1

Requires coverage for the inpatient

treatment of alcoholism.

Applies to group accident and health

insurance policies that provide inpatient

hospital coverage. Does not apply to

specified disease policies.

Requires coverage of diagnosis,

detoxification, and treatment of medical

complications of alcoholism to be the same

as for any other illness. Alcohol

rehabilitation must be covered but may be

limited as specified in the Rule.

Applies to individual and group HMO

contracts.

2

Requires coverage of non-prescription and

specialized amino acid-based elemental

formulas administered either by feeding

tube or orally when prescribed by a

physician as medically necessary. The law

does not designate a benefit level.

Applies to all individual and group health

insurance and all individual and group

HMO contracts..

Requires coverage for diagnosis and

treatment of autism spectrum disorders for

individuals under age 21. The law

specifies a maximum benefit of $36,000

per year.

Applies to all individual and group health

insurance policies and individual and

group HMO contracts.

Requires coverage of a complete and

thorough physical examination of the

breast at least every 3 years for women age

between ages of 20 and 40; then annually

for women age 40 and older. The law does

not specify a benefit level.

Coverage is required once a nationally

recognized exam code is approved.

Applies to all individual and group health

insurance and all individual and group

HMO contracts.

3

Requires coverage for a comprehensive

ultrasound screening when a mammogram

demonstrates heterogeneous or dense

breast tissue when found to be medically

necessary by a physician. Benefits must be

at least as favorable as for other

radiological exams and subject to same

dollar limits, deductibles and co-insurance

amounts.

Applies to all group and individual

insurance policies and all individual and

group HMO contracts.

Prohibits the denial of coverage for the

removal of breast implants when such

removal is medically necessary treatment

for sickness or injury. This provision does

not apply for implants implanted solely for

cosmetic reasons.

Applies to all individual and group health

insurance and all individual and group

HMO contracts.

If a policy provides prescription drug

benefits, it must also provide benefits for

any drug that has been prescribed for the

treatment of a type of cancer, even if the

drug has not been approved for that

specific cancer by the FDA. The drug

must be approved by the FDA and must be

recognized for treatment of the specific

cancer for which it has been prescribed by

an established reference compendia, three

of which are specified within the law.

Applies to group insurance policies (PPO)

and individual and group HMO contracts.

Requires coverage for all colorectal cancer

examinations and laboratory tests for

colorectal cancer, in accordance with

professional organizations and the federal

government as specified in the law.

Applies to individual and group insurance

policies.

Applies to individual and group HMO

contracts

4

Requires coverage for all outpatient

contraceptive services and all outpatient

contraceptive drugs and devices approved

by the Food and Drug Administration.

Applies to individual and group insurance

policies and individual and group HMO

contracts that provide coverage for

outpatient services and outpatient

prescription drugs.

Requires coverage for anesthesia and other

charges incurred in conjunction with

dental care provided in a hospital or

ambulatory surgical treatment center to:

• a young child (under age 6);

• a person with a medical condition

that requires hospitalization for the

• a disabled individual.

Does not require coverage of dental

Requires coverage for outpatient selfmanagement

training and education, and

specified equipment and supplies for Type

1 diabetes, Type 2 diabetes and gestational

diabetes mellitus. Equipment must be

covered to the extent durable medical

equipment is covered by the policy.

Pharmaceuticals and supplies must be

covered to the extent there is coverage for

pharmaceuticals and supplies in the policy

or in an attached rider. See the law for list

of covered supplies and equipment.

Applies to group insurance policies and

group HMO contracts.

5

Requires coverage for the human

papillomavirus vaccine. The law does not

specify the benefit.

Applies to all individual and group health

insurance and all individual and group

HMO contracts.

Requires coverage for the diagnosis and

treatment of infertility, including coverage

for IVF, GIFT, ZIFT.

Applies to group insurance policies and

group HMO contracts that provide

coverage for more than 25full-time

employees. (See law for exceptions

relating to religious organizations or

institutions.)

