state of illinois department of central management services bureau of benefits · 2020. 2. 13. ·...

State of IllinoisDepartment of Central Management ServicesBureau of Benefits

Illinois State Capitol, Springfield

Clark Bridge, Alton North Point Marina, Zion Spoon River Scenic Drive, Fulton County

Jim Edgar Panther CreekState Fish and Wildlife Area, Chandlerville

Chicago Skyline, Chicago

Giant City State Park, MakandaDana Thomas House,

Springfield

Chicago Theatre, Chicago

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Employee Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 1: Enrollment and Eligibility InformationEligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Qualifying Changes in Status Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Opt Out and Waiver of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Time Away from Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Time Away from Work Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

COBRA Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30COBRA Second Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Chapter 2: Health, Dental, Vision and Life Coverage InformationHealth Plan Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Managed Care Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Quality Care Health Plan (QCHP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Prescription Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Employee Assistance Program (EAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Dental Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Vision Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Life Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Chapter 3: Optional ProgramsFlexible Spending Accounts (FSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Commuter Savings Program (CSP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Adoption Benefit Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Smoking Cessation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Chapter 4: MiscellaneousCoordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Chapter 5: ReferenceGlossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Table of Contents

Benefits Handbookwww.benefitschoice.il.gov

2Benefits Handbook www.benefitschoice.il.gov

Your Group Insurance BenefitsYour benefits are a very important part of your compensationpackage as a State of Illinois employee. Please read thishandbook carefully as it contains vital information aboutyour benefits.

The Bureau of Benefits within the Department of CentralManagement Services (Department) is the bureau thatadministers the State Employees Group InsuranceProgram (Program) as set forth in the State Employees GroupInsurance Act of 1971 (Act). You have the opportunity to reviewyour choices and change your coverage for each plan yearduring the annual Benefit Choice Period. If a qualifying changein status occurs, you may be allowed to make a change to yourcoverage that is consistent with the qualifying event. See thesection ‘Enrollment Periods’ for more information.

Group InsuranceRepresentative (GIR)A Group Insurance Representative (GIR) is your employingagency’s liaison to the Department. Every State agencyhas a GIR. Some of the larger agencies also have GroupInsurance Preparers (GIP) who may assist the GIR withyour insurance needs. GIRs and GIPs are valuableresources for answering questions you may have aboutyour eligibility for coverage and to assist you in enrolling orchanging the benefits you have selected.

To identify your GIR, call your agency personnel office orvisit the Benefits website at www.benefitschoice.il.govthen click on the ‘Contact Information’ link. If you are onleave of absence, contact your employing agency GIR. Ifyou are on an extended disability leave, your GIR may belocated at your retirement system office. If you haveterminated State service and are continuing coverage underCOBRA, contact the Department’s Group Insurance Division.

Where To Get Additional InformationIf you have questions after reviewing this book,please refer to the following:

F The Department’s website contains the most up-to-dateinformation regarding benefits and links to planadministrators’ websites. Visit www.benefitschoice.il.govfor information.

F Annual Benefit Choice Options booklet. This bookletcontains the most current information regarding

changes for the plan year. New benefits, changes inpremium amounts and changes in plan administratorsare included in the booklet. Review this bookletcarefully as it contains important eligibility andbenefit information that may affect your coverage.Visit www.benefitschoice.il.gov to view the booklet.

F Each individual plan administrator can provide youwith specific information regarding plan coverageinclusions/exclusions.

F The Department can answer your benefit questions orrefer you to the appropriate resource for assistance.The Group Insurance Division can be reached at:

DCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208(800) 442-1300 or (217) 782-2548TDD/TTY: (800) 526-0844

ID CardsThe plan administrators produce ID cards at the time ofenrollment. Cards are mailed to the employee’s currentaddress on file with the Bureau of Benefits. To obtainadditional cards, contact the plan administrator. Links tothe plan administrators’ websites can be found atwww.benefitschoice.il.gov.

Health Insurance Portability andAccountability Act (HIPAA)Title II of the federally enacted Health Insurance Portabilityand Accountability Act of 1996, commonly referred to asHIPAA, was designed to protect the confidentiality and securityof health information and to improve efficiency in healthcaredelivery. HIPAA standards protect the confidentiality ofmedical records and other personal health information, limitthe use and release of private health information, and restrictdisclosure of health information to the minimum necessary.

The State contracts with business associates (health planadministrators and other carriers) to provide services including,but not limited to, claims processing, utilization review,behavioral health services and prescription drug benefits.

If you are enrolled in the Program, a copy of the Notice ofPrivacy Practices will be sent to you on an annual basis.Additional copies are available on the Benefits website.

Introduction

3 Benefits Handbookwww.benefitschoice.il.gov

It is each employee’s responsibility to know theirbenefits, including coverage limitations andexclusions, and to review the information in thispublication. Referral and/or approval for treatment bya physician does not ensure coverage under the plan.

You must notify the Group Insurance Representative (GIR)at your employing agency or university if:

F You and/or your dependents experience a change ofaddress. When you and/or your dependents move,you must notify the GIR at your employing agency.Updating your address with the personnel office orpayroll department does not automatically updateyour address for group insurance purposes. Ifenrolled in the Commuter Savings Program (CSP), youwill need to verify that the plan administrator has thecorrect information on their website. Changing youraddress does not automatically change your health planto a plan in that geographic area. Make sure to contactyour GIR immediately when moving to a new addressas you may be eligible to change health plans. Youhave 60 days from the date of your move to changehealth plans. Refer to the managed care coverage mapin the Benefit Choice Options booklet for health planoptions available in your county.

NOTE: Your address may be updated based upon aforwarding order from the United States Post Office.

F Your dependent loses eligibility. Dependents that areno longer eligible under the Program (including divorcedspouses or partners of a dissolved civil union or domesticpartner relationship) must be reported to your GIRimmediately. Failure to report an ineligible dependentis considered a fraudulent act. Any premiumpayments you make on behalf of the ineligibledependent which result in an overpayment will notbe refunded. Additionally, the ineligible dependentmay lose any rights to COBRA continuation coverage.

F You go on a leave of absence or have time away fromwork. When you go on a leave of absence and are notreceiving a paycheck or are ineligible for payrolldeductions, you are still responsible to pay for your groupinsurance coverage. You should immediately contactyour GIR for your options, if any, to make changes toyour current coverage. Requested changes will beeffective the date of the written request if made within 60days of beginning the leave. You will be billed by theDepartment for the cost of your current coverage.

Failure to pay the bill may result in a loss of coverageand/or the filing of an involuntary withholding orderthrough the Office of the Comptroller.

F You get married or enter into a civil union, or yourmarriage, domestic partnership or civil unionpartnership is dissolved.

F You have a baby or adopt a child.

F Your dependent’s employment status changes.

F You have or gain other coverage. If you have groupcoverage provided by a plan other than the Program, orif you or your dependents gain other coverage duringthe plan year, you must provide that information to yourGIR immediately.

F You receive a United States court order making youfinancially responsible for the dependent's healthinsurance (e.g., a court makes a determination of amember's paternity).

Contact your GIR if you are uncertain whether or not alife-changing event needs to be reported. See the‘Enrollment Periods’ section in this chapter for a completelisting of qualifying changes in status.

If you and/or your dependent experience a change inMedicare status or become eligible for Medicarebenefits, a copy of the Medicare card must be provided tothe State of Illinois Medicare Coordination of Benefits (COB)Unit. Failure to notify the Medicare COB Unit of you and/oryour dependent’s Medicare eligibility may result insubstantial financial liabilities. Refer to the ‘MedicareSection’ for the Medicare COB Unit’s contact information.

Employees should periodically review the following to ensureall benefit information is accurate:

F Payroll Deductions. It is your responsibility to ensurepayroll deductions are accurate for the insurance coverageand benefit programs you have selected/enrolled.

F Beneficiary Designations. You should periodicallyreview all beneficiary designations and make theappropriate updates. Remember, you may have deathbenefits through various State-sponsored programs,each having a separate beneficiary form:

• State of Illinois life insurance

• Retirement benefits

• Deferred Compensation

Employee Responsibilities

If You Live or SpendTime Outside IllinoisEmployees who move or spend time out of Illinois or thecountry will need to contact their plan administrator to verifywhether their coverage will continue while they are outsideof the service area if they are enrolled in a managed careplan. For those in certain areas contiguous to the State ofIllinois, some managed care health plan options may beavailable. Refer to the current Benefit Choice Optionsbooklet or contact the managed care health plan directlyfor information on plans available.

Dependents Who Live Apart fromthe Employee Eligible dependents who are enrolled in an HMO plan andlive apart from the employee’s residence and are out of theplan’s service area for any part of a plan year will be limitedto coverage for emergency services only. It is crucial thatemployees who have an out-of-area dependent (such as acollege student) contact the managed care plan tounderstand the plan’s guidelines on this type of coverage.

Power of AttorneyEmployees may want to consider having a financial powerof attorney on file with the health plan to allow arepresentative to act on their behalf. For purposes ofgroup insurance, a financial or property power of attorneyis necessary; a healthcare power of attorney does notpermit changes to health insurance coverage.

Penalty for FraudFalsifying information/documentation or failing to provideinformation/documentation in order to obtain/continuecoverage under the Program is considered a fraudulentact. The State of Illinois will impose a financial penalty,including, but not limited to, repayment of all premiums theState made on behalf of the employee and/or the dependent,as well as expenses incurred by the Program.

Employee Responsibilities (cont.)



Chapter 1Chapter 1: Enrollment and Eligibility InformationEligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Qualifying Changes in Status Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Opt Out and Waiver of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Time Away from Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Time Away from Work Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

COBRA Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

COBRA Second Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31


Eligibility for the State Employees Group InsuranceProgram (Program) is defined by the applicable federalstatute or the State Employees Group Insurance Act of1971 (5 ILCS 375/1 et seq.) or as hereafter amended (Act),and by such policies, rules and regulations as shall bepromulgated thereunder.

Eligibility for Basic Life and optional life insurance varies;see the ‘Life Insurance Coverage’ section in Chapter 2 fordetails. See the ‘Premium Payment’ section for cost ofcoverage information.

Employee EligibilityIn order to be eligible for group insurance benefits as anemployee the person must be working at least 50% of anormal work period and paid a salary through theComptroller’s Office or a local university payroll or certainother agencies/departments as specified in the Act, andeligible to participate in and contribute to one of thefollowing five State retirement systems:

– State Employees’ Retirement System (SERS)

– State Universities Retirement System (SURS)

– Teachers’ Retirement System (TRS)

– General Assembly Retirement System (GARS)

– Judges’ Retirement System (JRS)

NOTE: Although your employment status may beclassified as full-time, your eligibility for group insurancecould be classified as part-time based upon an annualreview of hours worked. In this case, you will beresponsible for a portion of the State’s contribution(see the ‘Premium Payment’ section for details).

F Full-time Employees - Permanent employees whowork 100% of a normal work period are eligible toparticipate in the health, dental, vision and life plansunder the State Employees Group Insurance Program.Full-time employees include the following groups:

• Employees of the StateEmployees who work 100% of a normal work period,as well as part-time employees hired prior to January 1,1980, that have been continuously employed.

• Elected State OfficialsEmployees of the State elected by popular vote.

• University Full-time FacultyEmployees working greater than or equal to 9 monthsof the year.

• University Full-time Non-FacultyEmployees hired to work an average of 37.5 hours ormore per week on a permanent basis.

F Part-time Employees - Employees who work 50-99%of a normal work period are eligible to participate in thehealth, dental, vision and life plans under the Program.Part-time employees include the following groups:

• Permanent Part-time Employees of the State andPart-time University Non-Faculty EmployeesEmployees working at least 50% of the averageweekly hours required of a full-time employee in asimilar position. This part-time percentage requirementdoes not apply to those eligible for the Program andcontinuously employed before January 1, 1980.

• University Part-time Faculty (Academic Year)Faculty employees hired to work only one contractperiod of 4.5 continuous months (e.g., filling in forfaculty on maternity leave) are eligible for insurancebenefits only if their contract is 100%. Since theemployee is only working half of a full academic year,the percentage for insurance purposes is 50%.

• Agency/University Seasonal ServiceEmployees who work greater than or equal to 6 monthsbut not less than 975 hours per 12 month work period.

• University Part-time Non-Faculty (Academic Year)Employees hired to work greater than 4, but less than12, continuous months, but not less than 730 hoursper 12 month work period.

Others eligible as employees include:

• Individuals receiving ordinary or accidental disabilitybenefits or total permanent or total temporary disabilityunder the Workers’ Compensation Act or OccupationalDisease Act for injuries or illnesses contracted in thecourse of employment with the State of Illinois.

• Emergency appointments may participate at their ownexpense.

Ineligible employees include:

• Contractual employees.

• Temporary employees.

• Employees whose work visa has expired.

• Employees who are ineligible to participate in andcontribute to one of the five State retirement systems.

Eligibility Requirements

ELIGIB

ILITYR

EqU

IREM

ENTS


• Employees hired on or after January 1, 1980, who areworking less than 50% of a normal work period.

Eligible As DependentsEligible dependents of an employee may participate in theProgram. Dependent coverage is an additional cost for allemployees.

Eligible dependents of the employee include:

F Spouse (does not include ex-spouses, common-lawspouses, persons not legally married or the newspouse of a survivor).

F Same-Sex Domestic Partner (enrolled prior toJune 1, 2011).

F Civil Union Partner (enrolled on or after June 1, 2011).

F Child from birth to age 26, including:

– Natural child.

– Adopted child.

– Stepchild or child of a civil union partner.

– Child for whom the employee has permanent legalguardianship.

– Adjudicated child for whom a U.S. court decree hasestablished a member’s financial responsibility forthe child’s medical, dental or other healthcare.

F Child age 26 and older, including:

– Adult Veteran Child. Unmarried adult child age 26up to, but not including, age 30, an Illinois residentand has served as a member of the active or reservecomponents of any of the branches of the U.S.Armed Forces and received a release or dischargeother than a dishonorable discharge.

– Other. (1) Recipient of an organ transplant after June30, 2000, and eligible to be claimed as a dependentfor income tax purposes by the employee, except fora dependent child who need only be eligible to beclaimed for tax years in which the child is age 27 orabove, or (2) an unmarried individual continuouslyenrolled as a dependent of the employee in the StateInsurance Program (or CNA for university staff) since2/11/83 with no break in coverage and eligible to beclaimed as a dependent for income tax purposes bythe employee. The period of time the dependent wasenrolled with Golden Rule Insurance Company (prior

to April 1, 1988) does not count toward therequirement of continuous enrollment.

– Disabled. Child age 26 or older who is continuouslydisabled from a cause originating prior to age 26. Inaddition, for tax years in which the child is age 27 orabove, eligible to be claimed as a dependent forincome tax purposes by the employee.

Certification of Dependent CoverageIn addition to the following certification periods, the GroupInsurance Division may ask the employee to certify theirdependent either randomly or during an audit anytimeduring the year.

Birth Date Certification. Employees must verify continuedeligibility for dependents turning age 26 and 30. Employeeswith dependents turning age 26 and 30 will receive a letterfrom the Department several weeks prior to the birth monththat contains information regarding continuation of coveragerequirements and options. The employee must provide therequired documentation to the Department prior to thedependent’s birth date. Failure to certify the dependent’seligibility will result in the dependent’s coverage beingterminated effective the end of the birth month.

Annual Certification. Employees are required to certify allIRS dependents in the following categories on an annualbasis: Domestic Partner, Civil Union Partner, Civil UnionPartner Children, Disabled, Other and Adult Veteran Child(age 26 and older).

Reinstatement of Dependent Coverage. If coverage fora dependent is terminated for failure to certify and theemployee provides the required documentation within 30days from the date the termination was processed, coveragewill be reinstated retroactive to the date of termination.

After 30 days the coverage will be reinstated only with aqualifying change in status (see qualifying change in statusreasons in the ‘Enrollment Periods’ section later in thischapter). Termination of coverage for failure to certifyis not a qualifying change in status. Nonretroactivereinstatement will cause a break in coverage which wouldprevent a dependent from qualifying for continuedcoverage in the Other category.

NOTE: Dependents with life insurance coverage only,as well as dependents of COBRA participants, mustalso certify eligibility for coverage.

Contact your GIR for questions regardingcertification of a dependent.

Eligibility Requirements (cont.)

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Employees may enroll, opt out or change benefit

selections with supporting documentation during

the following periods (see the ‘Documentation

Requirements’ chart in this chapter):

F Initial Enrollment

F Annual Benefit Choice Period

F Qualifying Change in Status (as permitted under theInternal Revenue Code)

Initial EnrollmentA “new” employee is one who has not previously beenenrolled in the State Employees Group Insurance Program(Program) or one who has had greater than a 10-day breakin coverage (the 10-day break does not apply to coverageterminated due to nonpayment of premium). Employeeswith a break in employment status of less than 10 daysexperience no break in insurance coverage and are notconsidered a “new” employee, nor are they eligible forinitial enrollment options. Preexisting condition limitationsdo not apply to coverage under the State plan.

Employees have 10 calendar days from their initialemployment date to make health, dental, vision, life anddependent coverage elections. All employees, includingpart-time employees, who fail to make benefit electionswithin the 10-day initial enrollment period will automaticallybe enrolled in the Quality Care Health Plan (QCHP) andthe Quality Care Dental Plan (QCDP) with no dependentcoverage, and will be provided with Basic Life coverage.

Employees eligible for the employer-paid portion of premiumsmust be enrolled as a member in their own right. Whenboth an employee and his/her spouse, civil union partner ordomestic partner are eligible as employees, each must beenrolled as a member in their own right. Employees mustprovide their social security number (SSN) to enroll inthe Program.

New employees have the following options:

F Elect a health plan (includes prescription, behavioralhealth and vision coverage).

F Elect not to participate in the health plan. See the ‘Opt Outand Waiver of Coverage’ section in this chapter for details.

F Elect to participate or not to participate in the dentalplan (enrollment in the health plan is required if electingthe dental coverage).

F Enroll eligible dependents. Documentation, includingsocial security numbers (SSNs), must be providedwithin 15 days of the employment date. Dependentcoverage will not be allowed if the documentation is notprovided within the 15-day period. Additional time isallotted to provide the SSN when adding newborns andnewly-adopted children. See ‘Dependent Coverage’later in this section for more information.

F Elect Member Optional Life insurance coverage up to8 times the annual base salary; statement of healthapproval is required for increments of 5 to 8 times.

F Elect optional Spouse Life, Child Life or Accidental Deathand Dismemberment (AD&D). Statement of healthapproval is not required during the Initial Enrollment Period.

F Enroll in the Flexible Spending Accounts (FSA) Program.Employees have 60 days from their hire date in whichto enroll in an FSA.

Effective Date of Coverage Due to Initial Enrollment:

Employees scheduled to begin State employment on a day inwhich they are scheduled to work every available day in thepay period have an effective date of the first day of that payperiod. Employees scheduled to begin State employment ona day in which they are not scheduled to work everyavailable day in the pay period have an effective date of thefirst day they physically begin work. Dependent coverage iseffective the same day as the employee’s coverage.

Annual Benefit Choice PeriodThe Benefit Choice Period is normally held annually May 1stthrough May 31st. During this 31-day period, employeesmay change their coverage elections. Coverage electedduring the annual Benefit Choice Period becomes effectiveJuly 1st. Elected coverage remains in effect throughout theentire plan year, unless the employee experiences aqualifying change in status or the Department institutes aspecial enrollment period which would allow the member tochange their coverage elections.

Documentation is required when adding dependent coverage.See the ‘Documentation Requirements – AddingDependent Coverage’ chart later in this chapter.

Employees may make the following changes duringthe annual Benefit Choice Period:

F Change health plans.

F Re-enroll in the Program if coverage is currently

Enrollment Periods

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terminated due to nonpayment of premium (subject toeligibility criteria). NOTE: Any outstanding premiumsplus the July premium must be paid before coveragewill be reinstated.

F Re-enroll in the Program following an opt out or waiverof coverage.

F Elect not to participate in the health plan. See the ‘Opt Outand Waiver of Coverage’ section in this chapter for details.

F Add or drop dental coverage (enrollment in the healthplan is required if electing the dental coverage).

F Add or drop dependent coverage. When adding coverage,documentation, including social security numbers (SSNs),must be provided within 10 days of the last day of theBenefit Choice Period. If the documentation is notprovided within the 10-day period, the dependent coveragewill not be added. See ‘Dependent Coverage’ later in thissection for more information.

F Increase, decrease or terminate Member Optional Lifeinsurance coverage; add or drop AD&D, Spouse Life orChild Life coverage. An approved statement of health isrequired to increase or add Member Optional Life,Spouse Life or Child Life coverage. A statement ofhealth is not required to add or increase AD&D coverage.

F Enroll or re-enroll in the Flexible Spending Accounts(FSA) Program.

Effective Date of Coverage Due to the AnnualBenefit Choice Period:

All Benefit Choice health, dental and dependent coveragechanges become effective July 1st. Life insurance coveragechanges requiring a statement of health become effectiveJuly 1st if the approval date from the life insurance planadministrator is on or before July 1st. If the approval dateis after July 1st, the effective date will be the statement ofhealth approval date.

Qualifying Change in StatusPursuant to Section 125 of the Internal Revenue Code,premiums paid by the employee for health, dental and lifeinsurance coverage are tax exempt. The tax exemptionapplies only to premiums that are payroll deducted on a pretaxbasis. The Internal Revenue Code requires plans that providethe tax-exempt premium to prohibit changes in the employee’selection during the plan year unless there is a qualifyingchange in status. See the ‘Qualifying Change in Status’ chartfor allowable election changes consistent with the event.

Any request to change an election mid-year must be

consistent with the qualifying event the employee hasexperienced.

Qualifying change in status events include, but arenot limited to:

F Events that change an employee’s legal relationshipstatus, including marriage, civil union partnership,death of spouse or civil union partner, divorce, legalseparation, civil union dissolution or annulment.

F Events that change an employee’s number of dependents,including birth, death, adoption, placement for adoption ortermination of a domestic partner relationship.

F Events that change the employment status of the employee,the employee’s spouse or civil union partner, or theemployee’s dependent. Events include termination orcommencement of employment, strike or lockout,commencement of, or return from, an unpaid leave ofabsence or change in worksite.

F Events that cause a dependent to satisfy or cease tosatisfy eligibility requirements for coverage.

F A change of residential or work county for theemployee, spouse, civil union partner or dependent.

Employees experiencing a qualifying change in status have60 days to change certain benefit selections. Employeesmust submit proper supporting documentation to their GroupInsurance Representative (GIR) within the 60-day periodin order for the change to become effective. See ‘EffectiveDate of Coverage Due to a Qualifying Change in Status’later in this section.

See the ‘qualifying Changes in Status’ chart in thischapter for a complete list of qualifying change instatus events and corresponding options.

Effective Date of Coverage Due to a QualifyingChange in Status:

Coverage election changes made due to a qualifyingevent are effective the later of:

F The date the request for change was signed.

F The date the event occurred.

Qualifying Change in Status Effective Date Exceptions:

F Newborns, natural or adopted. A child is considered anewborn if they are within 60 days of birth. If the requestto add the child is made within 60 days of the birth,coverage may be retroactive to the date of birth.

F Adopted children, other than newborn. Requests toadd an adopted child who is 60 days old or older will be

Enrollment Periods (cont.)


effective the date of the placement of the child, the filingof the adoption petition or the entry of the adoption orderprovided that the request is received within 60 days ofthe placement of the child, filing of the adoption petitionor the entry of the adoption order.

F Flexible Spending Accounts. Requests to elect orchange an FSA become effective the first day of thepay period following the date the request for changewas signed or the date of the qualifying event,whichever is later.

Other Allowable Mid-year ChangesThere are some coverage options that are taxable andtherefore can be changed anytime during the year.Coverage options that can be changed any time during theplan year include:

F Changes in employee’s life insurance coverage above$50,000. Includes Basic Life and any Member OptionalLife insurance coverage. An approved statement ofhealth is required to add or increase coverage.

F Changes to Spouse Life or Child Life coverage. Anapproved statement of health is required to addcoverage, unless the spouse, civil union partner or childis newly acquired, in which case a statement of healthis not required.

F Changes to Accidental Death and Dismemberment (AD&D)coverage. A statement of health is not required to add orincrease AD&D coverage.

F Adding or dropping dependents as long as the employee’sdependent monthly contribution category remains ‘Twoor More Dependents’.

Effective Date of Coverage for Other AllowableMid-year Changes:

The effective date for adding or dropping dependents whenthe employee is in the ‘Two or More Dependents’ monthlycontribution category is:

F The date the request for change was signed if the formwas given to the GIR within 15 days of the employeesigning the form, or

F The date the GIR received the form if the form wasgiven to the GIR after the 15-day period.

The effective date of coverage when adding or increasingMember Optional Life, or when adding Spouse Life orChild Life, will be the statement of health approval date.The life plan administrator will send a copy of the statement

of health approval/denial letter to the individual whorequested the change.

