Illinois Employment Law – Health Insurance Mandates

•  Eosinophilic disorders; and

•  Short bowel syndrome.

This mandate applies when the prescribing physician has issued a written order stating that an amino acid-based elemental formula is medically necessary.

•  At least every three years for women between ages 20 and 40; and

•  Annually for women age 40 or older.

•  Contraceptive drugs, devices and other products approved by the FDA, including those available over-the-counter (but excluding male condoms);

•  Voluntary sterilization procedures;

•  Contraceptive services, patient education and counseling on contraception; and

•  Follow-up services related to the covered contraceptive drugs, devices, products and procedures.

•  A child age six or under;

•  A person with a medical condition that requires hospitalization or general anesthesia for dental care; or

•  A disabled individual.

Plans must also cover anesthetics and other charges incurred in conjunction with dental care provided by a dentist to a covered individual in a dental office, oral surgeon’s office, hospital, or ambulatory surgical treatment center if the individual is under age 19 and has been diagnosed with an autism spectrum disorder or a developmental disability.

This coverage may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the plan. This mandate does not require coverage of dental services.

•  Blood glucose monitors, including blood glucose monitors for the legally blind;

•  Cartridges for the legally blind; and

•  Lancets and lancing devices.

Cost-sharing for these benefits must be the same as those that apply for other services provided by the same type of provider.

Plans that provide a drug benefit must also cover the following, which must be subject to the same cost-sharing provisions as other covered drugs:

•  Insulin;

•  Syringes and needles;

•  Test strips for glucose monitors;

•  FDA-approved oral agents used to control blood sugar; and

•  Glucagon emergency kits.

Finally, coverage for diabetes self-management training may be limited to the following:

•  Three medically necessary visits to a qualified provider upon initial diabetes diagnosis; and

•  Two medically necessary visits to a qualified provider when a significant change in the patient’s symptoms or medical condition has occurred.

•  The condition is diagnosed by a breast biopsy that demonstrates an increased disposition to the development of breast cancer; or

•  The insured’s medical history confirms a chronic, relapsing, symptomatic breast condition.

•  A baseline mammogram for women 35 to 39 years of age;

•  An annual mammogram for women 40 years of age or older; and

•  A mammogram at the age and intervals considered medically necessary by the woman’s health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing or other risk factors; and

•  A screening MRI when medically necessary, as determined by a licensed physician.

Plans must also provide coverage for a comprehensive ultrasound screening and MRI if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a licensed physician.

This coverage must be provided at no cost to the insured and may not be applied to an annual or lifetime maximum benefit.

•  Reconstruction of the breast upon which the mastectomy has been performed;

•  Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

•  Prostheses and treatment for physical complications at all stages of mastectomy, including lymphedemas.

This coverage must be subject to the deductible and coinsurance conditions applied to the mastectomy. When a mastectomy is performed and there is no evidence of malignancy, coverage may be limited to the provision of prosthetic devices and reconstructive surgery within two years of the mastectomy.

•  A minimum of 48 hours after a vaginal delivery for the mother and the newborn; or

•  A minimum of 96 hours after a caesarian section delivery for the mother and newborn.

A shorter hospital stay may be provided if the attending physician determines it is appropriate, based on certain guidelines, and depending on the coverage and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the infant in the first 48 hours after discharge.

•  The financial requirements and treatment limitations applicable to these benefits are no more restrictive than the predominant financial requirements and treatment limitations applied to substantially all hospital and medical benefits covered by the policy; and

•  There are no separate cost-sharing requirements or treatment limitations that are applicable only to these benefits.

This mandate also contains specific parity requirements for aggregate lifetime limits and annual limits and must be interpreted in a manner consistent with federal regulations issued under the federal Mental Health Parity and Addiction Equity Act of 2008.

This mandate does not apply to small employers. A “small employer” is one that employed an average of 50 or fewer employees during the preceding calendar year.

This mandate requires coverage based on medical necessity and consistent with the mental health parity requirements, provided coverage for each calendar year may not be less than the following:

•  45 days of inpatient treatment, including substance use disorder treatment in a licensed residential treatment center;

•  60 visits for outpatient treatment including group and individual outpatient treatment;

•  20 additional outpatient visits for speech therapy for treatment of pervasive developmental disorders.

Plans may not include a lifetime limit on the number of days of covered inpatient treatment or the number of covered outpatient visits.

•  Asymptomatic men age 50 and over;

•  African American men age 40 and over; and

•  Men age 40 and over with a family history of prostate cancer.

•  That in-person contact occur between a health care provider and a patient;

•  The health care provider to document a barrier to an in-person consultation for coverage of services to be provided through telehealth;

•  The use of telehealth when the health care provider has determined that it is not appropriate; or

•  The use of telehealth when a patient chooses an in-person consultation.

Cost-sharing applicable to services provided through telehealth may not exceed the cost-sharing required for the same services provided through in-person consultation.

•  The charges are otherwise eligible for reimbursement under the plan; and

•  The services provided are medically necessary and within the scope of the provider’s license.

Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists, as defined under Illinois regulations. The treatment for autism spectrum disorders includes care that is prescribed, provided, or ordered by a licensed physician or a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a licensed physician.

•  Mental illness rendered in a hospital solely because such hospital lacks surgical facilities; or

•  Rehabilitation following either a physical or mental illness rendered in a hospital solely because such hospital lacks surgical facilities.

·       The disorder or condition treated is covered by the plan, and

·       The health care provider is authorized to provide the services under state statutes and in accordance with accepted principles of his or her profession.

•  The child’s attainment of the policy’s limiting age; or

•  The employee’s death, if coverage is not available through spousal continuation.

The continuation coverage may last for a maximum period of 2 years.

For military veterans to qualify for dependent coverage up to age 30, the veteran must:

•  Be an Illinois resident;

•  Have served as a member of the active or reserve components of any of the branches of the Armed Forces of the United States, including the National Guard; and

•  Have received a release or discharge other than a dishonorable discharge.

•  Incapable of self-sustaining employment; and

•  Dependent on his or her parents or other care providers for lifetime care and supervision because of a condition that occurred before the child reached the limiting age.