(215 ILCS 125/4‑2) (from Ch. 111 1/2, par. 1408.2)
Sec. 4‑2. Medical assistance; coverage of child.
(a) In this Section, "Medicaid" means medical assistance authorized under Section 1902 of the Social Security Act.
(b) A contract or evidence of coverage delivered, issued for delivery, renewed, or amended by a Health Maintenance Organization may not contain any provision which limits or excludes payments of health care services to or on behalf of the enrollee because the enrollee or any covered dependent is eligible for or is receiving Medicaid benefits in this or any other state.
(c) To the extent that payment for covered expenses has been made under Article V, VI, or VII of the Illinois Public Aid Code for health care services provided to an individual, if a third party has a legal liability to make payments for those health care services, the State is considered to have acquired the rights of the individual to payment.
(d) If a child is covered under a health care plan of a Health Maintenance Organization in which the child's noncustodial parent is an enrollee, the Health Maintenance Organization shall:
(1) Provide necessary information to the child's |
| custodial parent to enable the child to obtain benefits under that health care plan. | |
(2) Permit the child's custodial parent (or the |
| provider, with the custodial parent's approval) to submit claims for payment for covered services without the approval of the noncustodial parent. | |
(3) Make payments on claims submitted in accordance |
| with paragraph (2) directly to the custodial parent, the provider of health care services, or the state Medicaid agency. | |
(e) A Health Maintenance Organization may not deny enrollment of a child under the health care plan in which the child's parent is an enrollee on any of the following grounds:
(1) The child was born out of wedlock.
(2) The child is not claimed as a dependent on the |
| parent's federal income tax return. | |
(3) The child does not reside with the parent or in |
| the service area covered by the health care plan. | |
(f) If a parent is required by a court or administrative order to provide coverage for a child under a health care plan in which the parent is enrolled, and that offers coverage for eligible dependents, the Health Maintenance Organization, upon receiving a copy of the order, shall:
(1) Upon application, permit the parent to enroll in |
| the health care plan a child who is otherwise eligible for that coverage, without regard to any enrollment season restrictions that might otherwise be applicable as to the time period within which a person may enroll in the plan. | |
(2) Enroll the child in the health care plan upon |
| application of the child's other parent, the state agency administering the Medicaid program, or the state agency administering a program for enforcing child support and establishing paternity under 42 U.S.C. 651 through 669 (or another child support enforcement program), if the parent is enrolled in the health care plan but fails to apply for enrollment of the child. | |
(g) A Health Maintenance Organization may not impose, on a state agency that has been assigned the rights of an enrollee in a health care plan who receives Medicaid benefits, requirements that are different from requirements applicable to an assignee of any other enrollee in that health care plan.
(h) Nothing in subsections (e) and (f) prevents a Health Maintenance Organization from denying any such application if the child is not eligible for coverage according to the Health Maintenance Organization's medical underwriting standards.
(i) The Health Maintenance Organization may not disenroll (or otherwise eliminate coverage of) the child from the health care plan unless the Health Maintenance Organization is provided satisfactory written evidence of either of the following:
(1) The court or administrative order is no longer |
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(2) The child is or will be enrolled in a comparable |
| health care plan obtained by the parent under such order and that enrollment is currently in effect or will take effect not later than the date the prior coverage is terminated. | |
(Source: P.A. 89‑183, eff. 1‑1‑96.) |
(215 ILCS 125/4‑4) (from Ch. 111 1/2, par. 1408.4)
Sec. 4‑4. Sexual assault or abuse victims; coverage of expenses; recovery of State funds; reimbursement of Department of Public Health.
(1) Contracts or evidences of coverage issued by a health maintenance organization, which provide benefits for health care services, shall to the full extent of coverage provided for any other emergency or accident care, provide for the payment of actual expenses incurred, without offset or reduction for benefit deductibles or co‑insurance amounts, in the examination and testing of a victim of an offense defined in Sections 12‑13 through 12‑16 of the Criminal Code of 1961, as now or hereafter amended, or an attempt to commit such offense, to establish that sexual contact did occur or did not occur, and to establish the presence or absence of sexually transmitted disease or infection, and examination and treatment of injuries and trauma sustained by a victim of such offense.
(2) For purposes of enabling the recovery of State funds, any health maintenance organization subject to this Section shall upon reasonable demand by the Department of Public Health disclose the names and identities of its enrollees entitled to benefits under this provision to the Department of Public Health whenever the Department of Public Health has determined that it has paid, or is about to pay for, health care services for which a health maintenance organization is liable under this Section. All information received by the Department of Public Health under this provision shall be held on a confidential basis and shall not be subject to subpoena and shall not be made public by the Department of Public Health or used for any purpose other than that authorized by this Section.
