(215 ILCS 5/355a) (from Ch. 73, par. 967a)
Sec. 355a.
Standardization of terms and coverage.
(1) The purpose of this Section shall be (a) to provide
reasonable standardization and simplification of terms and coverages of
individual accident and health insurance policies to facilitate public
understanding and comparisons; (b) to eliminate provisions contained in
individual accident and health insurance policies which may be
misleading or unreasonably confusing in connection either with the
purchase of such coverages or with the settlement of claims; and (c) to
provide for reasonable disclosure in the sale of accident and health
coverages.
(2) Definitions applicable to this Section are as follows:
(a) "Policy" means all or any part of the forms |
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constituting the contract between the insurer and the insured, including the policy, certificate, subscriber contract, riders, endorsements, and the application if attached, which are subject to filing with and approval by the Director.
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(b) "Service corporations" means voluntary health
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and dental corporations organized and operating respectively under the Voluntary Health Services Plans Act and the Dental Service Plan Act.
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(c) "Accident and health insurance" means insurance
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written under Article XX of the Insurance Code, other than credit accident and health insurance, and coverages provided in subscriber contracts issued by service corporations. For purposes of this Section such service corporations shall be deemed to be insurers engaged in the business of insurance.
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(3) The Director shall issue such rules as he shall deem necessary
or desirable to establish specific standards, including standards of
full and fair disclosure that set forth the form and content and
required disclosure for sale, of individual policies of accident and
health insurance, which rules and regulations shall be in addition to
and in accordance with the applicable laws of this State, and which may
cover but shall not be limited to: (a) terms of renewability; (b)
initial and subsequent conditions of eligibility; (c) non‑duplication of
coverage provisions; (d) coverage of dependents; (e) pre‑existing
conditions; (f) termination of insurance; (g) probationary periods; (h)
limitation, exceptions, and reductions; (i) elimination periods; (j)
requirements regarding replacements; (k) recurrent conditions; and (l)
the definition of terms including but not limited to the following:
hospital, accident, sickness, injury, physician, accidental means, total
disability, partial disability, nervous disorder, guaranteed renewable,
and non‑cancellable.
The Director may issue rules that specify prohibited policy
provisions not otherwise specifically authorized by statute which in the
opinion of the Director are unjust, unfair or unfairly discriminatory to
the policyholder, any person insured under the policy, or beneficiary.
(4) The Director shall issue such rules as he shall deem necessary
or desirable to establish minimum standards for benefits under each
category of coverage in individual accident and health policies, other
than conversion policies issued pursuant to a contractual conversion
privilege under a group policy, including but not limited to the
following categories: (a) basic hospital expense coverage; (b) basic
medical‑surgical expense coverage; (c) hospital confinement indemnity
coverage; (d) major medical expense coverage; (e) disability income
protection coverage; (f) accident only coverage; and (g) specified
disease or specified accident coverage.
Nothing in this subsection (4) shall preclude the issuance of any
policy which combines two or more of the categories of coverage
enumerated in subparagraphs (a) through (f) of this subsection.
No policy shall be delivered or issued for delivery in this State
which does not meet the prescribed minimum standards for the categories
of coverage listed in this subsection unless the Director finds that
such policy is necessary to meet specific needs of individuals or groups
and such individuals or groups will be adequately informed that such
policy does not meet the prescribed minimum standards, and such policy
meets the requirement that the benefits provided therein are reasonable
in relation to the premium charged. The standards and criteria to be
used by the Director in approving such policies shall be included in the
rules required under this Section with as much specificity as
practicable.
The Director shall prescribe by rule the method of identification of
policies based upon coverages provided.
(5) (a) In order to provide for full and fair disclosure in the
sale of individual accident and health insurance policies, no such
policy shall be delivered or issued for delivery in this State unless
the outline of coverage described in paragraph (b) of this subsection
either accompanies the policy, or is delivered to the applicant at the
time the application is made, and an acknowledgment signed by the
insured, of receipt of delivery of such outline, is provided to the
insurer. In the event the policy is issued on a basis other than that
applied for, the outline of coverage properly describing the policy must
accompany the policy when it is delivered and such outline shall clearly
state that the policy differs, and to what extent, from that for which
application was originally made. All policies, except single premium
nonrenewal policies, shall have a notice prominently printed on the
first page of the policy or attached thereto stating in substance, that
the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if after
examination of the policy the policyholder is not satisfied for any
reason.
(b) The Director shall issue such rules as he shall deem necessary
or desirable to prescribe the format and content of the outline of
coverage required by paragraph (a) of this subsection. "Format" means
style, arrangement, and overall appearance, including such items as the
size, color, and prominence of type and the arrangement of text and
captions. "Content" shall include without limitation thereto,
statements relating to the particular policy as to the applicable
category of coverage prescribed under subsection 4; principal benefits;
exceptions, reductions and limitations; and renewal provisions,
including any reservation by the insurer of a right to change premiums.
Such outline of coverage shall clearly state that it constitutes a
summary of the policy issued or applied for and that the policy should
be consulted to determine governing contractual provisions.
(6) Prior to the issuance of rules pursuant to this Section, the
Director shall afford the public, including the companies affected
thereby, reasonable opportunity for comment. Such rulemaking is subject
to the provisions of the Illinois Administrative Procedure Act.
(7) When a rule has been adopted, pursuant to this Section, all
policies of insurance or subscriber contracts which are not in
compliance with such rule shall, when so provided in such rule, be
deemed to be disapproved as of a date specified in such rule not less
than 120 days following its effective date, without any further or
additional notice other than the adoption of the rule.
(8) When a rule adopted pursuant to this Section so provides, a
policy of insurance or subscriber contract which does not comply with
the rule shall not less than 120 days from the effective date of such
rule, be construed, and the insurer or service corporation shall be
liable, as if the policy or contract did comply with the rule.
(9) Violation of any rule adopted pursuant to this Section shall be
a violation of the insurance law for purposes of Sections 370 and 446 of
the Insurance Code.
(Source: P.A. 90‑177, eff. 7‑23‑97; 90‑372, eff. 7‑1‑98; 90‑655, eff.
7‑30‑98.)
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(215 ILCS 5/356r)
Sec. 356r.
Woman's principal health care provider.
(a) An individual or group policy of accident and health insurance or a
managed care plan amended, delivered, issued, or renewed in this State after
November 14, 1996 that
requires an insured or enrollee to designate an individual to coordinate care
or to control access to health care services shall also permit a female insured
or enrollee to designate a participating woman's principal health care
provider,
and the insurer or managed care plan shall provide the following written
notice to all female insureds or enrollees no later than 120 days after the
effective date of this amendatory Act of 1998; to all new enrollees at the
time of enrollment;
and thereafter to all existing enrollees at least annually, as a part of a
regular publication or informational mailing:
"NOTICE TO ALL FEMALE PLAN MEMBERS:
YOUR RIGHT TO SELECT A WOMAN'S PRINCIPAL
HEALTH CARE PROVIDER.
Illinois law allows you to select "a woman's |
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principal health care provider" in addition to your selection of a primary care physician. A woman's principal health care provider is a physician licensed to practice medicine in all its branches specializing in obstetrics or gynecology or specializing in family practice. A woman's principal health care provider may be seen for care without referrals from your primary care physician. If you have not already selected a woman's principal health care provider, you may do so now or at any other time. You are not required to have or to select a woman's principal health care provider.
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Your woman's principal health care provider must be
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a part of your plan. You may get the list of participating obstetricians, gynecologists, and family practice specialists from your employer's employee benefits coordinator, or for your own copy of the current list, you may call [insert plan's toll free number]. The list will be sent to you within 10 days after your call. To designate a woman's principal health care provider from the list, call [insert plan's toll free number] and tell our staff the name of the physician you have selected.".
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If the insurer or managed care plan exercises the option set forth in
subsection
(a‑5), the notice shall also state:
"Your plan requires that your primary care physician
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and your woman's principal health care provider have a referral arrangement with one another. If the woman's principal health care provider that you select does not have a referral arrangement with your primary care physician, you will have to select a new primary care physician who has a referral arrangement with your woman's principal health care provider or you may select a woman's principal health care provider who has a referral arrangement with your primary care physician. The list of woman's principal health care providers will also have the names of the primary care physicians and their referral arrangements.".
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No later than 120 days after the effective date of this amendatory Act of
1998, the insurer or managed
care plan shall provide each employer who has a policy of insurance or a
managed
care plan with the insurer or managed care plan with a list of physicians
licensed to practice medicine in all its branches specializing in obstetrics or
gynecology or specializing in family practice who have contracted with the
plan. At the time of enrollment and thereafter within 10 days after a request
by an insured or enrollee, the insurer or managed care plan also shall provide
this list directly to the insured or enrollee.
The list shall include each physician's address, telephone
number, and specialty. No insurer or plan formal or informal
policy may restrict a female insured's or enrollee's right to designate a
woman's
principal health care provider, except as set forth in subsection (a‑5).
If the
female enrollee is an enrollee of a managed care plan under contract with the
Department of Public Aid, the physician chosen by the enrollee as her woman's
principal health care provider must be a Medicaid‑enrolled provider.
This requirement does not require a female insured or enrollee to make a
selection of a woman's principal health care provider.
The female insured or enrollee may designate a physician licensed to practice
medicine in
all its branches specializing in family practice as her woman's principal
health care provider.
(a‑5) The insured or enrollee may be required by the insurer or managed care
plan to select a woman's principal health care provider who has a
referral
arrangement with the insured's or enrollee's individual who coordinates care or
controls access to health care services
if such referral arrangement exists
or to
select a new individual to coordinate care or to control access to health care
services who has a referral arrangement with the
woman's principal health care provider chosen by the insured or enrollee, if
such referral arrangement exists. If an
insurer or a managed care plan requires an insured or enrollee to select a new
physician under this subsection (a‑5), the insurer or managed care plan must
provide the insured or enrollee with both options to select a new physician
provided in this subsection
(a‑5).
Notwithstanding a plan's restrictions of the frequency or timing of making
designations of primary care providers, a female enrollee or insured who is
subject to the selection requirements of this subsection, may, at any time,
effect a change in primary care physicians in order to make a
selection of a woman's principal health care provider.
(a‑6) If an insurer or managed care plan exercises the option in
subsection (a‑5), the list to be provided under subsection (a) shall identify
the referral arrangements that exist between the individual who
coordinates
care or controls access to health care services and the woman's principal
health care provider in order to assist the female insured or enrollee to make
a selection within the insurer's or managed care plan's requirement.
(b) If a female insured or enrollee has designated a woman's principal
health care provider, then the insured or enrollee must be given direct access
to the woman's principal health care provider for services covered by the
policy or plan without the need
for a referral or prior approval. Nothing shall prohibit the insurer or
managed care plan from requiring prior authorization or approval from either a
primary care provider or the woman's principal health care provider for
referrals for additional care or services.
