reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Section 2012.130 - Standard Format Outline of Coverage Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
This Section implements, interprets and makes specific the
				provisions of Section 351A-8 of the Code in prescribing a standard format and
				the content of an outline of coverage.
a) The outline of coverage shall be a
			 free-standing document, using no smaller than ten point type.
b) The outline of coverage shall contain no
			 material of an advertising nature.
c) Text which is capitalized or underscored
			 in the standard format outline of coverage may be emphasized by other means
			 which provide prominence equivalent to such capitalization or
			 underscoring.
d) Use of the text
			 and sequence of text of the standard format outline of coverage is mandatory
			 unless otherwise specifically indicated.
e) The standard format, including style,
			 arrangement and overall appearance, and the content of an outline of coverage
			 appears in Exhibit C of this Part.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Section 2012.140 - Requirement to Deliver Shopper's Guide

Current through Register Vol. 48, No. 28, July 12, 2024
a) A long-term care insurance shopper's guide
			 in the format developed by the National Association of Insurance Commissioners,
			 or a guide developed or approved by the Director shall be provided to all
			 prospective applicants of a long-term care insurance policy or certificate.
1) In the case of insurance producer
			 solicitations, a producer must deliver the shopper's guide prior to the
			 presentation of an application or enrollment form.
2) In the case of direct response
			 solicitations, the shopper's guide must be presented in conjunction with any
			 application or enrollment form.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Section 2012.145 - Long-Term Care Insurance Partnership Program

Current through Register Vol. 48, No. 28, July 12, 2024
a) In accordance with section 6021 of the
			 Deficit Reduction Act of 2005 (
			 42 USC
			 1305 ) and the Illinois Long-Term Care
			 Partnership Program Act [215 ILCS 132 ], in addition to the applicable
			 provisions of this Part, the provisions of this Section shall apply to any
			 qualified State long-term care insurance partnership policy.
b) The policy provides the following
			 inflation protections:
1) If the policy is
			 sold to an individual who has not attained age 61 as of the date of purchase,
			 the policy shall provide compound annual inflation protection at a rate of at
			 least 3%, or at a rate based on the changes in the Consumer Price Index for All
			 Urban Consumers: U.S. city average as determined by the Bureau of Labor
			 Statistics of the U.S. Department of Labor.
2) If the policy is sold to an individual who
			 has attained age 61 but has not attained age 76 as of the date of purchase, the
			 policy shall provide inflation protection expressed in simple or compound
			 interest annually at a rate of at least 3% or at a rate based on the changes in
			 the Consumer Price Index for All Urban Consumers: U.S. city average as
			 determined by the Bureau of Labor Statistics of the U.S. Department of
			 Labor.
3) If the policy is sold to
			 an individual who has attained age 76 as of the date of purchase, the policy
			 may, but is not required to, provide some level of inflation
			 protection.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Section 2012.150 - Penalties

Current through Register Vol. 48, No. 28, July 12, 2024
In addition to any other penalties provided by the laws of this
				State any insurer or any insurance producer found to have violated any
				requirement of this State relating to the regulation of long-term care
				insurance or the marketing of such insurance shall be subject to a fine of up
				to 3 times the amount of any commissions paid for each policy involved in the
				violation or up to $10,000, whichever is greater.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Exhibit B - Replacement Notice for Direct Response Solicitations

Current through Register Vol. 48, No. 28, July 12, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
				SICKNESS OR LONG-TERM CARE INSURANCE
[Insurance Company's Name and Address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE
				FUTURE.
According to [your application] [information you have
				furnished], you intend to lapse or otherwise terminate existing accident and
				sickness or long-term care insurance and replace it with the long-term care
				insurance policy delivered herewith issued by [Company Name] Insurance Company.
				Your new policy provides 30 days within which you may decide, without cost,
				whether you desire to keep the policy. For your own information and protection,
				you should be aware of and seriously consider certain factors which may affect
				the insurance protection available to you under the new policy.
You should review this new coverage carefully, comparing it
				will all accident and sickness or long-term care insurance coverage you now
				have, and terminate your present policy only if, after due consideration, you
				find that purchase of this long-term coverage is a wise decision.
1. Health conditions which you may presently
			 have (preexisting conditions), may not be immediately or fully covered under
			 the new policy. This could result in denial or delay in payment of benefits
			 under the new policy, whereas a similar claim might have been payable under
			 your present policy.
2. State law
			 provides that your replacement policy or certificate may not contain new
			 preexisting conditions or probation periods. Your insurer will waive any time
			 periods applicable to preexisting conditions or probationary periods in the new
			 policy (or coverage) for similar benefits to the extent such time was spent
			 (depleted) under the original policy.
3. If you are replacing existing long-term
			 care insurance coverage you may wish to secure the advice of your present
			 insurer or its insurance producer regarding the proposed replacement of your
			 present policy. This is not only your right, but it is also in your best
			 interest to make sure you understand all the relevant factors involved in
			 replacing your present coverage.
4.
			 [To be included only if the application is attached to the policy.] If, after
			 due consideration, you still wish to terminate you present policy and replace
			 it with new coverage, read the copy of the application attached to your new
			 policy and be sure that all questions are answered fully and correctly.
			 Omissions or misstatements in the application could cause an otherwise valid
			 claim to be denied. Carefully check the application and write to [Company Name
			 and Address] within 30 days if any information is not correct and complete, or
			 if any past medical history has been left out of the application.
____________________________________
(Company Name)
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Exhibit D - Rescission Reporting Format

