reglab/housing_qa huggingface dataset:
215 ILCS 125/4-1
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1408)Sec. 4-1.     Description and securing of services.     Every Health Maintenance Organization shall at the time of enrollment  and annually thereafter provide its enrollees a description of the services  and information as to where and how to secure them.  The Health  Maintenance Organization shall issue to each subscriber or enrollee a group  contract or evidence of coverage.  The group contract or evidence of  coverage and related material shall be delivered or issued for delivery to  an enrollee within 30 days from the later of the effective date of coverage  or the date on which the Health Maintenance Organization is provided  completed notification of enrollment.    (Source: P.A. 86-620.)
215 ILCS 125/4-3
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1408.3)Sec. 4-3.     (Repealed).     (Source: Repealed by P.A. 89-183, eff. 1-1-96.)
215 ILCS 125/4-4
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (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 11-1.20 through 11-1.60 or 12-13 through 12-16  of the Criminal Code of 1961 or the Criminal Code of 2012, 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. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13.)
215 ILCS 125/4-5
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1408.5)Sec. 4-5.     Organ Transplants.     No contract or evidence  of coverage issued by a health maintenance organization which provides  coverage for health care services 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 a health maintenance  organization 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.    (Source: P.A. 87-218.)
215 ILCS 125/4-6
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1408.6)Sec. 4-6.     Complaint handling procedure.     (a) Every health maintenance  organization shall establish and maintain a complaint system providing  reasonable procedures for resolving complaints initiated by enrollees.  Nothing herein shall be construed to preclude an enrollee or a  provider from filing a complaint with the Director or as limiting the  Director's ability to investigate such complaints.(b) When a complaint is received  by the Department of Insurance against a health maintenance organization or  producer (respondent), the respondent, shall be notified of the  complaint. The Department shall, in its notification, specify the date when  a report is to be received from the respondent, which shall be no later  than 21 days after notification is sent to the respondent.  A failure to  reply by the date specified may be followed by a collect telephone call or  collect telegram.  Repeated instances of failing to reply by the date  specified may result in further regulatory action.(c) Contents of Response or Report. (1) Each respondent shall supply  adequate documentation which explains all actions taken or not taken and  which were the basis for the complaint;(2) Documents necessary to support the respondent's position and  information requested by the Department, shall be furnished with the  respondent's reply;(3) The respondent's reply shall be in duplicate, but duplicate copies  of supporting documents shall not be required;(4) The respondent's reply shall include the name, telephone number and  address of the individual assigned to the complaint; and(5) The Department shall respect the confidentiality of medical reports  and other documents which by law are confidential.  Any other information  furnished by a respondent shall be marked "confidential" if the respondent  does not wish it to be released to the complainant.(d) Follow-up Conclusion. Upon receipt of the respondent's report, the  investigating deputy shall evaluate the material submitted; and(1) Advise the complainant of the action taken and disposition of his  complaint;(2) Pursue further investigation with respondent or complainant; or(3) Refer the investigation report to the appropriate branch within the  Department of Insurance for further regulatory action.    (Source: P.A. 86-620.)
215 ILCS 125/4-6.2
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1408.8)Sec. 4-6.2.     Breast implant removal.     No contract offered by  Health Maintenance Organizations shall deny coverage for the removal of breast  implants when the removal of the implants is medically necessary treatment for  a sickness or injury.  This Section does not apply to surgery performed for  removal of breast implants that were implanted solely for cosmetic reasons.  For the purpose of this Section, cosmetic reasons does not include cosmetic  surgery performed as reconstruction resulting from sickness or injury.    (Source: P.A. 87-938; 88-45.)
215 ILCS 125/4-6.3
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

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     Information;(b) National Comprehensive Cancer Network's Drugs &     Biologics Compendium;(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 125/4-6.4
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

Sec. 4-6.4.     Post-parturition care.     A health maintenance organization is  subject to the provisions of Section 356s of the Illinois  Insurance Code.    (Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)
215 ILCS 125/4-6.5
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

