DOI Pat Quinn Governor Andrew Boron, Director

Review Requirements Checklist

Individual HMO

Contact: Yvonne Clearwater

Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767-0001
217-785-5987

Effective Date: 10/10/12

Line(s) of Insurance: Individual HMO

Interactive Version of this document to be downloaded and submitted with this filing. Alteration of this document will result in rejection of the filing.

Links:

Each filing must include a completed Review Requirements Checklist that must contain a completed “Location of Standard in Filing” column for each required element of the filing. Please indicate the proper page # and form # for each entry.

FORM FILING REQUIREMENTS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Review Requirements Checklist Go to Review Requirements Checklists.
See next column

Each filing must include a completed Review Requirements Checklist that must contain a completed “Location of Standard in Filing” column for each required element of the filing. Please indicate the proper page # and form # for each entry.

 
Cover Letter and Letter of Submission

50 IL Adm. Code 1405.20 (e)
50 IL Adm. Code 2001.30 (a) (3)
50 IL Adm. Code 916.40 (b)

In addition to referencing any previously approved form number(s) as required by 50 IL Adm. Code 1405.20(e), those references must also include the filing number and SERFF tracking number (if applicable and available) for the referenced forms.

Letters of submission must generally describe the intent and use of the form being filed and, if applicable, how it will be used with any previously approved form(s).
 
Filing of Marketing and Advertising Materials 50 IL Admin. Code 5421.100 c) All brochures, media scripts, marketing and advertising material must be filed with the Division of Insurance prior to use.  
GENERAL REQUIREMENTS FOR ALL FILINGS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Entire Contract 50 IL Adm. Code 5421.110 d) The individual contract, including the application and any amendments and riders, constitutes the entire contract between the parties.  
Timely Payment of Health Care Services 215 ILCS 5/368a

Periodic payments must be made within 60 days of an enrollee's selection of a provider, or effective date of selection, whichever is later. In case of retrospective enrollment only 30 days after notice by the employer to the insurer. Subsequent payments must be in monthly periodic cycle. Penalty payment of 9% per year.

Payments other than periodic must be made within 30 days after receipt of due proof of loss. Same penalty provisions.

 
Grace Period 50 IL Adm. Code 5421.110 m) An individual contract must provide for a grace period of no less than 31 days.  
Free Look 50 IL Adm. Code 5421.110 o) There is a 10-day free look requirement with the exception of an individual HMO Medicare contract.  
Eligibility Requirements 50 IL Adm. Code 5421.110 e) The individual contract must contain eligibility requirements that explain the conditions that must be met to enroll in the plan, the limiting age for enrollees and eligible dependents, including the effects of Medicare eligibility, and a clear statement regarding newborn coverage.  
Cancellation 50 IL Adm. Code 5421.110 k)
50 IL Adm. Code 5421.111 a)

No HMO may cancel an individual contract except for one or more of the following reasons:

  • Failure to pay the premium;
  • Fraud or material misrepresentation;
  • Material violation of the terms of the contract or evidence of coverage;
  • Failure to establish a satisfactory patient-physician relationship;
  • Failure to meet or continue to meet eligibility requirements under the Basic Outpatient Preventive and Primary Care Services for Children Program offered by 50 IL Adm. Code 5421.131; or,
  • Such other good cause as appears in the contract.
 
Spousal continuation 215 ILCS 5/367.2 Spousal and dependent continuation rights in case of death, divorce or retirement.  
Dependent continuation 215 ILCS 5/367.2-5 Continuation rights for an insured's dependent child in the event of the death of the insured and the child is not eligible for coverage as a dependent under 215 ILCS 5/367.2.  
Extended age dependent continuation 215 ILCS 5/356z.12
215 ILCS 125/5-3(a)

Effective June 1, 2009 a policy that includes dependent coverage must allow unmarried dependents under the age of 26 to apply for coverage.

Additionally, polices must allow military veteran dependents under the age of 30 to apply for coverage if the veteran is an Illinois resident, not married; has served in the active or a reserve components of the U.S. Armed Forces (including the National Guard) and has received a release or discharge other than dishonorable.

Policies in force as of June 1, 2009 must provide for a 90 day open enrollment period for all dependents that meet the criteria described above beginning on the policy renewal date, but no later than May 31, 2010.

