Illinois Health Insurance Policy Requirements

Illinois has comprehensive health insurance regulations that work alongside federal requirements. Understanding these state-specific rules is essential for the licensing exam.

Regulatory Structure

Illinois health coverage is primarily regulated by IDOI:

Illinois HMO Act

The Illinois HMO Act specifically regulates Health Maintenance Organizations in Illinois:

• Requires IDOI licensure as an HMO
• Sets standards for quality of care
• Requires adequate provider networks
• Mandates grievance and appeals processes
• Sets financial solvency requirements

Free Look Period

Illinois provides a 10-day free look period for individual health insurance:

• Policyholder can return for full premium refund
• Begins when policy is delivered
• Applies to individual health policies

Exam Tip: Health insurance has a 10-day free look in Illinois. Remember this is the same as the standard life insurance free look (though seniors get 20 days for life insurance).

Required Coverage

Illinois mandates coverage for numerous benefits:

Essential Health Benefits

All individual and small group plans must cover:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorders
6. Prescription drugs
7. Rehabilitative services
8. Laboratory services
9. Preventive and wellness services
10. Pediatric services (including dental and vision)

Mental Health Parity

Illinois Mental Health Parity Act requires:

• Mental health benefits equal to medical/surgical benefits
• Same copays, deductibles, and limits
• Covers serious mental illness and substance use
• Applies to group and individual plans

Covered Conditions

Illinois law requires coverage for:

• Schizophrenia
• Bipolar disorder
• Major depression
• Obsessive-compulsive disorder
• Panic disorder
• Autism spectrum disorders (with mandated coverage for children)
• Substance use disorders

Pre-Existing Condition Protections

Illinois prohibits pre-existing condition exclusions:

Get Covered Illinois

Get Covered Illinois is the state's health insurance marketplace:

• Uses the federal Healthcare.gov platform
• Only place to get premium subsidies
• Offers qualified health plans (QHPs)
• Open enrollment and special enrollment periods

Key Features

• Plans categorized by metal tiers (Bronze, Silver, Gold, Platinum)
• Premium tax credits based on income
• Cost-sharing reductions for Silver plans
• Special enrollment for qualifying life events

Guaranteed Issue and Renewal

Illinois requires:

Guaranteed Issue

• Insurers must accept all applicants
• Cannot deny coverage based on health status
• Applies to individual and small group markets

Guaranteed Renewal

• Insurers cannot cancel coverage except for:
  • Non-payment of premium
  • Fraud or misrepresentation
  • Plan discontinuation (with notice)