When adding or increasing AD&D coverage the effectivedate is the date the request was received.

When terminating or decreasing any Optional Life coverageoutside the Benefit Choice Period, the effective date will bethe date of the request. A future effective date may berequested as long as it is within 60 days of the current date.

Dependent CoverageEnrolling Dependents

Dependents must be enrolled in the same health and dentalplans as the employee. Employees electing to opt out orwaive health plan coverage may enroll their dependentswith life insurance coverage only.

When both parents* are employees, either employee mayelect to cover the dependents; however, the samedependent cannot be enrolled under both employees for thesame type of coverage. For example, eligible dependentsmay be enrolled under one parent for health and dentalcoverage and enrolled under the other for life coverage.NOTE: Dependents whose coverage was terminated fornonpayment of premium under one parent cannot beenrolled under the other until all premiums due for thatdependent are paid.

Employees must complete the required enrollment forms toadd dependent coverage. Forms are available on theBenefits website.

* The term 'parent' includes a stepparent or a civil unionpartner of the child's parent.

Documentation Requirements

Documentation, including the dependent’s social securitynumber (SSN), is always required to enroll dependents.Failure to provide the required documentation in the allottedtime period will result in denial of dependent coverage. Ifdenied, the eligible dependent may be added during thenext Benefit Choice Period or upon the employeeexperiencing a qualifying change in status, as long as thedocumentation is provided in a timely manner.

An additional time period of 90 days is allotted to providethe SSN of newborns and adopted children; however, theelection time frames still apply to request the addition of thedependent coverage. If the SSN is not provided within 90days of the dependents’s date of birth or adoption date,coverage will be terminated. Refer to the ‘DocumentationRequirements – Adding Dependent Coverage’ chart later inthis chapter for specific documentation requirements.

Enrollment Periods (cont.)

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The Internal Revenue Code requires plans that provide the tax-exempt premium to prohibit changes in the employee’s deduction duringthe plan year unless there is a qualifying change in status. The chart below indicates those changes that employees are allowed tomake which are consistent with a qualifying change in status.

qualifying Changes in Status

EMPLOYEE – Qualifying Changes in Status

Corresponding HEALTH & DENTAL Options

Changes affecting the Employee Opt Out of Enroll or Add Newly Add Add Terminate Terminate Change WaiveHealth & Re-Enroll Acquired Existing Spouse Dependent Spouse or Health Health &Dental in the Child Child or Civil Coverage Civil Union Carrier Dental

Coverage Program Union Partner CoveragePartner Coverage

Adjudicated Child:X

Employee financially responsible

Adoption (or placement for adoption) X

Birth X

Custody awarded and requiresX X

dependent coverage (court ordered)

Custody loss (court ordered)/CourtX

Order expires

Divorce/Legal Separation/Annulment/X X X

Dissolution of Civil Union

Eligibility: Employee becomes eligible O P

for non-State group insurance coverage

Eligibility: Employee loses eligibility ofX X X Xnon-State group insurance coverage

(for other than nonpayment of premium)

Employment Status:X X P

Full-time to Part-time (≥50%)

Employment Status: Layoff O X X

Employment Status:O

Part-time participating to Full-time

Employment Status: Part-time waivingO X X

coverage, or working <50%, to Full-time

Health PCP leaves network X

Initial enrollment – within 10 days O X X P

Leave of Absence:O X X P

Employee entering nonpay status

Leave of Absence: Employee enteringO X X X

nonpay status responsible for 100%

Leave of Absence: Employee returnsO X X X P

to work from nonpay status

Marriage or Civil Union Partnership O X X X P

Medicaid or Medicare eligibility gained O X X P

Medicaid or Medicare eligibility loss X X X X

Military Leave of Absence X X X X

Military Leave of Absence: X X X X

Employee returns to work

Premium increase 30% or greater:X X X X

Employee’s non-State health insurance

Premium increase 30% or greater:X X P

Employee’s STATE health insurance

Residence/Work location:X

Employee’s county changes

Retirement O X X X X X X P

X = Eligible changes for all employees. P = Eligible changes for Part-time employees. O = Eligible changes for Full-time employees.Newly Acquired Child = A child for which the employee gained custody within the previous 60-day period, such as a new stepchild, adopted child, adjudicated child or a child for which the employee gainedcourt-ordered guardianship.Existing Child = A child for which the employee had custody prior to the previous 60-day period, such as a natural or adopted child, adjudicated child, stepchild or a child for which the employee is guardian.


qualifying Changes in Status(Whenever the term 'Spouse' is indicated on this page it also includes a Civil Union Partner.)

SPOUSE – Qualifying Changes in Status


Changes affecting the Spouse Employee Employee Add Newly Add Add Terminate Terminate Change WaiveMay Opt may Acquired Existing Spouse Dependent Spouse Health Health/Out of Enroll or Child Child Coverage Coverage Carrier Dental

Program Re-Enroll Coveragein the

Program

Coordination of spouse’sO X X X X X P

open enrollment period *

Death of spouse X X

Eligibility: Spouse loses eligibilityX X X

for group insurance coverage

Eligibility: Spouse now providedO X X Pwith group insurance coverage

Employment Status: O X X PSpouse gains employment

Employment Status:X X XSpouse loses employment

LOA: Spouse enters nonpay status X X

LOA: Spouse returns to work fromnonpay status X X

Medicare eligibility: Spouse gains X

Medicare eligibility: Spouse loses X

Premium of spouse’s employer increasesX X X30% or greater, or spouse’s employer

significantly decreases coverage

Residence/Work location:XSpouse’s county changes

DEPENDENT (other than Spouse) – Qualifying Changes in Status


Changes affecting a Dependent Employee Employee Add Newly Add Add Terminate Terminate Change Waive

(other than a Spouse) May Opt may Acquired Existing Spouse Dependent Spouse Health Health/Out of Enroll or Child Child Coverage Coverage Carrier Dental

Program Re-Enroll Coveragein the

Program

Death of Dependent X

Eligibility: Dependent becomesXeligible for State group coverage

Eligibility: Dependent loses eligibility X

for non-State group coverage

Eligibility: Dependent now eligible for X

non-State group coverage

LOA: Dependent enters nonpay status X

LOA: Dependent returns to work fromnonpay status X

Medicare eligibility: Dependent gains X

Medicare eligibility: Dependent loses X

Residence/Work location: X

Dependent’s county changes

* The employee’s request to change coverage must be consistent with, and on account of, the spouse’s election change.

X = Eligible changes for all employees. P = Eligible changes for Part-time employees. O = Eligible changes for Full-time employees.Existing Child = A child for which the employee had custody prior to the previous 60-day period, such as a natural or adopted child, adjudicated child, stepchild, childof a civil union partner or a child for which the employee is guardian.

qUALIFYINGCHANGE IN STATUS


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Type of Dependent

Adjudicated ChildBirth up to, but not including, age 26

Adoption or Placement for AdoptionBirth up to, but not including, age 26

Adult Veteran ChildChild age 26 up to, but not including, age 30

Disabled Child age 26 and older(onset of disability must have occurred prior to age 26)

Legal GuardianshipBirth up to, but not including, age 26

Natural ChildBirth up to, but not including, age 26

OtherOrgan transplant recipient

Spouse or Civil Union Partner

Stepchild or Child of Civil Union PartnerBirth up to, but not including, age 26

Supporting Documentation Required

• Judicial Support Order from a judge; or• Copy of DHFS Qualified Medical Support Order with the page that indicates the

employee must provide health insurance through the employer

• Adoption Decree/Order with judge’s signature and the circuit clerk’s file stamp,or a

• Petition for adoption with the circuit clerk’s file stamp

• Birth Certificate required, and • Proof of Illinois residency, and • Veterans’ Affairs Release form DD-214 (or equivalent), and the• Eligibility Certification Statement (CMS-138)• Copy of the tax return

• Birth Certificate required, and a• Letter from licensed physician detailing the dependent’s limitations, appropriate

ICD diagnosis code, capabilities, date of onset of condition, and a• Statement from the Social Security Administration with the Social Security

disability determination, and a• Copy of the Medicare card, and the• Eligibility Certification Statement (CMS-138)• Copy of the tax return

• Court Order with judge’s signature and circuit clerk’s file stamp

• Birth Certificate required

• Birth Certificate required, and • Proof of organ transplant performed after June 30, 2000, and the • Eligibility Certification Statement (CMS-138)• Copy of the tax return for dependents 26 and older

• Marriage Certificate or tax return• Civil Union Partnership Certificate. A tax return is also required if claiming the

civil union partner as a dependent.

• Birth Certificate required, and • Marriage or Civil Union Partnership Certificate indicating the employee is

married to, or the partner of, the child’s parent. A tax return is also required ifclaiming the civil union partner’s child as a dependent.

Note: Birth Certificate from either the State or admitting hospital which indicates the employee is the parent is acceptable.

* A valid social security number (SSN) is required to add dependent coverage. If the SSN has not yet been issued for a newborn or adopted child, the child will beadded to the employee’s coverage upon receipt of the birth certificate or adoption order without the SSN. The employee must provide the SSN within 90 days of thedate the coverage was requested in order to continue the dependent's coverage.

Documentation Requirements – Adding Dependent Coverage*


qualifying Event

Divorce, Dissolution of Civil Union Partnership or Annulment

Legal Separation

Loss of Court-Ordered Custody

Dependent Becomes Ineligible for GroupInsurance Coverage

Domestic Partner Ineligible or Relationship Terminates

Supporting Documentation Required

Divorce Decree or Judgment of Dissolution or Annulment filed in a U.S. Court– first and last pages with judge’s signature with circuit clerk’s file stamp.

Court Order with judge’s signature with circuit clerk’s file stamp.

Court Order indicating the employee no longer has custody of the dependent.The order must have judge’s signature with circuit clerk’s file stamp.

Email or signed memorandum from the employee indicating the dependent’sname, the reason for the termination and the effective date of the termination.

Domestic Partner Termination Form (available on the Benefits website).

Documentation Requirements – Terminating Dependent Coverage

When adding Dependent coverage due to or during the:

Initial Enrollment Period

Annual Benefit Choice Period(Normally held May 1 – May 31 each year)

qualifying Change in Status (Exception for birth or adoption – noted below)

Birth of Child (Natural or Adopted)

Adopted Children (Other than newborn)

If the coverage is requested…

Day 1 – 10 after hire date

During the Benefit Choice Period

Before, or the day of,the event

Day 1 – 60 after event

From birth up to 60 days after the birth

Within 60 days of theevent

And if the documentation is provided…

1 – 15 days after hiredate

Within 10 days of theBenefit Choice Periodending

1 – 60 days after theevent

From birth to 60 daysafter the birth

Within 60 days of theevent

Dependent coverage will be effective…

Date of hire

July 1st

Date of the event

Date of the request

Date of birth

Date of placement ofthe child, filing of thepetition or the entry ofthe adoption order

Documentation Time LimitsDependent health, dental and vision coverage may be added with the corresponding effective date when documentation is provided toyour agency GIR within the allowable time frame as indicated below. If documentation is provided outside the time frames, addingdependent coverage will not be allowed until the next annual Benefit Choice Period or if the employee experiences a qualifying changein status. Refer to the ‘Life Insurance Coverage’ section for effective dates of life coverage.

Penalty for FraudFalsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverageunder the Program is considered a fraudulent act. The State of Illinois will impose a financial penalty, including, but notlimited to, repayment of all premiums the State made on behalf of the employee and/or the dependent, as well as expensesincurred by the Program.

DOC. REqUIREMENTSAND TIME LIMITS


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Employees may opt out or waive coverage during

the following periods:

F Initial Enrollment

F Annual Benefit Choice Period

F Qualifying Change in Status (as permitted under theInternal Revenue Code)

Employees who opt out or waive coverage are

not eligible for the:

F Free influenza immunizations offered annually

F COBRA continuation of coverage

F Smoking Cessation Program

However, employees are still eligible for the:

F Flexible Spending Account (FSA) Program

F Commuter Savings Program (CSP)

F Paid Maternity/Paternity Benefit

F Employee Assistance Programs

F Adoption Benefit Program

Opting Out of Coverage(full-time employees only)In accordance with Public Act 92-0600, full-time employeesmay elect to opt out of the health coverage during the InitialEnrollment Period, the annual Benefit Choice Period or uponexperiencing a qualifying change in status. The electionto opt out of the health coverage includes, and willterminate, all employee and dependent health, dental,vision and prescription coverage. The employee will beenrolled in the Program with Basic Life coverage only, andwill remain eligible to elect Optional Life coverage.

Employees who elect to opt out of the Program must provideproof of other major medical insurance by an entity otherthan the Department of Central Management Services.Employees electing to opt out cannot be enrolled as adependent in any plan administered by the Department.

NOTE: An employee’s application for other health coverageis not acceptable proof of other coverage.

Waiver Option(part-time employees only)Eligible part-time employees may elect to waive coveragewhen they are required to pay a portion of the employer-paidcontribution. These employees may waive their coverageduring the Initial Enrollment Period, the annual BenefitChoice Period or upon experiencing a qualifying change instatus. Part-time employees may not waive coverage andbecome a dependent of their State-employed spouse orcivil union partner.

The election to waive coverage remains in effect until theeligible employee becomes full-time, elects to enroll duringthe next annual Benefit Choice Period or experiences aqualifying change in status.

Exception: Part-time employees who waived all coverageprior to July 1, 2003, and who have been continuouslyenrolled on their State-covered spouse’s coverage, maycontinue to waive coverage and be covered as adependent. This group of part-time employees is noteligible for life insurance coverage as a member.

Employees on Leave of AbsenceWaiving CoverageEmployees (full and part-time) on a leave of absence forwhich they are required to pay 100% of the cost of coverage(i.e., employee contribution plus the State’s contribution)have the option to waive health and dental coverage, aswell as drop any or all life coverage (including Basic Life,Member Optional Life, AD&D, Spouse Life and Child Life).The request to waive coverage must be made within 60days of the leave effective date. The effective date of thewaiver will be the date of the event or the date of therequest, whichever is later.

Full-time EmployeesThe election to waive coverage remains in effect until thefirst day of the pay period following the date the eligible full-time employee physically returns to work. The employeewill be reinstated with Basic Life coverage and the sameemployee health and dental coverage that they had prior togoing on the leave. Eligibility to be enrolled as adependent of their spouse or civil union partner ceasesupon the employee’s physical return to work; therefore,

Opt Out and Waiver of Coverage


coverage for these members will be effective the date ofthe physical return to work.

Part-time Employees

The election to waive coverage remains in effect until the

eligible part-time employee physically returns to work and

requests coverage.

Part-time employees who were enrolled in the Programprior to the leave and who request their coverage bereinstated upon returning to work will be reinstated withBasic Life coverage and the same health and dentalcoverage that they had prior to going on the leave. Therequest must be made within 60 days of the physical returnto work and will be effective the first day of the pay periodfollowing the date of the request for coverage.

Reinstating Dependent CoverageDependent coverage is not automatically reinstated uponthe employee’s return to work. Employees who would liketo have their dependent coverage reinstated must requestthe coverage within 60 days of returning to work.Coverage will be effective the date of the event (i.e., thephysical return to work) or the date of the request,whichever is later.

Special Provisions when BothSpouses or Civil Union Partnersare State MembersEmployees whose spouse or civil union partner has coveragethrough the State may elect to become a dependent oftheir State-covered spouse or civil union partner while theyare on a leave of absence only if the employee on theleave is required to pay 100% of the cost of coverage (i.e.,employee contribution plus the State’s contribution).Employees electing this option must waive all coverage,including health, dental, Basic Life and all Optional Lifecoverage. Eligibility to be enrolled as a dependentceases upon the employee’s physical return to work.

Reinstating Member Optional Life Coverage. In order toreinstate Member Optional Life coverage upon returning towork without being subject to statement of health approval,the spouse or civil union partner who was not on the leavemust have elected Spouse Life coverage while theirspouse or civil union partner was on the leave of absence.

Transferring Dependent Coverage. Any dependents thatare covered by the spouse or civil union partner who isgoing on the leave of absence may be transferred to theother’s coverage or dropped from coverage if requestedwithin 60 days of beginning the leave.

NOTE: Upon the employee’s return to work, the dependentcoverage will remain under the state-employed spouse orcivil union partner. Dependent coverage may be movedback to the original member’s coverage as long as themove is requested within 60 days of the employee’sphysical return to work date.

Opt Out and Waiver of Coverage (cont.)

Penalty for FraudFalsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverageunder the Program is considered a fraudulent act. The State of Illinois will impose a financial penalty, including, but notlimited to, repayment of all premiums the State made on behalf of the employee and/or dependent, as well as expensesincurred by the Program.

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The State covers the majority of the cost of health and dentalinsurance coverage and all of the cost of vision and Basic Lifeinsurance coverage for most employees. Employees areresponsible for a salary-based contribution for health insurance,as well as an additional cost for any optional coverage elected,including dental, life and dependent coverage.

Salary-based contributions, as well as the premiums foroptional coverage, are established annually and reflected in theBenefit Choice Options booklet. These contributions/premiumsare subject to change each plan year and are effective July 1st.It is each employee’s responsibility to verify the accuracyof premiums paid, whether payroll deducted or directbilled, and to notify the GIR of any errors.

Employee Contributions

Salary-Based Contribution

All employees are responsible for a salary-basedcontribution for health insurance coverage. The amountrequired is contingent upon the:

F employee’s status (i.e., full-time, part-time or leave ofabsence),

F type of health plan elected (i.e., managed care plan orthe Quality Care Health Plan),

F employee’s annual salary as of the preceding April 1st and

F coverage elections in effect on the first day of the payperiod.

This salary-based contribution will remain in effectthroughout the plan year (July 1 through June 30) unless theemployee (1) retires, (2) accepts a voluntary salary reductionor (3) returns to State employment at a different salary.Returning to work at a different salary applies to employeeswho return to work after having a 10-day or greater break inState service after terminating employment and does notapply to employees who return from a leave of absence.

NOTE: Employees who are off payroll may be responsiblefor additional premium amounts (see the ‘Time Away fromWork’ section for more information).

Premiums will not be prorated if an employee changestheir coverage elections or terminates from the Programon a day other than the first day of the pay period.

Optional Coverage Contributions

All employees are responsible for a portion of the cost ofelective dental and dependent coverage, as well as the fullcost of any Optional Life coverage.

Special provisions apply for the following types ofdependents if they cannot be claimed as a dependentunder the IRS tax code: adult veteran children age 26through age 29, domestic partners, civil union partners andchildren of civil union partners. All premiums for non-IRStax dependents must be paid on a post-tax basis.

F The premium for a non-IRS domestic partner, anon-IRS civil union partner or the non-IRSchild(ren) of a civil union partner, is the ‘OneDependent’ or ‘Two or More Dependent’ ratedepending on the number of non-IRS dependents inthese categories being covered.

F The premium for a non-IRS adult veteran child ages26 through 29 is 100% of the cost of coverage(employee portion plus the State contribution).

The value of the coverage for a domestic partner, civilunion partner and any children of the civil union partner isconsidered “imputed income” and will be reported asincome at the end of each calendar year. The premiumsfor these dependents and imputed income amounts areindicated in the Domestic Partner/Civil Union Partner FAQlocated on the Benefits website.

Full-time Employees

The salary-based contribution and optional coverage premiumsfor full-time active employees are payroll deducted.

Part-time Employees

In addition to the salary-based contribution required of allemployees, part-time employees participating in the Programare required to pay a portion of the State’s cost for health,dental and any dependent coverage. The portion the Statecontributes is the same percentage that the employee works.

For example, for a 75% part-time employee, the State willcontribute 75% of the State’s cost and the employee will beresponsible for the remaining 25% of the State’s cost, inaddition to the employee’s salary-based contribution.

Premium Payment


Part-time employees should check with their GroupInsurance Representative (GIR) to determine the exactpremium contribution required.

Premiums for most part-time active employees are payrolldeducted. There are certain part-time employees,including employees whose paycheck is not sufficient todeduct the part-time premiums or whose agency/universitycannot payroll deduct part-time premiums, which must bedirect billed by the Department.

Employees in Nonpay Status

Employees who are in nonpay status on the first work dayof a pay period will be direct billed by the Department.

Additionally, employees in dock/suspension status greaterthan 30 calendar days, regardless of whether the days wereconsecutive or intermittent, will be billed by the Departmentfor every pay period in which time in nonpay status occurs.

Employees Direct Billed by theDepartment

Billing Procedure and Time Frames

The Department bills the following:

F Employees on a leave of absence.

F Employees in a dock or suspension status.

F Employees on a voluntary furlough.

F Employees who have returned to work on a reducedwork schedule due to a medical condition and have adoctor’s statement.

F Employees who are working a reduced work scheduledue to a FMLA-protected family situation.

F Part-time employees who work for an agency or universitythat cannot payroll deduct premiums.

F Part-time employees whose paycheck is not sufficientto payroll deduct premiums.

F Military employees who are not receiving a paycheckor whose paycheck is not sufficient to payroll deductpremiums.

F Employees on an emergency appointment and formerGeneral Assembly employees.

A bill will be generated by the Department for the premiumamount due. Bills are generated and mailed the first week ofeach month. Payment must be made by the final due date toensure continuation of coverage. Employees who do notreceive a bill within 30 days of going off payroll should contacttheir agency GIR or the Department at (800) 442-1300.

Nonpayment of Premium

If payment is not received by the due date on the finalbilling notice, the Department will exercise its right underthe State Comptroller’s Act to collect delinquent groupinsurance premiums through involuntary withholding.Coverage may be terminated depending on the employee’swork status, as indicated below:

F Employees who have physically returned to theirnormal work schedule from a leave of absence willnot have their insurance coverage terminated; however,they remain responsible for all outstanding premiums.An order of involuntary withholding will be filed to collectthe amount owed.

Employees who return to their normal work scheduleafter coverage has been terminated will have member-only health, dental and Basic Life coverage reinstated.The effective date of coverage will be the date theemployee physically returns to work.

F Employees who have not returned to work, or whohave not returned to their normal work schedule,will have their insurance coverage terminated effectivethe first day of the month following the final billingnotice. An order of involuntary withholding will be filedat the time the coverage is terminated.

Coverage may be reinstated as long as all current andpast due premiums are received within 6 months of thedate the coverage was terminated.

Employees who return to work within 10 days of thecoverage being terminated will have their coveragereinstated with no break. These employees areresponsible for the premiums due for that pay period.

Premium Payment (cont.)

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Premium Payment (cont.)

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F Part-time employees who are direct billed (becausetheir payroll cannot deduct part-time premiums) willhave their insurance coverage terminated effective thefirst day of the month following the final billing notice. Anorder of involuntary withholding will be filed to collect theamount owed. These employees may elect to re-enrollin the Program during the next Benefit Choice Period aslong as all outstanding premiums have been paid.

Dependent coverage terminated due to nonpayment ofpremium will not be automatically reinstated. Refer to“Enrollment Periods” for re-enrollment opportunities fordependent coverage.

NOTE: Employees and/or their dependents who have hadcoverage terminated for nonpayment of premium are noteligible to be covered under another member, nor are theyeligible for coverage at retirement or through COBRA.

COBRA Participants

While a plan participant is on COBRA, a monthly bill isgenerated by the Department for the premium amount due.Bills are mailed the first week of each month and must bepaid by the due date to ensure continuation of coverage.Plan participants who do not receive a bill should contactthe Department for assistance. Failure to submit paymentwill result in termination of coverage retroactive tomidnight the last day of the month for which full paymentwas received.

Premium Refunds

Premium refunds based on corrections to an employee’sinsurance elections may be processed retroactively up tosix months. Employees who fail to notify their GIR within60 days of the dependent’s ineligibility will not receive apremium refund.

Premium Underpayments

Underpaid premiums are the responsibility of the employeeand must be paid in full, regardless of the time period forwhich the underpayment occurred.


Employees who are away from work for reasons including,but not limited to, an agency-approved medical or personalleave of absence, or for disciplinary reasons, continueinsurance coverage through the Program for a specifiedperiod of time. Depending upon the type of leave taken,the employee may be eligible to opt out/waive or modifytheir coverage elections. Employees should refer to the‘Opt Out and Waiver of Coverage’ section for options.

NOTE: Although the personnel office of each agencymust determine the type of leave for which an employeequalifies, the type of leave for group insurance purposesmay differ from what personnel designates. For exam-ple, a Family Responsibility Leave may be designated anFMLA or Personal Leave for insurance purposes.

The Department is responsible for billing employees for theircoverage when the member is off payroll on the first day ofa pay period or who is off payroll at any other time during

the pay period when the employee has dock/suspensiontime greater than 30 days in the fiscal year.

There are several categories of employees that must bebilled by the Department, including:

F Employees on an approved leave of absence.

F Employees in a dock or suspension status.

F Employees who have returned to work on a reducedwork schedule due to a medical condition with a doctor’sstatement.

F Employees who are working a reduced work scheduledue to an FMLA-protected family situation.