Requires coverage for (1) a baseline

mammogram for women ages 35 to 39 and

(2) an annual mammogram for women age

40 or older. Effective July 2005 - Requires

coverage for medically necessary mammograms for

Applies to individual and group insurance

policies and individual and group HMO

contracts.

Requires coverage for inpatient hospital

stay following a mastectomy for a length

of time the attending physician determines

is medically necessary in accordance with

protocols and guidelines based on sound

scientific evidence and upon evaluation of

the patient. If the patient is discharged

early, a post-discharge physician office

visit must be available to her within 48

hours and must be covered by the policy.

Applies to individual and group insurance

policies that provide benefits for surgical

coverage. Also applies to individual and

group HMO contracts.

6

Requires coverage for prosthetic devices or

reconstructive surgery incident to a

mastectomy. When a mastectomy is

performed and no evidence of malignancy

is found, the offered coverage is limited to

prosthetic devices and reconstructive

surgery within two years of the

mastectomy date.

In addition to reconstruction on the

affected breast, this law requires surgery

and reconstruction of the other breast (the

one the mastectomy was not performed on)

to produce a symmetrical appearance.

Also requires coverage for prostheses and

treatment for physical complications at all

stages of mastectomy, including

lymphedemas.

Applied to individual and group accident

and health policies that provide coverage

for mastectomies as a “shall offer”.

(Effective 1/1/81)

Applies as a mandate to individual and

group health policies and to individual and

group HMO contracts issued, amended,

delivered or renewed after July 3, 2001.

Requires coverage for maternity care

including prenatal and post-natal care and

care for complication of pregnancy.

Applies to individual and group HMO

contracts.

Requires coverage for treatment of

complications of pregnancy.

Applies to individual and group insurance

policies.

Requires coverage for a minimum of 48

hours inpatient hospital stay following a

vaginal delivery and 96 hours following a

caesarian section for both mother and

newborn. A shorter length of stay may be

provided under certain conditions and if a

post-discharge office visit or in-home

nurse visit is provided and covered.

Applies to individual and group insurance

policies that provide maternity coverage.

Also applies to individual and group HMO

contracts.

7

Requires coverage for prenatal HIV testing

ordered by an attending physician licensed

to practice medicine in all branches,

physician assistant or advanced practice

registered nurse.

Applies to individual and group insurance

policies and individual and group HMO

contracts amended, delivered, issued or

renewed after July 20, 2001.

Requires coverage of serious mental illness

under the same terms and conditions as

coverage for other illnesses and diseases.

Serious mental illness is defined within the

law. Coverage may be limited to 45 days

of inpatient treatment and 35 (60)

outpatient visits annually.

Requires additional 20 outpatient visits for

speech therapy for pervasive

developmental disorders.

Applies to group insurance policies that

provide coverage for hospital or medical

expenses that are amended, delivered,

issued or renewed after January 1, 2002.

Does not apply to employer groups with 50

or fewer employees.

Applies to group HMO policies effective

January 1, 2007.

Requires coverage for ten (10) days

inpatient mental health care per year. Also

requires coverage of twenty (20) individual

outpatient mental health care visits per

enrollee per year, as appropriate for

evaluation, short-term treatment and crisis

intervention services. Care in a day

hospital, residential non-hospital or

intensive outpatient mode may be

substituted on a two-to-one basis for

inpatient hospital services as deemed

appropriate by the primary care physician.

Group outpatient mental health care visits

may be substituted on a two-to-one basis

for individual mental health care visits as

deemed appropriate by the primary care

physician;

Requires coverage for medically necessary

preventative physical therapy for insureds

diagnosed with multiple sclerosis if

prescribed by a physician and if the

physical therapy includes reasonably

defined goals. Coverage must be the same

as physical therapy under the policy for

other conditions.

Applies to individual and group insurance

policies and HMO contracts.

