Effective1 /01 /08

Group Health Maintenance Organization

HOrgO2G

Group HMO Policies(Includes Point of Service Products)

HOrgO2G.001
HOrgO2G.002B

Each filing must include a completed Review Requirements Checklist that must contain a completed “Location of Standard in Filing” column for each required element of the filing. Please indicate the proper page # and form # for each entry. The checklists may be found at this link.

50 IL Adm. Code 1405.20 (e)
50 IL Adm. Code 2001.30 (a) (3)

In addition to referencing any previously approved form number(s) as required by 50 IL Adm. Code 1405.20(e), those references must also include the filing number and SERFF tracking number (if applicable and available) for the referenced forms.

Periodic payments must be made within 60 days of an enrollee's selection of a provider, or effective date of selection, whichever is later. In case of retrospective enrollment only 30 days after notice by the employer to the insurer. Subsequent payments must be in monthly periodic cycle. Penalty payment of 9% per year.

Payments other than periodic must be made within 30 days after receipt of due proof of loss. Same penalty provisions.

No HMO may cancel a group contract or evidence of coverage except for one or more of the following reasons:

· Failure to pay the premium;

· Fraud or material misrepresentation;

· Material violation of the terms of the contract or evidence of coverage;

· Failure to establish a satisfactory patient-physician relationship;

· Failure to meet or continue to meet eligibility requirements under the Basic Outpatient Preventive and Primary Care Services for Children Program offered by 50 IL Adm. Code 5421.131; or,

· Such other good cause as appears in the contract.

215 ILCS 5/367i
50 IL Adm. Code 2013

215 ILCS 125/5-3(a)

An HMO may require copayments, but not to exceed 50% of the usual and customary fee of the service.

Maximum copays per calendar year are $3,000 per enrollee and $6,000 per family.

Coverage must include diagnosis, detoxification and treatment of medical complications of the abuse of or addiction to alcohol or drugs on either an inpatient or outpatient basis.

Rehabilitation services must be included.

Coverage of screening by low-dose mammography for all women over 35;

Coverage requires baseline mammogram for women 35-39 and annual mammogram for women 40 years of age and older.

For women under 40 with a family history of breast cancer or other risk factors mammograms must be provided at an age and intervals considered medically necessary.

Coverage includes a comprehensive ultrasound screening of an entire breast or breasts when a mammogram demonstrates medical necessity as described.

Clinical breast examinations must be covered:

(1) at a minimum every three years for women over 20 years of age but less than 40; and,
(2) annually for women 40 years of age and older.

215 ILCS 125/4-6.1(b)
50 IL Adm. Code 5421.132

Coverage requirements include reconstruction of the breast upon which the mastectomy is performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment for physical complications at all stages of mastectomy, including lymphdemas.

Written notice of the availability of this coverage must be delivered to the enrollee upon enrollment and annually thereafter.

No HMO contract may deny medically necessary breast implant removal for a sickness or injury.

This provision does not apply to the removal of breast implants that were done solely for cosmetic purposes.

215 ILCS 5/356t
215 ILCS 125/4-6.5

Bulletin 99-6
215 ILCS 5/370c

The coverage must meet the minimum requirements of the Mental Health Parity Act. Please see Division Bulletin 99-6
Benefits for mental/nervous may not be combined with benefits for alcohol and substance abuse.

The benefit for serious mental illness, based on medical necessity, in addition to requiring 45 days of inpatient treatment also requires 60 outpatient visits and an additional 20 outpatient visits for speech therapy for the treatment of pervasive developmental disorders.

Benefits for serious mental illness are not applicable for small group.

215 ILCS 5/356(s)
215 ILCS 125/4-6.4
50 IL Adm. Code 5421.130 e)
50 IL Adm. Code 2603.30 a) 11)

Coverage must include prenatal and post-natal care and complications of pregnancy for mother as well as care of newborn.

Coverage must provide minimum of 48 hours inpatient care for normal delivery and 96 hours for caesarian section. Shorter lengths of stays are permitted based on decision of the PCP.

Coverage must include annual cervical smear or Pap smear test for female insureds, including surveillance tests for ovarian cancer for female insureds who are at risk for ovarian cancer; and,

Annual digital rectal examination and prostate-specific antigen test for males upon recommendation of the PCP. Must include asymptomatic men age 50 and over; African-American men age 40 and over; and men age 40 and over with family history of prostate cancer.

215 ILCS 5/356z.8

215 ILCS 125/5-3(a)

a.) A group health plan;

b.) Health insurance coverage;

c.) Part A or part B of title XVIII of the Social Security Act;

d.) Title XIX of the Social Security Act other than coverage consisting solely of benefits under Section 1928;

e.) Chapter 55 of title 10 of the United States Code;

f.) A medical care program of the Indian Health Service or of a tribal organization;

g.) A state health benefits risk pool;

h.) A health plan offered under chapter 89 of title 5, United States Code;

i.) A public health plan (as defined in regulations);

j.) A health benefit plan under Section 5(e) of the Peace Corps Act;

k.) Title XXI of the federal Social Security Act, a State Children's Health Insurance Program.

An HMO is required to establish a procedure to handle complaints regarding administrative issues and procedures, but nothing in these requirements prevents an enrollee from filing a complaint with the Division.

An HMO is required to respond to a complaint received from the Division of Insurance within 21 days of such notification.

An HMO must establish procedures for both expedited appeals of health care services and other appeals for health care services that meet the minimum requirements outlined herein.

If the case involves an adverse determination the HMO must provide the procedures for requesting an external independent review.

A health care plan is required to submit for the Division's review a mechanism for the joint selection of an independent external reviewer under the conditions described in 215 ILCS 134/45(f).

Any proposed changes to the mechanism must be filed for review with the Division's Managed Care unit.

An HMO must provide to each enrollee information regarding its functions, organization, and related institutions and describe the appropriate use of its services. This material must also include a description of the grievance procedure, directions on filing a grievance and "Notice of Availability of the Division"

.HMOs must provide description of coverage worksheets as detailed in 50 IL Adm. Code 5420.40.

HMOs must provide ID cards to their enrollees. Mandatory data elements for the card or other technology include:

· Processor control number if required for claims adjudication;

· Group number;

· Card issuer identifier;

· Cardholder ID number; and

· Cardholder name.

The back of the card or other technology is to include the claims submission names and addresses and the help desk telephone numbers and names.

Cards must be issued upon enrollment and reissued upon any change in the enrollee's coverage that affects any of the required elements.

815 ILCS 505 2QQ

215 ILCS 138/15

The focus of HB 4712 is on any card required for an individual to access products or services, while SB 2545 is more limited in that it just focuses on insurance cards.

HB 4712 prevents a person from:

· Publicly posting or displaying an individual's SSN;

· Printing an individual's SSN on any card required for the individual to access products or services, however, an entity providing an insurance card must print on the card a unique identification number as required by 215 ILCS 138/15.

· Being required to transmit an SSN over the Internet to access a web site unless the connection is secure or the SSN is encrypted;

· Requiring the individual to use his/her SSN to access a web site unless a PIN number or other authentication device is also used; and,

· Printing an individual's SSN on any materials mailed to an individual unless required by state or federal law.

Insurers are required to comply with both provisions.