Illinois Administrative Code

Section 2012.83 Incontestability Period a) For a policy or certificate that has been in force for less than 6 months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentat…

Section 2012.86 Nonforfeiture Benefits a) Except as provided in subsection (b), a long-term care insurance policy may not be delivered or issued for delivery in this State unless the policyholder or certificateholder has been offered the option of purchasing a policy or certifica…

Section 2012.90 Requirements for Application Forms and Replacement Coverage a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another long-term care insurance policy or cer…

Section 2012.95 Reporting Requirements All insurers shall: a) Maintain records for each insurance producer of that producer's amount of replacement sales as a percent of the producer's total annual sales and the amount of lapses of long-term care insurance policies sold by the in…

Section 2012.97 Annual Rate Certification Requirements a) This Section applies to any long-term care policy issued in this State on or after July 1, 2018. b) The annual rate certifications required by subsection (c) and the memorandum required by subsection (d), shall be filed in…

Section 2012.EXHIBIT C Standard Format Outline of Coverage [COMPANY NAME] [ADDRESS − CITY & STATE] [TELEPHONE NUMBER] LONG-TERM CARE INSURANCE OUTLINE OF COVERAGE [Policy Number or Group Master Policy and Certificate Number] [Except for policies or certificates which are guarante…

Section 2013.10 Authority This Part is adopted and promulgated by the Director of Insurance pursuant to Section 367i of the Illinois Insurance Code (Ill. Rev. Stat. 1991, ch. 73, par. 979i) [215 ILCS 5/367i]. (Source: Amended at 18 Ill. Reg. 16921, effective November 15, 1994)

Section 2013.20 Scope This Part is applicable to all group health or disability insurance contracts and group Health Maintenance Organization (HMO) contracts, issued for delivery in this State, renewed, amended or under which the level of benefits or premium is altered or modifie…

Section 2013.30 Definitions "Accrued Liability" means liabilities established on the date an injury is sustained or an illness commences. "Group Contract" means a contract for health or disability insurance or an HMO contract made with an employer or other entity that covers a gr…

Section 2013.40 Effective Date of Discontinuance for Non-Payment of Premium a) If a group contract subject to this Part provides for automatic discontinuance of the contract after a premium has remained unpaid through the grace period allowed for such payment, the carrier shall b…

Section 2013.50 Requirements for Notice of Discontinuance a) Any notice of discontinuance so given by the carrier shall advise the group contract holder to notify enrolled individuals covered under the contract within 10 working days after receipt of such notice of the date the g…

Section 2013.60 Extension of Benefits a) Every group contract subject to this Part must include a provision for a reasonable extension of benefits in the event of total disability on the date of discontinuance of the group contract as required by subsections (b) and (c) hereunder…

Section 2013.70 Continuance of Coverage in Situations Involving Replacement of One Group Contract by Another This Section sets standards for determining liability when one group contract replaces another group contract. a) Liability of prior carrier. 1) The prior carrier remains …

Section 2014.10 Purpose The purpose of this Part is to clarify the requirements for health insurance coverage of over-the-counter contraceptive drugs, devices, and products.

Section 2014.20 Applicability For policies, contracts, and certificates issued, delivered, amended, or renewed on or after January 1, 2025, except for excepted benefits, short-term, limited-duration health insurance coverage, Medicare Advantage plans, and coverage under the medic…

Section 2014.30 Definitions "Accident and health insurance" has the meaning ascribed in Section 4, Class 1(b) and 2(a) of the Code. "Code" means the Illinois Insurance Code [215 ILCS 5]. "Excepted benefits" has the meaning ascribed in the following federal regulations: For indivi…

Section 2014.40 Contraceptive Coverage a) A covered individual must not be required to have a prescription for over-the-counter contraceptive drugs, devices, and products as a condition for coverage to apply. b) Health insurance issuers with any policy, contract, or certificate s…

Section 2015.10 Purpose The purpose of this Part is to establish uniform definitions of terms associated with infertility coverage and to establish minimum benefit standards for infertility coverage to be provided in this State.

Section 2015.20 Applicability and Scope a) This Part shall apply to all group accident and health insurance policies and health maintenance organization group contracts that are issued, amended, delivered or renewed in this State which provide pregnancy-related benefits for emplo…

Section 2015.30 Definitions For purposes of this Part and Section 356m of the Code: "Artificial insemination" or "AI" means the introduction of sperm into an individual's vagina or uterus by noncoital methods, for the purpose of conception. "Assisted reproductive technologies" or…

Section 2015.35 Benefit Limitation/Oocyte Retrieval Limitation a) For treatments that include oocyte retrievals, coverage shall be required if the covered individual has been unable to attain a viable pregnancy, maintain a viable pregnancy, or sustain a successful pregnancy throu…

Section 2015.40 Oocyte Retrieval Limitation (Repealed) (Source: Repealed at 28 Ill. Reg. 12992, effective September 9, 2004)

Section 2015.43 Donor Expenses a) The medical expenses of a donor for procedures utilized to retrieve oocytes or sperm, and the subsequent procedure used to transfer the oocytes or sperm to the covered recipient or to the surrogate shall be covered. Associated donor medical expen…

Section 2015.50 Minimum Benefit Standards a) All diagnosis and treatment for infertility, including ART, shall be covered the same as any other illness or condition under the contract. Except as provided in this Part and permitted under Section 356m of the Code, a unique copaymen…

Section 2015.60 Permissible Exclusions a) Reversal of voluntary sterilization; however, in the event a voluntary sterilization is successfully reversed, infertility benefits shall be available if the covered individual meets the definition of "infertility" as set forth in Section…

Section 2016.10 Purpose To establish minimum benefit standards and guidelines for enforcement related to mastectomy coverage.

