Ill. Admin. Code tit. 50, § 4521.110 - Requirements for Group Contracts, Evidences of Coverage and Individual Contracts
a) Any
group contract, evidence of coverage, individual contract, enrollee handbook,
enrollment application, identification card or other form that affects the
terms and conditions applicable to the subscriber or enrollee in the provision
of health care services must be filed with and approved by the Director prior
to use in accordance with the filing requirements of Section
4521.112 of this Part and
Section 4-13 of the Act. The HMO shall issue to each subscriber or enrollee a
group contract, evidence of coverage, or individual contract. Any conflicting
information between the valid current document referenced in this subsection
issued to the subscriber or enrollee and the current group contract shall be
interpreted according to whichever is most beneficial to the subscriber or
enrollee. Any group contract, evidence of coverage, or individual contract
shall provide for the rendering of health care services as defined in that
document for either a specific period of not less than 12 months from the date
of issuance or for another period mutually agreed to by the HMO and the group
or individual contractholder, and shall provide for renewal on a basis mutually
agreed to by both parties, unless the HMO has given 31 days' written notice of
nonrenewal prior to the renewal date of the contract.
b) A detailed statement of any exceptions,
exclusions, or limitations shall be set forth in the group contract, evidence
of coverage, and individual contract for any type of health care service to be
excepted. Exception, exclusions, or limitations shall appear with the same
prominence in the group contract, evidence of coverage, and individual contract
as any benefit.
c) The group
contract, evidence of coverage, and individual contract shall set forth a
detailed statement of the terms and conditions of maternity benefits and any
related exceptions, exclusions, limitations, copayments, and deductibles.
Exceptions, exclusions, limitations, copayments, and deductibles applicable to
prenatal and postnatal care shall be covered no differently than any other
covered health care services provided pursuant to the contract, with the
exception of a limitation for coverage of routine prenatal care or delivery
when the enrollee is outside the service area against medical advice (except
when the enrollee is outside of the service area due to circumstances beyond
the enrollee's control) may be included in the group contract and evidence of
coverage.
d) Entire Contract. The
group contract, evidence of coverage, and individual contract shall contain a
statement that the group contract evidence of coverage and individual contract,
all applications, and any amendments shall constitute the entire agreement
between the parties. No portion of the charter, bylaws or other document of the
HMO shall be part of a contract or evidence of coverage unless set forth in
full in the document or attached to it.
e) Eligibility Requirements. The group
contract, evidence of coverage, and individual contract shall contain
eligibility requirements indicating the conditions that must be met to enroll
in a health care plan, the limiting age for enrollees and eligible dependents
including the effects of Medicare eligibility, and a clear statement regarding
coverage of newborn children as set forth in Sections 4-8 and 4-9 of the
Act.
f) Benefits and Services
Within the Service Area. The group contract, evidence of coverage, and
individual contract shall contain a specific description of benefits and
services available within the HMO's designated service area.
g) Emergency Care Services. The group
contract, evidence of coverage, and individual contract shall contain a
specific description of benefits and services available for emergencies 24
hours per day, 7 days per week, including disclosure of any restrictions on
emergency care services. No group contract, evidence of coverage, or individual
contract shall limit the coverage of emergency services within the service area
to those providers having a contract with the HMO.
h) Out-of-area Benefits and Services. The
group contract, evidence of coverage, and individual contract shall contain a
specific description of benefits and services available out of the HMO's
designated service area.
i)
Deductibles and Copayments
1) An HMO may
require deductibles and copayments from 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. Nothing within this subsection (i) shall preclude
the provider from charging reasonable administrative fees, such as service fees
for checks returned for non-sufficient funds and missed appointments.
2) 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.
3) No combination of deductibles and
copayments for basic health care services may exceed the annual maximum
out-of-pocket expenses of a high-deductible health plan as defined in
26 U.S.C.
223.
4) Deductibles and copayments applicable to
supplemental health care services or catastrophic-only plans as defined under
the federal Patient Protection and Affordable Care Act (Pub. L. 111-148 ),
are not subject to the annual limitations described in this Section.