Sets forth guidelines under which

experimental or investigational organ

transplantation procedures can be denied.

Applies to individual and group insurance

policies and to individual and group HMO

contracts.

9

Requires coverage for medically necessary

bone mass measurement and the diagnosis

and treatment of osteoporosis on the same

terms and conditions that generally apply

to other medical conditions.

Applies to individual and group insurance

policies, and to individual and group HMO

contracts.

Requires coverage for surveillance tests for

ovarian cancer for female insureds who are

at risk for ovarian cancer.

Applies to group insurance policies, except

specified disease policies, and limited

benefit policies and to individual and

group HMO contracts.

Requires coverage for an annual cervical

smear or pap smear for females.

Applies to group insurance policies, except

specified disease policies, and limited

benefit policies and to individual and

group HMO contracts.

Requires coverage of prescription inhalants

for persons with asthma or other lifethreatening

bronchial ailments, as often as

needed, if medically appropriate and

prescribed by the attending physician.

Policy restrictions, placed on refill

limitations, do not apply.

Applies to individual and group insurance

policies and HMO contracts that provide

coverage for prescription drugs.

Requires coverage of preventive health

services as appropriate for the patient

population including a health evaluation

program and immunizations to prevent or

arrest the further manifestation of human

illness or injury.

Applies to individual and group HMO

contracts.

10

Requires coverage for an annual digital

rectal examination and a prostate specific

antigen test for male insureds upon

recommendation of a physician for

asymptomatic men age 50 and over,

African American men age 40 and over,

men age 40 and over with family history.

Applies to group insurance policies, except

specified disease and limited benefit

policies, and to group HMO contracts.

Requires coverage for federally approved

shingles vaccine when ordered by a

physician for an enrollee who is age 60 or

older.

Applies to group and individual insurance

policies and individual and group HMO

contracts.

Prohibits exclusion or coverage for

emergency or other medical, hospital or

surgical expenses incurred as a result of

and related to an injury acquired while the

individual is intoxicated or under the

influence of a narcotic.

Applies to group and individual major

medical insurance and managed care plans.

11

Prohibits denial or limitation of coverage

to an adopted child solely because the

child is adopted.

Applies to individual and group insurance

policies and individual and group HMO

contracts.

Employees or members whose group

health insurance terminates due to

termination of employment or membership

must be offered continuation of coverage

for themselves and their dependents for a

period of 9 months.

Group insurance policies that insure

employees or members for hospital,

surgical, or major medical insurance on an

expense incurred basis and group HMO

contracts. Does not apply to specified

disease or accident only policies. The

insured or member must have been

continuously covered for at least three

months immediately prior to the

termination of coverage.

Not applicable if the group has terminated

the group policy or contract.

12

An employees’ spouse and dependent

children who are insured under the policy

must be offered continuation of coverage if

group coverage is terminated for the

spouse and dependents due to the

dissolution the marriage or death of the

employee (for any age spouse), or due to

retirement of the employee (for a spouse

age 55 or older).

Applies to group accident and health

insurance polices.

Applies to group HMO contracts

EFFECTIVE 1/1/2004.

A dependent child who is insured on the

policy must be offered dependent child

continuation upon attainment of the

limiting age under the policy or upon the

death of the employee (if coverage through

spousal continuation is not available).

Applies to group accident and health

insurance policies and group HMO

contracts.

Employees or members whose coverage

under the group plan has terminated, for

any reason other than (1) discontinuance of

the group policy in its entirety where there

is a succeeding carrier or (2) failure of the

employee or member to pay premium, are

entitled to a conversion policy.

Group insurance policies and group HMO

contracts where the insured has been

continuously covered for at least three

months immediately prior to the

termination of coverage.

Prohibits an individual insurance policy

that covers an insured and dependent

spouse from terminating the spouse solely

because of a break in the marital

relationship unless a valid judgment of

dissolution of marriage has been entered

into. If the policy is terminated due to a

dissolution of marriage, a conversion

policy must be offered to the spouse.