Refer to the ‘Premium Payment’ section in this chapterfor information regarding premium payments.

Time Away from Work

The Family Medical Leave Act of 1993 (FMLA) is afederal statute providing 12 weeks of job protection toemployees who are off work due to their own serioushealth condition, to care for a family member with aserious health condition, for the birth of a child, or tocare for or bond with a newborn, foster or adopted child.Family members under the nonmilitary provisions ofFMLA include a spouse, parent, son or daughter(biological, adopted, foster, stepchild, legal ward orchild of a person standing in loco parentis) who is under18 years of age, or who is 18 years of age or older andincapable of self care because of a mental or physicaldisability. Grandparents, siblings, in-laws, aunts/uncles,civil union partners and domestic partners do not countas family members, unless there is an in loco parentisrelationship.

FMLA also provides 12 weeks of job protection whenan employee misses work to address certain qualifyingexigencies arising out of the fact that the employee’sspouse, son, daughter or parent has been called to, oris on, active duty as a covered service member. Aparent, spouse, child or next of kin of a covered militaryservice member who is injured or becomes ill in the lineof duty is provided with 26 weeks of job protection.

While on an FMLA-qualifying leave of absence, theState continues to make the employer contributiontoward the insurance coverage. In order to qualify for

FMLA protection, employees must have beenemployed by the State for at least 12 months, haveworked at least 1250 hours over the 12 months priorto taking the leave and cannot have used all of theirallotted FMLA coverage for the same condition orany other FMLA covered condition in the preceding12 months.

For purposes of calculating the length of time the Statewill continue the employer contribution toward theinsurance coverage, the time period begins the day theemployee physically leaves work for an FMLA-qualifying reason. This period includes all time awayfrom work, including paid and unpaid time off, i.e.,vacation, sick, personal, maternity/paternity and dockand leave time taken for an FMLA-qualifying reason.The FMLA protection runs concurrent with any othertime away from work, whether paid or unpaid.

Full-time employees using intermittent FMLA are limitedto 12 workweeks of leave in which the State maintainsthe employer contribution and may choose this time aspaid or unpaid. Part-time employees are also entitledto 12 workweeks; however, the number of hours theyare eligible for is based on the average number ofhours they work per week. For example, a part-timeemployee who works 30 hours per week would beeligible for 360 hours of FMLA benefits (12 workweeksx 30 hours).

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Employees on any of the following approved leave typescontinue to pay the employee contribution while the Statemaintains the employer contribution for a specified period.A physical return to work of one pay period or less, or areturn to payroll in order to pay out benefit time (such assick or vacation time), does not extend the maximum lengthof the employer contribution. Refer to the ‘Time Away fromWork’ chart later in this section to determine the maximumlength of the employer contribution.

Employer Contributes to Cost of Coverage

• Disability Leaves (Nonoccupational and Occupational)

• Medical or Bonding Family Leave

• Military Caregiver or Qualifying Exigency Family Leave

• Educational/Sabbatical Leave

• Seasonal Leave

• Military Leave (activation)

• University Annual Break

• Dock or Suspension Status (limited to the first 30 calendar days)

Employee Responsible for All Contributions

• Family Leave Nonmedical

• Personal/General Leave

• Dock or Suspension Status(after the first 30 calendar days)

• Military Family Leave (when employee is the spouse, civil union partner or parentof a military person)

• Military Leave (deactivation)

Disability Leaves of AbsenceEmployees who are eligible for Medicare benefits arerequired to notify the State of Illinois MedicareCoordination of Benefits (COB) Unit. Failure to notify theMedicare COB Unit of Medicare eligibility may result insubstantial financial liabilities. Refer to the ‘Medicare’section for contact information for the Medicare COB Unit.

Occupational Disability (receiving Workers’Compensation benefits)

F Eligible for the Employer Contribution

F FMLA may apply

Employees are eligible for the employer contribution towardtheir group insurance coverage for as long as they arereceiving occupational disability benefits through Workers’Compensation. Part-time employees on an OccupationalDisability Leave electing to remain in the Group InsuranceProgram are treated as full-time for insurance premiumpurposes.

Employees approved by their personnel office for a disabilityleave who return to work on a reduced schedule due toa medical condition may be eligible for a benefit that allowsthem to continue coverage for a certain period of time withno change in premium. Employees must continue to provideacceptable medical documentation to their personnel officein order to be eligible for this benefit.

Employees who return to work on a reduced schedulecontinue to directly pay premiums to the Department.Employees should contact the Department if they havequestions regarding the cost of the coverage or the maximumtime frame that the employer contribution may continue.

NOTE: Workers’ Compensation only pays for medicalexpenses associated with the job-related injury/illness.Employees on an Occupational Disability Leave mustcontinue to pay the employee portion of insurancepremiums to the Department to ensure that any nonworkrelated illnesses or injuries of the employee and anydependents are covered.

Nonoccupational Disability


F FMLA may apply

Employees on an agency-approved NonoccupationalDisability Leave receiving a disability benefit check froma retirement system are eligible for the employercontribution as long as the employee is receiving disabilitybenefits from a retirement system.

Employees on an agency-approved NonoccupationalDisability Leave not receiving a disability benefit checkfrom a retirement system are eligible for the employercontribution for up to 24 months. At the end of the 24-month

Time Away from Work (cont.)

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period, the employee will be terminated from the GroupInsurance Program and offered COBRA.

NOTE: If an employee receives a benefit check fromWorkers’ Compensation or a disability check from aretirement system for less than 24 months, but remains onan agency-approved Nonoccupational Disability Leave afterthe benefit ends, the employee is eligible for the employercontribution for the remainder of the 24 months.

Employees approved by their personnel office for adisability leave who return to work on a reducedschedule due to a medical condition and are no longerreceiving a disability benefit may be eligible for a benefitthat allows them to continue coverage for a certain periodof time with no change in premium. Employees mustcontinue to provide acceptable medical documentation totheir personnel office in order to be eligible for this benefit.

Employees who return to work on a reduced schedulecontinue to directly pay premiums to the Department.Employees should contact the Department if they havequestions regarding the cost of the coverage or the maximumtime frame that the employer contribution may continue.

Family Leaves of AbsenceMedical or Bonding Family Leave


F FMLA may apply

Employees on an agency-approved family leave are eligiblefor the employer contribution toward their group insurancecoverage. The length of the employer contribution periodvaries – see the ‘Time Away from Work’ chart for details.

The following reasons qualify for a Medical or BondingFamily Leave.

• A leave taken to care for a temporarily disabled, incapacitatedor bedridden spouse, civil union partner, child or parentwith a serious health condition;

• A leave taken for the employee to care for a spouse, civilunion partner, child or parent in extraordinary need ofmedical or health care due to a serious health condition;

• A leave taken to provide nursing and/or custodial care for orto bond with the employee’s newborn or newly adopted child.

NOTE: FMLA does not apply to civil union partners or theirchildren, unless the child is also the employee’s child or theemployee stands, or intends to stand, in loco parentis tothe child.

Employees who return to work on a reduced scheduleor begin working a reduced schedule that is approvedby their personnel office for a Medical or Bonding FamilyLeave may be eligible for a benefit that allows them tocontinue coverage for a certain period of time with nochange in premium. Employees must continue to provideacceptable medical documentation to their personnel officein order to be eligible for this benefit.

Employees who return to work on a reduced schedulecontinue to directly pay premiums to the Department.Employees should contact the Department if they havequestions regarding the cost of the coverage or the maximumtime frame allowed for the employer contribution.

Military Caregiver or Military Qualifying ExigencyFamily Leave


F FMLA may apply

Employees on an agency-approved family leave who are offwork to care for a military member with a serious healthcondition or to address certain qualifying exigencies arisingout of the fact that the employee’s spouse, civil union partner,son, daughter or parent has been called to or is on coveredactive duty as a military member and is deployed to a foreigncountry are eligible for the employer contribution toward theirgroup insurance coverage. The length of the employercontribution period varies (see ‘Time Away from Work’ chart inthis section).

Military Family Leave (when employee is thespouse/parent/civil union partner of a military person)

F Not Eligible for the Employer Contribution

F FMLA Does Not Apply

Employees who do not meet the FMLA qualifyingrequirements may request an unpaid agency-approvedfamily leave for a period of up to 30 days for a reasonarising out of the fact that the employee’s spouse, civil unionpartner, son, daughter has been called to or is on coveredactive duty as a military member. These employees are noteligible for the employer contribution toward their groupinsurance coverage while on the unpaid leave.


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Nonmedical Family Leave



The family leave reasons listed below are not medical orhealthcare related and therefore do not qualify for FMLAprotection. Employees on a Nonmedical Family Leave areeligible to continue coverage in the Program for up to 24months provided the employee pays 100% of the employeeand employer contribution.

• A leave taken to respond to the temporary dislocation ofthe family due to a natural disaster, crime, insurrection,war or other disruptive event;

• A leave taken to settle the estate of a deceased memberof the employee’s family or to act as conservator if soappointed and providing the exercise of such functionsprecludes the employee from working;

• A leave taken to perform family responsibilities.

Other Leaves of AbsencePersonal/General Leave



Employees on an agency-approved Personal Leave areeligible to participate in the Group Insurance Program for amaximum of 24 months. Employees on a Personal Leaveare not eligible for the employer contribution; therefore,continued participation will be entirely at the employee’sexpense. If the employee does not return to work at theend of the 24-month period, coverage will be terminatedand the employee will be offered COBRA.

Employees who are granted a part-time or intermittentPersonal Leave will be considered a part-time employee forpremium purposes (see ‘Part-time Employees’ in the‘Premium Payment’ section). If the employee’s intermittentwork schedule is less than 50%, the employee will be placedon a Personal Leave and will be responsible for the entireamount of the employee and employer contribution.

Educational/Sabbatical Leave



Employees on an agency-approved, work-relatedEducational Leave are eligible for the employer contributionfor a 24-month lifetime benefit. Employees receiving apartial salary while on the leave are still considered as beingon a leave of absence for group insurance purposes andwill be billed by the Department. Employees who arereceiving full pay (100% of their regular salary) are notconsidered as being on a Sabbatical Leave for groupinsurance purposes.

For purposes of calculating the 24-month lifetime benefit,only the time spent on the Educational/Sabbatical Leave iscounted. For example, an employee who is on a 50%Educational/Sabbatical Leave and is working the other50% of the time for one year has used only six months ofthe lifetime benefit. If the employee does not return to workat the end of the 24-month period, coverage will be terminatedand the employee will be offered COBRA.

Dock and Suspension Time

F Eligible for the Employer Contribution for up to 30 calendar days per fiscal year

F FMLA may apply *

For insurance purposes, dock time is any unpaid absencefrom work, whether authorized (excused) or unauthorized(unexcused); whereas, a suspension is any absence fromwork for disciplinary reasons.

Employees in dock or suspension status are eligible for theemployer contribution for up to 30 calendar days per fiscalyear. Once the 30 days have been exhausted, employeesare no longer eligible for the employer contribution and mustpay 100% of the cost of the coverage for each applicable payperiod in which nonpay status occurs. The 30 calendar dayperiod does not reset for dock/suspension time that continuespast June 30th until the employee physically returns to work.

* FMLA protection may apply when dock days are takenfor an FMLA-qualifying reason.


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Voluntary Furlough

F Eligible for the Employer Contribution for up to 30 instances per fiscal year

F FMLA may apply *

Employees in voluntary furlough status are eligible for theemployer contribution for up to 30 instances per fiscal year.Once the 30 instances have been exhausted, employees areno longer eligible for the employer contribution and must pay100% of the cost of the coverage for each applicable payperiod in which nonpay status occurs. The 30 instances donot reset for voluntary furlough time that continues past June30th until the employee physically returns to work.

* FMLA protection may apply when furlough days aretaken for an FMLA-qualifying reason.

Seasonal Leave



Part-time agency and university seasonal workers on anagency-approved seasonal leave are required to pay thesame premium on leave as when actively working. Themaximum period for this type of leave is 6 months. Coveragewill be terminated at the end of the 6 month period if theemployee has not returned to work.

University Annual Break



Full-time faculty and academic year nonfaculty employeespay the same premium during the summer break period aswhen actively working. The maximum period for this typeof leave is 3 months. If the employee has not returned towork by September 1st, coverage will be terminated effectiveSeptember 1st.

Military Leave (Activation)



Employees who are on a military-connected leave forreasons that include basic training, special/advanced training,

annual training, emergency call up by the President orGovernor or any other training or duty in service to theUnited States Armed Forces are eligible for the employercontribution for their group insurance coverage while on theleave. The duration of the coverage will coincide with thelength of the time specified on the orders.

Military Leave (Deactivation)



Employees who have been released from covered activeduty are entitled to 90 days of group insurance coverageunder Uniformed Services Employment and Re-employmentRights Act (USERRA). These employees are not eligible forthe employer contribution toward their group insurancecoverage while using unpaid time for their leave.

Furlough (ISD/ISVI only)



Certain employees, as defined in the AFSCME contract,who work for the Illinois School for the Deaf and IllinoisSchool for the Visually Impaired, and their dependents,receive premium-free health, dental and life coveragethrough the summer months. If the employee has notreturned to work by September 1st, coverage will beterminated effective September 1st.

Permanent Layoff

Employees who have been permanently laid off may beeligible for 6 – 24 months of premium-free coverageequivalent to the coverage that was in place on the datepreceding the layoff. Employees should contact their GroupInsurance Representative (GIR) to ascertain if they areeligible for the premium-free coverage.

Employees who do not qualify for the premium-freecoverage have the option to continue health, dental andvision coverage under COBRA. Life insurance coveragemay be continued for one year entirely at the employee’sexpense. If interested in continuing life insurance coverage,the employee should contact their GIR.


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F In order to receive the employer contribution, the employeemust not only meet FMLA eligibility requirements andqualify for the leave with an FMLA-qualifying reason, butalso cannot have exhausted his/her annual 12 weeks ofFMLA protection.

F All time away from work categories listed below may runconcurrently for FMLA purposes.

NOT FMLA ProtectedFMLA Protected

Time Away from Work Chart

Time Away from WorkCategory

Family Leave * – Medical/Bonding is a leave that ismedical in nature and/or tocare for or to bond with anewborn or newly adoptedchild. Employees whoreturn to work on a reducedschedule are also eligible forthis leave.

Family Leave * – MilitaryCaregiver

Family Leave * – Militaryqualifying Exigency

Nonoccupational Disabilityreceiving a disability check

Nonoccupational Disabilitynot receiving a disability check

Nonoccupational Disabilitynot receiving a disability checkand on a reduced schedule(cannot exceed the 24 month maximum benefit for a Nonoccupational Leave)

Occupational Disability, includes employees who return to work on a reducedschedule

State MaintainsEmployer

Contribution

YES(no State

contribution ifthe leave is tocare for a civilunion partner)

YES

YES

YES

YES

YES

YES

MaximumCoverage

Period

12 weeks(agencies not

under the Governor)

6 months(agenciesunder the Governor)

26 weeks

12 weeks

n/a

24 months

3 months

n/a

Time Away from WorkCategory

Family Leave – Not MedicalRelated (or Family Leavecoverage period expired orFMLA eligibility requirementswere not met)

Military Family Leavecan run concurrent with FMLA

Military Leave (Activation)

Military Leave (Deactivation)

Permanent Layoff

Furlough (ISD/ISVI only)

Voluntary Furlough ≤ 30 instances **

Voluntary Furlough > 30 instances **

Personal/General Leave

Dock/Suspension ≤ 30 days **

Dock/Suspension > 30 days **

Seasonal Leave

University Annual Break

Educational/Sabbatical (must be work related)

State MaintainsEmployer

Contribution

NO

NO

YES

NO

VARIES

YES

YES

NO

NO

YES

NO

YES

YES

YES

MaximumCoverage

Period

24 months

30 days

n/a

90 days

24 months

4 months

30 instances

n/a

24 months

30 days

24 months

6 months

3 – 6 months

24 monthslifetime

* When both spouses are employees, time taken by either spouse accumulates toward the maximum coverage period. ** FMLA protection may apply when unpaid time is taken for an FMLA-qualifying reason.

A physical return to work of one pay period or less, or a return to payroll in order to pay out benefit time (such as sick or vacation time),does not extend the maximum length of the employer contribution.

If the ‘State Maintains Employer Contribution’ column indicates ‘Yes’, that means the State will continue to pay the same portionof the premium as when the employee was active on payroll. An exception is made for part-time employees on an OccupationalDisability leave, in which case the employee will be treated the same as a full-time employee for insurance purposes.

If the ‘State Maintains Employer Contribution’ column indicates ‘No’, that means the employee is required to pay 100% of theState and employee portions of the premium.

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This section describes the events and timing of thetermination of benefits. In most cases, health, dental andvision insurance coverage can be continued under theConsolidated Omnibus Budget Reconciliation Act (COBRA).Employees may be eligible to continue life insurancecoverage under portability and conversion options. See the‘Life Insurance Coverage’ section in Chapter 2 for details.

Termination ofEmployee CoverageAn employee’s coverage terminates at midnight:

F On the date of termination of State employment. Thedate of termination is not extended by any type of lumpsum payment.

F On the day in which a change to less than 50% part-time employment status occurs. This applies to anyemployee who actually works less than 50% of anormal work period, measured yearly, regardless ofclassification as full-time or part-time.

F On the date of the employee’s death.

F On the last day of the month in which payment is notreceived following the issuance of a final notice ofpremium due from the Department (employee and alldependents will be ineligible for COBRA).

F On the date that the maximum period allowed forpermanent layoff is reached as defined in the ‘TimeAway from Work’ section.

F On the date that the maximum period allowed for aleave of absence is reached as defined in the ‘TimeAway from Work’ section. NOTE: Coverage will notterminate for employees whose FMLA-qualifying leaveof absence reaches the maximum coverage period.Instead, these employees will be changed to being ona Personal/General leave of absence.

Termination of Dependent CoverageAn enrolled dependent’s coverage terminates at midnight:

F Simultaneous with termination of employee’s coverage.

F On the last day of the month in which a dependentloses eligibility.

F On June 30th for dependents who are voluntarilyterminated during the Benefit Choice Period (thesedependents will be ineligible for COBRA).

F On the requested date of a voluntary termination of adependent (these dependents will be ineligible for COBRA).

F On the date of dependent’s death.

F On the last day of the month in which the employee failsto certify continued eligibility for coverage of thedependent child.

F On the day preceding the dependent's:

– enrollment in the Program as a member.

– divorce or civil union partnership dissolution from theemployee. The divorce or civil union partnershipdissolution terminates the coverage for the spouse orcivil union partner and all applicable stepchildren orchildren of the civil union partner.

NOTE: Employees who fail to notify their GIR within 60days of the dependent’s ineligibility will not receive apremium refund, nor will the dependent be eligible forCOBRA.

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Termination


OverviewThe Consolidated Omnibus Budget Reconciliation Act of1985 (COBRA) and Sections 367.2, 367e and 367e.1 ofthe Illinois Insurance Code provides eligible coveredemployees and their eligible dependents the opportunity totemporarily extend their health coverage when coverageunder the health plan would otherwise end due to certainqualifying events. COBRA rights are restricted to certainconditions under which coverage is lost. The election tocontinue coverage must be made within a specifiedelection period. If elected, coverage will be reinstatedretroactive to the date following termination of coverage.

An initial notice is provided to all new employees uponenrollment in the Group Insurance Program. This notice isto acquaint individuals with COBRA law, notificationobligations and possible rights to COBRA coverage if lossof group health coverage should occur. If an initial notice isnot received, employees should contact their GroupInsurance Representative (GIR).

EligibilityCovered employees and dependents who lose coveragedue to certain qualifying events (see the ‘COBRA QualifyingEvents’ chart at the end of this section) are consideredqualified beneficiaries and may be allowed to continuecoverage under the provisions of COBRA. A qualifiedbeneficiary is an individual (including employee, spouse, civilunion partner, domestic partner or child) who loses employer-provided group health coverage and is entitled to electCOBRA coverage. The individual must have been coveredby the plan on the day before the qualifying event occurredand enrolled in COBRA effective the first day of eligibility orbe a newborn or newly adopted child of the coveredemployee. COBRA coverage is also available for memberswho are already enrolled in Medicare or in other groupinsurance coverage. Any voluntary termination ofcoverage will render the employee and any dependentsineligible for COBRA coverage.

Coverage available under COBRA for qualified beneficiariesis identical to the health, dental and vision insurance coverageprovided to employees. Individuals converting to COBRAwho elected not to participate in the dental plan prior tobecoming eligible for COBRA may not enroll in the dentalplan until the annual Benefit Choice Period. The life insurance

coverage in force on the date of termination is not availablethrough COBRA; however, the employee and/or dependentmay be eligible to convert or port their life insurance coverage.See the Life Insurance Coverage Certificate for details.

Covered dependents retain COBRA eligibility rights even ifthe employee chooses not to enroll. Qualified beneficiarieselecting continuation of coverage under COBRA will beenrolled as a member. NOTE: If the employee’s spouse,civil union partner or dependent child(ren) live at anotheraddress, the Department must be advised immediatelyso that notification can be sent to the proper address(es).

Employees who are terminated for gross misconduct orwho have opted out or waived health, dental and visioninsurance coverage, and their dependents, are not eligibleto participate in COBRA.

Notification of COBRA EligibilityThe employee or qualified beneficiary must notify theagency GIR within 60 days of the date of the terminationevent, or the date on which coverage would end, whicheveris earlier. Failure to notify the GIR within 60 days will resultin disqualification of COBRA continuation coverage.

The Department will send a letter to the qualified beneficiaryregarding COBRA rights within 14 days of receiving notificationfrom the GIR of the termination. Included with the letter willbe an enrollment form, premium payment information andimportant deadlines. If a letter is not received within 30 daysand you notified your GIR within the 60-day period, youshould contact the Department immediately for information.

COBRA EnrollmentIndividuals have 60 days from the date of the COBRAeligibility letter to elect enrollment in COBRA and 45 daysfrom the date of election to pay all premiums. Failure tocomplete and return the enrollment form or to submitpayment by the due dates will terminate COBRA rights. Ifthe enrollment form and all required payments are receivedby the due dates, coverage will be reinstated retroactive tothe date of the qualifying event.

COBRA Coverage

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Medicare or Other GroupCoverage - Impact on COBRAQualified beneficiaries who become eligible for Medicare orobtain other group insurance coverage (which does notimpose preexisting condition limitations or exclusions) afterenrolling in COBRA are required to notify the Department inwriting of their Medicare eligibility or other group coverage.These individuals are ineligible to continue COBRAcoverage and will be terminated from the COBRA program.

The Department reserves the right to retroactivelyterminate COBRA coverage if an individual is deemedineligible. Premiums will not be refunded for coverageterminated retroactively due to ineligibility.

COBRA ExtensionsF Disability Extension

Qualified beneficiaries covered under COBRA who havebeen determined to be disabled by the Social SecurityAdministration (SSA) may be eligible to extend coveragefrom 18 months to 29 months at an increased cost.Enrolled nondisabled family members are also eligiblefor the extension. See ‘Premium Payment under COBRA’later in this section for premium information.

To be eligible for the extension, the qualified beneficiarymust either (1) become disabled during the first 60 daysof COBRA continuation coverage or (2) been determineddisabled prior to the date of COBRA eligibility. In eithercase, the determination must have been made by theSocial Security Administration (SSA) and a copy of theSSA determination letter must be submitted to theDepartment within 60 days of the date of the SSAdetermination letter or the first day of COBRA coverage,whichever is later.

The affected qualified beneficiary must also notify theDepartment of any SSA final determination loss ofdisability status. This notification must be providedwithin 30 days of the SSA determination letter.

F Second qualifying Event Extension

If an employee who experienced a qualifying event thatresulted in an 18-month maximum continuation periodexperiences a second qualifying event before the endof the original 18-month COBRA coverage period, the

spouse, civil union partner, domestic partner and/ordependent child (must be a qualified beneficiary) mayextend coverage an additional 18 months for amaximum of 36 months.

Waiver of COBRA Rights andRevocation of that WaiverA qualified beneficiary may waive rights to COBRA coverageduring the 60-day election period and can revoke the waiverat any time before the end of the 60-day period. Coveragewill be retroactive to the qualifying event.

Premium Payment under COBRAThe qualified beneficiary has 45 days from the date coverageis elected to pay all premiums. Individuals electing COBRAare considered members and will be charged the memberrate. A divorced or widowed spouse (including a former civilunion partner) who has a dependent child on their coveragewould be considered the member and charged the memberrate, with the child being charged the applicable dependentrate. If only a dependent child elects COBRA, then eachchild would be considered a member and charged themember rate.

Once the COBRA enrollment form is received by theDepartment and the premium is paid, coverage will bereinstated retroactive to the date coverage was terminated.The Department will mail monthly billing statements to themember’s address on file on or about the 5th of eachmonth. Bills for the current month are due by the 25th ofthe same month. Final notice bills (those with a balancefrom a previous month) are due by the 20th of the samemonth. Failure to pay the premium by the final due datewill result in termination of coverage retroactive to the lastday of the month in which premiums were paid.

