Delivery Of Services - Required Provisions And Marketing

  1. Law
  2. Illinois Compiled Statutes
  3. INSURANCE
  4. Health Maintenance Organization Act.
  5. Delivery Of Services - Required Provisions And Marketing

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(215 ILCS 125/Art. IV heading)

ARTICLE IV. DELIVERY OF SERVICES - REQUIRED
PROVISIONS AND MARKETING.

 

(215 ILCS 125/4-1) (from Ch. 111 1/2, par. 1408)

Sec. 4-1. Description and securing of services. Every Health Maintenance Organization shall at the time of enrollment and annually thereafter provide its enrollees a description of the services and information as to where and how to secure them. The Health Maintenance Organization shall issue to each subscriber or enrollee a group contract or evidence of coverage. The group contract or evidence of coverage and related material shall be delivered or issued for delivery to an enrollee within 30 days from the later of the effective date of coverage or the date on which the Health Maintenance Organization is provided completed notification of enrollment.

(Source: P.A. 86-620.)

 

(215 ILCS 125/4-2) (from Ch. 111 1/2, par. 1408.2)

Sec. 4-2. Medical assistance; coverage of child.

(a) In this Section, "Medicaid" means medical assistance authorized under Section 1902 of the Social Security Act.

(b) A contract or evidence of coverage delivered, issued for delivery, renewed, or amended by a Health Maintenance Organization may not contain any provision which limits or excludes payments of health care services to or on behalf of the enrollee because the enrollee or any covered dependent is eligible for or is receiving Medicaid benefits in this or any other state.

(c) To the extent that payment for covered expenses has been made under Article V, VI, or VII of the Illinois Public Aid Code for health care services provided to an individual, if a third party has a legal liability to make payments for those health care services, the State is considered to have acquired the rights of the individual to payment.

(d) If a child is covered under a health care plan of a Health Maintenance Organization in which the child's noncustodial parent is an enrollee, the Health Maintenance Organization shall:

  • (1) Provide necessary information to the child's custodial parent to enable the child to obtain benefits under that health care plan.
  • (2) Permit the child's custodial parent (or the provider, with the custodial parent's approval) to submit claims for payment for covered services without the approval of the noncustodial parent.
  • (3) Make payments on claims submitted in accordance with paragraph (2) directly to the custodial parent, the provider of health care services, or the state Medicaid agency.

(e) A Health Maintenance Organization may not deny enrollment of a child under the health care plan in which the child's parent is an enrollee on any of the following grounds:

  • (1) The child was born out of wedlock.
  • (2) The child is not claimed as a dependent on the parent's federal income tax return.
  • (3) The child does not reside with the parent or in the service area covered by the health care plan.

(f) If a parent is required by a court or administrative order to provide coverage for a child under a health care plan in which the parent is enrolled, and that offers coverage for eligible dependents, the Health Maintenance Organization, upon receiving a copy of the order, shall:

  • (1) Upon application, permit the parent to enroll in the health care plan a child who is otherwise eligible for that coverage, without regard to any enrollment season restrictions that might otherwise be applicable as to the time period within which a person may enroll in the plan.
  • (2) Enroll the child in the health care plan upon application of the child's other parent, the state agency administering the Medicaid program, or the state agency administering a program for enforcing child support and establishing paternity under 42 U.S.C. 651 through 669 (or another child support enforcement program), if the parent is enrolled in the health care plan but fails to apply for enrollment of the child.

(g) A Health Maintenance Organization may not impose, on a state agency that has been assigned the rights of an enrollee in a health care plan who receives Medicaid benefits, requirements that are different from requirements applicable to an assignee of any other enrollee in that health care plan.

(h) Nothing in subsections (e) and (f) prevents a Health Maintenance Organization from denying any such application if the child is not eligible for coverage according to the Health Maintenance Organization's medical underwriting standards.

(i) The Health Maintenance Organization may not disenroll (or otherwise eliminate coverage of) the child from the health care plan unless the Health Maintenance Organization is provided satisfactory written evidence of either of the following:

  • (1) The court or administrative order is no longer in effect.
  • (2) The child is or will be enrolled in a comparable health care plan obtained by the parent under such order and that enrollment is currently in effect or will take effect not later than the date the prior coverage is terminated.

(Source: P.A. 89-183, eff. 1-1-96.)

 

(215 ILCS 125/4-3) (from Ch. 111 1/2, par. 1408.3)

Sec. 4-3. (Repealed).

(Source: Repealed by P.A. 89-183, eff. 1-1-96.)

 

(215 ILCS 125/4-4) (from Ch. 111 1/2, par. 1408.4)

Sec. 4-4. Sexual assault or abuse victims; coverage of expenses; recovery of State funds; reimbursement of Department of Public Health.

