(215 ILCS 97/5)
Sec. 5. Definitions.
"Affiliate" means a person that directly, or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with the person specified.
"Beneficiary" has the meaning given such term under Section 3(8) of the Employee Retirement Income Security Act of 1974.
"Bona fide association" means, with respect to health insurance coverage offered in a State, an association which:
(1) has been actively in existence for at least 5
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(2) has been formed and maintained in good faith for |
| purposes other than obtaining insurance; | |
(3) does not condition membership in the association |
| on any health status‑related factor relating to an individual (including an employee of an employer or a dependent of an employee); | |
(4) makes health insurance coverage offered through |
| the association available to all members regardless of any health status‑related factor relating to such members (or individuals eligible for coverage through a member); | |
(5) does not make health insurance coverage offered |
| through the association available other than in connection with a member of the association; and | |
(6) meets such additional requirements as may be |
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"Church plan" has the meaning given that term under Section 3(33) of the Employee Retirement Income Security Act of 1974.
"COBRA continuation provision" means any of the following:
(1) Section 4980B of the Internal Revenue Code of |
| 1986, other than subsection (f)(1) of that Section insofar as it relates to pediatric vaccines. | |
(2) Part 6 of subtitle B of title I of the Employee |
| Retirement Income Security Act of 1974, other than Section 609 of that Act. | |
(3) Title XXII of federal Public Health Service Act.
"Control" means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, the holding of policyholders' proxies by contract other than a commercial contract for goods or non‑management services, or otherwise, unless the power is solely the result of an official position with or corporate office held by the person. Control is presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds shareholders' proxies representing 10% or more of the voting securities of any other person or holds or controls sufficient policyholders' proxies to elect the majority of the board of directors of the domestic company. This presumption may be rebutted by a showing made in a manner as the Secretary may provide by rule. The Secretary may determine, after furnishing all persons in interest notice and opportunity to be heard and making specific findings of fact to support such determination, that control exists in fact, notwithstanding the absence of a presumption to that effect.
"Department" means the Department of Insurance.
"Employee" has the meaning given that term under Section 3(6) of the Employee Retirement Income Security Act of 1974.
"Employer" has the meaning given that term under Section 3(5) of the Employee Retirement Income Security Act of 1974, except that the term shall include only employers of 2 or more employees.
"Enrollment date" means, with respect to an individual covered under a group health plan or group health insurance coverage, the date of enrollment of the individual in the plan or coverage, or if earlier, the first day of the waiting period for enrollment.
"Federal governmental plan" means a governmental plan established or maintained for its employees by the government of the United States or by any agency or instrumentality of that government.
"Governmental plan" has the meaning given that term under Section 3(32) of the Employee Retirement Income Security Act of 1974 and any federal governmental plan.
"Group health insurance coverage" means, in connection with a group health plan, health insurance coverage offered in connection with the plan.
"Group health plan" means an employee welfare benefit plan (as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974) to the extent that the plan provides medical care (as defined in paragraph (2) of that Section and including items and services paid for as medical care) to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise.
"Health insurance coverage" means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer.
"Health insurance issuer" means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined herein) which is licensed to engage in the business of insurance in a state and which is subject to Illinois law which regulates insurance (within the meaning of Section 514(b)(2) of the Employee Retirement Income Security Act of 1974). The term does not include a group health plan.
"Health maintenance organization (HMO)" means:
(1) a Federally qualified health maintenance |
| organization (as defined in Section 1301(a) of the Public Health Service Act.); | |
(2) an organization recognized under State law as a |
| health maintenance organization; or | |
(3) a similar organization regulated under State law |
| for solvency in the same manner and to the same extent as such a health maintenance organization. | |
"Individual health insurance coverage" means health insurance coverage offered to individuals in the individual market, but does not include short‑term limited duration insurance.
"Individual market" means the market for health insurance coverage offered to individuals other than in connection with a group health plan.
"Large employer" means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 51 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year.
(1) Application of aggregation rule for large |
| employers. All persons treated as a single employer under subsection (b), (c), (m), or (o) of Section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. | |
(2) Employers not in existence in preceding year. |
| In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether the employer is a large employer shall be based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year. | |
(3) Predecessors. Any reference in this Act to an |
| employer shall include a reference to any predecessor of such employer. | |
"Large group market" means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer.
"Late enrollee" means with respect to coverage under a group health plan, a participant or beneficiary who enrolls under the plan other than during:
(1) the first period in which the individual is |
| eligible to enroll under the plan; or | |
(2) a special enrollment period under subsection (F) |
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"Medical care" means amounts paid for:
(1) the diagnosis, cure, mitigation, treatment, or |
| prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body; | |
(2) amounts paid for transportation primarily for |
| and essential to medical care referred to in item (1); and | |
(3) amounts paid for insurance covering medical care |
| referred to in items (1) and (2). | |
"Nonfederal governmental plan" means a governmental plan that is not a federal governmental plan.
"Network plan" means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care (including items and services paid for as medical care) are provided, in whole or in part, through a defined set of providers under contract with the issuer.
"Participant" has the meaning given that term under Section 3(7) of the Employee Retirement Income Security Act of 1974.
"Person" means an individual, a corporation, a partnership, an association, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing acting in concert, but does not include any securities broker performing no more than the usual and customary broker's function or joint venture partnership exclusively engaged in owning, managing, leasing, or developing real or tangible personal property other than capital stock.