(c) For the purposes of this Section the following terms are defined:
(1) "Woman's principal health care provider" means a
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physician licensed to practice medicine in all of its branches specializing in obstetrics or gynecology or specializing in family practice.
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(2) "Managed care entity" means any entity including
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a licensed insurance company, hospital or medical service plan, health maintenance organization, limited health service organization, preferred provider organization, third party administrator, an employer or employee organization, or any person or entity that establishes, operates, or maintains a network of participating providers.
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(3) "Managed care plan" means a plan operated by a
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managed care entity that provides for the financing of health care services to persons enrolled in the plan through:
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(A) organizational arrangements for ongoing
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quality assurance, utilization review programs, or dispute resolution; or
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(B) financial incentives for persons enrolled in
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the plan to use the participating providers and procedures covered by the plan.
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(4) "Participating provider" means a physician who
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has contracted with an insurer or managed care plan to provide services to insureds or enrollees as defined by the contract.
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(d) The original provisions of this Section became law on July 17,
1996 and took effect November 14, 1996, which is 120 days after
becoming law.
(Source: P.A. 89‑514; 90‑14, eff. 7‑1‑97; 90‑741, eff. 8‑13‑98.)
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(215 ILCS 5/363) (from Ch. 73, par. 975)
Sec. 363.
Medicare supplement policies; minimum standards.
(1) Except as otherwise specifically provided therein, this
Section and Section 363a of this Code shall apply to:
(a) all Medicare supplement policies and subscriber |
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contracts delivered or issued for delivery in this State on and after January 1, 1989; and
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(b) all certificates issued under group Medicare
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supplement policies or subscriber contracts, which certificates are issued or issued for delivery in this State on and after January 1, 1989.
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This Section shall not apply to "Accident Only" or "Specified Disease"
types of policies. The provisions of this Section are not intended to prohibit
or apply to policies or health care benefit plans, including group
conversion policies, provided to Medicare eligible persons, which policies
or plans are not marketed or purported or held to be Medicare supplement
policies or benefit plans.
(2) For the purposes of this Section and Section 363a, the following
terms have the following meanings:
(a) "Applicant" means:
(i) in the case of individual Medicare
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supplement policy, the person who seeks to contract for insurance benefits, and
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(ii) in the case of a group Medicare policy or
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subscriber contract, the proposed certificate holder.
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(b) "Certificate" means any certificate delivered or
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issued for delivery in this State under a group Medicare supplement policy.
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(c) "Medicare supplement policy" means an individual
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policy of accident and health insurance, as defined in paragraph (a) of subsection (2) of Section 355a of this Code, or a group policy or certificate delivered or issued for delivery in this State by an insurer, fraternal benefit society, voluntary health service plan, or health maintenance organization, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.) or a policy issued under a demonstration project specified in 42 U.S.C. Section 1395ss(g)(1), or any similar organization, that is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of persons eligible for Medicare.
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(d) "Issuer" includes insurance companies, fraternal
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benefit societies, voluntary health service plans, health maintenance organizations, or any other entity providing Medicare supplement insurance, unless the context clearly indicates otherwise.
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(e) "Medicare" means the Health Insurance for the
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Aged Act, Title XVIII of the Social Security Amendments of 1965.
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(3) No medicare supplement insurance policy, contract, or
certificate,
that provides benefits that duplicate benefits provided by Medicare, shall
be issued or issued for delivery in this State after December 31, 1988. No
such policy, contract, or certificate shall provide lesser benefits than
those required under this Section or the existing Medicare Supplement
Minimum Standards Regulation, except where duplication of Medicare benefits
would result.
(4) Medicare supplement policies or certificates shall have a
notice
prominently printed on the first page of the policy or attached thereto
stating in substance that the policyholder or certificate holder shall have
the right to return the policy or certificate within 30 days of its
delivery and to have the premium refunded directly to him or her in a
timely manner if, after examination of the policy or certificate, the
insured person is not satisfied for any reason.
(5) A Medicare supplement policy or certificate may not deny a
claim
for losses incurred more than 6 months from the effective date of coverage
for a preexisting condition. The policy may not define a preexisting
condition more restrictively than a condition for which medical advice was
given or treatment was recommended by or received from a physician within 6
months before the effective date of coverage.
(6) The Director shall issue reasonable rules and regulations
for the
following purposes:
(a) To establish specific standards for policy
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provisions of Medicare policies and certificates. The standards shall be in accordance with the requirements of this Code. No requirement of this Code relating to minimum required policy benefits, other than the minimum standards contained in this Section and Section 363a, shall apply to medicare supplement policies and certificates. The standards may cover, but are not limited to the following:
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(A) Terms of renewability.
(B) Initial and subsequent terms of eligibility.
(C) Non‑duplication of coverage.
(D) Probationary and elimination periods.
(E) Benefit limitations, exceptions and
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(F) Requirements for replacement.
(G) Recurrent conditions.
(H) Definition of terms.
(I) Requirements for issuing rebates or credits
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to policyholders if the policy's loss ratio does not comply with subsection (7) of Section 363a.
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(J) Uniform methodology for the calculating and
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reporting of loss ratio information.
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(K) Assuring public access to loss ratio
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information of an issuer of Medicare supplement insurance.
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(L) Establishing a process for approving or
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disapproving proposed premium increases.
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(M) Establishing a policy for holding public
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hearings prior to approval of premium increases.
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(N) Establishing standards for Medicare Select
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(O) Prohibited policy provisions not otherwise
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specifically authorized by statute that, in the opinion of the Director, are unjust, unfair, or unfairly discriminatory to any person insured or proposed for coverage under a medicare supplement policy or certificate.
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(b) To establish minimum standards for benefits and
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claims payments, marketing practices, compensation arrangements, and reporting practices for Medicare supplement policies.
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(c) To implement transitional requirements of
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Medicare supplement insurance benefits and premiums of Medicare supplement policies and certificates to conform to Medicare program revisions.
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(Source: P.A. 88‑313; 89‑484, eff. 6‑21‑96.)
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(215 ILCS 5/363a) (from Ch. 73, par. 975a)
Sec. 363a.
Medicare supplement policies; disclosure, advertising, loss
ratio standards.
(1) Scope. This Section pertains to disclosure requirements of
companies and agents and mandatory and prohibited practices of agents
when selling a policy to supplement the Medicare program or any other
health insurance policy sold to individuals eligible for Medicare. No policy
shall be referred to or labeled as a Medicare
supplement policy if it does not comply with the minimum standards
required by regulation pursuant to Section 363 of this Code. Except as
otherwise specifically provided in paragraph (d) of subsection (6), this
Section shall not apply to accident only or specified disease type of
policies or hospital confinement indemnity or other type policies clearly
unrelated to Medicare.
(2) Advertising. An advertisement that describes or offers to provide
information concerning the federal Medicare program shall comply with all
of the following:
(a) It may not include any reference to that program |
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on the envelope, the reply envelope, or the address side of the reply postal card, if any, nor use any language to imply that failure to respond to the advertisement might result in loss of Medicare benefits.
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(b) It must include a prominent statement to the
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effect that in providing supplemental coverage the insurer and agent involved in the solicitation are not in any manner connected with that program.
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(c) It must prominently disclose that it is an
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advertisement for insurance or is intended to obtain insurance prospects.
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(d) It must prominently identify and set forth the
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actual address of the insurer or insurers that issue the coverage.
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(e) It must prominently state that any material or
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information offered will be delivered in person by a representative of the insurer, if that is the case.
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The Director may issue reasonable rules and regulations for the
purpose of establishing criteria and guidelines for the advertising of
Medicare supplement insurance.
(3) Mandatory agent practices. For the purpose of this Act, "home
solicitation sale by an agent" means a sale or attempted sale of an
insurance policy at the purchaser's residence, agent's transient quarters,
or away from the agent's home office when the initial contact is personally
solicited by the agent or insurer. Any agent involved in any home
solicitation sale of a Medicare supplement policy or other policy of
accident and health insurance, subject to subsection (1) of this Section,
sold to individuals eligible for Medicare shall promptly do the following:
(a) Identify himself as an insurance agent.
(b) Identify the insurer or insurers for which he is
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(c) Provide the purchaser with a clearly printed or
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typed identification of his name, address, telephone number, and the name of the insurer in which the insurance is to be written.
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(d) Determine what, if any, policy is appropriate,
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suitable, and nonduplicative for the purchaser considering existing coverage and be able to provide proof to the company that such a determination has been made.
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(e) Fully and completely disclose the purchaser's
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medical history on the application if required for issue.
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(f) Complete a Policy Check List in duplicate as
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POLICY CHECK LIST
Applicant's Name:
Policy Number:
Name of Existing Insurer:
Expiration Date of Existing Insurance:
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Medicare |
Existing |
Supplement |
Insured's |
Pays |
Coverage |
Pays |
Responsibility |
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Service
Hospital
Skilled
Nursing
Home Care
Prescription
Drugs
This policy does/does not (circle one) comply with
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the minimum standards for Medicare supplements set forth in Section 363 of the Illinois Insurance Code.
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Signature of Applicant
Signature of Agent
This Policy Check List is to be completed in the
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presence of the purchaser at the point of sale, and copies of it, completed and duly signed, are to be provided to the purchaser and to the company.
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(g) Except in the case of refunds of premium made
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pursuant to subsection (5) of Section 363 of this Code, send by mail to an insured or an applicant for insurance, when the insurer follows a practice of having agents return premium refund drafts issued by the insurer, a premium refund draft within 2 weeks of its receipt by the agent from the insurer making such refund.
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(h) Deliver to the purchaser, along with every
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policy issued pursuant to Section 363 of this Code, an Outline of Coverage as described in paragraph (b) of subsection (6) of this Section.
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(4) Prohibited agent practices.
(a) No insurance agent engaged in a home
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solicitation sale of a Medicare supplement policy or other policy of accident and health insurance, subject to subsection (1) of this Section, sold to individuals eligible for Medicare shall use any false, deceptive, or misleading representation to induce a sale, or use any plan, scheme, or ruse, that misrepresents the true status or mission of the person making the call, or represent directly or by implication that the agent:
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(i) Is offering insurance that is approved or
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recommended by the State or federal government to supplement Medicare.
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(ii) Is in any way representing, working for, or
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compensated by a local, State, or federal government agency.
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(iii) Is engaged in an advisory business in
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which his compensation is unrelated to the sale of insurance by the use of terms such as Medicare consultant, Medicare advisor, Medicare Bureau, disability insurance consultant, or similar expression in a letter, envelope, reply card, or other.
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(iv) Will provide a continuing service to the
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purchaser of the policy unless he does provide services to the purchaser beyond the sale and renewal of policies.