It is the member’s responsibility to promptly notify theDepartment in writing of any address change or billingproblem.

The State does not contribute to the premium for COBRAcoverage. Most COBRA members must pay the applicablepremium plus a 2% administrative fee for participation. COBRAmembers who extend coverage for 29 months due to SSA’sdetermination of disability must pay the applicable premiumplus a 50% administrative fee for all months coveredbeyond the initial 18 months.

COBRA Coverage (cont.)

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Adding Dependents While onCOBRANewly-acquired dependents, including spouses, civilunion partners, children of civil union partners andstepchildren, may be added to existing COBRA coverage.Even though these dependents are eligible for COBRAcoverage, unless they are a newborn child or newlyadopted child, they are not considered “qualifiedbeneficiaries” and therefore would be ineligible for anextension if a second qualifying event would occur.

Existing dependents who are not enrolled on the first daythe member becomes eligible for COBRA continuationcoverage are not considered qualified beneficiaries. Thesedependents may only be added during the annual BenefitChoice Period and are also not eligible for secondqualifying event extensions.

Documentation requirements must be met to add dependents.See the ‘Documentation Requirements – Adding DependentCoverage’ chart in this chapter for details.

Termination of Coverage underCOBRACOBRA coverage terminates when the earliest ofthe following occurs:

F Maximum continuation period ends.

F Failure to make timely payment of premium.

F Covered member or dependent becomes a participantin another group health plan which does not impose apreexisting condition exclusion or limitation (for example,through employment or marriage).

F Covered member or dependent becomes entitled toMedicare. Special rules apply for End-Stage RenalDisease. Contact the Department for more information.

F Covered member or dependent reaches the qualifyingage for Medicare.

F Covered dependent gets divorced from COBRA member(includes when the COBRA member's civil unionpartnership with the covered dependent is dissolved).

F Covered dependent child or domestic partner loseseligibility.

F Upon the member’s death for any dependent notconsidered a qualified beneficiary.

Refer to the ‘COBRA Qualifying Events’ chart in thischapter for more information.

Conversion Privilege for HealthCoverageWhen COBRA coverage terminates, members may havethe right to convert to an individual health plan withoutproviding evidence of insurability. This conversion privilegeapplies to health coverage only. Members are eligible forthis conversion unless group health coverage endedbecause:

F the required premium was not paid, or

F the coverage was replaced by another group healthplan, including Medicare, or

F the COBRA coverage was voluntarily terminated.

Approximately two months before COBRA coverage ends,the Department will send a letter providing instructions onhow to apply for conversion. To be eligible for conversion,members must have been covered by the current COBRAhealth plan for at least 3 months and requested conversionwithin 31 days of exhaustion of COBRA coverage. Theconverted coverage, if issued, will become effective the dayafter COBRA coverage ended. Contact the appropriatehealth plan administrator for information regardingconversion. The Department is not involved in theadministration or premium rate structure of coverageobtained through conversion.


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qualifying Events

EMPLOYEE

Termination of employment for any reason, including layoff, except for gross misconduct

Termination of disability benefits

Maximum leave of absence period expires

Loss of eligibility due to reduction in work hours

DEPENDENT

Employee’s termination of employment for any reason

Employee’s termination of disability benefits

Employee’s maximum leave of absence period expires

Employee’s loss of eligibility due to reduction in work hours

Legal separation from member*

Loss of eligibility as a dependent child or domestic partner

Employee’s death

• Spouse under age 55

• Spouse age 55 or older if already enrolled in Medicare

• Spouse age 55 or older

• Dependent child

• Domestic partner

Dissolution of Marriage or Civil Union Partnership*

• Ex-Spouse under age 55

• Ex-Spouse age 55 or older if already enrolled in Medicare

• Ex-Spouse age 55 or older

• Stepchild or Child of a Civil Union Partner

Maximum Eligibility Period

18 months

18 months

18 months

18 months

18 months

18 months

18 months

18 months

36 months

36 months

36 months

36 months

Until obtains Medicare or reaches the qualifying age for Medicare

36 months

36 months

36 months

36 months


36 months

COBRA qUALIFYING EVENTSA COBRA qualifying event is any of the events shown below that result in a loss of coverage.

The term 'Spouse' in this chart includes civil union partners; 'Ex-spouse' includes civil union partners whose partnership has been dissolved.

* Dropping a spouse’s coverage during the annual Benefit Choice Period in anticipation of a divorce, civil union partnership dissolutionor legal separation will result in the spouse losing coverage effective July 1st. The spouse will be eligible for COBRA only once thedivorce, dissolution or legal separation actually occurs. Spouses whose coverage was terminated due to a divorce, dissolution orlegal separation must contact our office within 30 days of the event in order to be offered COBRA coverage.

Falsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverage underCOBRA is considered a fraudulent act. Premiums paid will not be refunded for coverage terminated retroactively due to ineligibility.

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* Dropping a spouse’s coverage during the annual Benefit Choice Period in anticipation of a divorce, civil union partnership dissolutionor legal separation will result in the spouse losing coverage effective July 1st. The spouse will be eligible for COBRA only once thedivorce, dissolution or legal separation actually occurs. Spouses whose coverage was terminated due to a divorce, dissolution orlegal separation must contact our office within 30 days of the event in order to be offered COBRA coverage.

qualifying Events

COBRA MEMBER (Previously an Employee)

SSA Disability determination within the first 60 days of COBRA

COBRA DEPENDENT

Loss of eligibility as a dependent child or as a domestic partner

Legal separation from COBRA member*

COBRA member’s death

• Spouse under age 55

• Spouse age 55 or older if already enrolled in Medicare

• Spouse age 55 or older

• Dependent child

• Domestic partner

Divorce from/Dissolution of civil union partnership with COBRA member*

• Ex-Spouse under age 55

• Ex-Spouse age 55 or older if already enrolled in Medicare

• Ex-Spouse age 55 or older

• Stepchild or Child of Civil Union Partner

Maximum Eligibility Period

Additional 11 months for a maximum of 29 months

Additional 18 months for amaximum of 36 months






SECOND qUALIFYING EVENTSThe events shown below will extend coverage for a qualified beneficiary

if it occurs during the original 18-month COBRA period.

The term 'Spouse' in this chart includes civil union partners; 'Ex-spouse' includes civil union partners whose partnership has been dissolved.

Falsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverage underCOBRA is considered a fraudulent act. Premiums paid will not be refunded for coverage terminated retroactively due to ineligibility.

A qualified beneficiary is an individual (including employee, spouse, civil union partner, domestic partner or child) who losesemployer-provided group health coverage and is entitled to elect COBRA coverage. The individual must have been coveredby the plan on the day before the qualifying event occurred and enrolled in COBRA effective the first day of eligibility or be anewborn or newly adopted child of the covered employee.

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Chapter 2Chapter 2: Health, Dental, Vision and Life Coverage Information

Health Plan Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Managed Care Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Quality Care Health Plan (QCHP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Prescription Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Employee Assistance Program (EAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Dental Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Vision Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Life Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

32 www.benefitschoice.il.govBenefits Handbook


OverviewThe State offers a variety of health plans from which to choose.Each plan provides health, behavioral health and prescriptiondrug benefits; however, the benefit levels, exclusions andlimitations differ. When making choices, employees shouldconsider health status, coverage needs and servicepreferences. Dependents will have the same health and dentalplan as the employee under whom they are enrolled.

The annual Benefit Choice Options booklet provides a listingof the health plans available and the Illinois counties in whichthey provide coverage.

Types of Health PlansThe types of health plans available are:

F Managed Care Plans

• Health Maintenance Organizations (HMOs)

• Open Access Plans (OAPs)

F Quality Care Health Plan (QCHP)

Disease Management Programsand Wellness OfferingsDisease management programs are utilized by the healthplans as a way to improve the health of plan participants.Plan participants may be contacted by their health plan toparticipate in these programs.

Wellness options and preventive measures are offered andencouraged by the health plans. Offerings range fromhealth risk assessments to educational materials and, insome cases, discounts on items such as gym membershipsand weight loss programs. These offerings are available toplan participants and are provided to help plan participantstake control of their personal health and well-being.Information about the various offerings is available onthe plan administrators’ websites.

Managed Care Health Plans Managed care is a method of delivering healthcare througha system of network providers. Managed care plansprovide comprehensive health benefits at lower out-of-pocket costs by utilizing network providers. Managed carehealth plans coordinate all aspects of a plan participant’shealthcare including medical, prescription drug andbehavioral health services.

Like any health plan, managed care plans have planlimitations including geographic availability and limitedprovider networks. Managed care coverage is offered incertain counties called service areas. Ordinarily, managedcare plans only cover members within the State; however,plans that have networks outside the State of Illinois mayprovide coverage. Employees should contact the managedcare plan administrator to ascertain if coverage is availableoutside their geographic area. Eligible dependents that liveapart from the employee’s residence for any part of a planyear may be subject to limited service coverage. It is criticalthat employees who have an out-of area dependent (suchas a college student) contact the managed care plan tounderstand the plan’s guidelines on out-of-area coverage.

Some managed care health plans are self insured,meaning all claims are paid by the State of Illinois eventhough managed care health plan benefits apply. Theseplans are not regulated by the Illinois Department ofInsurance and are not governed by the EmployeesRetirement Income Security Act (ERISA).

In order to have the most detailed information regarding aparticular managed care health plan, employees shouldask the plan administrator for its summary plan description(SPD) which describes the covered services, benefit levels,and exclusions and limitations of the plan’s coverage. TheSPD may also be referred to as a certificate of coverage ora summary plan document.

Employees should pay particular attention to themanaged care plan’s exclusions and limitations. It isimportant that plan participants understand whichservices are not covered under the plan. Employeesdeciding to enroll in a managed care health plan shouldread the SPD before seeking medical attention. It is theplan participant’s responsibility to become familiar withall of the specific requirements of the health plan.

There are two types of managed care plans, healthmaintenance organizations (HMOs) and open access plans(OAPs). Employees who enroll in an HMO must select aprimary care physician/provider (PCP) from the healthplan’s provider directory, which can be found on the plan’swebsite. Plan participants should contact the physician’soffice or the HMO plan administrator to find out if the PCPis accepting new patients. Plan participants are required touse participating physicians and hospitals for maximumbenefits. Employees enrolled in an OAP do not need toselect a PCP. For complete information on specific plancoverage or provider networks, contact the managed carehealth plan and review the SPD.

Health Plan Options

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Most managed care health plans impose benefit limitationson a plan year basis (July 1 through June 30); however,some managed care health plans impose benefit limitationson a calendar year basis (January 1 through December 31).

Refer to the annual Benefit Choice Options booklet for planadministrator information.

Health Maintenance Organization (HMO)HMO members must choose a primary care physician/provider (PCP) who will coordinate the healthcare,hospitalizations and referrals for specialty care. In mostcases a referral for specialty care will be restricted to thoseservices and providers authorized by the designated PCP.Additionally, referrals may also require prior authorizationfrom the HMO. To receive the maximum hospital benefit,your PCP or specialist must have admitting privileges to anetwork hospital.

Like any health plan, HMOs have plan limitations includinggeographic availability and limited provider networks. HMOcoverage is offered in certain counties called service areas.There is no coverage outside these service areas unlesspreapproved by the HMO. When traveling outside of thehealth plan’s service area, coverage is limited to life-threatening emergency services. For specific informationregarding out-of-area services or emergencies, call theplan administrator. NOTE: When an HMO plan is thesecondary plan and the plan participant does not utilize theHMO network of providers or does not obtain the requiredreferral, the HMO plan is not required to pay for services.Refer to the plan’s SPD for additional information.

Managed care health plan provider networks are subjectto change. Employees will be notified in writing by theplan administrator when a PCP network change occurs.Employees will have 60 days from the date the providerleaves the network to make a health plan change. If thedesignated PCP leaves the HMO network*, there arethree options:

F Choose another PCP within that plan,

F Enroll in a different managed care health plan, or

F Enroll in the QCHP plan.

Employees who change their health plan outside theBenefit Choice Period, regardless of the basis for thechange, will be responsible for any deductiblesrequired by the new plan (including prescriptiondeductibles), even if the plan participant met alldeductibles while covered by the previous health plan.

* The opportunity to change health plans applies only whenthe PCP leaves the network. This opportunity does notapply to specialists or womens’ healthcare providers whoare not the designated PCP, nor does it apply when ahospital leaves the network.

Open Access Plan (OAP) Open access plans combine similar benefits of an HMOwith the same type of coverage benefits as a traditionalhealth plan. Members who elect an OAP will have threetiers of providers from which to choose to obtain services.The benefit level is determined by the tier in which thehealthcare provider is contracted. Members enrolled in anOAP can mix and match providers and tiers. Specificbenefits are described in the summary plan document(SPD) on the OAP administrator’s website.

F Tier I offers a managed care network which provideenhanced benefits and require copayments whichmirror HMO copayments.

F Tier II offers another managed care network, in additionto the managed care network offered in Tier I, and alsoprovides enhanced benefits. Tier II requirescopayments, coinsurance and is subject to an annualplan year deductible.

F Tier III covers all providers which are not in themanaged care network of Tiers I or II (i.e., out ofnetwork providers). Using Tier III can offer membersflexibility in selecting healthcare providers, but involvehigher out-of pocket costs. Tier III has a higher planyear deductible and has a higher coinsurance amountthan Tier II services. In addition, certain services, suchas preventive/wellness care, are not covered whenobtained under Tier III. Furthermore, plan participantswho use out-of-network providers will be responsible forany amount that is over and above the charges allowedby the plan for services (i.e., allowable charges), whichcould result in much higher out-of-pocket costs. Whenusing out-of-network providers, it is recommended thatthe participant obtain a preauthorization of benefits toensure that medical services/stays will meet medicalnecessity criteria and be eligible for benefit coverage.

Members who use providers in Tiers II and III will beresponsible for the plan year deductible. Thesedeductibles ‘cross accumulate,’ which means that amountspaid toward the deductible in one tier, will apply toward thedeductible in the other tier.

Health Plan Options (Managed Care Health Plans cont.)


Health Plan Options (Quality Care Health Plan (QCHP))

Quality Care Health Plan (QCHP) The Quality Care Health Plan (QCHP) is the State’s self-insured health plan offering a comprehensive range ofbenefits. All claims and costs are paid by the State through athird-party administrator. For complete information regardingspecific plan coverage and the provider’s network, refer tothe summary plan description on the Benefits website.Benefit enhancements are available by utilizing the:

F Nationwide QCHP physician, hospital, ancillary servicesand transplant network.

F Pharmacy network.

F Behavioral health network.

Each of these three components is discussed separately inthis section. Each component has its own plan administrator.

Employee Responsibilities F The employee is always responsible for:

– Any amount required to meet plan year deductibles,additional deductibles and coinsurance amounts.

– Any amount over the allowable charges.

– Any penalties for failure to comply with the notificationrequirements.

– Any charges NOT covered by the plan or determinedby the plan administrator to be not medically necessaryservices.

NOTE: Specific dollar amounts and percentages thatapply to deductibles, “additional deductibles” andcoinsurance are updated each year in the Benefit ChoiceOptions booklet.

Plan Requirements Plan Year DeductibleThe plan year deductible requirement applies to all medicaland behavioral health services, except preventive services.The plan year deductible is based on the employee’s annualsalary as of the first of April preceding the beginning of theplan year. To verify the employee plan year deductibleor the family plan year deductible, review the currentBenefit Choice Options booklet. The plan year runs fromJuly 1 through June 30.

Salary-based deductibles stay in force for the entire planyear. The deductible is reassessed if the employee retires,accepts a voluntary reduction in pay or returns to Stateemployment at a different salary. Should the deductiblerequirement be reduced, only the lower deductible must bemet; however, no reimbursements will be made if the lowerdeductible has been exceeded. The annual deductible inforce at the time of termination of eligibility under the Programremains in force for those who elect continuation ofcoverage under COBRA.

Each family member’s plan year deductible will accumulatetoward a family plan year deductible. Once the family as aunit has satisfied the family plan year deductible, no furtherplan deductibles for any family member will be required foreligible charges incurred for the remainder of that plan year.The employee plan year deductible and/or the family planyear deductible accumulate toward the annual out-of-pocketmaximum.

Additional DeductiblesBesides the plan year deductible, plan participants mustpay additional deductibles for the following:

F Each emergency room visit that does not result in ahospital admission

F QCHP hospital admission

F Non-QCHP hospital admission

F Transplant hospital admission

Even though these additional deductibles do not applytoward the plan year deductible, they do accumulatetoward the annual out-of-pocket maximum.

CoinsuranceCoinsurance is the percentage of eligible charges that planparticipants must pay after the annual plan year deductiblehas been met. Eligible charges are charges for coveredservices and supplies which are medically necessary.

Out-of-Pocket Maximum Plan year deductibles, “additional deductibles” and eligiblecoinsurance payments accumulate toward the annual out-of-pocket maximum. There are two separate out-of-pocketmaximums: in-network and out-of-network. Coinsuranceand deductibles apply to one or the other, but not both.After the out-of-pocket maximum has been met, coinsuranceamounts are no longer required and the plan pays 100% ofeligible charges for the remainder of the plan year.

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The following do not apply toward out-of-pocketmaximums:

F Prescription drug deductibles and copayments.

F Notification penalties.

F Ineligible charges (i.e., amounts over the allowablecharge, charges for noncovered services and chargesfor services deemed not to be medically necessary).

F The portion of the Medicare Part A deductible the planparticipant is responsible to pay.

Medical NecessityF qCHP covers charges for services and supplies

that are medically necessary. Medically necessaryservices and supplies are those which are:

– provided by a hospital, medical facility or prescribedby a physician or other provider and are required toidentify and/or treat an illness or injury.

– consistent with the symptoms or diagnosis andtreatment of the condition (including pregnancy),disease, ailment or accidental injury.

– generally accepted in medical practice as necessaryand meeting the standards for good medical practicefor the diagnosis or treatment of the patient’s condition.

– the most appropriate supply or level of service whichcan be safely provided to the patient.

– not solely for the convenience of the patient, physician,hospital or other provider.

– repeated only as indicated as medically appropriate.

– not redundant when combined with other treatmentbeing rendered.

Predetermination of BenefitsPredetermination of benefits ensures that medicalservices/stays will meet medical necessity criteria and beeligible for benefit coverage. The plan participant’sphysician must submit written detailed medical informationto the medical plan administrator. For questions regarding apredetermination of benefits, contact the plan administrator.

Benefits are based on the plan participant’s eligibility andplan provisions in effect at the time services are rendered.Precise claim payment amounts can only be determinedupon receipt of the itemized bill and are subject to standardclaim payment policies including, but not limited to, multipleand incidental procedure reductions, allowable chargesand claim bundling and unbundling of procedures.

Allowable ChargesThe maximum amount the plan will pay an out-of-networkhealthcare professional for billed services is referred to asallowable charges. The amount that is over the allowablecharges amount is not considered eligible for payment bythe plan and therefore cannot be applied to the plan yeardeductible nor the out-of-pocket maximum. The planparticipant will be responsible for the entire amountthat is over and above the allowable charges amount.Allowable charges are usually applied when using out-of-network providers.

When processing any given claim, the plan administratortakes the following into account:

F Complexity of the services.

F Any unusual circumstances or complications that requireadditional skill, time or experience.

F Prevailing charge level in the geographic area wherethe provider is located and other geographic areashaving similar medical-cost experience.

Allowable charges applies to medical services, proceduresand/or supplies.

IMPORTANT: The amount of the claim that will be paid isbased on the allowable charges amount or the actualcharge made by the provider, whichever is less, for out-of-network services.

Health Plan Options (QCHP cont.)


Quality Care Health Plan (QCHP) Network The Quality Care Health Plan (QCHP) network includeshospitals, physicians and ancillary providers throughoutIllinois, as well as nationwide. The network provides qualityinpatient and outpatient care at negotiated rates, which resultin savings to plan participants. The network is subject tochange any time during the plan year.

Medical Case Management The Medical Case Management (MCM) Program is designedto assist plan participants requiring complex care in timesof serious or prolonged illness. There is no additional costto the plan participant for this service.

The referral to the MCM Program is made through eitherthe MCM administrator, the QCHP plan administrator or byrequest from a plan participant. Once referred, the planparticipant is assigned a case manager who serves as aliaison and facilitator between the patient, family, physicianand other healthcare providers. The case manager is aregistered nurse or other healthcare professional withextensive clinical background. The case manager caneffectively minimize the fragmentation of care.

Upon completing the MCM review, the case manager willmake a recommendation regarding the treatment setting,intensity of services and appropriate alternatives of care.To reach the MCM plan administrator, call the toll-freenumber listed in the plan administrator section of thecurrent Benefit Choice Options booklet located on theBenefits website.

Notification RequirementsNotification is the telephone call to the notification administratorinforming them of an upcoming admission to a facility suchas a hospital or skilled nursing facility or for an outpatientprocedure, therapy service or supply. If using a QCHPnetwork provider, the medical provider is responsible forcontacting the notification administrator on behalf of theplan participant.

If using a non-QCHP provider, the plan participant mayrequest that their non-QCHP medical provider contactthe notification administrator to provide specific medicalinformation, setting and anticipated length of stay to determinemedical appropriateness. The plan participant may alsomake notification, after which a medically qualified reviewerwill contact the plan participant’s physician or provider toobtain specific medical information.

Regardless of where services are rendered, it is the planparticipant’s responsibility to ensure that notification hasoccurred. Failure to contact the notification administratorprior to having a service performed may result in afinancial penalty and risk incurring noncovered charges.Notification is required for all plan participants includingthose with Medicare or other insurance as primary payer.

Contact information for the notification administrator can befound in the plan administrator section of the current BenefitChoice Options booklet. The toll-free number is also printedon your identification card. You can call seven days a week,twenty-four hours a day.

F Notification is required for the following:

(Contact the notification administrator for the mostup-to-date list of procedures requiring notification).

– Outpatient Surgery, Procedures, Therapies andSupplies/Equipment. Outpatient surgery andprocedures include, but are not limited to, items suchas imaging (MRI, PET, SPECT and CAT scan),physical, occupational or speech therapy, footorthotics, durable medical equipment (DME) supplies,infertility surgery, cardiac or pulmonary rehabilitation,skin removal or enhancement (lipectomy, selectinjectable drug treatment for varicose veins, etc.).

– Any Elective Inpatient Surgery or Non-EmergencyAdmission. Notification must be made at least sevendays before admission. The admission and length ofstay must be authorized before entering the facility.

– Skilled Nursing Facility, Extended Care Facility orNursing Home Admission. Notification must bemade at least seven days before admission. A reviewof the care being rendered will be conducted todetermine if the services are skilled in nature.

– Emergency or Urgent Admission. Notification mustbe made within two business days after the admission.

– Hospice Admission. Notification must be madeprior to the admission.

– Potential Transplants. Notification must be madeprior to beginning evaluation services. Benefits areonly available through the QCHP transplant networkof hospitals/facilities.


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F Notification is Not:

– A final determination of medical necessity. If thenotification administrator should determine that thesetting and/or anticipated length of stay are no longermedically necessary and NOT eligible for coverage,the physician will be informed immediately. The planparticipant will also receive written confirmation ofthis determination.

– A guarantee of benefits. Regardless of notificationof a procedure or admission, there will be no benefitpayment if the plan participant is ineligible for coverageon the date services were rendered or if the chargesare deemed ineligible.

– Enrollment of a newborn for coverage. Contactyour GIR to enroll a newborn within 60 days of birth.

– A determination of the amount which will be paid fora covered service. Benefits are based upon the planparticipant’s eligibility status and the plan provisions ineffect at the time the services are provided.

NOTE: For authorization procedures and time limits forbehavioral health services, see the ‘Behavioral Health’section later in this chapter.

Benefits for Services Received While Outside theUnited StatesThe plan covers eligible charges incurred outside of theUnited States for services that are generally accepted asmedically necessary within the United States. All planbenefits are subject to plan provisions and deductibles.The benefit for facility and professional charges is paid atthe non-QCHP rate. Notification is not required for medicallynecessary services rendered outside of the United States;however, medical necessity must be established prior toreimbursement. Payment for the services will most likelybe required from the employee at the time the servicesare rendered.

Plan participants must file a claim with the planadministrator for reimbursement. When filing a claim,enclose the itemized bill with a description of the servicestranslated to English and the total amount of billed charges,along with the name of the patient, date of service,diagnosis, procedure code and the provider’s name,address and telephone number. Reimbursement inAmerican dollars will be based on the conversion rate of thebilled currency on the date services were rendered.

Generally, Medicare will not pay for healthcare obtainedoutside the United States and its territories. WhenMedicare does not pay, QCHP becomes the primary payerand standard benefit levels will apply.

