reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 50 - INSURANCE › Part 2004 - ACCIDENT AND HEALTH RESERVES › Section 2004.30 - Active Life Reserves - Group Policies

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Section applies to accident and
			 health insurance as defined in Section 367 (excluding subsection (4) thereof)
			 and Section 367(a) of the Code [215 ILCS 5/367 and 367(a) ].
b) The minimum reserve for active lives on
			 all group accident and health policies shall be the pro rata gross unearned
			 premium.
c) If a group policy
			 contains a conversion option for terminated employees and such employees, under
			 this provision, may receive an individual policy without evidence of
			 insurability, the company shall establish a reserve for the morbidity cost
			 expected in excess of such costs assumed by the premium, if any, which is then
			 payable by or on behalf of such terminated employee. The group account shall be
			 charged with an amount (conversion charge) to establish this reserve and
			 thereafter such reserve shall be maintained as an individual policy active life
			 reserve.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2004 - ACCIDENT AND HEALTH RESERVES › Section 2004.40 - Claim Reserves - Present Value of Amounts Not Yet Due on Claims

Current through Register Vol. 48, No. 28, July 12, 2024
a) General (Also
			 called "Disabled Life Reserves" in the case of insurance providing loss-of-time
			 benefits for disability due to accident or sickness) Reserves are required for
			 claims on all health insurance policies, group and individual in Section
			 2004.20(b)
			  providing benefits for continuing loss, such
			 as loss-of-time or hospitalization.
b) Claim reserve standards for total
			 disability due to accident or sickness
1)
			 Interest. The maximum interest rate for reserves shall be 31/2% compounded
			 annually.
2) Morbidity. The reserve
			 shall be established in accordance with the 1964 Commissioners Disability
			 Table, except that for unreported claims and resisted claims and, at the option
			 of the company, claims with a duration of disablement of less than two years,
			 reserves may be based on the individual company's experience or other
			 assumptions designed to place a sound value on the liabilities. Reserves based
			 on such experience or assumptions shall be verified by the development of each
			 year's claims over a period of years.
3) For policies with an elimination period,
			 the duration of disablement shall be considered as dating from the time that
			 benefits would have begun to accrue had there been no elimination
			 period.
4) A new disability
			 connected with a previous disability which had a duration of at least one year
			 and terminated within six months of the new disability shall be considered a
			 continuation of the previous disability.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2004 - ACCIDENT AND HEALTH RESERVES › Section 2004.50 - Policies Issued Prior to Operative Date of Section 353a

Current through Register Vol. 48, No. 28, July 12, 2024
Any company may elect to establish and maintain reserves for
				policies issued prior to the operative date of Section 353a of the Code in
				accordance with the standards prescribed by Section 353a of the Code. In making
				such election a company may elect to revalue all previous issues or at its
				option may revalue only certain blocks of issues as determined by issue date or
				plan of coverage. Claim reserves may be revalued independent of active life
				reserves. Such election shall be made by filing written notice with the
				Director, stating the effective date of election and identifying the reserves
				or issues of policies to be revalued.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2005 - PRE-EXISTING ILLNESS › Section 2005.10 - Authority

Current through Register Vol. 48, No. 28, July 12, 2024
This Rule is issued by the Director of Insurance pursuant to
				Section 401 of the Illinois Insurance Code and it implements especially
				Sections 143, 359a and 154 of the Illinois Insurance Code by establishing
				minimum standards for the terms "pre-existing illness" or "pre-existing
				conditions" as constructed by definition of sickness and the provisions for
				Time Limit on Certain Defenses used in accident and health insurance
				policies.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2005 - PRE-EXISTING ILLNESS › Section 2005.20 - Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Part shall
			 apply to individual and group accident and health insurance policies to the
			 extent that they provide benefits and coverage that fall under an excepted
			 benefits plan and to all other individual and group insurance policies that are
			 not subject to 50 Ill. Adm. Code
			 2001.5
			 or 50 Ill. Adm. Code 2008.
b) For
			 purposes of this Part, the term "excepted benefits" means benefits under one or
			 more (or any combination) of the following:
1) Benefits not subject to requirements:
A) Coverage only for accident, or disability
			 income insurance, or any combination thereof;
B) Coverage issued as a supplement to
			 liability insurance;
C) Liability
			 insurance, including general liability insurance and automobile liability
			 insurance;
D) Workers' compensation
			 or similar insurance;
E) Automobile
			 medical payment insurance;
F)
			 Credit-only insurance;
G) Coverage
			 for on-site medical clinics; or
H)
			 Other similar insurance coverage, specified in this Chapter, under which
			 benefits for medical care are secondary or incidental to other insurance
			 benefits.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2005 - PRE-EXISTING ILLNESS › Section 2005.30 - The Minimum Definition of Pre-existing Illness or Pre-existing Condition