Insurers may not apply requirements for creditable coverage, continuous coverage or breaks in coverage during the initial enrollment period. However, preexisting condition limitations may be applied if creditable coverage has not been established.

Policies issued on or after June 1, 2009 must also provide for a 90 day open enrollment applicable to policies issued on or before May 31, 2010.
Insurers must provide an annual 30 day open enrollment period.
The law does not change HIPAA special enrollment requirements.

The attached link provides FAQ information from our web site.

 
Dependent students; medical leave of absence continuation 215 ILCS 5/356z.11
215 ILCS 125/5-3(a)

Effective June 1, 2009 a policy must continue to provide coverage for a dependent college student who has taken a medical leave of absence or reduced hours to part-time status due to a catastrophic illness or injury. Continuation is subject to all of the policy’s terms and conditions applicable to that form of insurance and shall terminate 12 months after the notice of the illness or injury or until coverage would have otherwise lapsed.

This coverage mirrors the requirements of H.R. 285, known as Michelle’s Law, signed by the President on October 9, 2008.
 
Coordination of Benefits 50 IL Adm. Code 5421.110 t)
50 IL Adm. Code 2009
HMOs are permitted, but not required, to adopt coordination of benefits (COB) provisions. An HMO electing to include COB must be consistent with the requirements of 50 IL Adm. Code 2009.  
Discontinuance and replacement of coverage 215 ILCS 5/367i
50 IL Adm. Code 2013.20
215 ILCS 125/5-3(a)
A contract shall provide a reasonable extension of benefits (up to 12 months) in the event of total disability on the date the policy is discontinued. In case of discontinuance the prior plan shall be liable only to the extent of its accrued liabilities and extension of benefits.  
Newborn Coverage 215 ILCS 125/4-8 The individual contract must state newborns are covered from the moment of birth. If additional premium is required the insurer may require notification within 31 days in order to have coverage continue.  
Pending & Adopted Children 215 ILCS 125/4-9 No contract that covers the insured's immediate family or children may exclude or limit coverage of an adopted child or a child not residing with the insured (foster child). A child residing with an enrollee pursuant to an interim court order of adoption is considered an adopted child. Grandchildren are considered dependents if appropriate documentation of dependency can be provided.  
Reinstatement 50 IL Adm. Code 5421.110 l) The individual contract must contain the conditions of the enrollee's right to reinstatement.  
Disabled Dependents 215 ILCS 125/4-9.1
50 IL Adm. Code 5421.110 u)
Provides continuation for handicapped dependent that has attained the limiting age of the contract.  
Deductibles and Copayments 50 IL Adm. Code 5421.110 i)

An HMO may require copayments, but not to exceed 50% of the usual and customary fee of the service.

Maximum copays per calendar year are $3,000 per enrollee and $6,000 per family.

 
Out of Area Benefits and Services 50 IL Adm. Code 5421.110 h) The individual contract must contain a specific description of the benefits and services that are available out of the HMO's service area.  
Benefits and Services Within the Service Area 50 IL Adm. Code 5421.110 f) The individual contract must contain a specific description of the benefits and services that are available in the HMO's service area.  
Grievance Procedure 50 IL Adm. 5421.110 x) The individual contract must provide a full description of the HMO's grievance procedure.  
Limitations and Exclusions 215 ILCS 125/4-14(3)
50 IL Adm. Code 5421.110 b)
There must be a detailed statement in the individual contract that describes the limitations and exclusions expressed with the same prominence as the description of the benefits.  
Notice of Address of Division of Insurance 50 IL Adm. Code 5421.110 n) No individual contract may be issued without notice of the complaint department of the HMO and the address of the Managed Care Unit of the Division of Insurance.  
REQUIREMENTS RELATING TO POLICY FORM REVIEW REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Basic Health Care Services 50 IL Adm. Code 5421.130 This section contains the minimum standards that must be met for basic health care services provided those services are determined to be medically necessary by the enrollee's primary care physician (PCP). Some of these services are outlined in more detail in this section of the checklist.  
Description of in-plan and out-of-plan Benefits 50 IL Adm. Code 5421.110 f) h) The individual contract must contain a specific description of benefits and services available both in-plan and out-of plan.  
Emergency Care Services 50 IL Adm. Code 5421.110 g)
50 IL Adm. Code 5421.130 d)
215 ILCS 134/10
215 ILCS 134/65

The individual contract must include a specific description of benefits available for emergencies 24 hours a day, 7 days a week.

