ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
Page Section
1-2
Section A
2-3
Section B
3
Section C
3-4
Section D
4-5
Section E
5-9
Section F
9-11
Section G
11
Section H
11-12
Section I
12-13
Section J
13-14 Section K
Line Review Requirement Reference Items that must be included with Filing
Location in filing or
applicable SERFF
Tracking #
a.1 Review Requirements Checklist
Review Requirements
Checklists
A completed checklist must be attached in the appropriate section under the Supporting Documentation tab in the SERFF
filing. Filings submitted without the correct completed checklist for the product included in the filing will be rejected.
a.2 Certificate of Compliance 50 IAC 916.50
Each company doing business in the State of Illinois shall submit with each form filing a Certificate of Compliance under
the Supporting Documentation Tab, as described in Section 916.50 and Exhibit A.
a.3 Rate Filing
215 ILCS 125/4-13
50 IAC 4521.60
50 IAC 2026
215 ILCS 5/355
Provide the SERFF Tracking # of the Rate filing.
SERFF Tracking #
a.4 External Review Filing
215 ILCS 180 et. Al.
50 IAC 4530.40
Companies must file all required sample notices found on the External Review Checklist.
SERFF Tracking #
a.5 Network Filing Required
215 ILCS 124 et. Al.
50 IAC 4540 et. Al.
Provide SERFF tracking number for Network Adequacy and Transparency Act required filing.
SERFF Tracking #
a.6 Letter of Submission
50 IAC 916.40(b)
50 IAC 4521.112
1). Each form must bear an identifying form number in the lower left corner of the first page. 2). The insurer shall file a
letter of submission, or provide the following information in the "Filing Description" field under the "General
Information" tab in the SERFF, containing: The name of the form, if any, and identifying form #; Whether the submission
is a new form; If the form is intended to supersede another, the number of the form replaced and the date it was
approved by the Department, with all changes from the previously approved form highlighted.
ACA Small Group HMO/POS
Company Name:
SERFF Tracking #:
Checklist Directions
• The checklist corresponding with the TOI of the filing must be completed to indicate where in the filing the statutory requirements appear (e.g. form number, page number and section number).
IMPORTANT NOTICE: This Checklist does not include all requirements of Illinois laws, regulations or bulletins. Companies are responsible for reviewing Illinois laws, regulations and bulletins to ensure compliance with
all statutory requirements for both benefits and company procedures.
CONTRACTUAL POLICY REQUIREMENTS
NETWORK POLICY REQUIREMENTS
MEMBERSHIP/ELIGIBILITY/COVERAGE PERIOD
GENERAL FILING REQUIREMENTS
Title
OUT-OF-POCKET/ELIGIBLE EXPENSES
BENEFITS - ESSENTIAL HEALTH BENEFITS/ILLINOIS MANDATES
BENEFITS - PREVENTIVE
BENEFITS - MENTAL HEALTH/SUBSTANCE USE DISORDER
BENEFITS - PRESCRIPTION DRUGS
ATTESTATIONS
HMO / POS REQUIREMENTS
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 1 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
a.7
Mental Health/Substance Use
Disorder – Supporting
Documentation Checklist
Mental Health Parity Checklist
Issuers must complete and attach the Mental Health/Substance Use Disorder – Supporting Documentation Template
under the Supporting Documentation tab of this
filing.
Affirmed
a.8
Mental Health Parity
Methodology
45 CFR 146.136
Carriers must provide methodology for determination of parity of benefits with the filing under the appropriate section
of the supporting documentation in this
filing. These documents may be marked as proprietary information.
Affirmed
a.9 Form of Policy 50 IAC 4521.110
No policy may be delivered or issued for delivery to any person in this state unless it adheres to the provisions of this
section.
a.10 Form Numbers
50 IAC 916.40(b)(2)(A)
Each form must bear an identifying form number in the lower left corner of the first page. Form numbers are limited to
30 characters.
b.1 Civil Union
750 ILCS 75/10
750 ILCS 75/20
Any definition or use of the terms “spouse,” “family,” “immediate family,” “dependent,” “next of kin,” and other terms
descriptive of spousal relationships must include the term "Civil Union." This includes the terms “marriage” or “married,”
or variations thereon. All contracts of insurance issued by Illinois-licensed insurers on Illinois risks must comply with the
Act.
b.2 Discrimination
215 ILCS 5/364
50 IAC 2603
215 ILCS 125/5-3(a)
50 IAC 4521.110(v)
PROHIBITED
b.3 Discretionary Clauses Prohibited
50 IAC 2001.3
50 IAC 4521.110(x)
PROHIBITED
b.4 Entire Contract 50 IAC 4521.110(d)
The individual contract and evidence of coverage shall contain a statement that the individual contract, all applications,
and any amendments shall constitute the entire agreement between the parties.
b.5
Grace Period for Advance
Premium Tax Credit Recipients
45 CFR 155.430(b)(2)(ii)
45 CFR 156.270(d) & (g)
A QHP issuer must provide a grace period of 3 consecutive months for an enrollee, who when failing to timely pay
premiums, is receiving advance payments of the premium tax credit.
b.6 Grace Period 50 IAC 4521.110(l)
A group contract not involving the use of a premium tax credit shall provide for a grace period for the payment of any
premium, except the first, during which coverage shall remain in effect if payment is made during the grace period. The
grace period for an individual contract shall not be less than 31 days.
b.7 Claims - Timely Payment 215 ILCS 5/368a(c)
all claims and indemnities concerning health care services other than for any periodic payment shall be paid within 30
days after receipt of due written proof of such loss.
b.8 Coordination of Benefits
50 IAC 4521.110(s)
50 IAC 2009 - Exhibit A
Policies are permitted, but not required, to contain coordination of benefits (COB) provisions. Any COB provision must be
consistent with the requirements of 50 IAC 2009.
b.9 Termination of policy 215 ILCS 97/30
A health insurer issuing individual coverage must renew or continue in force coverage at the option of the individual
except for:
1. Nonpayment of premium
2. Group Contract Cancellation
3. Termination of the plan
4. Fraud
5. Movement outside the service area; or 5. Association membership ceases. (This may be in the group agreement)
b.10
Administrative Complaints and
Appeals
215 ILCS 134/50
215 ILCS 125/4-6
50 IAC 4521.110(p)
1). Healthcare plans must accept and review appeals of determinations and complaints related to administrative issues
(not healthcare services, procedures & treatments) initiated by enrollees or healthcare providers
2). Complainants not satisfied with the plan's resolution of any complaint may appeal that final plan decision to the
Department.