Individual insurance policies.

Applies to HMO contracts effective

January 1, 2004.

13

This law gives parents with insurance

policies that cover dependents the right to

elect coverage for qualifying dependents

up to age 26 and up to age 30 for military

veteran dependents.

Applies to all individual and group health

policies and all individual and group

HMOs.

Requires coverage for a child who has

attained the limiting age under the policy if

the child continues to be incapable of

sustaining employment and is dependent

on his or her parents or other care

providers for lifetime care and supervision.

Applies to individual and group insurance

policies and to individual and group HMO

contracts.

Requires coverage of newborn children

from the moment of birth. Coverage must

include coverage of illness, injury,

congenital defects, birth abnormalities and

premature birth to the extent the services,

supplies or treatments are covered by the

policy. Notification to the company and

payment of premium may be required.

Applies to individual and group insurance

policies and to individual and group HMO

contracts.

14

Requires an insurer to offer benefits to an

applicant or policyholder for routine

patient care costs associated with

participation in an approved cancer

research trial. Coverage may have an

annual benefit limit of $10,000.

Applies to individual and group insurance

policies and to individual and group HMO

contracts.

The insurer shall offer optional coverage

for mental, emotional or nervous disorders

or conditions, other than serious mental

illness (see Mandated Benefits for serious

mental illnesses) up to the limits provided

in the policy. Benefits may be limited to

50% coinsurance and the annual benefit

may be limited to the lesser of $10,000 or

25% of the lifetime policy limit.

Prohibited insurers and HMOs that offered

mental health coverage from setting annual

or lifetime dollar limits on mental health

benefits that were lower than those for

medical and surgical benefits. Mental

health benefits were not required to be

offered and plans were still allowed to set

coinsurance amounts and limits on the

number of visits or days of coverage.

Applies to group insurance policies that

provide coverage for hospital or medical

expenses that are amended, delivered,

issued or renewed after January 1, 2002.

Applies to all group insurance policies

except those covering small employers

who have fewer than 51 employees.

Sunsets December 31, 2004.

(Effective January 1, 1998)

The insurer shall offer optional coverage

for the reasonable and necessary medical

treatment of temporomandibular joint

disorder and craniomandibular disorder.

The lifetime benefit may be limited to no

less than $2,500.00.

Applies to group insurance policies. The

group must accept or reject the coverage in

writing.

AN ACT concerning regulation.

Section 5. The State Employees Group Insurance Act of 1971

is amended by changing Section 6.11 as follows:

(5 ILCS 375/6.11)

Sec. 6.11. Required health benefits; Illinois Insurance

Code requirements. The program of health benefits shall provide

the post-mastectomy care benefits required to be covered by a

policy of accident and health insurance under Section 356t of

the Illinois Insurance Code. The program of health benefits

shall provide the coverage required under Sections 356g.5,

356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10,

356z.11, and 356z.12 and 356z.9 of the Illinois Insurance Code.

The program of health benefits must comply with Section 155.37

of the Illinois Insurance Code.

(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;

95-520, eff. 8-28-07; revised 12-4-07.)

Section 10. The Counties Code is amended by changing

Section 5-1069.3 as follows:

(55 ILCS 5/5-1069.3)

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Sec. 5-1069.3. Required health benefits. If a county,

including a home rule county, is a self-insurer for purposes of

providing health insurance coverage for its employees, the

coverage shall include coverage for the post-mastectomy care

benefits required to be covered by a policy of accident and

health insurance under Section 356t and the coverage required

under Sections 356g.5, 356u, 356w, 356x, 356z.6, and 356z.9,

356z.10, 356z.11, and 356z.12 and 356z.9 of the Illinois

Insurance Code. The requirement that health benefits be covered

as provided in this Section is an exclusive power and function

of the State and is a denial and limitation under Article VII,

Section 6, subsection (h) of the Illinois Constitution. A home

rule county to which this Section applies must comply with

every provision of this Section.