Current through Register Vol. 48, No. 28, July 12, 2024
RESCISSION REPORTING FORMS FOR LONG-TERM CARE
				POLICIES FOR THE STATE OF ILLINOIS FOR THE REPORTING YEAR 20[ ]
Company Name:
				________________________________________________
Address:
				______________________________________________________
____________________________________________________________
Phone Number:
				__________________________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of
				long-term care insurance policies or certificates. Those rescissions
				voluntarily effectuated by an insured are not required to be included in this
				report. Please furnish one form per rescission.
Policy Form #
Policy and Certificate #
Name of Insured
Date of Policy Issuance
Date/s Claim/s Submitted
Date of Rescission
Detailed reason for rescission:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
_____________________________
Signature
_____________________________
Name and Title (please type)
_____________________________
Date
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Exhibit H - Long-Term Care Insurance Suitability Letter

Current through Register Vol. 48, No. 28, July 12, 2024
Dear [Applicant]:
Your recent application for long-term care insurance included a
				"personal worksheet", which asked questions about your finances and your
				reasons for buying long-term care insurance. For your protection, State law
				requires us to consider this information when we review your application, to
				avoid selling a policy to those who may not need coverage.
[Your answers indicate that long-term care insurance may not
				meet your financial needs. We suggest that you review the information provided
				along with your application, including the booklet "Shopper's Guide to
				Long-Term Care Insurance" and the page titled "Things You Should Know Before
				Buying Long-Term Care Insurance." Your State insurance department also has
				information about long-term care insurance and may be able to refer you to a
				counselor free of charge who can help you decide whether to buy this
				policy.]
[You chose not to provide any financial information for us to
				review.]
We have suspended our final review of your application. If,
				after careful consideration, you still believe this policy is what you want,
				check the appropriate box below and return this letter to us within the next 60
				days. We will then continue reviewing your application and issue a policy if
				you meet our medical standards.
If we do not hear from you within the next 60 days, we will
				close your file and not issue you a policy. You should understand that you will
				not have any coverage until we hear back from you, approve your application and
				issue you a policy.
Please check one box and return in the enclosed
				envelope.
Yes, [although my worksheet indicates that long-term care
				insurance may not be a suitable purchase,] I wish to purchase this coverage.
				Please resume review of my application. [Delete the phrase in brackets if the
				applicant did not answer the questions about income.]
No. I have decided not to buy a policy at this time.
___________________________________________
APPLICANT'S
				SIGNATUREDATE
Please return to [issuer] at [address] by
				[date].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Exhibit I - Claims Denial Reporting Form: Long-Term Care Insurance

Current through Register Vol. 48, No. 28, July 12, 2024
Click here to view
				image
Instructions
The purpose of this format is to report all long-term care
				claim denials under in force long-term care insurance policies. "Denied" means
				a claim that is not paid for any reason other than for claims not paid for
				failure to meet the waiting period or because of an applicable preexisting
				condition.
State Data
Nationwide Data1
1
Total Number of Long-Term Care Claims Reported
2
Total Number of Long-Term Care Claims Denied/Not
						  Paid
3
Number of Claims Not Paid due to Preexisting Condition
						  Exclusion
4
Number of Claims Not Paid due to Waiting (Elimination)
						  Period Not Met
5
Net Number of Long-Term Care Claims Denied for
						  Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)
6
Percentage of Long-Term Care Claims Denied of Those
						  Reported (Line 5 Divided By Line 1)
7
Number of Long-Term Care Claims Denied due to:
8
* Long-Term Care Services Not Covered under the
						  Policy2
9
* Provider/Facility Not Qualified under the
						  Policy3
10
Benefit Eligibility Criteria Not
						  Met4
11
* Other
1 The nationwide data may be viewed
				as a more representative and credible indicator where the data for claims and
				denied for your state are small in number.
2 Example - home health care claim
				filed under a nursing home only policy.
3 Example - a facility that does not
				meet the minimum level of care requirements or the licensing requirements as
				outlined in the policy.
4 Example - a benefit trigger not
				met, certification by a licensed health care practitioner not provided, no plan
				of care.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Exhibit K - Replacement and Lapse Reporting Form