No HMO may limit emergency services within the service area to contracted providers.

 
Alcoholism and Drug Abuse 50 IL Adm. Code 5421.130 i)

Coverage must include diagnosis, detoxification and treatment of medical complications of the abuse of or addiction to alcohol or drugs on either an inpatient or outpatient basis.

Rehabilitation services must be included.

 
Preventive Services Covered Under the Affordable Care Act

Public Law 111-148-Patient Protection and Affordable Care Act

The Department requires the complete list of covered preventive services to appear in the certificate of insurance. The Department will not accept referring an insured to a web site or a 1-800 phone number.

The list also includes covered preventive services for women as well.
 
Preventive Health Care for Women

Company bulletin 2012-05

The federal Affordable Care Act (ACA) requires health care plans to include women's preventive health care such as mammograms, screening for cervical cancer, prenatal care and other services to be covered without cost sharing (when delivered by a network provider) by non-grandfathered group plans beginning on or after September 23, 2010 and by individual insurance plans beginning on or after the same date.

Additionally, health care plans must now comply with the guidelines released by the Health Resources and Services Administration (HRSA) on August 1, 2011. Non-grandfathered plans and issuers are required to provide coverage without cost sharing consistent with these guidelines in the first plan year (in the individual market, policy year) that begins on or after August 1, 2012. The HRSA web site is located at: http://www.hrsa.gov/WomensGuideLines.
 
Criminal Sexual Assault 215 ILCS 125/4-4 Coverage for criminal sexual assault must be at the same benefit levels as any other emergency or accident care situation.  
Mammography 215 ILCS 125/4-6.1(a)

Coverage of screening by low-dose mammography for all women over 35;

Coverage requires baseline mammogram for women 35-39 and annual mammogram for women 40 years of age and older.

For women under 40 with a family history of breast cancer or other risk factors mammograms must be provided at an age and intervals considered medically necessary.

Coverage includes a comprehensive ultrasound screening of an entire breast or breasts when a mammogram demonstrates medical necessity as described.

Coverage must be provided at no cost to the insured and shall not be applied to an annual or lifetime maximum benefit.

 
Clinical Breast Exam 215 ILCS 5/356g.5
215 ILCS 125/4-6.5

Clinical breast examinations must be covered:

  1. at a minimum every three years for women over 20 years of age but less than 40; and,
  2. annually for women 40 years of age and older.

 

 
Reconstructive Breast Surgery 215 ILCS 125/4-6.1(b)
50 IL Adm. Code 5421.132

Coverage requirements include reconstruction of the breast upon which the mastectomy is performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment for physical complications at all stages of mastectomy, including lymphdemas.

Written notice of the availability of this coverage must be delivered to the enrollee upon enrollment and annually thereafter.

 
Breast Cancer Pain Medication and Therapy 215 ILCS 5/356g.5-1
215 ILCS 125/5-3(a)
Coverage must include all medically necessary pain medication and pain therapy related to the treatment of breast cancer under the same terms and condition applicable to treatment of other conditions. The term “pain therapy” is defined.  
Breast Implant Removal 215 ILCS 125/4-6.2

No HMO contract may deny medically necessary breast implant removal for a sickness or injury.

This provision does not apply to the removal of breast implants that were done solely for cosmetic purposes.

 
Fibrocystic Breast Condition 215 ILCS 125/4-16 No individual contract may deny or exclude coverage for fibrocystic breast condition in the absence of a breast biopsy demonstrating an increased disposition to the development of breast cancer unless the enrollee's medical history is able to confirm a chronic, relapsing, symptomatic breast condition.  
Post Mastectomy Care 215 ILCS 5/356t
215 ILCS 125/4-6.5
Coverage must provide inpatient treatment following mastectomy for a length of time to be determined by attending physician; must also provide for availability of post-discharge physician office visit or in-home nurse visit within 48 hours of discharge.  
Organ Transplant 215 ILCS 125/4-5 No individual contract may deny reimbursement for an organ transplant as experimental or investigational unless supported by appropriate, required documentation.  
Prescription Drugs, Cancer Treatment: Off-Label Use 215 ILCS 125/4-6.3 No HMO that provides prescription drug coverage for certain types of cancer may exclude coverage of any drug on the basis that the drug has not been FDA approved for that particular type of cancer if documentation is provided in certain medical reference compendia as to the efficacy of that drug for the form of cancer in question, or if the drug has been 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 here or in Great Britain.  
Mental, Emotional or Nervous Disorders 50 IL Adm. Code 5421.130 h) An individual contract must provide 10 days of inpatient care and 20 visits for outpatient care per year.  
Maternity and Post-Parturition Care 215 ILCS 5/356(s)
215 ILCS 125/4-6.4
50 IL Adm. Code 5421.130 e)
50 IL Adm. Code 2603.30 a) 11)

Coverage must include prenatal and post-natal care and complications of pregnancy for mother as well as care of newborn.