"Placement" or being "placed" for adoption, in connection with any placement for adoption of a child with any person, means the assumption and retention by the person of a legal obligation for total or partial support of the child in anticipation of adoption of the child. The child's placement with the person terminates upon the termination of the legal obligation.
"Plan sponsor" has the meaning given that term under Section 3(16)(B) of the Employee Retirement Income Security Act of 1974.
"Preexisting condition exclusion" means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.
"Small employer" means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year.
(1) Application of aggregation rule for small |
| employers. All persons treated as a single employer under subsection (b), (c), (m), or (o) of Section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. | |
(2) Employers not in existence in preceding year. |
| In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer shall be based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year. | |
(3) Predecessors. Any reference in this Act to a |
| small employer shall include a reference to any predecessor of that employer. | |
"Small group market" means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a small employer.
"State" means each of the several States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
"Waiting period" means with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period of time that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.
(Source: P.A. 94‑502, eff. 8‑8‑05.) |
(215 ILCS 97/20)
Sec. 20. Increased portability through limitation on preexisting condition exclusions.
(A) Limitation of preexisting condition exclusion period; crediting for periods of previous coverage. Subject to subsection (D), a group health plan, and a health insurance issuer offering group health insurance coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:
(1) the exclusion relates to a condition (whether |
| physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6‑month period ending on the enrollment date; | |
(2) the exclusion extends for a period of not more |
| than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and | |
(3) the period of any such preexisting condition |
| exclusion is reduced by the aggregate of the periods of creditable coverage (if any, as defined in subsection (C)(1)) applicable to the participant or beneficiary as of the enrollment date. | |
(B) Preexisting condition exclusion. A group health plan, and health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition.
Genetic information shall not be treated as a condition described in subsection (A)(1) in the absence of a diagnosis of the condition related to such information.
(C) Rules relating to crediting previous coverage.
(1) Creditable coverage defined. For purposes of |
| this Act, the term "creditable coverage" means, with respect to an individual, coverage of the individual under any of the following: | |
(a) A group health plan.
(b) Health insurance coverage.
(c) Part A or part B of title XVIII of the |
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(d) Title XIX of the Social Security Act, other |
| than coverage consisting solely of benefits under Section 1928. | |
(e) Chapter 55 of title 10, United States Code.
(f) A medical care program of the Indian Health |
| Service or of a tribal organization. | |
(g) A State health benefits risk pool.
(h) A health plan offered under chapter 89 of |
| title 5, United States Code. | |
(i) A public health plan (as defined in |
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(j) A health benefit plan under Section 5(e) of |
| the Peace Corps Act (22 U.S.C. 2504(e)). | |
(k) Title XXI of the federal Social Security |
| Act, State Children's Health Insurance Program. | |
Such term does not include coverage consisting |
| solely of coverage of excepted benefits. | |
(2) Excepted benefits. For purposes of this Act, |
| the term "excepted benefits" means benefits under one or more of the following: | |
(a) Benefits not subject to requirements:
(i) Coverage only for accident, or |
| disability income insurance, or any combination thereof. | |
(ii) Coverage issued as a supplement to |
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(iii) Liability insurance, including general |
| liability insurance and automobile liability insurance. | |
(iv) Workers' compensation or similar |
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(v) Automobile medical payment insurance.
(vi) Credit‑only insurance.
(vii) Coverage for on‑site medical clinics.
(viii) Other similar insurance coverage, |
| specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. | |
(b) Benefits not subject to requirements if |
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(i) Limited scope dental or vision benefits.
(ii) Benefits for long‑term care, nursing |
| home care, home health care, community‑based care, or any combination thereof. | |
(iii) Such other similar, limited benefits |
| as are specified in rules. | |
(c) Benefits not subject to requirements if |
| offered, as independent, noncoordinated benefits: | |
(i) Coverage only for a specified disease or |
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(ii) Hospital indemnity or other fixed |
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(d) Benefits not subject to requirements if |
| offered as separate insurance policy. Medicare supplemental health insurance (as defined under Section 1882(g)(1) of the Social Security Act), coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code, and similar supplemental coverage provided to coverage under a group health plan. | |
(3) Not counting periods before significant breaks |
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(a) In general. A period of creditable coverage |
| shall not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, there was a 63‑day period during all of which the individual was not covered under any creditable coverage. | |
(b) Waiting period not treated as a break in |
| coverage. For purposes of subparagraph (a) and subsection (D)(3), any period that an individual is in a waiting period for any coverage under a group health plan (or for group health insurance coverage) or is in an affiliation period (as defined in subsection (G)(2)) shall not be taken into account in determining the continuous period under subparagraph (a). | |
(4) Method of crediting coverage.
(a) Standard method. Except as otherwise |
| provided under subparagraph (b), for purposes of applying subsection (A)(3), a group health plan, and a health insurance issuer offering group health insurance coverage, shall count a period of creditable coverage without regard to the specific benefits covered during the period. | |
(b) Election of alternative method. A group |
| health plan, or a health insurance issuer offering group health insurance, may elect to apply subsection (A)(3) based on coverage of benefits within each of several classes or categories of benefits specified in regulations rather than as provided under subparagraph (a). Such election shall be made on a uniform basis for all participants and beneficiaries. Under such election a group health plan or issuer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within such class or category. | |
(c) Plan notice. In the case of an election |
| with respect to a group health plan under subparagraph (b) (whether or not health insurance coverage is provided in connection with such plan), the plan shall: | |
(i) prominently state in any disclosure |
| statements concerning the plan, and state to each enrollee at the time of enrollment under the plan, that the plan has made s
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