Current through Register Vol. 48, No. 12, March 22, 2024
a) General Rules
1) Each individual policy of accident and
health insurance shall include a renewal, continuation or nonrenewal provision.
The language or specifications of the provision must be consistent with the
requirements of 50 Ill. Adm. Code 2001. Subpart A and the type of plan issued.
The provision shall be appropriately captioned, shall appear on the first page
of the policy, and shall clearly state the duration, when limited, of
renewability and the duration of the term of coverage for which the policy is
issued and for which it may be renewed.
2) Except for riders or endorsements by which
the insurer effectuates a request made in writing by the policyholder or
exercises a specifically reserved right under the policy, all riders or
endorsements added to a policy after date of issue or at reinstatement or
renewal that reduce or eliminate benefits or coverage in the policy shall
require signed acceptance by the policyholder. After date of policy issue, any
rider or endorsement that increases benefits or coverage with a concomitant
increase in premium during the policy term must be agreed to by the insured,
except if the increased benefits or coverage is required by law.
3) When a separate additional premium is
charged for benefits provided in connection with riders or endorsements, the
premium charge shall be set forth in the policy.
4) A policy that provides for the payment of
benefits based on standards described as "usual and customary", "reasonable and
customary", or words of similar import shall include a definition of those
terms and an explanation of those terms in its accompanying outline of
coverage.
5) If a policy providing
excepted benefits or a grandfathered health plan contains any limitations with
respect to preexisting conditions, those limitations must appear as a separate
paragraph of the policy and be labeled as "Preexisting Condition
Limitations".
6) All accident only
policies shall contain a prominent statement on the first page of the policy or
attached to the policy in either contrasting color or in boldface type at least
equal to the size of type used for policy captions, a prominent statement as
follows:
"This is an accident only policy and it does not pay benefits
for loss from sickness."
7)
All policies, except single premium nonrenewal policies, shall have a notice
prominently printed on the first page of the policy or attached thereto stating
in substance, that the policyholder shall have the right to return the policy
within 10 days after its delivery and to have the premium refunded if after
examination of the policy the policyholder is not satisfied for any
reason.
8) If age is to be used as
a determining factor for reducing the maximum aggregate benefits made available
in the policy as originally issued, that fact must be prominently set forth in
the outline of coverage.
9) If a
policy contains a conversion privilege, it shall comply, in substance, with the
following: the caption of the provision shall be "Conversion Privilege", or
words of similar import. The provision shall indicate the persons eligible for
conversion, the circumstances applicable to the conversion privilege, including
any limitations on the conversion, and the person by whom the conversion
privilege may be exercised. The provision shall specify the benefits to be
provided on conversion or may state that the converted coverage will be as
provided on a policy form then being used by the insurer for that
purpose.
10) All specified disease
policies shall contain a prominent statement on the first page of the policy in
contrasting color and in bold face type at least equal to the size of type used
for policy captions, a prominent statement as follows: "This is a limited
policy. Read it carefully."
11)
Notice Requirements:
A) At the time of
purchase of fixed indemnity contracts, the fixed indemnity insurer must provide
notice within the application indicating that the fixed indemnity is not
minimum essential coverage (MEC) within the meaning of
26 USC
5000A(f) and does not
satisfy the ACA individual mandate. That notice must contain the following
verbiage displayed prominently in the plan materials in at least 14-point type
that has the following language:
"THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A
SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER
MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR
TAXES."
B) The notice
requirement of subsection (a)(11)(A) applies to all hospital or other fixed
indemnity insurance policy years beginning on or after January 1,
2015.
C) These notice requirements
do not apply to individual hospital indemnity or other fixed indemnity
insurance policies issued before January 1, 2015 that do not require an
application as a condition of renewal, are guaranteed renewable or
non-cancelable, and only condition renewal on the timely payment of premiums
with no renewal application form required.
D) These notice requirements apply only to
hospital indemnity or other fixed indemnity insurance policies sold in the
individual market. They do not apply to any other type or category of insurance
that is listed separately as an excepted benefit in the federal Public Health
Service Act (42 USC ch. 6A) (e.g., disability income insurance, specified
disease insurance, accident only insurance, etc.), regardless of whether the
benefits under that coverage are paid as a fixed dollar amount per day or other
period, or per service.
