Health plans - Illinois

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.

Illinois Compiled Statutes include a variety of provisions, some of which include the following:

• The Employees Dental Freedom of Choice Act indicates that plans that provide dental coverage only upon the condition that plan participants obtain dental services from a list of dentists or groups of dentists must provide an alternative plan whereby the participants may obtain services from dentists not on the list. If a participant elects the alternative plan, the employer must contribute the same dollar amount toward the payment of dental services under the alternative plan as it would have contributed under the original plan.
• If a plan covering dependents terminates when that dependent reaches the limiting age, the coverage does not end if that person is handicapped, i.e., is incapable of self-sustaining employment and is dependent on his or her parents or other care providers for lifetime care and supervision.
• Newborns are covered from moment of birth.
• Children are covered, even if their mother has taken diethylstilbestrol (DES).
• Victims of sexual assault.
• Organ transplant procedures even if the procedure is deemed experimental or investigational by the federal Department of Health and Human Services.
• Treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.
• Temporomandibular joint disorder and craniomandibular disorder.
• Annual prostate-specific antigen tests.
• Diabetes self-management training and education.
• Colorectal cancer examination and screening.
• Prenatal HIV testing.
• Adjunctive services in dental care.
• Contraceptives if prescriptions are covered.
• Prescription inhalants
• Inpatient hospital for the treatment of alcoholism.
• Participants may elect optometric services received from either a physician or an optometrist.
• Plans with dependent coverage must not terminate coverage of unmarried qualifying dependents up to the age of 26 and up to age 30 for military veteran dependents. The dependent need not be enrolled in an educational institution.
• Plans must cover individuals under 21 years old for the diagnosis and treatment of autism spectrum disorders to the extent that such diagnosis and treatment are not already covered by the policy of accident and health insurance or managed care plan. Coverage is subject to a maximum of $36,000 per year, but must not be subject to any limits on the number of visits to a service provider.
• Group plans delivered, issued, or renewed after January 1, 2016 must cover charges incurred, and anesthetics provided by a dentist in conjunction with dental care provided 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. A covered individual shall be required to make two visits to the dental care provider prior to accessing other coverage.
• Effective January 1, 2019, Public Act 100-1102 (HB 2617) revises the IL insurance code to require individual or group accident and health policies to provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

State

Contact

Department of Financial and Professional Regulation, Department of Insurance

Regulations

215 ILCS 115/2 (Dental Freedom of Choice)

215 ILCS 5/356 (Accident and Health Insurance) and 367 (Group Accident and Health Insurance)

215 ILCS 5/356z.12 (Young Adult Dependent Coverage)

For more information specific to health benefits for women, see the topic Women’s Health Rights.

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)