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Contact Person: |
Illinois
Division of Insurance |
320
West Washington Street |
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Cindy
Colonius |
Review
Requirements Checklist |
Springfield,
IL 62767-0001 |
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217-782-4572
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Effective 05/15/09 |
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Filing |
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Business |
Insurance |
Code(s) |
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Preferred Provider
Organization |
Large and Small group PPO
(POS products must be filed with an HMO base. The PPO portion may only be the
out-of-network benefits.) |
H16G.001 |
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Click here for interactive version of this document to be down loaded and submitted with this filing |
Word Document - Alteration of this document will result in rejection of the filing |
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Illinois
Insurance Code Link |
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Illinois Administrative
Code Link |
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Product
Coding Matrix |
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REVIEW
REQUIREMENTS |
REFERENCE |
DESCRIPTION OF REVIEW
STANDARDS REQUIREMENTS |
LOCATION
OF STANDARD IN FILING |
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NOTE:
These brief summaries do not include all requirements of all laws, regulations,
bulletins, or requirements, so review actual law, regulation, bulletin,
or requirement for details to ensure that forms are fully compliant
before filing with the Department of Insurance. |
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FORM
FILING REQUIREMENTS |
REFERENCE |
DESCRIPTION
OF REVIEW STANDARDS REQUIREMENTS |
LOCATION
OF STANDARD IN FILING
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| Uniform
Transmittal Document (Etrans)
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| Form Filing Requirements for Certificates intended for out-of-state use. | Policies sitused in Illinois, but intended for insureds who neither work in nor reside in Illinois, must be filed on an informational basis to claim exemption from Illinois mandates and other required provisions. Insurers not specifically filing under the exemption provided by 215 ILCS 5/352(c) must submit such filings for approval. |
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| Review Requirements Checklist | Go to Review Requirements Checklists on DOI web site. See next column | 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. |
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| Cover Letter and Letter of Submission | 50 IL Adm. Code 1405.20 (e) |
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. Letters of submission must generally describe the intent and use of the form being filed and, if applicable, how it will be used with any previously approved form(s). |
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GENERAL
REQUIREMENTS FOR ALL FILINGS |
REFERENCE |
DESCRIPTION
OF REVIEW STANDARDS REQUIREMENTS |
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Entire Contract |
The policy, including
the application and any amendments and riders, constitutes the entire
contract of insurance and no change is valid unless approved by an executive
officer of the company and unless such approval be endorsed hereon or
attached hereto. |
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Time Limit on Certain
Defenses |
A policy is incontestable
two years from the date of issue except for fraudulent misstatements
made by the applicant on the application. |
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Timely Payment of Claims |
Claims must be paid
within 30 days following receipt of written due proof of loss. |
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Timely Payment of Health
Care Services |
Periodic payments must be made within
60 days of insured's selection of a provider or effective date of selection,
whichever is later. In case of retrospective enrollment only 30 days
after notice by employer to 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. |
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Continuation of coverage |
Continuation rights
applicable according to state continuation (up to 9 months) or federal
COBRA. Continuation available because of reduction in hours below minimum
required by group plan effective 1/1/04. |
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Conversion |
Conversion must be
made available to anyone who has been continuously insured under the
group policy for three months and whose insurance has been terminated
for any reason other than discontinuance of the group policy in its
entirety. |
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Continuation of Coverage
upon employee death |
Coverage must continue
for dependents for at least 90 days after death of the insured. Insurers
may charge additional premium. |
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Spousal continuation |
Spousal and dependent
continuation rights in case of death, divorce or retirement. |
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Dependent continuation |
Continuation rights
for an insured's dependent child in the event of the death of the insured
and the child is not eligible for coverage as a dependent under 215
ILCS 5/367.2. |
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| Extended age dependent continuation |
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Effective June 1, 2009 a policy that includes dependent coverage must allow unmarried dependents under the age of 26 to apply for coverage. Additionally, polices must allow military veteran dependents under the age of 30 to apply for coverage if the veteran is an Illinois resident, not married; has served in the active or a reserve components of the U.S. Armed Forces (including the National Guard) and has received a release or discharge other than dishonorable. Insurers must provide an annual 30 day open enrollment period. The law does not change HIPAA special enrollment requirements. The attached link provides FAQ information from our web site. |
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| Dependent students; medical leave of absence continuation | Effective June 1, 2009 a policy must continue to provide coverage for a dependent college student who has taken a medical leave of absence or reduced hours to part-time status due to a catastrophic illness or injury. Continuation is subject to all of the policy’s terms and conditions applicable to that form of insurance and shall terminate 12 months after the notice of the illness or injury or until coverage would have otherwise lapsed. This coverage mirrors the requirements of H.R. 285, known as Michelle’s Law, signed by the President on October 9, 2008. |
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Coordination of Benefits |
Based on same premise
as NAIC Model with some language variance. |
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Discontinuance and
replacement of coverage |
A policy shall provide
a reasonable extension of benefits (up to 12 months) in the event of
total disability on the date the policy is discontinued. In case of
discontinuance the prior plan shall be liable only to the extent of
its accrued liabilities and extension of benefits. |
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Newborn Coverage |
The policy must state
newborns covered from the moment of birth. If additional premium is
required insurer may require notification within 31 days in order to
have coverage continue. |
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Pending & Adopted
Children |
No policy that covers
the insured's immediate family or children may exclude or limit coverage
of an adopted child or a child not residing with the insured (foster
child). A child residing with an insured pursuant to an interim court
order of adoption is considered an adopted child.