E) These
notice requirements do not apply to individual hospital indemnity or other
fixed indemnity insurance policyholders who are age 65 or older and are
enrolled in Medicare.
b) Outline of Coverage Requirements for
Individual Coverages
1) No individual accident
and health insurance policy shall be delivered or issued for delivery in this
State unless an appropriate Summary of Benefits, in accordance with 50 Ill.
Adm. Code
2001.10,
that includes an outline of coverage as prescribed in subsections (c) through
(l) is completed as to the policy and is delivered in accordance with Section
355a(5)(a) of the Illinois Insurance Code [
215 ILCS
5/355a(5)(a) ].
2) In the event that a policy is issued on a
basis other than that applied for, an outline of coverage properly describing
the policy must accompany the policy when it is delivered and, if an outline of
coverage was delivered earlier, contain the following statement, in not less
than 12 point type, immediately above the company name:
NOTICE
Read this outline of coverage carefully. It is not identical to
the outline of coverage provided upon application and the coverage originally
applied for has not been issued.
3) In those cases in which a policy designed
to supplement existing coverage is approved, the outline of coverage shall
prominently state that coverage is designed to supplement other health
insurance policies owned by the insured.
4) The appropriate outline of coverage for
policies providing hospital coverage that only meets the standards of Section
2007.70(b)(2)
shall be that statement contained in subsection (c) of this Section. The
appropriate outline of coverage for policies providing coverage that meets the
standards of both Section
2007.70(b)(2)
and (3) shall be the statement contained in
subsection (e) of this Section. The appropriate outline of coverage for
policies providing coverage that meets the standards of Section
2007.70(b)(2)
and (5), (b)(3) and (5), or (b)(2), (3) and
(5) shall be the statement contained in subsection (g) of this
Section.
c) Basic
Hospital Expense Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed in this
subsection (c), shall be issued in connection with policies meeting the
standards of Section
2007.70(b)(2).
The items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
BASIC HOSPITAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) Basic Hospital
Expense Coverage - Policies of this category are designed to provide to persons
insured coverage for hospital expenses incurred as a result of a covered
accident or sickness. Coverage is provided for daily hospital room and board,
miscellaneous hospital services, and hospital outpatient services, subject to
any limitations, deductibles and co-payment requirements set forth in the
policy. Coverage is not provided for physicians or surgeons fees or unlimited
hospital expenses.
3) (A brief
specific description of the benefits, including dollar amounts and number of
days duration where applicable, contained in this policy in the following
order:
A) daily hospital room and
board;
B) miscellaneous hospital
services;
C) hospital out-patient
services; and
D) other benefits, if
any.)
AGENCY NOTE: The description of benefits in this subsection
(f)(3) shall be stated clearly and concisely.
4) (A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefits described in subsection
(c)(3).)
5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to charge
premiums.)
d) Basic
Medical-Surgical Expense Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed in this
subsection (d), shall be issued in connection with policies meeting the
standards of Section
2007.70(b)(3).
The items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control your policy. The
policy itself sets forth in detail the rights and obligations of both you and
your insurance company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) Basic
Medical-Surgical Expense Coverage - Policies of this category are designed to
provide to persons insured coverage for medical-surgical expenses incurred as a
result of a covered accident or sickness. Coverage is provided for surgical
services, anesthesia services, and in-hospital medical services, subject to any
limitations, deductibles and co-payment requirements set forth in the policy.
Coverage is not provided for hospital expenses or unlimited medical surgical
expenses.
3) (A brief specific
description of the benefits, including dollar amounts and number of days
duration where applicable, contained in this policy, in the following order:
A) surgical services;
B) anesthesia services;
C) in-hospital medical services;
and
D) other benefits, if
any.)
4) (A description
of any policy provisions that exclude, eliminate, restrict, reduce, limit,
delay, or in any other manner operate to qualify payment of the benefits
described in subsection (d)(3).)
5)
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
e) Basic
Hospital and Medical Surgical Expense Coverage (Outline of Coverage) An outline
of coverage, in the form prescribed in this subsection (e), shall be issued in
connection with policies meeting the standards of Section
2007.70(b)(2)
and (3). The items included in the outline of
coverage must appear in the sequence prescribed.
