(215 ILCS 125/4‑2) (from Ch. 111 1/2, par. 1408.2)
Sec. 4‑2.
Medical assistance; coverage of child.
(a) In this Section, "Medicaid" means medical assistance authorized under
Section 1902 of the Social Security Act.
(b) A contract or
evidence of coverage delivered, issued for delivery, renewed, or amended by
a Health Maintenance Organization may not contain any provision
which
limits or excludes payments of health care services
to or on behalf of the enrollee because the enrollee or any covered
dependent is eligible for or is receiving Medicaid
benefits in this or any other state.
(c) To the extent that payment for covered expenses has been made under
Article V, VI, or VII of the Illinois Public Aid Code for health care services
provided to an individual, if a third party has a legal liability to make
payments for those health care services, the State is considered to have
acquired the rights of the individual to payment.
(d) If a child is covered under a health care plan of a Health Maintenance
Organization in which
the child's noncustodial parent is an enrollee, the Health Maintenance
Organization shall:
(1) Provide necessary information to the child's |
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custodial parent to enable the child to obtain benefits under that health care plan.
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(2) Permit the child's custodial parent (or the
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provider, with the custodial parent's approval) to submit claims for payment for covered services without the approval of the noncustodial parent.
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(3) Make payments on claims submitted in accordance
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with paragraph (2) directly to the custodial parent, the provider of health care services, or the state Medicaid agency.
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(e) A Health Maintenance Organization may not deny enrollment of a child
under the
health care plan in which the child's parent is an enrollee on any of the
following
grounds:
(1) The child was born out of wedlock.
(2) The child is not claimed as a dependent on the
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parent's federal income tax return.
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(3) The child does not reside with the parent or in
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the service area covered by the health care plan.
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(f) If a parent is required by a court or administrative order to provide
coverage for a child under a health care plan in which the parent is enrolled,
and that offers coverage for eligible
dependents, the Health Maintenance Organization,
upon receiving a copy of the order, shall:
(1) Upon application, permit the parent to enroll in
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the health care plan a child who is otherwise eligible for that coverage, without regard to any enrollment season restrictions that might otherwise be applicable as to the time period within which a person may enroll in the plan.
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(2) Enroll the child in the health care plan upon
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application of the child's other parent, the state agency administering the Medicaid program, or the state agency administering a program for enforcing child support and establishing paternity under 42 U.S.C. 651 through 669 (or another child support enforcement program), if the parent is enrolled in the health care plan but fails to apply for enrollment of the child.
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(g) A Health Maintenance Organization may not impose, on a state agency that
has been assigned
the
rights of an enrollee in a health care plan who
receives Medicaid benefits, requirements that are different from requirements
applicable to an assignee of any other enrollee in that health care
plan.
(h) Nothing in subsections (e) and (f) prevents a Health Maintenance
Organization from denying any such application if the child is not eligible for
coverage
according to the Health Maintenance Organization's medical underwriting
standards.
(i) The Health Maintenance Organization may not disenroll (or otherwise
eliminate coverage
of) the child from the health
care plan unless the Health Maintenance Organization is provided
satisfactory written evidence of either of the following:
(1) The court or administrative order is no longer
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(2) The child is or will be enrolled in a comparable
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health care plan obtained by the parent under such order and that enrollment is currently in effect or will take effect not later than the date the prior coverage is terminated.
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(Source: P.A. 89‑183, eff. 1‑1‑96.)
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(215 ILCS 125/4‑6.1) (from Ch. 111 1/2, par. 1408.7)
Sec. 4‑6.1. Mammograms; mastectomies.
(a) Every contract or evidence of coverage
issued by a Health Maintenance Organization for persons who are residents of
this State shall contain coverage for screening by low‑dose mammography
for all women 35 years of age or older for the presence of occult breast
cancer. The coverage shall be as follows:
(1) A baseline mammogram for women 35 to 39 years of
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(2) An annual mammogram for women 40 years of age or
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(3) A mammogram at the age and intervals considered
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medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer or other risk factors.
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These benefits shall be at least as favorable as for other radiological
examinations and subject to the same dollar limits, deductibles, and
co‑insurance factors. For purposes of this Section, "low‑dose mammography"
means the x‑ray examination of the breast using equipment dedicated
specifically for mammography, including the x‑ray tube, filter, compression
device, and image receptor, with radiation exposure delivery of less than 1
rad per breast for 2 views of an average size breast.