Hospital Bill Audit ProgramThe Hospital Bill Audit Program applies to QCHP andnon-QCHP hospital charges. Under the program, a memberor dependent who discovers an error or overcharge on ahospital bill and obtains a corrected bill is eligible for 50% ofthe resulting savings. There is no cap on the savings amount.Related nonhospital charges, such as radiologists andsurgeons are not eligible charges under this program. Thisprogram applies only when QCHP is the primary payer.

Reimbursement documentation required:

– Original incorrect bill,

– Corrected copy of the bill, and

– Employee’s name, telephone number and last fourdigits of the SSN.

Submit Documentation to:

Hospital Bill Audit ProgramDCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208


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AcupunctureF Charges for treatment of diagnosed chronic pain with a

written referral from a physician or dentist. Coverage issubject to frequency limitations. Note: Chronic pain isdefined as pain that persists longer than the amount oftime normally expected for healing.

Ambulance (See Exclusion #5 and #43)

F Transportation charges to the nearest hospital/facilityfor emergency medically necessary services for apatient whose condition warrants such service. Theplan administrator should be notified as soon aspossible for a determination of coverage. Medicallynecessary transportation charges (emergency groundor air ambulance) will be paid at the 90% benefit levelafter the annual plan year deductible has been met.Services that are determined not to be medicallynecessary will not be covered.

F Transportation services eligible for coverage:

– From the site of the disabling illness, injury, accidentor trauma to the nearest hospital qualified to providetreatment (includes air ambulance when medicallynecessary).

– From a remote area, by air, land or water (inside oroutside the United States), to the nearest hospitalqualified to provide emergency medical treatment.

– From a facility which is not equipped to treat thepatient’s specific injury, trauma or illness to the nearesthospital equipped to treat the injury, trauma or illness.

Behavioral Health In an emergency or a life-threatening situation, call 911, orgo to the nearest hospital emergency room. Planparticipants must call the behavioral health plan administrator

within 48 hours to avoid a financial penalty. Authorizationrequirements still apply when plan participants have othercoverage, such as Medicare.

F Inpatient services must be authorized prior to admissionor within 48 hours of an emergency admission toreceive in-network or out-of-network benefits.Authorization is required with each new admission.Failure to notify the behavioral health plan administratorof an admission to an inpatient facility within 48 hourswill result in a financial penalty and risk incurringnoncovered charges.

F Partial hospitalization and intensive outpatienttreatment must be authorized prior to admission toreceive in-network or out-of-network benefits.Authorization is required before beginning each treatmentprogram. Failure to notify the behavioral health planadministrator of a partial hospitalization or intensiveoutpatient program will result in a financial penalty andrisk incurring noncovered charges.

F Outpatient services received at the in-network benefitlevel must be provided by a QCHP network provider.Most routine outpatient services (such as therapysessions and medication management) will be coveredwithout the need for prior authorization. Authorizationrequirements for certain specialty outpatient servicesare noted below. Outpatient services that are notconsistent with usual treatment practice for a planparticipant’s condition will be subject to a medicalnecessity review. The behavioral health administratorwill contact the plan participant’s provider to discuss thetreatment if a review will be applied. Outpatientservices received at the out-of-network benefit levelmust be provided by a licensed professional includinglicensed clinical social worker (LCSW), registerednurse, clinical nurse specialist (RN CNS), licensedclinical professional counselor (LCPC), licensedmarriage and family therapist (LMFT), psychologist orpsychiatrist to be eligible for coverage.

Quality Care Health Plan – Medical Benefits SummaryIn-Network Benefit: Preventive services are paid at 100%. Unless otherwise indicated, a 90% benefit level will be applied to all other eligible services, supplies and therapies.

Out-of-Network Benefit: Unless otherwise indicated, all eligible services, supplies andtherapies, including preventive services, are paid at 60% of allowable charges.

This document contains a brief overview of some of the benefits available under the Quality Care Health Plan (QCHP). Contact theplan administrator for more information or coverage requirements and/or limitations. In order for any service, therapy or supply tobe considered eligible for coverage, it must be medically necessary as determined by the plan administrator. Theinformation below indicates the requirements and benefit levels of the covered services, supplies and therapies for thestandard benefit level (60% of allowable charges). There is a 90% enhanced benefit level for utilizing network providers.

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F Electroconvulsive therapy, psychological testingand applied behavioral analysis must be authorizedto receive in-network or out-of-network benefits. Failureto obtain authorization will result in the risk of incurringnoncovered charges.

F No benefits are available for residential treatment.

Breast ReconstructionFollowing MastectomyF The plan provides coverage, subject to and consistent

with all other plan provisions, for services following amastectomy, including:

– Reconstruction of the breast (including implants) onwhich the mastectomy was performed.

– Surgery and reconstruction on the other breast(including implants) to produce a symmetricalappearance.

– Prosthesis and treatment for any physicalcomplications at any stage of mastectomy, includingpost-surgical lymphedema (swelling associated withthe removal of lymph nodes) rendered by a providercovered under the plan.

– Mastectomy bras are covered following surgery or achange in prosthesis.

Cardiac RehabilitationF Phase I and Phase II when ordered by a physician.

Chiropractic ServicesF Maximum of thirty (30) visits per plan year will be covered.

F No coverage for chiropractic services considered to bemaintenance in nature, in that medical information does notdocument progress in the improvement of the condition.

Christian Science PractitionerF Coverage for the services of a Christian Science Nurse

or Practitioner.

– A Christian Science Nurse is a nurse who is listed in aChristian Science Journal at the time services aregiven and who: (a) has completed nurses’ training at a

Christian Science Benevolent Association Sanitarium;or (b) is a graduate of another School of Nursing; or(c) had three consecutive years of Christian ScienceNursing, including two years of training.

– A Christian Science Practitioner is an individual whois listed as such in the Christian Science Journal atthe time the medical services are provided and whoprovides appropriate treatment in lieu of treatment bya medical doctor.

CircumcisionF Charges for professional services.

F Charges for circumcision are considered to be coveredservices when billed as a separate claim for thenewborn as long as the newborn is enrolled in the planand the surgery is performed within the first thirty (30)days following birth.

Dental Services (See Exclusion #14 and # 15)

F Accidental Injury:

– Coverage for professional services necessary as aresult of an accidental injury to sound natural teethcaused by an external force. Care must be renderedwithin three months of original accidental injury. Theappropriate facility benefit applies.

F Nonaccidental: Coverage limited to:

– Anesthesia and facility charges for dependentchildren age six and under.

– A medical condition that requires anesthesia andfacility charges for dental care (not anxiety orbehavioral related conditions). Professional servicesare not covered under the medical plan.

Diabetic CoverageF Charges for dietitian services and consultation when

diagnosed with diabetes. No coverage unless orderedin conjunction with a diagnosis of diabetes.

F Charges for routine foot care by a physician whendiagnosed with diabetes.

F Charges for insulin pumps and related supplies whendeemed medically necessary.

In-Network Benefit: Preventive services are paid at 100%. Unless otherwise indicated, a90% benefit level will be applied to all other eligible services, supplies and therapies.


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Dialysis F Charges for hemodialysis and peritoneal dialysis.

Durable Medical Equipment(DME) (See Exclusion #5)

F Short-term Rental:

– Rental fees up to the purchase price for items thattemporarily assist an impaired person duringrecovery. Examples include canes, crutches,walkers, hospital beds and wheelchairs.

F Purchase:

– Charges to purchase the equipment. Equipmentshould be purchased only if it is expected that therental costs will exceed the purchase price.

F DME exclusions include, but are not limited to:

– Repairs or replacements due to negligence or loss ofthe item.

– Newer or more efficient models.

F DME is eligible for coverage when provided as the mostappropriate and lowest cost alternative as required bythe person’s condition.

NOTE: See Prosthetic Appliances for permanentreplacement of a body part.

Emergency ServicesThe facility in which emergency treatment is rendered andthe level of care determines the benefit level (hospital,urgent care center, physician office). For emergencytransportation services, refer to the ‘Ambulance’ section.

F Emergency Room:

– 90% of allowable charges after the specialemergency room deductible at a QCHP or non-QCHP facility. The special deductible applies toeach visit to an emergency room which does notresult in an inpatient admission.

F Physician’s Office:

– 90% of allowable charges; no special emergency roomdeductible applies. Treatment must be rendered within

72 hours of an injury or illness and meet the definition ofemergency services presented above. Nonemergencymedically necessary care is considered at 60% ofallowable charges.

F Urgent Care or Similar Facility:

– 90% of allowable charges; no special emergencyroom deductible applies. Treatment must be renderedwithin 72 hours of an injury or illness and meet thedefinition of emergency services presented above.This benefit applies to professional fees only. Facilitycharges not covered when services are performed in aphysician’s office or urgent care center.Nonemergency medically necessary care isconsidered at 60% of allowable charges.

Eye Care (See Exclusion #11 and #27)

F Charges for treatment of injury or illness to eye.

Foot Orthotics Notification is required. Refer to ‘NotificationRequirements’ in the ‘Quality Care Health Plan’ section ofthe Benefits Handbook for more information.

F Must be custom molded or fit to the foot and ordered bya physician or podiatrist.

Hearing Services F Diagnostic hearing exams performed by an audiologist

are covered up to $150 and hearing aids are coveredup to $600 every three plan years.

F Professional service charges for the hearing examassociated with the care and treatment of an injury oran illness.

Hospice F Written notification of the terminal condition is required

from the attending physician.

F Inpatient hospice requires notification. Refer to ‘NotificationRequirements’ in the ‘Quality Care Health Plan’ section ofthe Benefits Handbook for more information.



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Inpatient Hospital/Facility Services(See Exclusions #3, #6, #8, #32)

F Hospital/facility charges.

NOTE: Failure to provide notification of an upcomingadmission or surgery will result in a financial penaltyand denial of coverage for services not deemedmedically necessary. Refer to ‘Notification Requirements’in the ‘Quality Care Health Plan’ section of the BenefitsHandbook for more information.

Infertility Treatment Benefits are provided for the diagnosis and treatment ofinfertility. Infertility is defined as the inability of oppositesex partners to conceive after one consecutive year ofunprotected sexual intercourse or the inability to sustain asuccessful pregnancy.

F Predetermination of Benefits:

– A written predetermination of benefits must beobtained from the health plan administrator prior tobeginning infertility treatment to ensure optimumbenefits. Documentation required from the physicianincludes the patient’s reproductive history includingtest results, information pertaining to conservativeattempts to achieve pregnancy and the proposedplan of treatment with physicians’ current proceduralterminology (CPT) codes.

F Infertility Benefits:

– Coverage is provided only if the plan participant hasbeen unable to obtain or sustain a successfulpregnancy through reasonable, less costly, medicallyappropriate infertility treatment for which coverage isavailable under this plan.

F Coverage for assisted reproductive procedures include,but is not limited to:

– Artificial insemination, invitro fertilization (IVF) andsimilar procedures which include but are not limitedto: gamete intrafallopian tube transfer (GIFT), lowtube ovum transfer (TET) and uterine embryolavage.

– A maximum of three (3) artificial inseminationprocedures per menstrual cycle for a total of eight (8)cycles per lifetime.

– A maximum of four (4) procedures per lifetime for anyof the following: invitro fertilization, gameteintrafallopian tube transfer (GIFT), zygote intrafallopiantube transfer (ZIFT) and other similar procedures.

– If a live birth results from an invitro procedure, twoadditional procedures are eligible for coverage.

– Eligible medical costs associated with sperm or eggdonation by a person covered under the plan mayinclude, but are not limited to, monitoring the cycle ofa donor and retrieval of an egg for the purpose ofdonating to a covered individual.

– Retrieval does not count toward the number ofmaximum attempts.

F Benefit Level:

– The appropriate benefit level will apply (i.e.,physician charges, lab and radiology are covered at90% for in-network or 60% of allowable charges forout-of-network providers).

F Infertility treatment exclusions include, but are notlimited to:

– Medical or nonmedical costs of anyone NOTcovered under the plan.

– Nonmedical expenses of a sperm or egg donorcovered under the plan including, but not limited totransportation, shipping or mailing, administrativefees such as donor processing, search for a donor orprofiling a donor, cost of sperm or egg purchasedfrom a donor bank, cryopreservation and storage ofsperm or embryo or fees payable to a donor.

– Infertility treatment deemed experimental orunproven in nature.

– Persons who previously had a voluntary sterilizationor persons who are unable to achieve pregnancyafter a reversal of a voluntary sterilization.

– Payment for medical services rendered to asurrogate for purposes of attempting or achievingpregnancy. This exclusion applies whether thesurrogate is a plan participant or not.

– Pre-implantation genetic testing.



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Lab and Radiology F Outpatient:

– Charges at a physician’s office, hospital, clinic orurgent care center.

F Inpatient:

– If billed by a hospital as part of a hospitalconfinement, paid at the appropriate hospital benefitlevel.

F Professional charges:

– Professional charges associated with theinterpretation of the lab or radiology procedures.

Medical Supplies (See Exclusions #3, #5, #19)

F Medical supplies include, but are not limited to ostomysupplies, surgical dressings and surgical stockings.

Morbid Obesity Treatment (See Exclusion #12)

F Charges for professional services.

F Obesity surgery is eligible for coverage dependent onmedical necessity and predetermination of benefits.

Newborn Care (See Exclusion #41)

F Charges for professional services in an office orhospital setting.

F Benefits are available for newborn care only if thedependent is enrolled no later than 60 days followingthe birth.

Occupational Therapy/PhysicalTherapy (See Exclusion #10)

Notification is required. Refer to ‘NotificationRequirements’ in the ‘Quality Care Health Plan’ section ofthe Benefits Handbook for more information.

F Covered if administered under the supervision of andbilled by a licensed or registered occupational therapist,physical therapist or physician.

Outpatient Hospital/FacilityServices, including Surgery(See Exclusions #3, #4, #6)

F Covered if performed at a hospital/facility.

F Covered if performed at an ambulatory surgicaltreatment center which is licensed by the Department ofPublic Health, or the equivalent agency in other states,to perform outpatient surgery.

Physician ServicesF Charges for medical treatment of an injury or illness.

Physician Services – Surgical(See Exclusions #12, #13, #16)

F Inpatient Surgery:

– Follow-up care by the surgeon is considered part ofthe cost of the surgical procedure and is NOTcovered as a separate charge.

F Outpatient Surgery:

– If surgery is performed in a physician’s office, thefollowing will be considered as part of the fee:

– Surgical tray and supplies.

– Local anesthesia administered by the physician.

– Medically necessary follow-up visits.

F Plastic and reconstructive surgery is limited for thefollowing:

– An accidental injury.

– Congenital deformities evident at infancy.

– Reconstructive mammoplasty following a mastectomy.

F Assistant surgeon:

– A payable assistant surgeon is a physician whoassists the surgeon, subject to medical necessity.

– Up to 20% of allowable charges of eligible charges.

F Multiple surgical procedures:

– Standard plan guidelines are used in processing



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claims when multiple surgical procedures areperformed during the same operative session.

– Charges for the most inclusive (comprehensive)procedure. Additional procedures are paid at alesser level. Contact the plan administrator for apredetermination of benefits.

Podiatry Services (See Exclusion #9)

Notification is required. Refer to ‘NotificationRequirements’ in the ‘Quality Care Health Plan’ section ofthe Benefits Handbook for more information.

Prescription DrugsF Drug charges if billed by a physician’s office and not

obtained at a pharmacy.

F Prescription drugs obtained as part of a skilled carefacility stay are payable by the health planadministrator.

F Prescription drugs obtained as part of a hospital stayare payable at the appropriate facility benefit level.

F Prescription drugs billed by a skilled nursing facility,extended care facility or a nursing home must besubmitted to the prescription drug plan administrator.

Preventive ServicesRoutine preventive care services which do NOT require adiagnosis or treatment are covered at 100% when utilizinga network provider. Out-of-network preventive care iscovered at 60% of allowable charges. Your doctor willdetermine the tests and frequency that are right for youbased on your age, gender and family history. Preventiveservices are not subject to the plan year deductible.

NOTE: Claims which indicate a diagnosis are notconsidered preventive and are subject to the plan yeardeductible and coinsurance.

Prosthetic AppliancesA prosthetic appliance is one which replaces a body part.Examples are artificial limbs and artificial eyes.

F Charges for:

– The original prosthetic appliance.

– Replacement of a prosthetic appliance due to growthor a change in the person’s medical condition.

– Repair of a prosthetic appliance due to normal wearand usage and no longer functional.

F No payment will be made if the appliance is damagedor lost due to negligence.

F Prosthetic appliances exclusions include, but are notlimited to:

– Appliances not recommended or approved by aphysician.

– Appliances to overcome sexual dysfunction, exceptwhen the dysfunction is related to an injury or illness.

– Items considered cosmetic in nature such as artificialfingernails, toenails, eyelashes, wigs, toupees orbreast implants.

– Experimental or investigational appliances.

Skilled Nursing Service – HomeSettingF Contact the Notification/Medical Case Management

plan administrator for a determination of benefits.

F The benefit for skilled nursing service will be limited tothe lesser of the cost for care in a home setting or theaverage cost in a skilled nursing facility, extended carefacility or nursing home within the same geographicregion.

F The continued coverage for skilled nursing service willbe determined by the review of medical records andnursing notes.

Skilled Nursing – In a SkilledNursing Facility, ExtendedCare Facility or Nursing Home(See Exclusions #3, #5, #19)

F Benefits are subject to skilled care criteria and will beallowed for the most cost-effective setting or the level ofcare required as determined by the Notification/MedicalCase Management plan administrator.



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F Must be a licensed healthcare facility primarily engagedin providing skilled care.

F Notification is required at least seven days prior toadmission or at time of transfer from an inpatienthospital stay.

F Benefits are limited to the average cost of availablefacilities within the same geographic region.

F The service must be medically necessary.

F The continued coverage for skilled nursing service willbe determined by the review of medical records andnursing notes.

F Prescription drug charges must be submitted to thehealth plan administrator.

NOTE: Extended care facilities are sometimes referredto as nursing homes. Most care in nursing homes isNOT skilled care and therefore is NOT covered. Manypeople purchase long-term care insurance policies tocover those nursing home services which are NOTcovered by medical insurance or Medicare.

Speech TherapyNotification is required. Refer to ‘NotificationRequirements’ in the ‘Quality Care Health Plan’ section ofthe Benefits Handbook for more information.

F Charges for medically necessary speech therapyordered by a physician.

F Treatment must be for a speech disorder resulting frominjury or illness serious enough to significantly interferewith the ability to communicate at the appropriate agelevel.

F The therapy must be restorative in nature with theability to improve communication.

F The person must have the potential for communication.

Transplant Services(Notification Required)

In order for any organ, tissue or bone marrowtransplant to be covered under the plan, one of thedesignated procedure specific transplant hospitals

must be utilized. The transplant candidate must contactthe Notification/Medical Case Management planadministrator of the potential transplant. Once notificationoccurs, the Medical Case Manager (MCM) will coordinateall treatments and further notification is not required.Those refusing to participate in the MCM program will benotified that coverage may be terminated under the plan fortreatment of the condition.

The transplant benefit includes all diagnostic treatment andrelated services necessary to assess and evaluate thetransplant candidate. All related transplant chargessubmitted by the transplant hospital are covered at 90% ofthe contracted rate.

In some cases, transplants may be considered nonviablefor some candidates, as determined by the MCM planadministrator in coordination with the transplant hospital.

F Transplant exclusions include, but are not limited to:

– Investigational drugs, devices or experimentalprocedures.

– Charges related to the search for an unrelated bonemarrow donor.

– A corneal transplant is not part of the transplanthospital benefit; however, standard benefits applyunder the medical portion of the coverage.

Transplant Coordination ofDonor/Recipient BenefitsF When both the donor and the recipient are covered

under the plan, both are entitled to benefits under theplan, under separate claims.

F When only the recipient is covered, the donor’s chargesare covered as part of the recipient’s claim if the donordoes not have insurance coverage, or if the donor’sinsurance denies coverage for medical expensesincurred.

F When only the recipient is covered and the donor’sinsurance provides coverage, the plan will coordinatewith the donor’s plan.

F When only the donor is covered, only the donor’scharges will be covered under the plan.



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F When both donor and recipient are members of thesame family and are both covered by the plan, nodeductible or coinsurance shall apply.

The transplant hospital network is subject to changethroughout the year. Call the Notification/Medical CaseManagement plan administrator for current transplanthospitals.

Transplant – Transportation andLodging BenefitF The maximum expense reimbursement is $2,400 per

case. Automobile mileage reimbursement is limited tothe mileage reimbursement schedule established by theGovernor’s Travel Control Board. Lodging per diem islimited to $70. There is no reimbursement for meals.

F The plan will also cover transportation and lodgingexpenses for the patient and one immediate familymember or support person prior to the transplant andfor up to one year following the transplant. This benefitis available only to those plan participants who havebeen accepted as a candidate for transplant services.

F Requests for reimbursement for transportation andlodging with accompanying receipts should beforwarded to:

Organ Transplant ReimbursementDCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

F The plan participant has twelve months from the dateexpenses were incurred to submit eligible charges forreimbursement. Requests submitted after the twelve-month limit will not be considered for reimbursement.

Urgent Care ServicesUrgent care is care for an unexpected illness or injury thatrequires prompt attention, but is less serious than emergencycare. Treatment may be rendered in facilities such as aphysician’s office, urgent care facility or prompt care facility.This benefit applies to professional fees only. If a facility fee isbilled, the emergency room deductible applies.

NOTE: See Emergency Services for medicallynecessary emergency care.



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1. For services or care not recommended, approved andprovided by a person who is licensed under the IllinoisMedical Practices Act or other similar laws of Illinois,other states, countries or by a nurse midwife who hascompleted an organized program of study recognizedby the American College of Nurse Midwives or by aChristian Science Practitioner.

2. For services and supplies not related to the care andtreatment of an injury or illness, unless specificallystated in this document to be a covered service ineffect at the time the service was rendered. Excludedservices and supplies include, but are not limited to:sports-related health checkups, employer-requiredcheckups, wigs and hairpieces.

3. For care, treatment, services or supplies which are notmedically necessary for the diagnosed injury orillness, or for any charges for care, treatment, servicesor supplies which are deemed unreasonable by theplan.

4. For charges for the services, room and board orsupplies that exceed allowable charges.

5. For personal convenience items, including but notlimited to: telephone charges, television rental, guestmeals, wheelchair/van lifts, nonhospital typeadjustable beds, exercise equipment, special toiletseats, grab bars, ramps, transportation services orany other services or items determined by the plan tobe for personal convenience.

6. For rest, convalescence, custodial care or education,institutional or in-home nursing services which areprovided for a person due to age, mental or physicalcondition mainly to aid the person in daily living suchas home delivered meals, child care, transportation orhomemaker services.

7. For extended care and/or hospital room and boardcharges for days when the bed has not been occupiedby the covered person (holding charges).

8. For private room charges which are not medicallynecessary as determined by the plan administrator.

9. For routine foot care, including removal in whole or inpart of corns, calluses, hyperplasia, hypertrophy and

the cutting, trimming or partial removal of toenails,except for patients with the diagnosis of diabetes.

10. For chiropractic services, occupational therapy andphysical therapy considered to be maintenance innature, in that medical documentation indicates thatmaximum medical improvement has been achieved.

11. For keratotomy or other refractive surgeries.

12. For the diagnosis or treatment of obesity, exceptservices for morbid obesity, as approved by the planadministrator.

13. For sexual dysfunction, except when related to aninjury or illness.

14. For services relating to the diagnosis, treatment, orappliance for temporomandibular joint disorders orsyndromes (TMJ), myofunctional disorders or otherorthodontic therapy.

15. For an internal accidental injury to the mouth causedby biting on a foreign object and outpatient servicesfor routine dental care.

16. For the expense of obtaining an abortion, inducedmiscarriage or induced premature birth, unless it is aphysician’s opinion that such procedures arenecessary for the preservation of the life of the womanseeking such treatment, or except in an inducedpremature birth intended to produce a live viable childand such procedure is necessary for the health of thewoman or her unborn child.

17. For cosmetic surgery or therapies, except for therepair of accidental injury, for congenital deformitiesevident in infancy or for reconstructive mammoplastyafter partial or total mastectomy when medicallyindicated.

18. For services rendered by a healthcare providerspecializing in behavioral health services who is acandidate in training.

19. For services and supplies which do not meet acceptedstandards of medical or dental practice at the time theservices are rendered.

Quality Care Health Plan (QCHP) Exclusions and Limitations

No benefits are available:

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20. For treatment or services which are investigational,experimental or unproven in nature including, but notlimited to, procedures and/or services: which areperformed in special settings for research purposes or ina controlled environment; which are being studied forsafety, efficacy and effectiveness; which are awaitingendorsement by the appropriate national medicalspecialty organization; which medical literature does notaccept as a reasonable alternative to existing treatments;or, that do not yet meet medical standards of care.

21. For services due to bodily injury or illness arising outof or in the course of a plan participant’s employment,which is compensable under any Workers’Compensation or Occupational Disease Act or law.