SECTION B - CONTRACTUAL POLICY REQUIREMENTS
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 2 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
b.11
Notice of Department of
Insurance
215 ILCS 5/143c
215 ILCS 125/4-7
Policy must provide the address of complaint department of the insurance company and the address of the Illinois
Department of Insurance:
The Illinois Department of Insurance
Office of Consumer Health Insurance
320 West Washington Street
Springfield, IL 62767
b.12 Binding Arbitration
215 ILCS 125/5-3(a)
215 ILCS 5/356z.3a (NEW)
P.A. 103-0440
In the event that a medical bill is not resolved within 30 days, permits the health insurance issuer, nonparticipating
provider, or the facility to initiate binding arbitration for a single bill or group of bills.
c.1
Provider Termination - Transition
of Care
45 CFR 156.230(d)(2)
215 ILCS 134/25
50 IAC 4520.60
215 ILCS 124/20(a) & (b)
Policy must contain a provision to ensure continuity of care for enrollees in cases where a provider is terminated without
cause or for new members whose provider is not a member of the plan’s network. Must allow an enrollee in active
course of treatment to continue treatment until the treatment is complete or for 90 days, whichever is shorter, at in-
network cost-sharing rates.
c.2
Women’s Principal HealthCare
Provider
215 ILCS 125/5-3.1(a)
215 ILCS 5/356r
45 CFR 147.138
45 CFR 149.310
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. Referral requirements prohibited for accessing any participating
OB/GYN physician.
c.3
Emergency Services Incurred
with Non-Participating Providers
50 IAC 2051.310(a)(6)(J)
50 IAC 4520.110(c)
215 ILCS 124/10(b)(7)
Policy must state that benefits for emergency care received from non-participating provider must be paid at no greater
out-of-pocket to the member than had a participating provider been utilized.
c.4 Out of Area Benefits and Services 50 IAC 4521.110(h)
The individual contract and evidence of coverage shall contain a specific description of benefits and services available out
of the HMO's designated service area.
c.5 Standing Referral to a Specialist 215 ILCS 134/40(b)
A health care plan shall establish a procedure by which an enrollee who requires the treatment of a specialist physician
or other health care provider may obtain a standing referral to that individual. Such a referral may be effective for up to
one year and may be renewed and re-renewed.
c.6
Utilization of Health Care
Facilities
215 ILCS 134/43
A health care plan must provide its enrollees with a description of their rights and responsibilities for obtaining referrals
and for making appropriate use of health care facilities when their PCP is not available.
d.1
Dependent Children - Adopted
(and Pending) Foster Child
215 ILCS 125/4-9
26 USC 152(f)(c)
42 USC 300gg-91(d)(12)
A policy that covers the insured’s immediate family or children must provide the same coverage for an adopted child or a
child not residing with the insured.
d.2 Dependent Children - Disabled
215 ILCS 125/4-9.1
50 IAC 4521.110(t)
If a policy contains a provision for a limiting age for dependents, that provision will not be applicable to a disabling
condition that occurred before the attainment of the limiting age.
d.3 Dependent Children - Newborn 215 ILCS 125/4-8
A policy of accident and health insurance shall cover the hospital or medical expenses of newborn infants from and after
the moment of birth. To guarantee coverage from the moment of birth, the insured must apply for coverage for the
newborn within 31 days of birth.
d.4
Dependent Children Covered to
Age 26 or 30
215 ILCS 5/356z.12
215 ILCS 125/5-3(a)
45 CFR 147.120(b)(1)
A policy that includes dependent coverage must offer coverage to all dependents up to age 26, regardless of marital
status, financial dependency on parents or residence. Policies must include coverage for dependents up to age 30, who is
an Illinois resident, who has been released from military service other than dishonorable discharged.
d.5 Reinstatement 50 IAC 4521.110(k) The individual contract and evidence of coverage, shall contain the conditions of the enrollee's right to reinstatement
d.6 Eligibility Requirements
215 ILCS 125/4-8
50 IAC 4521.110(e)
The individual contract and evidence of coverage must contain eligibility requirements that explain the conditions that
must be met to enroll in the plan, the limiting age for enrollees and eligible dependents, including the effects of Medicare
eligibility, and a clear statement regarding newborn coverage.
SECTION C - NETWORK POLICY REQUIREMENTS
SECTION D - MEMBERSHIP/ELIGIBILITY/COVERAGE PERIOD
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 3 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
d.7 Continuation of Coverage 215 ILCS 125/4-9.2
A group policy insures employees or members shall provide that employees or members whose insurance under the
group policy would otherwise terminate because of termination of employment or membership or because of a
reduction in hours below the minimum required by the group plan shall be entitled to continue their coverage for
themselves and their eligible dependents.
d.8 Spousal Continuation Privilege
215 ILCS 5/367.2
215 ILCS 125/5-3(a)
Policy must provide for a continuation of the existing insurance benefits for an employee's spouse and dependent
children who are insured under the provisions of that group policy or certificate thereunder, notwithstanding that the
marriage is dissolved by judgment or terminated by the death of the employee or, after the effective date of this
amendatory Act of the 93rd General Assembly, notwithstanding the retirement of the employee provided that the
employee's spouse is at least 55 years of age, in each case without any other eligibility requirements.
d.9
Dependent Child Continuation
Privilege
215 ILCS 5/367.2-5
215 ILCS 125/5-3(a)
Policy must provide for a continuation of the existing insurance benefits for an employee's dependent child who is
insured under the provisions of that group policy or certificate in the event of the death of the employee and the child is
not eligible for coverage as a dependent under the provisions of Section 367.2 (Spousal Continuation Privilege) or the
dependent child has attained the limiting age under the policy.
d.10 Discontinuance and Replacement
215 ILCS 5/367i
215 ILCS 125/5-3(a)
50 IAC 2013
Group health insurance policies issued, amended, delivered or renewed on and after the effective date of this
amendatory Act of 1989, shall provide a reasonable extension of benefits in the event of total disability on the date the
policy is discontinued for any reason.