Current through Register Vol. 48, No. 28, July 12, 2024
Long-Term Care Insurance
Replacement and Lapse Reporting Form
For the State of
				______________________________
Reporting Year of
				____________________________
Company Name:
				___________________________________Due: June 30 annually
Company Address:
				_____________________________________________________
Company NAIC Number:
				_________________________________________________
Contact Person:
				_______________________________________________________
Phone Number:
				________________________________________________________
Instructions
The purpose of this form is to report on a statewide basis
				information regarding long-term care insurance policy replacements and lapses.
				Specifically, every insurer shall maintain records for each agent on that
				agent's amount of long-term care insurance replacement sales as a percent of
				the agent's total annual sales and the amount of lapses of long-term care
				insurance policies sold by the agent as a percent of the agent's total annual
				sales. The tables below should be used to report the 10% of the insurer's
				agents with the greatest percentages of replacements and lapses.
Listing of the 10% of Agents with the Greatest Percentage of
				Replacements
Agent's Name
Number of Policies Sold By This Agent
Number of Policies Replaced By This Agent
Number of Replacements As % of Number Sold By This
						  Agent
Listing of the 10% of Agents with the Greatest Percentage of
				Lapses
Agent's Name
Number of Policies Sold By This Agent
Number of Policies Lapsed By This Agent
Number of Lapses As % of Number Sold By This
						  Agent
Company Totals:
Percentage of Replacement Policies Sold to Total Annual
						  Sales
_______%
Percentage of Replacement Policies Sold to Policies in
						  Force (as of the end of the preceding calendar year)
_______%
Percentage of Lapsed Policies to Total Annual
						  Sales
_______%
Percentage of Lapsed Policies to Policies in Force (as
						  of the end of the preceding calendar year)
_______%
Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Exhibit M - Long-Term Care Insurance Partnership Certification Form

Current through Register Vol. 48, No. 28, July 12, 2024
Long-Term Care Insurance Partnership
				Certification Form
NOTE: This Form must be completed and submitted with each
				long-term care policy or certificate form for which the insurer is seeking
				Partnership qualification. A separate form must be completed for each policy
				form and a specimen copy of the form, including all riders and endorsements,
				must be attached. A long-term care insurance policy or certificate form may not
				be issued in Illinois as a partnership policy or certificate unless and until
				this form has been submitted to and approved by the Illinois Department of
				Insurance.
Under section 1917(b)(5)(B)(iii) of the Social Security Act (
				42 USC
				1396 p(b)(5)(B)(iii) ), the state insurance
				commissioner of a state implementing a qualified state long-term care insurance
				partnership ("Qualified Partnership") may certify that long-term care insurance
				policies (including certificates issued under a group insurance contract)
				covered under the Qualified Partnership meet certain consumer protection
				requirements, and policies so certified are deemed to satisfy those
				requirements. These consumer protection requirements are set forth in section
				1917(b)(5)(A) of the Social Security Act (
				42 USC
				1396 p(b)(5)(A) ) and principally include
				certain specified provisions of the Long-Term Care Insurance Model Regulation
				and Long-Term Care Insurance Model Act promulgated by the National Association
				of Insurance Commissioners (as adopted as of October 2000) (referred to herein
				as the "2000 Model Regulation" and "2000 Model Act", respectively).
Click here to view
				image
I.
GENERAL
			 INFORMATION
A.
Name, address and
			 telephone number of issuer:
__________________________________________________________
__________________________________________________________
__________________________________________________________
B.
Name, address, telephone number, and
			 email address (if available) of an employee of issuer who will be the contact
			 person for information relating to this form:
__________________________________________________________
__________________________________________________________
__________________________________________________________
C.
Policy form numbers (or
			 other identifying information, such as certificate series) for policies covered
			 by this Issuer Certification Form:
__________________________________________________________
__________________________________________________________
__________________________________________________________
Illinois Administrative Code › Title 50 - INSURANCE › Part 2013 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 2013.10 - Authority

Current through Register Vol. 48, No. 28, July 12, 2024
This Part is adopted and promulgated by the Director of
				Insurance pursuant to Section 367i of the Illinois Insurance Code (Ill. Rev.
				Stat. 1991, ch. 73, par. 979i) [215 ILCS
				5/367i ].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2013 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 2013.20 - Scope