Section 2016.20 Applicability and Scope This Part, incorporating requirements established by the Federal Women's Health and Cancer Rights Act of 1998 (WHCRA) (42 USC 300gg-6, 300gg-52, incorporating 29 USC 1185(b)) shall apply to all individual and group accident and health insur…

Section 2016.30 Required Coverage for Reconstructive Surgery Following Mastectomies Every policy, contract, or certificate of group or individual insurance that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of an insured who is recei…

Section 2016.40 Notice of Coverage An insurer providing health insurance coverage shall provide notice to each insured under the plan regarding the coverage required by this Part. Such notice shall be in writing and prominently positioned in any literature or correspondence made …

Section 2016.50 Prohibitions An insurer offering individual or group health insurance may not: a) Deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Part;…

Section 2016.60 Provider Reimbursement Nothing in this Section shall be construed to prevent an insurer from negotiating the level and type of reimbursement with a provider for care provided in accordance with this Part.

Section 2017.10 Purpose The purpose and intent of this Part is to promote the utilization of standardized forms in the billing and reimbursement of health care, which will reduce the number of forms used and increase efficiency in the reimbursement of health care through standard…

Section 2017.20 Applicability and Scope a) Except as otherwise specifically provided, the requirements of this Part apply to health plans, health care practitioners and institutional health care providers. b) A health plan or provider of health care treatment shall not refuse to …

Section 2017.30 Definitions CDT Codes means the current dental terminology prescribed by the American Dental Association. CPT Codes means the current procedural terminology published by the American Medical Association. HCFA means the Health Care Financing Administration of the U…

Section 2017.40 Requirements for Use of HCFA Form 1500 a) Health plans shall accept an appropriately completed HCFA Form 1500 from health care practitioners. Health care practitioners, other than dentists, shall use the HCFA Form 1500 when filing claims with health plans for prof…

Section 2017.50 Requirements for Use of UB92/HCFA Form 1450 a) Institutional health care providers shall use the UB92/HCFA Form 1450 when filing claims with health plans for health care services. b) Health plans shall accept the UB92/HCFA Form 1450 from institutional health care …

Section 2017.60 Requirements for Use of J510/J511/J512 Form a) Dentists shall use the J510/J511/J512 Form and instructions provided by the American Dental Association for use of the J510/J511/J512 Form for filing claims with health plans for professional services. b) Health plans…

Section 2017.70 General Provisions a) Nothing in this Part shall preclude the filing of a claim electronically. b) Health plans shall accept forms submitted in compliance with this Part for the processing of claims. c) Health care practitioners, institutional health care provider…

Section 2018.10 Purpose and Applicability a) This Part provides the contents of the electronic form that an insurer imposing prior authorization requirements on prescription benefits is required to utilize and accept for any health insurance coverage beginning July 1, 2021 under …

Section 2018.20 Definitions "Code" means the Illinois Insurance Code [215 ILCS 5]. "Department" means the Illinois Department of Insurance. "Insurer" means a "health insurance issuer" as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act [215…

Section 2018.30 Uniform Electronic Prior Authorization Form for Prescription Benefits On and after July 1, 2021, an insurer that imposes prior authorization requirements on prescription benefits in any health insurance coverage shall utilize and accept the uniform electronic prio…

Section 2019.10 Purpose The purpose of this Part is to establish minimum benefit standards for diabetic pharmaceuticals, supplies and durable medical equipment coverage to be provided in this State.

Section 2019.20 Applicability and Scope This Part applies to all group accident and health insurance policies and health maintenance organization group contracts that are amended, delivered, issued or renewed in this State after the effective date of this Part. This Part also app…

Section 2019.30 Definitions Durable Medical Equipment means blood glucose monitors, blood glucose monitors for the legally blind, cartridges for the legally blind and lancets and lancing devices. Pharmaceuticals and Supplies means insulin, syringes, needles, test strips for gluco…

Section 2019.40 Minimum Benefit Standards a) Coverage for durable medical equipment shall be subject to the same deductible, copayment, and coinsurance provisions provided for other durable medical equipment, depending on whether the coverage is provided under the policy or a dur…

Section 2020.10 Scope This Part shall apply to any insurance company licensed to do business in this State which is transacting the kind or kinds of business described as Class 1(b) or Class 2(a) of Section 4 of the Illinois Insurance Code [215 ILCS 5/4].

Section 2020.100 Effective Date for Existing Policies Any policy containing a reimbursement or subrogation provision that is in effect prior to November 1, 2007 shall comply with the provisions of this Part upon the renewal of that policy. (Source: Added at 31 Ill. Reg. 14723, ef…

Section 2020.20 Purpose The purpose of this Part is to clarify policy form language concerning the application of Sections 357.18 and 357.19 of the Illinois Insurance Code [215 ILCS 5/357.18 and 357.19] and the use of reimbursement and subrogation provisions in such policy forms.…

Section 2020.30 Definitions Code means the Illinois Insurance Code [215 ILCS 5]. Department means the Illinois Department of Insurance. (Source: Amended at 31 Ill. Reg. 14723, effective October 22, 2007)

Section 2020.40 Reimbursement Provision Right of Reimbursement: In addition to any other requirements set forth in the Code or Department regulations, if an insurer includes a reimbursement provision in its policy, that provision shall be in the form set forth in subsection (a)(1…