medical treatment of temporomandibular joint disorder and craniomandibular disorder.  The lifetime benefit may be limited to no less than $2,500.00.

Applies to group insurance policies.  The group must accept or reject the coverage in writing.

Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16)

Tobacco Use Cessation P.A. 9709592

Requires insurers to offer optional coverage or optional reimbursement of up to $500.00 annually for a tobacco use cessation program for covered individuals age 18 and older.

Applies to group policies that provide hospital or medical treatment or services on an expense-incurred basis. Does not apply to short-term travel, disability income, long term care, accident only or specified disease policies. (215 ILCS 5/356z.16) Effective January 1, 2012.

* Group policies subject to the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 may not impose financial requirements (e.g., deductibles, co-payments, or coinsurance) or treatment limitations (e.g., limits on the frequency of treatment, number of visits, or days of coverage) for the treatment of mental health or substance use disorders that are more restrictive than those applied to medical and surgical benefits.  For example, a group policy that did not contain a limit on the number of outpatient visits for medical/surgical benefits could not limit the number of outpatient visits for mental health or substance use disorder benefits.

For more information on federal mental health parity laws, please see the fact sheet prepared by the U.S. Department of Labor (http://www.dol.gov/ebsa/newsroom/fsmhparity.html)

Allowable Coverage

Wellness Coverage

P.A. 96-639 (SB 1877)
[215 ILCS 356z.17]
[215 ILCS 125/5-3]

Health policies may offer wellness coverage that provides certain incentives for participation in health behavior wellness programs that are approved or offered by the insurer or plan.

Applies to individual and group accident and health policies and to individual and group HMO coverage.

Effective January 1, 2010