Illinois health insurance and woman health needs       

NOTE:  The following laws do not apply to self-insured employers or to trusts or insurance policies written outside Illinois.  However, for HMOs, the laws do apply in certain situations to contracts written outside of Illinois if the HMO member is a resident of Illinois and the HMO has established a provider network in Illinois.  To determine if your HMO provides the benefits required by the following laws, you should contact the HMO directly or check your certificate of coverage.

Birth Control

Effective January 1, 2004 all individual and group insurance and HMO policies that provide coverage for outpatient services and outpatient prescription drugs or devices, must also provide coverage for all outpatient contraceptive services and all outpatient contraceptive drugs and devices approved by the Food and Drug Administration.  Deductibles, coinsurance, waiting periods are the same as those imposed for any other outpatient prescription drug or device under the policy. (215 ILCS 5/356z.4 and 215 ILCS 125/5.3))

Maternity

HMOs must cover maternity care, including prenatal and post-natal care and care for complications of pregnancy and care with respect to a newborn. (50 Ill. Admin. Code 5421.130e)

Other health insurance policies, including PPO policies, must provide coverage for complications of pregnancy.  [50 Ill. Admin. Code 2603.30(11)]

Federal law (Pregnancy Discrimination Act of 1978, which amended Title VII of the Civil Rights Act) requires employers with 15 or more employees to cover maternity. Note that employers may choose to self-insure this portion of the benefit or they may provide the coverage through the insurance policy. 

Maternity – Prenatal HIV Testing

All group and individual health policies offered by insurance companies and HMOs are required to cover prenatal HIV testing ordered by an attending physician, physician assistant or advanced practice registered nurse. (215 ILCS 5/356z.1 and 215 ILCS 125/4-6.5)

Maternity – Post Parturition Care

All group and individual health insurance policies offered by health insurance companies and HMOs must cover 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.  (215 ILCS 5/356s and 215 ILCS 125/4-6.4)

Mammograms

All group and individual health insurance policies offered by insurance companies and health maintenance organizations (HMOs) in Illinois must cover routine mammograms for all women age 35 and older, at the same rate they would pay for any other diagnostic x-ray.

A routine mammogram is an x-ray examination of the breast for the presence of breast cancer, even if no symptoms are present.  The insurance company or HMO must pay for routine mammograms according to the following schedule:

age 35 to 39 – baseline mammogram
age 40 or older – an annual mammogram

Effective July 6, 2005, coverage must be expanded to include a mammogram at the age and intervals considered medically necessary by the woman’s health care provider for women under age 40 who have a family history of breast cancer or other risk factors.  This benefit must be provided in policies or certificates upon issuance or renewal on or after July 6, 2005.  (215 ILCS 5/356g and 215 ILCS 125/4-6.1)

Fibrocystic Condition

At least 50% of women of reproduction age have a fibrocystic condition.  These women have lumps in the breast, along with pain and tenderness.  An insurer or HMO may not refuse to cover you, nor may they attach an exclusionary rider to your policy, solely because you have been diagnosed as having fibrocystic condition, unless you have had a breast biopsy that indicates you are likely to incur breast cancer or your medical history shows the condition to be chronic. (215 ILCS 5/356n and 215 ILCS 125/4-16)

Breast Surgery

For both group and individual coverage, HMOs and insurance companies must allow the attending physician to determine the length of hospital stay following a mastectomy, the removal of a breast.  The insurance company or HMO must provide coverage as long as the attending physician determines the length of stay to be medically necessary and in accordance with protocols and guidelines based on sound scientific evidence and an evaluation of the patient. (215 ILCS 5/356t and 215 ILCS 125/4-6.5)

For group and individual HMO and insurance policies that provide coverage for mastectomies, the law also requires coverage for prosthetic devices or reconstructive surgery related to the mastectomy.  Prosthetic devices include breast prosthesis and bras.  Reconstructive surgery includes reconstruction of the breast on which the mastectomy has been performed, as well as surgery and reconstruction of the other breast to produce symmetrical appearance.  Coverage is also required for prosthetic devices and treatment for physical complications at all stages mastectomy, including lymph edemas.  The coverage may be subject to annual deductibles and coinsurance provisions as deemed appropriate and consistent with other benefits covered under the insurance. (215 ILCS 5/356g(b) and 215 ILCS 125/4-6.1)

In Illinois, no individual or group insurance or HMO policy may deny coverage for the removal of breast implants if:

1. the implants were not inserted for purely cosmetic reasons; and
2. it is medically necessary for the breast implants to be removed.

