Alcoholism
215 ILCS 5/367(7)
|
Requires coverage for the inpatient treatment of alcoholism. |
Applies to group accident and health insurance policies that
provide inpatient hospital coverage. Does not apply to
specified disease policies. |
Alcoholism
50 Ill. Admin. Code 5421.130(i)
|
Requires coverage of diagnosis, detoxification, and
treatment of medical complications of alcoholism to be the
same as for any other illness. Alcohol rehabilitation must
be covered but may be limited as specified in the Rule. |
Applies to individual and group HMO contracts. |
Breast Implant Removal
215 ILCS 5/356p
215 ILCS 125/4-6.2
|
Prohibits the denial of coverage for the removal of breast
implants when such removal is medically necessary treatment
for sickness or injury. This provision does not apply for
implants implanted solely for cosmetic reasons. |
Applies to all individual and group health insurance and all
individual and group HMO contracts. |
Cancer Off-Label Drugs
215 ILCS 5/370r
215 ILCS 125/4-6.3
|
If
a policy provides prescription drug benefits, it must also
provide benefits for any drug that has been prescribed for
the treatment of a type of cancer, even if the drug has not
been approved for that specific cancer by the FDA. The drug
must be approved by the FDA and must be recognized for
treatment of the specific cancer for which it has been
prescribed by an established reference compendia, three of
which are specified within the law. |
Applies to group insurance policies (PPO) and individual and
group HMO contracts. |
Colorectal Cancer Screening
215 ILCS 5/356x
215 ILCS 125/5-3
Public Act 93-0568
Effective 1/1/04 |
Requires coverage for all colorectal cancer examinations and
laboratory tests for colorectal cancer, in accordance with
professional organizations and the federal government as
specified in the law. |
Applies to individual and group insurance policies.
Applies to individual and group HMO contracts |
Contraceptives
215 ILCS 5/356z.4
Public Act 93-0102
Effective 1/1/04
|
Requires coverage for all outpatient contraceptive services
and all outpatient contraceptive drugs and devices approved
by the Food and Drug Administration. |
Applies to individual and group insurance policies and
individual and group HMO contracts that provide coverage for
outpatient services and outpatient prescription drugs. |
Dental Adjunctive Services
215 ILCS 5/356z.2
Public Act 92-764
Effective 1/1/03 |
Requires coverage for anesthesia and other charges incurred
in conjunction with dental care provided in a hospital or
ambulatory surgical treatment center to:
-
a young child (under age 6);
-
a person with a medical condition that requires
hospitalization for the procedure: or
-
a disabled individual.
Does not require coverage of dental services. |
Applies to individual and group insurance policies and
individual and group HMO contracts. Does not apply to
short-term travel, accident only, limited, or specified
disease policies or to policies designed for Medicare
beneficiaries. |
Diabetes Self Management
215 ILCS 5/356w
215 ILCS 125/5-3
Public Act 90-741
Effective 1/1/99 |
Requires coverage for outpatient self-management training
and education, and specified equipment and supplies for Type
1 diabetes, Type 2 diabetes and gestational diabetes
mellitus. Equipment must be covered to the extent durable
medical equipment is covered by the policy. Pharmaceuticals
and supplies must be covered to the extent there is coverage
for pharmaceuticals and supplies in the policy or in an
attached rider. See the law for list of covered supplies
and equipment.
|
Applies to group insurance policies and group HMO contracts. |
Infertility
215 ILCS 5/356m
215 ILCS 125/5-3
|
Requires coverage for the diagnosis and treatment of
infertility, including coverage for IVF, GIFT, ZIFT. |
Applies to group insurance policies and group HMO contracts
that provide coverage for more than 25full-time employees.
(See law for exceptions relating to religious organizations
or institutions.) |
Mammograms
215 ILCS 5/356g
215 ILCS 125/4-6.1
Amended effective 7/6/05
SB
0012 PA 094-0121
|
Requires coverage for (1) a baseline
mammogram for women ages 35 to 39 and (2) an annual
mammogram for women age 40 or older.
New: Requires
coverage for medically necessary mammograms for women under
age 40 who have a family history of breast cancer or other
risk factors |
Applies to individual and group insurance policies and
individual and group HMO contracts. |
Mastectomy – Post Mastectomy Care
215 ILCS 5/356t
215 ILCS 125/4-6.5 |
Requires coverage for inpatient hospital stay following a
mastectomy for a length of time the attending physician
determines is medically necessary in accordance with
protocols and guidelines based on sound scientific evidence
and upon evaluation of the patient. If the patient is
discharged early, a post-discharge physician office visit
must be available to her within 48 hours and must be covered
by the policy. |
Applies to individual and group insurance policies that
provide benefits for surgical coverage. Also applies to
individual and group HMO contracts. |
Mastectomy - Reconstruction
215 ILCS 5/356g(b)
215 ILCS 4-6.1
Effective 1/1/81 and 7/3/01
Public Act 92-0048
|
Requires coverage for prosthetic devices or reconstructive
surgery incident to a mastectomy. When a mastectomy is
performed and no evidence of malignancy is found, the
offered coverage is limited to prosthetic devices and
reconstructive surgery within two years of the mastectomy
date.