Current through Register Vol. 48, No. 28, July 12, 2024
a) A "pre-existing
			 illness" or "pre-existing condition" as constructed by the definition of
			 sickness and the provisions for Time Limit on Certain Defenses in an accident
			 and health insurance policy issued after the effective date of this Part shall
			 mean any disease, illness, sickness, malady or condition which was:
1) diagnosed or treated by a legally
			 qualified physician prior to the effective date of coverage for the insured
			 with consultation, advice or treatment by a legally qualified physician
			 occurring within 24 months prior to the effective date of coverage for the
			 insured; or
2) diagnosed or treated
			 by a legally qualified physician prior to the effective date of coverage for
			 the insured, but a legally qualified physician demonstrates that there is a
			 reasonable medical question that the disease, illness, sickness, malady or
			 condition involved did continue within 24 months prior to the effective date of
			 coverage for the insured without the necessity of consultation, advice or
			 treatment by a legally qualified physician; or
3) evident because there was a clear,
			 distinct symptom or symptoms of the disease, illness, sickness, malady or
			 condition demonstrable prior to the effective date of coverage for the insured
			 with the occurrence of such symptoms being evident within 12 months prior to
			 the effective date of coverage for the insured and in which, in the opinion of
			 a legally qualified physician, would;
A)
			 indicate that the diseases, illness, sickness, malady or condition probably
			 began and manifested itself before the effective date of the coverage for the
			 insured, and
B) would cause an
			 ordinarily prudent person to seek diagnosis, care or treatment.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2005 - PRE-EXISTING ILLNESS › Section 2005.40 - Application of the Definition

Current through Register Vol. 48, No. 28, July 12, 2024
a) In
			 applying Section
			 2005.30
			 to determine if an insured received consultation, advice or treatment from a
			 physician for a disease, illness, sickness, malady or condition, the
			 consultation, advice or treatment must be clearly indicated in the insured's
			 medical records or from the statements of the insured's legally qualified
			 physician or other relevant evidence.
1) If
			 an application contains conflicting answers, or if an answer is clearly
			 incomplete, the insurer has an obligation to investigate further. For example,
			 if a question about medical history is answered with the name of a physician,
			 but there is no statement concerning the condition treated or the reason for
			 the visit, the insurer has an obligation to investigate further. An insurer
			 failing to make that investigation and then taking appropriate action would be
			 estopped from using a "pre-existing condition" or "pre-existing illness" as
			 grounds for denying the claim or rescinding the policy for the particular
			 disease, illness, sickness, malady or condition.
2) If a particular disease, illness,
			 sickness, malady or condition was not diagnosed by a legally qualified
			 physician before the effective date of the coverage for the insured, but
			 symptomatology was evident regardless of consultation, advice or treatment by a
			 legally qualified physician, the disease or condition will not be considered
			 pre-existing if there were interrogatories appropriate to the symptoms on the
			 application for insurance and if the symptoms were disclosed on the application
			 for insurance and the insurer did not make an investigation and take
			 appropriate action.
3) If there was
			 no application or the interrogatories on any application for insurance were not
			 appropriate to the symptoms, a legally qualified physician must decide if the
			 symptomatology was sufficient prior to the effective date of the policy to make
			 a diagnosis and demonstrate manifestation of the disease, illness, sickness,
			 malady or condition.
4) In the
			 administration of this Section, if the Medical Director, similar employee or
			 other physician retained by the insurer who qualifies as a legally qualified
			 physician decides the medical questions of Section
			 2005.30(a)(2)
			 or (a)(3), the physician shall notify either
			 the insured or his or her attending physician or other legally qualified
			 physician of the insured of all of the relevant facts supporting the decision.
			 If the attending physician or other legally qualified physician of the insured
			 offers facts that demonstrate there is good reason that the disease, illness,
			 sickness, malady or condition did not exist prior to the effective date of
			 coverage for the insured, the definition of a pre-existing illness must be
			 construed favorably for the insured.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2005 - PRE-EXISTING ILLNESS › Section 2005.50 - Policy Form Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
All policies which exclude the payment of a claim due to a
				"Pre-existing Illness" or "Pre-existing Condition" as constructed by terms used
				in the definition of illness or insuring clause of a policy such as
				"manifests", "beings", "commences", etc., shall contain a definition of these
				terms within any policy or contain a provision defining the terms "Pre-existing
				Illness" or "Pre-existing Conditions" within any policy approved by the
				Department of Insurance on or after the effective date of this
				Rule.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2005 - PRE-EXISTING ILLNESS › Section 2005.60 - Effective Date