(3) Whenever the Department of Public Health finds that it has paid for all or part of any health care services for which a health maintenance organization is obligated to pay under this Section, the Department of Public Health shall be entitled to receive reimbursement for its payments from such organization provided that the Department of Public Health has notified the organization of its claims before the organization has paid such benefits to its enrollees or in behalf of its enrollees.
(Source: P.A. 91‑357, eff. 7‑29‑99.) |
(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 |
| medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors. | |
(4) A comprehensive ultrasound screening of an entire |
| breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches. | |
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. The term also includes digital mammography.
(a‑5) Coverage as described in subsection (a) shall be provided at no cost to the enrollee and shall not be applied to an annual or lifetime maximum benefit.
(b) No contract or evidence of coverage issued by a health maintenance organization that provides for the surgical procedure known as a mastectomy shall be issued, amended, delivered, or renewed in this State on or after the effective date of this amendatory Act of the 92nd General Assembly unless that coverage also provides for prosthetic devices or reconstructive surgery incident to the mastectomy, providing that the mastectomy is performed after the effective date of this amendatory Act. Coverage for breast reconstruction in connection with a mastectomy shall include:
(1) reconstruction of the breast upon which the |
| mastectomy has been performed; | |
(2) surgery and reconstruction of the other breast |
| to produce a symmetrical appearance; and | |
(3) prostheses and treatment for physical |
| complications at all stages of mastectomy, including lymphedemas. | |
Care shall be determined in consultation with the attending physician and the patient. The offered coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy and all other terms and conditions applicable to other benefits. When a mastectomy is performed and there is no evidence of malignancy, then the offered coverage may be limited to the provision of prosthetic devices and reconstructive surgery to within 2 years after the date of the mastectomy. As used in this Section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician.
Written notice of the availability of coverage under this Section shall be delivered to the enrollee upon enrollment and annually thereafter. A health maintenance organization may not deny to an enrollee eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Section. A health maintenance organization may not penalize or reduce or limit the reimbursement of an attending provider or provide incentives (monetary or otherwise) to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with this Section.
(c) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 94‑121, eff. 7‑6‑05; 95‑431, eff. 8‑24‑07; 95‑1045, eff. 3‑27‑09.) |
(215 ILCS 125/4‑6.3)
Sec. 4‑6.3. Prescription drugs; cancer treatment. No health maintenance organization that provides coverage for prescribed drugs approved by the federal Food and Drug Administration for the treatment of certain types of cancer shall exclude coverage of any drug on the basis that the drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the federal Food and Drug Administration. The drug, however, must be approved by the federal Food and Drug Administration and must be recognized for the treatment of the specific type of cancer for which the drug has been prescribed in any one of the following established reference compendia:
(a) the American Hospital Formulary Service Drug
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(b) National Comprehensive Cancer Network's Drugs & |
| |
(c) Thomson Micromedex's Drug Dex;
(d) Elsevier Gold Standard's Clinical Pharmacology; or
(e) other authoritative compendia as identified from |
| time to time by the Federal Secretary of Health and Human Services; | |
or if not in the compendia, recommended for that particular type of cancer in formal clinical studies, the results of which have been published in at least two peer reviewed professional medical journals published in the United States or Great Britain.
Any coverage required by this Section shall also include those medically necessary services associated with the administration of a drug.
Despite the provisions of this Section, coverage shall not be required for any experimental or investigational drugs or any drug that the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed. This Section shall apply only to cancer drugs. Nothing in this Section shall be construed, expressly or by implication, to create, impair, alter, limit, notify, enlarge, abrogate or prohibit reimbursement for drugs used in the treatment of any other disease or condition.
(Source: P.A. 96‑457, eff. 8‑14‑09.) |
(215 ILCS 125/4‑7) (from Ch. 111 1/2, par. 1409)
Sec. 4‑7. Solicitations of enrollees. Solicitations of enrollees by a Health Maintenance Organization authorized under this Act, or its representatives shall not be construed to be violative of any provisions of law relating to solicitation or advertising by health professionals. No solicitation may be made which advertises, identifies or makes a qualitative judgment concerning any health professional who provides services for a Health Maintenance Organization. Nothing in this Section precludes a Health Maintenance Organization from providing to a particular potential enrollee the names of health providers upon request by that particular potential individual enrollee. No Health Maintenance Organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. Health Maintenance Organizations shall be subject to Section 143c of the "Illinois Insurance Code", approved June 29, 1937, as amended.
