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Illinois Insurance FactsIllinois Department of Financial and Professional Regulation
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Illinois Insurance FactsIllinois Department of Financial and Professional Regulation
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The following is a list of Mandated Benefits, Mandated Coverages and Mandated Offers required by Illinois health insurance and HMO laws and regulations. This list includes the basic mandates; it is not an all-inclusive comprehensive description of all requirements for insurance companies and HMOs. Effective dates have been included for mandates passed recently. Please note, state laws do not apply to self-insured employer health plans or to health and welfare benefit plans. For more information regarding Illinois health insurance and HMO requirements, whether listed or not, please contact our Office of Consumer Health Insurance toll-free at (877) 527-9431 or visit us on our website at www.idfpr.com/doi/default2.asp.
Alcoholism
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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. |
Alcoholism
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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. |
Amino Acid-Based Elemental Formulas |
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.. |
Breast Exam |
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. |
Applies to all individual and group health insurance and all individual and group HMO contracts. |
Breast Ultrasound Screening |
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. |
Breast Implant Removal
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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. |
Cancer Off-Label Drugs
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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. |
Colorectal Cancer Screening |
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. |
Contraceptives |
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. |
Dental Adjunctive Services |
Requires coverage for anesthesia and other charges incurred in conjunction with dental care provided in a hospital or ambulatory surgical treatment center to:
Does not require coverage of dental services. |
Applies to individual and group insurance policies and individual and group HMO contracts. Does not apply to short-term travel, accident only, limited, or specified disease policies or to policies designed for Medicare beneficiaries. |
Diabetes Self Management |
Requires coverage for outpatient self-management 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.
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Applies to group insurance policies and group HMO contracts. |
HPV Vaccine |
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. |
Infertility
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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.) |
Mammograms215 ILCS 5/356g 215 ILCS 125/4-6.1Amended effective July 6, 2005SB 0012 PA 094-0121 |
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 women under age 40 who have a family history of breast cancer or other risk factors |
Applies to individual and group insurance policies and individual and group HMO contracts. |
Mastectomy – Post Mastectomy Care |
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. |
Mastectomy - Reconstruction
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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 |
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.
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Maternity |
Requires coverage for maternity care including prenatal and post-natal care and care for complication of pregnancy. |
Applies to individual and group HMO contracts. |
Maternity – Complications of Pregnancy |
Requires coverage for treatment of complications of pregnancy. |
Applies to individual and group insurance policies. |
Maternity – Post Parturition Care |
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. |
Maternity – Prenatal HIV Testing |
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. |
Mental Illness - Serious Amended June 26, 2006 by HB 4202 – PA 94-0921 to increase outpatient visits to 60. Amended January 1, 2007 by HB 4125, PA 94-0906 to apply to HMOs and to add 20 additional outpatient visits for speech therapy for pervasive developmental disorders. |
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. Note: See Mandated Offers for other Mental Health related requirements. |
Mental Illness – HMO |
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; |
Effective January 1, 2007 Applies to individual HMO contracts only. |
Multiple Sclerosis |
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. |
Organ Transplants
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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. |
Osteoporosis |
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. |
Ovarian Cancer Testing Effective January 1, 2006 |
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. |
Pap Smears |
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. |
Prescription Inhalants |
Requires coverage of prescription inhalants for persons with asthma or other life-threatening 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. |
Preventive Health Services |
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. |
Prostate Specific Antigen Testing |
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. |
Under the Influence |
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. |
Adopted Children
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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. |
Continuation |
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. |
Continuation for Spouse
Public Act 93-0477 |
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. |
Continuation for Dependent Children |
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. |
Conversion |
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. NOTE: Conversion should also be offered after COBRA or Illinois Continuation has been exhausted. |
Conversion for Spouse |
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.
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Handicapped Dependents
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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. |
Newborn |
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. |
Investigational Cancer Treatment |
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. |
Mental Illness - Non-Serious
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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. |
Applies to group insurance policies that provide coverage for hospital or medical expenses that are amended, delivered, issued or renewed after January 1, 2002.
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TMJ |
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. |
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