Illinois Administrative Code › Title 50 - INSURANCE › Part 4521 - HEALTH MAINTENANCE ORGANIZATION › Section 4521.110 - Requirements for Group Contracts, Evidences of Coverage and Individual Contracts

Current through Register Vol. 48, No. 28, July 12, 2024
a) Any
			 group contract, evidence of coverage, individual contract, enrollee handbook,
			 enrollment application, identification card or other form that affects the
			 terms and conditions applicable to the subscriber or enrollee in the provision
			 of health care services must be filed with and approved by the Director prior
			 to use in accordance with the filing requirements of Section
			 4521.112 of this Part and
			 Section 4-13 of the Act. The HMO shall issue to each subscriber or enrollee a
			 group contract, evidence of coverage, or individual contract. Any conflicting
			 information between the valid current document referenced in this subsection
			 issued to the subscriber or enrollee and the current group contract shall be
			 interpreted according to whichever is most beneficial to the subscriber or
			 enrollee. Any group contract, evidence of coverage, or individual contract
			 shall provide for the rendering of health care services as defined in that
			 document for either a specific period of not less than 12 months from the date
			 of issuance or for another period mutually agreed to by the HMO and the group
			 or individual contractholder, and shall provide for renewal on a basis mutually
			 agreed to by both parties, unless the HMO has given 31 days' written notice of
			 nonrenewal prior to the renewal date of the contract.
b) A detailed statement of any exceptions,
			 exclusions, or limitations shall be set forth in the group contract, evidence
			 of coverage, and individual contract for any type of health care service to be
			 excepted. Exception, exclusions, or limitations shall appear with the same
			 prominence in the group contract, evidence of coverage, and individual contract
			 as any benefit.
c) The group
			 contract, evidence of coverage, and individual contract shall set forth a
			 detailed statement of the terms and conditions of maternity benefits and any
			 related exceptions, exclusions, limitations, copayments, and deductibles.
			 Exceptions, exclusions, limitations, copayments, and deductibles applicable to
			 prenatal and postnatal care shall be covered no differently than any other
			 covered health care services provided pursuant to the contract, with the
			 exception of a limitation for coverage of routine prenatal care or delivery
			 when the enrollee is outside the service area against medical advice (except
			 when the enrollee is outside of the service area due to circumstances beyond
			 the enrollee's control) may be included in the group contract and evidence of
			 coverage.
d) Entire Contract. The
			 group contract, evidence of coverage, and individual contract shall contain a
			 statement that the group contract evidence of coverage and individual contract,
			 all applications, and any amendments shall constitute the entire agreement
			 between the parties. No portion of the charter, bylaws or other document of the
			 HMO shall be part of a contract or evidence of coverage unless set forth in
			 full in the document or attached to it.
e) Eligibility Requirements. The group
			 contract, evidence of coverage, and individual contract shall contain
			 eligibility requirements indicating the conditions that must be met to enroll
			 in a health care plan, the limiting age for enrollees and eligible dependents
			 including the effects of Medicare eligibility, and a clear statement regarding
			 coverage of newborn children as set forth in Sections 4-8 and 4-9 of the
			 Act.
f) Benefits and Services
			 Within the Service Area. The group contract, evidence of coverage, and
			 individual contract shall contain a specific description of benefits and
			 services available within the HMO's designated service area.
g) Emergency Care Services. The group
			 contract, evidence of coverage, and individual contract shall contain a
			 specific description of benefits and services available for emergencies 24
			 hours per day, 7 days per week, including disclosure of any restrictions on
			 emergency care services. No group contract, evidence of coverage, or individual
			 contract shall limit the coverage of emergency services within the service area
			 to those providers having a contract with the HMO.
h) Out-of-area Benefits and Services. The
			 group contract, evidence of coverage, and individual contract shall contain a
			 specific description of benefits and services available out of the HMO's
			 designated service area.
i)
			 Deductibles and Copayments
1) An HMO may
			 require deductibles and copayments from enrollees as a condition for the
			 receipt of specific health care services, including basic health care services.
			 Deductibles and copayments shall be the only allowable charge, other than
			 premiums, assessed enrollees. Nothing within this subsection (i) shall preclude
			 the provider from charging reasonable administrative fees, such as service fees
			 for checks returned for non-sufficient funds and missed appointments.
2) Copayments and deductibles appearing in
			 the policy shall be for specific dollar amounts or for specific percentages of
			 the cost of the health care services.
3) No combination of deductibles and
			 copayments for basic health care services may exceed the annual maximum
			 out-of-pocket expenses of a high-deductible health plan as defined in
			 26 U.S.C.
			 223.
4) Deductibles and copayments applicable to
			 supplemental health care services or catastrophic-only plans as defined under
			 the federal Patient Protection and Affordable Care Act (Pub. L. 111-148),
			 are not subject to the annual limitations described in this Section.
5) This subsection (i) applies to enrollees
			 and does not limit the health care plan payment for services provided by
			 non-participating providers.