Illinois Insurance Facts Insurance Coverage for Newborn Children Revised July 2006

Illinois law requires newborn children of covered insured members to be covered from the moment of birth under all individual and group health plans which offer dependent coverage for the principal enrollee or insured individual. 

Who Must Offer The Coverage?

Under the law, all accident and health insurance policies and HMO certificates must provide benefits to a newborn child immediately from the moment of birth.  The newborn must be added to the policy regardless of illness, injury, congenital defects, birth abnormalities or premature birth and benefits must be paid for those conditions to the extent of the policy provisions.
 

Who Is Covered?

Newborn children of insured individuals must be provided coverage under the law if dependent coverage for the principal insured or enrollee is offered under the plan and the newborn meets the definition of a dependent under the policy. 

What Are The Limitations?

If the insured member does not have dependent coverage in place when the baby is born, immediate coverage is required by the law as long as an application is completed and applicable premium is paid within 31 days after the baby is born.  Failure to apply for the coverage and pay the applicable premium may result in the insurance company’s refusal to add the baby for coverage.

What If I Did Not Previously Elect Coverage Through My Group
For Myself Or My Dependents?

The birth of a newborn creates a “special enrollment period” under HIPAA (Health Insurance Portability and Accountability Act).  That law allows you to add yourself, your spouse and your newborn child (if dependent coverage is an option under your plan) for coverage under your group health plan without evidence of insurability.  However, you must take that action within 30 days of the child's birth.  Other dependents may only be added during an open enrollment period.

Frequently Asked Questions About Newborn Coverage

1. I am expecting my first child.  My group insurance offers dependent coverage; however, currently I have no dependents covered.  How do I add my baby?
•  As soon as your baby is born, you should contact your insurance company.  If your coverage is through your employer, you may be required to notify the employer.  Request an application to add the baby as a dependent and ask if there is a premium due for adding the baby to your coverage.  Submit the application and premium as soon as possible, but in no event, not later than 30 days after the baby is born.  If you mail the application, it is best to send it certified mail so you have proof that it was sent in time.  Be sure to keep a copy of the application for your records.

 

2. My wife is expecting our first child.  I am covered for health insurance at my job and my wife is covered at her job.  My coverage is better so we wish to add the baby to my coverage.  Since the cost for dependent coverage is the same no matter how many dependents, I would like to add my wife also.  Is that possible?
• Yes.  When the baby is born, you may add  your wife and your newborn to your coverage as long as you do so within 30 days after the baby is born.

 

3. We had previously attempted to add my wife to the group plan during a recent “enrollment period”; however, she was declined for a health reason.  Can the company decline her for coverage when the baby is born?
   • No.  During a special enrollment period under HIPAA triggered by the birth of a baby,  your wife and newborn may be added to coverage regardless of health conditions as long as they are added within 30 days of the birth of the baby.

 

4. My group health plan does not pay claims for preexisting conditions for the first year of coverage.  Will my wife’s health condition be denied as a preexisting condition for the first year?  If my baby is born with a health problem will claims be denied for that condition for the first year?

• Your baby will be covered for all conditions from the moment of birth and cannot be denied for preexisting conditions under the policy as long as you add the baby within 30 days after birth
  For your wife, the answer depends upon how long she has been covered by her group health plan.  She should request a “certificate of creditable coverage” from her group health plan which should be submitted to your plan.  The period of time your wife has been covered by her group health plan should be credited toward the preexisting condition exclusion period on your plan.  If she has been covered more than one year, the preexisting condition exclusion period should be waived by your plan.  If, for example, she has been covered under her plan for only nine months, your plan would apply the nine months to the preexisting exclusion period and she would have three months remaining before claims for those conditions would be eligible for benefits under your plan.

 

5. We are expecting our second child.  My health coverage charges additional premium for each dependent.  How do we add our second child and when is premium due?

• You should notify the insurance company as soon as the new baby is born.  The company will automatically provide coverage for the new baby for the first 31 days following birth without requiring that additional premium be paid.  However, the coverage will terminate on day 32 unless you submit an application for the new baby within 31 days after the birth and pay the additional premium due beginning on day 32.

 

6. My baby was born with several birth defects, including physical abnormalities, which require cosmetic surgery.  My insurance company has paid all expenses for the baby’s problems except for the cosmetic surgery because they say it is not covered under the policy.  Why don’t they have to pay for all services my child needs for his birth defects and abnormalities?
• The law only requires coverage to the extent it is provided in the policy.  The newborn is not entitled to benefits, which are not contained in the policy.  Therefore, if the insurance policy excludes cosmetic surgery, the company is within its rights to deny those claims for your baby.

 

7. My 17-year-old daughter is expecting a baby.  My daughter is not married, still lives with me and is a dependent on my health insurance policy.  Can I add the baby to my health insurance coverage when she is born?

• It depends on the definition of “dependent” within the policy.  Most insurance policies do not include grandchildren as dependents within the policy.  If a grandchild is not an eligible dependent, the company is not required to add the newborn to your coverage.

 

8. I did not take the health insurance coverage offered by my employer when I first began my job because I was covered under my husband’s policy.  My employer’s coverage is now more attractive because it offers better benefits so I would like to be added.  However, I have been told that since I did not enroll when I first became employed, I have to wait until the next open enrollment period which is in nine months.  I am pregnant and my baby is due next month.  Can I add myself to my employer’s health plan when the baby is born?

• Yes.  The birth of the baby creates a special enrollment period under HIPAA and you may add yourself, your spouse and the baby within 30 days after the baby is born.

For More Information On Newborn Coverage

1. Call our 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 http://www.idfpr.com/DOI/default2.asp

A copy of the newborn laws (215 ILCS 5/356c for insurance companies or 215 ILCS 125/4-8 for HMOs) and the HIPAA law (215 ILCS 97/35) may be obtained from http://www.idfpr.com/DOI/Rules/laws_regs.asp.