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(b) No agent engaged in a home solicitation sale of
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a Medicare supplement policy or other policy of accident and health insurance sold to individuals eligible for Medicare shall misrepresent, directly or by implication, any of the following:
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(i) The identity of the insurance company or
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(ii) That the assistance programs of the State
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or county or the federal Medicare programs for medical insurance are to be discontinued or are increasing in cost to the prospective buyer or are in any way endangered.
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(iii) That an insurance company in which the
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prospective purchaser is insured is financially unstable, cancelling its outstanding policies, merging, or withdrawing from the State.
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(iv) The coverage of the policy being sold.
(v) The effective date of coverage under the
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(vi) That any pre‑existing health condition of
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the purchaser is irrelevant.
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(vii) The right of the purchaser to cancel the
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policy within 30 days after receiving it.
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(5) Mandatory company practices. Any company involved in the sale of
Medicare supplement policies or any policies of accident and health insurance
(subject to subsection (1) of this Section) sold to individuals eligible
for Medicare shall do the following:
(a) Be able to readily determine the number of
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accident and health policies in force with the company on each insured eligible for Medicare.
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(b) Make certain that policies of Medicare
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supplement insurance are not issued, and any premium collected for those policies is refunded, when they are deemed duplicative, inappropriate, or not suitable considering existing coverage with the company.
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(c) Maintain copies of the Policy Check List as
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completed by the agent at the point of sale of a Medicare supplement policy or any policy of accident and health insurance (subject to subsection (1) of this Section) sold to individuals eligible for Medicare on file at the company's regional or other administrative office.
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(6) Disclosures. In order to provide for full and fair disclosure in
the sale of Medicare supplement policies, there must be compliance with the following:
(a) No Medicare supplement policy or certificate
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shall be delivered in this State unless an outline of coverage is delivered to the applicant at the time application is made and, except for direct response policies, an acknowledgement from the applicant of receipt of the outline is obtained.
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(b) Outline of coverage requirements for Medicare
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(i) Insurers issuing Medicare supplement
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policies or certificates for delivery in this State shall provide an outline of coverage to all applicants at the time application is made and, except for direct response policies, shall obtain an acknowledgement of receipt of the outline from the applicant.
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(ii) If an outline of coverage is provided at
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the time of application and the Medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and shall contain immediately above the company name, in no less than 12 point type, the following statement:
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"NOTICE: Read this outline of coverage
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carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.".
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(iii) The outline of coverage provided to
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applicants shall be in the form prescribed by rule by the Department.
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(c) Insurers issuing policies that provide hospital
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or medical expense coverage on an expense incurred or indemnity basis, other than incidentally, to a person or persons eligible for Medicare shall provide to the policyholder a buyer's guide approved by the Director. Delivery of the buyer's guide shall be made whether or not the policy qualifies as a "Medicare Supplement Coverage" in accordance with Section 363 of this Code. Except in the case of direct response insurers, delivery of the buyer's guide shall be made at the time of application, and acknowledgement of receipt of certification of delivery of the buyer's guide shall be provided to the insurer. Direct response insurers shall deliver the buyer's guide upon request, but not later than at the time the policy is delivered.
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(d) Outlines of coverage delivered in connection
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with policies defined in subsection (4) of Section 355a of this Code as Hospital confinement Indemnity (Section 4c), Accident Only Coverage (Section 4f), Specified Disease (Section 4g) or Limited Benefit Health Insurance Coverage to persons eligible for Medicare shall contain, in addition to other requirements for those outlines, the following language that shall be printed on or attached to the first page of the outline of coverage:
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"This policy, certificate or subscriber contract IS
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NOT A MEDICARE SUPPLEMENT policy or certificate. It does not fully supplement your federal Medicare health insurance. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.".
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(e) In the case wherein a policy, as defined in
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paragraph (a) of subsection (2) of Section 355a of this Code, being sold to a person eligible for Medicare provides one or more but not all of the minimum standards for Medicare supplements set forth in Section 363 of this Code, disclosure must be provided that the policy is not a Medicare supplement and does not meet the minimum benefit standards set for those policies in this State.
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(7) Loss ratio standards.
(a) Every issuer of Medicare supplement policies or
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certificates in this State, as defined in Section 363 of this Code, shall file annually its rates, rating schedule, and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall demonstrate that the actual and anticipated losses in relation to premiums comply with the requirements of this Code.
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(b) Medicare supplement policies shall, for the
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entire period for which rates are computed to provide coverage, on the basis of incurred claims experience and earned premiums for the period and in accordance with accepted actuarial principles and practices, return to policyholders in the form of aggregate benefits the following:
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(i) In the case of group policies, at least 75%
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of the aggregate amount of premiums earned.
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(ii) In the case of individual policies, at
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least 60% of the aggregate amount of premiums earned; and beginning November 5, 1991, at least 65% of the aggregate amount of premiums earned.
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(iii) In the case of sponsored group policies in
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which coverage is marketed on an individual basis by direct response to eligible individuals in that group only, at least 65% of the aggregate amount of premiums earned.
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(c) For the purposes of this Section, the insurer
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shall be deemed to comply with the loss ratio standards if: (i) for the most recent year, the ratio of the incurred losses to earned premiums for policies or certificates that have been in force for 3 years or more is greater than or equal to the applicable percentages contained in this Section; and (ii) the anticipated losses in relation to premiums over the entire period for which the policy is rated comply with the requirements of this Section. An anticipated third‑year loss ratio that is greater than or equal to the applicable percentage shall be demonstrated for policies or certificates in force less than 3 years.
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(8) Applicability. This Section shall apply to those companies
writing
the kind or kinds of business enumerated in Classes 1(b) and 2(a) of
Section 4 of this Code and to those entities organized and operating under
the Voluntary Health Services
Plans Act and the Health Maintenance Organization Act.
(9) Penalties.
(a) Any company or agent who is found to have
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violated any of the provisions of this Section may be required by order of the Director of Insurance to forfeit by civil penalty not less than $500 nor more than $5,000 for each offense. Written notice will be issued and an opportunity for a hearing will be granted pursuant to subsection (2) of Section 403A of this Code.
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(b) In addition to any other applicable penalties
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for violations of this Code, the Director may require insurers violating any provision of this Code or regulations promulgated pursuant to this Code to cease marketing in this State any Medicare supplement policy or certificate that is related directly or indirectly to a violation and may require the insurer to take actions as are necessary to comply with the provisions of Sections 363 and 363a of this Code.
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(c) After June 30, 1991, no person may advertise,
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solicit for the sale or purchase of, offer for sale, or deliver a Medicare supplement policy that has not been approved by the Director. A person who knowingly violates, directly or through an agent, the provisions of this paragraph commits a Class 3 felony. Any person who violates the provisions of this paragraph may be subjected to a civil penalty not to exceed $10,000. The civil penalty authorized in this paragraph shall be enforced in the manner provided in Section 403A of this Code.
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(10) Replacement. Application forms shall include a question
designed
to elicit information as to whether a Medicare supplement policy or
certificate is intended to replace any similar accident and sickness policy
or certificate presently in force. A supplementary application or other
form to be signed by the applicant containing the question may be used.
Upon determining that a sale of Medicare supplement coverage will involve
replacement, an insurer, other than a direct response insurer, or its
agent, shall furnish the applicant, prior to issuance or delivery of the
Medicare supplement policy or certificate, a notice regarding replacement
of Medicare supplement coverage. One copy of the notice shall be provided
to the applicant, and an additional copy signed by the applicant shall be
retained by the insurer. A direct response insurer shall deliver to the
applicant at the time of the issuance of the policy the notice regarding
replacement of Medicare supplement coverage.
(Source: P.A. 93‑32, eff. 7‑1‑03.)
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(215 ILCS 5/367) (from Ch. 73, par. 979)
Sec. 367.
Group accident and health insurance.
(1) Group accident and health insurance is hereby declared to be that
form of accident and health insurance covering not less than 2
employees,
members, or employees of members, written under a
master policy issued to any governmental corporation, unit, agency or
department thereof, or to any corporation, copartnership, individual
employer, or to any association upon application of an executive officer or
trustee of such association having a constitution or bylaws and formed in
good faith for purposes other than that of obtaining insurance, where
officers, members, employees, employees of members or classes or department
thereof, may be insured for their individual benefit. In addition a group
accident and health policy may be written to insure any group which may be
insured under a group life insurance policy. The term "employees" shall
include the officers, managers and employees of subsidiary or affiliated
corporations, and the individual proprietors, partners and employees of
affiliated individuals and firms, when the business of such subsidiary or
affiliated corporations, firms or individuals, is controlled by a common
employer through stock ownership, contract or otherwise.
(2) Any insurance company authorized to write accident and health
insurance in this State shall have power to issue group accident and
health policies. No policy of group accident and health insurance may
be issued or delivered in this State unless a copy of the form thereof
shall have been filed with the department and approved by it in
accordance with Section 355, and it contains in substance those
provisions contained in Sections 357.1 through 357.30 as may be applicable
to group accident and health insurance and the following provisions:
(a) A provision that the policy, the application of |
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the employer, or executive officer or trustee of any association, and the individual applications, if any, of the employees, members or employees of members insured shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer or trustee, or by the individual employees, members or employees of members shall (in the absence of fraud) be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the policy, unless it is contained in a written application.
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(b) A provision that the insurer will issue to the
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employer, or to the executive officer or trustee of the association, for delivery to the employee, member or employee of a member, who is insured under such policy, an individual certificate setting forth a statement as to the insurance protection to which he is entitled and to whom payable.
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(c) A provision that to the group or class thereof
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originally insured shall be added from time to time all new employees of the employer, members of the association or employees of members eligible to and applying for insurance in such group or class.
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(3) Anything in this code to the contrary notwithstanding, any group
accident and health policy may provide that all or any portion of any
indemnities provided by any such policy on account of hospital, nursing,
medical or surgical services, may, at the insurer's option, be paid
directly to the hospital or person rendering such services; but the
policy may not require that the service be rendered by a particular
hospital or person. Payment so made shall discharge the insurer's
obligation with respect to the amount of insurance so paid. Nothing in this
subsection (3) shall prohibit an insurer from providing incentives for
insureds to utilize the services of a particular hospital or person.
(4) Special group policies may be issued to school districts
providing medical or hospital service, or both, for pupils of the
district injured while participating in any athletic activity under the
jurisdiction of or sponsored or controlled by the district or the
authorities of any school thereof. The provisions of this Section
governing the issuance of group accident and health insurance shall,
insofar as applicable, control the issuance of such policies issued to
schools.
(5) No policy of group accident and health insurance may be issued
or delivered in this State unless it provides that upon the death of the
insured employee or group member the dependents' coverage, if any,
continues for a period of at least 90 days subject to any other policy
provisions relating to termination of dependents' coverage.