(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;

95-520, eff. 8-28-07; revised 12-4-07.)

Section 15. The Illinois Municipal Code is amended by

changing Section 10-4-2.3 as follows:

(65 ILCS 5/10-4-2.3)

Sec. 10-4-2.3. Required health benefits. If a

municipality, including a home rule municipality, is a

self-insurer for purposes of providing health insurance

coverage for its employees, the coverage shall include coverage

for the post-mastectomy care benefits required to be covered by

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a policy of accident and health insurance under Section 356t

and the coverage required under Sections 356g.5, 356u, 356w,

356x, 356z.6, and 356z.9, 356z.10, 356z.11, and 356z.12 and

356z.9 of the Illinois Insurance Code. The requirement that

health benefits be covered as provided in this is an exclusive

power and function of the State and is a denial and limitation

under Article VII, Section 6, subsection (h) of the Illinois

Constitution. A home rule municipality to which this Section

applies must comply with every provision of this Section.

(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;

95-520, eff. 8-28-07; revised 12-4-07.)

Section 20. The School Code is amended by changing Section

10-22.3f as follows:

(105 ILCS 5/10-22.3f)

Sec. 10-22.3f. Required health benefits. Insurance

protection and benefits for employees shall provide the

post-mastectomy care benefits required to be covered by a

policy of accident and health insurance under Section 356t and

the coverage required under Sections 356g.5, 356u, 356w, 356x,

356z.6, and 356z.9, 356z.11, and 356z.12 of the Illinois

Insurance Code.

(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;

revised 12-4-07.)

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Section 25. The Illinois Insurance Code is amended by

adding Section 356z.11 and Section 356z.12 as follows:

(215 ILCS 5/356z.11 new)

Sec. 356z.11. Dependent students; medical leave of

absence. A group or individual policy of accident and health

insurance or managed care plan amended, delivered, issued, or

renewed after the effective date of this amendatory Act of the

95th General Assembly must continue to provide coverage for a

dependent college student who takes a medical leave of absence

or reduces his or her course load to part-time status because

of a catastrophic illness or injury.

Continuation of coverage under this Section is subject to

all of the policy's terms and conditions applicable to those

forms of insurance. Continuation of insurance under the policy

shall terminate 12 months after notice of the illness or injury

or until the coverage would have otherwise lapsed pursuant to

the terms and conditions of the policy, whichever comes first,

provided the need for part-time status or medical leave of

absence is supported by a clinical certification of need from a

physician licensed to practice medicine in all its branches.

The provisions of this Section do not apply to short-term

travel, accident-only, limited, or specified disease policies

or to policies or contracts designed for issuance to persons

eligible for coverage under Title XVIII of the Social Security

Act, known as Medicare, or any other similar coverage under

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State or federal governmental plans.

(215 ILCS 5/356z.12 new)

Sec. 356z.12. Dependent coverage.

(a) A group or individual policy of accident and health

insurance or managed care plan that provides coverage for

dependents and that is amended, delivered, issued, or renewed

after the effective date of this amendatory Act of the 95th

General Assembly shall not terminate coverage or deny the

election of coverage for an unmarried dependent by reason of

the dependent's age before the dependent's 26th birthday.

(b) A policy or plan subject to this Section shall, upon

amendment, delivery, issuance, or renewal, establish an

initial enrollment period of not less than 90 days during which

an insured may make a written election for coverage of an

unmarried person as a dependent under this Section. After the

initial enrollment period, enrollment by a dependent pursuant

to this Section shall be consistent with the enrollment terms

of the plan or policy.

(c) A policy or plan subject to this Section shall allow

for dependent coverage during the annual open enrollment date

or the annual renewal date if the dependent, as of the date on

which the insured elects dependent coverage under this

subsection, has:

(1) a period of continuous creditable coverage of 90

days or more; and

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(2) not been without creditable coverage for more than

63 days.