(1) Contracts or evidences of coverage issued by a health maintenance organization, which provide benefits for health care services, shall 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 co-insurance amounts, in the examination and testing of a victim of an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such offense, to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense.

(2) For purposes of enabling the recovery of State funds, any health maintenance organization subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its enrollees entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay for, health care services for which a health maintenance organization is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section.

(3) Whenever the Department of Public Health finds that it has paid for all or part of any health care services for which a health maintenance organization is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such organization provided that the Department of Public Health has notified the organization of its claims before the organization has paid such benefits to its enrollees or in behalf of its enrollees.

(Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13.)

 

(215 ILCS 125/4-5) (from Ch. 111 1/2, par. 1408.5)

Sec. 4-5. Organ Transplants. No contract or evidence of coverage issued by a health maintenance organization which provides coverage for health care services shall deny reimbursement for an otherwise covered expense incurred for any organ transplantation procedure solely on the basis that such procedure is deemed experimental or investigational unless supported by the determination of the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services that such procedure is either experimental or investigational or that there is insufficient data or experience to determine whether an organ transplantation procedure is clinically acceptable. If a health maintenance organization has made written request, or had one made on its behalf by a national organization, for determination by the Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within the federal Department of Health and Human Services as to whether a specific organ transplantation procedure is clinically acceptable and said organization fails to respond to such a request within a period of 90 days, the failure to act may be deemed a determination that the procedure is deemed to be experimental or investigational.

(Source: P.A. 87-218.)

 

(215 ILCS 125/4-6) (from Ch. 111 1/2, par. 1408.6)

Sec. 4-6. Complaint handling procedure. (a) Every health maintenance organization shall establish and maintain a complaint system providing reasonable procedures for resolving complaints initiated by enrollees. Nothing herein shall be construed to preclude an enrollee or a provider from filing a complaint with the Director or as limiting the Director's ability to investigate such complaints.

(b) When a complaint is received by the Department of Insurance against a health maintenance organization or producer (respondent), the respondent, shall be notified of the complaint. The Department shall, in its notification, specify the date when a report is to be received from the respondent, which shall be no later than 21 days after notification is sent to the respondent. A failure to reply by the date specified may be followed by a collect telephone call or collect telegram. Repeated instances of failing to reply by the date specified may result in further regulatory action.

(c) Contents of Response or Report. (1) Each respondent shall supply adequate documentation which explains all actions taken or not taken and which were the basis for the complaint;

(2) Documents necessary to support the respondent's position and information requested by the Department, shall be furnished with the respondent's reply;

(3) The respondent's reply shall be in duplicate, but duplicate copies of supporting documents shall not be required;

(4) The respondent's reply shall include the name, telephone number and address of the individual assigned to the complaint; and

(5) The Department shall respect the confidentiality of medical reports and other documents which by law are confidential. Any other information furnished by a respondent shall be marked "confidential" if the respondent does not wish it to be released to the complainant.

(d) Follow-up Conclusion. Upon receipt of the respondent's report, the investigating deputy shall evaluate the material submitted; and

(1) Advise the complainant of the action taken and disposition of his complaint;

(2) Pursue further investigation with respondent or complainant; or

(3) Refer the investigation report to the appropriate branch within the Department of Insurance for further regulatory action.

(Source: P.A. 86-620.)

 

(215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)

Sec. 4-6.1. Mammograms; mastectomies.

(a) Every contract or evidence of coverage issued by a Health Maintenance Organization for persons who are residents of this State shall contain coverage for screening by low-dose mammography for all women 35 years of age or older for the presence of occult breast cancer. The coverage shall be as follows:

  • (1) A baseline mammogram for women 35 to 39 years of age.
  • (2) An annual mammogram for women 40 years of age or older.
  • (3) A mammogram at the age and intervals considered medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
  • (4) For an individual or group policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
  • (5) For an individual or group policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly, a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.

A policy subject to this subsection shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223).

For purposes of this Section:

"Diagnostic mammogram" means a mammogram obtained using diagnostic mammography.

"Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast.

"Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with radiation exposure delivery of less than 1 rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis.

"Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.

If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this subsection, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this subsection.

(a-5) Coverage as described in subsection (a) shall be provided at no cost to the enrollee and shall not be applied to an annual or lifetime maximum benefit.

(b) No contract or evidence of coverage issued by a health maintenance organization that provides for the surgical procedure known as a mastectomy shall be issued, amended, delivered, or renewed in this State on or after the effective date of this amendatory Act of the 92nd General Assembly unless that coverage also provides for prosthetic devices or reconstructive surgery incident to the mastectomy, providing that the mastectomy is performed after the effective date of this amendatory Act. Coverage for breast reconstruction in connection with a mastectomy shall include:

  • (1) reconstruction of the breast upon which the mastectomy has been performed;
  • (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and
  • (3) prostheses and treatment for physical complications at all stages of mastectomy, including lymphedemas. Care shall be determined in consultation with the attending physician and the patient. The offered coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy and all other terms and conditions applicable to other benefits. When a mastectomy is performed and there is no evidence of malignancy, then the offered coverage may be limited to the provision of prosthetic devices and reconstructive surgery to within 2 years after the date of the mastectomy. As used in this Section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician.

