Chapter 215 — INSURANCE

(215 ILCS 123/70) Sec. 70. Rules. The Director shall promulgate rules as may be necessary or desirable to carry out the provisions of this Act. (Source: P.A. 90-337, eff. 1-1-98.)

(215 ILCS 123/75) Sec. 75. Severability. The provisions of this Act are severable under Section 1.31 of the Statute on Statutes. (Source: P.A. 90-337, eff. 1-1-98.)

(215 ILCS 124/1) Sec. 1. Short title. This Act may be cited as the Network Adequacy and Transparency Act. (Source: P.A. 100-502, eff. 9-15-17.)

(215 ILCS 124/10) (Text of Section from P.A. 103-650 and 104-28) Sec. 10. Network adequacy. (a) Before issuing, delivering, or renewing a network plan, an issuer providing a network plan shall file a description of all of the following with the Director: (1) The written policies …

(215 ILCS 124/15) Sec. 15. Notice of nonrenewal or termination. (a) A network plan must give at least 60 days' notice of nonrenewal or termination of a provider to the provider and to the beneficiaries served by the provider. The notice shall include a name and address to which a…

(215 ILCS 124/20) (Text of Section before amendment by P.A. 104-333) Sec. 20. Transition of services. (a) A network plan shall provide for continuity of care for its beneficiaries as follows: (1) If a beneficiary's provider leaves the network plan's network of providers for reaso…

(215 ILCS 124/25) Sec. 25. Network transparency. (a) A network plan shall post electronically an up-to-date, accurate, and complete provider directory for each of its network plans, with the information and search functions, as described in this Section. (1) In making the directo…

(215 ILCS 124/3) Sec. 3. Applicability of Act. This Act applies to an individual or group policy of health insurance coverage with a network plan amended, delivered, issued, or renewed in this State on or after January 1, 2019. This Act does not apply to an individual or group po…

(215 ILCS 124/30) Sec. 30. Administration and enforcement. (a) Issuers, as defined in this Act, have a continuing obligation to comply with the requirements of this Act. Other than the duties specifically created in this Act, nothing in this Act is intended to preclude, prevent, …

(215 ILCS 124/35) Sec. 35. Provider requirements. Providers shall comply with 42 U.S.C. 300gg-138 and 300gg-139 and the regulations promulgated thereunder, as well as Section 20, paragraph (2) of subsection (a) of Section 25, subsections (h) and (j) of Section 25, and Section 36 …

(215 ILCS 124/36) Sec. 36. Complaint of incorrect charges. (a) A beneficiary who, taking into account the reimbursement, if any, by the issuer, incurs a cost in excess of the in-network cost-sharing for a covered service from a provider, facility, or hospital that was listed as i…

(215 ILCS 124/40) Sec. 40. Confidentiality. (a) All records in the custody or possession of the Department are presumed to be open to public inspection or copying unless exempt from disclosure by Section 7 or 7.5 of the Freedom of Information Act. Except as otherwise provided in …

(215 ILCS 124/5) Sec. 5. Definitions. In this Act: "Authorized representative" means a person to whom a beneficiary has given express written consent to represent the beneficiary; a person authorized by law to provide substituted consent for a beneficiary; or the beneficiary's tr…

(215 ILCS 124/50) Sec. 50. Funds for enforcement. Moneys from fines and penalties collected from issuers for violations of this Act shall be deposited into the Insurance Producer Administration Fund for appropriation by the General Assembly to the Department to be used for provid…

(215 ILCS 124/55) Sec. 55. Uniform electronic provider directory information notification forms. (a) On or before January 1, 2026, the Department shall develop and publish a uniform electronic provider directory information form that issuers shall make available to onboarding, cu…

(215 ILCS 124/99) Sec. 99. Effective date. This Act takes effect upon becoming law. (Source: P.A. 100-502, eff. 9-15-17.)

(215 ILCS 125/1-1) (from Ch. 111 1/2, par. 1401) Sec. 1-1. This Act shall be known and may be cited as the "Health Maintenance Organization Act". (Source: P.A. 85-20.)