e.1 Out-Of- Pocket Expense
Section 1302 of the ACA
42 USC 300gg-6
Policy must state all out-of-pocket limitations. The ACA sets the annual limitation on cost sharing. 2025 Out-of-pocket
maximums: Self-Only $9,200 -- Other than self-only coverage $18,400
e.2 Precertification Penalties
50 IAC 2051.310(a)(6)(K)
215 ILCS 124/10(b)(8)
If a plan intends to impose penalties for failure to pre-certify a hospital admission, the penalty must be defined in the
policy and may not exceed $1,000. The penalty may be no more frequent than a per confinement basis.
e.3
Emergency Services Prior to
Stabilization
215 ILCS 134/65
50 IAC 4520.110(b)
The plan shall cover emergency services in a manner that those services will be provided without imposing a requirement
under the plan for prior authorization of services or any limitation on coverage when the provider of services does not
have a contractual relationship with the plan for the providing of services.
e.4 Post Stabilization Services
215 ILCS 134/70
50 IAC 4520.120
If prior authorization for covered post-stabilization services is required by the healthcare plan, the plan shall provide
access 24 hours a day, 7 days a week to persons designated by the plan to make such determinations. The health care
plan shall provide reimbursement for covered post-stabilization medical services if: 1). authorization to render them is
received from the healthcare plan or its delegated health care provider, or 2). after two documented good faith efforts,
the treating health care provider has attempted to contact the enrollee's health care plan and neither the plan nor
designated persons were accessible or the authorization was not denied within 60 minutes of the request.
e.5 Deductibles and Copayments
215 ILCS 125/4-20
50 IAC 4521.110(i)
An HMO 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 shall be the only allowable charge, other than
premiums, assessed enrollees. Copayments and deductibles appearing in the policy shall be for specific dollar amounts
or for specific percentages of the cost of the health care services.
e.6 Refunds/ Additional Premiums 215 ILCS 125/5-3(f)
If an HMO and a group policy holder (employer or other enrollment unit) agree to refund arrangements or charge
additional premiums, the following terms and conditions must be met: 1). the amount of, and other terms and
conditions with respect to, the refund or additional premium are set forth in the group or enrollment unit contract
agreed in advance of the period for which a refund is to be paid or additional premium is to be charged (which period
shall not be less than one year); 2). the amount of the refund or additional premium shall not exceed 20% of the HMO's
profitable or unprofitable experience with respect to the group or other enrollment unit for the period.
e.7 Copay/Deductible Accumulators 215 ILCS 134/30(d)
A health care plan shall apply any third-party payments, financial assistance, discount, product vouchers, or any other
reduction in out-of-pocket expenses made by or on behalf of such insured for prescription drugs toward a covered
individual's deductible, copay, or cost-sharing responsibility, or out-of-pocket maximum associated with the individual's
health insurance. HDHP with HSA exempt from counting third-party payments until the minimal deductible under 26
U.S.C. § 223 has been met.
SECTION E - OUT-OF-POCKET/ ELIGIBLE EXPENSES
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 4 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
e.8
Prescription drug flat copay
benefits/plan choice
215 ILCS 134/45.3
Flat copay requirement -- please provide for each corresponding service area, the plan name(s), metal level(s), and
schedule that meet this requirement. Any plans with prescription riders must also provide this information. The
minimum requirement for PY 2025 is two group plans per service area, per metal level, with a flat copay prescription
benefit structure.
NEW for PY 2025: a QHP Issuer on the Federally-facilitated Exchange is limited to two non-standardized plan options per
product network type, metal level (excluding catastrophic), and inclusion of dental and/or vision coverage, in any service
area. The Issuer must offer at least one standardized plan option at every product network type, metal level (excluding
catastrophic plans), and throughout every service area that it also offers a non-standardized option, including the income-
based CSR variations for silver plans.
f.1 Essential Health Benefits
Section 1302 of the ACA
42 USC 18022
45 CFR 147.126
50 IAC 2001.11
50 IAC 4521.130(l)
Mandated
f.2
Inpatient Hospital Services (e.g.,
Hospital Stay)
Benchmark p. 15 Essential Health Benefit
f.3
Outpatient Surgery
Physician/Surgical Services
(Ambulatory Patient Services)
Benchmark p. 15 Essential Health Benefit
f.4
Outpatient Facility Fee (e.g.,
Ambulatory Surgery Center)
Benchmark p. 21 Essential Health Benefit
f.5 Emergency Medical Condition
215 ILCS 134/10
Benchmark p. 7
Required to use definition of emergency medical condition as defined in the Managed Care Reform and Patient's Rights
Act.
f.6
Emergency Transportation/
Ambulance
215 ILCS 125/4-15
Benchmark p. 17
Essential Health Benefit
f.7 Emergency Room Services Benchmark p. 7 Essential Health Benefit
f.8
Emergency Medical Care
- Criminal Sexual Assault
215 ILCS 125/4-4
Policy must state that it will provide coverage for charges for testing and examination for victims of criminal sexual
assault for actual expenses incurred, without offset or reduction for benefit deductibles or coinsurance amounts.
f.9
Home Health
Care
215 ILCS 5/356z.53
215 ILCS 125/5-3(a)
Benchmark p. 5
Mandated
f.10 Hospice Benchmark p. 28 Essential Health Benefit
f.11 Skilled Nursing Facility Benchmark p. 21 Essential Health Benefit
f.12 Office Visit Benchmark p. 8 & 11 Essential Health Benefit
f.13
Referrals and Second
Opinions/Additional Surgical
Opinion
215 ILCS 125/4-10
50 IAC 4521.130(a)
Benchmark p. 11
Plan must contain a description of any limitation for referrals and access to second opinions to ensure access and
availability of health care services for the insured is not restricted. Coverage includes benefits for an additional surgical
opinion following a recommendation for elective surgery.
f.14 Physician Surgical Benefits Benchmark p. 10 Including assist at surgery services
f.15 Anesthesia Services Benchmark p. 10 Inpatient and Ambulatory Surgical Centers
f.16
Dental Anesthesia Services -
Other Indications
215 ILCS 5/356z.2
215 ILCS 125/5-3(a)
Benchmark p. 10
Mandated for certain criteria
f.17
Dental Anesthesia Services -
Autism
215 ILCS 5/356z.2(a-5)
215 ILCS 125/5-3(a)
Mandated under age 26
f.18
Anesthesia Services – Oral
Surgery
Benchmark p. 10
Benefits are provided for anesthesia services administered by oral and maxillofacial surgeons when such services are
rendered in the surgeon's office or Ambulatory Surgical Facility.