Written notice of the availability of coverage under this Section shall be delivered to the enrollee upon enrollment and annually thereafter. A health maintenance organization may not deny to an enrollee eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Section. A health maintenance organization may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives (monetary or otherwise) to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with this Section.

(c) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)

 

(215 ILCS 125/4-6.2) (from Ch. 111 1/2, par. 1408.8)

Sec. 4-6.2. Breast implant removal. No contract offered by Health Maintenance Organizations shall deny coverage for the removal of breast implants when the removal of the implants is medically necessary treatment for a sickness or injury. This Section does not apply to surgery performed for removal of breast implants that were implanted solely for cosmetic reasons. For the purpose of this Section, cosmetic reasons does not include cosmetic surgery performed as reconstruction resulting from sickness or injury.

(Source: P.A. 87-938; 88-45.)

 

(215 ILCS 125/4-6.3)

Sec. 4-6.3. Prescription drugs; cancer treatment. No health maintenance organization that provides coverage for prescribed drugs approved by the federal Food and Drug Administration for the treatment of certain types of cancer shall exclude coverage of any drug on the basis that the drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the federal Food and Drug Administration. The drug, however, must be approved by the federal Food and Drug Administration and must be recognized for the treatment of the specific type of cancer for which the drug has been prescribed in any one of the following established reference compendia:

  • (a) the American Hospital Formulary Service Drug Information;
  • (b) National Comprehensive Cancer Network's Drugs & Biologics Compendium;
  • (c) Thomson Micromedex's Drug Dex;
  • (d) Elsevier Gold Standard's Clinical Pharmacology; or
  • (e) other authoritative compendia as identified from time to time by the Federal Secretary of Health and Human Services; or if not in the compendia, recommended for that particular type of cancer in formal clinical studies, the results of which have been published in at least two peer reviewed professional medical journals published in the United States or Great Britain.

Any coverage required by this Section shall also include those medically necessary services associated with the administration of a drug.

Despite the provisions of this Section, coverage shall not be required for any experimental or investigational drugs or any drug that the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed. This Section shall apply only to cancer drugs. Nothing in this Section shall be construed, expressly or by implication, to create, impair, alter, limit, notify, enlarge, abrogate or prohibit reimbursement for drugs used in the treatment of any other disease or condition.

(Source: P.A. 96-457, eff. 8-14-09.)

 

(215 ILCS 125/4-6.4)

Sec. 4-6.4. Post-parturition care. A health maintenance organization is subject to the provisions of Section 356s of the Illinois Insurance Code.

(Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)

 

(215 ILCS 125/4-6.5)

Sec. 4-6.5. Required health benefits; Illinois Insurance Code requirements. A health maintenance organization is subject to the provisions of Sections 155.37, 356g.5, 356t, 356u, and 356z.1 of the Illinois Insurance Code.

(Source: P.A. 95-189, eff. 8-16-07.)

 

(215 ILCS 125/4-7) (from Ch. 111 1/2, par. 1409)

Sec. 4-7. Solicitations of enrollees. Solicitations of enrollees by a Health Maintenance Organization authorized under this Act, or its representatives shall not be construed to be violative of any provisions of law relating to solicitation or advertising by health professionals. No solicitation may be made which advertises, identifies or makes a qualitative judgment concerning any health professional who provides services for a Health Maintenance Organization. Nothing in this Section precludes a Health Maintenance Organization from providing to a particular potential enrollee the names of health providers upon request by that particular potential individual enrollee. No Health Maintenance Organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. Health Maintenance Organizations shall be subject to Section 143c of the "Illinois Insurance Code", approved June 29, 1937, as amended.

If the Director finds that any advertisement of a plan has materially failed to comply with the provisions of this Act or the rules thereunder, the Director may, by order, require the plan to publish in the same or similar medium, an approved correction or retraction of any untrue, misleading, or deceptive statement contained in the advertising and may prohibit such plan from publishing or distributing, or allowing to be published or distributed on its behalf such advertisement or any new materially revised advertisement without first having filed a copy thereof with the Director 30 days prior to the publication or distribution thereof, or any shorter period specified in such order. An order issued under this Section shall be effective for 12 months from its issuance, and may be renewed by order if the advertisements submitted under this Section indicate difficulties of voluntary compliance with the applicable provisions of this Act and the rules thereunder.

(Source: P.A. 85-20.)