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Part shall
			 be effective October 30, 1974.
b)
			 For all policies which were approved by the Director of Insurance before the
			 effective date of this Part shall, for all such policies issued or delivered in
			 this State after the effective date of this Part, administer the term
			 "pre-existing illness" or other such terms in accordance with the requirements
			 of this Part.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2007 - MINIMUM STANDARDS OF INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 2007.10 - Authority

Current through Register Vol. 48, No. 28, July 12, 2024
This Part is issued by the Director of Insurance pursuant to
				Section 401 of the Illinois Insurance Code [215 ILCS
				5/401 ] which empowers the Director ". . . to make
				reasonable rules and regulations as may be necessary for making effective . .
				." the insurance laws of this State. This Part implements Section 355a of the
				Illinois Insurance Code [215 ILCS
				5/355a ].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2007 - MINIMUM STANDARDS OF INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 2007.20 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
The purpose of this Part is to define terms, establish minimum
				standards for benefits, prohibit certain policy provisions and require
				disclosure provisions and replacement procedures in relation to policies of
				individual accident and health insurance.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2007 - MINIMUM STANDARDS OF INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 2007.30 - Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Part
			 applies to all individual accident and health insurance policies except that it
			 does not apply to individual policies issued pursuant to a conversion privilege
			 under a policy of group or individual insurance when the individual policy
			 includes provisions that are inconsistent with the requirements of this Part,
			 nor to policies being issued to employees or members as additions to franchise
			 plans in existence prior to July 17, 1978.
b) The requirements contained in this Part
			 are in addition to any other applicable regulations.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2007 - MINIMUM STANDARDS OF INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 2007.40 - Revision of Noncomplying Policy Form and Subscriber Contracts Certificate of Compliance Required

Current through Register Vol. 48, No. 28, July 12, 2024
a) Any policy
			 as defined in Section 355a of the Illinois Insurance Code [215 ILCS
			 5/355a ] previously filed and approved by the Director
			 need not be refiled if such policy is in compliance with the requirements of
			 this Part. Any previously approved policy which does not comply with the
			 requirements of this Part shall be amended by rider or revised and resubmitted
			 in duplicate with a duplicate letter of transmittal.
b) All forms and contracts required to be
			 revised and resubmitted by this Part shall be accompanied by a Certificate of
			 Compliance as required by 50 Ill. Adm. Code 916.Exhibit A.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2007 - MINIMUM STANDARDS OF INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 2007.60 - Prohibited Policy Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 Except as provided in the Section
			 2007.50 definition of
			 "sickness", no policy shall contain provisions establishing a probationary or
			 waiting period during which no coverage is provided under the policy. An
			 excepted benefit policy may specify a probationary or waiting period not to
			 exceed six months for specified diseases or conditions and losses resulting
			 therefrom for hernia, varicose veins, adenoids, appendix and tonsils. However,
			 the permissible six months exception shall not be applicable when the specified
			 diseases or conditions are treated on an emergency basis. Accident policies
			 shall not contain a probationary or waiting period.
b) No policy or rider for additional coverage
			 may be issued as a dividend unless an equivalent cash payment is offered to the
			 policyholder as an alternative to the dividend policy or rider. No such
			 dividend policy or rider shall be issued for an initial term of less than six
			 months.
c) A disability policy,
			 hospital confinement indemnity policy or specified disease policy may contain a
			 "return of premium" or "cash value benefit" so long as:
1) The policy provides for a return of 100%
			 of all premiums paid less the claims incurred by the time the insured attains
			 age 65. A percentage of less than 100%, but greater than 50%, is permissible if
			 the "return of premium" or "cash value benefit" has been in force for 10 years
			 or less;
2) The policy contains a
			 reasonable nonforfeiture benefit and provides for the value to be paid
			 automatically upon lapse or death;
3) The surrender value percentages are not
			 less than those calculated assuming 1958 Commissioners Standard Ordinary
			 Mortality, 5% interest and 5 year preliminary term;
4) An acceptable method of reserving is
			 approved by the Director concurrent with approval of the policy. Reserves
			 should exceed or equal the cash value at all durations;
5) The surrender value percentages are
			 calculated assuming a zero percent future claim offset;
6) The surrender value percentages are
			 defined for all policy years (surrender value percentages may be shown only for
			 the first 20 policy years, but under these conditions the contract shall define
			 the method used to determine the surrender value percentages after the
			 20th contract year);
7) The interim surrender value percentages
			 are defined when premiums are paid within a contract year;
8) The policy does not tie the return of
			 premium to anything less than 100% of the premiums paid less claims
			 paid.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2007 - MINIMUM STANDARDS OF INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 2007.100 - Severability