(6) No group hospital policy covering miscellaneous hospital
expenses issued or delivered in this State shall contain any exception
or exclusion from coverage which would preclude the payment of expenses
incurred for the processing and administration of blood and its
components.
(7) No policy of group accident and health insurance, delivered in
this State more than 120 days after the effective day of the Section,
which provides inpatient hospital coverage for sicknesses shall exclude
from such coverage the treatment of alcoholism. This subsection shall
not apply to a policy which covers only specified sicknesses.
(8) No policy of group accident and health insurance, which
provides benefits for hospital or medical expenses based upon the actual
expenses incurred, issued or delivered in this State shall contain any
specific exception to coverage which would preclude the payment of
actual expenses incurred in the examination and testing of a victim of
an offense defined in Sections 12‑13 through 12‑16 of the Criminal Code
of 1961, 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 the victim of
such offense, arising out of the offense. Every group policy of accident
and health insurance which specifically provides benefits for routine
physical examinations shall provide full coverage for expenses incurred in
the examination and testing of a victim of an offense defined in Sections
12‑13 through 12‑16 of the Criminal Code of 1961, or an attempt to commit such
offense, as set forth in this
Section. This subsection shall not apply to a policy which covers hospital
and medical expenses for specified illnesses and injuries only.
(9) For purposes of enabling the recovery of State funds, any insurance
carrier subject to this Section shall upon reasonable demand by the Department
of Public Health disclose the names and identities of its insureds 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, hospital or medical expenses for which an insurance carrier 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.
(10) Whenever the Department of Public Health finds that it has paid all
or part of any hospital or medical expenses which an insurance carrier is
obligated to pay under this Section, the Department of Public Health shall
be entitled to receive reimbursement for its payments from such insurance
carrier provided that the Department of Public Health has notified the
insurance carrier of its claim before the carrier has paid the benefits to
its insureds or the insureds' assignees.
(11) (a) No group hospital, medical or surgical expense
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policy shall contain any provision whereby benefits otherwise payable thereunder are subject to reduction solely on account of the existence of similar benefits provided under other group or group‑type accident and sickness insurance policies where such reduction would operate to reduce total benefits payable under these policies below an amount equal to 100% of total allowable expenses provided under these policies.
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(b) When dependents of insureds are covered under 2
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policies, both of which contain coordination of benefits provisions, benefits of the policy of the insured whose birthday falls earlier in the year are determined before those of the policy of the insured whose birthday falls later in the year. Birthday, as used herein, refers only to the month and day in a calendar year, not the year in which the person was born. The Department of Insurance shall promulgate rules defining the order of benefit determination pursuant to this paragraph (b).
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(12) Every group policy under this Section shall be subject to the
provisions of Sections 356g and 356n of this Code.
(13) No accident and health insurer providing coverage for hospital
or medical expenses on an expense incurred basis 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 an accident and
health insurer 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.
(14) Whenever a claim for benefits by an insured under a dental
prepayment program is denied or reduced, based on the review of x‑ray
films, such review must be performed by a dentist.
(Source: P.A. 91‑549, eff. 8‑14‑99.)
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(215 ILCS 5/367.2) (from Ch. 73, par. 979.2)
Sec. 367.2.
Spousal continuation privilege; group contracts.
A. No policy of group accident or health insurance, nor any
certificate thereunder shall be delivered or issued for delivery in this
State after December 1, 1985, unless the policy provides for a continuation
of the existing insurance benefits for an employee's spouse and dependent
children who are insured under the provisions of that group policy or
certificate thereunder, notwithstanding that the marriage is dissolved by
judgment or terminated by the death of the employee or, after the
effective date of this amendatory Act of the 93rd General Assembly, notwithstanding the
retirement of the employee provided that
the employee's
spouse is at
least 55 years of age, in each case without any other eligibility
requirements. The provisions of this amendatory Act of the 93rd General
Assembly apply to every
group policy of accident or health insurance and every certificate issued
thereunder delivered or issued for delivery after the effective date of
this amendatory Act of the 93rd General Assembly.
B. Within 30 days of the entry of judgment or the death or
retirement of the employee, the spouse of an employee insured under
the policy who seeks a continuation of coverage thereunder shall give the
employer or the insurer written notice of the dissolution of the
marriage
or the death or retirement of the employee. The employer, within 15
days of receipt of the notice
shall give written notice
of the dissolution of the employee's marriage or the death or retirement of
the employee and that former spouse's or retired employee's spouse's
residence
to the insurance
company issuing the policy.
The employer shall immediately send a copy of the notice to the former
spouse of the employee or the spouse of the retired employee at the retired
employee's spouse's residence or at the former spouse's residence. For
purposes of this Act, the term "former spouse" includes "widow" or "widower".
C. Within 30 days after the date of receipt of a notice from the
employer, retired employee's spouse or former spouse or of the initiation
of a new group policy, the insurance company, by certified mail, return
receipt requested, shall notify the retired employee's spouse or former
spouse at his or her residence that the policy may be continued for that
retired employee's spouse or former spouse and covered dependents, and the
notice shall include:
(i) a form for election to continue the insurance |
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(ii) the amount of periodic premiums to be charged
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for continuation coverage and the method and place of payment; and
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(iii) instructions for returning the election form
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within 30 days after the date it is received from the insurance company.
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Failure of the retired employee's spouse or former spouse to exercise the
election to continue insurance coverage by notifying the insurance company
in writing within such 30
day period
shall terminate the continuation of benefits and the right to continuation.
If the insurance company fails to notify the retired employee's spouse
or former spouse as provided for in subsection C hereof, all premiums shall
be waived from the date the notice was required until notice is sent, and
the benefits shall continue under the terms and provisions of the policy,
from the date the notice was required until the notice is sent,
notwithstanding any other provision hereof, except where the benefits in
existence at the time the company's notice was to be sent pursuant to
subsection C are terminated as to all employees.
D. With respect to a former spouse who has not attained the age of 55
at the time continuation coverage begins, the monthly premium
for
continuation shall be computed as follows:
(i) an amount, if any, that would be charged an
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employee if the former spouse were a current employee of the employer, plus;
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(ii) an amount, if any, that the employer would
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contribute toward the premium if the former spouse were a current employee.
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Failure to pay the initial monthly premium within 30 days after the date of
receipt of notice required in subsection C of this Section terminates
the continuation benefits and the right to continuation benefits.
The continuation coverage for former
spouses who have not attained the
age of 55 at the time coverage begins shall terminate upon the
earliest to happen of the following:
(i) The failure to pay premiums when due, including
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any grace period allowed by the policy; or
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(ii) When coverage would terminate under the terms
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of the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
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(iii) the date on which the former spouse first
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becomes, after the date of election, an insured employee under any other group health plan; or
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(iv) the date on which the former spouse remarries;
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(v) the expiration of 2 years from the date
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continuation coverage began.
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Upon the termination of continuation coverage, the former
spouse shall be
entitled to convert the coverage to an individual policy.
The continuation rights granted to former spouses who have not attained age
55
shall also
include eligible dependents insured prior to the dissolution of marriage or the
death of the
employee.
E. With respect to a retired employee's spouse or former spouse who
has attained the age of 55 at the time continuation coverage begins, the
monthly premium for the continuation shall be computed as follows:
(i) an amount, if any, that would be charged an
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employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
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(ii) an amount, if any, that the employer would
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contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
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Beginning 2 years after coverage begins under this paragraph, the
monthly premium shall be computed as follows:
(i) an amount, if any, that would be charged an
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employee if the retired employee's spouse or former spouse were a current employee of the employer, plus;
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(ii) an amount, if any, that the employer would
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contribute toward the premium if the retired employee's spouse or former spouse were a current employee.
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(iii) an additional amount, not to exceed 20% of (i)
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and (ii) above, for costs of administration.
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Failure to pay the initial monthly premium within 30 days after the date
of receipt of the notice required in subsection C of this Section
terminates the continuation benefits and the right to continuation benefits.
The continuation coverage for retired employees'
spouses and former spouses
who have attained the age of 55 at the time coverage begins shall
terminate upon the earliest to happen of the following:
(i) The failure to pay premiums when due, including
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any grace period allowed by the policy; or
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(ii) When coverage would terminate, except due to
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the retirement of an employee, under the terms of the existing policy if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or retirement to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless the master policy in existence at the time is modified or terminated as to all employees; or
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(iii) the date on which the retired employee's
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spouse or former spouse first becomes, after the date of election, an insured employee under any other group health plan; or
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(iv) the date on which the former spouse remarries;
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(v) the date that person reaches the qualifying age
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or otherwise establishes eligibility under the Medicare Program pursuant to Title XVIII of the federal Social Security Act.
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Upon the termination of continuation coverage, the former
spouse shall be
entitled to convert the coverage to an individual policy.
The continuation rights granted to former spouses who have attained age 55
shall also
include eligible dependents insured prior to the dissolution of marriage, the
death of the
employee, or the retirement of the employee.
F. The renewal, amendment, or extension of any group policy affected by
this Section shall be deemed to be delivery or issuance for delivery of a
new policy or contract of insurance in this State.
G. If (i) the policy is canceled, and (ii) another
insurance company
contracts to provide group health and accident insurance to the employer,
and (iii) continuation coverage is in effect for the retired employee's
spouse or former spouse at the time of cancellation and (iv) the employee
is or would have been included under the new group policy, then the new
insurer must also offer continuation coverage to the retired employee's
spouse and to an employee's former spouse under the same terms and
conditions as contained in this Section.
H. This Section shall not limit the right of the retired employee's spouse
or any former spouse to exercise
the privilege to convert to an individual policy as contained in this Code.
I. No person who obtains coverage under this Section shall be required
to pay a rate greater than that applicable to any employee or member
covered under that group except as provided in clause (iii) of the
second paragraph of subsection E.
(Source: P.A. 93‑477, eff. 1‑1‑04.)
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(215 ILCS 5/367.2‑5)
Sec. 367.2‑5.
Dependent child continuation privilege; group contracts.
(a) No policy of group accident or health insurance, nor any certificate
thereunder
shall be amended, renewed, delivered, or issued for delivery in this State
after
July 1,
2004, unless the policy provides for a continuation of the existing insurance
benefits for
an employee's dependent child who is insured under the provisions of that group
policy
or certificate in the event of the death of the employee and the child is not
eligible for
coverage as a dependent under the provisions of Section 367.2 or the dependent
child has
attained the limiting age under the policy.
(b) In the event of the death of the employee, if continuation coverage is
desired,
the dependent child or a responsible adult acting on behalf of the dependent
child shall
give the employer or the insurer written notice of the death of employee within
30 days of
the date the coverage terminates. The employer, within 15 days of receipt of
the notice,
shall give written notice to the insurance company issuing the policy of the
death of the
employee and the dependent child's residence. The employer shall immediately
send a
copy of the notice to the dependent child or responsible adult at the dependent
child's
residence.