SECTION F - BENEFITS - ESSENTIAL HEALTH BENEFITS / ILLINOIS MANDATES
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 5 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
f.19
Allergy Testing and Treatment
(Serum)
Benchmark p. 11
50 IAC 4521.130(g)
Essential Health Benefit
f.20
Amino Acid-Based Elemental
Formulas
215 ILCS 5/356z.10
215 ILCS 125/5-3(a)
Mandated
f.21 Bariatric Surgery (Obesity) Benchmark p. 21
Essential Health Benefit
f.22
Breast - Fibrocystic Breast
Condition
215 ILCS 125/4-16 Policy must provide coverage for fibrocystic breast condition.
f.23 Breast - Post Mastectomy Care
215 ILCS 125/4-6.5
215 ILCS 5/356t
Benchmark p. 24
Mandated
f.24
Breast Cancer Pain Medication
and Therapy
215 ILCS 5/356g.5-1
215 ILCS 125/5-3(a)
Benchmark p. 12 & 32
Mandated
f.25 Breast Implant Removal
215 ILCS 125/4-6.2
Benchmark p. 25
Mandated
f.26
Breast Reconstruction After
Mastectomy
215 ILCS 125/4-6.1(b)
50 IAC 4521.132
Benchmark p. 24
Essential Health Benefit
Mandated
f.27 Breast Reduction Surgery
215 ILCS 356z.54
215 ILCS 125/5-3(a)
Mandated
f.28
Cancer - Qualified Clinical Cancer
Trials
215 ILCS 5/364.01
215 ILCS 125/5-3(a)
Benchmark p. 34
Policy must not exclude routine patient care services if associated with a clinical cancer trial and the services are included
in the policy benefit structure.
f.29
Chiropractic & Osteopathic
Manipulation
Benchmark p. 12
Essential Health Benefit
May be limited to 25 visits per benefit period.
f.30 Accidental Injury -- Dental Benchmark p. 17 Essential Health Benefit
f.31 Dental Care - Oral Surgery Benchmark p. 10
Essential Health Benefit
Allowed limitations found in the Benchmark
f.32
Temporomandibular Joint
Disorder (TMJ)
Benchmark p. 24
215 ILCS 125/5-3(a)
215 ILCS 130/4003
215 ILCS 165/10
215 ILCS 5/356q
Essential Health Benefit
TMJ optional coverage expansion.
f.33
Diabetes - Self Management,
Education and Nutrition
215 ILCS 125/5-3(a)
215 ILCS 5/356w
Benchmark p. 11
Essential Health Benefit
Mandated
f.34 Routine Foot Care
215 ILCS 5/356w(f)
215 ILCS 125/5-3(a)
Benchmark p. 11 & 35
Essential Health Benefit
Covered only for persons diagnosed with Diabetes
f.35 Diabetic Supplies
215 ILCS 5/356w(d)(e)
50 IAC 2019.40
215 ILCS 125/5-3(a)
Benchmark p. 31
Essential Health Benefit under Durable Medical Equipment
Mandated
f.36 Continuous Glucose Monitors
215 ILCS 5/356z.59
215 ILCS 125/5-3(a)
Mandated
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 6 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
f.37 Diabetes Telehealth Services
215 ILCS 5/356z.22
215 ILCS 125/5-3(a)
Mandated if telehealth benefits are covered.
f.38 Durable Medical Equipment Benchmark p. 13 Essential Health Benefit
f.39 Compression Sleeves
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0091
Mandated for compression sleeves that is medically necessary for the enrollee to prevent or mitigate lymphedema.
f.40
Dry Needling by Physical
Therapist
215 ILCS 125/5-3(a)
215 ILCS 5/356z.28 (NEW)
P.A. 103-0426
OPTIONAL
f.41
Neuromuscular, Neurological, or
Cognitive Impairment for
Children
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0458
Mandated
Expands insurance coverage to include therapy, diagnostic testing, and equipment for children who have been clinically
or genetically diagnosed with any disease, syndrome, or disorder including low tone neuromuscular impairment.
f.42
Habilitative and Rehabilitative
Services and Devices
45 CFR 156.115(a)(5)
Benchmark pp. 8 & 11, 22 & 35
50 IAC 4521.130(j)
Essential Health Benefit
May not combine habilitative and rehabilitative visit limitations.
Outpatient rehabilitation therapy, including but not limited to, speech therapy, physical therapy, and occupational
therapy directed at improving physician functioning of a member must be provided up to 60 treatments per year for
conditions which are expected to result in significant improvement within two months as determined by the PCP and
HMO Medical Director.
f.43 Habilitative Services for Children
215 ILCS 5/356z.15
215 ILCS 125/5-3(a)
Essential Health Benefit
Mandated - Prohibits denial of benefits solely on location of where medically necessary services are rendered.
f.44 Hearing Aids
215 ILCS 5/356z.30 (UPDATED)
215 ILCS 125/5-3(a)
P.A. 103-0530
Essential Health Benefit
Mandated -- One per ear every 3 years
f.45
Cochlear Implants/Bone
anchored hearing aids
Benchmark p.17 Essential Health Benefit -- Cochlear implants covered for all ages
f.46 Infertility (Fertility) Treatment
Benchmark p. 23
215 ILCS 5/356m
215 ILCS 125/5-3(a)
50 IAC 2015
Essential Health Benefit, for groups with more than 25 employees
Expands infertility to include a broader inclusive patient base, including coverage of surrogates. Note: this mandate only
applies to groups of more than 25 members.
f.47 Fertility Preservation Services
215 ILCS 5/356z.32
215 ILCS 125/5-3(a)
Mandated
f.48 Maternity and Newborn Care
215 ILCS 125/4-8
215 ILCS 5/356s
215 ILCS 125/4-6.4
Benchmark p. 8 & 22
Essential Health Benefit
Mandated
f.49 PANDAS/PANS
215 ILCS 5/356z.25
215 ILCS 125/5-3(a)
Mandated
f.50
Physical Therapy - Multiple
Sclerosis Patients
215 ILCS 5/356z.8
215 ILCS 125/5-3(a)
Essential Health Benefit
Mandated
f.51 Private-Duty Nursing Benchmark p. 17 Essential Health Benefit
f.52 Prosthetics/Orthotics
215 ILCS 5/356z.18 (UPDATED)
215 ILCS 125/5-3(a)
Benchmark p. 13
P.A. 103-0512
Essential Health Benefit
Mandated
May exclude foot orthotics defined as an in-shoe device
Provides that with respect to an enrollee at any age, in addition to coverage of a prosthetic or custom orthotic device,
benefits shall be provided for a prosthetic or custom orthotic device determined by the enrollee's provider to be the
most appropriate model that is medically necessary for the enrollee to perform physical activities
f.53 Cosmetic Surgery Benchmark p. 35
Essential Health Benefit
May be excluded except for correction of congenital deformities or conditions resulting from accidental injuries, scars,
tumors, or diseases.