Coverage must provide minimum of 48 hours inpatient care for normal delivery and 96 hours for caesarian section. Shorter lengths of stays are permitted based on decision of the PCP.

 
Pap and Prostate tests 215 ILCS 5/356u
215 ILCS 125/4-6.5

Coverage must include annual cervical smear or Pap smear test for female insureds, including surveillance tests for ovarian cancer for female insureds who are at risk for ovarian cancer; and,

Annual digital rectal examination and prostate-specific antigen test for males upon recommendation of the PCP. Must include asymptomatic men age 50 and over; African-American men age 40 and over; and men age 40 and over with family history of prostate cancer.

 
Qualified Clinical Cancer Trials 215 ILCS 5/364.01(c)-(i)
215 ILCS 125/5-3(a)
No group policy of accident and health insurance shall exclude coverage for any routine patient care for an insured participating in a qualified clinical cancer trial if the policy covers that same care for insureds not so enrolled.  
Colorectal Cancer Screening 215 ILCS 5/356x
215 ILCS 125/5-3(a)
Must cover all colorectal cancer exams and lab tests for colorectal cancer as prescribed by the PCP according to stated guidelines; may not impose greater copays, ded or waiting periods.  
Diabetes Supplies and Testing 215 ILCS 5/356w
215 ILCS 125/5-3(a)
Coverage must be provided for outpatient self-management training and education, equipment and supplies. Guidelines are provided.  
Prenatal HIV testing 215 ILCS 5/356z.1
215 ILCS 125/4-6.5
Must be provided if coverage includes maternity benefit.  
Emergency Ambulance Transportation 215 ILCS 125/4-15 An individual contract must include coverage for emergency transportation by ground or air ambulance.  
Adjunctive Services in Dental Care 215 ILCS 5/356z.2
215 ILCS 125/5-3(a)
This coverage is limited to children age 6 or under; to individuals with medical conditions that require hospitalization and general anesthesia for dental care; and for disabled individuals.  
Prescription Inhalants 215 ILCS 5/356z.5
215 ILCS 125/5-3(a)
If the individual contract provides RX coverage it may not deny or limit coverage for prescription inhalants when diagnosis is asthma or other life-threatening bronchial ailments; additional guidelines provided.  
Coverage for contraceptives 215 ILCS 5/356z.4
215 ILCS 125/5-3(a)
If the individual contract provides coverage for OP services and RX or devices it must provide enrollee and dependent coverage for all OP and contraceptive drugs and devices approved by the FDA; may not impose greater copays, ded or waiting periods.  
Bone Mass Measurement/Osteoporosis 215 ILCS 5/356z.6
215 ILCS 125/5-3(a)
Coverage must include medically necessary bone mass measurement and diagnosis and treatment of osteoporosis the same as any other illness.  
Multiple Sclerosis Preventative Physical Therapy 215 ILCS 5/356z.8
215 ILCS 125/5-3(a)
Coverage must provide for medically necessary preventative physical therapy for insureds diagnosed with this disease. A definition of “preventative physical therapy” is included. Coverage limitations, deductibles, coinsurance features, etc. must be provided the same as any other illness.  
Amino acid-based elemental formulas 215 ILCS 5/356z.10
215 ILCS 125/5-3(a)
Coverage must include reimbursement for amino acid-based elemental formulas, regardless of delivery method, for diagnosis and treatment of conditions described herein.  
Coverage for Human Papillomavirus Vaccine 215 ILCS 5/356z.9
215 ILCS 125/5-3(a)
Coverage must include benefit for FDA approved human papillomarivus vaccine (HPV).  
Shingles Vaccine 215 ILCS 5/356z.13
215 ILCS 125/5-3(a)
Coverage must include a vaccine for shingles that is approved by the federal Food and Drug Administration if it is ordered by a physician for an insured/enrollee who is 60 years of age or older.  
Autism Spectrum Disorders 215 ILCS 5/356z.14
215 ILCS 125/5-3(a)
Coverage must be provided for individuals under age 21 for the diagnosis and treatment of autism spectrum disorders to the extent that such care is not already covered by the policy.  
Habilitative Services for Children 215 ILCS 5/356z.15
215 ILCS 125/5-3
A group or individual policy of accident and health or a managed care plan must provide coverage for habilitative services for children less than 19 years of age with congenital, genetic, or early acquired disorders as described.  
Prosthetic and customized orthotic devices 215 ILCS 5/356z.18
215 ILCS 125/5-3(a)
A group or individual major medical policy of accident or health insurance or a managed care plan must provide coverage for prosthetic and orthotic devices subject to other general exclusions, limitations and financial requirements of the policy.  
Outpatient Rehabilitative Therapy 50 IL Adm. Code 5421.130 j) Coverage must include, but is not limited to, speech, physical and occupational therapy for up to 60 treatments per year.  
Health Care External Review Act 215 ILCS 5/155.36
215 ILCS 180/
215 ILCS 180/75
215 ILCS 134/45
The Act provides uniform standards for the establishment and maintenance of external review procedures.