In
addition to reconstruction on the
affected breast, this law requires surgery and
reconstruction of the other breast (the one the mastectomy
was not performed on) to produce a symmetrical appearance.
Also requires coverage for prostheses and treatment for
physical complications at all stages of mastectomy,
including lymphedemas. |
Applied to individual and group accident and health policies
that provide coverage for mastectomies as a “shall offer”.
(Effective 1/1/81)
Applies as a mandate to individual and group health policies
and to individual and group HMO contracts issued, amended,
delivered or renewed after July 3, 2001.
|
Maternity
50 Ill. Admin. Code 5421.130(e) |
Requires coverage for maternity care including prenatal and
post-natal care and care for complication of pregnancy.
|
Applies to individual and group HMO contracts. |
Maternity – Complications of Pregnancy
50 Ill. Admin. Code 2603.30(11) |
Requires coverage for treatment of complications of
pregnancy. |
Applies to individual and group insurance policies. |
Maternity – Post Parturition Care
215 ILCS 5/356s
215 ILCS 125/4-6.4 |
Requires coverage for a minimum of 48 hours inpatient
hospital stay following a vaginal delivery and 96 hours
following a caesarian section for both mother and newborn.
A shorter length of stay may be provided under certain
conditions and if a post-discharge office visit or in-home
nurse visit is provided and covered. |
Applies to individual and group insurance policies that
provide maternity coverage. Also applies to individual and
group HMO contracts. |
Maternity – Prenatal HIV Testing
215 ILCS 5/356z.l
215 ILCS 4-6.5
Public Act 92-0130
Effective 7/20/01 |
Requires coverage for prenatal HIV testing ordered by an
attending physician licensed to practice medicine in all
branches, physician assistant or advanced practice
registered nurse. |
Applies to individual and group insurance policies and
individual and group HMO contracts amended, delivered,
issued or renewed after July 20, 2001. |
Mental Illness - Serious
215 ILCS 5/370c(b)(1)
Public Act 92-0185
Effective 1/1/02
Amended June 26, 2006 by HB 4202 – PA 94-0921 to
increase outpatient visits to 60.
Amended January 1, 2007 by HB 4125, PA 94-0906 to
apply to HMOs and to add 20 additional outpatient visits for
speech therapy for pervasive developmental disorders. |
Requires coverage of serious mental illness under the same
terms and conditions as coverage for other illnesses and
diseases. Serious mental illness is defined within the
law. Coverage may be limited to 45 days of inpatient
treatment and 35 (60) outpatient visits annually.
Requires additional 20 outpatient visits for speech therapy
for pervasive developmental disorders. |
Applies to group insurance policies that provide coverage
for hospital or medical expenses that are amended,
delivered, issued or renewed after January 1, 2002.
Does not apply to employer groups with 50 or fewer
employees.
Applies to group HMO policies effective January 1,
2007.
Note: See Mandated Offers for other Mental
Health related requirements. |
Mental Illness – HMO
50 Ill. Adm. Code 5421.130(h) |
Requires coverage for ten (10) days inpatient mental health
care per year. Also requires coverage of twenty (20)
individual outpatient mental health care visits per enrollee
per year, as appropriate for evaluation, short-term
treatment and crisis intervention services. Care in a day
hospital, residential non-hospital or intensive outpatient
mode may be substituted on a two-to-one basis for inpatient
hospital services as deemed appropriate by the primary care
physician. Group outpatient mental health care visits may
be substituted on a two-to-one basis for individual mental
health care visits as deemed appropriate by the primary care
physician; |
Effective January 1, 2007 Applies to individual HMO
contracts only. |
Multiple Sclerosis
Preventative Physical Therapy
PA 094-1076 SB 2917
215 ILCS 6/356z.8
Effective December 29, 2006 |
Requires coverage for medically necessary preventative
physical therapy for insureds diagnosed with multiple
sclerosis if prescribed by a physician and if the physical
therapy includes reasonably defined goals. Coverage must be
the same as physical therapy under the policy for other
conditions. |
Applies to individual and group insurance policies and HMO
contracts. |
Organ Transplants
215 ILCS 5/367(13)
215 ILCS 5/356k
215 ILCS 125/4-5
|
Sets forth guidelines under which experimental or
investigational organ transplantation procedures can be
denied. |
Applies to individual and group insurance policies and to
individual and group HMO contracts. |
Osteoporosis
215 ILCS 5/356z.6
Effective January 1, 2005 |
Requires coverage for medically necessary bone mass
measurement and the diagnosis and treatment of osteoporosis
on the same terms and conditions that generally apply to
other medical conditions. |
Applies to individual and group insurance policies, and to
individual and group HMO contracts. |
Ovarian Cancer Testing
215 ILCS 5/356u
SB 521 PA 94-0122
Effective 1/1/06
|
Requires coverage for surveillance tests for ovarian cancer
for female insureds who are at risk for ovarian cancer.