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 7 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
f.54
Reconstructive Services (Physical
Appearance)
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0123
Mandated - may not deny coverage for medically necessary reconstructive services that are intended to restore physical
appearance.
f.55 Cleft Lip/Cleft Palate
215 ILCS 125/5-3(a)
215 ILCS 5/356z.55 (NEW)
P.A. 103-0426
Mandated
f.56
Transplants - Human Organ
Transplants
215 ILCS 5/356k
215 ILCS 125/4-5
Benchmark p. 18 & 31
Essential Health Benefit
Mandated
f.57
Transplants - Human Organ
Transplants Transportation and
Lodging
Benchmark p. 18
Benefits must be provided for transportation and lodging for covered patient receiving transplant and a companion. If
the recipient of the transplant is a dependent child under the limiting age of this Certificate, benefits for transportation
and lodging will be provided for the transplant recipient and two companions. For benefits to be available, the patient's
place of residency must be more than 50 miles from the Hospital where the transplant will be performed.
f.58 Cardiopulmonary Monitors
215 ILCS 125/5-3(a)
215 ILCS 5/356z.34 (NEW)
P.A. 103-0426
Mandated
f.59 Human Breast Milk
215 ILCS 125/5-3(a)
215 ILCS 5/356z.38 (NEW)
P.A. 103-0426
Mandated
f.60 Basic Health Care Services 50 IAC 4521.130
Except when superseded by other law or ACA EHB requirements, HMO's must provide coverage for Basic Health Care
Services as provided by 50 IAC 4521.130.
f.61 Whole Body Skin Examination
215 ILCS 5/356z.37
215 ILCS 125/5-3(a)
Mandated
No Cost Sharing
f.62 Diagnostic Mammogram
215 ILCS 125/4-6.1
215 ILCS 5/356g(a)(6)
Mandated
No Cost Sharing
HDHP with HSA Exempt from no cost-sharing requirement until the minimal deductible under 26 U.S.C. § 223 has been
met.
f.63 Tick-Borne Disease
215 ILCS 125/5-3(a)
215 ILCS 5/356z.35
Mandated
f.64 Pancreatic cancer
215 ILCS 5/356z.47
215 ILCS 125/5-3(a)
Coverage for medically necessary pancreatic cancer screening.
f.65 Biomarker testing
215 ILCS 5/356z.46
215 ILCS 125/5-3(a)
Biomarker testing must be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing
monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence.
f.66 Telehealth mandate
215 ILCS 5/356z.22
215 ILCS 125/5-3(a)
Mandates telehealth coverage.
f.67 Colonoscopy
215 ILCS 5/356z.48
215 ILCS 125/5-3(a)
No cost-sharing for medically necessary colonoscopies that are follow up exams based on initial screen.
f.68 Port wine stains
215 ILCS 5/356z.51
215 ILCS 125/5-3(a)
Mandates coverage for medically necessary elimination or maximum feasible treatment of nevus flammeus (port wine
stains) for children aged 18 years or younger - does not cover cosmetic removal.
f.69 Comprehensive cancer testing
215 ILCS 5/356z.50
215 ILCS 125/5-3(a)
Mandates coverage for medically necessary comprehensive cancer testing.
f.70 Home Saliva Cancer Screening
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0445
Mandated
cover a medically necessary home saliva cancer screening every 24 months if the patient: (1) is asymptomatic and at high
risk for the disease being tested for; or (2) demonstrates symptoms of the disease being tested for at a physical exam.
f.71 Proton Beam Therapy
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0325
Mandated
shall not apply a higher standard of clinical evidence for the coverage of proton beam therapy than the insurer applies for
the coverage of any other form of radiation therapy treatment.
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 8 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
f.72 Liver Disease Screening
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0084
Mandated for preventative liver disease screenings for individuals 35 years of age or older and under the age of 65 at
high risk for liver disease.
NO COST SHARE
f.73 A1C testing
215 ILCS 5/356z.49
215 ILCS 125/5-3(a)
Coverage for A1C testing recommended by a health care provider for prediabetes, type 1 diabetes, and type 2 diabetes.
f.74 Vitamin D testing
215 ILCS 5/356z.44
215 ILCS 125/5-3(a)
Coverage for vitamin D testing recommended by a health care provider in accordance with vitamin D deficiency risk
factors identified by the CDC.
f.75
Improving health care for
pregnant and post partum
individuals act
215 ILCS 5/356z.40
215 ILCS 125/5-3(a)
Mandates clinically appropriate case management programs for high-risk pregnancies and all pregnant and postpartum
individuals have access to mh/sud benefits.
f.76 Pediatric Palliative Care
215 ILCS 5/356z.57
215 ILCS 125/5-3(a)
Plan must provide coverage for community-based pediatric palliative care and hospice care to any qualifying child with a
serious illness by a trained interdisciplinary team. Allows a child to receive community-based pediatric palliative care and
hospice care while continuing to pursue curative treatment and disease-directed therapies for the qualifying illness.
f.77
Hormone therapy to treat
menopause
215 ILCS 5/356z.56
215 ILCS 125/5-3(a)
Mandated
g.1 Preventive Services ACA
42 U.S.C. 300gg-13
50 IAC 2001.8
50 IAC 4521.110(x)
Benefits shall be provided at no cost sharing to the member when these services are delivered by a network provider.