(COMPANY NAME)
BASIC HOSPITAL AND MEDIAL SURGICAL
EXPENSE COVERAGE OUTLINE OF COVERAGE
1) Read Your Policy Carefully - This outline
of coverage provides a very brief description of the important features of your
policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
2) Basic Hospital and Medical Surgical
Expense Coverage - Policies of this category are designed to provide, to
persons insured, coverage for hospital and medical-surgical expenses incurred
as a result of a covered accident or sickness. Coverage is provided for daily
hospital room and board, miscellaneous hospital services, hospital out-patient
services, surgical services, anesthesia services, and in-hospital medical
services, subject to any limitations, deductibles and co-payment requirements
set forth in the policy. Coverage is not provided for unlimited hospital or
medical-surgical expenses.
3) (A
brief specific description of the benefits, including dollar amounts and number
of days duration where applicable, contained in this policy, in the following
order:
A) daily hospital room and
board;
B) miscellaneous hospital
services;
C) hospital out-patient
services;
D) surgical
services;
E) anesthesia
services;
F) in-hospital medical
services; and
G) other benefits, if
any.)
4) (A description
of any policy provisions that exclude, eliminate, restrict, reduce, limit,
delay, or in any other manner operate to qualify payment of the benefits
described in subsection (e)(3).)
5)
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
f) Hospital
Confinement Indemnity Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall be
issued in connection with policies meeting the standards of Section
2007.70(b)(4).
The items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
HOSPITAL CONFINEMENT INDEMNITY COVERAGE
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) Hospital Confinement
Indemnity Coverage - Policies of this category are designed to provide to
persons insured, coverage in the form of a fixed daily benefit during periods
of hospitalization resulting from a covered accident or sickness, subject to
any limitations set forth in the policy. These policies do not provide any
benefits other than the fixed daily indemnity for hospital confinement and any
additional benefit described in subsections (f)(3) through (f)(6).
3) (A brief specific description of the
benefits contained in this policy, in the following order:
A) daily benefit payable during hospital
confinement; and
B) duration of
benefit described in (A).)
AGENCY NOTE: The description of benefits in this subsection
(f)(3) shall be stated clearly and concisely.
4) (A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefits described in (f)(3).)
5) (A description of policy provisions
respecting renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums.)
6) (Any benefits provided in addition to the
daily hospital benefit.)
g) Major Medical Coverage (Outline of
Coverage)
An outline of coverage, in the form prescribed in this
subsection (g), shall be issued in connection with policies meeting the
standards of Section
2007.70(b)(5).
The items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
MAJOR MEDICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) Major Medical Expense
Coverage - Policies of this category are designed to provide, to persons
insured, coverage for major hospital, medical, and surgical expenses incurred
as a result of a covered accident or sickness. Coverage is provided for daily
hospital room and board, miscellaneous hospital services, surgical services,
anesthesia services, in-hospital medical services, and out of hospital care,
subject to any deductibles, co-payment provisions, or other limitations that
may be set forth in the policy. Basic hospital or basic medical insurance
coverage is not provided.
3) (A
brief specific description of the benefits, including dollar amounts, contained
in this policy, in the following order:
A)
daily hospital room and board;
B)
miscellaneous hospital services;
C)
surgical services;
D) anesthesia
services;
E) in-hospital medical
services;
F) out of hospital
care;
G) maximum dollar amount for
covered charges; and
H) other
benefits, if any.)
AGENCY NOTE: The description of benefits in this subsection
(g)(3) shall be stated clearly and concisely, and shall include a description
of any deductible or co-payment provision applicable to the benefits
described.
4) (A
description of policy provisions that exclude, eliminate, restrict, reduce,
limit, delay, or in any other manner operate to qualify payment of the benefits
described in subsection (g)(3).)
5)
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
h) Disability
Income Protection Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed in this
subsection (h), shall be issued in connection with policies meeting the
standards of Section
2007.70(b)(6).
