Health Insurance Continuation Rights – Illinois Spousal Law
Revised November 2012
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.
With the high costs of medical care, maintaining health coverage is very important to most individuals and families. Illinois law does not require employers to provide health benefits for their employees or their families. However, if you are covered by an employer's health benefits, loss of coverage can be devastating.
State and federal laws give certain employees, spouses and dependent children the right to continue employer-sponsored health benefits at group rates if they lose their benefits because of specific “qualifying events.” The type of qualifying event determines who is qualified for continued coverage and for how long.
This fact sheet provides specific information on the Illinois Spousal Continuation Law and compares its basic provisions to three other continuation laws: the Illinois Continuation Law, the Illinois Dependent Child Continuation Law and the federal continuation requirements under COBRA, the Consolidated Omnibus Budget Reconciliation Act. The chart at the bottom of this fact sheet provides a comparison of the laws pertaining to continuation of health benefits.
Under all four laws:
- The employer or plan administrator must notify you of your right to continue your health benefits when certain qualifying events have occurred. If both the state and federal laws apply to your situation, the employer or plan administrator must offer you both options. You must choose one or the other option.
NOTE: In some cases, the spouse, former spouse, dependent child or guardian must notify the employer and/or insurer that a qualifying event has occurred, such as divorce from or death of the covered employee or attainment of the limiting age by the dependent child. If you don’t give proper notification, your continuation rights may be lost.
- Once you are offered continuation, you must elect to continue coverage within a certain time period, called the election period. If you don’t tell the employer you want to continue coverage before the election period expires, you may lose your right to continue coverage. If you have the option of either the state or federal continuations, once you make your choice, you can't change your decision if the election period has expired.
- Coverage will continue for the maximum amount of time required by law. However, coverage may end earlier in some cases, such as when the beneficiary becomes eligible for Medicare, or if the employer no longer offers any group health insurance benefits for employees.
- You must pay the entire premium for the coverage, including the part you used to pay as well as the part the employer paid before the qualifying event. In addition, you may also be required to pay an administrative fee under certain circumstances for COBRA and Spousal Continuation.
Your group insurance certificate, evidence of coverage or benefit plan summary booklet explains your options and responsibilities in detail. You should read the information now. Don’t wait until you need your continuation rights.
What Is The Illinois Spousal Continuation Coverage Law?
The Illinois Spousal Continuation Law protects a covered spouse and dependent children who lose group health insurance coverage due to death or retirement of the employee or divorce from the employee.
Which Plans are Subject to the Illinois Spousal Continuation Coverage Law?
- Employers offering fully insured Illinois group and accident health plans, regardless of the group’s size.
- Employers offering fully insured Illinois HMO coverage, regardless of the group’s size
The Illinois spousal continuation law does not apply to:
- Self-insured employers;
- Self-insured health and welfare benefit plans, such as union plans;
- Insurance policies or trusts written in other states.
Note: For HMOs, the law applies to contracts written outside of Illinois if the HMO member is a resident of Illinois and the HMO has established a provider network in Illinois. To determine if your HMO coverage provides Illinois continuation, contact the HMO or check your certificate of coverage.
Who Is Eligible for Illinois Spousal Continuation Coverage?
Spousal continuation may be triggered when one of the following qualifying events occurs: divorce from the employee, death of the employee or retirement of the employee as follows:
- The divorced or widowed spouse (any age) and dependent children of the employee who were covered under the group plan on the day before the qualifying event;
- The spouse and dependent children of a retired employee, if the spouse is age 55 or older, who were covered under the group plan on the day before the qualifying event.
What Are the Notification Deadlines?
The eligible spouse must notify the employer and insurance company in writing of the dissolution of marriage or the death or retirement of the employee within 30 days of the qualifying event.
The employer must notify the insurance company within 15 days after receiving your request for spousal continuation. The insurance company must notify you of the right to continuation by certified mail, return receipt requested, within 30 days after receipt of the notice from the employer.
The spouse must return the notice of continuation election form by certified mail, return receipt requested, within 30 days after the date of mailing receipt from the insurance company.
How Much Will Spousal Continuation Coverage Cost?
If you are a former spouse under age 55, the premium for Illinois Spousal Continuation coverage is the amount that would be charged if you were an employee of the employer. You are responsible for the entire premium. This amount includes any contribution that the employer would normally make on behalf of active employees.
If you are a spouse or former spouse age 55 or older, for the initial two years of Spousal Continuation coverage, the premium is the amount that would be charged if you were an employee of the employer. You are responsible for the entire premium. This amount includes any contribution the employer would normally make on behalf of active employees. After the initial two years of coverage, the premium may be adjusted to include a 20% administration fee.
What Benefits Are Available Under Spousal Continuation Coverage?
Benefits for hospital, surgical or major medical are the same as they were under the previous group coverage.
How Long Does Spousal Continuation Coverage Last?
Continuation resulting from an employee's death or divorce shall be offered for a maximum period of two years if you are under age 55 at time of the qualifying event. If you are age 55 or older at the time of qualifying event, the maximum period of coverage extends until you are eligible for Medicare.
Continuation resulting from an employee's retirement is only available to spouses who are age 55 or older at the time of the retirement. The maximum period of coverage extends until the spouse is eligible for Medicare.
