a)
Coverage for Essential Health Benefits Package
1) A health insurance issuer that offers
health insurance coverage in the individual or small group market shall ensure
that the coverage includes an essential health benefits (EHB) package in
accordance with the requirements in subsections (b) and (c). (See
42 USC
300gg-6(a).)
2) The provisions of this Section regarding
the inclusion of essential pediatric oral care benefits shall be deemed to be
satisfied for qualified health plans made available in the small group market
or individual market in Illinois outside the Health Benefits Exchange, issued
for policy or plan years beginning on or after January 1, 2015, that do not
include the essential pediatric oral care benefits if the health insurance
issuer has obtained reasonable assurance that the pediatric oral care benefits
are provided to the purchaser or enrollee of the qualified health plan. The
health insurance issuer shall be deemed to have obtained reasonable assurance
that the pediatric oral care benefits are provided to the purchaser of the
qualified health plan if:
A) At least one
Exchange certified stand-alone dental plan that offers the minimum essential
pediatric oral care benefits that are required under subsection (c)(1)(J) and
it is available for purchase by the small group or individual
purchaser;
B) The health insurance
issuer prominently discloses to the purchaser, or enrollee in the case of a
group plan, in a form approved by the Director, at the time that it offers the
qualified health plan, that the plan does not provide the essential pediatric
oral care benefits; and
C) The
health insurance issuer has received and kept records of written, verbal or
electronic confirmation from the purchaser, or enrollee in the case of a group
plan, that he or she has obtained, or is obtaining, other coverage that
includes essential pediatric oral care benefits.
b) Essential Health Benefits Package
In this Section, the term "essential health benefits package"
means, with respect to any health plan, coverage that:
1) provides for the essential health benefits
defined under subsection (c);
2)
limits cost-sharing for such coverage in accordance with Section
2001.12(a);
and
c) Essential Health Benefits
1) In General
Subject to subsection (c)(2), essential health benefits shall
include at least the following general categories and the items and services
covered within the categories:
A)
Ambulatory patient services;
B)
Emergency services;
C)
Hospitalization;
D) Maternity and
newborn care;
E) Mental health and
substance use disorder services, including behavioral health
treatment;
F) Prescription
drugs;
G) Rehabilitative and
habilitative services and devices;
H) Laboratory services;
I) Preventive and wellness services and
chronic disease management; and
J)
Pediatric services, including oral and vision care. (See
42 USC
18022(a) and
(b).)
2) Specific Requirements
Essential health benefits shall include:
A) For plan years 2017-2019, those specific
benefits and limits described in the Illinois EHB Benchmark Plan selected from
the Blue Cross Blue Shield of Illinois plan in the Small Group Market
designated "Blue PPO Gold 011", published by the Centers for Medicare &
Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244 (
http://www.cms.gov/CCIIO/
Resources/Data-Resources/Downloads/IL-BMP.zip).
B) For plan years 2020 onward, those specific
benefits and limits described in the Illinois EHB Benchmark Plan designated
"The Access to Care and Treatment Plan", published by the Centers for Medicare
& Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244
(
http://www.cms.gov/CCIIO/
Resources/Data-Resources/Downloads/2020-BPM-IL.zip).
This subsection (c)(2) does not include any later amendments
or editions, if any, to the Illinois EHB Benchmark Plans.