(b) No contract or evidence of coverage issued by a health maintenance
organization that provides for the
surgical procedure known as a mastectomy shall be issued, amended, delivered,
or renewed in this State on or after the effective date of this amendatory Act
of the 92nd General Assembly unless that coverage also provides for prosthetic
devices or reconstructive surgery incident to the mastectomy, providing that
the mastectomy is performed after the effective date of this amendatory Act.
Coverage for breast reconstruction in connection
with a mastectomy shall
include:
(1) reconstruction of the breast upon which the
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mastectomy has been performed;
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(2) surgery and reconstruction of the other breast
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to produce a symmetrical appearance; and
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(3) prostheses and treatment for physical
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complications at all stages of mastectomy, including lymphedemas.
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Care shall be determined in consultation with the attending physician and the
patient.
The offered coverage for prosthetic devices and
reconstructive surgery shall be subject to the deductible and coinsurance
conditions applied to the mastectomy and all other terms and conditions
applicable to other benefits. When a mastectomy is performed and there is
no evidence of malignancy, then the offered coverage may be limited to the
provision of prosthetic devices and reconstructive surgery to within 2
years after the date of the mastectomy. As used in this Section,
"mastectomy" means the removal of all or part of the breast for medically
necessary reasons, as determined by a licensed physician.
Written notice of the availability of coverage under this Section shall be
delivered to the enrollee upon enrollment and annually thereafter. A
health maintenance organization may not deny to an enrollee eligibility, or
continued eligibility, to enroll or
to renew coverage under the terms of the plan solely for the purpose of
avoiding the requirements of this Section. A health maintenance organization
may not penalize or
reduce or
limit the reimbursement of an attending provider or provide incentives
(monetary or otherwise) to an attending provider to induce the provider to
provide care to an insured in a manner inconsistent with this Section.
(Source: P.A. 94‑121, eff. 7‑6‑05.)
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(215 ILCS 125/4‑7) (from Ch. 111 1/2, par. 1409)
Sec. 4‑7.
Solicitations of enrollees.
Solicitations of enrollees
by a Health Maintenance Organization
authorized under this Act, or its representatives shall not be construed to
be violative of any provisions of law relating to solicitation or
advertising by health professionals. No solicitation may be made which
advertises, identifies or makes a qualitative judgment concerning any
health professional who provides services for a Health Maintenance
Organization. Nothing in this Section precludes a Health Maintenance
Organization from providing to a particular potential enrollee the names of
health providers upon request by that particular potential individual
enrollee. No Health Maintenance Organization, or representative thereof,
may cause or knowingly permit the use of advertising which is untrue or
misleading, solicitation which is untrue or misleading, or any form of
evidence of coverage which is deceptive. Health Maintenance Organizations
shall be subject to Section 143c of the "Illinois Insurance Code", approved
June 29, 1937, as amended.
If the Director finds that any advertisement of a plan has materially
failed to comply with the provisions of this Act or the rules thereunder,
the Director may, by order, require the plan to publish in the same or
similar medium, an approved correction or retraction of any untrue,
misleading, or deceptive statement contained in the advertising and may
prohibit such plan from publishing or distributing, or allowing to be
published or distributed on its behalf such advertisement or any new
materially revised advertisement without first having filed a copy thereof
with the Director 30 days prior to the publication or distribution thereof,
or any shorter period specified in such order. An order issued under this
Section shall be effective for 12 months from its issuance, and may be
renewed by order if the advertisements submitted under this Section
indicate difficulties of voluntary compliance with the applicable
provisions of this Act and the rules thereunder.
(Source: P.A. 85‑20.)
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(215 ILCS 125/4‑9.2) (from Ch. 111 1/2, par. 1409.2‑2)
Sec. 4‑9.2.
Continuation of group HMO coverage after termination of
employee or membership. A group contract delivered, issued for delivery,
renewed, or amended in this State that covers employees or members for health
care services shall provide that employees or members whose coverage under
the group contract would otherwise terminate because of termination of
employment or membership or because of a reduction in hours below the minimum
required by the group contract shall be entitled to continue their coverage
under
that group contract, for themselves and their eligible dependents, subject
to all of the group contract's terms and conditions applicable to those
forms of coverage and to the following conditions:
(1) Continuation shall only be available to an |
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employee or member who has been continuously covered under the group contract (and for similar benefits under any group contract that it replaced) during the entire 3 month period ending with the termination of employment or membership or reduction in hours below the minimum required by the group contract.