Current through Register Vol. 48, No. 28, July 12, 2024
This Part is applicable to all group health or disability
				insurance contracts and group Health Maintenance Organization (HMO) contracts,
				issued for delivery in this State, renewed, amended or under which the level of
				benefits or premium is altered or modified, covering persons as employees of
				employers or as members of unions or associations.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2013 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 2013.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Accrued Liability" means liabilities established on the date
				an injury is sustained or an illness commences.
"Group Contract" means a contract for health or disability
				insurance or an HMO contract made with an employer or other entity that covers
				a group of persons, identified as individuals, because of their relationship to
				the covered entity.
"Prior Carrier" means the carrier of group health care coverage
				provided by the employer or other entity immediately prior to the effective
				date of discontinuance and which has or has not been replaced by a succeeding
				plan.
"Succeeding Carrier" means the carrier of group health coverage
				provided by an employer or other entity which is issued within 90 days after
				the discontinuance of the prior plan.
"Totally Disabled" means:
For employees, the inability of the covered employee to perform
				his or her regular or customary occupational duties because of injury or
				disease; and after benefits have been paid for 24 months, the covered person
				cannot perform the duties of any gainful occupation for which he or she is
				reasonably fitted by training, education or experience; or
For dependents or retired employees, the inability because of
				injury or disease to engage in substantially all of the normal activities of a
				person in good health of like age and sex.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2013 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 2013.40 - Effective Date of Discontinuance for Non-Payment of Premium

Current through Register Vol. 48, No. 28, July 12, 2024
a) If a group contract subject to this Part
			 provides for automatic discontinuance of the contract after a premium has
			 remained unpaid through the grace period allowed for such payment, the carrier
			 shall be liable for valid claims for covered losses incurred prior to the end
			 of the grace period. The carrier shall, however, be entitled to the premium due
			 for coverage provided during the grace period.
b) If the actions of the carrier after the
			 end of the grace period indicate that it considers the group contract as
			 continuing in force beyond the end of the grace period by continuing to
			 recognize claims subsequently incurred, the carrier shall be liable for valid
			 claims for losses beginning prior to the effective date of written notice of
			 discontinuance to the contract holders or other entity responsible for making
			 payments to the carrier. The effective date of discontinuance shall not be
			 prior to midnight at the end of the third scheduled work day after the date
			 upon which the notice is delivered.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2013 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 2013.50 - Requirements for Notice of Discontinuance

Current through Register Vol. 48, No. 28, July 12, 2024
a) Any notice of discontinuance so given by
			 the carrier shall advise the group contract holder to notify enrolled
			 individuals covered under the contract within 10 working days after receipt of
			 such notice of the date the group contract will discontinue and to advise,
			 unless otherwise provided in the contract, the carrier shall not be liable for
			 claims for losses incurred after the date of discontinuance.
b) In the instance in which the plan involves
			 employee contributions, if the contract holder continues to collect
			 contributions for the coverage after the date of discontinuance, the group
			 contract holder may be held solely liable for the benefits with respect to the
			 period for which the contributions have been collected.
c) Simultaneously with the notice of
			 discontinuance, the carrier shall furnish to the group contract holder a sample
			 of a notice form to be distributed to the enrolled individuals indicating such
			 discontinuance, the effective date thereof, and advising the enrolled
			 individuals to refer to their certificates in order to determine what rights,
			 if any, are available to them upon such discontinuance.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2013 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 2013.60 - Extension of Benefits

Current through Register Vol. 48, No. 28, July 12, 2024
a) Every group
			 contract subject to this Part must include a provision for a reasonable
			 extension of benefits in the event of total disability on the date of
			 discontinuance of the group contract as required by subsections (b) and (c)
			 hereunder.
b) In the case of
			 hospital and medical expense coverages and HMO plans, other than dental,
			 pharmaceutical or other limited expense coverages, such extension will be
			 considered "reasonable" if it provides for an extension until the earliest of
			 the following:
1) the end of twelve months;
			 or
2) the date the maximum benefit
			 is reached; or
3) the end of total
			 disability.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2013 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 2013.70 - Continuance of Coverage in Situations Involving Replacement of One Group Contract by Another