 

(215 ILCS 125/4-8) (from Ch. 111 1/2, par. 1409.1)

Sec. 4-8. Newborn Infants. (1) No contract or evidence of coverage issued by a Health Maintenance Organization which provides for coverage of dependents of the principal enrollee shall 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.

(2) Each such contract or evidence of coverage shall contain a provision stating that benefits shall be granted immediately with respect to newborn infants from the moment of birth and that such coverage shall include illness, injury, congenital defects, birth abnormalities and premature birth.

(3) If payment of a specific premium is required under the terms of a contract to provide coverage for a child, there may be requirements that notification of birth of a newly born infant be given to the Health Maintenance Organization within the 31 days following the birth in order to have coverage continued beyond such 31 day period and that such specific premium be paid within 30 days following receipt of such notice.

(4) In the event that no other members of the enrollee's immediate family are covered, immediate coverage for the first newborn infant shall be provided if the enrollee applies for dependent's coverage within 31 days of the newborn's birth. Such coverage shall be contingent upon payment of the additional premium.

(5) The requirements of this Section shall apply, on or after the sixtieth day following the effective date of this amendatory Act of 1989, (a) to all such evidences of coverage delivered or issued for delivery, and (b) to all such group contracts delivered, issued for delivery, renewed or amended. The health maintenance organizations which issue such evidences of coverage that are in effect on the sixtieth day following the effective date of this amendatory Act of 1989 shall extend to owners of such contracts, on or before the first contract anniversary following such date, the opportunity to apply for the addition to their contracts of a provision as set forth in subsection (2) above, with, at the option of the health maintenance organization, payment of a premium appropriate thereto.

(Source: P.A. 86-620.)

 

(215 ILCS 125/4-9) (from Ch. 111 1/2, par. 1409.2)

Sec. 4-9. Adopted children. No contract or evidence of coverage issued by a Health Maintenance Organization which provides for coverage of dependents of the principal enrollees shall 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. For purposes of this Section, a child who is in the custody of a principal enrollee, pursuant to an interim court order of adoption or, in the case of group insurance, placement of adoption, whichever comes first, vesting temporary care of the child in the enrollee, is an adopted child, regardless of whether a final order granting adoption is ultimately issued.

(Source: P.A. 91-549, eff. 8-14-99.)

 

(215 ILCS 125/4-9.1) (from Ch. 111 1/2, par. 1409.2-1)

Sec. 4-9.1. Dependent Coverage Termination.

(a) The attainment of a limiting age under a group contract or evidence of coverage which provides that coverage of a dependent person of an enrollee shall terminate upon attainment of the limiting age for dependent persons does not operate to terminate the coverage of a person who, because of a disabling condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment and is dependent on his or her parents or other care providers for lifetime care and supervision.

(b) For purposes of subsection (a), "dependent on other care providers" is defined as requiring a Community Integrated Living Arrangement, group home, supervised apartment, or other residential services licensed or certified by the Department of Human Services (as successor to the Department of Mental Health and Developmental Disabilities), the Department of Public Health, or the Department of Healthcare and Family Services (formerly Department of Public Aid).

(c) Proof of such incapacity and dependency shall be furnished to the health maintenance organization by the enrollee within 31 days of a request for the information by the health maintenance organization and subsequently as may be required by the health maintenance organization, but not more frequently than annually. In the absence of proof submitted within 31 days of such inquiry that such dependent is a person who has a disability and is a dependent, the health maintenance organization may terminate coverage of such person at or after attainment of the limiting age. In the absence of such inquiry, coverage of any person who has a disability and is a dependent shall continue through the term of the group contract or evidence of coverage or any extension or renewal thereof.

(Source: P.A. 99-143, eff. 7-27-15.)

 

(215 ILCS 125/4-9.2) (from Ch. 111 1/2, par. 1409.2-2)

Sec. 4-9.2. Continuation of group HMO coverage after termination of employee or membership. A group contract delivered, issued for delivery, renewed, or amended in this State that covers employees or members for health care services shall provide that employees or members whose coverage under the group contract would otherwise terminate because of termination of employment or membership or because of a reduction in hours below the minimum required by the group contract shall be entitled to continue their coverage under that group contract, for themselves and their eligible dependents, subject to all of the group contract's terms and conditions applicable to those forms of coverage and to the following conditions:

  • (1) Continuation shall only be available to an employee or member who has been continuously covered under the group contract (and for similar benefits under any group contract that it replaced) during the entire 3 month period ending with the termination of employment or membership or reduction in hours below the minimum required by the group contract. With respect to an employee or member who is involuntarily terminated between September 1, 2008 and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, continuation shall be available if the employee or member was covered under the group contract the day prior to such termination.
  • (2) Continuation shall not be available for any enrollee who is covered by Medicare, except for those individuals who have been covered under a group Medicare supplement policy. Continuation shall not be available for any enrollee who is covered by any other insured or uninsured plan that provides hospital, surgical, or medical coverage for individuals in a group and under which the enrollee was not covered immediately before termination or reduction in hours below the minimum required by the group contract or who exercises his or her conversion privilege under the group policy.
  • (3) Continuation need not include dental, vision care, prescription drug, or similar supplementary benefits that are provided under the group contract in addition to its basic health care services.
  • (4) Within 10 days after the employee's or member's termination or reduction in hours below the minimum required by the group contract, written notice of continuation shall be presented to the employee or member by the employer. If the employee or member is unavailable, written notice shall be mailed by the employer to the last known address of the employee or member within 10 days after the employee's or member's termination or reduction in hours below the minimum required by the group plan. The employer shall also send a copy of the notice to the HMO. An employee or member who wishes continuation of coverage must request continuation in writing within the 30 day period following the later of (i) the date of termination or reduction in hours below the minimum required by the group contract or (ii) the date the employee is presented or mailed written notice of the right of continuation by either the employer or the group policyholder. In no event, however, shall the employee or member elect continuation more than 60 days after the date of termination or reduction in hours below the minimum required by the group contract. Written notice of continuation presented to the employee or member by the policyholder, or mailed by the policyholder to the last known address of the employee, shall constitute the giving of notice for the purpose of this paragraph.
  • The HMO shall not deny coverage to the employee or member due to the employer's failure to provide notice pursuant to this Section to the employee or member. Until the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, in the event the employee or member contacts the HMO regarding continuation rights and advises that notice has not been provided by the employer or group policyholder, the HMO shall provide a written explanation to the employee or member of the employee's or member's continuation rights pursuant to this Section.
  • (4a) Unless contrary to the provisions of, or any rules promulgated pursuant to, the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage and who are terminated or whose reduction in hours below the minimum required by the group occurs between the effective date of this amendatory Act of the 96th General Assembly and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, the notice requirements of this Section are not satisfied unless notice is presented or mailed to the employee or member by the HMO informing the employee or member of the availability of premium reduction with respect to such coverage under the federal American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by HMOs pursuant to this paragraph (4a).
  • (4b) Unless contrary to the provisions of, or any rules promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, with respect to employees or members of health plans that are subject solely to State continuation coverage who were terminated or whose reduction in hours below the minimum required by the group occurred between September 1, 2008, and the effective date of this amendatory Act of the 96th General Assembly and who have an election of continuation of coverage pursuant to this Section in effect, notice shall be presented or mailed to the employee or member by the HMO informing the employee or member of the availability of premium reduction with respect to such coverage under the federal American Recovery and Reinvestment Act of 2009. Such written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009 and shall be presented or mailed to the employee or member within 14 days of the effective date of this amendatory Act of the 96th General Assembly. The Department shall publish models for the notification that shall be provided by HMOs pursuant to this paragraph (4b).
  • (5) An employee or member electing continuation must pay to the group policyholder or his employer, on a monthly basis in advance, the total amount of premium required by the HMO, including that portion of the premium contributed by the policyholder or employer, if any, but not more than the group rate for the coverage being continued with appropriate reduction in premium for any supplementary benefits that have been discontinued under paragraph (3) of this Section. The premium rate required by the HMO shall be the applicable premium required on the due date of each payment.
  • (6) Continuation of coverage under the group contract for any person shall terminate when the person becomes eligible for Medicare or is covered by any other insured or uninsured plan that provides hospital, surgical, or medical coverage for individuals in a group and under which the person was not covered immediately before termination or reduction in hours below the minimum required by the group contract as provided in paragraph (2) of this Section or, if earlier, at the first to occur of the following:
    • (a) The expiration of 12 months after the employee's or member's coverage because of termination of employment or membership or reduction in hours below the minimum required by the group contract.
    • (b) If the employee or member fails to make timely payment of a required contribution, the end of the period for which contributions were made or, with respect to an employee or member who is an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, the date that the individual ceases to be eligible for premium assistance under Section 3001(a)(2)(A)(ii)(I) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended.
    • (c) The date on which the group contract is terminated or, in the case of an employee, the date his or her employer terminates participation under the group contract. If, however, this paragraph applies and the coverage ceasing by reason of termination is replaced by similar coverage under another group contract, then (i) the employee or member shall have the right to become covered under the replacement group contract for the balance of the period that he or she would have remained covered under the prior group contract in accordance with paragraph (6) had a termination described in this item (c) not occurred and (ii) the prior group contract shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.
  • (7) A notification of the continuation privilege shall be included in each evidence of coverage.
  • (8) Continuation shall not be available for any employee who was discharged because of the commission of a felony in connection with his or her work, or because of theft in connection with his or her work, for which the employer was in no way responsible if the employee (i) admitted to committing the felony or theft or (ii) was convicted or placed under supervision by a court of competent jurisdiction.
  • (9) An employee or member without an election of continuation of coverage pursuant to this Section in effect on the effective date of this amendatory Act of the 96th General Assembly may elect continuation pursuant to this paragraph (9) if the employee or member: (i) would be an assistance eligible individual as defined in Section 3001(a)(3) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009 if such an election were in effect and (ii) at the time of termination was eligible for continuation pursuant to paragraphs (1) and (2) of this Section.
  • Unless contrary to the provisions of, or any rules promulgated pursuant to, Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, written notice of continuation pursuant to this paragraph (9) shall be presented to the employee or member by the HMO or mailed by the HMO to the last known address of the employee or member within 30 days after the effective date of this amendatory Act of the 96th General Assembly. The written notice shall conform to all applicable requirements set forth in Section 3001(a)(7) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009. The Department shall publish models for the notification that shall be provided by HMOs pursuant to this paragraph (9).
  • An employee or member electing continuation of coverage under this paragraph (9) must request such continuation in writing within 60 days after the date the employee or member receives written notice of the right of continuation by the HMO.
  • Continuation of coverage elected pursuant to this paragraph (9) shall commence with the first period of coverage beginning on or after February 17, 2009, the effective date of the federal American Recovery and Reinvestment Act of 2009, and shall not extend beyond the period of continuation that would have been required if the coverage had been elected pursuant to paragraph (4) of this Section.
  • With respect to an employee or member who elects continuation of coverage under this paragraph (9), the period beginning on the date of the employee or member's involuntary termination of employment and ending on the date of the first period of coverage on or after February 17, 2009 shall be disregarded for purposes of determining the 63-day period referred to in Section 20 of the Illinois Health Insurance Portability and Accountability Act.