Current through Register Vol. 48, No. 28, July 12, 2024
If any provision of this Part or the application thereof to any
				person or circumstances is for any reason held to be invalid, the remainder of
				the Part and the application of such provision to other persons or
				circumstances shall not be affected thereby.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart A - GENERAL PROVISIONS › Section 2008.10 - Authority

Current through Register Vol. 48, No. 28, July 12, 2024
This Part is issued by the Director of the Department of
				  Financial and Professional Regulation-Division of Insurance (Director) pursuant
				  to Section 401 of the Illinois Insurance Code [215 ILCS
				  5/401 ] which empowers the Director to make reasonable
				  rules and regulations as may be necessary for making effective the insurance
				  laws of this State. This Part implements Sections 363 and 363a of the Illinois
				  Insurance Code [215 ILCS 5/363 and 363 a].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart A - GENERAL PROVISIONS › Section 2008.20 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
The purpose of this Part is to provide for the reasonable
				  standardization of coverage and simplification of terms and benefits of
				  Medicare supplement policies; to facilitate public understanding and comparison
				  of such policies; to eliminate provisions contained in such policies which may
				  be misleading or confusing in connection with the purchase of such policies or
				  with the settlement of claims; and to provide for full disclosures in the sale
				  of accident and sickness insurance coverages to persons eligible for
				  Medicare.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart A - GENERAL PROVISIONS › Section 2008.30 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
a) Except
				as otherwise specifically provided in Sections
				2008.70,
				2008.75,
				2008.76,
				2008.80,
				2008.90
				and
				2008.103
				of this Part, this Part shall apply to:
1)
				All Medicare supplement policies delivered or issued for delivery in this State
				on or after June 1, 1982; and
2)
				All certificates issued under group Medicare supplement policies, which
				policies or contracts have been delivered or issued for delivery in this
				State.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart B - COVERAGE, POLICY & BENEFIT PROVISIONS › Section 2008.45 - Creditable coverage

Current through Register Vol. 48, No. 28, July 12, 2024
Creditable coverage means:
a) With respect to an individual, coverage of
				the individual provided under any of the following:
1) A group health plan;
2) Health insurance coverage;
3) Part A or Part B of Title XVIII of the
				Social Security Act (Medicare);
4)
				Title XIX of the Social Security Act (Medicaid), other than coverage consisting
				solely of benefits under Section 1928;
5) Chapter 55 (CHAMPUS) (10 USC);
6) A medical care program of the Indian
				Health Service or of a tribal organization;
7) A state health benefits risk
				pool;
8) A health plan offered
				under Chapter 89 (Federal Employees Health Benefits Program) (5 USC);
9) A public health plan as defined in federal
				regulation; and
10) A health
				benefit plan under Section 5(e) of the Peace Corps Act (
				22 USC
				2504(e) ).
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart B - COVERAGE, POLICY & BENEFIT PROVISIONS › Section 2008.60 - Policy Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
a) Except
				for permitted preexisting condition clauses as described in Section
				2008.70(a)(1),
				Section
				2008.71(a)(1),
				and Section
				2008.64(a)(1)
				of this Part, no policy or certificate may be advertised, solicited or issued
				for delivery in this State as a Medicare supplement policy if such policy or
				certificate contains limitations or exclusions on coverage that are more
				restrictive than those of Medicare.
b) No Medicare supplement policy or
				certificate may use waivers to exclude, limit, or reduce coverage or benefits
				for specifically named or described preexisting diseases or physical
				conditions.
c) No Medicare
				supplement policy or certificate in force in the State shall contain benefits
				which duplicate benefits provided by Medicare.
d) Subject to Sections
				2008.70(a)(4),
				(5) and (7) and
				2008.71(a)(4)
				and (5):
1)
				A Medicare supplement policy with benefits for outpatient prescription drugs in
				existence prior to January 1, 2006 shall be renewed for current policyholders
				who do not enroll in Part D at the option of the policyholder.
2) A Medicare supplement policy with benefits
				for outpatient prescription drugs shall not be issued after December 31,
				2005.
3) After December 31, 2005, a
				Medicare supplement policy with benefits for outpatient prescription drugs will
				not be renewed after the policyholder enrolls in Medicare Part D unless:
A) The policy is modified to eliminate
				outpatient prescription coverage for expenses of outpatient prescription drugs
				incurred after the effective date of the individual's coverage under a Part D
				plan; and
B) Premiums are adjusted
				to reflect the elimination of outpatient prescription drug coverage at the time
				of Medicare Part D enrollment, accounting for any claims paid, if
				applicable.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart B - COVERAGE, POLICY & BENEFIT PROVISIONS › Section 2008.63 - Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020