Implants inserted after a mastectomy due to sickness or injury are not considered purely cosmetic.  (215 ILCS 5/356p and 215 ILCS 125/4-6.2)

PAP Smears

Group health insurance policies issued by insurance companies and HMOs must pay for an annual cervical smear or PAP smear test for female insureds.
(215 ILCS 5/356u and 215 ILCS 125/4-6.5 and 50 Ill. Adm. Code 5421.130g)

Ovarian Cancer Screening
(215 ILCS 5/356u)

(215 ILCS 5/356u and 215 ILCS 125/4-6.5)

Effective January 1, 2006 group insurance policies issued, delivered or renewed by insurance companies and HMOs must pay for surveillance tests for ovarian cancer for female insureds who are at risk for ovarian cancer.  Under the law, you are considered at risk for ovarian cancer if you have:

• a family history with one or more first-degree relatives with ovarian cancer,
• a family history of clusters of women relatives with breast cancer,
• a family history of nonpolyposis colorectal cancer, or
• have tested positive for BRCA1 or BRCA2 mutations.

Surveillance tests are annual tests using:

• CA-125 serum tumor marker testing,
• Transvaginal ultrasound,
• Pelvic examination.

Sexual Assault or Abuse

Insurance companies and HMOs in Illinois must waive all deductibles and copayments for covered members who are victims of sexual assault or abuse.  Insurers and HMOs must cover examination and testing of the victim to establish that sexual contact did or did not occur, to establish the presence or absence of sexually transmitted disease or infection, and to treat the injuries and trauma sustained by the victim of the offense. (215 ILCS 5/356e and 215 ILCS 125/4-4)

 

Domestic Abuse

After January 1, 1998, no life, health or disability income insurance company may deny, refuse to issue or reissue, cancel, or restrict your coverage solely because you:

1. are the subject of abuse;
2. have sought treatment for abuse; or
3. have sought protection or shelter from abuse.

 

The insurance company may not charge higher premiums, deny a claim, or ask you for information relating to the abuse.  If the company obtains information regarding the abuse, the fact that the condition or treatment is abuse-related must be kept confidential.
 
An insurance company may restrict coverage or charge higher premiums for coverage based on your physical or mental condition, no matter what the cause.  For example, a company may decline to cover you if you have a permanent disability as a result of abuse.  In this case, the denial of coverage would be due to the permanent disability condition itself, not because the condition is abuse-related. (215 ILCS 5/155.22a)

 

Genetic Testing

Effective June 23, 1997, a health insurer or HMO may not seek or use genetic testing information to deny health coverage.  The company or HMO may only use genetic test information if you voluntarily give the information, and the test results are in your favor.  The company or HMO may not give the information to another party without your permission. (215 ILCS 5/356v and 215 ILCS 125/5-3)

These restrictions on genetic testing information do not apply to life insurance policies.

 

Woman’s Principal Health Care Provider

HMOs and some Preferred Provider Organizations ("gated" PPOs) require their members to select a Primary Care Physician (PCP) to manage all care.  In addition, female enrollees may also designate an obstetrician or gynecologist, or a physician specializing in family practice as their Woman’s Principal Health Care Provider (WPHCP).  The WPHCP can provide services without a referral from the PCP, but the HMO or PPO can require that your primary care physician and your woman's principle health care provider have a referral arrangement with one another.

Both the PCP and WPHCP must be selected from a list of physicians who have contracted with the HMO or PPO to provide health care. (215 ILCS 5/356r and 215 ILCS 125/5-3.1)