(c) In the event of the dependent child attaining the limiting age under the
policy,
if continuation coverage is desired, the dependent child shall give the
employer or the
insurer written notice of the attainment of the limiting age within 30 days of
the date the
coverage terminates. The employer, within 15 days of receipt of the notice,
shall give
written notice to the insurance company issuing the policy of the attainment
of the
limiting age by the dependent child and of the dependent child's residence.
(d) Within 30 days after the date of receipt of a notice from the employer,
dependent child, or responsible adult acting on behalf of the dependent child,
or of the
initiation of a new group policy, the insurance company, by certified mail,
return receipt
requested, shall notify the dependent child or responsible adult at the
dependent child's
residence that the policy may be continued for the dependent child. The
notice shall
include:
(1) a form for election to continue the insurance |
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(2) the amount of periodic premiums to be charged
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for continuation coverage and the method and place of payment; and
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(3) instructions for returning the election form
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within 30 days after the date it is received from the insurance company.
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Failure of the dependent child or the responsible adult acting on behalf of
the dependent
child to exercise the election to continue insurance coverage by notifying the
insurance
company in writing within such 30 day period shall terminate the continuation
of benefits
and the right to continuation.
If the insurance company fails to notify the dependent child or responsible
adult acting on
behalf of the dependent child as provided for in this subsection (d), all
premiums shall
be waived from the date the notice was required until notice was sent, and the
benefits shall
continue under the terms and provisions of the policy, from the date the notice
was
required until the notice was sent, notwithstanding any other provision hereof,
except where
the benefits in existence at the time the company's notice was to be sent
pursuant to
this subsection (d) are terminated as to all employees.
(e) The monthly premium for continuation shall be computed as follows:
(1) an amount, if any, that would be charged an
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employee if the dependent child were a current employee of the employer, plus;
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(2) an amount, if any, that the employer would
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contribute toward the premium if the dependent child were a current employee.
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Failure to pay the initial monthly premium within 30 days after the date of
receipt of
notice required in subsection (d) of this Section terminates the continuation
benefits and
the right to continuation benefits.
Continuation coverage provided under this Act shall terminate upon the
earliest to happen
of the following:
(1) the failure to pay premiums when due, including
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any grace period allowed by the policy;
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(2) when coverage would terminate under the terms of
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the existing policy if the dependent child was still an eligible dependent of the employee;
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(3) the date on which the dependent child first
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becomes, after the date of election, an insured employee under any other group health plan; or
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(4) the expiration of 2 years from the date
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continuation coverage began.
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Upon the termination of continuation coverage, the dependent child shall be
entitled to
convert the coverage to an individual policy.
(f) The renewal, amendment, or extension of any group policy affected by
this
Section shall be deemed to be delivery or issuance for delivery of a new policy
or
contract of insurance in this State.
(g) If (1) the policy is cancelled, and (2) another insurance company
contracts to
provide group health and accident insurance to the employer, and (3)
continuation
coverage is in effect for the dependent child at the time of cancellation, and
(4) the
employee is or would have been included under the new group policy, then the
new
insurer must also offer continuation coverage to the dependent child under the
same
terms and conditions as contained in this Section.
(h) This Section shall not limit the right of any dependent child to
exercise the
privilege to convert to an individual policy as contained in this Code.
(i) No person who obtains coverage under this Section shall be required to
pay a
rate greater than that applicable to any employee or member covered under that
group.
(Source: P.A. 93‑477, eff. 1‑1‑04.)
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(215 ILCS 5/367e) (from Ch. 73, par. 979e)
Sec. 367e.
Continuation of Group Hospital, Surgical and Major Medical
Coverage After Termination of Employment or Membership.
A group policy delivered, issued for delivery, renewed or amended in this
state which insures employees or members
for hospital, surgical or major medical insurance on an expense incurred
or service basis, other than for specific diseases or for accidental injuries
only, shall provide that employees or members whose insurance under the
group policy would otherwise terminate because of termination of employment
or membership or because of a reduction in hours below the minimum required
by the group plan shall be entitled to continue their hospital, surgical and
major medical insurance under that group policy, for themselves and their
eligible dependents, subject to all of the group policy's terms and conditions
applicable to those forms of insurance and to the following conditions:
1. Continuation shall only be available to an |
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employee or member who has been continuously insured under the group policy (and for similar benefits under any group policy which it replaced) during the entire 3 months period ending with such termination or reduction in hours below the minimum required by the group plan.
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2. Continuation shall not be available for any
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person who is covered by Medicare, except for those individuals who have been covered under a group Medicare supplement policy. Neither shall continuation be available for any person who is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan or who exercises his conversion privilege under the group policy.
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3. Continuation need not include dental, vision
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care, prescription drug benefits, disability income, specified disease, or similar supplementary benefits which are provided under the group policy in addition to its hospital, surgical or major medical benefits.
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4. Upon termination or reduction in hours below the
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minimum required by the group plan written notice of continuation shall be presented to the employee or member by the employer or mailed by the employer to the last known address of the employee. An employee or member who wishes continuation of coverage must request such continuation in writing within the ten‑day period following the later of: (i) the date of such termination or reduction in hours below the minimum required by the group plan, or (ii) the date the employee is given written notice of the right of continuation by either the employer or the group policyholder. In no event, however, may the employee or member elect continuation more than 60 days after the date of such termination or reduction in hours below the minimum required by the group plan. 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 provision.
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5. An employee or member electing continuation must
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pay to the group policyholder or his employer, on a monthly basis in advance, the total amount of premium required by the insurer, including that portion of the premium contributed by the policyholder or employer, if any, but not more than the group rate for the insurance being continued with appropriate reduction in premium for any supplementary benefits which have been discontinued under paragraph (3) of this Section. The premium rate required by the insurer shall be the applicable premium required on the due date of each payment.
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6. Continuation of insurance under the group policy
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for any person shall terminate when he becomes eligible for Medicare or is covered by any other insured or uninsured plan which provides hospital, surgical or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination or reduction in hours below the minimum required by the group plan as provided in condition 2 above or, if earlier, at the first to occur of the following:
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(a) The date 9 months after the date the
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employee's or member's insurance under the policy would otherwise have terminated because of termination of employment or membership or reduction in hours below the minimum required by the group plan.
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(b) If the employee or member fails to make
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timely payment of a required contribution, the end of the period for which contributions were made.
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(c) The date on which the group policy is
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terminated or, in the case of an employee, the date his employer terminates participation under the group policy. However, if this (c) applies and the coverage ceasing by reason of such termination is replaced by similar coverage under another group policy, the following shall apply:
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(i) The employee or member shall have the
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right to become covered under that other group policy, for the balance of the period that he would have remained covered under the prior group policy in accordance with condition 6 had a termination described in this (c) not occurred.
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(ii) The prior group policy shall continue
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to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.
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7. A notification of the continuation privilege
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shall be included in each certificate of coverage.
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8. Continuation shall not be available for any
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employee who was discharged because of the commission of a felony in connection with his work, or because of theft in connection with his work, for which the employer was in no way responsible; provided the employee admitted his commission of the felony or theft or such act has resulted in a conviction or order of supervision by a court of competent jurisdiction.
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The requirements of this amendatory Act of 1983 shall apply to any group
policy as defined in this Section, delivered or issued for delivery on or after
180 days following the effective date of this amendatory Act of 1983.
The requirements of this amendatory Act of 1985 shall apply to any
group policy as defined in this Section, delivered, issued for delivery,
renewed or amended on or after 180 days following the effective date of
this amendatory Act of 1985.
(Source: P.A. 93‑477, eff. 1‑1‑04.)
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(215 ILCS 5/367e.1)
Sec. 367e.1.
Group Accident and Health Insurance Conversion Privilege.
(A) A group policy which provides hospital, medical, or major
medical expense insurance, or any combination of these coverages, on an
expense‑incurred basis, but not including a policy which provides
benefits for specific diseases or for accidental injuries only, shall
provide that an employee or member (i) whose insurance under the group
policy has been terminated for any reason other than discontinuance of
the group policy in its entirety where there is a succeeding carrier, or
failure of the employee or member to pay any required contribution; and
(ii) who has been continuously insured under the group policy (and under
any group policy providing similar benefits which it replaces) for at
least three months immediately prior to termination, shall be entitled
to have issued to him by the insurer a policy of health insurance
(hereafter referred to as the converted policy), subject to the
following conditions:
(1) Written application for the converted policy |
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shall be made and the first premium paid to the insurer not later than the latter of (i) thirty‑one days after such termination or (ii) 15 days after the employee or member has been given written notice of the existence of the conversion privilege, but in no event later than 60 days after such termination.
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Written notice presented to the employee or member by
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the policyholder, or mailed by the policyholder to the last known address of the employee or member, shall constitute the giving of notice for the purpose of this provision.
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(2) The converted policy shall be issued without
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evidence of insurability.
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(3) The initial premium for the converted policy
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shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of each person to be covered under the converted policy and to the type and amount of the insurance provided. Conditions pertaining to health shall not be an acceptable basis of classification for the purposes of this subsection. The frequency of premium payment shall be the frequency customarily required by the insurer for the policy form and plan selected, provided that the insurer shall not require premium payments less frequently than quarterly without the consent of the insured.
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(4) The effective date of the converted policy shall
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be the day following the termination of insurance under the group policy.
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(5) The converted policy shall cover the employee or
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member and his dependents who were covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.
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(6) The insurer shall not be required to issue a
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converted policy covering any person if such person is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded). Furthermore, the insurer shall not be required to issue a converted policy covering any person if (i) such person is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) such person is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any statute, and the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person together with the converted policy would result in overinsurance according to the insurer's standards.
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(7) In the event that coverage would be continued
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under the group policy on an employee following his retirement prior to the time he is or could be covered by Medicare, he may elect, in lieu of such continuation of such group insurance, to have the same conversion rights as would apply had his insurance terminated at retirement by reason of termination of employment or membership.
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(8) Subject to the conditions set forth above, the
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conversion privilege shall also be available (i) to the surviving spouse, if any, at the death of the employee or member, with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death, otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or, if the group policy provides for continuation of dependents' coverage following the employee's or member's death, at the end of such continuation; (ii) to the spouse of the employee or member upon termination of coverage of the spouse, while the employee or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time; or (iii) to a child solely with respect to himself upon termination of his coverage by reason of ceasing to be a qualified family member under the group policy, if a conversion privilege is not otherwise provided above with respect to such termination.
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(9) A notification of the conversion privilege shall
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be included in each certificate.
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(10) The insurer may elect to provide group
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insurance coverage in lieu of the issuance of a converted policy.