The requirements of this amendatory Act of 1992 shall apply to any group contract, as defined in this Section, delivered or issued for delivery on or after 180 days following the effective date of this amendatory Act of 1992.

(Source: P.A. 96-13, eff. 6-18-09; 96-894, eff. 5-17-10.)

 

(215 ILCS 125/4-10) (from Ch. 111 1/2, par. 1409.3)

Sec. 4-10. Medical necessity; dispute resolution; independent second opinion. Each Health Maintenance Organization shall provide a mechanism for the timely review by a physician holding the same class of license as the primary care physician, who is unaffiliated with the Health Maintenance Organization, jointly selected by the patient (or the patient's next of kin or legal representative if the patient is unable to act for himself), primary care physician and the Health Maintenance Organization in the event of a dispute between the primary care physician and the Health Maintenance Organization regarding the medical necessity of a covered service proposed by a primary care physician. In the event that the reviewing physician determines the covered service to be medically necessary, the Health Maintenance Organization shall provide the covered service. Future contractual or employment action by the Health Maintenance Organization regarding the primary care physician shall not be based solely on the physician's participation in this procedure.

(Source: P.A. 100-201, eff. 8-18-17.)

 

(215 ILCS 125/4-11) (from Ch. 111 1/2, par. 1409.4)

Sec. 4-11. Any person who enrolls recipients of Public Aid or Medicare in a health maintenance organization, either personally or by mail, shall, on or after July 1, 1989, be licensed as a limited insurance representative under Section 495.1 of the Illinois Insurance Code. No such person shall be required to pass a written examination in order to qualify to be licensed as a limited insurance representative under this Section.

(Source: P.A. 85-1246.)

 

(215 ILCS 125/4-12) (from Ch. 111 1/2, par. 1409.5)

Sec. 4-12. Changes in Rate Methodology and Benefits, Material Modifications. A health maintenance organization shall file with the Director, prior to use, a notice of any change in rate methodology, or benefits and of any material modification of any matter or document furnished pursuant to Section 2-1, together with such supporting documents as are necessary to fully explain the change or modification.

(a) Contract modifications described in subsections (c)(5), (c)(6) and (c)(7) of Section 2-1 shall include all form agreements between the organization and enrollees, providers, administrators of services and insurers of health maintenance organizations.

(b) Material transactions or series of transactions other than those described in subsection (a) of this Section, the total annual value of which exceeds the greater of $100,000 or 5% of net earned subscription revenue for the most current twelve month period as determined from filed financial statements.

(c) Any agreement between the organization and an insurer shall be subject to the provisions of the laws of this State regarding reinsurance as provided in Article XI of the Illinois Insurance Code. All reinsurance agreements must be filed. Approval of the Director is required for all agreements except the following: individual stop loss, aggregate excess, hospitalization benefits or out-of-area of the participating providers unless 20% or more of the organization's total risk is reinsured, in which case all reinsurance agreements require approval.