22. For court mandated services if not a covered serviceunder this plan or not considered to be medicallynecessary by the appropriate plan administrator.

23. For services or supplies for which a charge would nothave been made in the absence of coverage or forservices or supplies for which a plan participant is notrequired to pay.

24. For services arising out of war or an act of war,declared or undeclared, or from participation in a riot,or incurred during or as a result of a plan participant’scommission or attempted commission of a felony.

25. For services related to the reversal of sterilization.

26. For lenses (eye glasses or removable contact lenses)except initial pair following cataract surgery.

27. For expenses associated with obtaining, copying orcompleting any medical or dental reports/records.

28. For services rendered while confined within any federalhospital, except for charges a covered person is legallyrequired to pay, without regard to existing coverage.

29. For charges imposed by immediate relatives of thepatient or members of the plan participant’s householdas defined by the Centers for Medicare and MedicaidServices.

30. For services rendered prior to the effective date ofcoverage under the plan or subsequent to the datecoverage is terminated.

31. For private duty nursing, skilled or unskilled, in ahospital or facility where nursing services are normallyprovided by staff.

32. For services or care provided by an employer-sponsored health clinic or program.

33. For travel time and related expenses required by aprovider.

34. For facility charges when services are performed in aphysician’s office.

35. For residential treatment for behavioral healthservices.

36. For the treatment of educational disorders relating tolearning, motor skills, communication and pervasivedevelopment conditions.

37. For nonmedical counseling or ancillary services,including but not limited to custodial services,education, training, vocational rehabilitation,behavioral training, biofeedback, neuro feedback,hypnosis, sleep therapy, employment counseling,back-to-school, return to work services, workhardening programs, driving safety and services,training, educational therapy or nonmedical ancillaryservices for learning disabilities, developmentaldelays, autism (except as provided under coveredexpenses) or mental retardation.

38. For telephone, email and internet consultations andtelemedicine.

39. For expenses associated with legal fees.

40. For medical and hospital care and cost for the infantchild of a dependent, unless this infant is otherwiseeligible under the plan.

41. For transsexual surgery including medical orpsychological counseling and hormonal therapy inpreparation for, or subsequent to any such surgery.

42. For transportation between healthcare facilitiesbecause of patient’s choice; transportation of patientswho have no other available means of transportation;transportation that is not medically necessary; orMedicar or similar type of transportation when used forpatient’s convenience.

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OverviewPlan participants enrolled in any State health plan haveprescription drug benefits included in the coverage.Regardless of the plan chosen, a prescription deductibleapplies to each plan participant each plan year. Anannual prescription deductible must be satisfied before theprescription copayments apply; however, if the cost of theprescription is less than the plan’s prescription copayment,the plan participant will pay the cost of the prescription (seean example in the annual Benefit Choice Options bookleton the Benefits website).

Employees who change health plans outside the annualBenefit Choice Period will be responsible for satisfying theprescription deductible of the new health plan even if theypreviously met the prescription deductible of their previoushealth plan.

Plan participants who have additional prescription drugcoverage, including Medicare, should contact theirprescription plan administrator for coordination of benefits(COB) information.

Prior authorization may be required for a select group ofmedications. If a prescription is presented for one of thesemedications, the pharmacist will indicate that a priorauthorization is needed before the prescription can be filled.To receive a prior authorization, the prescribing physicianmust provide medical information including a diagnosisto the prescription drug plan administrator for review.Once a prior authorization is in place, the prescriptions maybe filled until the authorization expires, usually one year.

Formulary ListAll prescription medications are compiled on a formulary list(i.e., drug list) maintained by each health plan's prescriptionbenefit manager (PBM). Formulary lists categorize drugs inthree levels: generic, preferred brand and nonpreferred brand.Each level requires a different copayment amount. Eachplan maintains a formulary list of medications. Formularylists are subject to change any time during the plan year. Tocompare formulary lists, cost-savings programs and to obtaina list of network pharmacies that participate in the varioushealth plans, plan participants should visit the website of theirhealth plan. Certain health plans notify plan participants bymail when a prescribed medication they are currently takingis reclassified into a different formulary category. If aformulary change occurs, plan participants should consultwith their physician to determine if a change in prescription isappropriate.

Health MaintenanceOrganizations (HMOs)Health maintenance organizations (HMOs) use a separateprescription benefit manager (PBM) to administer theirprescription drug benefits. Employees who elect one of thesehealth plans must utilize a pharmacy participating in the plan’spharmacy network or the full retail cost of the medication willbe charged. If the employee uses a nonparticipatingpharmacy, partial reimbursement may be provided if the planparticipant files a claim with the health plan. It should be notedthat most plans do not cover over-the-counter drugs or drugsprescribed by medical professionals (including dentists), otherthan the plan participant’s primary care physician (PCP) or anyspecialist the plan participant was referred to by their PCP.Employees should direct prescription benefit questions tothe respective health plan administrator. Refer to theannual Benefit Choice Options booklet for specificinformation regarding deductible and copaymentamounts.

Open Access Managed CarePlans and the Quality CareHealth Plan (QCHP) Open access managed care plans and the Quality CareHealth Plan (QCHP) have prescription drug benefitsadministered through the self-insurance plans’ prescriptionbenefit manager (PBM). Prescription drug benefits areindependent of other medical services and are not subjectto the medical plan year deductible or out-of-pocketmaximums. Most drugs purchased with a prescription froma physician or a dentist are covered; however, over-the-counter drugs are not covered, even if purchased with aprescription. If a plan participant elects a brand name drugand a generic is available, the plan participant must pay thecost difference between the brand product and the genericproduct, in addition to the generic copayment. Membersenrolled in the QCHP or an open access managed careplan are limited to a 60-day maximum supply per fill.Members may receive a 90-day supply of medication fortwo copayments by utilizing the mail order option. See the‘Mail Order Prescriptions’ section for details.

Prescription Drug Step Therapy (PDST) is required formembers who have their prescription drug benefitsadministered through QCHP or one of the open access

Prescription Coverage

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Prescription Coverage (cont.)managed care plans are subject to a coverage tool calledPDST for specific drugs. PDST requires the member to firsttry one or more specified drugs to treat a particular conditionbefore the plan will cover another (usually more expensive)drug that their doctor may have prescribed. PDST isintended to reduce costs to both the member and the plan byencouraging the use of medications that are less expensivebut can still treat the member’s condition effectively.

Members who are taking a medication that requiresstep therapy will receive a letter explaining that the planwill not cover that particular medication unless thealternative medication is tried first. The letter will alsohave directions on how a member’s physician may requesta coverage review if the physician believes they should takethe original medication without trying the alternativemedication first.

Compound drugs are covered under the prescription drugplan. Compound drugs purchased from a network pharmacyare subject to the applicable copayment. As these are uniquemedications, contact the prescription drug plan administratorimmediately if the network pharmacy attempts to chargemore than the appropriate copayment.

Injectable and intravenous medications may be obtainedthrough a retail network pharmacy or through the prescriptiondrug plan administrator’s mail order pharmacy.

If a network pharmacy does not stock a particular drug orsupply and is unable to obtain it, call the prescription drugplan administrator for further direction.

Prepackaged prescriptions – A copayment is based on a1 to 30-day supply as prescribed by the physician. Sincemanufacturers sometimes prepackage products in amountsthat may be more or less than a 30-day supply as prescribed,more than one copayment may be required.

– Example A (more than a 30-day supply):Manufacturers commonly prepackage lancets inunits of 100. If the 30-day prescription is for 90 units,two copayments are required since the prepackagedamount exceeds the 30-day supply as required bythe prescription.

– Example B (less than a 30-day supply):Manufacturers commonly prepackage certain supplies,such as inhalers and tubes of ointment. Since thepackaged medication may be less than a 30-daysupply, more than one packaged unit may be required;therefore, more than one copayment will be required.

Prescribed medical supplies are supplies necessary for

the administration of prescription drugs such as coveredhypodermic needles and syringes. Copayments apply.

Diabetic supplies and insulin that are purchased with aprescription are covered through the plan and are subjectto the appropriate copayment.

Some diabetic supplies are also covered under MedicarePart B. If the plan participant is not Medicare Part Bprimary, the appropriate copayment must be paid at the timeof purchase at a network pharmacy. If Medicare Part B isprimary, the plan participant is responsible for the Medicarecoinsurance at the time of purchase. The claim must firstbe submitted to Medicare for reimbursement. Upon receiptof the Medicare Summary Notice (MSN), a claim may befiled with the prescription drug plan administrator for anysecondary benefit due. If the diabetic supplies are billed bya physician or medical supplier, the supplies would be paidby the health plan administrator.

Insulin pumps and their related supplies are not coveredunder the prescription drug plan. In order to receivecoverage for these items, contact the health plan administratorlisted in the current Benefit Choice Options booklet.

Nonmaintenance Medication

In-Network Pharmacy

Retail pharmacies that contract with the prescription benefitmanager (PBM) and accept the copayment amount formedications are referred to as in-network pharmacies. Planparticipants who use an in-network pharmacy must presenttheir prescription ID card/number or they will be required topay the full retail cost. If, for any reason, the pharmacycannot verify eligibility when they submit the claimelectronically, the plan participant will need to submit a claimform to the PBM.

The maximum supply of nonmaintenance medicationallowed at one fill is 60 days, although two copayments willbe charged for any prescription that exceeds a 30-daysupply. A list of in-network pharmacies, as well as claimforms, is available on the Benefits website.

Out-of-Network Pharmacy

Pharmacies that do not contract with the PBM are referredto as out-of-network pharmacies. In most cases,prescription drug costs will be higher when an out-of-network pharmacy is used. If a medication is purchased atan out-of-network pharmacy, the plan participant must pay the


full retail cost at the time the medication is dispensed.Reimbursement of eligible charges may be obtained bysubmitting a paper claim and the original prescriptionreceipt to the PBM. Reimbursement will be provided atthe applicable brand or generic in-network price minus theappropriate in-network copayment. Claim forms areavailable on the Benefits website.

Maintenance Medication

The Maintenance Medication Program (MMP) wasdeveloped to provide an enhanced benefit to plan participantswho use maintenance medications. The MMP is comprisedof a Maintenance Pharmacy Network and a Mail OrderPharmacy. A maintenance medication is medication that istaken on a regular basis for conditions such as high bloodpressure and high cholesterol. To determine whether amedication is considered a maintenance medication, contact amaintenance network pharmacy or the PBM.

The MMP is comprised of a Maintenance PharmacyNetwork and a Mail Order Pharmacy. Both options aredescribed in the next section.

Maintenance Pharmacy Network

The Maintenance Pharmacy Network is a network ofretail pharmacies that contract with the PBM to accept thecopayment amount for maintenance medication. Whenplan participants use the Maintenance Pharmacy Networkfor maintenance medications they will receive a 90-daysupply of medication (equivalent to 3 fills) for only twoand a half copayments. Pharmacies in this network mayalso be an in-network retail pharmacy as described in the‘Nonmaintenance Medication’ section. If a planparticipant uses an in-network pharmacy that is notpart of the Maintenance Pharmacy network, only thefirst two 30-day fills (or only the first 60-day fill) will becovered at the regular copayment amount; subsequentfills will be charged at two times the copayment rate. Alist of pharmacies participating in the MaintenancePharmacy Network is available on the Benefits website.

Mail Order Pharmacy

The Mail Order Pharmacy provides participants theopportunity to receive medications directly from the PBM.Both maintenance and nonmaintenance medicationsmay be obtained through the mail order process. Whenplan participants use the Mail Order Pharmacy formaintenance medications they will receive a 90-day supplyof medication (equivalent to 3 fills) for only two and a

half copayments. To utilize the Mail Order Pharmacy, planparticipants must submit an original prescription from theattending physician. For maintenance medication, theprescription should be written for a 90-day supply andinclude up to three 90-day refills totaling one year ofmedication. The original prescription must be attached to acompleted Mail Order form and sent to the addressindicated on the form. Order forms can be obtained bycontacting the PBM or by accessing the Benefits website.

Special Note Regarding Medications forNursing Home/Extended Care Facility Patients

Due to the large amounts of medication generallyadministered at nursing homes and extended carefacilities, many of these types of facilities cannot maintainmore than a 30-day supply of prescriptions per patient. Inorder to avoid being charged a double copayment for a 30-day supply, the patient or person who is responsible for thepatient’s healthcare (such as a spouse, civil union partner,power of attorney or guardian) should submit a letterrequesting an ‘exception’ to the double copayment for theirmedication. The effective date of the exception is thereceipt date of the request. NOTE: Since each request isbased on a specific list of medications, any newlyprescribed medication(s) must be sent as another request.

Request Requirements

F Must be in the form of a letter.

F Must include the patient’s name, a list of all medicationsthe patient is taking and the dosage of each medication.


DCMS Group Insurance DivisionMember Services Unit801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

Coordination of BenefitsThis Program coordinates with Medicare and other groupplans. The appropriate copayment will be applied for eachprescription filled.

Exclusions and LimitationsThe Program reserves the right to exclude or limit coverageof specific prescription drugs or supplies.

Prescription Coverage (cont.)

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Employee Assistance Program

EMPLOYEE ASSISTANCEPROGRAM

The Employee Assistance Program (EAP) provides a valuableresource for support and information during difficult times. TheEAP is a confidential assessment and referral service that willlink the individual to EAP counselors who will help develop thelife management skills needed to enjoy life more fully.

Getting help is easy, convenient and confidential. Trainedcustomer service associates and EAP care managers areavailable via a toll-free telephone number (phone numbers canbe found on the Benefits website). Individuals will be directedto counseling services to assist with a variety of concerns.

The EAP is a no cost, voluntary and confidential program thatprovides problem identification, counseling and referral servicesfor employees and their families. EAP counselors areexperienced in providing support, understanding and guidancefor a broad range of needs. The EAP provides confidentialassistance on a variety of concerns including, but not limited to:

F Anger management

F Anxiety

F Conflict at work or home

F Domestic violence

F Elder care issues

F Family/parenting issues

F Feelings of worry or the blues

F Financial concerns

F Grief/loss

F Pre and postnatal concerns

F Problems with alcohol or drugs

F Stress

Authorization EAP is a benefit at no cost to the member, howeverauthorization is required before services are rendered. Ifhelp is needed beyond the scope of the EAP services, theEAP counselor may refer the individual for additional help.Call the plan administrator for further information.

Getting AssistanceThe EAP counselor will help clarify the reason the individualis seeking assistance, identify available options and helpdevelop a plan. Short-term counseling may be all that isrequired with the EAP counselor.

Privacy and ConfidentialityAll calls and counseling sessions are confidential. Informationwill not be disclosed unless written consent is given or asrequired by law.

EligibilityActive State employees and their dependents participatingin the State Employees Group Insurance Program mayaccess this benefit regardless of their choice of health plan.Active employees who opt out or waive health, dental andvision coverage remain eligible for this benefit.Dependents of members who opted out of the health planare not eligible for this benefit.

Accessing ServicesThere are two separate Employee Assistance Programs foractive employees: the Personal Support Program (PSP)through AFSCME Council 31 and the EAP through the EAPbehavioral health administrator.

F Bargaining unit employees represented by AFSCMECouncil 31 and covered under the collective bargainingagreement between the State of Illinois and AFSCMEmust access EAP services through the PersonalSupport Program. See the Benefit Choice Optionsbooklet for plan administrator information.

F All other active and eligible employees NOTrepresented or covered by the collective bargainingagreement between the State of Illinois and AFSCMEmust contact the EAP behavioral health administrator.See the Benefit Choice Options booklet for planadministrator information.

Services beyond EAPIf the individual is referred for additional help beyond thescope of services provided by the EAP and elects to usethose services, the resulting costs and copayments, asapplicable, are the individual’s responsibility.

Management SupportWorkplace Support Services are available to helpmanagers, supervisors and HR representatives address awide variety of workplace issues. Workplace Supportconsultants work with you to assess the seriousness of theproblem and to help you determine the appropriate level ofintervention based on your Agencies policies. Levels ofintervention range from a basic management consultation,where you can learn to talk more effectively with theemployee or employees who are experiencing difficulties,to the most structured form of intervention, the mandatoryreferral, in which the employee’s participation in treatmentis required as a condition of continued employment.


OverviewBehavioral health services are for the diagnosis and treatmentof mental health and/or substance abuse disorders. Eligiblecharges are for those services deemed medically necessaryby the plan administrator. The coverage of behavioral healthservices (mental health and substance abuse) complieswith the federal Mental Health Parity and Addiction EquityAct of 2008. This federal law requires health plans to coverbehavioral health services at benefit levels equal to thoseof the plan’s medical benefits.

Managed Care PlansCoverage for behavioral health services is provided underall of the managed care plans. There are no restrictionsregarding the number of visits and hospital days allowedper plan year. Covered services for behavioral health muststill meet the managed care plan administrator’s medicalnecessity criteria and will be paid in accordance with themanaged care benefit schedule. Please contact themanaged care plan for specific benefit information.

Quality CareHealth Plan (QCHP)The charges for behavioral health services are included in aplan participant’s annual plan deductible and annual out-of-pocket maximum. Covered services for behavioral healthwhich meet the plan administrator’s medical necessitycriteria are paid in accordance with the Quality Care HealthPlan (QCHP) benefit schedule for in-network and out-of-network providers. Please contact the behavioral healthplan administrator for specific benefit information and for alisting of in-network hospital facilities and participatingproviders.

Authorization Requirements

for Behavioral Health Services

In an emergency or a life-threatening situation, call 911, orgo to the nearest hospital emergency room. Planparticipants must call the behavioral health plan administratorwithin 48 hours to avoid a financial penalty. Authorizationrequirements still apply when plan participants have othercoverage, such as Medicare.

F Inpatient services must be authorized prior to admissionor within 48 hours of an emergency admission toreceive in-network or out-of-network benefits.Authorization is required with each new admission.Failure to notify the behavioral health plan administratorof an admission to an inpatient facility within 48 hourswill result in a financial penalty and risk incurringnoncovered charges.

F Partial hospitalization and intensive outpatienttreatment must be authorized prior to admission toreceive in-network or out-of-network benefits.Authorization is required before beginning each treatmentprogram. Failure to notify the behavioral health planadministrator of a partial hospitalization or intensiveoutpatient program will result in a financial penalty andrisk incurring noncovered charges.

F Outpatient services received at the in-network benefitlevel must be provided by a QCHP network provider.Most routine outpatient services (such as therapysessions and medication management) will be coveredwithout the need for prior authorization. Authorizationrequirements for certain specialty outpatient servicesare noted below. Outpatient services that are notconsistent with usual treatment practice for a planparticipant’s condition will be subject to a medicalnecessity review. The behavioral health administratorwill contact the plan participant’s provider to discuss thetreatment if a review will be applied. Outpatientservices received at the out-of-network benefit levelmust be provided by a licensed professional includinglicensed clinical social worker (LCSW), registerednurse, clinical nurse specialist (RN CNS), licensedclinical professional counselor (LCPC), licensedmarriage and family therapist (LMFT), psychologist orpsychiatrist to be eligible for coverage.

F Electroconvulsive therapy, psychological testingand applied behavioral analysis must be authorizedto receive in-network or out-of-network benefits. Failureto obtain authorization will result in the risk of incurringnoncovered charges.

F No benefits are available for residential treatment.

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OverviewThe Quality Care Dental Plan (QCDP) is designed to offerplan participants coverage for basic dental services regardlessof the health plan chosen. Employees who opt out of thehealth plan are not eligible for dental coverage.

Each plan participant is subject to an annual dental plandeductible for all dental services, except those listed in theDental Schedule of Benefits as ‘Diagnostic’ or ‘Preventive’.Once the deductible has been met, the plan participant issubject to a maximum annual dental benefit. See thecurrent Benefit Choice Options booklet for the amount ofthe maximum benefit.

F Plan participants may go to any dentist.

F The maximum benefit amount paid for eligible servicesis listed in the Dental Schedule of Benefits. Dentalprocedure codes that are not listed in the Dental Scheduleof Benefits are not covered by the plan and are noteligible for payment. Employees are responsible for allcharges over the scheduled amount and/or over theannual maximum benefit. The Dental Schedule ofBenefits is available on the Benefits website atwww.benefitschoice.il.gov.

F Plan participants may obtain dental identification cardsfrom the dental plan administrator.

Employees may enroll in the dental plan at the time ofinitial hire, upon opting into the health plan or during theannual Benefit Choice Period. A monthly premium willapply for dental coverage.

Employees may opt out of the dental plan at the time ofinitial hire or during the annual Benefit Choice Period. Theelection to drop coverage will remain in effect the entire planyear, without exception.

Choosing a Provider With QCDP, plan participants can choose any dentalprovider for services; however, plan participants will receiveenhanced benefits, resulting in lower out-of-pocket costs,when they receive services from a network provider. Thereare two separate networks of providers that a plan participantmay utilize for dental services: the PPO network and thePremier network.

• PPO Network: If you receive services from a PPOdentist, your out-of-pocket expenses will often be lessbecause these providers accept a reduced PPO fee (lessany deductible). If the PPO fee is higher than theamount listed on the Schedule of Benefits, you will berequired to pay the difference.

• Premier Network: If you receive services from aPremier dentist, your out-of-pocket expenses may beless because Premier providers accept the allowedPremier fee (less any deductible). If the allowed fee ishigher than the amount listed on the Schedule ofBenefits, you will be required to pay the difference.

Out-of-Network ServicesIf you receive services from a dentist who does notparticipate in either the PPO or Premier network, theamount paid by the plan will be in accordance with theSchedule of Benefits.

Preventive and Diagnostic Services Preventive and diagnostic services are not subject tothe annual deductible and include, but are not limited to:

• Two periodic oral examinations per person per plan year.

• Two adult or child prophylaxis (scaling and polishingof teeth) per person per plan year.

• Two bitewing radiographs per person per plan year.

• One full mouth radiograph per person every threeplan years.

Prosthodontics Prosthodontics, which include implants, crowns, bridgesand dentures, are subject to the following limitations:

• Prosthodontics to replace missing teeth are coveredonly for teeth that are lost while the person iscovered under this plan.

• Immediate dentures are covered only if five or moreteeth are extracted on the same day.

• Permanent dentures to replace immediate dentures arecovered only if placed in the person’s mouth within twoyears from the placement of the immediate denture.

• Replacement dentures are covered only under one of

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the following circumstances:

– Existing denture is at least 5 years old, or

– Structural changes in the person's mouth requirenew dentures.

• Replacement crowns are covered only when the existingcrown is at least 5 years old.

• Replacement bridges are covered only when the existingbridge is at least 5 years old.

Child OrthodonticsThe child orthodontia benefit is available only to children whobegin treatment prior to the age of 19. A maximum lifetimebenefit for child orthodontia applies regardless of the numberof courses of treatment. The annual plan year deductible willneed to be satisfied unless it was previously satisfied forother dental services incurred during the plan year.

The maximum lifetime benefit amount applies to each planparticipant and does not start over with each course oftreatment. A course of treatment can be for anyorthodontic services, not only the placement of braces.For example, a child may have a retaining device whenthey are 8 years old and then have braces installed whenthey are 15. The benefit amount for the retainer plus thebenefit amount for the braces can not exceed themaximum lifetime benefit amount allowed.

The benefit amount that will be paid for orthodontic treatmentdepends on the length of treatment plan as determined bythe orthodontist. The length of treatment time frames andthe associated benefit amount allowed is listed in theannual Benefit Choice Options booklet.

Twenty-five percent (25%) of the applicable orthodontiabenefit, based on the length of treatment, will be reimbursedafter the initial banding. The remaining benefit will beprorated over the remaining length of treatment period.

Provider PaymentIf you use a network dentist, you will not have to pay thedentist at the time of service (with the exception ofapplicable deductibles, charges for noncovered services,charges over the amount listed on the Schedule of Benefitsand/or amounts over the annual maximum benefit).Network dentists will automatically file the dental claim fortheir patients. Employees who use a network provider anddo not have any out-of-pocket costs for their visit will not

receive an explanation of benefits (EOB). The employeemay, however, view their EOB on the dental planadministrator’s website.

Participants who use an out-of-network dentist mayhave to pay the entire bill at the time of service and/orfile their own claim form depending on the paymentarrangements the plan participant has with theirdentist. Out-of-network dentists can elect to acceptassignment from the plan or may require other paymentterms. Coordination of benefits applies to any other dentalcoverage.

Pretreatment EstimateFor both prosthodontics and orthodontics, although notrequired, a pretreatment estimate is strongly encouraged toassist plan participants in determining the benefitsavailable. To obtain a pretreatment estimate planparticipants should contact their dental provider.

Benefits for Services ReceivedWhile Outside the United StatesThe plan covers eligible charges incurred for servicesreceived outside of the United States. All plan benefits aresubject to plan provisions and deductibles.

Payment for the services may be required at the timeservice is provided and a paper claim must be filed withthe dental plan administrator. When filing the claim,enclose the itemized bill with a description of the servicetranslated to English and converted to U.S. currency alongwith the name of the patient, date of service, diagnosis,procedure code and the provider’s name, address andtelephone number.

