215 ILCS 5/355a
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 5/ - Illinois Insurance Code.|Article XX - Accident And Health Insurance

 (from Ch. 73, par. 967a)Sec. 355a. Standardization of terms and coverage.(1) The purposes of this Section shall be (a) to provide  reasonable standardization and simplification of terms and coverages of  individual accident and health insurance policies to facilitate public  understanding and comparisons; (b) to eliminate provisions contained in  individual accident and health insurance policies which may be  misleading or unreasonably confusing in connection either with the  purchase of such coverages or with the settlement of claims; and (c) to  provide for reasonable disclosure in the sale of accident and health  coverages.(2) Definitions applicable to this Section are as follows:(a) "Policy" means all or any part of the forms     constituting the contract between the insurer and the insured, including the policy, certificate, subscriber contract, riders, endorsements, and the application if attached, which are subject to filing with and approval by the Director.(b) "Service corporations" means voluntary health and     dental corporations organized and operating respectively under the Voluntary Health Services Plans Act and the Dental Service Plan Act.(c) "Accident and health insurance" means insurance     written under Article XX of this Code, other than credit accident and health insurance, and coverages provided in subscriber contracts issued by service corporations.  For purposes of this Section such service corporations shall be deemed to be insurers engaged in the business of insurance.(3) The Director shall issue such rules as he shall deem necessary  or desirable to establish specific standards, including standards of  full and fair disclosure that set forth the form and content and  required disclosure for sale, of individual policies of accident and  health insurance, which rules and regulations shall be in addition to  and in accordance with the applicable laws of this State, and which may  cover but shall not be limited to:  (a) terms of renewability; (b)  initial and subsequent conditions of eligibility; (c) non-duplication of  coverage provisions; (d) coverage of dependents; (e) pre-existing  conditions; (f) termination of insurance; (g) probationary periods; (h)  limitation, exceptions, and reductions; (i) elimination periods; (j)  requirements regarding replacements; (k) recurrent conditions; and (l)  the definition of terms, including, but not limited to, the following:  hospital, accident, sickness, injury, physician, accidental means, total  disability, partial disability, nervous disorder, guaranteed renewable,  and non-cancellable.The Director may issue rules that specify prohibited policy  provisions not otherwise specifically authorized by statute which in the  opinion of the Director are unjust, unfair or unfairly discriminatory to  the policyholder, any person insured under the policy, or beneficiary.(4) The Director shall issue such rules as he shall deem necessary  or desirable to establish minimum standards for benefits under each  category of coverage in individual accident and health policies, other  than conversion policies issued pursuant to a contractual conversion  privilege under a group policy, including but not limited to the  following categories:  (a) basic hospital expense coverage; (b) basic  medical-surgical expense coverage; (c) hospital confinement indemnity  coverage; (d) major medical expense coverage; (e) disability income  protection coverage; (f) accident only coverage; and (g) specified  disease or specified accident coverage.Nothing in this subsection (4) shall preclude the issuance of any  policy which combines two or more of the categories of coverage  enumerated in subparagraphs (a) through (f) of this subsection.No policy shall be delivered or issued for delivery in this State  which does not meet the prescribed minimum standards for the categories  of coverage listed in this subsection unless the Director finds that  such policy is necessary to meet specific needs of individuals or groups  and such individuals or groups will be adequately informed that such  policy does not meet the prescribed minimum standards, and such policy  meets the requirement that the benefits provided therein are reasonable  in relation to the premium charged. The standards and criteria to be  used by the Director in approving such policies shall be included in the  rules required under this Section with as much specificity as  practicable.The Director shall prescribe by rule the method of identification of  policies based upon coverages provided.(5) (a) In order to provide for full and fair disclosure in the  sale of individual accident and health insurance policies, no such  policy shall be delivered or issued for delivery in this State unless  the outline of coverage described in paragraph (b) of this subsection  either accompanies the policy, or is delivered to the applicant at the  time the application is made, and an acknowledgment signed by the  insured, of receipt of delivery of such outline, is provided to the  insurer.  In the event the policy is issued on a basis other than that  applied for, the outline of coverage properly describing the policy must  accompany the policy when it is delivered and such outline shall clearly  state that the policy differs, and to what extent, from that for which  application was originally made. All policies, except single premium  nonrenewal policies, shall have a notice prominently printed on the  first page of the policy or attached thereto stating in substance, that  the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if after  examination of the policy the policyholder is not satisfied for any  reason.