(Source: P.A. 86-620.)

 

(215 ILCS 125/4-13) (from Ch. 111 1/2, par. 1409.6)

Sec. 4-13. Prior approval of policy forms. No health maintenance organization shall issue or deliver in this State a group contract or evidence of coverage, attach an endorsement or rider thereto, incorporate by reference bylaws or other matter therein, or use an application blank in this State until the form and content of the group contract or evidence of coverage, endorsement, rider, bylaw, or other matter incorporated by reference or application blank has been filed with and approved by the Director, except that any such endorsement or rider that is to be attached to a group contract or evidence of coverage after the date the group contract or evidence of coverage is issued must be filed with, reviewed, and approved by the Director before the date it is attached to a group contract or evidence of coverage issued or delivered in this State. The Director shall withhold approval of any such group contract, evidence of coverage, endorsement, rider, bylaw, or other matter incorporated by reference or application blank if it contains provisions that may encourage misrepresentation or that are unjust, unfair, inequitable, ambiguous, misleading, inconsistent, deceptive, or contrary to the law or public policy of this State or contains exceptions and conditions that unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the group contract or evidence of coverage. The Director shall not withhold approval of a form under this Section solely because of the absence of coverage for mental health services if the Department of Children and Family Services presents evidence that coverage of mental health services for clients of that Department will be provided by another entity. In all cases the Director shall approve or disapprove any such form within 60 days after submission unless the Director extends by not more than an additional 30 days the period within which he shall approve or disapprove any such form by giving written notice to the organization of the extension before expiration of the initial 60-day period.

The Director shall withdraw his approval of a group contract or evidence of coverage, endorsement, rider, bylaw, or other matter incorporated by reference or application blank if he subsequently determines that the group contract or evidence of coverage, endorsement, rider, bylaw, other matter, or application blank is misrepresentative, unjust, unfair, inequitable, ambiguous, misleading, inconsistent, deceptive, or contrary to the law or public policy of this State, or contains exceptions or conditions that unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the group contract or evidence of coverage. The Director shall not withdraw approval of a form under this Section solely because of the absence of coverage for mental health services if the Department of Children and Family Services presents evidence that coverage of mental health services for clients of that Department is being or will be provided by another entity.

If a previously approved group contract or evidence of coverage, endorsement, rider, bylaw, or other matter incorporated by reference or application blank is withdrawn for use, the Director shall serve upon the company an order of withdrawal of use, either personally or by mail. If the service is by mail, the service shall be completed if the notice is deposited in the post office, postage prepaid, addressed to the health maintenance organization's last known address specified in the records of the Department of Insurance. The order of withdrawal of use shall take effect 30 days from the date of mailing but shall be stayed if within the 30-day period a written request for hearing is filed with the Director. The hearing shall be held at the time and place designated in the order given by the Director. The hearing may be held either in the City of Springfield, the City of Chicago, or in the county where the principal business address of the health maintenance organization is located.

The action of the Director in disapproving or withdrawing the form shall be subject to judicial review under the Administrative Review Law.

(Source: P.A. 88-487.)

 

(215 ILCS 125/4-14) (from Ch. 111 1/2, par. 1409.7)

Sec. 4-14. Evidence of Coverage.

(a) Every subscriber shall be issued an evidence of coverage, which shall contain a clear and complete statement of:

  • (1) The health services to which each enrollee is entitled;
  • (2) Eligibility requirements indicating the conditions which must be met to enroll in a Health Care Plan;
  • (3) Any limitation of the services, kinds of services or benefits to be provided, and exclusions, including any reasonable deductibles, copayments, or other charges;
  • (4) The terms or conditions upon which coverage may be cancelled or otherwise terminated;
  • (5) Where and in what manner information is available as to where and how services may be obtained; and
  • (6) The method for resolving complaints.

(b) Any amendment to the evidence of coverage may be provided to the subscriber in a separate document.

(Source: P.A. 97-1148, eff. 1-24-13.)

 

(215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8)

Sec. 4-15. (a) No contract or evidence of coverage for basic health care services delivered, issued for delivery, renewed or amended by a Health Maintenance Organization shall exclude coverage for emergency transportation by ambulance. For the purposes of this Section, the term "emergency" means a need for immediate medical attention resulting from a life threatening condition or situation or a need for immediate medical attention as otherwise reasonably determined by a physician, public safety official or other emergency medical personnel.

(b) Upon reasonable demand by a provider of emergency transportation by ambulance, a Health Maintenance Organization shall promptly pay to the provider, subject to coverage limitations stated in the contract or evidence of coverage, the charges for emergency transportation by ambulance provided to an enrollee in a health care plan arranged for by the Health Maintenance Organization. By accepting any such payment from the Health Maintenance Organization, the provider of emergency transportation by ambulance agrees not to seek any payment from the enrollee for services provided to the enrollee.