Policy must contain language indicating that all preventive services covered are covered with no cost-sharing to the
member pursuant to A and B recommendations found in the United States Preventive Services Task Force (USPSTF)
guidelines.
g.2
Preventive Services -
Immunizations
42 U.S.C. 300gg-13(a)(2)
50 IAC 2001.8(1)(B)
50 IAC 4521.110(x)
Plans are required to cover immunizations recommended by the Advisory Committee on Immunization Practices without
charging a deductible, copayment or coinsurance.
g.3 Preventive Services - Women
42 U.S.C. 300gg-13(a)(4)
50 IAC 2001.8(1)(D)
50 IAC 4521.110(x)
Plans are required to cover women's preventive services guidelines supported by the Health Resources & Services
Administration without charging a deductible, copayment or coinsurance.
g.4
Preventive Services - Children/
Adolescents
42 U.S.C. 300gg-13(a)(3)
50 IAC 2001.8(1)(C)
50 IAC 4521.110(x)
Plans are required to cover children's preventive services guidelines supported by the Health Resources & Services
Administration without charging a deductible, copayment or coinsurance. Benefits must include routine hearing
screenings/examinations.
g.5 Sterilization
215 ILCS 5/356z.4(a)(3)(B)
215 ILCS 5/356z.4 (a)(4)
215 ILCS 125/5-3(a)
Essential Health Benefit
Mandated
No Cost Sharing In-Network
Male Sterilization: HDHP with HAS exempt from no cost-sharing requirement until the minimal deductible under 26
U.S.C. § 223 has been met.
g.6 Breast Exam - Clinical
215 ILCS 125/4-6.5
215 ILCS 5/356g.5
Coverage is required for clinical breast examinations. NO COST SHARING IN-NETWORK
g.7
Breast Feeding (Lactation)
Support, Supplies and Counseling
- Breast Pumps
50 IAC 2001.8
50 IAC 4521.110(x)
HRSA Guidelines
g.8
Colorectal Cancer Examination
and Screening
215 ILCS 5/356x
215 ILCS 125/5-3(a)
Benchmark p. 12 & 16
Essential Health Benefit
Mandated
No Cost Sharing In-Network
SECTION G - BENEFITS - PREVENTIVE
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 9 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
g.9
Contraceptive/Birth Control
Services
215 ILCS 5/356z.4
215 ILCS 125/5-3(a)
CMS FAQ ACA Implementation
Part 54, Q2
CB 2022-15
Essential Health Benefit
Mandated
No Cost Sharing In-Network
Requires insurers to cover pharmacists ordering contraceptives for individuals without a script from a physician.
Male condoms are required to be covered at no cost-sharing as a preventative service when a female enrollee obtains a
prescription. Carte blanche exclusions for male condoms is prohibited
g.10
Patient Care Services Provided
by a Pharmacist
215 ILCS 125/5-3(a)
215 ILCS 5/356z.45
Coverage for health care or patient care services provided by a pharmacist if 1) the pharmacist meets the requirements
set forth in section 43 of the Pharmacy Practice Act; 2) health plan provides coverage for the same service provided by a
licensed physician, advanced practice registered nurse, or a physician assistant; 3) the pharmacist is included in the
health benefit plan's network of participating providers; 4) a reimbursement has been successfully negotiated in good
faith between the pharmacist and the health plan.
g.11 Prescription Estrogen
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0420
Mandated
coverage for one or more therapeutic equivalent versions of vaginal estrogen in its formulary. Therapeutic equivalent
version" has the meaning given to that term in paragraph (2) of subsection (a) of Section 356z.4.
No Cost Sharing
g.12
Coverage of pharmacy testing,
screening, vaccinations, and
treatment
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0001
Mandated
shall provide coverage for health care or patient care services provided by a pharmacist if: (1) the pharmacist meets the
requirements and scope of practice described in paragraph (15), (16), or (17) of subsection (d) of Section 3 of the
Pharmacy Practice Act; (2) the health plan provides coverage for the same service provided by a licensed physician, an
advanced practice registered nurse, or a physician assistant; (3) the pharmacist is included in the health benefit plan's
network of participating providers; and (4) reimbursement has been successfully negotiated in good faith between the
pharmacist and the health plan.
g.13 Coverage for Abortion
215 ILCS 5/356z.4a
215 ILCS 125/5-3(a)
CB 2022-15
Requires coverage for abortion services.
Coverage for abortion care may not impose deductible, coinsurance, waiting period, or other cost-sharing limitation that
is greater than that required for other pregnancy-related benefits covered by the policy.
Coverage shall not impose any restrictions or delays on the coverage
g.14
Abortifacients, Hormonal
Therapy, and Human
Immunodeficiency Virus Pre-
Exposure Prophylaxis and Post-
Exposure Prophylaxis
215 ILCS 5/356z.60
215 ILCS 125/5-3(a)
Mandated
No Cost Sharing In-Network
HDHP with HSA exempt from no cost-sharing requirement until the minimal deductible under 26 U.S.C. § 223 has been
met.
g.15 HIV screening - pregnant women
215 ILCS 5/356z.1
215 ILCS 125/4-6.5
Essential Health Benefit
Mandated
No Cost Sharing In-Network
g.16
Human Papillomavirus Vaccine
(HPV)
215 ILCS 5/356z.9
215 ILCS 125/5-3(a)
Essential Health Benefit
Mandated
No Cost Sharing In-Network
g.17 Mammography - Screening
215 ILCS 5/356g(a)
215 ILCS 125/4-6.1
Benchmark p. 24
Essential Health Benefit
Mandated
No Cost Sharing In-Network
g.18
Osteoporosis - Bone Mass
Measurement
215 ILCS 5/356z.6
215 ILCS 125/5-3(a)
Benchmark p. 16
Essential Health Benefit
Mandated
NO COST SHARING IN-NETWORK
g.19
Pap Tests/ Prostate- Specific
Antigen Tests/ Ovarian Cancer
Surveillance Test
215 ILCS 5/356u
215 ILCS 125/4-6.5
Benchmark p. 16
Essential Health Benefit
Mandated
No Cost Sharing In-Network
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 10 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
g.20 Shingles Vaccine (Herpes Zoster)
215 ILCS 5/356z.13
215 ILCS 125/5-3(a)
Benchmark p. 12 & 19
Essential Health Benefit
Mandated
No Cost Sharing In-Network
g.21
Tobacco Smoking Cessation
Program
215 ILCS 5/356z.21
215 ILCS 125/5-3(a)
Benchmark p. 19
Essential Health Benefit
Mandated
No Cost Sharing In-Network
g.22
Mental Health Prevention and
Wellness Visits.