5) This subsection (i) applies to enrollees
and does not limit the health care plan payment for services provided by
non-participating providers.
j) Cancellation. The group contract, evidence
of coverage, and individual contract shall contain the conditions upon which
they can be cancelled by the HMO or the enrollee as set forth in Section
4521.111.
k) Reinstatement. The group contract,
evidence of coverage, and individual contract shall contain the conditions of
the enrollee's right to reinstatement.
l) Grace Period
1) A group contract or individual 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 a group contract shall not be less than 10 days. The grace period for an
individual contract shall not be less than 31 days. During the grace period,
the HMO shall remain liable for providing the services and benefits contracted
for. The subscriber shall remain liable for the payment of the premium for the
time coverage was in effect during the grace period and the enrollee shall
remain liable for the payment of any applicable share of the premium for the
time coverage was in effect, as well as for any copayments owed.
m) No group contract, evidence of coverage,
or individual contract may be delivered in this State unless the subscriber or
enrollee is provided written notice required by Section 143c of the Illinois
Insurance Code [215 ILCS 5/143c ].
n) Right to Examine Contract. An individual
contract, with the exception of an HMO Medicare contract entered into between
the Health Care Financing Administration and the HMO under Title XVIII of the
Social Security Act (42
U.S.C. 1395 through
1395lll), as amended from time to
time, shall contain a provision stating that an enrollee who has entered into
an agreement with an HMO shall be permitted to return the individual contract
within ten days after receiving it and to receive a refund of the premium paid
if the enrollee is not satisfied with the contract for any reason. If the
individual contract is returned to the HMO or to its representative through
whom it was purchased, it is considered void from the beginning. However, if
services are rendered or claims are paid for the enrollee or dependent by the
HMO during the 10-day examination period, the enrollee shall not be permitted
to return the contract and receive a refund of the premium paid.
o) An HMO Medicare contract entered into
between the Health Care Financing Administration and the HMO under Title XVIII
of the Social Security Act, as amended from time to time, shall be delivered to
the enrollee at least 15 days prior to the effective date of the contract. The
enrollee shall be permitted to return the HMO Medicare contract prior to the
effective date and to receive a refund of the premium paid if the enrollee is
not satisfied with the contract for any reason, provided the enrollee complies
with the disenrollment procedures of Title XVIII of the Social Security Act, as
amended from time to time.
p) Every
HMO will provide to every enrollee of the HMO information that generally
describes the philosophy, functions, and organization of the HMO and related
institutions, and specific information that describes the appropriate use of
the HMO's services, including a general description of benefits and
limitations. The HMO shall include in its enrollee information a description of
the HMO's grievance procedure, directions for filing a grievance, and a Notice
of Availability of the Department.
q) Every HMO shall provide enrollees with an
identification card that must prominently display the following information:
1) the words "Health Maintenance
Organization" or "HMO";
2)
disclaimer language concerning an enrollee's unauthorized use of providers not
selected by the HMO;
3) a current
telephone number for the enrollees to use when health care services are
required outside of normal office hours; and
4) the name of all enrollees entitled to
coverage, along with all other mandated information, if the HMO does not issue
a card to each enrollee who is entitled to coverage. In these situations, at
least two cards must be issued to the primary enrollee upon enrollment and the
HMO must issue additional cards to all enrollees at the request of the enrollee
for no additional charge. Notification of the right to order additional cards
for no additional charge must be included with information required to be
disseminated to enrollees under subsection (p).
r) Enrollment Application. No individual
contract shall be issued except upon the signed enrollment application of the
enrollee for whom coverage is being sought. Any information or statement of the
applicant shall appear on the application in the form of interrogatories by the
HMO and answers by the applicant. The enrollee shall not be bound by any
statement made within an application for health care coverage unless a copy of
the application is attached to the individual contract. Group enrollment
applications must be maintained on file by the HMO; otherwise, disputes arising
from statements made within the applications will be resolved in the enrollee's
favor. Except for those instances involving fraud or material
misrepresentation, an HMO's failure to investigate incomplete or conflicting
answers on an enrollment application shall estop the HMO from subsequently
denying coverage on the basis of those responses.
s) Coordination of Benefits
1) HMOs are permitted, but not required, to
adopt coordination of benefits provisions for group contracts, evidence of
coverage, or individual contracts to avoid over insurance and to provide for
the orderly payment of claims when a person is covered by two or more group
health insurance or health care plans.