Current through Register Vol. 48, No. 28, July 12, 2024
The Medicare Access and CHIP Reauthorization Act of 2015
				  (MACRA) (P.L.
				  114-10, added
				  42 USC
				  1395ss(z)), which imposes
				  the following standards on all Medicare supplement policies or certificates
				  delivered or issued for delivery in this State to individuals newly eligible
				  for Medicare on or after January 1, 2020. No policy or certificate that
				  provides coverage of the Medicare Part B deductible may be advertised,
				  solicited, delivered, or issued for delivery in this State as a Medicare
				  supplement policy or certificate to individuals newly eligible for Medicare on
				  or after January 1, 2020. All policies must comply with the following benefit
				  plan standards. Benefit plan standards applicable to Medicare supplement
				  policies and certificates issued to individuals eligible for Medicare before
				  January 1, 2020 remain subject to the requirements of Section
				  2008.70 for Pre-Standardized
				  Plans, Section 2008.71 for 1990 Plans, or
				  Section 2008.64 for 2010 Plans.
a) Benefit Requirement. The standards and
				requirements of Section
				2008.67 shall apply to all
				Medicare supplement policies or certificates delivered or issued for delivery
				to individuals newly eligible for Medicare on or after January 1, 2020, with
				the following exceptions:
1) Standardized
				Medicare Supplement Benefit Plan C is redesignated as Plan D and shall provide
				the benefits contained in Section
				2008.67(f)(3)
				but shall not provide coverage for 100% or any portion of the Medicare Part B
				deductible.
2) Standardized
				Medicare Supplement Benefit Plan F is redesignated as Plan G and shall provide
				the benefits contained in Section
				2008.67(f)(5)
				but shall not provide coverage for 100% or any portion of the Medicare Part B
				deductible.
3) Standardized
				Medicare Supplement Benefit Plans C, F and F with High Deductible may not be
				offered to individuals newly eligible for Medicare on or after January 1,
				2020.
4) Standardized Medicare
				Supplement Benefit Plan F with High Deductible is redesignated as Plan G with
				High Deductible and shall provide the benefits contained in Section
				2008.67(f)(6)
				but shall not provide coverage for 100% or any portion of the Medicare Part B
				deductible. In addition, the Medicare Part B deductible paid by the beneficiary
				shall be considered an out-of-pocket expense in meeting the annual high
				deductible.
5) The reference to
				Plans C or F contained in Section
				2008.67(b) is
				deemed a reference to Plans D or G, respectively, for purposes of this
				Section.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart B - COVERAGE, POLICY & BENEFIT PROVISIONS › Section 2008.73 - Medicare Select Policies and Certificates

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Section shall apply to Medicare
				Select policies and certificates, as defined in this Section. No policy or
				certificate may be advertised as a Medicare Select policy or certificate unless
				it meets the requirements of this Section.
b) For the purposes of this Section:
1) "Complaint" means any dissatisfaction
				expressed by an individual concerning a Medicare Select issuer or its network
				providers.
2) "Grievance" means
				dissatisfaction expressed in writing by an individual insured under a Medicare
				Select policy or certificate with the administration, claims practices, or
				provision of services concerning a Medicare Select issuer or its network
				providers.
3) "Medicare Select
				Issuer" means an issuer offering, or seeking to offer, a Medicare Select policy
				or certificate.
4) "Medicare Select
				Policy" or "Medicare Select Certificate" means respectively a Medicare
				supplement policy or certificate that contains restricted network
				provisions.
5) "Network Provider"
				means a provider of health care, or a group of providers of health care, which
				has entered into a written agreement with the issuer to provide benefits
				insured under a Medicare Select policy.
6) "Restricted Network Provision" means any
				provision which conditions the payment of benefits, in whole or in part, on the
				use of network providers.
7)
				"Service Area" means the geographic area approved by the Director within which
				an issuer is authorized to offer a Medicare Select policy.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart C - ENROLLMENT & ELIGIBILITY › Section 2008.74 - Open Enrollment