The items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
DISABILITY INCOME PROTECTION COVERAGE
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) Disability Income
Protection Coverage - Policies of this category are designed to provide, to
persons insured, coverage for disabilities resulting from a covered accident or
sickness, subject to any limitations set forth in the policy. Coverage is not
provided for basic hospital, basic medical-surgical, or major medical
expenses.
3) (A brief specific
description of the benefits contained in this policy:)
AGENCY NOTE: The description of benefits shall be stated
clearly and concisely.
4) (A
description of any policy provisions that exclude, eliminate, restrict, reduce,
limit, delay, or in any other manner operate to qualify payment of the benefits
described in subsection (h)(3).)
5)
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
i) Accident
Only Coverage (Outline of Coverage)
An outline of coverage in the form prescribed in this
subsection (i) shall be issued in connection with policies meeting the
standards of Section
2007.70(b)(7).
The items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY)
ACCIDENT ONLY COVERAGE
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) Accident Only
Coverage - Policies of this category are designed to provide, to persons
insured, coverage for certain losses resulting from a covered accident ONLY,
subject to any limitations contained in the policy. Coverage is not provided
for basic hospital, basic medical-surgical, or major medical
expenses.
3) (A brief specific
description of the benefits contained in this policy:)
AGENCY NOTE: The description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provision applicable to the benefits described. Proper disclosure of
benefits that vary according to accidental cause shall be made in accordance
with Section
2007.70(e).
4) (A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefits described in subsection
(i)(3).)
5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change premiums.)
j) Specified Disease or
Specified Accident Coverage (Outline of Coverage)
An outline of coverage in the form prescribed in this
subsection (j), shall be issued in connection with policies meeting the
standards of Section
2007.70(b)(8).
The coverage shall be identified by the appropriate bracketed title. The items
included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
(SPECIFIED DISEASE) (SPECIFIED ACCIDENT COVERAGE)
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) (Specified Disease)
(Specified Accident) Coverage - Policies of this category are designed to
provide, to persons insured, restricted coverage paying benefits ONLY when
certain losses occur as a result of (specified diseases) or (specified
accidents). Coverage is not provided for basic hospital, basic
medical-surgical, or major medical expenses.
3) (A brief specific description of the
benefits, including dollar amounts, contained in this policy:)
AGENCY NOTE: The description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provisions applicable to the benefits described. Proper disclosure
of benefits that vary according to accidental cause shall be made in accordance
with Section
2007.70(b)(1)(L).
4) (A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefits described in subsection
(j)(3).)
5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restriction or any reservation of right to change
premiums.)
k) Limited
Benefit Health Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed in this
subsection (k), shall be issued in connection with policies that do not meet
the minimum standards of Section
2007.70(b)(2)
through (b)(7). The items included in the
outline of coverage must appear in the sequence prescribed:
(COMPANY NAME)
LIMITED BENEFIT HEALTH COVERAGE
OUTLINE OF COVERAGE
1)
Read Your Policy Carefully - This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
2) Limited Benefit
Health Coverage - Policies of this category are designed to provide, to persons
insured, limited or supplemental coverage.
3) (A brief specific description of the
benefits, including dollar amounts, contained in this policy:)
AGENCY NOTE: The description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provisions applicable to the benefits described. Proper disclosure
of benefits that vary according to accidental cause shall be made in accordance
with Section
2007.70(b)(1)(L).
4) (A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefits described in subsection
(k)(3).)
5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
l)
Non-Conventional Coverage (Outline of Coverage)
The outline of coverage shall include the following
information:
1) The name and principal
address of the insurer.
2) An
appropriate statement of identification of the type of coverage provided by the
policy.
3) A description of each of
the principal benefits and coverages, including the benefit amounts, duration
or limits, elimination periods, inner limits and any other items appropriate to
the coverage provided.
4) A
description of the terms and conditions of renewability of the policy,
including any limitations by age, time or event, rights to change premium,
status requirements and any other matters appropriate to the terms and
conditions of renewability (including any rights of cancellation reserved to
the insurer).
5) A description of
the principal exceptions, reductions and limitations contained in the policy,
including the preexisting conditions, if any, and the circumstances under which
any reduction provisions become operative.
6) A statement that the Outline of Coverage
is only a brief summary of the policy and is not the contract of insurance. The
policy itself sets forth the rights and obligations of the insured and
insurer.