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Illinois and Health Reform

Illinois supported the implementation of health reform, despite other state’s attempts to extinguish the law. The state opted for a partnership exchange, using the federal health insurance marketplace to enroll residents in subsidized coverage. Private insurance companies have adjusted their guidelines to suit the new laws which substantially changed small group and individual coverage. Moving forward with Medicaid expansion, Illinois offers more coverage to individuals with low income through this public program, as well as through subsidies and the exchange. One of 25 states to pass a bill in favor of offering Medicaid to a larger audience under reform, Illinois now offers health insurance to childless adults under age 65: a brand new group for the family and disability-oriented program.

At the end of 2013, Illinois residents who once joined the state risk pool or PCIP between 2010-13 were able to enroll in a personal health plan without facing the same underwriting challenges for conditions or gender. Even without having a condition, premium rating was biased against other high-risk groups such as women in Illinois, which has since changed. Gender, occupation, and health status cannot affect your premium under any type of health plan. Since its beginnings in 2010, the Affordable Care Act has proven helpful through several moderate changes, including continuation of dependent coverage. If you’re still unsure how this law will unfold, here are the present and future provisions to affect Illinoisans.


2010-2013 Health Care Reforms in Illinois

During the health law’s transitional period, it changed some more subtle aspects of health insurance law, though they have made a significant impact. Insurers are now required to spend the majority (80-85 percent) of their premiums income on improving the quality of and access to healthcare for their members under the medical loss ratio (MLR). If a company does not follow the MLR, their members will each receive a rebate check for the amount they are owed if they had spent according to this law. 2012 was the first year Illinoisans received a refund, and they may each September depending on how their health plan complies.

Lifetime maximums are no longer permitted, and annual out-of-pocket limits will also be lifted. These amounts have been increasing each year since the law’s inception. In 2013, the yearly coverage limit is $3 million, and after 2014 there is no limit. Insurers are also banned from rescinding policies, or canceling benefits for a member without just cause (such as fraud or misrepresentation).

Pre-existing conditions have been treated a bit differently since the law’s establishment, allowing children up to age 18 with health problems to get insured no matter what. Unfortunately, they could still receive a rate increase, but insurers on the individual market cannot deny them a plan. The creation of the Pre-existing Condition Insurance Plan (PCIP) temporarily assisted adults without access to individual coverage, in addition to the state risk pool, while Illinois residents waited for the exchanges to open and laws to change in 2014.

One of the most important provisions made effective immediately, which has also grown over time, is free preventive care for all privately insured Americans. Individual health plans were required to not accept any out-of-pocket payments or copays for annual exams, well child care, well woman care, and various other exams, screenings, and immunizations. For young adults with health insurance through their parent’s private plan, coverage was made available until age 26. Within the first year, 125,000 people ages 19-25 were able to stay insured in Illinois because of the new law.¹


Illinois Health Reform After 2014

As the final provisions of the ACA are adopted by Illinois in 2014, more forms of coverage have become available and more people are able to get insured. Illinois residents have the option of buying a health insurance plan or paying a tax for being uninsured under the individual mandate. In order for more individuals to get coverage, the Illinois health insurance exchange is open to anyone whose income is over 138 percent of the federal poverty level. To make this coverage more affordable for low-to-moderateincome households, the government provides subsidies to help pay premiums for those who earn between 138 and 400 percent FPL. HHS Secretary Kathleen Sebelius celebrated the state’s acceptance of the exchange, saying the state will be “able to tailor the new marketplace… to the needs that are particular for Illinois citizens.” State officials anticipated up to 1 million residents would enroll within the first two years.

Illinois also added a new group to their Medicaid program: adults with income up to 138 percent of poverty, who previously were unable to afford coverage or be accepted by Illinois Medicaid. This could potentially cover an additional 342,000 people in Illinois who do not have insurance, if every uninsured person in this group enrolled in the program. Regarding Medicaid expansion, Democratic Gov. Pat Quinn said, “access to quality health care is a fundamental right,” and noted that the law will “improve the health of hundreds of thousands of people across Illinois, strengthen our health care system and create thousands of good jobs in the health care field.”

Laws for individual, small group, and employer health insurance changed to include new underwriting processes, accepting all individuals regardless of health conditions or gender. Premiums can only increase for smokers and as you age, according to the law. Insurers who enroll sick people for coverage cannot limit a member’s coverage based on their conditions, either, meaning the end of exclusions and elimination riders.

Illinois insurance companies must offer ten categories of essential health benefits (EHBs) in some of their plans, known as qualified health plans (QHPs) sold on and off the exchange to individuals and families. EHBs cover categories of services such as maternity and newborn care, emergency services, hospitalization, ambulatory services, prescriptions, prevention and disease management, and mental health care. This will improve the quality of Illinois health plans on the private market by ensuring comprehensive plans are very inclusive.





1. Healthcare.gov. How the Health Care Law is Making a Difference for the People of Illinois.

2. Chicago Tribune. Illinois is cleared to run health insurance exchange.

3. Chicago Tribune. Illinois Senate Approves Medicaid Expansion Bill.