If you presently own an individual health insurance plan or are researching your options, you’ll find it helpful to know the state provisions for coverage and protections you have. Health plans can be frustrating and confounding, and when they are, you should know your rights and the extent to which they can be exercised, as well. While you can file a complaint, you may not be able to get your insurer to pay for an uncovered or excluded service. If you were ever turned down for a medical policy, it is important to know that you can get coverage and where to apply. Because of the federal health law, and thanks to former Illinois senator, President Barack Obama, everyone in the state is able to enroll in individual health plans on and off the Illinois health insurance exchange.
Illinois gave us the figurehead of the Patient Protection and Affordable Care Act, whose laws uprooted and replaced former ones. Before the ACA, there were less strict underwriting regulations and fewer consumer protections. Illinois is now a guaranteed issue state, and prohibits the use of elimination riders and exclusion periods for pre-existing conditions beginning January 1, 2014. Insurers are no longer able to discriminate against pre-existing conditions. The state requires certain benefits also be covered, and the health care law mandates that ten categories of services be included in some individual plans in Illinois. As a policyholder, you have the ability to notify your insurer of any area where they need improvement, and also the right to inform them that they should have covered a claim they denied, if it is indeed one of your covered benefits.
Under federal law, Illinois insurers must renew your health plan at the end of a term for an additional year. Guaranteed renewability also protects responsible policyholders by not allowing insurers to cancel your benefits at any time once you’ve been accepted for coverage. However, if you intentionally provide false information on your application, neglect to pay premiums, or commit health insurance fraud, you are unable to benefit from this law. This protection is designed to help people who become ill after their health plan has begun from losing coverage when they need it most. Insurers were once able to rescind policies if a person contracted HIV or got cancer during their plan year, leaving sick people without insurance.
Illinois insurers cannot increase rates, issue exclusions for, or decline coverage to any applicant because of their health. Until 2014, Illinois insurance companies were able to limit the amount of coverage sold to individuals with health problems or a flawed medical history. They could look back 24 months into your history, and if you had a qualifying condition, they could ask for information dating back even further than the state’s maximum look-back period. If you were accepted for coverage with a condition, you may have been issued an elimination rider, which permanently eliminated certain illness-related benefits from your plan. Exclusion periods could also be imposed, allowing the insurer to not cover healthcare services relating to your condition for any length of time up to 24 months. Health plans may have also increased your premiums or decided to not sell you coverage altogether, depending on their criteria.
Starting in 2010, insurers had to accept all applicants under age 18, regardless of their health status, and beginning in 2014 people of all ages could obtain coverage due to nondiscrimination laws.
Illinois has provided certain policyholders with many categories of benefits that predate health reform. This follows the healthcare law’s requirements for essential health benefits (EHBs) and offers additional coverage, though not across all plans. Not all private health plans have to cover essential benefits, and the state-mandated services are more specific than the EHB categories required by the ACA. Some of these benefits are nationwide coverage provisions, such as keeping a child on your plan until a certain age, or if they are disabled. The following services are included in the current state legislature for some major medical health insurance plans:
- Autism spectrum disorder care
- Birth control medications and supplies
- Breast implant removal
- Coverage for adopted children and newborns under parent’s plan
- Coverage for disabled dependents under parent’s plan
- Coverage for dependents up to age 26 on parent’s plan
- Dental anesthesia
- Diabetes management supplies and care
- Gardasil (HPV immunization)
- Habilitative care for children
- Infertility treatment
- Mammograms and breast cancer screenings
- Mastectomy, hospital stay, and reconstructive surgery
- Maternity care and prenatal prevention
- Mental health and substance abuse treatment
- Organ transplants
- Ovarian cancer screenings
- PAP tests
- Physical therapy to prevent multiple sclerosis
- Prescription medications for cancer
- Preventive care and certain immunizations
- Prosthetics and orthotics
- Well child care
1. Kaiser State Health Facts. Individual Market Rate Restrictions – Illinois.
2. Kaiser State Health Facts. Individual Market Portability Rules – Illinois.