Your spousal continuation may terminate earlier than the maximum period of coverage if:
- You fail to make timely premium payments;
- The group coverage would terminate even though you were still married to the employee (unless the employee retires during the election period);
- You become an insured employee under any other group health plan;
- You remarry.
What Happens When Spousal Continuation Coverage Ends?
You or your dependent children can convert coverage to an individual policy at any time during the continuation period or at the end of the period, except when the continuing person becomes eligible for Medicare.
You may also want to shop around for an individual policy on your own. You may be able to find better coverage at a more affordable rate. An insurance broker in your area can assist you in applying for individual coverage. However individual policies may underwrite applicants, may apply pre-existing condition limitation periods, and may attach riders to permanently exclude coverage for an existing health condition.
If you or your dependent children have a medical condition that precludes the purchase of individual coverage, the HIPAA CHIP plan offered by the Illinois Comprehensive Health Insurance Plan may be an option when the continuation policy expires. You must exhaust your continuation coverage in order to be eligible for HIPAA CHIP. This plan provides coverage for individuals with an uninsurable health condition, without preexisting condition exclusions or limitations, if there has not been a break in coverage of more than 90 days. We encourage you to apply for the HIPAA CHIP plan at least two months prior to your Illinois spousal continuation coverage expiration in order to allow ample time for the application to be processed. For an application and information, you should contact the Illinois Comprehensive Health Insurance Plan (ICHIP) at (866) 851-2751 or at http://www.chip.state.il.us/.
NOTE: If you have a medical condition that renders you uninsurable and you elect a conversion policy rather than HIPAA CHIP, you will lose your rights to elect HIPAA CHIP. If you elect the conversion policy and then decide, for whatever reason, to drop it, you will not be eligible for the HIPAA CHIP plan. You will have to apply for coverage with the regular CHIP plan, which may have a waiting list and does not pay for preexisting conditions for the first six months of coverage.
For More Information About the Illinois Spousal Continuation Coverage Law
Call our Consumer Services Section at (312) 814-2420 or
our Office of Consumer Health Insurance toll free at (877) 527-9431
or visit us on our website at http://insurance.illinois.gov
A copy of the law is available 215 ILCS 5/367.2
Comparison of Continuation Laws – Illinois Department of Insurance
|COBRA||Illinois Continuation (mini-COBRA)||Illinois Spousal Continuation||Dependent Continuation|
|Applicability||Applies to employer groups with 20 or more employees.||Applies to all group HMO and insurance policies which insure employees or members for hospital, surgical or major medical insurance.||Applies to all group accident and health and group HMO policies.||Applies to all group accident and health and group HMO policies.|
|Who Is Eligible||Employee, spouse or former spouse and/or covered dependent children.||Employees and covered dependents.||Divorced or widowed spouses (any age) and covered dependent children.Spouses (age 55 or older) of retired employees, and covered dependents.||Covered dependent children of deceased employee, who are not otherwise covered under the Spousal Continuation Law.Covered dependent children who attain the limiting age under the insurance policy or HMO certificate.|
|Coverage Requirements||Must be covered by the group plan on the day prior to the qualifying event.||Employee and covered dependents must be covered on the group plan for 3 continuous months before qualifying event.||Spouse and dependents must be covered on the day prior to the qualifying event.||Dependent child must be covered on the day prior to the qualifying event.|
|Qualifying Events||For employee, spouse, former spouse & covered dependent children upon:
||Loss of coverage due to termination of employment or reduction in hours below the minimum required by the group plan.||Must be offered to divorced spouse or widowed spouse and dependent children upon divorce from or death of employee.
Must be offered to spouse (age 55 or older) and dependent children of retiree upon employee’s retirement.
|Must be offered to dependent child after death of insured if coverage is not available under the Spousal Continuation Law.
Must be offered to dependent child upon attainment of limiting age under the insurance policy or HMO certificate.
Coverage must be the same as under the group plan.
|Coverage must be the same as under the group plan but need not include dental, vision or prescription drugs.||Coverage must be the same as under the group plan.||Coverage must be the same as under the group plan.|
|Length of Continuation Coverage||Loss of employment or reduced hours – maximum of 18 months. May be extended to 29 months if disabled.
Divorce or legal separation from employee, death of employee or employee entitled to Medicare – maximum of 36 months for spouse, former spouse and dependent children.
Loss of dependent child status-maximum of 36 months.
|12 months||Spouse under age 55 – Divorced or widowed spouse (not spouse of retiree) and dependent children –Coverage is provided for maximum of 2 years.
Spouse age 55 or older – Divorced or widowed spouse or spouse of retiree and dependent children – coverage is provided until spouse is eligible for Medicare.
|Coverage is provided for a maximum of 2 years.|
|Premiums||Premium may not exceed 102% of group rate.
Plan may charge 150% after 18 months if the 11-month extension for disability is granted.
|Premiums may not exceed the group rate.||Spouse under age 55 – Divorced or widowed spouse premium may not exceed the group rate.
Spouse age 55 or older – Divorced or widowed spouse or spouse of retiree, administration fee may be added to group rate after first two years of coverage.
|Premiums shall not exceed the amount that would be charged to an employee if the dependent child was an employee PLUS the amount the employer would contribute toward the premium if the dependent child were an employee.|