Current through Register Vol. 48, No. 28, July 12, 2024
This Section sets standards for determining liability when one
				group contract replaces another group contract.
a) Liability of prior carrier.
1) The prior carrier remains liable only to
			 the extent of its accrued liabilities and extensions of benefits. The position
			 of the prior carrier shall be the same whether the group contract holder or
			 other entity secures replacement coverage from a new carrier, the same carrier,
			 self-insures, or foregoes the provision of coverage.
2) Employees and dependents who are totally
			 disabled on the date of discontinuance of the group policy of the prior carrier
			 shall be provided an extension of benefits for a disabling illness, injury or
			 condition as described in Section
			 2013.60.
3) The prior carrier, if an HMO, may limit
			 the extension of benefits for a totally disabling illness, injury or condition
			 to services provided by or through their participating providers, unless
			 services are rendered on an emergency basis.
4) No prior carrier may terminate the
			 required extension of benefits because the totally disabled person becomes
			 covered under the succeeding carrier's contract.
5) The prior carrier must provide the
			 extension of benefits without cost to the totally disabled person except for
			 copayments, coinsurance and deductibles in effect at the time of discontinuance
			 and following the discontinuance of coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2014 - CONTRACEPTIVE COVERAGE › Section 2014.20 - Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
For policies, contracts, and certificates issued, delivered,
				amended, or renewed on or after January 1, 2025, except for excepted benefits,
				short-term, limited-duration health insurance coverage, Medicare Advantage
				plans, and coverage under the medical assistance program in the Illinois Public
				Aid Code [305 ILCS 5], this Part applies to all individual and group accident
				and health insurance, health care plans, limited health care plans, and
				voluntary health services plans, including pharmaceutical-only policies,
				contracts, and certificates.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2014 - CONTRACEPTIVE COVERAGE › Section 2014.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Accident and health insurance" has the meaning ascribed in
				Section 4, Class 1(b) and 2(a) of the Code.
"Code" means the Illinois Insurance Code [215 ILCS 5].
"Excepted benefits" has the meaning ascribed in the following
				federal regulations:
For individual health insurance coverage,  45 CFR 148.220  (May
				14, 2020) (no later editions or amendments); and
For group health insurance coverage,  45 CFR 146.145(b)  (Oct.
				31, 2016) (no later editions or amendments).
"Health care plan" has the meaning ascribed in Section 1-2(7)
				of the Health Maintenance Organization Act [215 ILCS 125].
"Health insurance issuer" has the meaning ascribed in Section 5
				of the Health Insurance Portability and Accountability Act [215 ILCS
				97].
"Limited health care plan" has the meaning ascribed in Section
				1002 of the Limited Health Service Organization Act [215 ILCS 130].
"Short-term, limited-duration health insurance coverage" has
				the meaning ascribed in Section 5 of the Short-Term, Limited-Duration Health
				Insurance Coverage Act [215 ILCS 190].
"Voluntary health services plan" has the meaning ascribed in
				Section 2 of the Voluntary Health Services Plans Act [215 ILCS
				165].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2014 - CONTRACEPTIVE COVERAGE › Section 2014.40 - Contraceptive Coverage

Current through Register Vol. 48, No. 28, July 12, 2024
a) A covered
			 individual must not be required to have a prescription for over-the-counter
			 contraceptive drugs, devices, and products as a condition for coverage to
			 apply.
b) Health insurance issuers
			 with any policy, contract, or certificate subject to Section 2014.20 are
			 prohibited from requiring a prescription as a condition to cover
			 over-the-counter contraceptives. Coverage as written and in operation must
			 include over-the-counter contraceptive drugs, devices, and products in
			 compliance with Section 356z.4(a) of the Code.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2015 - INFERTILITY COVERAGE › Section 2015.20 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Part
			 shall apply to all group accident and health insurance policies and health
			 maintenance organization group contracts that are issued, amended, delivered or
			 renewed in this State which provide pregnancy-related benefits for employees of
			 an employer that has more than 25 full-time employees at the time of issue or
			 renewal thereof. This Part does not apply to any coverage or policy that
			 provides an excepted benefit, as that term is defined in Section 2791(c) of the
			 federal Public Health Service Act (42 U.S.C. 300gg-91), to the extent
			 provided in Section 352b of the Code.
b) If a group policy is subject to both
			 42 U.S.C.
			 300gg-6(a), as implemented
			 by the Illinois Essential Health Benefits (EHB) Benchmark Plan identified at 50
			 Ill. Adm. Code 2001.11(c)(2),
			 and Section 356m of the Code, the policy shall provide infertility benefits
			 that comply with both provisions, as well as any provision of this Part
			 implementing an applicable statutory requirement for infertility benefits that
			 is not superseded by current State or federal law. For that policy, whenever
			 Section 356m of the Code and the applicable Illinois EHB Benchmark Plan provide
			 different minimum benefit standards such that one source requires coverage
			 under an infertility benefit in a given situation and the other source does not
			 or imposes a less stringent standard, whichever of the sources requires the
			 most coverage will determine the minimum benefit standard for that situation
			 under the policy. Nothing in this subsection shall be construed to enlarge the
			 scope of policies that are subject to
			 42 U.S.C.
			 300gg-6(a) or Section
			 356m of the Code.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2015 - INFERTILITY COVERAGE › Section 2015.35 - Benefit Limitation/Oocyte Retrieval Limitation