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(B) A converted policy issued upon the exercise of the conversion
privilege required by subsection (A) of this Section shall conform to
the following minimum standards:
(1) If the group policy provided hospital, surgical,
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or medical expense insurance, or a combination thereof, the converted policy shall provide benefits on an expense‑incurred basis equal to the lesser of (i) the hospital room and board, miscellaneous hospital, surgical and medical benefits provided under the group policy; and (ii) the corresponding benefits described below:
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(a) Hospital room and board benefits in an
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amount per day elected by the group policyholder, but in no event less than 60% of the then average semi‑private hospital room and board charge in the State, such benefits to be payable for a maximum of not less than 70 days for any period of hospital confinement, as defined in the converted policy.
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(b) Miscellaneous hospital benefits for any one
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period of hospital confinement in an amount up to twenty times the hospital room and board daily benefit provided under the converted policy.
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(c) Surgical benefits according to a surgical
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schedule providing a benefit amount elected by the group policy holder, but in no event less than 60% of the then average surgical charge in the State and with a maximum amount appropriate thereto. The maximum surgical benefit shall be applicable to all surgical operations of an individual resulting from or contributed to by the same and all related causes occurring in one period of disability. Two or more surgical procedures performed in the course of a single operation through the same incision, or in the same natural body orifice, may be treated as one surgical procedure with the payment determined by the scheduled benefit for the most expensive procedure performed. The surgical schedule shall be consistent with the schedule of operations customarily offered by the insurer under group or individual health insurance policies.
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(d) Non‑surgical medical attendance benefits for
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in‑hospital services in an amount elected by the group policyholder, but in no event less than 60% of the then average in‑hospital physician's visit charge in the State, such benefits may be limited to one visit per day of hospitalization and a maximum number of visits numbering not less than seventy for any period of hospital confinement as defined in the converted policy.
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(2) If the group policy provided major medical
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insurance, the insurer may offer the insurance described in (1) above only, major medical insurance only, or a combination of the insurance described in (1) above and major medical insurance. If the insurer elects to provide major medical insurance, the converted policy shall provide:
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(a) A maximum benefit at least equal to (i) or
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(i) A maximum payment of twenty‑five
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thousand dollars for all covered medical expenses incurred during the covered person's lifetime with an annual restoration of the lesser of, while coverage is in force, one thousand dollars and the amount counted against the maximum benefit which was not previously restored; or
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(ii) A maximum payment of twenty‑five
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thousand dollars for each unrelated injury or illness.
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(b) Payment of benefits for covered medical
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expenses, in excess of the deductible, at a rate not less than 80% except as otherwise permitted below.
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(c) A deductible for each benefit period which,
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at the option of the insurer, shall be (i) the greater of $500 and the benefits deductible; (ii) the sum of the benefits deductible and $100; or (iii) the corresponding deductible in the group policy. The term "benefit period," as used herein, means, when the maximum payment is determined by (a) (i) above, either a calendar year or a period of twelve consecutive months; and, when the maximum payment is determined by (a) (ii) above, a period of twenty‑four consecutive months. The term "benefits deductible," as used herein, means the value of any benefits provided on an expense‑incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical, or medical insurance policy or hospital or medical service subscriber contract of medical practice or other prepayment plan, or any other plans or program whether on an insured or uninsured basis, or of any similar benefits which are provided or made available pursuant to or in accordance with the requirements of any statute and, if, pursuant to the provisions of this subsection, the converted policy provides both the coverage described in (1) above and major medical insurance, the value of the coverage described in (1) above. The insurer may require that the deductible be satisfied during a period of not less than three months. If the maximum payment is determined by (a) (i) above, and if no benefits become payable during the preceding benefit period due to the cash deductible not being satisfied; credit shall be given, in the succeeding benefit period, to any expense applied toward the cash deductible of the preceding benefit period and incurred during the last three months of such preceding benefit period, subject to any requirement that the deductible be satisfied during a specified period of time.
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(d) The term "covered medical expenses," as used
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above, may be limited (i) in the case of hospital room and board benefits, maximum surgical schedule, and non‑surgical medical attendance benefits to amounts not less than the amounts provided in (1) (a), (1) (c) and (1) (d) above; and (ii) in the case of mental and nervous condition treatments while the patient is not a hospital in‑patient, to co‑insurance of 50%, a maximum benefit of $500 per calendar year or twelve consecutive month periods subject to the inclusion by the insurer of reasonable limits on the number of visits and the maximum permissible expense per visit.
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(3) The converted policy may contain any exclusion,
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reduction, or limitation contained in the group policy and any exclusion, reduction, or limitation customarily used in individual accident and health policies delivered or issued for delivery in this state. It is not required that the converted policy contain all of the covered medical expenses or the same level of benefits as provided in the group policy.
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(4) The insurer may, at its option, also offer
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alternative plans for group accident and health conversion.
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(5) The converted policy may only exclude a
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pre‑existing condition excluded by the group policy. Any hospital, surgical, medical or major medical benefits payable under the converted policy may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder and, during the first policy year of such converted policy, the benefits payable under the converted policy may be so reduced so that they are not in excess of the benefits that would have been payable had the individual's insurance under the group policy remained in force and effect.
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(6) The converted policy may provide for the
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termination of coverage thereunder of any person when he is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded).
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(7) The converted policy may provide that the
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insurer may request information from the converted policyholder, in advance of any premium due date of the converted policy, to determine whether any person covered thereunder (i) is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or (ii) is eligible for similar benefits (whether or not covered therefor) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or (iii) has similar benefits provided for or available to such person, pursuant to or in accordance with the requirements of any statute. The converted policy may also provide that the insurer need not renew the converted policy or the coverage of any person insured thereunder if either the benefits provided or available under the sources referred to in (i), (ii), (iii) above for such person, together with the converted policy, would result in overinsurance according to the insurer's standards, or if the converted policyholder refuses to provide the requested information.
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(8) The converted policy shall not contain any
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provision allowing the insurer to non‑renew due to a change in the health of an insured.
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(9) The converted policy may contain any provisions
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permitted herein and may also include any other provisions not expressly prohibited by law. Any provisions required or permitted herein may be made a part of the converted policy by means of an endorsement or rider.
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(10) In the conversion of group health insurance in
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accordance with the provisions of subsection (A) above, the insurer may, at its option, accomplish the conversion by issuing one or more converted policies.
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(11) With respect to any person who was covered by
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the group policy, the period specified in the Time Limit on Certain Defenses provisions of the converted policy shall commence with the date the person's insurance became effective under the group policy.
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(12) If the insurer elects to provide group
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insurance coverage in lieu of a converted policy, the benefit levels required for a converted policy must be applicable to such group insurance coverage.
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(C) The requirements of this Section shall apply to any group policy
of accident and health insurance delivered, issued for delivery, renewed
or amended on or after 180 days following the effective date of this
Section.
(Source: P.A. 93‑477, eff. 1‑1‑04.)
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(215 ILCS 5/367h) (from Ch. 73, par. 979h)
Sec. 367h.
Deputy's continuance privilege.
As used in this Section:
1. The terms "municipality" and "creditable service"
shall have the meaning ascribed to such terms by Sections 7‑105
and 7‑113, respectively, of the Illinois Pension Code, as now or hereafter
amended.
The term "deferred pensioner" means a deputy who has retired,
having accumulated enough creditable service to qualify for a pension, but
who has not attained the required age.
2. The term "deputy" shall mean a "sheriff's
law enforcement employee" as defined in Section 7‑109.3 of the Illinois
Pension Code, and include only
persons under the coverage of Article 7 of that Code, as heretofore or
hereafter
amended.
3. The "retirement or disability period" of a deputy means the period:
a. which begins on the day the deputy is removed |
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from a sheriff's police department payroll because of the occurrence of any of the following events, to wit: (i) the deputy retires as a deferred pensioner, (ii) the deputy retires from active service as a deputy with an attained age and accumulated creditable service which together qualify the deputy for immediate receipt of retirement pension benefits under Section 7‑142.1 of the Illinois Pension Code, or (iii) the deputy's disability is established under Article 7 of the Illinois Pension Code; and
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b. which ends on the first to occur of any of the
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following events, to wit: (i) the deputy's reinstatement or reentry into active service in the sheriff's police department as provided for under Article 7 of the Illinois Pension Code, (ii) the deputy's exercise of any refund option or acceptance of any separation benefit available under Article 7 of the Illinois Pension Code, (iii) the deputy's loss pursuant to Section 7‑219 of the Illinois Pension Code of any benefits provided for in Article 7 of that Code, or (iv) the deputy's death or ‑‑ if at the time of the deputy's death the deputy is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 7 of the Illinois Pension Code ‑‑ the death or remarriage of that spouse.
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No policy of group accident and health insurance under which deputies
employed by a municipality are insured for their individual benefit shall
be issued or delivered in this State to any municipality unless such group
policy provides for the election of continued group insurance coverage for
the retirement or disability period of each deputy who is insured under the
provisions of the group policy on the day immediately preceding the day
on which the retirement or disability period of such deputy begins. So
long as any required premiums for continued group insurance coverage are
paid in accordance with the provisions of the group policy, an election
made pursuant to this Section shall provide continued group insurance coverage
for a deputy throughout the retirement or disability period of the
deputy and, unless
the deputy otherwise elects and subject to any other provisions of the
group policy which relate either to the provision or to the termination
of dependents' coverage and which are not inconsistent with this Section,
for any dependents of the deputy who are insured under the group policy on the
day immediately preceding the day on which the retirement or disability
period of the deputy begins; provided, however, that when such continued
group insurance coverage is in effect with respect to a deputy on the date
of the deputy's death but the retirement or disability period of
the deputy
does not end with such deputy's death, then the deceased deputy's surviving
spouse upon whose death or remarriage such retirement or disability period
will end shall be entitled, without further election and upon payment of
any required premiums in accordance with the provisions of the group policy,
to maintain such continued group insurance coverage in effect until the end of
such retirement or disability period. Continued group insurance coverage shall
be provided in accordance with this Section at the same premium rate from time
to time charged for equivalent coverage provided under the group policy with
respect to covered deputies whose retirement or disability period has not
begun, and no distinction or discrimination in the amount or rate of premiums
or in any waiver of premium
or other benefit provision shall be made between continued group insurance
coverage elected pursuant to this Section and equivalent coverage provided
to deputies under the group policy other than pursuant to the provisions
of this Section; provided that no municipality shall be required by reason
of any provision of this Section to pay any group insurance premium other
than one that may be negotiated in a collective bargaining agreement.
If the group policy provides for a reduction in benefits and premium for
insureds who become eligible for medicare, such provision shall apply to
persons electing continued coverage under this Section.