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Notwithstanding any Medicare Part B late enrollment penalty, no issuer shall
				deny or condition the issuance or effectiveness of any Medicare supplement
				policy or certificate available for sale in this State, nor discriminate in the
				pricing of such a policy or certificate because of the health status, claims
				experience, receipt of health care, or medical condition of an applicant in the
				case of an application for a policy or certificate that is submitted prior to
				or during the 6 month period beginning with the first day of the month in which
				an individual is both 65 years of age or older and is enrolled for benefits
				under Medicare Part B. Each Medicare supplement policy and certificate
				currently available from an insurer shall be made available to all applicants
				who qualify under this subsection (a) without regard to age.
b) If an applicant qualifies under subsection
				(a) and submits an application during the time period referenced in subsection
				(a) and, as of the date of application, has had a continuous period of
				creditable coverage:
1) Of at least 6 months,
				the issuer shall not exclude benefits based on a preexisting condition,
				or
2) That is less than 6 months,
				the issuer shall reduce the period of any preexisting condition exclusion by
				the aggregate of the period of creditable coverage applicable to the applicant
				as of the enrollment date. The Secretary shall specify the manner of the
				reduction under this subsection (b)(2).
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart C - ENROLLMENT & ELIGIBILITY › Section 2008.75 - Guaranteed Issue for Eligible Persons

Current through Register Vol. 48, No. 28, July 12, 2024
All Medicare supplement insurance policies shall be
				  guaranteed issue to eligible persons who meet the requirements of this Section
				  (see 42 U.S.C.
				  1395ss(s)).
a) Guaranteed Issue
1) Eligible persons are those individuals
				described in subsection (b) who seek to enroll under the policy during the
				period specified in subsection (c), and who submit evidence of the date of
				termination, disenrollment, or Medicare Part D enrollment with the application
				for a Medicare supplement policy.
2) With respect to eligible persons, an
				issuer shall not deny or condition the issuance or effectiveness of any
				Medicare supplement policy or certificate described in subsection (e) that is
				offered and is available for issuance to new enrollees by the issuer; shall not
				discriminate in the pricing of such a Medicare supplement policy because of
				health status, claims experience, receipt of health care, or medical condition;
				and shall not impose an exclusion of benefits based on a preexisting condition
				under such a Medicare supplement policy.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart D - CLAIMS, REFUNDS & CREDITS › Section 2008.76 - Standards for Claims Payment

Current through Register Vol. 48, No. 28, July 12, 2024
a) An
				issuer shall comply with Section 1882(c)(3) of the Social Security Act (as
				enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of
				1987 (OBRA) ( P.L. 100-203 )) by:
1)
				Accepting a notice from a Medicare carrier on dually assigned claims submitted
				by participating physicians and suppliers as a claim for benefits in place of
				any other claim form otherwise required and making a payment determination on
				the basis of the information contained in that notice;
2) Notifying the participating physician or
				supplier and the beneficiary of the payment determination;
3) Paying the participating physician or
				supplier directly;
4) Furnishing,
				at the time of enrollment, each enrollee with a card listing the policy name,
				number, and a central mailing address to which notices from a Medicare carrier
				may be sent;
5) Paying user fees
				for claim notices that are transmitted electronically or otherwise;
				and
6) Providing to the Secretary
				of Health and Human Services, at least annually, a central mailing address to
				which all claims may be sent by Medicare carriers.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart D - CLAIMS, REFUNDS & CREDITS › Section 2008.80 - Loss Ratio Standards and Refund or Credit of Premium

Current through Register Vol. 48, No. 28, July 12, 2024
a) Loss Ratio Standards.
1) A Medicare supplement policy form or
				certificate form shall not be delivered or issued for delivery unless the
				policy form or certificate form:
A) Can be
				expected, as estimated for the entire period for which rates are computed to
				provide coverage, to return to policyholders and certificateholders in the form
				of aggregate benefits (not including anticipated refunds or credits) provided
				under the policy form or certificate form:
i)
				At least 75% of the aggregate amount of premiums earned in the case of group
				policies; or
ii) At least 65% of
				the aggregate amount of premiums earned in the case of individual
				policies.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart E - RATES, COMPENSATION AGREEMENT, DISCLOSURE, REPLACEMENT & MARKETING › Section 2008.81 - Filing and Approval of Policies and Certificates and Premium Rates

Current through Register Vol. 48, No. 28, July 12, 2024
a) An issuer shall
				not deliver or issue for delivery a policy or certificate to a resident of this
				State unless the policy form or certificate form has been filed with and
				approved by the Director pursuant to 50 Ill. Adm. Code 916.
b) An issuer shall file any riders or
				amendments to policy or certificate forms to delete outpatient prescription
				drug benefits as required by the Medicare Prescription Drug, Improvement, and
				Modernization Act of 2003 only with the Director in the state in which the
				policy or certificate was issued.
c) An issuer shall not use or change premium
				rates for a Medicare supplement policy or certificate unless the rates, rating
				schedule and supporting documentation have been filed with and approved by the
				Director pursuant to 50 Ill. Adm. Code 916.
d) Except as provided in subsection (d)(1),
				an issuer shall not file for approval more than one form of a policy or
				certificate of each type for each standard Medicare supplement benefit plan.
1) An issuer may offer, with the approval of
				the Director, up to four additional policy forms or certificate forms of the
				same type for the same standard Medicare supplement benefit plan, one for each
				of the following cases:
A) The inclusion of
				new or innovative benefits;
B) The
				addition of either direct response or producer marketing methods;
C) The addition of either guaranteed issue or
				underwritten coverage;
D) The
				offering of coverage to individuals eligible for Medicare by reason of
				disability.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart E - RATES, COMPENSATION AGREEMENT, DISCLOSURE, REPLACEMENT & MARKETING › Section 2008.82 - Permitted Compensation Arrangements