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(2) Continuation shall not be available for any
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enrollee who is covered by Medicare, except for those individuals who have been covered under a group Medicare supplement policy. Continuation shall not be available for any enrollee who is covered by any other insured or uninsured plan that provides hospital, surgical, or medical coverage for individuals in a group and under which the enrollee was not covered immediately before termination or reduction in hours below the minimum required by the group contract or who exercises his or her conversion privilege under the group policy.
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(3) Continuation need not include dental, vision
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care, prescription drug, or similar supplementary benefits that are provided under the group contract in addition to its basic health care services.
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(4) Upon termination or reduction in hours below the
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minimum required by the group contract, 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 continuation in writing within the 10 day period following the later of (i) the date of termination or reduction in hours below the minimum required by the group contract or (ii) the date the employee is given written notice of the right of continuation by either the employer or the group policyholder. In no event, however, shall the employee or member elect continuation more than 60 days after the date of termination or reduction in hours below the minimum required by the group contract. Written notice of continuation presented to the employee or member by the policyholder, or mailed by the policyholder to the last known address of the employee, shall constitute the giving of notice for the purpose of this paragraph.
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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 HMO, including that portion of the premium contributed by the policyholder or employer, if any, but not more than the group rate for the coverage being continued with appropriate reduction in premium for any supplementary benefits that have been discontinued under paragraph (3) of this Section. The premium rate required by the HMO shall be the applicable premium required on the due date of each payment.
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(6) Continuation of coverage under the group
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contract for any person shall terminate when the person becomes eligible for Medicare or is covered by any other insured or uninsured plan that provides hospital, surgical, or medical coverage for individuals in a group and under which the person was not covered immediately before termination or reduction in hours below the minimum required by the group contract as provided in paragraph (2) of this Section or, if earlier, at the first to occur of the following:
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(a) The expiration of 9 months after the
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employee's or member's coverage because of termination of employment or membership or reduction in hours below the minimum required by the group contract.
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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 contract is
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terminated or, in the case of an employee, the date his or her employer terminates participation under the group contract. If, however, this paragraph applies and the coverage ceasing by reason of termination is replaced by similar coverage under another group contract, then (i) the employee or member shall have the right to become covered under the replacement group contract for the balance of the period that he or she would have remained covered under the prior group contract in accordance with paragraph (6) had a termination described in this item (c) not occurred and (ii) the prior group contract shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.
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(7) A notification of the continuation privilege
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shall be included in each evidence 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 or her work, or because of theft in connection with his or her work, for which the employer was in no way responsible if the employee (i) admitted to committing the felony or theft or (ii) was convicted or placed under supervision by a court of competent jurisdiction.
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The requirements of this amendatory Act of 1992 shall apply to any
group contract, as defined in this Section, delivered or issued for
delivery on or after 180 days following the effective date of this
amendatory Act of 1992.
(Source: P.A. 93‑477, eff. 1‑1‑04.)
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(215 ILCS 125/4‑13) (from Ch. 111 1/2, par. 1409.6)
Sec. 4‑13.
Prior approval of policy forms.
No health maintenance
organization shall issue or deliver in this State a group contract or
evidence of coverage, attach an endorsement or rider thereto, incorporate
by reference bylaws or other matter therein, or use an application blank in
this State until the form and content of the group contract or evidence of
coverage, endorsement, rider, bylaw, or other matter incorporated by
reference or application blank has been filed with and approved by the
Director, except that any such endorsement or rider that is to be attached
to a group contract or evidence of coverage after the date the group contract
or evidence of coverage is issued must be filed with, reviewed, and approved by
the Director before the date it is attached to a group contract or evidence of
coverage issued or delivered in this State. The Director shall withhold
approval of any such group contract, evidence of coverage, endorsement, rider,
bylaw, or other matter incorporated by reference or application blank if it
contains provisions that may encourage misrepresentation or that are unjust,
unfair, inequitable, ambiguous, misleading, inconsistent, deceptive, or
contrary to the law or public policy of this State or contains exceptions and
conditions that unreasonably or deceptively affect the risk purported to be
assumed in the general coverage of the group contract or evidence of coverage.
The Director shall not withhold approval of a form under this Section solely
because of the absence of coverage for mental health services if the Department
of Children and Family Services presents evidence that coverage of mental
health services for clients of that Department will be provided by another
entity. In all cases the Director shall approve or disapprove any such form
within 60 days after submission unless the Director extends by not more than an
additional 30 days the period within which he shall approve or disapprove any
such form by giving written notice to the organization of the extension before
expiration of the initial 60‑day period.