(b) The Director shall issue such rules as he shall deem necessary  or desirable to prescribe the format and content of the outline of  coverage required by paragraph (a) of this subsection. "Format" means  style, arrangement, and overall appearance, including such items as the  size, color, and prominence of type and the arrangement of text and  captions.  "Content" shall include without limitation thereto,  statements relating to the particular policy as to the applicable  category of coverage prescribed under subsection (4); principal benefits;  exceptions, reductions and limitations; and renewal provisions,  including any reservation by the insurer of a right to change premiums.  Such outline of coverage shall clearly state that it constitutes a  summary of the policy issued or applied for and that the policy should  be consulted to determine governing contractual provisions.(c) Without limiting the generality of paragraph (b) of this subsection (5), no qualified health plans shall be offered for sale directly to consumers through the health insurance marketplace operating in the State in accordance with Sections 1311 and  1321 of the federal Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments thereto, or regulations or guidance issued thereunder (collectively, "the Federal Act"), unless the following information is made available to the consumer at the time he or she is comparing policies and their premiums:(i) With respect to prescription drug benefits, the     most recently published formulary where a consumer can view in one location covered prescription drugs; information on tiering and the cost-sharing structure for each tier; and information about how a consumer can obtain specific copayment amounts or coinsurance percentages for a specific qualified health plan before enrolling in that plan.  This information shall clearly identify the qualified health plan to which it applies.(ii) The most recently published provider directory     where a consumer can view the provider network that applies to each qualified health plan and information about each provider, including location, contact information, specialty, medical group,  if any, any institutional affiliation, and whether the provider is accepting new patients at each of the specific locations listing the provider. Dental providers shall notify qualified health plans electronically or in writing of any changes to their information as listed in the provider directory. Qualified health plans shall update their directories in a manner consistent with the information provided by the provider or dental management service organization within 10 business days after being notified of the change by the provider. Nothing in this paragraph (ii) shall void any contractual relationship between the provider and the plan.  The information shall clearly identify the qualified health plan to which it applies.(d) Each company that offers qualified health plans for sale directly to consumers through the health insurance marketplace operating in the State shall make the information in paragraph (c) of this subsection (5), for each qualified health plan that it offers, available and accessible to the general public on the company's Internet website and through other means for individuals without access to the Internet.(e) The Department shall ensure that State-operated Internet websites, in addition to the Internet website for the health insurance marketplace established in this State in accordance with the Federal Act, prominently provide links to Internet-based materials and tools to help consumers be informed purchasers of health insurance.(f) Nothing in this Section shall be interpreted or implemented in a manner not consistent with the Federal Act.  This Section shall apply to all qualified health plans offered for sale directly to consumers through the health insurance marketplace operating in this State for any coverage year beginning on or after January 1, 2015.(6) Prior to the issuance of rules pursuant to this Section, the  Director shall afford the public, including the companies affected  thereby, reasonable opportunity for comment.  Such rulemaking is subject  to the provisions of the Illinois Administrative Procedure Act.(7) When a rule has been adopted, pursuant to this Section, all  policies of insurance or subscriber contracts which are not in  compliance  with such rule shall, when so provided in such rule, be  deemed to be disapproved as of a date specified in such rule not less  than 120 days following its effective date, without any further or  additional notice other than the adoption of the rule.(8) When a rule adopted pursuant to this Section so provides, a  policy of insurance or subscriber contract which does not comply with  the rule shall, not less than 120 days from the effective date of such  rule, be construed, and the insurer or service corporation shall be  liable, as if the policy or contract did comply with the rule.(9) Violation of any rule adopted pursuant to this Section shall be  a violation of the insurance law for purposes of Sections 370 and 446 of this   Code.  (Source: P.A. 99-329, eff. 1-1-16; 100-201, eff. 8-18-17.)