Sec. 4-6.5. Required health benefits; Illinois Insurance Code  requirements.  A health maintenance organization is subject to the provisions  of Sections 155.37, 356g.5, 356t, 356u, and 356z.1 of the Illinois Insurance Code.       (Source: P.A. 95-189, eff. 8-16-07.)
215 ILCS 125/4-7
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (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
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (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
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1409.2)Sec. 4-9.     Adopted children.     No contract or evidence of coverage  issued by a Health Maintenance Organization which provides for coverage of  dependents of the principal enrollees shall exclude a child from coverage or  eligibility for coverage or limit coverage for a child solely on the basis  that he or she is an adopted child.  For purposes of this Section, a child  who is in the custody of a principal enrollee, pursuant to an interim court  order of adoption or, in the case of group insurance, placement of adoption,  whichever comes first, vesting temporary care of the child in the enrollee,  is  an  adopted child, regardless of whether a final order granting adoption is  ultimately issued.    (Source: P.A. 91-549, eff. 8-14-99.)
215 ILCS 125/4-9.1
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1409.2-1)Sec. 4-9.1. Dependent Coverage Termination.(a) The attainment of a limiting age under a group contract or  evidence of coverage which provides that coverage of a dependent person of  an enrollee shall terminate upon attainment of the limiting age for  dependent persons does  not operate to terminate the coverage of a person who, because  of a disabling condition that occurred before attainment of the limiting age,  is incapable of self-sustaining employment and is dependent on his  or her  parents or other care providers for lifetime care and supervision.(b) For purposes of subsection (a), "dependent on other care providers" is  defined as requiring a Community Integrated Living Arrangement, group home,  supervised apartment, or other residential services licensed or certified by  the Department of Human Services (as successor to the Department of Mental  Health and Developmental Disabilities), the Department  of Public Health, or the Department of Healthcare and Family Services (formerly Department of Public Aid).(c) Proof of such incapacity and dependency shall be furnished to the health  maintenance organization by the enrollee within  31 days of a request for the  information by the health maintenance organization and subsequently as may  be required by the health maintenance organization, but not more frequently  than annually.  In the absence of proof submitted within 31 days of such  inquiry that such dependent is a person who has a disability and is a dependent, the health  maintenance organization may terminate coverage of such person at or  after attainment of the limiting age.  In the absence of such inquiry,  coverage of any person who has a disability and is a dependent shall continue through the  term of the group contract or evidence of coverage or any extension or  renewal thereof.  (Source: P.A. 99-143, eff. 7-27-15.)
215 ILCS 125/4-10
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1409.3)Sec. 4-10. Medical necessity; dispute resolution; independent second opinion.  Each Health Maintenance Organization shall provide a mechanism  for the timely review by a physician holding the same class of license as  the primary care physician, who is unaffiliated with the Health Maintenance  Organization, jointly selected by the patient (or the patient's next of  kin or legal representative if the patient is unable to act for himself),  primary care physician and the Health Maintenance Organization in the event  of a dispute between the primary care physician and the Health Maintenance  Organization regarding the medical necessity of a covered service proposed  by a primary care physician.  In the event that the reviewing physician  determines the covered service to be medically necessary, the Health  Maintenance Organization shall provide the covered service.  Future  contractual or employment action by the Health Maintenance Organization  regarding the primary care physician shall not be based solely on the  physician's  participation in this procedure.  (Source: P.A. 100-201, eff. 8-18-17.)
215 ILCS 125/4-11
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1409.4)Sec. 4-11.         Any person who enrolls recipients of  Public Aid or Medicare in a health maintenance organization, either personally or by  mail, shall, on or after July 1, 1989, be licensed as a limited insurance  representative under Section 495.1 of the Illinois  Insurance Code.  No such person shall be required to pass a written  examination in order to qualify to be licensed as a limited insurance  representative under this Section.    (Source: P.A. 85-1246.)
215 ILCS 125/4-12
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 125/ - Health Maintenance Organization Act.|Article IV - Delivery Of Services - Required Provisions And Marketing

 (from Ch. 111 1/2, par. 1409.5)Sec. 4-12.         Changes in Rate Methodology and Benefits, Material  Modifications.  A health maintenance organization shall file with the  Director, prior to use, a notice of any change in rate methodology, or  benefits and of any material modification of any matter or document  furnished pursuant to Section 2-1, together with such supporting documents  as are necessary to fully explain the change or modification.(a) Contract modifications described in subsections (c)(5), (c)(6) and  (c)(7) of Section 2-1 shall include all form agreements between the  organization and enrollees, providers, administrators of services and  insurers of health maintenance organizations.(b) Material transactions or series of transactions other than those  described in subsection (a) of this Section, the total annual value of  which exceeds the greater of $100,000 or 5% of net earned subscription  revenue for the most current twelve month period as determined from filed  financial statements.(c) Any agreement between the organization and an insurer shall be  subject to the provisions of the laws of this State regarding reinsurance  as provided in Article XI of the Illinois Insurance Code.  All reinsurance  agreements must be filed.  Approval of the Director is required for all  agreements except the following:  individual stop loss, aggregate excess,  hospitalization benefits or out-of-area of the participating providers  unless 20% or more of the organization's total risk is reinsured, in which  case all reinsurance agreements require approval.    (Source: P.A. 86-620.)