Please note the disclosure provisions in section 75.
 
Health Care External Review Act Time Frame Requirements 215 ILCS 180/35
215 ILCS 180/40
215 ILCS 180/42
Time Frames Chart
Please note the statutory references for the time lines for external review as well as a chart to aid for compliance purposes.  
Health Care External Review Carrier Obligations for Filing Notices and Forms 215 ILCS 180/20
50 IL. Adm. Code 5430.40
Health carriers must file for approval sample copies of:

  • Notices and forms required to file for a right to external review
  • Descriptions for both standard and expedited external review procedures
  • Statements informing the insured and any authorized representative that a standard or expedited external review request deemed ineligible by the plan may be appealed to the Department of Insurance by filing a complaint
  • Notification (until July 1, 2013) that if an external independent review upholds an adverse determination the insured has a right to appeal that decision to the Department of Insurance
 
REQUIREMENTS SPECIFIC TO HIPPA REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Guaranteed Renewability 215 ILCS 97/50(A)(B)

Except as provided, an insurer in the individual market must continue coverage except for:

  • Nonpayment of premium;
  • Fraud;
  • Termination of the plan;
  • Movement outside of the service area; or,
  • Membership in the association ceases.
 
Uniform Termination of Coverage Notification Requirements 215 ILCS 97/50 (C) Insurers must comply with the uniform notification requirements for discontinuing a particular type of coverage and discontinuing all coverage in the state. Notification requirements must appear in the certificate.  
Notice Requirement 215 ILCS 97/60 An insurer electing to uniformly modify, terminate or discontinue coverage in accordance with Section 30 or 50 of Act 97 (HIPAA) must provide 90 days advance notice to the Division by certified mail.  
MANAGED CARE REFORM AND PATIENT RIGHTS ACT PROVISIONS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Transition of Services 215 ILCS 134/25
50 IL Adm. Code 5420.60
A health care plan must provide for continuity of care for an ongoing course of treatment for its enrollees in circumstances in which the enrollee's PCP leaves the network as described. Treatment is available for 90 days from the date of the notice of the physician's termination or if the enrollee has entered the third trimester of a pregnancy.  
Definition of Emergency Medical Condition 215 ILCS 5/155.36
215 ILCS 134/10
A health care plan must use this definition that includes “prudent lay person” language.  
Emergency Services Prior to Stabilization 215 ILCS 134/65
50 IL Adm. Code 5420.110
A health care plan that provides, or is required to provide, coverage for emergency services may not make payments contingent upon whether the provider is in or out-of plan, or whether prior authorization is obtained.  
Post-Stabilization Medical Services 215 ILCS 134/70
50 IL Adm. Code 5420.120
The health care plan will be responsible for providing post-stabilization medical services if authorization is received from the health care plan, or one of its delegated providers, or after 2 documented good faith efforts by the treating health care provider as described.  
Standing Referral to Specialist 215 ILCS 134/40(b) A health care plan shall establish a procedure by which an enrollee who requires the treatment of a specialist physician or other health care provider may obtain a standing referral to that individual. Such a referral may be effective for up to one year and may be renewed and re-renewed.  
Utilization of Health Care Facilities 215 ILCS 134/43 A health care plan must provide its enrollees with a description of their rights and responsibilities for obtaining referrals and for making appropriate use of health care facilities when their PCP is not available.  
Administrative Appeals: Complaint Handling Procedures 215 ILCS 134/50
215 ILCS 134/55
215 ILCS 125/4-6
50 IL Adm. Code 5420.90

An HMO is required to establish a procedure to handle complaints regarding administrative issues and procedures, but nothing in these requirements prevents an enrollee from filing a complaint with the Division.