Current through Register Vol. 48, No. 28, July 12, 2024
a) For treatments that include oocyte
			 retrievals, coverage shall be required if the covered individual has been
			 unable to attain a viable pregnancy, maintain a viable pregnancy, or sustain a
			 successful pregnancy through reasonable, less costly medically appropriate
			 infertility treatments for which coverage is available under the policy, plan,
			 or contract. This requirement shall be waived in the event that the covered
			 individual or partner has a medical condition that renders the less costly
			 treatments useless.
b) For
			 treatments that include oocyte retrievals, coverage is not required if the
			 covered individual has already undergone four completed oocyte retrievals,
			 except that if a live birth follows a completed oocyte retrieval, then coverage
			 shall be required for a maximum of two additional completed oocyte retrievals
			 after the first live birth. Such coverage applies to the covered individual per
			 lifetime of that individual, for treatment of infertility, regardless of the
			 source of payment.
1) Following the final
			 completed oocyte retrieval for which coverage is available, coverage for one
			 subsequent procedure used to transfer the oocytes or sperm to the covered
			 recipient or to a surrogate shall be provided.
2) The policy or contract may provide a
			 maximum number of completed oocyte retrievals for which the covered individual
			 is eligible for coverage, which must be at least six (up to four cycles, plus
			 an additional two after a live birth).
Illinois Administrative Code › Title 50 - INSURANCE › Part 2015 - INFERTILITY COVERAGE › Section 2015.43 - Donor Expenses

Current through Register Vol. 48, No. 28, July 12, 2024
a) The medical
			 expenses of a donor for procedures utilized to retrieve oocytes or sperm, and
			 the subsequent procedure used to transfer the oocytes or sperm to the covered
			 recipient or to the surrogate shall be covered. Associated donor medical
			 expenses, including but not limited to physical examination, laboratory
			 screening, psychological screening, and prescription drugs, shall also be
			 covered if established as prerequisites to donation by the insurer.
b) No group accident and health policy or
			 health maintenance organization group contract that provides coverage as
			 required by this Part shall exclude coverage for a known donor. In the event
			 the insured or member does not have arrangements with a known donor, the health
			 plan may require the use of a contracted facility. If the insured or member
			 uses a known donor, the health plan may require the use of contracted providers
			 by the donor for all medical treatment including, but not limited to, testing,
			 prescription drug therapy and ART procedures, if benefits are contingent upon
			 the use of such contracted providers.
c) If an oocyte donor is used, then the
			 completed oocyte retrieval performed on the donor shall count against the
			 insured or member as one completed oocyte retrieval under Section
			 2015.35(b).
Illinois Administrative Code › Title 50 - INSURANCE › Part 2015 - INFERTILITY COVERAGE › Section 2015.50 - Minimum Benefit Standards

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 All diagnosis and treatment for infertility, including ART, shall be covered
			 the same as any other illness or condition under the contract. Except as
			 provided in this Part and permitted under Section 356m of the Code, a unique
			 copayment, coinsurance, deductible, benefit maximum, waiting period, exclusion,
			 restriction, or other limitation shall not be applied to the coverage for the
			 diagnosis or treatment of infertility, including, but not limited to, ART or
			 prescription drug therapy, nor to the coverage for standard fertility
			 preservation services required under Section 356z.32 of the Code. If the policy
			 or contract does not contain a prescription drug benefit, then one shall be
			 established solely for coverage of prescription drug therapies for infertility.
			 Except as otherwise provided in this Part, infertility coverage shall include
			 services to a surrogate and to a covered individual or the covered individual's
			 donor when a surrogate is arranged. Fertility services rendered to a surrogate
			 or donor to treat the covered individual's infertility shall be subject to and
			 count toward the covered individual's cost-sharing requirements, benefit
			 maximum, waiting period, network-based, and other exclusions, restrictions, or
			 limitations.
b) Nothing in this
			 Part shall be construed to prohibit the use of the same medical management
			 techniques and medical necessity criteria with a surrogate that the policy
			 would apply to a covered individual for the same service, nor to prohibit the
			 collection of the same information about the surrogate that would be collected
			 about a covered individual for medical management of the service.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2015 - INFERTILITY COVERAGE › Section 2015.60 - Permissible Exclusions

