Current through Register Vol. 48, No. 12, March 22, 2024
a)
Eligibility.
1) A health maintenance
organization may undertake to provide or arrange for and to pay for or
reimburse the cost of basic outpatient preventive and primary health care
services for children in Illinois who:
A) are
without health care coverage:
i) through a
parent's employment;
ii) through
failure to qualify for medical assistance under the Illinois Public Aid Code or
failure to qualify for coverage under the State Children's Health Insurance
Program of the Social Security Act as amended by the Balanced Budget Act of
1997, P.L.
105-33;
iii) through any other health plan. For
purposes of this Section, health plan means a policy, contract, certificate or
agreement offered by a carrier to provide, deliver, arrange for, pay for or
reimburse any of the costs of health care services. Health plan does not
include accident-only, credit, dental, vision, Medicare supplement, partnership
or traditional long-term care, or disability income insurance coverage issued
as a supplement to liability insurance, worker's compensation or similar
insurance, or automobile medical payment insurance or short-term and
catastrophic health insurance policies, or a policy that pays on a
cost-incurred basis, or student insurance;
iv) due to a loss of medical assistance when
a parent has moved from welfare to work and does not find employment that
offers health care coverage;
B) are 18 years of age or under;
C) have resided in the State of Illinois for
at least 30 days and continue to reside in the State of Illinois.
2) The coverage will be made
available to an adult on behalf of an enrollee. For purposes of this Section,
enrollee is defined as an eligible child on whose behalf the policy is
purchased. The financially responsible party (FRP) is the person or entity
paying the premium on behalf of the enrollee. The certificate and/or policy
will be issued to the parent or legal guardian of the enrollee. If the FRP and
parent or legal guardian are different, both shall be listed on the face page
of the certificate and/or policy. The name of the enrollee shall also be listed
on the face page of the certificate and/or policy.
b) Required Basic Minimum Outpatient
Preventive and Primary Health Care Services for Children to be Provided. The
following minimum standards shall meet the requirements for basic outpatient
preventive and primary health care services to be provided under this
subsection, provided that the services are medically necessary as determined by
the enrollee's primary care physician, and if required by the HMO, are
authorized on a prospective and timely basis by the HMO's medical director.
1) Preventive health services provided by the
enrollee's primary care physician in the office, as appropriate for the patient
population, including a health evaluation program and immunizations to prevent
or arrest the further manifestation of human illness or injury including, but
not limited to, allergy injections and allergy serum. The health evaluation
program shall include at least periodic physical examinations and medical
history, blood pressure testing, and uterine cervical cytological testing as
required by Section 356u of the Illinois Insurance Code [
215 ILCS
5/356u ] as well as health education concerning
appropriate health care practices;
2) Basic or general physician services for
illness or injury, provided by the enrollee's primary care physician in the
office;
3) Emergency services for
accidental injury or emergency illness 24 hours per day, 7 days per week.
Emergency services are covered benefits inside and out of the plan's service
area;
4) Outpatient diagnostic
x-rays and laboratory services provided, arranged or authorized by the
enrollee's primary care physician.
c) Supplemental Basic Health Care Services
that may be Provided in Addition to Basic Outpatient Preventive and Primary
Health Care Services for Children. In addition to the minimum required health
services listed in subsection (b), the HMO may offer Supplemental Basic Health
Care Services, provided that the services are medically necessary as determined
by the enrollee's primary care physician and, if required by the HMO, are
authorized on a prospective and timely basis by the HMO's Medical Director.
Supplemental Basic Health Care Services includes any services listed in Section
5421.130
of this Part. To the extent that Supplemental Basic Health Care Services are
provided under this subsection, the minimum requirements of Section
5421.130
of this Part must be met for those services.
d) Supplemental Services that may be Provided
in Addition to Basic Outpatient Preventive and Primary Health Care Services for
Children. In addition to the Supplemental Basic Health Care Services provided
in Section
5421.131(c)
of this Section, the HMO may offer the following Supplemental Services:
1) preventive dental services, including
diagnostic services, x-rays and restorations (fillings);
2) vision screening, including one pair of
eyeglasses per year;
3)
prescription drugs.
e)
Copayments, Deductibles and Benefit Maximums for Basic Outpatient Preventive
Services, Primary Health Care Services, Supplemental Basic Health Care Services
and Supplemental Services for Children. An HMO may require copayments of
enrollees as a condition for the receipt of specific health care services under
this Part. Deductibles and copayments shall be the only allowable charge, other
than premiums. Copayments shall be for a specific dollar amount. Deductibles
shall be either for a specific dollar amount or for a specific percentage of
the cost of the health care service. No single deductible or copayment for
health services may exceed 25% of the usual and customary fee of the service to
the HMO and must be waived when, in a calendar year, deductibles and copayments
paid for the receipt of health care services exceed $500 per enrollee. This
subsection does not preclude the provider from charging reasonable
administrative fees such as service fees for checks returned for non-sufficient
funds and missed appointments.
f)
Necessary Disclosure Requirements.
1) The
policy or certificate issued under this Section shall prominently disclose all
limitations, exclusions, copayments and deductibles. Such disclosure shall
include, but is not limited to:
A) A
prominent statement on the first page of the policy or certificate, in either
contrasting color or in boldface type at least equal to the size of type used
for policy captions, as follows:
"Notice to Buyer. This is a limited benefit (policy)
(certificate). Benefits provided are not intended to cover all of your medical
expenses."
B) Exclusion of
inpatient hospital services.
C)
Statement that pre-existing conditions may not be excluded or
limited.
D) Exclusion of services
that are not provided, arranged or authorized by the primary care physician,
and if required by the HMO, are subject to authorization on a prospective and
timely basis by the HMO's medical director, except for emergency
services.
2) In the
event services are offered under this Section by the HMO and purchased on
behalf of the enrollee, full disclosure of the scope of those limited benefits
shall be prominently stated within the policy or certificate.
3) Eligibility requirements shall be
prominently disclosed in the policy or certificate.
4) Terms of cancellation shall be prominently
disclosed pursuant to Section
5421.111
of this Part.
g)
Advertising. All advertising materials used to market policies pursuant to 50
Ill. Adm. Code 916 and/or certificates pursuant to this Part shall be filed and
accepted by the Director in accordance with the requirements of Section 4-17 of
the Act prior to use.
h) Grace
Period Extension. For purposes of this Part, the grace periods of Section
5421.110(m)
of this Part apply. In the event an FRP, other than the parent or guardian,
fails to pay the premium within the grace period, the parent or guardian will
be so notified and be given an additional 30 days in which to pay the premium
or obtain another FRP.