Within 15 days of the beginning of the retirement or disability period
of any deputy entitled to elect continued group insurance coverage under any
group policy affected by this Section, the municipality last employing such
deputy shall give written notice of such beginning by certified mail, return
receipt requested, to the insurance company issuing such policy. The notice
shall include the deputy's name and last known place of residence and the
beginning date of the deputy's retirement or disability period.
Within 15 days of the date of receipt of such notice from the municipality,
the insurance company by certified mail, return receipt requested, shall
give written notice to the deputy at the deputy's last known place of
residence that coverage under the group policy may be continued for the
retirement or disability period of the deputy as provided in this Section.
Such notice shall set forth: (i) a statement of election to be filed by
the deputy if the deputy wishes to continue such group insurance
coverage,
(ii) the amount of monthly premium, including a statement of the portion
of such monthly premium attributable to any dependents' coverage which the
deputy may elect, and (iii) instructions as to the return of the election
form to the insurance company issuing such policy. Election shall be made,
if at all, by returning the statement of election to the insurance company
by certified mail, return receipt requested, within 15 days after having
received it.
If the deputy elects to continue coverage, it shall be the obligation
of the deputy to pay the monthly premium directly to the municipality which
shall forward it to the insurance company issuing the group insurance
policy, or as otherwise
directed by the insurance company; provided, however, that the deputy
shall be entitled to designate on the statement of election
required to be filed with the insurance company that the total
monthly premium, or such portion thereof as is not contributed by
a municipality, be deducted by the Illinois Municipal Retirement Fund
from the monthly pension payment otherwise payable
to or on behalf of the deputy pursuant to Article 7 of the Illinois Pension Code, and be remitted by such Fund to
the insurance company. The portion, if any, of the monthly premium
contributed by a municipality for such continued group insurance
coverage shall be paid by
the directly to the insurance company issuing the group insurance
policy, or as directed by the insurance company. Such continued
group insurance coverage shall relate back to the beginning of the deputy's
retirement or disability period.
The amendment, renewal or extension of any group insurance policy affected
by this Section shall be deemed to be the issuance of a new policy of insurance
for purposes of this Section.
In the event that a municipality makes a program of accident, health,
hospital or medical benefits available to its deputies through
self‑insurance, or by participation in a pool or reciprocal insurer, or by
contract in a form other than a policy of group insurance with one or more
medical service plans, health care service corporations, health maintenance
organizations, or any other professional corporations or plans under which
health care or reimbursement for the costs thereof is
provided, whether the cost of such benefits is borne by the municipality or
the deputies or both, such deputies and their surviving spouses shall have
the same right to elect continued coverage under such program of benefits
as they would have if such benefits were provided by a policy of group
accident and health insurance. In such cases, the notice of right to elect
continued coverage shall be sent by the municipality; the statement of
election shall be sent to the municipality; and references to the required
premium shall refer to that portion of the cost of such benefits which is not
borne by the municipality, either voluntarily or pursuant to the provisions
of a collective bargaining agreement. In the case of a municipality
providing such benefits through self‑insurance or participation in a pool or
reciprocal insurer, the right to elect continued coverage which is provided
by this paragraph shall be implemented and made available to the deputies of
the municipality and qualifying surviving spouses not later than July 1, 1986.
The amendment, renewal or extension of any such contract in a form other
than a policy of group insurance policy shall be deemed the formation of a
new contract for the purposes of this Section.
This Section shall not limit the exercise of any conversion privileges
available under Section 367e.
(Source: P.A. 90‑655, eff. 7‑30‑98.)
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(215 ILCS 5/367j) (from Ch. 73, par. 979j)
Sec. 367j.
Municipal employee's continuance privilege.
(a) As used in this Section:
(1) The term "creditable service" shall have the |
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meaning ascribed to it by Section 7‑113 of the Illinois Pension Code.
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(2) The term "municipality" means any municipality,
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instrumentality, or participating instrumentality (as those terms are defined in Sections 7‑105, 7‑107 and 7‑108, respectively, of the Illinois Pension Code) that participates in the Illinois Municipal Retirement Fund pursuant to Section 7‑132 of the Illinois Pension Code.
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(3) The term "employee" shall mean an employee as
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defined in Section 7‑109 of the Illinois Pension Code, but does not include any person who is a deputy as defined in Section 367h of this Code.
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(4) The "retirement or disability period" of an
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employee means the period:
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|
(A) which begins on the day the employee is
|
|
removed from the municipality payroll because of the occurrence of either of the following events: (i) the employee retires from active service as an employee with an attained age and accumulated creditable service which together qualify the employee for immediate receipt of retirement pension benefits under Article 7 of the Illinois Pension Code, or (ii) the employee's disability is established under Article 7 of the Illinois Pension Code; and
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(B) which ends on the first to occur of any of
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|
the following events: (i) the employee's reinstatement or reentry into active service as provided for under Article 7 of the Illinois Pension Code, (ii) the employee's exercise of any refund option or acceptance of any separation benefit available under Article 7 of the Illinois Pension Code, (iii) the employee's loss pursuant to Section 7‑219 of the Illinois Pension Code of any benefits provided for in Article 7 of that Code, or (iv) the employee's death or, if at the time of the employee's death the employee is survived by a spouse who, in that capacity, is entitled to receive a surviving spouse's monthly pension pursuant to Article 7 of the Illinois Pension Code, the death or remarriage of that spouse.
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(b) No policy of group accident and health insurance under which
employees of a municipality are insured for their individual benefit shall
be issued or delivered in this State to a municipality unless such group
policy provides for the election of continued group insurance coverage for
the retirement or disability period of each employee who is insured under
the provisions of the group policy on the day immediately preceding the day
on which the retirement or disability period of such employee begins. So
long as any required premiums for continued group insurance coverage are
paid in accordance with the provisions of the group policy, an election
made pursuant to this Section shall provide continued group insurance
coverage for an employee throughout the retirement or disability period of
the employee and, unless the employee otherwise elects and subject to any
other provisions of the group policy which relate either to the provision
or to the termination of dependents' coverage and which are not
inconsistent with this Section, for any dependents of the employee who are
insured under the group policy on the day immediately preceding the day on
which the retirement or disability period of the employee begins; provided,
however, that when such continued group insurance coverage is in effect
with respect to an employee on the date of the employee's death but the
retirement or disability period of the employee does not end with the
employee's death, then the deceased employee's surviving spouse upon whose
death or remarriage such retirement or disability period will end shall be
entitled, without further election and upon payment of any required
premiums in accordance with the provisions of the group policy, to maintain
such continued group insurance coverage in effect until the end of the
retirement or disability period. Continued group insurance coverage shall
be provided in accordance with this Section at the same premium rate from
time to time charged for equivalent coverage provided under the group
policy with respect to covered employees whose retirement or disability
period has not begun, and no distinction or discrimination in the amount or
rate of premiums or in any waiver of premium or other benefit provision
shall be made between continued group insurance coverage elected pursuant
to this Section and equivalent coverage provided to employees under the
group policy other than pursuant to the provisions of this Section;
provided that no municipality shall be required by reason of any provision
of this Section to pay any group insurance premium other than one that may
be negotiated in a collective bargaining agreement. If the group policy
provides for a reduction in benefits and premium for insureds who become
eligible for medicare, such provision shall apply to persons electing
continued coverage under this Section.
Within 15 days of the beginning of the retirement or disability period of
any employee entitled to elect continued group insurance coverage under any
group policy affected by this Section, the municipality last employing such
employee shall give written notice of such beginning by certified mail,
return receipt requested, to the insurance company issuing such policy.
The notice shall include the employee's name and last known place of
residence and the beginning date of the employee's retirement or disability
period.
Within 15 days of the date of receipt of such notice from the municipality,
the insurance company by certified mail, return receipt requested, shall
give written notice to the employee at the employee's last known place of
residence that coverage under the group policy may be continued for the
retirement or disability period of the employee as provided in this
Section. Such notice shall set forth: (i) a statement of election to be
filed by the employee if the employee wishes to continue such group
insurance coverage, (ii) the amount of monthly premium, including a
statement of the portion of such monthly premium attributable to any
dependents' coverage which the employee may elect, and (iii) instructions
as to the return of the election form to the insurance company issuing such
policy. Election shall be made, if at all, by returning the statement of
election to the insurance company by certified mail, return receipt
requested, within 15 days after having received it.
If the employee elects to continue coverage, it shall be the obligation
of the employee to pay the monthly premium directly to the municipality
which shall forward it to the insurance company issuing the group insurance
policy, or as otherwise directed by the insurance company; provided,
however, that the employee shall be entitled to designate on the statement
of election required to be filed with the insurance company that the total
monthly premium, or such portion thereof as is not contributed by a
municipality, be deducted by the Illinois Municipal Retirement Fund from
the monthly pension payment otherwise payable to or on behalf of the
employee pursuant to Article 7 of the Illinois Pension Code, and be
remitted by such Fund to the insurance company. The portion, if any, of
the monthly premium contributed by a municipality for such continued group
insurance coverage shall be paid by the municipality directly to the
insurance company issuing the group insurance policy, or as directed by the
insurance company. Such continued group insurance coverage shall relate
back to the beginning of the employee's retirement or disability period.
The amendment, renewal or extension of any group insurance policy affected
by this Section shall be deemed to be the issuance of a new policy of insurance
for purposes of this Section.
(c) In the event that a municipality makes a program of accident,
health, hospital or medical benefits available to its employees through
self‑insurance, or by participation in a pool or reciprocal insurer, or by
contract in a form other than a policy of group insurance with one or more
medical service plans, health care service corporations, health maintenance
organizations, or any other professional corporations or plans under which
health care or reimbursement for the costs thereof is provided, whether the
cost of such benefits is borne by the municipality or the employees or
both, such employees and their surviving spouses shall have the same
right to elect continued coverage under such program of benefits
as they would have if such benefits were provided by a policy of group
accident and health insurance. In such cases, the notice of right to elect
continued coverage shall be sent by the municipality; the statement of
election shall be sent to the municipality; and references to the required
premium shall refer to that portion of the cost of such benefits which is not
borne by the municipality, either voluntarily or pursuant to the provisions
of a collective bargaining agreement. In the case of a municipality
providing such benefits through self‑insurance or participation in a pool or
reciprocal insurer, the right to elect continued coverage which is provided
by this paragraph shall be implemented and made available to the employees
of the municipality and qualifying surviving spouses not later than July 1,
1991.
The amendment, renewal or extension of any such contract in a form other
than a policy of group insurance policy shall be deemed the formation of a
new contract for the purposes of this Section.
(d) This Section shall not limit the exercise of any conversion
privileges available under Section 367e.
(Source: P.A. 86‑1444; 87‑435.)
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(215 ILCS 5/370c) (from Ch. 73, par. 982c)
(Text of Section from P.A. 94‑402)
Sec. 370c. Mental and emotional disorders.