(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402) Sec. 1-2. Definitions. As used in this Act, unless the context otherwise requires, the following terms shall have the meanings ascribed to them: (1) "Advertisement" means any printed or published material, audiovisual material and …

(215 ILCS 125/1-3) (from Ch. 111 1/2, par. 1402.1) Sec. 1-3. Definitions of admitted assets. "Admitted Assets" includes the investments authorized or permitted by Section 3-1 of this Act and, in addition thereto, only the following: (1) Amounts due from affiliates pursuant to man…

(215 ILCS 125/2-1) (from Ch. 111 1/2, par. 1403) Sec. 2-1. Certificate of authority - Exception for corporate employee programs - Applications - Material modification of operation. (a) No organization shall establish or operate a Health Maintenance Organization in this State with…

(215 ILCS 125/2-10) Sec. 2-10. Directors. (a) After June 30, 2002, the corporate powers for domestic organizations issued a certificate of authority under this Act must be exercised by, and its business and affairs must be under the control of, a board of directors composed of no…

(215 ILCS 125/2-2) (from Ch. 111 1/2, par. 1404) Sec. 2-2. Determination by Director. (a) Upon receipt of an application for issuance of a certificate of authority, the Director shall transmit copies of such application and accompanying documents to the Director of the Illinois D…

(215 ILCS 125/2-3) (from Ch. 111 1/2, par. 1405) Sec. 2-3. Powers of health maintenance organizations. The powers of a health maintenance organization include, but are not limited to the following: (a) The purchase, lease, construction, renovation, operation, or maintenance of ho…

(215 ILCS 125/2-3.1) (from Ch. 111 1/2, par. 1405.1) Sec. 2-3.1. (a) No health maintenance organization shall cause to be dispensed any drug other than that prescribed by a physician. Nothing herein shall prohibit drug product selection under Section 3.14 of the "Illinois Food, D…

(215 ILCS 125/2-4) (from Ch. 111 1/2, par. 1406) Sec. 2-4. Required minimum net worth; special contingent reserve; deficiency; impairment. (a) A health maintenance organization issued a certificate of authority on or after the effective date of this amendatory Act of 1987 shall h…

(215 ILCS 125/2-5) (from Ch. 111 1/2, par. 1406.1) Sec. 2-5. Claims Liabilities. Every Health Maintenance Organization shall, at all times, maintain liabilities in an amount estimated in the aggregate to provide for the payment of all claims incurred and any due and unpaid provid…

(215 ILCS 125/2-6) (from Ch. 111 1/2, par. 1406.2) Sec. 2-6. Statutory deposits. (a) An organization subject to the provisions of this Act shall make and maintain with the Director through December 30, 1993, for the protection of enrollees of the organization, a deposit of securi…

(215 ILCS 125/2-7) Sec. 2-7. (Repealed). (Source: P.A. 92-16, eff. 6-28-01. Repealed by P.A. 97-486, eff. 1-1-12.)

(215 ILCS 125/2-8) (from Ch. 111 1/2, par. 1407.01) Sec. 2-8. Provider agreements. (a) All provider contracts currently in existence between any organization and any hospital which are renewed on or after 180 days following the effective date of this amendatory Act of 1987, and a…

(215 ILCS 125/2-9) (from Ch. 111 1/2, par. 1407.02) Sec. 2-9. Subordinated Indebtedness. An organization having a certificate of authority under this Act may borrow or assume a liability for the repayment of a sum of money upon a written agreement that the loan or advance with in…

(215 ILCS 125/3-1) (from Ch. 111 1/2, par. 1407.3) Sec. 3-1. Investment Regulations. (a) Any health maintenance organization may invest its funds as provided in this Section and not otherwise. A health maintenance organization that is organized as an insurance company may also ac…

(215 ILCS 125/4-1) (from Ch. 111 1/2, par. 1408) Sec. 4-1. Description and securing of services. Every Health Maintenance Organization shall at the time of enrollment and annually thereafter provide its enrollees a description of the services and information as to where and how t…

(215 ILCS 125/4-10) (from Ch. 111 1/2, par. 1409.3) Sec. 4-10. Medical necessity; dispute resolution; independent second opinion. Each Health Maintenance Organization shall provide a mechanism for the timely review by a physician holding the same class of license as the primary c…

(215 ILCS 125/4-11) (from Ch. 111 1/2, par. 1409.4) Sec. 4-11. Any person who enrolls recipients of Public Aid or Medicare in a health maintenance organization, either personally or by mail, shall, on or after July 1, 1989, be licensed as a limited insurance representative under …