An insured may elect coverage for a dependent who does not meet

the continuous creditable coverage requirements of this

subsection (c) and that dependent shall not be denied coverage

due to age.

For purposes of this subsection (c), "creditable coverage"

shall have the meaning provided under subsection (C)(1) of

Section 20 of the Illinois Health Insurance Portability and

Accountability Act.

(d) Military personnel. A group or individual policy of

accident and health insurance or managed care plan that

provides coverage for dependents and that is amended,

delivered, issued, or renewed after the effective date of this

amendatory Act of the 95th General Assembly shall not terminate

coverage or deny the election of coverage for an unmarried

dependent by reason of the dependent's age before the

dependent's 30th birthday if the dependent (i) is an Illinois

resident, (ii) served as a member of the active or reserve

components of any of the branches of the Armed Forces of the

United States, and (iii) has received a release or discharge

other than a dishonorable discharge. To be eligible for

coverage under this subsection (d), the eligible dependent

shall submit to the insurer a form approved by the Illinois

Department of Veterans' Affairs stating the date on which the

dependent was released from service.

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(e) Calculation of the cost of coverage provided to an

unmarried dependent under this Section shall be identical.

(f) Nothing in this Section shall prohibit an employer from

requiring an employee to pay all or part of the cost of

coverage provided under this Section.

(g) No exclusions or limitations may be applied to coverage

elected pursuant to this Section that do not apply to all

dependents covered under the policy.

(h) A policy or plan subject to this Section shall not

condition eligibility for dependent coverage provided pursuant

to this Section on enrollment in any educational institution.

(i) Notice regarding coverage for a dependent as provided

pursuant to this Section shall be provided to an insured by the

insurer:

(1) upon application or enrollment;

(2) in the certificate of coverage or equivalent

document prepared for an insured and delivered on or about

the date on which the coverage commences; and

(3) in a notice delivered to an insured on a

semi-annual basis.

Section 30. The Health Maintenance Organization Act is

amended by changing Section 5-3 as follows:

(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)

Sec. 5-3. Insurance Code provisions.

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(a) Health Maintenance Organizations shall be subject to

the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,

141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,

154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,

356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,

356z.11, 356z.12 356z.9, 364.01, 367.2, 367.2-5, 367i, 368a,

368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408,

408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection

(2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,

XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

(b) For purposes of the Illinois Insurance Code, except for

Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health

Maintenance Organizations in the following categories are

deemed to be "domestic companies":

(1) a corporation authorized under the Dental Service

Plan Act or the Voluntary Health Services Plans Act;

(2) a corporation organized under the laws of this

State; or

(3) a corporation organized under the laws of another

state, 30% or more of the enrollees of which are residents

of this State, except a corporation subject to

substantially the same requirements in its state of

organization as is a "domestic company" under Article VIII

1/2 of the Illinois Insurance Code.

(c) In considering the merger, consolidation, or other

acquisition of control of a Health Maintenance Organization

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pursuant to Article VIII 1/2 of the Illinois Insurance Code,

(1) the Director shall give primary consideration to

the continuation of benefits to enrollees and the financial

conditions of the acquired Health Maintenance Organization

after the merger, consolidation, or other acquisition of

control takes effect;

(2)(i) the criteria specified in subsection (1)(b) of

Section 131.8 of the Illinois Insurance Code shall not

apply and (ii) the Director, in making his determination

with respect to the merger, consolidation, or other

acquisition of control, need not take into account the

effect on competition of the merger, consolidation, or

other acquisition of control;

(3) the Director shall have the power to require the

following information:

(A) certification by an independent actuary of the

adequacy of the reserves of the Health Maintenance

Organization sought to be acquired;

(B) pro forma financial statements reflecting the

combined balance sheets of the acquiring company and

the Health Maintenance Organization sought to be

acquired as of the end of the preceding year and as of

a date 90 days prior to the acquisition, as well as pro

forma financial statements reflecting projected

combined operation for a period of 2 years;

(C) a pro forma business plan detailing an

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acquiring party's plans with respect to the operation

of the Health Maintenance Organization sought to be

acquired for a period of not less than 3 years; and

(D) such other information as the Director shall

require.