215 ILCS 125/5-3(a)
215 ILCS 5/356z.61 (NEW)
P.A. 103-0535
Mandated
one annual mental health prevention and wellness visit for children and for adults up to 60 minutes.
No Cost Sharing
g.23 Wellness Programs
215 ILCS 5/356z.17
215 ILCS 125/5-3(a)
50 IAC 2001.9(b)(2)(B) & (c)(3) &
(f)(g)(h)(i)(j)(k)
OPTIONAL - Activity and outcome based wellness programs are not allowed in individual plans; however, participatory
programs are allowed.
h.1 Autism Spectrum Disorder
215 ILCS 5/356z.14
215 ILCS 125/5-3(a)
Mandated for individuals under age 21. Prohibits denial of benefits solely on location of where medically necessary
services are rendered.
h.2
Mental (Behavioral) Health
Treatment
(Inpatient/Outpatient)
215 ILCS 5/370c et. Al.
215 ILCS 5/370c.1 et. Al.
215 ILCS 125/5-3(a)
Essential Health Benefit
Mandated
h.3
Substance Use Disorders
(Inpatient/Outpatient)
215 ILCS 5/370c et. Al.
215 ILCS 5/370c.1 et. Al.
215 ILCS 125/5-3(a)
Essential Health Benefit
Mandated
h.4
Recovery Housing for persons
with substance use disorders
215 ILCS 5/356z.31
215 ILCS 125/5-3(a)
OPTIONAL - A policy may provide coverage for residential extended care services and supports for persons recovery
housing for persons with substance use disorders who are at risk of a relapse following discharge from a health care
clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal
management program, or hospital emergency department so long as specific conditions are met.
h.5 Tele-Psychiatry Benchmark p. 11
Essential Health Benefit
Required to be covered as a medical care visit
i.1 Inhalants - Prescription
215 ILCS 5/356z.5
215 ILCS 125/5-3(a)
Mandated
i.2
Immunosuppressant Drugs -
Organ Transplant Medication
Notification Act
215 ILCS 175/15
Plans must cover medically necessary immunosuppressant drugs with a written prescription after an approved human
organ transplant. When a prescribing physician has indicated on a prescription "MAY NOT SUBSTITUTE", a health
insurance policy or healthcare service plan that covers immunosuppressant drugs, may not require, or cause a
pharmacist to interchange another immunosuppressant drug or formulation, issued on behalf of a person to inhibit or
prevent the activity of the immune system of the patient to prevent the rejection of the transplanted organs & tissues
without notification and the documented consent of the prescribing physician and the patient.
i.3
Prescription Drugs - Cancer
Treatment
215 ILCS 125/4-6.3
Benchmark p. 32
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.
i.4 Cancer Drug Parity
215 ILCS 125/5-3(a)
215 ILCS 5/356z.20 (NEW)
P.A. 103-0426
Mandated
i.5 Immune Gamma Globulin
215 ILCS 125/5-3(a)
215 ILCS 5/356z.24 (NEW)
P.A. 103-0426
Mandated
SECTION I - BENEFITS - PRESCRIPTION DRUGS - ALL POLICIES
SECTION H - BENEFITS - MENTAL HEALTH/SUBSTANCE USE DISORDER SERVICES
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 11 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
i.6 Opioid Antagonists
215 ILCS 125/5-3(a)
215 ILCS 5/356z.23 (NEW)
P.A. 103-0426
Mandated
i.7 Synchronization
215 ILCS 5/356z.26
215 ILCS 125/5-3(a)
Mandated
i.8
Opioid Medically Assisted
Treatment (MAT)
Benchmark p. 21 Essential Health Benefit
i.9
Intranasal opioid reversal agent
associated with opioid
prescriptions
Benchmark p.32
Essential Health Benefit
Benefits will be provided for at least one intranasal opioid reversal agent prescription for initial prescriptions of opioids
with dosages of 50 MME or higher.
i.10
Topical Anti-Inflammatory acute
and chronic pain medication
Benchmark p. 32 Essential Health Benefit
i.11 Epinephrine Injectors
215 ILCS 125/5-3(a)
215 ILCS 5/356z.33 (UPDATED)
P.A. 103-0454
Coverage for medically necessary epinephrine injectors for persons 18 years of age or under. Caps the cost of a twin-pack
of medically necessary epinephrine at $60.
i.12 Insulin Co-Pay
215 ILCS 125/5-3(a)
215 ILCS 5/356z.41 (UPDATED)
P.A. 103-0429
Required to limit cost sharing $35 per 30 day supply
i.13 Prenatal Vitamins
215 ILCS 125/5-3(a)
215 ILCS 5/356z.58 (NEW)
P.A. 103-0426
Mandated
j.1
Stage 4 Advanced Metastatic
Cancer
215 ILCS 5/356z.29
215 ILCS 125/5-3(a)
This policy directly or indirectly covers the treatment of stage 4 advanced metastatic cancer shall not limit or exclude
coverage for a drug approved by the United States Food and Drug Administration by mandating that the insured shall
first be required to fail to successfully respond to a different drug or prove a history of failure of the drug as long as the
use of the drug is consistent with best practices for treatment of stage 4 advanced metastatic cancer and is supported by
peer-reviewed medical literature.
Affirmed
j.2
Mental Health and Addiction
Parity
45 CFR 156.110(a)(5)
45 CFR 146.136
215 ILCS 5/370c.1
The policy documents attached to this filing are in compliance with Federal and State Mental Health Parity laws.
Affirmed
j.3
Short-term opioid prescription
limitations
Benchmark p. 31 This policy limits short-term opioid prescriptions to no more than 7 days.
Affirmed
j.4 Prescription Drug Exception
45 CFR 156.122(c)
215 ILCS 134/45.1
A process is in place for standard exception requests, expedited exception requests, and external exception request
reviews as stipulated in 215 ILCS 134/45.1 and 45 CFR 156.22(c). Plans must advise enrollees of the process for making
exceptions for non-covered prescription drugs when: 1). the drug is not covered based on the health benefit plans
formulary; 2). the health benefit plan is discontinuing coverage of the drug; 3). the prescription drug alternatives required
to be used in accordance with a step therapy requirement, a). has been ineffective in the treatment or b). has caused an
adverse reaction or harm to the enrollee; or 4). the number of doses available under a dose restriction for the
prescription drug, a). has been ineffective in the treatment of the enrollee's disease or medical condition or b). the
known relevant physical and mental characteristics of the enrollee, and known characteristics of the drug regimen, is
likely to be ineffective or adversely affect the drug's effective or patient compliance.