Current through Register Vol. 48, No. 28, July 12, 2024
a) Reversal
			 of voluntary sterilization; however, in the event a voluntary sterilization is
			 successfully reversed, infertility benefits shall be available if the covered
			 individual meets the definition of "infertility" as set forth in Section
			 2015.30 of this Part.
b) Payment for services rendered to a
			 surrogate after the surrogate has been discharged to regular obstetrical care,
			 non-medical expenses incurred by the covered individual to contract with the
			 surrogate, and any other services rendered to a surrogate that are not directly
			 related to treatment of the covered individual's infertility.
c) Expenses for cryopreservation and storage
			 of sperm, eggs, and embryos. The exclusion must not apply to costs for
			 subsequent procedures of a medical nature necessary to make use of the
			 cryopreserved and stored substance if the procedures are deemed
			 non-experimental and non-investigational. The exclusion also must not apply to
			 expenses for cryopreservation when a covered individual receives those services
			 under the conditions provided in Section 356z.32 of the Code relating to
			 iatrogenic infertility;
d)
			 Non-medical costs of a donor or a surrogate;
e) Travel costs for travel within 100 miles
			 of the insured's or member's home address as filed with the insurer or health
			 maintenance organization, travel costs not medically necessary, not mandated or
			 required by the insurer or health maintenance organization;
f) Infertility treatments deemed experimental
			 in nature. However, where infertility treatment includes elements which are not
			 experimental in nature along with those which are, to the extent services may
			 be delineated and separately charged, those services which are not experimental
			 in nature shall be covered. No insurer or HMO required to provide infertility
			 coverage shall deny reimbursement for an infertility service or procedure on
			 the basis that such service or procedure is deemed experimental or
			 investigational unless supported by the written determination of the American
			 Society for Reproductive Medicine (formerly known as the American Fertility
			 Society or the American College of Obstetrics). These entities will provide
			 such determinations for specific procedures or treatments only and will not
			 provide determinations on the appropriateness of a procedure or treatment for a
			 specific individual. Coverage is required for all procedures specifically
			 listed in Section 356m of the Code, regardless of experimental
			 status.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2016 - MASTECTOMIES › Section 2016.20 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
This Part, incorporating requirements established by the
				Federal Women's Health and Cancer Rights Act of 1998 (WHCRA) (
				42 USC
				300gg-6,
				300gg-52,
				incorporating
				29 USC
				1185(b) ) shall apply to all
				individual and group accident and health insurance policies, contracts, or
				certificates of insurance.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2016 - MASTECTOMIES › Section 2016.30 - Required Coverage for Reconstructive Surgery Following Mastectomies

Current through Register Vol. 48, No. 28, July 12, 2024
Every policy, contract, or certificate of group or individual
				insurance that provides medical and surgical benefits with respect to a
				mastectomy shall provide, in a case of an insured who is receiving benefits in
				connection with a mastectomy and who elects breast reconstruction in connection
				with such mastectomy, coverage in a manner determined in consultation with the
				attending physician and the patient for:
a) Reconstruction for the breast on which the
			 mastectomy has been performed;
b)
			 Surgery and reconstruction of the other breast to produce a symmetrical
			 appearance; and
c) Prostheses and
			 physical complications for all stages of mastectomy, including lymphedemas.
Such coverage may be subject to annual deductibles and
				coinsurance provisions as may be deemed appropriate and as are consistent with
				those established for other benefits under the plan coverage. Written notice of
				the availability of coverage under this Part shall be delivered to the insured
				upon enrollment and annually thereafter.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2016 - MASTECTOMIES › Section 2016.40 - Notice of Coverage

Current through Register Vol. 48, No. 28, July 12, 2024
An insurer providing health insurance coverage shall provide
				notice to each insured under the plan regarding the coverage required by this
				Part. Such notice shall be in writing and prominently positioned in any
				literature or correspondence made available or distributed by the insurer and
				shall be transmitted the earlier of:
a) In the next mailing made by the insurer to
			 the insured;
b) As part of any
			 yearly informational packet sent to the insured.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2016 - MASTECTOMIES › Section 2016.50 - Prohibitions

Current through Register Vol. 48, No. 28, July 12, 2024
An insurer offering individual or group health insurance may
				not:
a) Deny to an insured
			 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
			 Part; or
b) Penalize or otherwise
			 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
			 Part.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2016 - MASTECTOMIES › Section 2016.60 - Provider Reimbursement

Current through Register Vol. 48, No. 28, July 12, 2024
Nothing in this Section shall be construed to prevent an
				insurer from negotiating the level and type of reimbursement with a provider
				for care provided in accordance with this Part.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2017 - UNIFORM MEDICAL CLAIM AND BILLING FORMS › Section 2017.10 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
The purpose and intent of this Part is to promote the
				utilization of standardized forms in the billing and reimbursement of health
				care, which will reduce the number of forms used and increase efficiency in the
				reimbursement of health care through standardization.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2017 - UNIFORM MEDICAL CLAIM AND BILLING FORMS › Section 2017.20 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
a) Except
			 as otherwise specifically provided, the requirements of this Part apply to
			 health plans, health care practitioners and institutional health care
			 providers.
b) A health plan or
			 provider of health care treatment shall not refuse to accept a claim or bill
			 submitted on the uniform claim and billing forms defined in Section
			 2017.30 of this
			 Part.
c) The adoption of uniform
			 claim forms and uniform billing forms by the Director under this Part does not
			 preclude a health plan, hospital, medical, or dental service corporation, or
			 other prepayment organization from obtaining any necessary additional
			 information regarding a claim from the claimant, provider of health care or
			 treatment, or certifier of coverage, as may be required.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2017 - UNIFORM MEDICAL CLAIM AND BILLING FORMS › Section 2017.40 - Requirements for Use of HCFA Form 1500