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Disabled Dependents |
Provides continuation
for handicapped dependent that has attained the limiting age of the
policy. |
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REQUIREMENTS RELATING
TO POLICY FORM REVIEW |
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Alcoholism |
For inpatient coverage
alcoholism must be treated the same as any other illness. The Division
relies on the premise that since it may not be excluded from the coverage
it must be treated as any other medical condition. |
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| Emergency Coverage Under the Influence of Alcohol or Narcotics | 215 ILCS 5/367k | No policy may exclude coverage for any emergency or other medical, hospital or surgical expenses incurred as a result of and related to an injury sustained while an insured is either intoxicated or under the influence of a narcotic, regardless of the conditions under which the substance is administered. | |
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Criminal Sexual Assault |
No policy for hospital
or medical expenses issued on an expense-incurred basis may exclude
coverage for charges for examination and testing of sexual criminal
assault. |
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Infertility Coverage |
The treatment of infertility
is only required for employer groups with more than 25 employees. |
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Mammography
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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.
Coverage includes a comprehensive ultrasound screening of an entire breast or breasts when a mammogram demonstrates medical necessity as described. Coverage must be provided at no cost to the insured and shall not be applied to an annual or lifetime maximum benefit. When coverage is available through contracted providers and such a provider is not utilized, plan provisions specific to the use of those non-contracted providers must be applied without distinction to the coverage required and shall be at least as favorable as for other radiological examinations covered by the policy or contract.
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| Clinical Breast Exam | 215 ILCS 5/356g.5 | 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,
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Reconstructive breast
surgery |
Coverage requires:
reconstruction of breast upon which mastectomy 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. |
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| Breast Cancer Pain Medication and Therapy | 215 ILCS 5/356g.5-1 | Coverage must include all medically necessary pain medication and pain therapy related to the treatment of breast cancer under the same terms and condition applicable to treatment of other conditions. The term “pain therapy” is defined. | |
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Post Mastectomy Care |
Coverage must provide
inpatient treatment following mastectomy for length of time to be determined
by attending physician; must also provide for availability of post-discharge
physician office visit or in-home nurse visit within 48 hours of discharge. |
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Organ Transplant |
No accident and health
insurer may deny reimbursement for an organ transplant as experimental
or investigational unless supported by appropriate, required documentation.
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Mental, emotional or
Nervous Disorders/Serious Mental Illness |
The coverage must meet the minimum requirements of the Mental Health Parity Act. Please see Division Bulletin 99-6 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. The sunset provision for serious mental illness has been removed.