(Source: P.A. 86-833; 86-1028.)

 

(215 ILCS 125/4-16) (from Ch. 111 1/2, par. 1409.9)

Sec. 4-16. Fibrocystic condition; denial of coverage. No contract or evidence of coverage issued by a Health Maintenance Organization shall be denied by the Organization, nor shall 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.

(Source: P.A. 87-519; 87-1066.)

 

(215 ILCS 125/4-17)

Sec. 4-17. Basic outpatient preventive and primary health care services for children. In order to attempt to address the needs of children in Illinois (i) without health care coverage, either through a parent's employment, through medical assistance under the Illinois Public Aid Code, or any other health plan or (ii) who lose medical assistance if and when their parents move from welfare to work and do not find employment that offers health care coverage, a health maintenance organization may undertake to provide or arrange for and to pay for or reimburse the cost of basic outpatient preventive and primary health care services. The Department shall promulgate rules to establish minimum coverage and disclosure requirements. These requirements at a minimum shall include routine physical examinations and immunizations, sick visits, diagnostic x-rays and laboratory services, and emergency outpatient services. Coverage may also include preventive dental services, vision screening and one pair of eyeglasses, prescription drugs, and mental health services. The coverage may include any reasonable co-payments, deductibles, and benefit maximums subject to limitations established by the Director by rule. Coverage shall be limited to children who are 18 years of age or under, who have resided in the State of Illinois for at least 30 days, and who do not qualify for medical assistance under the Illinois Public Aid Code. Any such coverage shall be made available to an adult on behalf of such children and shall not be funded through State appropriations. In counties with populations in excess of 3,000,000, the Director shall not approve any arrangement under this Section unless and until an arrangement for at least one health maintenance organization under contract with the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) for furnishing health services pursuant to Section 5-11 of the Illinois Public Aid Code and for which the requirements of 42 CFR 434.26(a) have been waived is approved.

(Source: P.A. 95-331, eff. 8-21-07.)

 

(215 ILCS 125/4-18)

Sec. 4-18. Retirement facility residents. With respect to an enrollee who is a resident of a retirement facility consisting of a long-term care facility, as defined in the Nursing Home Care Act, and residential apartments, a contract or evidence of coverage issued, amended, delivered, or renewed after the effective date of this amendatory Act of 1997 shall provide that the enrollee's primary care physician must refer the enrollee to the retirement facility's long-term care facility for Medicare covered skilled nursing services if the primary care physician finds that:

  • (1) it is in the best interests of the patient;
  • (2) the facility, if not a participating provider in the specific health maintenance organization, agrees during the preauthorization period to a negotiated rate for skilled nursing services covered in that organization's health care plan; and
  • (3) the facility meets all the requirements of a participating provider for skilled nursing services as defined and covered under the health maintenance organization's health care plan.

Both the facility and the health maintenance organization must fully disclose all pertinent information to consumers to assure that their decisions are based upon full knowledge of the implications of their decision making.

(Source: P.A. 90-408, eff. 1-1-98; 90-655, eff. 7-30-98.)

 

(215 ILCS 125/4-19)

Sec. 4-19. Purchase of ophthalmic goods or services. A health maintenance organization may not require a provider, as a condition of participation in the health maintenance organization's health care plan, to purchase ophthalmic goods or services, including but not limited to eyeglass frames, in a quantity or dollar amount in excess of the quantity or dollar amount an enrollee purchases under the terms of the health care plan.

(Source: P.A. 93-1077, eff. 1-18-05.)

 

(215 ILCS 125/4-20)

Sec. 4-20. Deductibles and copayments.

(a) A Health Maintenance Organization may require deductibles and copayments of enrollees as a condition for the receipt of specific health care services, including basic health care services. Deductibles and copayments shall be the only allowable charges, other than premiums, assessed enrollees. Nothing within this subsection (a) shall preclude the provider from charging reasonable administrative fees, such as service fees for checks returned for non-sufficient funds and missed appointments.

(b) Deductibles and copayments shall be for specific dollar amounts or for specific percentages of the cost of the health care services.

(c) No combination of deductibles and copayments paid for the receipt of basic health care services may exceed the annual maximum out-of-pocket expenses of a high deductible health plan as defined in 26 U.S.C. 223.

(d) Deductibles and copayments applicable to supplemental health care services, catastrophic-only plans as defined under the federal Affordable Care Act, or pre-existing conditions are not subject to the annual limitations described in this Section.

(e) This Section applies to enrollees and does not limit the health care plan payment for services provided by non-participating providers.

(f) This Section applies to enrollees and does not limit the health care plan payment for services provided by non-participating providers.

(Source: P.A. 97-1148, eff. 1-24-13.)


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