Dental Coverage (cont.)

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Dental Coverage (cont.)

Dental Exclusions and LimitationsNo benefits shall be payable for:

1. Dental services covered under the health plan.

2. Services rendered prior to the plan participant’s effectivedate of coverage or subsequent to the date of terminationof coverage.

3. Services not listed in this plan description or for servicesrendered prior to the date a service or procedure becamea covered benefit as indicated in this plan description.

4. Services performed to correct development malformationincluding, but not limited to, cleft palate, mandibularprognathism, enamel hypoplasia, fluorosis and anodontia(i.e., the absence of teeth).

5. Dental services relating to the diagnosis or treatment,including appliances, for temporomandibular jointdisorders (TMJ) and myofunctional disorders,craniofacial pain disorders and orthognathic surgery.However, occlusal guards are covered.

6. Services not necessary or not consistent with the diagnosisor treatment of a dental condition, as determined by thedental plan administrator.

7. Orthodontia of deciduous (baby) teeth or adult orthodontia.

8. Services compensable under the Workers’ CompensationAct or Employer’s Liability Law.

9. Procedures or surgeries undertaken for primarily cosmeticreasons.

10. Construction of duplicate dentures.

11. Replacement of a prosthesis for which benefits werepaid under this plan, if the replacement occurs within fiveyears from the date the expense was incurred, unless:

– The replacement is made necessary by the initialplacement of an opposing full prosthesis or theextraction of natural teeth;

– The prosthesis is a stayplate or a similar temporaryprosthesis and is being replaced by a permanentprosthesis; or

– The prosthesis, while in the oral cavity, has beendamaged beyond repair, as a result of injury whileeligible under the plan.

12. Customization of dental prosthesis, including personalized,elaborate dentures or specialized techniques.

13. Expenses associated with obtaining, copying orcompleting any dental or medical reports.

14. Charges for procedures considered experimental innature.

15. Service or care performed by a family member or otherperson normally residing with the participant.

16. Services provided or paid for by a governmental agencyor under any governmental program or law, except forcharges which the person is legally obligated to pay.This exception extends to any benefits provided underthe U.S. Social Security Act and its amendments.

17. General anesthesia, conscious sedation and intravenoussedation services (with the exception of childrenunder age 6) unless medically necessary. Supportingdocumentation from a physician will be reviewed by thedental plan administrator.

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OverviewThe vision plan is designed to assist with the costs of well-vision care and to encourage the maintenance of visionthrough regular eye exams. Periodic eye exams candetect and prevent ailments not only in the eyes, butthroughout the body. The plan provides coverage whenglasses or contacts are required. For more information,contact the vision plan administrator.

EligibilityAll plan participants covered by any of the health plansoffered by the State Employees Group Insurance Programare eligible for vision care benefits. Benefit levels arepublished on an annual basis in the Benefit Choice Optionsbooklet.

Frequency of BenefitsEach service component is available once every 24 monthsfrom the last time the benefit component was used, exceptfor the eye examination benefit which is available once every12 months from the last time used. Each service componentis independent and may be obtained at separate times fromseparate providers. For example, a plan participant mayreceive an eye examination from one provider and purchaseframes/lenses from a different provider.

Provider ServicesMaterials and services obtained from a network provider arepaid at the network provider coverage benefit level. Applicablecopayments and additional charges must be paid at thetime of service. Eligible services or materials may be obtainedfrom any licensed optometrist, ophthalmologist or optician.A directory of network providers can be found on the planadministrator’s website.

If an out-of-network provider is used, the plan participantmust pay the provider in full and request reimbursement fromthe vision plan administrator. To request reimbursement,send an itemized receipt and a claim form requestingreimbursement to the vision plan administrator.Reimbursement will be paid up to the maximum allowanceamount as detailed in the schedule of benefits, out-of-network provider coverage chart in the annual BenefitChoice Options booklet. Out-of-network provider benefitsare paid directly to the covered employee. Claim forms areavailable on the Benefits website and through the planadministrator.

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OverviewThere are two types of coverage available: Basic Lifeinsurance coverage and Optional Life insurance coverage.Life insurance options change upon retirement. Refer tothe Retiree, Annuitant and Survivor Benefits Handbookfor life insurance options available to retirees and survivors.For more information regarding life insurance coverageand benefits, consult the State of Illinois Group Term LifeCertificate of Insurance or contact the life insurance planadministrator.

Basic Life CoverageTerm life insurance coverage is provided automatically atno cost to eligible employees through the State EmployeesGroup Insurance Program. This coverage is provided tofull-time and part-time employees. Each eligible activeemployee, regardless of age, is insured for an amountequal to their annual basic salary.

Optional Life CoverageEmployees may purchase Optional Life insurancecoverage. All premiums for Optional Life insurancecoverage are at the employee’s expense. MemberOptional Life premiums are based on age. Rates arepublished each year in the Benefit Choice Options booklet.

Optional Life insurance coverage choices include:

F Member Optional Life. Coverage up to eight times theBasic Life amount.

F Accidental Death and Dismemberment (AD&D).Accidental Death and Dismemberment (AD&D) isavailable to members in either (1) an amount equal totheir Basic Life amount, or (2) the combined amount oftheir Basic and Member Optional Life, subject to a totalmaximum of five times the Basic Life insurance amountor $3,000,000, whichever is less.

F Spouse Life. Term coverage of $10,000. Spouse Lifeapplies to civil union partners, but does not apply todomestic partners.

F Child Life. Term coverage of $10,000 per child. Alldependent children age 25 and under are eligible forChild Life coverage, except individuals enrolled in theOther category. Children in the Disabled category areeligible for life coverage as long as they continue tomeet eligibility requirements.

Changes to CoverageCertain changes to life insurance coverage may be madeany time during the plan year.

Adding or Terminating AD&D, Spouse Life and/orChild Life

The following life insurance options may be added ordropped any time without a qualifying change in status:

• AD&D coverage

• Spouse Life coverage *

• Child Life coverage *

* Statement of health approval is required (see ‘Statementof Health Approval’ in this section) to add coverage unlessthe spouse, civil union partner or child is newly acquired.

Member Optional Life Coverage

Employees may add, increase, terminate or decreaseMember Optional Life any time during the plan year withoutexperiencing a qualifying change in status event if, at thetime of the request, the employee’s Basic Life + MemberOptional Life coverage combined totals $50,000 or greater.

When electing to decrease or terminate Member OptionalLife coverage, the total amount of Basic Life + MemberOptional Life coverage cannot drop below $50,000. IfBasic Life + Member Optional Life is less than $50,000 atthe time of the request, the employee must wait until eithera qualifying change in status occurs or until the annualBenefit Choice Period to change their election.

Example: An employee with a base salary of $25,000 whohas three times Member Optional Life coverage has a totalamount of $100,000 in life insurance coverage (Basic Life =$25,000 + Member Optional Life = $75,000). Since BasicLife + Member Optional Life is greater than $50,000, theemployee would be allowed to increase or decrease thecoverage any time during the plan year. This employeewould not be allowed to terminate all Member Optional Lifeuntil the next Benefit Choice Period or until they experienceda qualifying event since that change would make thecombined amount of life coverage less than $50,000.

Life Insurance Coverage


Statement of Health ApprovalWhen an employee requests to increase Member OptionalLife, or requests to add Spouse Life or Child Life coverage,evidence of insurability (an approved statement of healthapplication) is required. If approved, coverage will beeffective the date the statement of health was approved bythe life insurance plan administrator.

A statement of health is not required for newborns addedwithin 60 days of birth, or for newly-acquired dependents(including a spouse, civil union partner, adopted child,stepchild, child of civil union partner or child for whom theemployee has obtained legal guardianship) added within60 days of the qualifying event. Statement of healthapplications are available on the Benefits website.

Effective Date of Life Coverage ChangeWhen increasing Member Optional Life, or when addingMember Optional Life, Spouse Life or Child Life, theeffective date of the coverage will be the statement ofhealth approval date. The life plan administrator will senda letter to the employee and the GIR that indicateswhether the statement of health application was approvedor denied.

When adding or increasing AD&D coverage theeffective date will be the date the request was received bythe GIR.

When terminating or decreasing any Optional Lifecoverage outside the Benefit Choice Period, the effectivedate will be the date of the request. A future effectivedate may be requested as long as it is within 60 days ofthe current date.

Requests made during the Benefit Choice Period to add,increase, decrease or terminate any Optional Lifecoverage will be effective July 1st.

Accelerated BenefitsLife insurance benefits may be paid prior to deathunder certain circumstances. Accelerated benefits offeraccess to a portion of life insurance benefits if theemployee is diagnosed with a terminal illness with a lifeexpectancy of 24 months or less. Contact your GroupInsurance Representative (GIR) or the life insurance planadministrator for more information.

Beneficiary FormA life insurance beneficiary form must be completed by theemployee at the time of employment. It is the employee’sresponsibility to contact the life insurance plan administratorwith any changes to the beneficiary designation and/orbeneficiary address.

Continuing Life InsuranceCoverage after EmploymentTerminatesWhen State employment terminates life insurance coveragemay be continued at the member’s expense. Basic Lifeand Member Optional Life coverage may be converted to aform of individual life insurance (not term insurance) offeredby the life insurance plan administrator. Member OptionalLife insurance coverage may be ported in lieu of converting.In order to continue coverage, the member must contacttheir GIR or the plan administrator within 31 days of thedate the member terminates employment. Contact the lifeinsurance plan administrator for additional informationregarding conversion and portability options.

Should the member choose to continue coverage throughone of the available insurance products, the full premiummust be paid directly to the plan administrator. Once themember makes the selection, the Program is no longerinvolved in the administration or premium rate structure ofthese insurance products.

Life Insurance Coverage uponRetirementEmployees under age 60 who retire are insured for anamount equal to their annual basic salary as of their lastday of employment. Once the retired employee reachesage 60, Basic Life coverage decreases to $5,000. ForOptional Life insurance options refer to the Retiree,Annuitant and Survivor Benefits Handbook.

Death of a Plan ParticipantIn the case of a member or dependent’s death, the survivorshould contact the agency GIR or the life planadministrator, Minnesota Life, for assistance with filing aclaim for death benefits. A copy of the death certificate willbe required by the life plan administrator. Minnesota Lifecan be contacted toll-free at (888) 202-5525.

Life Insurance Coverage (cont.)

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Chapter 3Chapter 3: Optional Programs

Flexible Spending Accounts (FSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Commuter Savings Program (CSP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Adoption Benefit Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Smoking Cessation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

60 www.benefitschoice.il.govBenefits Handbook


The Flexible Spending Account (FSA) Program offers twotax-savings plans, the Medical Care Assistance Plan (MCAP)and the Dependent Care Assistance Plan (DCAP).

F Medical Care Assistance Plan (MCAP). This planuses tax-free dollars to pay eligible medically-necessaryexpenses incurred by the employee, spouse anddependent(s) during the plan year.

F Dependent Care Assistance Plan (DCAP). This planuses tax-free dollars to pay eligible child (age 12 and under)and/or adult daycare expenses during the plan year.

The FSA plan year runs from July 1 through June 30. EligibleState employees may set aside tax-free monies each yearto MCAP (per employee) and/or DCAP (per household).Employees should refer to the current Benefit Choice Optionsbooklet for the maximum amount allowed for an FSA.

Employees may enroll in DCAP up to the maximum amountallowed under the IRS guidelines; however, the totalmaximum contribution for a married couple cannot exceedthe maximum contribution amount allowed under the IRSrules per calendar year.

When enrolling in an FSA, employees designate theamount they wish to have deducted from each paycheck.The designated amount is deposited into the employee’sMCAP and/or DCAP account before any state, federal orsocial security taxes are withheld, resulting in reducedtaxes and greater disposable income.

Only the expenses of eligible dependents may be reimbursed.Dependents must qualify under the Internal Revenue Codein order to be eligible. See the FSA Booklet on the Benefitswebsite for dependent eligibility qualifications.

Employee EligibilityIn order to be eligible to participate in an FSA, employees must:

F work full-time or part-time not less than 50%; and

F be eligible to participate in one of the State’s health plans.

In addition to the two eligibility requirements that apply toall FSA enrollments, a DCAP participant and their spousemust be unavailable to care for the qualifying individual(child or adult). Therefore, the following eligibility rulealso applies to all DCAP enrollments.

F The employee's spouse must be either (1) gainfullyemployed; (2) a full-time student; (3) disabled andincapable of self-care; or (4) seeking employment andhave income for the year.

Temporary, intermittent and contractual employees, as wellas retirees, are not eligible to participate in the FSA Program.

EnrollmentEnrolling in an FSA must take place during the annualBenefit Choice Period, with the following two exceptions:

F Initial Hire: New employees have 60 days from thedate of employment to enroll.

F qualifying Change in Status: Employees whoexperience an eligible change in status have 60 days fromthe date of the qualifying event to enroll. The enrollmentmust be on account of and consistent with the nature ofthe event. Qualifying events and the associated allowablechange are indicated on the Change in Status formavailable on the Benefits website.

Employees who enroll in MCAP and/or DCAP during theannual Benefit Choice Period have an effective date of July1st. Employees who enroll in either plan during the plan yearhave an effective date of the first day of the pay periodfollowing the date the enrollment form was signed or the dateof the qualifying event, whichever is later. Employees maybegin submitting eligible expenses and/or services forreimbursement on or after effective date.

Qualifying Changes in StatusEmployees who experience an eligible change in statushave 60 days from the date of the qualifying event to enroll,change their election or revoke participation. Any electionchange must be on account of and consistent with thenature of the event. Qualifying events and the associatedallowable change are indicated on the Change in Statusform available on the Benefits website.

Employees who experience a qualifying change in statuswhich allows them to enroll or make a change in thetheir deduction amount will have an effective date of thefirst day of the pay period following the date the Change inStatus or Enrollment form was signed or the date of thequalifying event, whichever is later.

Employees who experience a qualifying change in statuswhich terminates their participation in the program (eithervoluntarily or involuntarily, such as termination of employment)will have an effective date of the last day of the pay periodfollowing the issue date of the paycheck in which the eventoccurred. Eligible expenses may only be submitted forreimbursement if they were incurred on or prior to that date.

Flexible Spending Accounts

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FLEXIBLE SPENDING ACCOUNT

Leave of Absence, Terminationand RetirementIn general, FSA participants who go off payroll are not eligibleto participate in an FSA. Reasons for ineligibility includetermination of employment, retirement or being on an unpaidleave of absence. MCAP participants who are ineligible forany of these reasons may continue participation in MCAPby continuing to make their deduction payment through thedirect pay MCAP COBRA option (post-tax) or by having allremaining plan year MCAP deductions taken from theirfinal paycheck or supplemental check (pretax). Thesecontinuation options apply only to MCAP participants.

F Lump-Sum Option: Employees who will be terminatingemployment or unexpectedly retiring during the planyear may elect to have all remaining plan year deductionstaken from their final paycheck or vacation/sicksupplemental check as a lump sum deduction. Electingthis option which will permit the participant to file claimsfor reimbursement through the end of the plan year,including the grace period. Employees interested inthis option should complete the MCAP COBRA form(available on the Benefits website) and contact theirGIR/P to have the lump-sum payment coordinated withthe payroll department.

F MCAP COBRA Option: Employees who areterminating employment, retiring or who are going onan unpaid leave of absence may elect to make directpayments each month to the FSA Unit for their MCAPdeductions. Participants electing this option will notreceive the pretax benefit; however, the participant willbe permitted to file claims for reimbursement throughthe end of the period for which they have paid. Thoseinterested in continuing participation through directpayments should complete the MCAP COBRA form(available on the Benefits website) and contact theFSA Unit at CMS. The FSA Unit will coordinate thecontinued enrollment and explain the paymentprocess. Payments must be sent to the FSA Unit untilthe participant returns to payroll. The participant isresponsible for submitting the MCAP COBRA paymenteach month; no monthly bill will be sent.

Re-enrollment in FSARe-enrollment in the Flexible Spending Accounts (FSA)Program is not automatic. Employees must re-enroll in theprogram each year during the annual Benefit ChoicePeriod. All employees who enroll in either MCAP and/or

DCAP will be mailed a re-enrollment packet to the addresson file at the beginning of the next annual Benefit ChoicePeriod. Employees are responsible for making surethey re-enroll whether or not they receive the re-enrollment packet. Employees who do not receive apacket by the first week of May should request anenrollment form from their agency GIR/P or obtain one fromthe Benefits website if they wish to participate. Theeffective date of Benefit Choice enrollments is July 1st.

Employees who return to work from a leave of absence inwhich their enrollment in FSA was terminated, must completeand submit a new MCAP or DCAP Enrollment Form to theGIR/P within 60 days of their return to payroll. The effectivedate of the FSA will be the first day of the pay period followingthe date the enrollment form was signed or the date theemployee returned to payroll, whichever is later.

The Following Applies toMCAP Accounts OnlyReimbursement of Over-the-Counter Items

Certain over-the-counter (OTC) items are reimbursablethrough an employee’s MCAP account. The main factor indetermining whether an OTC item will be eligible forreimbursement is whether or not the item is, or contains, amedicine or a drug. Items that are not, or do not contain, amedicine or a drug, such as Band-Aids or saline, arereimbursable. Over-the-counter items that do contain amedicine or a drug may be reimbursable as long as therequest is accompanied by a prescription. All OTC itemsmust meet IRS regulations in order to be reimbursed.

Throughout the plan year, an over-the-counter item may beadded to the IRS’s list of items eligible for reimbursement. Ifthis occurs, reimbursement for the item may be requested evenif the item was purchased prior to the date the item was addedto the list. Employees cannot, however, enroll in the MCAPprogram or increase their MCAP contribution simply becausean OTC item they use is added to the list of eligible items.

A list of eligible OTC categories can be found on the planadministrator’s website.

MCAP Grace Period

In an effort to prevent plan participants from forfeiting MCAPcontributions, the IRS instituted a ‘grace period’ for MCAPexpenses. This grace period applies to employees enrolledin the MCAP plan only.

Flexible Spending Accounts (cont.)


The MCAP grace period, which runs 75 days after the endof the plan year (i.e., until September 15th), allows MCAPparticipants to incur eligible healthcare expenses and bereimbursed out of the prior plan year’s MCAP account (if abalance is available). As with all claims, reimbursementrequests for grace period expenses must be submitted tothe plan administrator by the end of the run-out period,September 30th.

Expenses incurred during the grace period will be paidfrom the funds remaining in the prior plan year’s MCAPaccount before funds from the current plan year areaccessed. Once the prior year’s MCAP account balancehas been depleted, all other services incurred during thegrace period will be reimbursed out of the new plan year’sMCAP account.

IMPORTANT: During the grace period, employees whohave receipts for services/items that were incurred during theprevious plan year that were paid for with out-of-pocket fundsshould submit those receipts prior to using the FSAcard. Employees who use their FSA card July 1st throughSeptember 15th will have those charges subtracted fromtheir prior plan year’s account balance; thereby, depletingthe funds. Once the funds are depleted, any paperclaims submitted for reimbursement for servicesprovided during the prior plan year will be rejected.

Reimbursement Options for Orthodontic Braces

Employees who are planning to pay orthodontia expensesout of their MCAP account should request a pretreatmentestimate from the dental plan administrator prior to theannual Benefit Choice Period for purposes of accuratelyestimating their annual deduction amount. Under orover estimating the cost of braces is not a qualifyingevent to allow an employee to change their MCAP election.Employees should allow 4-6 weeks to obtain the estimate.

The orthodontist’s office will design a treatment plan for theindividual receiving the braces. The amount remainingafter the insurance payment and the deductible is subtractedis reimbursable through MCAP. The employee can bereimbursed in any of the following methods:

F One Lump Sum Payment. Employees can request alump sum payment of the full amount only in the planyear in which the banding is done.

F Two Lump Sum Payments. Employees, who have acontract that designates two lump-sum payments, onein each plan year, can request reimbursement for the

first lump sum payment in the first plan year and theremaining payment in the second plan year.

F Initial Down Payment and Monthly Contract. Theamount that an employee is required to pay as a downpayment on the first visit is reimbursable in that planyear. The remaining balance is reimbursable throughmonthly payments if the employee has a monthlycontract (copy of the patient’s contract is required).

F Monthly Contract. Employees who have a contractindicating monthly payments will be reimbursed themonthly payment amount each month. If the contractextends more than a 12-month period, the monthlypayments will be reimbursable throughout both planyears (copy of the patient’s contract is required).

Orthodontic treatment, other than braces, is reimbursedjust as any other dental claim.

FSA Card The State of Illinois offers employees enrolled in MCAP anFSA card to electronically access their MCAP account forimmediate reimbursement. There is no fee for the card. Thecard is loaded each year the employee enrolls in MCAP withthe elected annual amount and can be used the first day ofeligibility. Funds in an MCAP account can be accessed byeither using the FSA card or by submitting a paper claim.

When using the FSA card, prescriptions, over-the-counteritems and copayments are paid directly out of the employee’saccount without the need to provide documentation to the planadministrator. NOTE: Purchases made at drugstores that arenot IIAS* certified will need to have documentation submittedto the plan administrator. For a list of IIAS-certified merchants,visit the plan administrator’s website.

The State’s dental and vision insurance benefits are basedupon a schedule of benefits that allows a maximum amountto be paid for the eligible service. Since benefit levels arenot known ‘copayments,’ but are instead a ‘maximumbenefit amount,’ these amounts cannot be automaticallyadjudicated; therefore, documentation must be submittedto the plan administrator for these services.

When using the card for dental and vision services,participants should direct the provider to exclude theportion that will be paid by insurance from the amountswiped. If the provider does not exclude the insuranceportion when swiping the card, the employee will be


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responsible for reimbursing the FSA plan any amountthat was paid by insurance.

Repayment to the plan can be in the form of substitutinganother eligible, unreimbursed claim from another date ofservice or a personal check made payable to the State ofIllinois for the ineligible amount.

Employees Who Have Waived or Opted Out of HealthCoverage

Part-time employees who waive health, dental and visioncoverage or full-time employees who opt out of the coveragemay still elect to receive the FSA card; however, since theseemployees do not have coverage through the State of Illinois,the copayment amounts are not known by the FSA planadministrator. For this reason, follow-up documentationwill be required for all transactions, except prescriptions*and eligible OTC*.

Employees, who have transactions for which follow-updocumentation is required, but not provided, may besubject to involuntary withholding.

* The automatic adjudication system that allows eligiblemedical FSA expenses to be purchased with the FSAcard is called the Inventory Information Approval System(IIAS). This system is only used for auto adjudication ofprescription and eligible over-the-counter items.

Claim ReimbursementEmployees enrolled in MCAP are eligible to be reimbursedthe entire amount for which they enrolled effective theireligibility begin date.

Employees enrolled in DCAP may be reimbursed only theamount that is in their DCAP account at the time the claim isreceived by the plan administrator. If the claim amountexceeds the balance in the DCAP account, the outstandingbalance will be carried over until the next payroll deduction isreceived by the plan administrator. At that time, the remainingportion of the claim will be paid. DCAP expenses incurred whilethe employee and/or the employee’s spouse is not actively atwork or looking for work are ineligible for reimbursement.

Claim SubmissionEmployees must use a separate claim form for each planyears’ expenses. Claims for reimbursement may be madevia the online claims submission process on the planadministrator’s website, faxed or mailed. Reimbursementrequests must contain dates of service that occurred on orafter the eligibility begin date. Claim forms that are incomplete,do not have adequate documentation or that cross planyears (with the exception of dates of service occurringduring the ‘MCAP grace period,’ explained later in thissection) will not be paid. The plan administrator will send aletter (or email if the employee has signed up to ‘GoGreen’) to the employee indicating the reason the claimwas unpaid and will request that the employee send themissing and/or correct information for processing.

Employees have three months from the close of theplan year to submit claims for reimbursement. Thisthree-month period is referred to as the ‘run-outperiod.’ IRS regulations require employees to forfeit allfunds not requested by the September 30th run-outdeadline.

FSA Account Statements Employees who opted to ‘Go Green’ when they registeredfor an account on the FSA plan administrator’s website willreceive an email notice indicating that a PDF copy of theFSA statement is available by logging into their onlineaccount. Employees who did not enter an email willreceive a paper copy of the statement in the mail.

MCAP services/items indicated in RED on the quarterlystatement are FSA card transactions that must besubstantiated (i.e., follow-up documentation must beprovided to the plan administrator). Items indicated on thequarterly statement in RED for more than two consecutivestatement cycles will cause the employee’s card to besuspended. Furthermore, any paper claims submitted afterthe two cycles will be automatically substituted for anyoutstanding card transactions. It is the employee’sresponsibility to carefully review the statement.

For More Information For more information regarding the FSA Program, pleasecontact the FSA Unit at (800) 442-1300 or (217) 558-4509.