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Post-Parturition Care |
If coverage provides
maternity benefit it 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 attending physician. |
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Pap and Prostate tests |
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, |
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Colorectal Cancer Screening |
Must cover all colorectal
cancer exams and lab tests for colorectal cancer as prescribed by physician
according to stated guidelines; may not impose greater copays, ded or
waiting periods. |
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Diabetes Supplies and
Testing |
Coverage must be provided
for outpatient self-management training and education, equipment and
supplies. Guidelines are provided. |
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Prenatal HIV testing |
Must be provided if
coverage includes maternity benefit. |
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Adjunctive Services
in Dental Care |
This coverage is limited
to children under the age of 6; to individuals with medical conditions
that require hospitalization and general anesthesia for dental care;
and for disabled individuals. |
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Prescription Inhalants |
If policy provides
RX coverage it may not deny or limit coverage for prescription inhalants
when diagnosis is asthma or other life-threatening bronchial ailments;
additional guidelines provided. |
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Coverage for contraceptives |
If policy provides
coverage for OP services and RX or devices it must provide insured and
dependent coverage for all OP and contraceptive drugs and devices approved
by the FDA; may not impose greater copays, ded or waiting periods. |
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Bone Mass Measurement/Osteoporosis |
Coverage must include
medically necessary bone mass measurement and diagnosis and treatment
of osteoporosis the same as any other illness. |
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| Multiple Sclerosis Preventative Physical Therapy | 215 ILCS 5/356z.8 | Coverage must provide for medically necessary preventative physical therapy for insureds diagnosed with this disease. A definition of "preventative physical therapy" is included. Coverage limitations, deductibles, coinsurance features, etc. must be provided the same as any other illness. | |
| Amino acid-based elemental formulas | 215 ILCS 5/356z.10 | Coverage must include reimbursement for amino acid-based elemental formulas, regardless of delivery method, for diagnosis and treatment of conditions described herein. | |
| Coverage for Human Papillomavirus Vaccine | 215 ILCS 5/356z.9 | Coverage must include benefit for FDA approved human papillomarivus vaccine (HPV). | |
| Shingles Vaccine | Coverage must include a vaccine for shingles that is approved by the federal Food and Drug Administration if it is ordered by a physician for an insured/enrollee who is 60 years of age or older. | ||
| Autism Spectrum Disorders | Coverage must be provided for individuals under age 21 for the diagnosis and treatment of autism spectrum disorders to the extent that such care is not already covered by the policy. | ||
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REQUIREMENTS RELATING
SPECIFICALLY TO PREFERRED PROVIDER ORGANIZATION FILINGS |
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Non-Participating Provider
Services |
A notice must be provided
to consumers explaining that a larger out-of-pocket expense may occur
if non-participating providers are used. Provision must use same language
as in statute, but may be modified to suit insurer terminology. |
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Definition of Emergency |
Insurers are required to use this definition
that includes, "prudent lay person" language.
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Emergency Care Coverage |
Payment may not be
contingent upon whether services are performed by a preferred or non-preferred
provider. |
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Utilization Review |
Any preferred provider
organization providing hospital, medical or dental services must have
a utilization review program and the program must be registered with
the Division. |
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Accessibility and Availability
of Providers (Networks) |
PPO filings may
not be approved until the insurer has filed the network it will be using
on an informational basis. |
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Nondiscrimination Between
Providers |
An insurer or administrator
shall not refuse to contract with any noninstitutional provider meeting
the terms and conditions established by the entity. |
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REQUIREMENTS SPECIFIC
TO HIPPA |
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Small employer (Definition) |
"Small employer"
means, in connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at least
2 but not more than 50 employees on business days during the preceding
calendar year and who employs at least 2 employees on the first day
of the plan year. |
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Creditable Coverage |
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. |
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Pre-Existing Conditions |
Pre-existing condition
exclusions are limited to conditions for which medical advice, diagnosis,
care, or treatment was recommended or received within the 6-month period
ending on the enrollment date. The exclusion may extend for no more
than 12 months or 18 months for a late enrollee. |
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Small Group Guarantee
Issue |
Insurers must accept
every small employer that applies for such coverage. Insurers must also
accept every eligible individual who applies for enrollment during the
period in which the individual first becomes eligible to enroll in the
coverage. |
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Network Plans Exceptions |
Insurer may limit guarantee
availability. May deny coverage to small group if it can demonstrate
that it does not have the capacity to deliver services adequately to
enrollees of any additional groups because of obligations to other existing
groups and enrollees. This exception must be applied uniformly. If this
exception is invoked, insurer is barred from writing coverage in small
group market in that particular service area for 180 days. |