An HMO is required to respond to a complaint received from the Division of Insurance within 21 days of such notification.

 
Appeals and Grievances Relating to Health Care Services 215 ILCS 134/45(a)(b)(c), (d)

An HMO must establish procedures for both expedited appeals of health care services and other appeals for health care services that meet the minimum requirements outlined herein.

If the case involves an adverse determination the HMO must provide the procedures for requesting an external independent review.

 
External Independent Review 215 ILCS 134/45(e) and (f)
50 IL Adm. Code 5420.70

A health care plan is required to submit for the Division's review a mechanism for the joint selection of an independent external reviewer under the conditions described in 215 ILCS 134/45(f).

Any proposed changes to the mechanism must be filed for review with the Division's Managed Care unit.

 
Notice of Nonrenewal or Termination 215 ILCS 134/20 A health care plan is required to provide 60 days notice of nonrenewal or termination of a health care provider to both the provider and to his/her enrollees.  
POINT OF SERVICE (POS) PLAN REQUIREMENTS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Filing of POS Product 215 ILCS 125/4.5-1
50 IL Adm. Code 5421.113

The filing must include an HMO portion (base) and an indemnity portion. The HMO filing must be filed with the HMO unit and the indemnity portion must be filed with the LAH unit.

Illinois does not permit a POS plan with a preferred provider organization (PPO) base and an HMO "tail" (out-of-network piece).

 
GENERAL INFORMATION REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Civil Unions

Company Bulletin 2011-06

The Religious Freedom Protection Act and Civil Union Act, 750 ILCS 75/, allows both same-sex and different-sex couples to enter into a civil union with all of the obligations, protections, and legal rights that Illinois provides to married heterosexual couples.  
Rate Filing Required 50 IL Adm. Code 5421.60
215 ILCS 125/4-12
Company Bulletin 2010-08
An HMO must file its rates with the Division's actuarial unit.

The Federal Patient Protection and Affordable Care Act (PPACA) has established premium reporting and review processes for all health insurance issuers. The Rate Filing Actuarial Memorandum and Rate Data Collection Form are available on the Department's web site under Company Bulletin 2010-08.
 
Standardized Individual and Small Employer Application Form 215 ILCS 5/359b
50 IL Adm. Code 2030
Company Bulletin 2010-10
All health insurance carriers offering health benefit plans in either the individual or small group market must use the standard health application beginning on January 1, 2011.  
Retrospective Rate Filings 215 ILCS 125/5-3 (f) An HMO may effect refunds or charge additional premium under the circumstances described.  
Medically Necessary Dispute Resolution 215 ILCS 125/4-10 Each HMO must establish a dispute resolution process in which a physician, holding the same class of license as the PCP and not affiliated with the HMO, is jointly selected by the patient and the HMO in the event of a dispute regarding medical necessity of a covered service proposed by the patient's PCP. In the event the reviewing physician determines the covered service is medically necessary the HMO will be required to provide the service.  
Provision of Information 50 IL Adm. Code 5421.110(q)
50 IL Adm. Code 5420.40

An HMO must provide to each enrollee information regarding its functions, organization, and related institutions and describe the appropriate use of its services. This material must also include a description of the grievance procedure, directions on filing a grievance and "Notice of Availability of the Division".

HMOs must provide description of coverage worksheets as detailed in 50 IL Adm. Code 5420.40.

 
ID Card Required 50 IL Adm. Code 5421.110(r)
215 ILCS 139/15

HMOs must provide ID cards to their enrollees. Mandatory data elements for the card or other technology include:

  • Processor control number if required for claims adjudication;
  • Group number;
  • Card issuer identifier;
  • Cardholder ID number; and
  • Cardholder name.

The back of the card or other technology is to include the claims submission names and addresses and the help desk telephone numbers and names.