If the Director finds that any advertisement of a plan has materially failed to comply with the provisions of this Act or the rules thereunder, the Director may, by order, require the plan to publish in the same or similar medium, an approved correction or retraction of any untrue, misleading, or deceptive statement contained in the advertising and may prohibit such plan from publishing or distributing, or allowing to be published or distributed on its behalf such advertisement or any new materially revised advertisement without first having filed a copy thereof with the Director 30 days prior to the publication or distribution thereof, or any shorter period specified in such order. An order issued under this Section shall be effective for 12 months from its issuance, and may be renewed by order if the advertisements submitted under this Section indicate difficulties of voluntary compliance with the applicable provisions of this Act and the rules thereunder.
(Source: P.A. 85‑20.) |
(215 ILCS 125/4‑8) (from Ch. 111 1/2, par. 1409.1)
Sec. 4‑8. Newborn Infants. (1) No contract or evidence of coverage issued by a Health Maintenance Organization which provides for coverage of dependents of the principal enrollee shall contain any disclaimer, waiver or other limitation relative to the eligibility or coverage of newborn infants of a principal enrollee from and after the moment of birth.
(2) Each such contract or evidence of coverage shall contain a provision stating that benefits shall be granted immediately with respect to newborn infants from the moment of birth and that such coverage shall include illness, injury, congenital defects, birth abnormalities and premature birth.
(3) If payment of a specific premium is required under the terms of a contract to provide coverage for a child, there may be requirements that notification of birth of a newly born infant be given to the Health Maintenance Organization within the 31 days following the birth in order to have coverage continued beyond such 31 day period and that such specific premium be paid within 30 days following receipt of such notice.
(4) In the event that no other members of the enrollee's immediate family are covered, immediate coverage for the first newborn infant shall be provided if the enrollee applies for dependent's coverage within 31 days of the newborn's birth. Such coverage shall be contingent upon payment of the additional premium.
(5) The requirements of this Section shall apply, on or after the sixtieth day following the effective date of this amendatory Act of 1989, (a) to all such evidences of coverage delivered or issued for delivery, and (b) to all such group contracts delivered, issued for delivery, renewed or amended. The health maintenance organizations which issue such evidences of coverage that are in effect on the sixtieth day following the effective date of this amendatory Act of 1989 shall extend to owners of such contracts, on or before the first contract anniversary following such date, the opportunity to apply for the addition to their contracts of a provision as set forth in subsection (2) above, with, at the option of the health maintenance organization, payment of a premium appropriate thereto.
(Source: P.A. 86‑620.) |
(215 ILCS 125/4‑9.2) (from Ch. 111 1/2, par. 1409.2‑2)
Sec. 4‑9.2. Continuation of group HMO coverage after termination of employee or membership. A group contract delivered, issued for delivery, renewed, or amended in this State that covers employees or members for health care services shall provide that employees or members whose coverage under the group contract would otherwise terminate because of termination of employment or membership or because of a reduction in hours below the minimum required by the group contract shall be entitled to continue their coverage under that group contract, for themselves and their eligible dependents, subject to all of the group contract's terms and conditions applicable to those forms of coverage and to the following conditions:
(1) Continuation shall only be available to an
| employee or member who has been continuously covered under the group contract (and for similar benefits under any group contract that it replaced) during the entire 3 month period ending with the termination of employment or membership or reduction in hours below the minimum required by the group contract. With respect to an employee or member who is involuntarily terminated between September 1, 2008 and the end of the period set forth in Section 3001(a)(3)(A) of Title III of Division B of the federal American Recovery and Reinvestment Act of 2009, as now or hereafter amended, continuation shall be available if the employee or member was covered under the group contract the day prior to such termination. | |
(2) Continuation shall not be available for any |
| enrollee who is covered by Medicare, except for those individuals who have been covered under a group Medicare supplement policy. Continuation shall not be available for any enrollee who is covered by any other insured or uninsured plan that provides hospital, surgical, or medical coverage for individuals in a group and under which the enrollee was not covered immediately before termination or reduction in hours below the minimum required by the group contract or who exercises his or her conversion privilege under the group policy. | |
(3) Continuation need not include dental, vision |
| care, prescription drug, or similar supplementary benefits that are provided under the group contract in addition to its basic health care services. | |
(4) Within 10 days after the employee's or member's |
| termination or reduction in hours below the minimum required by the group contract, written notice of continuation shall be presented to the employee or member by the employer. If the employee or member is unavailable, written notice shall be mailed by the employer to the last known address of the employee or member within 10 days after the employee's or member's termination or reduction in hours below the minimum required by the group plan. The employer shall also send a copy of the notice to the HMO. An employee or member who wishes continuation of coverage must request continuation in writing within the 30 day period following the later of (i) the date of termination or reduction in hours below the minimum required by the group contract or (ii) the date the employee is presented
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