Affirmed
SECTION J - ATTESTATIONS
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 12 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
j.5 Prescription Drug Formulary
215 ILCS 134/15 (a-5)(1)
215 ILCS 134/25(a)(3)
215 ILCS 125/4-6.5
215 ILCS 5/155.37
No policy of health insurance shall be offered for sale directly to consumers through the health insurance marketplace
unless the most recently published prescription drug formulary is made available to the consumer when comparing
policies and premiums.
Plans offering prescription drugs shall not remove a drug from its formulary or negatively change its preferred or cost-tier
sharing unless, at least 60 days before making the formulary change
Affirmed
j.6
Transition of Services (Incl.
Formulary)
215 ILCS 134/25
Mandated. Continuity/transition of care requirements Affirmed
j.7
Autism - Prohibition on Coverage
Termination
215 ILCS 5/356z.14(h-10)
215 ILCS 125/5-3(a)
This policy does not restrict coverage under an individual contract on the basis that the individual declined an alternative
medication or covered service under certain circumstances.
Affirmed
j.8 Prohibition on Rescissions
50 IAC 2001.7
50 IAC 4521.110(x)
45 CFR 147.128
A group health insurance coverage shall not rescind such policy with respect to an enrollee once the enrollee is covered
under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed
an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the
terms of the plan or coverage. Such plan or coverage may not be cancelled except with
30 days-notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).
Affirmed
j.9
Discontinuance of Particular
Type of Coverage - HIPAA
50 IAC 2025
215 ILCS 97/30(C)(1)
50 IAC 2001.4(g)(h) & (j)
Insurers must comply with the uniform termination requirements for discontinuing a particular type of coverage in the
state. 1). The health insurance issuer may only discontinue a particular type of health insurance coverage upon the
renewal date of the coverage with ninety (90) days’ notice to insureds. 2). The health insurance issuer must offer to be
purchased all products being marketed in that market. The health insurance issuer may not limit which products are to
be offered for purchase.
Affirmed
j.10
Discontinuance of All Coverage -
HIPAA
215 ILCS 97/30(C)(2)
50 IAC 2025
215 ILCS 97/60
Insurers must comply with the uniform termination requirements for discontinuing all coverage in the state. Notification
to the Department is required for discontinuation of all health insurance coverage in the individual market 90 days before
the issuer notifies covered individuals, which must be given 180 days before the effective date of termination.
Affirmed
j.11
Modification of Coverage –
HIPAA
50 ILCS 2025
215 ILCS 97/30(D)
An insurer may only modify a contract at renewal as long as the modification is consistent with Illinois law and consistent
on a uniform basis among all individuals with that policy form.
Affirmed
j.12
Use of Information Derived from
Genetic Testing
215 ILCS 5/356v
410 ILCS 513/20
215 ILCS 125/5-3(a)
An insurer may not seek information derived from genetic testing for use in connection with a policy of accident and
health insurance. An insurer that receives information derived from genetic testing, regardless of the source of that
information, may not use the information for a nontherapeutic purpose as it relates to a policy of accident and health
insurance. An insurer shall not use or disclose protected health information that is genetic information for underwriting
purposes.
Affirmed
j.13 Use of SSN on ID Cards
815 ILCS 505/2QQ
815 ILCS 505/2RR
215 ILCS 139/15 (NEW)
A person or entity may not print an individual's social security number on an insurance card. 815 ILCS 505/2RR prevents
a person, including insurers, from printing an individual's SSN on any materials mailed to an individual unless required by
state or federal law.
Affirmed
j.14
Schedule of Benefits and
Coverage (SBCs)
50 IAC 2001.10
50 IAC 4521.110(x)
50 IAC 4521.110(b)
SBCs must be filed for approval under the form schedule tab. Please attest that all SBCs in this filing meet the
requirements of the referenced Illinois Administrative Code (50 IAC 2001.10)
Affirmed
j.15
Prohibition on Medicaid
Language
215 ILCS 125/4-2(b)
An HMO contract may not contain any provision which limits or excludes payments of health care services to or on behalf
of the enrollee because the enrollee or any covered dependent is eligible for or is receiving Medicaid benefits in this or
any other state.
Affirmed
k.1 In Plan/Out of Plan Services
215 ILCS 125/4.5-1(a)(3)
50 IAC 4521.113
Point of Service plan may not offer services out-of-plan without providing those services on an in-plan basis
SECTION K - POS PLAN REQUIREMENTS
If the filing to which this checklist is attached holds a policy that will be used as a base plan for a Point-of-Service (POS) product, this section must be completed.
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 13 of 14
ACA Small Group HMO/POS
Updated MAY 2024
Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767
k.2 Comparison of Benefits 50 IAC 4521.113(a)(7) Point of Service plan filing must include a comparison of benefits offered by the HMO carrier and the indemnity carrier.
k.3 ID Cards
50 IAC 4521.113(a)(2)
215 ILCS 139/15 (NEW)
Point of Service plan filing must include enrollment application and member identification card disclosing the names of
both the HMO and indemnity carrier.
k.4 Limited Benefit Disclosure 215 ILCS 125/4.5-1(a)(7)
HMO must include the following disclosure on its Point of Service plan contracts and evidences of coverage: "WARNING,
LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that when you
elect to utilize the services of a non-participating provider for a covered service in non-emergency situations, benefit
payments to such non-participating provider are not based upon the amount billed. The basis of your benefit payment
will be determined according to your policy's fee schedule, usual and customary charge (which is determined by
comparing charges for similar services adjusted to the geographical area where the services are performed), or other
method as defined by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE
POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-participating providers may bill members for any
amount up to the billed charge after the plan has paid its portion of the bill. Participating providers have agreed to accept
discounted payments for services with no additional billing to the member other than co-insurance and deductible
amounts. You may obtain further information about the participating status of professional providers and information on
out-of-pocket expenses by calling the toll free telephone number on your identification card."
k.5 Out of Network Benefits
Point of Service plan out of network benefits must meet applicable requirements stated within this checklist. If the out-
of- network piece is being offered through an agreement with an insurer, please provide the SERFF Tracking #.
SERFF Tracking #
Emily Downs, Assistant Deputy Director - Health Compliance
Emily.Downs@Illinois.gov
Page 14 of 14