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Guaranteed Renewability |
Insurers in the small
group or large group market must renew or continue in force a group's
coverage at the option of the plan sponsor. Such guaranteed renewability
is not applicable in cases of nonpayment of premium, fraud or misrepresentation,
and violation of minimum participation requirements. For insurers ceasing
to market to small or large group market or both, network plans may
nonrenew coverage if there are no enrollees of the group who live, reside
or work in the service area. Coverage through a bona fide association
may be nonrenewed if the employer ceases to be a member of the association. |
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Uniform Termination
of Coverage Notification Requirements |
Insurers must comply
with the uniform notification requirements for discontinuing a particular
type of coverage and discontinuing all coverage in the state. Notification
requirements must appear in certificate. |
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| Notice Requirement | 215 ILCS 97/60 | An insurer electing to uniformly modify, terminate or discontinue coverage in accordance with Section 30 or 50 of Act 97 (HIPAA) must provide 90 days advance notice to the Division by certified mail. | |
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Portability |
Individuals moving
within the group market and from individual coverage to group coverage
(not group to individual coverage; unless to the alternative mechanism)
will have pre-existing exclusions reduced by creditable coverage under
prior plans if there is no more than a 63 day break in coverage. |
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GENERAL INFORMATION |
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| Discretionary Authority | 215
ILCS 5/143(1) 50 IL Adm. Code 2001.3 |
Insurers are not permitted to place discretionary authority language in contracts of accident and health. |
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Rate Filings |
Rule 916 does not require
the filing of Group Rates, except for Credit, Medicare Supplement and
Long Term Care, which do need to be filed. Rates also need to be provided
for individual accident and health filings. |
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Blanket Group Policies |
Provides guidelines
for covering special groups of people as listed. |
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Discretionary Group
Policies |
Filings will only be
approved if the Division determines that the issuance of the policy
is not contrary to the public interest; the issuance will result in
economies of acquisition and administration; and, the benefits under
the policy are reasonable in relation to the premium charged. Informational
filings are required. |
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Optional Coverage for
TMJ |
Insurers providing
hospital, medical or surgical care must offer coverage for TMJ and craniomandibular
disorder. |
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Women's Principal HealthCare
Provider |
Insurer that requires
insured to select PCP must allow female insureds the right to select
a participating woman's principal health care provider. Notification
required. |
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| Prescription Drugs; Cancer Treatment | 215 ILCS 5/356z.7 | Coverage for prescribed drugs for certain types of cancer shall not exclude coverage of any drug on the basis that the drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the federal Food and Drug Administration if proper documentation, as outlined, is provided. | |
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Discrimination |
Guidelines for Unfair
Discrimination based on sex, sexual preference or marital status. Forbids
excluding coverage for dependent child maternity. |
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Right of Reimbursement |
Provides guidelines
for reimbursement and subrogation rights due to negligence of a third party.
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Optometric Services
Election |
A policy that covers
optometry must include an informational notice to the policyholder that
it has the option to have such services reimbursed to either a physician
or optometrist. |
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Dental Coverage Reimbursement
Rates |
All group or individual
accident and health coverage that also includes dental and bases reimbursement
on usual and customary fees must disclose specific information. |
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HIV/AIDS Questions
on Application |
Questions designed to elicit information regarding AIDS, ARC and HIV must be specifically related to the testing, diagnosis or treatment done by a physician or an appropriately licensed clinical professional acting within the scope of his/her license. |
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Use of SSN on ID Cards |
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 must comply with both provisions.
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Cancer Clinical Trials |
Insurers may not cancel
or nonrenew any individual's coverage due to participation in a qualified
cancer clinical trial. Guidelines are provided. |
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DEPARTMENT POSITIONS |
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Hospital Definition |
The definition of hospital
must allow for those hospitals providing surgery, etc., on a formal
arrangement basis with another institution. |
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Prohibited Terms |
Policies may not use
terms such as "external" and "violent" in connection
with the definition of accident and health. |
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Intoxication Definition |
An intoxication definition
must be included in the policy if it is listed as an exclusion. A reasonable
example would be, "Intoxication means that which is defined and
determined by the laws of the jurisdiction where the loss or cause of
the loss was incurred." |
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Prohibited Exclusion |
General Body System
exclusions are not permissible. |
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| Precertification Penalties | 215 ILCS 5/143(1) | The Division will permit a failure to precertify a hospital admission penalty of the lesser of up to $1,000 or 50% of the billed charge. The penalty may be no more frequent than a per confinement basis. |