The Director shall withdraw his approval of a group contract or evidence of
coverage, endorsement, rider, bylaw, or other matter incorporated by reference
or application blank if he subsequently determines that the group contract or
evidence of coverage, endorsement, rider, bylaw, other matter, or application
blank is misrepresentative, unjust, unfair, inequitable, ambiguous, misleading,
inconsistent, deceptive, or contrary to the law or public policy of this State,
or contains exceptions or conditions that unreasonably or deceptively affect
the risk purported to be assumed in the general coverage of the group contract
or evidence of coverage. The Director shall not withdraw approval of a form
under this Section solely because of the absence of coverage for mental health
services if the Department of Children and Family Services presents evidence
that coverage of mental health services for clients of that Department is being
or will be provided by another entity.
If a previously approved group contract or evidence of coverage,
endorsement, rider, bylaw, or other matter incorporated by reference or
application blank is withdrawn for use, the Director shall serve upon the
company an order of withdrawal of use, either personally or by mail. If the
service is by mail, the service shall be completed if the notice is deposited
in the post office, postage prepaid, addressed to the health maintenance
organization's last known address specified in the records of the Department of
Insurance. The order of withdrawal of use shall take effect 30 days from the
date of mailing but shall be stayed if within the 30‑day period a written
request for hearing is filed with the Director. The hearing shall be held at
the time and place designated in the order given by the Director. The hearing
may be held either in the City of Springfield, the City of Chicago, or in the
county where the principal business address of the health maintenance
organization is located.
The action of the Director in disapproving or withdrawing the form shall be
subject to judicial review under the Administrative Review Law.
(Source: P.A. 88‑487.)
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(215 ILCS 125/4‑17)
Sec. 4‑17.
Basic outpatient preventive and primary health care services
for children. In order to attempt to address the needs of children in Illinois
(i) without health care coverage, either through a parent's employment, through
medical assistance under the Illinois Public Aid Code, or any other health plan
or (ii) who lose medical assistance if and when their parents move from welfare
to work and do not find employment that offers health care coverage, a
health maintenance organization may undertake to provide or arrange for and to
pay for or reimburse the cost of basic outpatient preventive and primary health
care services. The Department shall promulgate rules to establish minimum
coverage and disclosure requirements. These requirements at a minimum shall
include routine physical examinations and immunizations, sick visits,
diagnostic x‑rays and laboratory services, and emergency outpatient services.
Coverage may also include preventive dental services, vision screening and one
pair of eyeglasses, prescription drugs, and mental health services.
The coverage may include any
reasonable co‑payments, deductibles, and benefit maximums subject to
limitations established by the Director by rule. Coverage shall be
limited to children who are 18 years of age or under, who have resided
in the State of Illinois for at least 30 days, and who do not qualify for
medical assistance under the Illinois Public Aid Code. Any such coverage
shall be made available to an adult on behalf of such children
and shall not be funded through State appropriations. In counties with
populations in excess of 3,000,000, the Director shall not approve any
arrangement under this Section unless and until an arrangement for at least one
health maintenance organization under
contract with the Illinois Department of Public Aid for furnishing health
services pursuant to Section 5‑11 of the Illinois Public Aid Code and for which
the requirements of 42 CFR 434.26(a) have been waived is approved.
(Source: P.A. 90‑376, eff. 8‑14‑97; 90‑655, eff. 7‑30‑98.)
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(215 ILCS 125/4‑18)
Sec. 4‑18.
Retirement facility residents.
With respect to an
enrollee who is a resident of a retirement facility consisting of a long‑term
care facility, as defined in the Nursing Home Care Act, and residential
apartments, a contract or evidence of coverage issued, amended, delivered, or
renewed after the effective date of this amendatory Act of 1997 shall provide
that the enrollee's primary care physician must refer the enrollee to the
retirement facility's long‑term care facility for Medicare covered skilled
nursing services if the primary care physician finds that:
(1) it is in the best interests of the patient;
(2) the facility, if not a participating provider in |
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the specific health maintenance organization, agrees during the preauthorization period to a negotiated rate for skilled nursing services covered in that organization's health care plan; and
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(3) the facility meets all the requirements of a
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participating provider for skilled nursing services as defined and covered under the health maintenance organization's health care plan.
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Both the facility and the health maintenance organization must fully disclose
all pertinent information to consumers to assure that their decisions are based
upon full knowledge of the implications of their decision making.
(Source: P.A. 90‑408, eff. 1‑1‑98; 90‑655, eff. 7‑30‑98.)
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