2) If an HMO adopts coordination of benefits,
the provision must be consistent with the coordination of benefits requirements
set forth in 50 Ill. Adm. Code 2009.
3) To the extent necessary for an HMO to meet
its obligations as a secondary carrier under 50 Ill. Adm. Code 2009, and when
an enrollee has established a credit within the reserve bank, the HMO shall
make payments for services that are:
A)
received from non-participating providers;
B) provided outside its services areas;
or
C) not covered under the terms
of health care plan.
t) Dependents-termination of
coverage-disability and dependency, proof-application. Every group contract,
evidence of coverage, or individual contract providing that coverage of a
dependent person of an enrollee terminates upon attainment of the limiting age
for dependent persons shall comply with the requirements of Section 4-9.1 of
the Act.
u) Conversion of Coverage
1) The group contract and evidence of
coverage shall contain a conversion provision that provides that each enrollee
has the right to convert coverage to an individual or group HMO contract in the
following circumstances:
A) upon cancellation
of eligibility for coverage under a group contract;
B) upon cancellation of the group contract;
or
C) upon non-renewal of the group
contract.
2) The
conversion contract shall cover the enrollee and the enrollee's eligible
dependents who were covered by the group contract on the date of cancellation
or non-renewal of coverage. To obtain the conversion contract, an enrollee
shall submit a written application, along with the application premium payment,
within 31 days after the date the enrollee's coverage is cancelled.
3) The HMO may require copayments and
deductibles under a conversion contract that differ from the group
contract.
4) A conversion contract
shall not be required to be made available if:
A) The cancellation of the enrollee's
coverage occurred for any of the reasons listed in Section
4521.111(a);
B) The enrollee is covered by or is eligible
for benefits under Title XVIII of the Social Security Act (42 U.S.C.
1395-1395ll l);
C) The enrollee is covered by similar
hospital, medical, or surgical benefits under State or federal law;
D) The enrollee is covered by similar
hospital, medical, or surgical benefits under any arrangement of coverage for
individuals in a group, whether on an insured or uninsured basis;
E) The enrollee is covered for similar
benefits through individual coverage;
F) The enrollee has not been continuously
covered during the three-month period immediately preceding cancellation of
that person's coverage;
G) The
enrollee has moved outside of the service area of the health maintenance
organization;
H) The cancellation
of the enrollee's coverage occurred in relation to the HMO being placed in
rehabilitation or liquidation proceedings pursuant to Section 5-6 of the Act;
or
I) The group contract has been
discontinued in its entirety and there is a succeeding carrier providing
coverage to the group in its entirety.
5) Benefits or coverage shall be considered
"similar" if coverage is provided for at least 12 months under comprehensive
type medical coverage.
6) At a
minimum, the conversion contract shall provide basic health care
services.
7) The conversion
contract shall begin coverage of the enrollee and any dependents formerly
covered under the group contract on the date of termination from the group or
the former individual contract.
8)
Coverage shall be provided without requiring evidence of insurability and shall
not impose any pre-existing condition limitations or exclusions.
v) Discrimination between
individuals of the same class in the terms and conditions of the health care
plan, or in the amount charged for coverage under a health care plan except
when the rate differential is based on sound actuarial principles, or in any
other manner whatsoever, is prohibited.
w) Grievance Procedure
The group contract, evidence of coverage, and individual contract shall set forth a full description of the HMO grievance procedure required by Section 4521.40.
x) The provisions of 50 Ill. Adm. Code 2001,
Subparts A and C, shall apply to this Part.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.