Current through Register Vol. 48, No. 28, July 12, 2024
a) An issuer or other entity may provide
				commission or other compensation to an insurance producer for the sale of a
				Medicare supplement policy or certificate only if the first year commission or
				other first year compensation is no more than 200% of the commission or other
				compensation paid for selling or servicing the policy or certificate in the
				second year or period.
b) The
				commission or other compensation provided in subsequent (renewal) years must be
				the same as that provided in the second year or period and must be provided for
				no fewer than five renewal years.
c) No issuer or other entity shall provide
				compensation to its insurance producers and no insurance producer shall receive
				compensation greater than the renewal compensation payable by the replacing
				issuer on renewal policies or certificates if an existing policy or certificate
				is replaced.
d) For purposes of
				this Section, "compensation" includes pecuniary or non-pecuniary remuneration
				of any kind relating to the sale or renewal of the policy or certificate
				including but not limited to bonuses, gifts, prizes, awards and finders
				fees.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart E - RATES, COMPENSATION AGREEMENT, DISCLOSURE, REPLACEMENT & MARKETING › Section 2008.91 - Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare

Current through Register Vol. 48, No. 28, July 12, 2024
a) Section 1882(d) of the federal Social
				Security Act prohibits the sale of health insurance policies (the term policy
				or policies includes certificates) that duplicate Medicare benefits unless the
				policy will pay benefits without regard to other health coverage and the policy
				includes the prescribed disclosure statement on, or together with, the
				application.
b) All types of health
				insurance policies that duplicate Medicare shall include one of the disclosure
				statements found in Appendix Q of this Part, according to the particular policy
				type involved, on the application or together with the application. The
				disclosure statement may not vary from those found in Appendix Q of this Part
				in terms of language or format (type size, type proportional spacing, bold
				character, line spacing, and usage of boxes around text).
c) State and Federal law prohibits insurers
				from selling a Medicare supplement policy to a person that already has a
				Medicare supplement policy except as a replacement.
d) Property/Casualty and Life insurance
				policies are not considered health insurance.
e) Disability income policies are not
				considered to provide benefits that duplicate Medicare.
f) Traditional Long-Term Care or Long-Term
				Care Partnership insurance policies that coordinate with Medicare and other
				health insurance are not considered to provide benefits that duplicate
				Medicare.
g) The Federal law does
				not preempt Illinois law.
h) The
				Federal law does not preempt existing Illinois form filing
				requirements.
i) Section 1882 of
				the federal Social Security Act was amended in subsection (d)(3)(A) to allow
				for alternative disclosure statements. The disclosure statements already in
				Appendix Q remain. Issuers may use either disclosure statements with the
				requisite insurance product. However, issuers should use either the original
				disclosure statements found in Appendix Q of this Part or the alternative
				disclosure statements, not use both simultaneously.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart E - RATES, COMPENSATION AGREEMENT, DISCLOSURE, REPLACEMENT & MARKETING › Section 2008.101 - Standards for Marketing

Current through Register Vol. 48, No. 28, July 12, 2024
a) An
				issuer, directly or through its producers, shall:
1) Establish fair and accurate marketing
				procedures which comply with the standards set forth in Section 363a(5) and (6)
				of the Code.
2) Establish marketing
				procedures to assure duplicative insurance benefits are not sold or
				issued.
3) Display prominently by
				type, stamp or other appropriate means, on the first page of the policy, the
				following:
"Notice to buyer: This policy may not cover all of your
				  medical expenses."
4)
				Inquire and otherwise make every reasonable effort to identify whether a
				prospective applicant or enrollee for Medicare supplement insurance already has
				accident and sickness insurance and the types and amounts of such
				insurance.
5) Establish auditable
				procedures for verifying compliance with this subsection (a).
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart E - RATES, COMPENSATION AGREEMENT, DISCLOSURE, REPLACEMENT & MARKETING › Section 2008.102 - Appropriateness of Recommended Purchase and Excessive Insurance