Current through Register Vol. 48, No. 28, July 12, 2024
a) Health plans shall accept an appropriately
			 completed HCFA Form 1500 from health care practitioners. Health care
			 practitioners, other than dentists, shall use the HCFA Form 1500 when filing
			 claims with health plans for professional services.
b) Health plans shall not require health care
			 practitioners to use any coding system for the filing of claims for health care
			 services other than the following:
1) current
			 HCPCS Codes or current CPT Codes;
2) current ICD-CM Codes; and
3) For anesthesia services, current HCPCS
			 Level 1 Codes.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2017 - UNIFORM MEDICAL CLAIM AND BILLING FORMS › Section 2017.50 - Requirements for Use of UB92/HCFA Form 1450

Current through Register Vol. 48, No. 28, July 12, 2024
a) Institutional health care providers shall
			 use the UB92/HCFA Form 1450 when filing claims with health plans for health
			 care services.
b) Health plans
			 shall accept the UB92/HCFA Form 1450 from institutional health care providers
			 when completed in accordance with instructions provided by the National Uniform
			 Billing Committee and the Illinois Uniform Billing Committee.
c) Health plans shall not require
			 institutional health care providers to use any coding system for the filing of
			 claims for health care services other than the following:
1) ICD-CM Codes;
2) Revenue Codes;
3) HCPCS Codes or CPT Codes.
The ICD-CM Codes, Revenue Codes, HCPCS and CPT Codes must be
				used in accordance with the instructions provided by the National Uniform
				Billing Committee and the Illinois Uniform Billing Committee.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2017 - UNIFORM MEDICAL CLAIM AND BILLING FORMS › Section 2017.60 - Requirements for Use of J510/J511/J512 Form

Current through Register Vol. 48, No. 28, July 12, 2024
a) Dentists shall use the J510/J511/J512 Form
			 and instructions provided by the American Dental Association for use of the
			 J510/J511/J512 Form for filing claims with health plans for professional
			 services.
b) Health plans shall
			 accept the J510/J511/J512 Form from dentists when completed in accordance with
			 instructions provided by the American Dental Association.
c) Health plans shall not require a dentist
			 to use any code other than the CDT codes for the filing of claims for dental
			 care services or to routinely furnish additional information with the
			 submission of a J510/J511/J512 Form, unless the use of supplemental codes is
			 defined and permitted in a written contract between the issuer and
			 dentist.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2017 - UNIFORM MEDICAL CLAIM AND BILLING FORMS › Section 2017.70 - General Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
a) Nothing
			 in this Part shall preclude the filing of a claim electronically.
b) Health plans shall accept forms submitted
			 in compliance with this Part for the processing of claims.
c) Health care practitioners, institutional
			 health care providers and health plans shall use and accept the most current
			 editions of the HCFA Form 1500, UB92/HCFA Form 1450 or J510/J511/J512
			 Form.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2018 - UNIFORM ELECTRONIC PRIOR AUTHORIZATION FORM FOR PRESCRIPTION BENEFITS › Section 2018.10 - Purpose and Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
a) This
			 Part provides the contents of the electronic form that an insurer imposing
			 prior authorization requirements on prescription benefits is required to
			 utilize and accept for any health insurance coverage beginning July 1, 2021
			 under Section 364.3 of the Code. This form is intended to simplify exchanges of
			 information between prescribing providers and insurers for prior authorization
			 requests.
b) This Part does not
			 apply to any health insurance coverage that does not require prior
			 authorization for any prescription benefits.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2018 - UNIFORM ELECTRONIC PRIOR AUTHORIZATION FORM FOR PRESCRIPTION BENEFITS › Section 2018.20 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Code" means the Illinois Insurance Code [215 ILCS 5].
"Department" means the Illinois Department of Insurance.
"Insurer" means a "health insurance issuer" as defined in
				Section 5 of the Illinois Health Insurance Portability and Accountability Act
				[215 ILCS 97].
"Health insurance coverage" has the meaning ascribed in Section
				5 of the Illinois Health Insurance Portability and Accountability Act.
"Prescribing provider" has the meaning ascribed in Section
				364.3(a) of the Code.
"Prescription" has the meaning ascribed in Section 3(e) of the
				Pharmacy Practice Act [225 ILCS 85].