(d) The provisions of Article VIII 1/2 of the Illinois

Insurance Code and this Section 5-3 shall apply to the sale by

any health maintenance organization of greater than 10% of its

enrollee population (including without limitation the health

maintenance organization's right, title, and interest in and to

its health care certificates).

(e) In considering any management contract or service

agreement subject to Section 141.1 of the Illinois Insurance

Code, the Director (i) shall, in addition to the criteria

specified in Section 141.2 of the Illinois Insurance Code, take

into account the effect of the management contract or service

agreement on the continuation of benefits to enrollees and the

financial condition of the health maintenance organization to

be managed or serviced, and (ii) need not take into account the

effect of the management contract or service agreement on

competition.

(f) Except for small employer groups as defined in the

Small Employer Rating, Renewability and Portability Health

Insurance Act and except for medicare supplement policies as

defined in Section 363 of the Illinois Insurance Code, a Health

Maintenance Organization may by contract agree with a group or

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other enrollment unit to effect refunds or charge additional

premiums under the following terms and conditions:

(i) the amount of, and other terms and conditions with

respect to, the refund or additional premium are set forth

in the group or enrollment unit contract agreed in advance

of the period for which a refund is to be paid or

additional premium is to be charged (which period shall not

be less than one year); and

(ii) the amount of the refund or additional premium

shall not exceed 20% of the Health Maintenance

Organization's profitable or unprofitable experience with

respect to the group or other enrollment unit for the

period (and, for purposes of a refund or additional

premium, the profitable or unprofitable experience shall

be calculated taking into account a pro rata share of the

Health Maintenance Organization's administrative and

marketing expenses, but shall not include any refund to be

made or additional premium to be paid pursuant to this

subsection (f)). The Health Maintenance Organization and

the group or enrollment unit may agree that the profitable

or unprofitable experience may be calculated taking into

account the refund period and the immediately preceding 2

plan years.

The Health Maintenance Organization shall include a

statement in the evidence of coverage issued to each enrollee

describing the possibility of a refund or additional premium,

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Public Act 095-0958

and upon request of any group or enrollment unit, provide to

the group or enrollment unit a description of the method used

to calculate (1) the Health Maintenance Organization's

profitable experience with respect to the group or enrollment

unit and the resulting refund to the group or enrollment unit

or (2) the Health Maintenance Organization's unprofitable

experience with respect to the group or enrollment unit and the

resulting additional premium to be paid by the group or

enrollment unit.

In no event shall the Illinois Health Maintenance

Organization Guaranty Association be liable to pay any

contractual obligation of an insolvent organization to pay any

refund authorized under this Section.

(Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;

95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)

Section 35. The Voluntary Health Services Plans Act is

amended by changing Section 10 as follows:

(215 ILCS 165/10) (from Ch. 32, par. 604)

Sec. 10. Application of Insurance Code provisions. Health

services plan corporations and all persons interested therein

or dealing therewith shall be subject to the provisions of

Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,

149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v, 356w,

356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8,

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Public Act 095-0958

356z.9, 356z.10, 356z.11, 356z.12 356z.9, 364.01, 367.2, 368a,

401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs

(7) and (15) of Section 367 of the Illinois Insurance Code.

(Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;

95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.

8-28-07; revised 12-5-07.)

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Public Act 095-0958

For children diagnosed with autism, early intervention and continued treatment is critical.

Beginning December 12, 2008, all individual and group health insurance policies and HMO

contracts must abide by the provisions of Public Act 95-1005 (215 ILCS 356z.14). This new Illinois

law provides coverage for the diagnosis and treatment of autism spectrum disorders for children

The law became effective December 12, 2008. Any policy issued, delivered, amended or renewed

after this date must include autism coverage required by the law.