(a) (1) On and after the effective date of this Section,
every insurer which delivers, issues for delivery or renews or modifies
group A&H policies providing coverage for hospital or medical treatment or
services for illness on an expense‑incurred basis shall offer to the
applicant or group policyholder subject to the insurers standards of
insurability, coverage for reasonable and necessary treatment and services
for mental, emotional or nervous disorders or conditions, other than serious
mental illnesses as defined in item (2) of subsection (b), up to the limits
provided in the policy for other disorders or conditions, except (i) the
insured may be required to pay up to 50% of expenses incurred as a result
of the treatment or services, and (ii) the annual benefit limit may be
limited to the lesser of $10,000 or 25% of the lifetime policy limit.
(2) Each insured that is covered for mental, emotional or nervous
disorders or conditions shall be free to select the physician licensed to
practice medicine in all its branches, licensed clinical psychologist,
licensed clinical social worker, or licensed clinical professional counselor of
his choice to treat such disorders, and
the insurer shall pay the covered charges of such physician licensed to
practice medicine in all its branches, licensed clinical psychologist,
licensed clinical social worker, or licensed clinical professional counselor up
to the limits of coverage, provided (i)
the disorder or condition treated is covered by the policy, and (ii) the
physician, licensed psychologist, licensed clinical social worker, or licensed
clinical professional counselor is
authorized to provide said services under the statutes of this State and in
accordance with accepted principles of his profession.
(3) Insofar as this Section applies solely to licensed clinical social
workers and licensed clinical professional counselors, those persons who may
provide services to individuals shall do so
after the licensed clinical social worker or licensed clinical professional
counselor has informed the patient of the
desirability of the patient conferring with the patient's primary care
physician and the licensed clinical social worker or licensed clinical
professional counselor has
provided written
notification to the patient's primary care physician, if any, that services
are being provided to the patient. That notification may, however, be
waived by the patient on a written form. Those forms shall be retained by
the licensed clinical social worker or licensed clinical professional counselor
for a period of not less than 5 years.
(b) (1) An insurer that provides coverage for hospital or medical
expenses under a group policy of accident and health insurance or
health care plan amended, delivered, issued, or renewed after the effective
date of this amendatory Act of the 92nd General Assembly shall provide coverage
under the policy for treatment of serious mental illness under the same terms
and conditions as coverage for hospital or medical expenses related to other
illnesses and diseases. The coverage required under this Section must provide
for same durational limits, amount limits, deductibles, and co‑insurance
requirements for serious mental illness as are provided for other illnesses
and diseases. This subsection does not apply to coverage provided to
employees by employers who have 50 or fewer employees.
(2) "Serious mental illness" means the following psychiatric illnesses as
defined in the most current edition of the Diagnostic and Statistical Manual
(DSM) published by the American Psychiatric Association:
(A) schizophrenia;
(B) paranoid and other psychotic disorders;
(C) bipolar disorders (hypomanic, manic, depressive,
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(D) major depressive disorders (single episode or
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(E) schizoaffective disorders (bipolar or
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(F) pervasive developmental disorders;
(G) obsessive‑compulsive disorders;
(H) depression in childhood and adolescence; and
(I) panic disorder.
(3) Upon request of the reimbursing insurer, a provider of treatment of
serious mental illness shall furnish medical records or other necessary data
that substantiate that initial or continued treatment is at all times medically
necessary. An insurer shall provide a mechanism for the timely review by a
provider holding the same license and practicing in the same specialty as the
patient's provider, who is unaffiliated with the insurer, jointly selected by
the patient (or the patient's next of kin or legal representative if the
patient is unable to act for himself or herself), the patient's provider, and
the insurer in the event of a dispute between the insurer and patient's
provider regarding the medical necessity of a treatment proposed by a patient's
provider. If the reviewing provider determines the treatment to be medically
necessary, the insurer shall provide reimbursement for the treatment. Future
contractual or employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in this procedure.
Nothing prevents
the insured from agreeing in writing to continue treatment at his or her
expense. When making a determination of the medical necessity for a treatment
modality for serous mental illness, an insurer must make the determination in a
manner that is consistent with the manner used to make that determination with
respect to other diseases or illnesses covered under the policy, including an
appeals process.
(4) A group health benefit plan:
(A) shall provide coverage based upon medical
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necessity for the following treatment of mental illness in each calendar year;
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(i) 45 days of inpatient treatment; and
(ii) 35 visits for outpatient treatment
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including group and individual outpatient treatment;
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(B) may not include a lifetime limit on the number
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of days of inpatient treatment or the number of outpatient visits covered under the plan; and
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(C) shall include the same amount limits,
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deductibles, copayments, and coinsurance factors for serious mental illness as for physical illness.
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(5) An issuer of a group health benefit plan may not count toward the number
of outpatient visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover the outpatient
visits under the same terms and conditions as it covers outpatient visits for
the treatment of physical illness.
(6) An issuer of a group health benefit
plan may provide or offer coverage required under this Section through a
managed care plan.
(7) This Section shall not be interpreted to require a group health benefit
plan to provide coverage for treatment of:
(A) an addiction to a controlled substance or
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cannabis that is used in violation of law; or
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(B) mental illness resulting from the use of a
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controlled substance or cannabis in violation of law.
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(8) (Blank).
(Source: P.A. 94‑402, eff. 8‑2‑05.)
(Text of Section from P.A. 94‑584)
Sec. 370c. Mental and emotional disorders.
(a) (1) On and after the effective date of this Section,
every insurer which delivers, issues for delivery or renews or modifies
group A&H policies providing coverage for hospital or medical treatment or
services for illness on an expense‑incurred basis shall offer to the
applicant or group policyholder subject to the insurers standards of
insurability, coverage for reasonable and necessary treatment and services
for mental, emotional or nervous disorders or conditions, other than serious
mental illnesses as defined in item (2) of subsection (b), up to the limits
provided in the policy for other disorders or conditions, except (i) the
insured may be required to pay up to 50% of expenses incurred as a result
of the treatment or services, and (ii) the annual benefit limit may be
limited to the lesser of $10,000 or 25% of the lifetime policy limit.
(2) Each insured that is covered for mental, emotional or nervous
disorders or conditions shall be free to select the physician licensed to
practice medicine in all its branches, licensed clinical psychologist,
licensed clinical social worker, or licensed clinical professional counselor of
his choice to treat such disorders, and
the insurer shall pay the covered charges of such physician licensed to
practice medicine in all its branches, licensed clinical psychologist,
licensed clinical social worker, or licensed clinical professional counselor up
to the limits of coverage, provided (i)
the disorder or condition treated is covered by the policy, and (ii) the
physician, licensed psychologist, licensed clinical social worker, or licensed
clinical professional counselor is
authorized to provide said services under the statutes of this State and in
accordance with accepted principles of his profession.
(3) Insofar as this Section applies solely to licensed clinical social
workers and licensed clinical professional counselors, those persons who may
provide services to individuals shall do so
after the licensed clinical social worker or licensed clinical professional
counselor has informed the patient of the
desirability of the patient conferring with the patient's primary care
physician and the licensed clinical social worker or licensed clinical
professional counselor has
provided written
notification to the patient's primary care physician, if any, that services
are being provided to the patient. That notification may, however, be
waived by the patient on a written form. Those forms shall be retained by
the licensed clinical social worker or licensed clinical professional counselor
for a period of not less than 5 years.
(b) (1) An insurer that provides coverage for hospital or medical
expenses under a group policy of accident and health insurance or
health care plan amended, delivered, issued, or renewed after the effective
date of this amendatory Act of the 92nd General Assembly shall provide coverage
under the policy for treatment of serious mental illness under the same terms
and conditions as coverage for hospital or medical expenses related to other
illnesses and diseases. The coverage required under this Section must provide
for same durational limits, amount limits, deductibles, and co‑insurance
requirements for serious mental illness as are provided for other illnesses
and diseases. This subsection does not apply to coverage provided to
employees by employers who have 50 or fewer employees.
(2) "Serious mental illness" means the following psychiatric illnesses as
defined in the most current edition of the Diagnostic and Statistical Manual
(DSM) published by the American Psychiatric Association:
(A) schizophrenia;
(B) paranoid and other psychotic disorders;
(C) bipolar disorders (hypomanic, manic, depressive,
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(D) major depressive disorders (single episode or
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(E) schizoaffective disorders (bipolar or
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(F) pervasive developmental disorders;
(G) obsessive‑compulsive disorders;
(H) depression in childhood and adolescence;
(I) panic disorder; and
(J) post‑traumatic stress disorders (acute, chronic,
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(3) Upon request of the reimbursing insurer, a provider of treatment of
serious mental illness shall furnish medical records or other necessary data
that substantiate that initial or continued treatment is at all times medically
necessary. An insurer shall provide a mechanism for the timely review by a
provider holding the same license and practicing in the same specialty as the
patient's provider, who is unaffiliated with the insurer, jointly selected by
the patient (or the patient's next of kin or legal representative if the
patient is unable to act for himself or herself), the patient's provider, and
the insurer in the event of a dispute between the insurer and patient's
provider regarding the medical necessity of a treatment proposed by a patient's
provider. If the reviewing provider determines the treatment to be medically
necessary, the insurer shall provide reimbursement for the treatment. Future
contractual or employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in this procedure.
Nothing prevents
the insured from agreeing in writing to continue treatment at his or her
expense. When making a determination of the medical necessity for a treatment
modality for serous mental illness, an insurer must make the determination in a
manner that is consistent with the manner used to make that determination with
respect to other diseases or illnesses covered under the policy, including an
appeals process.
(4) A group health benefit plan:
(A) shall provide coverage based upon medical
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necessity for the following treatment of mental illness in each calendar year;
|
|
(i) 45 days of inpatient treatment; and
(ii) 35 visits for outpatient treatment
|
|
including group and individual outpatient treatment;
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|
(B) may not include a lifetime limit on the number
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|
of days of inpatient treatment or the number of outpatient visits covered under the plan; and
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(C) shall include the same amount limits,
|
|
deductibles, copayments, and coinsurance factors for serious mental illness as for physical illness.
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(5) An issuer of a group health benefit plan may not count toward the number
of outpatient visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover the outpatient
visits under the same terms and conditions as it covers outpatient visits for
the treatment of physical illness.
(6) An issuer of a group health benefit
plan may provide or offer coverage required under this Section through a
managed care plan.
(7) This Section shall not be interpreted to require a group health benefit
plan to provide coverage for treatment of:
(A) an addiction to a controlled substance or
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cannabis that is used in violation of law; or
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(B) mental illness resulting from the use of a
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controlled substance or cannabis in violation of law.
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(8)
This subsection (b) is inoperative after December 31, 2005.
(Source: P.A. 94‑584, eff. 8‑15‑05.)
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