Current through Register Vol. 48, No. 28, July 12, 2024
a) In recommending
				the purchase or replacement of any Medicare supplement policy or certificate,
				an insurance producer shall make reasonable efforts to determine the
				appropriateness of a recommended purchase or replacement. For purposes of this
				subsection the insurer will be deemed to make reasonable efforts to determine
				the appropriateness of the recommended purchase if the insurer complies with
				the standards set forth in Sections 363a(5) and (6) of the Code.
b) Any sale of a Medicare supplement policy
				or certificate that will provide an individual more than one Medicare
				supplement policy or certificate is prohibited.
c) An issuer shall not issue a Medicare
				supplement policy or certificate to an individual enrolled in Medicare Part C
				unless the effective date of the coverage is after the termination date of the
				individual's Part C coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart F - REPORTING & PROHIBITIONS › Section 2008.103 - Reporting of Multiple Policies

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				On or before March 1 of each year an issuer shall report the following
				information prescribed in Appendix P of this Part for every individual resident
				of this State for which the issuer has in force more than one Medicare
				supplement policy or certificate:
1) Policy
				and certificate number, and
2) Date
				of issuance.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart F - REPORTING & PROHIBITIONS › Section 2008.104 - Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates

Current through Register Vol. 48, No. 28, July 12, 2024
a) If a Medicare
				supplement policy or certificate replaces another Medicare supplement policy or
				certificate, the replacing issuer shall waive any time periods applicable to
				preexisting conditions, waiting periods, elimination periods and probationary
				periods in the new Medicare supplement policy or certificate for similar
				benefits to the extent such time was spent under the original policy.
b) If a Medicare supplement policy or
				certificate replaces another Medicare supplement policy or certificate which
				has been in effect for at least six months, the replacing policy shall not
				provide any time period applicable to preexisting conditions, waiting periods,
				elimination periods and probationary periods for benefits similar to those
				contained in the original policy or certificate.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart F - REPORTING & PROHIBITIONS › Section 2008.107 - Prohibition Against Use of Genetic Information and Requests for Genetic Testing

Current through Register Vol. 48, No. 28, July 12, 2024
This Section applies to all policies with policy years
				  beginning on or after May 21, 2009.
a)
				An issuer of a Medicare supplement policy or certificate;
1) shall not deny or condition the issuance
				or effectiveness of the policy or certificate (including the imposition of any
				exclusion of benefits under the policy based on a pre-existing condition) on
				the basis of the genetic information with respect to such individual;
				and
2) shall not discriminate in
				the pricing of the policy or certificate (including the adjustment of premium
				rates) of an individual on the basis of the genetic information with respect to
				such individual.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Section 2008.110 - Severability

Current through Register Vol. 48, No. 28, July 12, 2024
If any provision of this Part or the application thereof to
				  any person or circumstances is for any reason held to be invalid, the remainder
				  of this Part and the application of such provision to other persons or
				  circumstances shall not be affected thereby.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix A - Policy Checklist

Current through Register Vol. 48, No. 28, July 12, 2024
Applicant's Name
				  ________________________________________________________
Policy Number
				  ___________________________________________________________
Name of Existing Insurer
				  ___________________________________________________
Expiration Date of Existing Insurance
				  __________________________________________
SERVICE
BENEFIT
MEDICARE PAYS
EXISTING COVERAGE
SUPPLEMENT PAYS
YOU PAY
Hospital
Inpatient
First 60 Days
All But ($ )
61st to
							 90th Day
All But ($ ) a Day
91st to
							 150th Day (Lifetime Reserve)
($ ) a Day
Beyond 150 Days
Nothing
Skilled Nursing Home Care
First 20 Days Additional 80 Days
100% of Cost All But ($ ) A Day
Beyond 100 Days
Nothing
Medical Expense
Physician's Services in hospital, office or home,
							 inpatient and out-patient medical services and supplies at a hospital, physical
							 and speech therapy and ambulance
80% of Medicare Determined allowable charges
							 after
($ ) Deductible
Prescription Drugs
Inpatient Prescription Drugs. 80% of allowable
							 charges for immunosuppressive drugs during the first year following a covered
							 transplant.
This policy does/does not comply with the minimum standards
				  set forth in Section 363 of the Illinois Insurance Code.
DATE __________________ SIGNATURE OF APPLICANT
				  _________________________
SIGNATURE OF INSURANCE
				  PRODUCER
Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart G - MISCELLANEOUS PROVISIONS › Appendix S - Medicare Supplement Refund Calculation Format

Current through Register Vol. 48, No. 28, July 12, 2024
Click here to view
				  image
Click here to view
				  image
Click here to view
				  image
Click here to view
				  image