Cards must be issued upon enrollment and reissued upon any change in the enrollee's coverage that affects any of the required elements.

 
Use of SSN on ID Cards 815 ILCS 505 2QQ
215 ILCS 138/15

The focus of HB 4712 is on any card required for an individual to access products or services, while SB 2545 is more limited in that it just focuses on insurance cards.

HB 4712 prevents a person from:

  • Publicly posting or displaying an individual's SSN;
  • Printing an individual's SSN on any card required for the individual to access products or services, however, an entity providing an insurance card must print on the card a unique identification number as required by 215 ILCS 138/15.
  • Being required to transmit an SSN over the Internet to access a web site unless the connection is secure or the SSN is encrypted;
  • Requiring the individual to use his/her SSN to access a web site unless a PIN number or other authentication device is also used; and,
  • Printing an individual's SSN on any materials mailed to an individual unless required by state or federal law.

Insurers must comply with both provisions.

 
Women's Principal HealthCare Provider 215 ILCS 125/5-3.1
215 ILCS 5/356r
An HMO that requires enrollees to select a PCP must allow female enrollees the right to select a participating woman's principal health care provider. Notification is required.  
Discrimination 50 IL Adm Code 2603 Guidelines for Unfair Discrimination based on sex, sexual preference or marital status. Forbids excluding coverage for dependent child maternity.  
Basic Outpatient Preventive and Primary Health Care Services for Children 215 ILCS 125/4-17
50 IL Adm. Code 5421.131
An HMO may choose to provide or arrange to pay for or reimburse the cost of basic outpatient preventive and primary health care services for children who are without health care coverage.  
HMO Medicare Contract 50 IL Adm. Code 5421.110 (p) An HMO Medicare contract must be delivered to the enrollee at least 15 days prior to the effective date of coverage and the enrollee will have the option to return the contract prior to the effective date with a full refund of coverage.  
No Medicaid Limitation or Exclusion 215 ILCS 125/4-2(b) No individual contract may limit or exclude coverage because an enrollee or dependent is receiving Medicaid benefits.  
Dental Coverage Reimbursement Rates 215 ILCS 5/355.2
215 ILCS 125/5-3(a)
No individual contract that also includes dental and bases reimbursement on usual and customary fees must disclose specific information.  
HIV/AIDS Questions on Application 215 ILCS 5/143(1) Questions designed to elicit information regarding AIDS, ARC and HIV must be specifically related to the testing, diagnosis or treatment done by a physician or an appropriately licensed clinical professional acting within the scope of his/her license.  
Qualified Clinical Cancer Trials 215 ILCS 5/364.01(a),(b)
215 ILCS 125/5-3(a)
No insurer may cancel or non-renew any individual's coverage due to participation in a qualified cancer clinical trial.  
Prohibition against Substitution of Hospitalist 215 ILCS 5/134/30(c) No health care plan, or one of its subcontractors, may require an enrollee who is hospital confined to substitute his/her primary care physician for a hospitalist who is under the control of that entity.  
Wellness Coverage 215 ILCS 5/356z.17
215 ILCS 125/5-3(a)
Individual and group accident and health insurers and HMOs may offer reasonably designed programs for wellness coverage.  
Organ Transplant Medication Notification Act 215 ILCS 175 Provides guidelines for health insurance policies and health care service plans that cover immunosuppressant drugs.  
Use of Information Derived from Genetic Testing 215 ILCS 5/356v
215 ILCS 97/20(A)(1)
215 ILCS 125/5-3(a)
Insurers must comply with the Genetic Information privacy Act as well as the provisions found in 215 ILCS 97/20(A)(1).  
Cardiovascular Disease 215 ILCS 5/356z.19 Insurers and managed care plans must develop and implement procedures to communicate on an annual basis with adult enrollees regarding the importance and value of early detection and proactive management of cardiovascular disease.  
DEPARTMENT POSITIONS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.
LOCATION OF STANDARD IN FILING
Hospital Definition 215 ILCS 5/143(1) The definition of hospital must allow for those hospitals providing surgery, etc., on a formal arrangement basis with another institution.  
Precertification penalties 215 ILCS 5/143(1) The Division will permit a failure to precertify a hospital admission penalty of the lesser of up to $1,000 or 50% of the billed charge. The penalty may be no more frequent than a per confinement basis.