Illinois Administrative Code
Title 50 - INSURANCE
Part 4521 - HEALTH MAINTENANCE ORGANIZATION
Section 4521.113 - Point of Service Plan Requirements
Current through Register Vol. 48, No. 12, March 22, 2024
a) The filing as described in this subsection shall be comprised of an HMO filing and an indemnity filing. The filing shall be coordinated by the HMO. The filing must contain reasonable financial incentives for point of service members to utilize HMO services provided or arranged by the designated HMO primary care physician and shall include:
b) Out-of-network claims shall be filed with the HMO. The HMO is responsible for coordinating payment of all claims.
c) Covered services rendered by a participating physician without proper authorization shall be covered at the out-of-network benefit level.
d) For purposes of coordination of benefits, the two policies comprising the point of service product shall be considered to be one policy.
e) For purposes of conversion and State continuation, the HMO shall provide each enrollee who has a POS plan the right to convert to either an HMO option or indemnity option. The HMO may, but is not required to, offer the enrollee the right to continue under a POS option. Once the enrollee has chosen an option, the other plan's options will no longer be available. Should the enrollee choose to continue or convert coverage under a point of service plan, then the plan shall meet applicable standards for Illinois conversion or continuation requirements. In the event of any inconsistency between these standards, then the most favorable to the enrollee shall apply.