(215 ILCS 125/4-12) (from Ch. 111 1/2, par. 1409.5) Sec. 4-12. Changes in rate methodology and benefits, material modifications. A health maintenance organization shall file with the Director, prior to use, a notice of any change in rate methodology, or benefits and of any materi…

(215 ILCS 125/4-13) (from Ch. 111 1/2, par. 1409.6) Sec. 4-13. Prior approval of policy forms. No health maintenance organization shall issue or deliver in this State a group contract or evidence of coverage, attach an endorsement or rider thereto, incorporate by reference bylaws…

(215 ILCS 125/4-14) (from Ch. 111 1/2, par. 1409.7) Sec. 4-14. Evidence of Coverage. (a) Every subscriber shall be issued an evidence of coverage, which shall contain a clear and complete statement of: (1) The health services to which each enrollee is entitled; (2) Eligibility re…

(215 ILCS 125/4-15) (from Ch. 111 1/2, par. 1409.8) Sec. 4-15. (a) No contract or evidence of coverage for basic health care services delivered, issued for delivery, renewed or amended by a Health Maintenance Organization shall exclude coverage for emergency transportation by amb…

(215 ILCS 125/4-16) (from Ch. 111 1/2, par. 1409.9) Sec. 4-16. Fibrocystic condition; denial of coverage. No contract or evidence of coverage issued by a Health Maintenance Organization shall be denied by the Organization, nor shall any contract or evidence of coverage contain an…

(215 ILCS 125/4-17) Sec. 4-17. Basic outpatient preventive and primary health care services for children. In order to attempt to address the needs of children in Illinois (i) without health care coverage, either through a parent's employment, through medical assistance under the …

(215 ILCS 125/4-18) Sec. 4-18. Retirement facility residents. With respect to an enrollee who is a resident of a retirement facility consisting of a long-term care facility, as defined in the Nursing Home Care Act, and residential apartments, a contract or evidence of coverage is…

(215 ILCS 125/4-19) Sec. 4-19. Purchase of ophthalmic goods or services. A health maintenance organization may not require a provider, as a condition of participation in the health maintenance organization's health care plan, to purchase ophthalmic goods or services, including bu…

(215 ILCS 125/4-2) (from Ch. 111 1/2, par. 1408.2) Sec. 4-2. Medical assistance; coverage of child. (a) In this Section, "Medicaid" means medical assistance authorized under Section 1902 of the Social Security Act. (b) A contract or evidence of coverage delivered, issued for deli…

(215 ILCS 125/4-20) Sec. 4-20. Deductibles and copayments. (a) A Health Maintenance Organization may require deductibles and copayments of enrollees as a condition for the receipt of specific health care services, including basic health care services. Deductibles and copayments s…

(215 ILCS 125/4-3) (from Ch. 111 1/2, par. 1408.3) Sec. 4-3. (Repealed). (Source: Repealed by P.A. 89-183, eff. 1-1-96.)

(215 ILCS 125/4-4) (from Ch. 111 1/2, par. 1408.4) Sec. 4-4. Sexual assault or abuse victims; coverage of expenses; recovery of State funds; reimbursement of Department of Public Health. (1) Contracts or evidences of coverage issued by a health maintenance organization, which pro…

(215 ILCS 125/4-5) (from Ch. 111 1/2, par. 1408.5) Sec. 4-5. Organ Transplants. No contract or evidence of coverage issued by a health maintenance organization which provides coverage for health care services shall deny reimbursement for an otherwise covered expense incurred for …

(215 ILCS 125/4-6) (from Ch. 111 1/2, par. 1408.6) Sec. 4-6. Complaint handling procedure. (a) Every health maintenance organization shall establish and maintain a complaint system providing reasonable procedures for resolving complaints initiated by enrollees. Nothing herein sha…

(215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7) Sec. 4-6.1. Mammograms; mastectomies. (a) Every contract or evidence of coverage issued by a Health Maintenance Organization for persons who are residents of this State shall contain coverage for screening by low-dose mammograp…

(215 ILCS 125/4-6.2) (from Ch. 111 1/2, par. 1408.8) Sec. 4-6.2. Breast implant removal. No contract offered by Health Maintenance Organizations shall deny coverage for the removal of breast implants when the removal of the implants is medically necessary treatment for a sickness…