|
Applies to group insurance policies, except specified
disease policies, and limited benefit policies and to
individual and group HMO contracts. |
Pap Smears
215 ILCS 5/356u
215 ILCS 125/4-6.5
50 Ill. Adm. Code 5421.130g |
Requires coverage for an annual cervical smear or pap smear
for females. |
Applies to group insurance policies, except specified
disease policies, and limited benefit policies and to
individual and group HMO contracts. |
Prescription Inhalants
Public Act 93-0529
215 ILCS 5/356z.4
Effective 8/14/03 |
Requires coverage of prescription inhalants for persons with
asthma or other life-threatening bronchial ailments, as
often as needed, if medically appropriate and prescribed by
the attending physician. Policy restrictions, placed on
refill limitations, do not apply. |
Applies to individual and group insurance policies and HMO
contracts that provide coverage for prescription drugs. |
Preventive Health Services
(Including Well Child Care)
50 Ill. Adm. Code 5421.130g |
Requires coverage of preventive health services as
appropriate for the patient population including a health
evaluation program and immunizations to prevent or arrest
the further manifestation of human illness or injury. |
Applies to individual and group HMO contracts. |
Prostate Specific Antigen Testing
215 ILCS 5/356u
215 ILCS 125/4-6.5 |
Requires coverage for an annual digital rectal examination
and a prostate specific antigen test for male insureds upon
recommendation of a physician for asymptomatic men age 50
and over, African American men age 40 and over, men age 40
and over with family history. |
Applies to group insurance policies, except specified
disease and limited benefit policies, and to group HMO
contracts. |
Adopted Children
215 ILCS 5/356h
215 ILCS 125/4-9
|
Prohibits denial or limitation of coverage to an adopted
child solely because the child is adopted. |
Applies to individual and group insurance policies and
individual and group HMO contracts. |
Continuation
215 ILCS 5/367e
215 ILCS 125/4-9.2 |
Employees or members whose group health insurance terminates
due to termination of employment or membership must be
offered continuation of coverage for themselves and their
dependents for a period of 9 months. |
Group insurance policies that insure employees or members
for hospital, surgical, or major medical insurance on an
expense incurred basis and group HMO contracts. Does not
apply to specified disease or accident only policies. The
insured or member must have been continuously covered for at
least three months immediately prior to the termination of
coverage.
Not applicable if the group has terminated the group policy
or contract. |
Continuation for Spouse
215 ILCS 5/367.2
Public Act 93-0477
Adds application to HMOs effective 1/1/04
|
An
employees’ spouse and dependent children who are insured
under the policy must be offered continuation of coverage if
group coverage is terminated for the spouse and dependents
due to the dissolution the marriage or death of the employee
(for any age spouse), or due to retirement of the employee
(for a spouse age 55 or older). |
Applies to group accident and health insurance polices.
Applies to group HMO contracts EFFECTIVE 1/1/2004. |
Continuation for Dependent Children
Public Act 93-0477
215 ILCS 5/367.2-5
Effective 7/1/04 |
A
dependent child who is insured on the policy must be offered
dependent child continuation upon attainment of the limiting
age under the policy or upon the death of the employee (if
coverage through spousal continuation is not available). |
Applies to group accident and health insurance policies and
group HMO contracts. |
Conversion
215 ILCS 5/367e.1
50 Ill. Adm. Code 5421.110v |
Employees or members whose coverage under the group plan has
terminated, for any reason other than (1) discontinuance of
the group policy in its entirety where there is a succeeding
carrier or (2) failure of the employee or member to pay
premium, are entitled to a conversion policy. |
Group insurance policies and group HMO contracts where the
insured has been continuously covered for at least three
months immediately prior to the termination of coverage.
NOTE: Conversion should also be offered
after COBRA or Illinois Continuation has been exhausted. |
Conversion for Spouse
215 ILCS 5/356d |
Prohibits an individual insurance policy that covers an
insured and dependent spouse from terminating the spouse
solely because of a break in the marital relationship unless
a valid judgment of dissolution of marriage has been entered
into. If the policy is terminated due to a dissolution of
marriage, a conversion policy must be offered to the spouse. |
Individual insurance policies.
Applies to HMO contracts effective January 1, 2004.
|
Handicapped Dependents
(Attainment of Limiting Age)
215 ILCS 5/356b
215 ILCS 5/367(b)
215 ILCS 125/4-9.1
|
Requires coverage for a child who has attained the limiting
age under the policy if the child continues to be incapable
of sustaining employment and is dependent on his or her
parents or other care providers for lifetime care and
supervision. |
Applies to individual and group insurance policies and to
individual and group HMO contracts. |
Newborn
215 ILCS 5/356c
215 ILCS 125/4-8 |
Requires coverage of newborn children from the moment of
birth. Coverage must include coverage of illness, injury,
congenital defects, birth abnormalities and premature birth
to the extent the services, supplies or treatments are
covered by the policy. Notification to the company and
payment of premium may be required. |
Applies to individual and group insurance policies and to
individual and group HMO contracts. |