If you are covered by a group health insurance policy (i.e., through your employer) issued before

December 12, 2008, you may have to wait until the date that the policy is amended or renewed

All individual and group health insurance policies and HMO contracts (and voluntary health service

organization contracts) must abide by the new law. Health coverage provided to state, county, and

municipal employees (and employees subject to the Schools Code (105 ILCS 5/1-1 et seq.)) must

also provide the autism benefits.

o Self-insured, non-public employers.

o Self-insured health and welfare plans, such as union plans.

o Insurance policies or trusts issued in other states.

The law does not change the autism coverage provided by public health care programs such as

FamilyCare and All Kids. Contact the specific program for more information about its autism

coverage.

Children under the age of 21 who have health coverage through an individual or group policy, as

described above, will receive coverage for the diagnosis and treatment of autism spectrum

disorders.

The new law requires coverage for the diagnosis of autism spectrum disorders. For individuals

diagnosed with an autism spectrum disorder, the new law also requires coverage for the following

treatment:

o Psychiatric care;

o Psychological care;

o Habilitative or rehabilitative care (counseling and treatment programs intended to develop,

maintain, and restore the functioning of an individual); and

o Therapeutic care, including behavioral, speech, occupational, and physical therapies

addressing the following areas:

o Self-care and feeding

o Pragmatic, receptive, and expressive language

o Cognitive functioning

o Applied behavioral analysis, intervention, and modification

o Motor planning

o Sensory processing

Insurance companies may not impose dollar limits, deductibles or copayments for the diagnosis or

This law requires insurance companies to provide coverage for the diagnosis and treatment of

autism up to an annual limit of $36,000. An insurance company may provide coverage beyond this

limit, but is not required to do so by this law.

• Insurance companies are prohibited from limiting the number of visits to a physician or other

service provider.

• Treatments for conditions not diagnosed as autism will not apply to the $36,000 annual limit.

The Illinois Serious Mental Illness Mandate (215 ILCS 370c) requires group insurance policies

1005. For more information about the Serious Mental Illness Mandate, please see the Division’s

fact sheet on Mental Health Coverage at http://www.idfpr.com/doi/HealthInsurance/mental_hlth.asp.

Insurance companies may not categorize benefits historically covered under the Serious Mental

(http://www.idfpr.com/DOI/pressRelease/pr08/HB5285DependentCoverage.pdf).

Yes. Illinois law allows insurance companies to exclude coverage for pre-existing conditions,

including autism, for up to 2 years. Specific exclusion periods vary based on individual

circumstances, including the type of policy and an individual’s history of health insurance coverage.

For more information, please see the Division’s fact sheet on HIPAA and pre-existing conditions

(http://www.idfpr.com/DOI/HealthInsurance/HIPAA_preexisting_cond.asp).

Illinois law governing pre-existing condition limitations for dependent children will change in

Like coverage for other conditions, coverage for the treatment of autism is subject to insurance

company determinations of medical necessity. An insurance company may deny coverage for a

certain treatment if the treatment is not medically necessary or does not result in improved clinical

status.

A treatment must be considered medically necessary if it is reasonably expected to:

o Prevent the onset of an illness, condition, injury, disease or disability;

o Reduce or ameliorate the physical, mental or developmental effects of an illness, condition,

injury, disease or disability; or

o Help an individual achieve or maintain maximum functional activity in performing daily

activities.

determination made by a physician with expertise in the most current and effective treatments for

autism spectrum disorders.

Appeal procedures and applicable state laws differ for HMOs and insurance companies. For more

information, please see the Division’s fact sheet on Medical Necessity

(http://www.idfpr.com/DOI/HealthInsurance/Medical_Necessity.asp).

Call the Division of Insurance Consumer Services Section at (312) 814-2427 or

our Office of Consumer Health Insurance toll free at (877) 527-9431

or visit us on our website at www.ins.state.il.us