FLEXIBLE SPENDING ACCOUNT


OverviewThe Commuter Savings Program (CSP) is an IRS-approved,optional benefit that gives eligible employees the opportunityto use tax-free dollars to pay out-of-pocket, work-relatedcommuting and/or parking expenses (up to IRS limits). CSPcontributions are deducted from the participant’s paycheckbefore federal, state and social security taxes are withheld.Refer to the current Benefit Choice Options booklet for currentmonthly maximum limits.

EligibilityFull-time and part-time employees working 50% or greater ofa normal work period who have payroll checks processedthrough the Office of the Comptroller may enroll in CSP atany time. Employees who enter a nonpay status due to aleave of absence, dock time or suspension, retirement ortermination of employment are not eligible to continue inthe program.

Transit BenefitCSP allows eligible employees to use pretax dollars to payfor mass-transit or vanpooling expenses incurred forwork-related commuting costs. The transit media selected(e.g., CTA, Metra, etc.) is conveniently mailed directly tothe participant prior to the beginning of the benefit month.

Parking BenefitCSP allows eligible employees to use pretax dollars to payfor work-related parking expenses. Participants may electto have payments made directly to the parking provider ormay elect to be reimbursed by the plan administrator fortheir parking expenses. Direct payments to the parkingprovider will be made prior to the beginning of the benefitmonth. Employees electing to be reimbursed for theirparking expenses must request the reimbursement via theplan administrator’s website. Reimbursement for parkingexpenses cannot be made until the employee’s CSP payrolldeduction is received by the plan administrator.

Electing, Changing orCancelling the CSP BenefitCommuter Savings Program (CSP) benefits may be elected,changed or cancelled at any time. Enrollment in CSP is ona month-to-month basis. Participants may select a ‘recurring’option that allows the benefit to continue until the participantcancels or changes it via the plan administrator’s website.Enrolling, changing or cancelling a benefit is done viathe plan administrator’s website or by calling the planadministrator. All enrollments, changes and cancellationsmust be completed by close of business the 10th of eachmonth to be effective the 1st of the following month. Forexample, in order receive a transit pass for the month ofNovember; the employee must elect the benefit no laterthan October 10th.

Payroll DeductionsContributions are deducted from participant’s paycheck in thesame month as the benefit month. For example, employeesenrolled to receive a transit pass for the benefit month ofNovember will have payroll deductions for that benefit takenon the November payrolls. It is each participant’s responsibilityto verify the accuracy of CSP payroll deductions.

Lost or Missing Passesor VouchersParticipants should call the plan administrator if they fail toreceive their pass or voucher by the 3rd workday of themonth for which the benefit is effective. In order to receivereimbursement for a lost pass, a receipt proving a purchaseof a replacement pass is required. The receipt must besubmitted with a completed Refund Claim form, which canbe found on the Benefits website or the plan administrator’swebsite.

For More Information For more information regarding CSP, please contact theFSA Unit at (800) 442-1300 or (217) 558-4509.

Commuter Savings Program

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ADOPTION BENEFITPROGRAM

OverviewRecognizing adoption as a meaningful and viable way tobuild a family, the Department provides an Adoption BenefitProgram to assist employees who adopt a child. To encourageadoption, especially of children who traditionally wait longerfor families, the Adoption Benefit Program will reimburseeligible employees for some adoption expenses.

EligibilityThe Adoption Benefit Program is available to all employeeswho are eligible for benefits under the State EmployeesGroup Insurance Program (Program). Active employeeswho opt out or waive health coverage under the Programremain eligible for the Adoption Benefit Program.

The adoption must be final before expenses are eligible forreimbursement. The request for reimbursement must bereceived within one year from the end of the plan year theadoption became final. If both husband and wife are Stateemployees, only one adoption benefit is available per child.

Waiting ChildrenHundreds of children in Illinois are waiting to be adopted.Most live in foster homes, group homes or residential centersoperated by child welfare agencies. Because many of thesechildren wait too long for families, the State of Illinois isdetermined to shorten their wait by finding permanenthomes for more of them. The Adoption Benefit Programwill help in this effort.

Waiting Children are defined as:

F Minority children age three (3) and over and Caucasianchildren age eleven (11) and over, or

F Children with a diagnosis of a specific mental, physicalor emotional disability, or

F Children who need to be adopted with brothers andsisters, or

F Foreign children age three (3) and over.

Benefit AmountThe Adoption Benefit Program pays eligible expenses up toa maximum of $1,500 for a waiting child and up to amaximum of $1,000 for any other child. All adoptionbenefits are subject to Medicare and social security taxes.If more than one child is adopted, benefits are available foreach child.

Eligible ExpensesThe following adoption charges are eligible for reimbursement:

F Legal fees.

F Court fees.

F Adoption agency fees, including foreign adoption fees(adoption agency must be licensed by the State ofIllinois).

F Required medical exams for the child.

F Initial immunizations for the child.

F Transportation costs to bring the child to the adoptingparents (or for the adult accompanying the child to theUnited States).

Ineligible ExpensesThe following charges are not eligible for payment:

F Expenses for adopting stepchildren or the children of acivil union partner.

F Expenses for adopting children related to either parent,such as grandchildren, nephews, nieces, cousins,brothers or sisters.

F Transportation for the adopting parents.

F Medical examination fees for the adopting parents.

F Cost of personal items for either parents or child duringor after the adoption, such as clothing or food.

F Expenses provided by other adoption assistanceprograms.

F Pledges, gifts or support fees to an adoption agency.

The following documentation must be submitted:

F Receipts of eligible expenses.

F An informal memo or letter to the Department statingthat an adoption has been completed of a child who isnot related to the employee, civil union partner or spouse.

F The memo or letter must include the State employee’sname, address, employee work and/or home telephonenumber and agency name.

F A copy of the adoption decree from a court in the UnitedStates or the Department of Children and Family Services(DCFS) home study approval letter for adoption of achild outside the United States.

Adoption Benefit Program



Adoption Benefit ProgramDCMS Group Insurance Division 801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

Leave of Absence for AdoptionFor details concerning an eligible leave of absence foradoption, contact your agency’s personnel office.

For More InformationThe Department is the plan administrator of the AdoptionBenefit Program. Questions regarding the Adoption BenefitProgram or enrollment of the child in group insurancebenefits should be directed to the Department. Forquestions about adoptions in general, please contact theAdoption Information Center of Illinois at (800) 572-2390.

Adoption Benefit Program (cont.)

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OverviewEligible plan participants are entitled to receive a rebatetowards the cost of a smoking cessation program. Themaximum rebate is $200, limited to one per plan year andavailable only upon completion of a smoking cessationprogram. Please note that many managed care plans offersmoking cessation programs separate from the State’sSmoking Cessation Program. Employees who utilize asmoking cessation program through their managed careplan are not eligible for the Smoking Cessation Programbenefit through the Department. Contact the managedcare plan for more information regarding their smokingcessation program options and limitations.

EligibilityThe Smoking Cessation Program is available to all employeeswho are eligible for benefits under the State EmployeesGroup Insurance Program and their enrolled dependents.Active employees who opt out or waive health coverageunder the Program are not eligible for the SmokingCessation Program.

Ineligible for Reimbursement

The following therapies are not eligible for reimbursementunless they are an integral part of a smoking cessationprogram.

F Hypnosis (even if an integral part, will not be reimbursedunless performed by a medical doctor);

F Acupuncture;

F Prescription drug therapy;

F Nonprescription drug therapy;

F Aricular therapy.

Reimbursement Documentation Requirements

F Receipt indicating payment for the smoking cessationprogram.

F Program certificate verifying the number of sessions anddate of completion of the smoking cessation program.

F Employee’s name, address, agency name and agencytelephone number.


Smoking Cessation ProgramDCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

For More InformationThe Department of Central Management Services(Department) is the plan administrator of the SmokingCessation Program. Questions regarding the SmokingCessation Program should be directed to the Departmentat (800) 442-1300.

Smoking Cessation Program

SMOkING CESSATIONPROGRAM


Chapter 4Chapter 4: Miscellaneous

Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78


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If a plan participant enrolled in the Program is entitled to primarybenefits under another group plan, the amount of benefitspayable under the Program may be reduced. The reductionmay be to the extent that the total payment provided by allplans does not exceed the total allowable expense incurred forthe service. Allowable expense is defined as a medicallynecessary service for which part of the cost is eligible forpayment by this plan or one of the plans identified below.

Under coordination of benefits (COB) rules, the Department’splan first calculates what the benefit would have been for theclaim if there was no other plan involved. The Department’splan then considers the amount paid by the primary plan andpays the claim up to 100% of the allowable expense.

NOTE: When a managed care health plan is thesecondary plan and the plan participant does not utilizethe managed care health plan’s network of providers ordoes not obtain the required referrals, the managedcare health plan is not required to pay. Refer to themanaged care plan’s summary plan document foradditional information.

The State of Illinois coordinates benefits with the following:

F Any group insurance plan.

F Medicare.

F Any Veterans’ Administration (VA) plan.

F Any “no-fault” motor vehicle plan. This term means amotor vehicle plan which is required by law and providesmedical or dental care payments which are made, inwhole or in part, without regard to fault. A person whohas not complied with the law will be deemed to havereceived the benefits required by the law.

The State of Illinois does not coordinate benefits with thefollowing:

F Private individual insurance plans.

F Any student insurance policy (elementary, high schooland college).

F Medicaid or any other State-sponsored health insuranceprogram.

F TRICARE.

It is the employee’s responsibility to provide otherinsurance information (including Medicare) to theMedicare COB Unit. Any changes to other insurancecoverage must be reported promptly to the MedicareCOB Unit (contact information located in the Medicaresection).

Order of Benefit DeterminationThe Department’s medical and dental plans follow theNational Association of Insurance Commissioners (NAIC)model regulations. These regulations dictate the order ofbenefit determination, except for members who are eligiblefor Medicare due to End-Stage Renal Disease (ESRD).Refer to the ‘Medicare’ section for details regardingcoordination of benefits for plan participants eligible forMedicare. The rules below are applied in sequence. Ifthe first rule does not apply, the sequence is followed untilthe appropriate rule that applies is found. Special rules applyfor children of civil union partners. Contact the Departmentfor more information.

Employee or Member

The plan that covers the plan participant as an activeemployee or member is primary:

1. over the plan that covers the plan participant as adependent.

2. over the plan that covers the plan participant as alaid-off employee or retiree.

3. over the plan that covers the plan participant underCOBRA.

4. if it has been in effect the longest, back to the originaleffective date under the employer group, whether ornot the insurance company has changed over thecourse of coverage.

Dependent Children of Parents Not Separated orDivorced

The following “Birthday Rule” is used if a child is coveredby more than one group plan. The plans must pay in thefollowing order:

1. The plan covering the parent whose birthday* fallsearlier in the calendar year is the primary plan.

2. If both parents have the same birthday, the plan thathas provided coverage longer is the primary plan.

* Birthday refers only to the month and day in a calendaryear, not the year in which the person was born.

NOTE: Some plans not covered by state law may followthe Gender Rule for dependent children. This rule statesthat the father’s coverage is the primary carrier. In theevent of a disagreement between two plans, the GenderRule applies.

Coordination of Benefits


Dependent Children of Separated or DivorcedParents

If a child is covered by more than one group plan and theparents are separated or divorced, the plans must pay inthe following order:

1. The plan of the parent with custody of the child;

2. The plan of the spouse of the parent with custody ofthe child;

3. The plan of the parent not having custody of the child.

NOTE: If the terms of a court order state that one parentis responsible for the healthcare expenses of the childand the health plan has been advised of the responsibility,that plan is primary payer over the plan of the otherparent.

Dependent Children of Parents with Joint Custody

The Birthday Rule applies to dependent children of parentswith joint custody.

Coordination of Benefits (cont.)

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OverviewMedicare is a federal health insurance program for individualsage 65 and older, individuals under age 65 with certaindisabilities and individuals of any age with End-Stage RenalDisease (ESRD).

The Social Security Administration (SSA) or the RailroadRetirement Board (RRB)** determines Medicare eligibilityupon application and enrolls eligible plan participants into theMedicare Program. The Medicare Program is administeredby the Centers for Medicare and Medicaid Services (alsoknown as the federal CMS).

Medicare has the following parts:

F Part A is insurance that helps pay for inpatient hospitalfacility charges, skilled nursing facility charges, hospicecare and some home healthcare services. MedicarePart A does not require a monthly premium contributionfrom plan participants with enough earned work credits.Plan participants without enough earned work creditshave the option to enroll in Medicare Part A and pay amonthly premium contribution.

F Part B is insurance that helps pay for outpatient servicesincluding physician office visits, labs, x-rays and somemedical supplies. Medicare Part B requires a monthlypremium contribution.

F Part C (also known as Medicare Advantage) is insurancethat helps pay for a combination of the coverageprovided in Medicare Parts A, B and D. An individualmust already be enrolled in Medicare Parts A and B inorder to enroll in a Medicare Part C plan. Medicare PartC requires a monthly premium contribution.

F Part D is insurance that helps pay for prescription drugs.Generally, Medicare Part D requires a monthly premiumcontribution.

Medicare Due to AgePlan Participants Age 65 and older

The State of Illinois Group Insurance Program requires

all plan participants to contact the SSA and apply for

Medicare benefits three months prior to turning age 65.

Medicare Part A

Eligibility for premium-free Medicare Part A occurs when anindividual is age 65 or older and has earned at least 40work credits from paying into Medicare through SocialSecurity. An individual who is not eligible for premium-freeMedicare Part A benefits based on his/her own work creditsmay qualify for premium-free Medicare Part A benefitsbased on the work history of a current, former or deceasedspouse. All plan participants that are determined to beineligible for Medicare Part A based on their own workhistory are required to apply for premium-free MedicarePart A on the basis of a spouse (when applicable).

If the SSA determines that a plan participant is eligible forpremium-free Medicare Part A, the State of Illinois GroupInsurance Program requires that the plan participantaccept the Medicare Part A coverage and submit a copyof the Medicare identification card to the Medicare COBUnit upon receipt.

If the SSA determines that a plan participant is not eligiblefor Medicare Part A benefits at a premium-free rate, theState of Illinois Group Insurance Program does not requirethe plan participant to purchase Medicare Part A coverage;however, the State does require the plan participant toprovide a written statement from the SSA advising ofhis/her Medicare Part A ineligibility. The plan participant isrequired to submit a copy of the SSA statement to theMedicare COB Unit.

Medicare Part B

Most plan participants are eligible for Medicare Part B uponturning the age of 65.

Medicare

In order to apply for Medicare benefits, plan participants should contact the local SSA office or callthe SSA at (800) 772-1213. Plan participants may enroll in Medicare Part A on the SSA website atwww.socialsecurity.gov.

** Railroad Retirement Board (RRB) participants should contact their local RRB office or callthe RRB at (877) 772-5772 to apply for Medicare.


The State of Illinois Group Insurance Program does notrequire plan participants to enroll in Medicare Part B if theyare still actively working. The SSA allows plan participantsto delay enrollment in Medicare Part B (without penalty)until the plan participant either retires or losescurrent/active employment status (usually due to adisability-related leave of absence). At that time, the Staterequires the plan participant to enroll in Medicare Part B.

Medicare Due to DisabilityPlan Participants Age 64 and Under

Plan participants are automatically eligible for Medicare(Parts A and B) disability insurance after receiving SocialSecurity disability payments for a period of 24 months.

Medicare Part A

Plan participants who become eligible for Medicare disabilitybenefits are required to accept the Medicare Part Acoverage and submit a copy of the Medicare identificationcard to the Medicare COB Unit upon receipt.

Medicare Part B

Actively working plan participants who become eligible forMedicare disability benefits are not required to accept theMedicare Part B coverage. The SSA allows planparticipants to delay enrollment into Medicare Part B untilretirement or the loss of current/active employment statusoccurs. At that time, the State requires the plan participantto enroll in Medicare Part B.

Plan participants who are no longer working (withoutcurrent/active employment status due to retirement or adisability-related leave of absence) are required to enroll inMedicare Part B. The Medicare Part B requirementremains in effect as long as the employee is withoutcurrent/active employment status and does notpermanently return to work. Refer to the ‘Medicare Part BReduction’ section for more information.

Medicare Due to End-StageRenal Disease (ESRD)All State of Illinois Group Insurance Program planparticipants who are receiving regular dialysistreatments or who have had a kidney transplant on thebasis of ESRD are required to apply for Medicare benefits.

Plan participants must contact the State of Illinois MedicareCoordination of Benefits (COB) Unit at (800) 442-1300.The State of Illinois Medicare COB Unit calculates the 30-month coordination period in order for plan participants tosign up for Medicare benefits on time to avoid additionalout-of-pocket expenditures.

Medicare Part A

Plan participants who become eligible for Medicare benefitson the basis of ESRD are required to accept the MedicarePart A coverage and submit a copy of the Medicareidentification card to the Medicare COB Unit upon receipt.

Medicare Part B

The State of Illinois Group Insurance Program allowsactively working plan participants who are eligible forMedicare on the basis of ESRD to delay enrollment inMedicare Part B until the end of the ESRD coordinationperiod. Medicare Part B is required at the end of theESRD coordination period.

Medicare Coordination with theQuality Care Health Plan (QCHP)When Medicare is the primary payer, QCHP will coordinatebenefits with Medicare as follows:

Medicare Part A - Hospital Insurance

In-Network Provider: After Medicare Part A pays, QCHPpays 90% of the Medicare Part A deductible after theQCHP annual plan deductible has been met.

Out-of-Network Provider: After Medicare Part A pays,QCHP pays 60% of the Medicare Part A deductible afterthe QCHP annual plan deductible has been met.

Medicare Part B - Medical Insurance

In-Network Provider: After Medicare Part B pays, QCHPpays 90% of the balance after the QCHP annual plandeductible has been met.

Out-of-Network Provider: After Medicare Part B pays,QCHP pays 60% of the balance after the QCHP annualplan deductible has been met.

Medicare (cont.)

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Medicare Part B ReductionFailure to enroll or remain enrolled in Medicare Part Bwhen Medicare is determined to be the primary payer overthe QCHP will result in a reduction of eligible benefitpayments by the QCHP plan. For in-network providerclaims, QCHP will estimate the portion of the claim thatMedicare Part B would have paid. QCHP will then pay90% of the 20% claim balance (after the QCHP annual planyear deductible has been satisfied). For out-of-networkprovider claims, QCHP will pay 60% of the 20% of theclaim balance (after the QCHP plan year deductible hasbeen satisfied). The difference between the total chargeand the amount QCHP pays is the plan participant’sresponsibility.

Services and Supplies NotCovered by MedicareServices and supplies that are not covered by Medicare willbe paid by QCHP in the same manner (i.e., same benefitlevels and deductibles) as if the plan participant did nothave Medicare (provided the services and supplies meetmedical necessity and benefit criteria and would normallybe eligible for QCHP coverage).

Medicare CrossoverMedicare crossover is an electronic transmittal of claimdata from Medicare (after Medicare has processed theirportion of the claim) to the QCHP plan administrator forsecondary benefits.

In order to set up Medicare Crossover, plan participantsmust contact the QCHP plan administrator and provide theMedicare Health Insurance Claim Number (HICN) locatedon the front side of their Medicare identification card.

Private Contracts with Providerswho Opt Out of MedicareSome healthcare providers choose to opt out of the Medicareprogram. When a plan participant has medical servicesrendered by a provider who has opted out of the Medicareprogram, a private contract is usually signed explaining thatthe plan participant is responsible for the cost of the medicalservices rendered. Neither providers nor plan participants areallowed to bill Medicare. Therefore, Medicare will not pay forthe service (even if it would normally qualify as beingMedicare eligible) or provide a Medicare Summary Notice tothe plan participant. If the service(s) would have normallybeen covered by Medicare, the QCHP plan administrator willestimate the portion of the claim that Medicare Part B wouldhave paid. The QCHP plan administrator will then pay 90%of the 20% claim balance (after the QCHP annual plan yeardeductible has been satisfied) for services rendered by in-network QCHP providers. For out-of-network QCHP providerclaims, QCHP will pay 60% of the 20% (after the QCHP planyear deductible has been satisfied). The difference betweenthe total charge and what QCHP pays is the plan participant’sresponsibility.

Medicare (cont.)

Medicare COB Unit Contact Information

Department of Central Management ServicesMedicare Coordination of Benefits Unit801 S. 7th Street, P.O. Box 19208Springfield, Illinois 62794-9208

Phone: (800) 442-1300 or (217) 782-7007Fax: (217) 557-3973

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Subrogation and Reimbursement OverviewDepartment plans will not pay for expenses incurred forinjuries received as the result of an accident or incident forwhich a third party is liable. These plans also do notprovide benefits to the extent that there is other coverageunder nongroup medical payments (including automobileliability) or medical expense type coverage to the extent ofthat coverage.

However, the plans will provide benefits otherwise payableunder one of these plans, to or on behalf of its coveredpersons, but only on the following terms and conditions:

F In the event of any payment under one of these plans, theplan shall be subrogated to all of the covered person’srights of recovery against any person or entity. Thecovered person shall execute and deliver instrumentsand documents and do whatever else is necessary tosecure such rights. The covered person shall do nothingafter loss to prejudice such rights. The covered personshall cooperate with the plan and/or any representativesof the plan in completing such documents and in providingsuch information relating to any accident as the planby its representatives may deem necessary to fullyinvestigate the incident. The plan reserves the right towithhold or delay payment of any benefits otherwisepayable until all executed documents required by thisprovision have been received from the covered person.

F The plan is also granted a right of reimbursement fromthe proceeds of any settlement, judgment or otherpayment obtained by or on behalf of the covered person.This right of reimbursement is cumulative with and notexclusive of the subrogation right granted in the precedingparagraph, but only to the extent of the benefits paid bythe plan.

F The plan, by payment of any proceeds to a coveredperson, is thereby granted a lien on the proceeds ofany settlement, judgment or other payment intended for,payable to or received by or on behalf of the coveredperson or a representative. The covered person inconsideration for such payment of proceeds, consentsto said lien and shall take whatever steps are necessaryto help the plan secure said lien.

F The subrogation and reimbursement rights and liensapply to any recoveries made by or on behalf of thecovered person as a result of the injuries sustained,including but not limited to the following:

• Payments made directly by a third party tortfeasoror any insurance company on behalf of a thirdparty tortfeasor or any other payments on behalfof a third party tortfeasor.

• Any payments or settlements or judgments orarbitration awards paid by any insurance companyunder an uninsured or underinsured motoristcoverage, whether on behalf of a covered personor other person.

• Any other payments from any source designedor intended to compensate a covered person forinjuries sustained as the result of negligence oralleged negligence of a third party.

• Any Workers’ Compensation award or settlement.

F The parents of any minor covered person understandand agree that the State’s plan does not pay for expensesincurred for injuries received as a result of an accidentor incident for which a third party is liable. Any benefitspaid on behalf of a minor covered person are conditionalupon the plan’s express right of reimbursement. Noadult covered person hereunder may assign any rightsthat such person may have to recover medical expensesfrom any tortfeasor or other person or entity to any minorchild or children of the adult covered person without theexpress prior written consent of the plan. In the eventany minor covered child is injured as a result of the actsor omissions of any third party, the adult coveredpersons/parents agree to promptly notify the plan of theexistence of any claim on behalf of the minor childagainst the third party tortfeasor responsible for theinjuries. Further, the adult covered persons/parentsagree, prior to the commencement of any claim againstthe third party tortfeasors responsible for the injuries tothe minor child, to either assign any right to collectmedical expenses from any tortfeasor or other personor entity to the plan, or at their election, to prosecute aclaim for medical expenses on behalf of the plan.


SUBROGATION ANDREIMBURSEMENT

SUBROGATION ANDREIMBURSEMENT

Subrogation and Reimbursement (cont.)In default of any obligation hereunder by the adult coveredpersons/parents, the plan is entitled to recover the conditionalbenefits advanced plus costs (including reasonable attorneys’fees), from the adult covered persons/parents.

F No covered person shall make any settlement whichspecifically excludes or attempts to exclude the benefitspaid by the plan.

F The plan’s right of recovery shall be a prior lien againstany proceeds recovered by a covered person, whichright shall not be defeated nor reduced by the applicationof any so-called “Made-Whole Doctrine,” “RimesDoctrine” or any other such doctrine purporting to defeatthe plan’s recovery rights by allocating the proceedsexclusively to nonmedical expense damages.

F No covered person under the plan shall incur anyexpenses on behalf of the plan in pursuit of the plan’srights to subrogation or reimbursement, specifically, nocourt costs nor attorneys’ fees may be deducted fromthe plan’s recovery without the prior express writtenconsent of the plan. This right shall not be defeated byany so-called “Fund Doctrine,” “Common Fund Doctrine”or “Attorney’s Fund Doctrine.”

F The plan shall recover the full amount of benefits paidhereunder without regard to any claim of fault on thepart of any covered person, whether under comparativenegligence or otherwise.

F The benefits under this plan are secondary to anycoverage under no-fault, medical payments or similarinsurance.

F This subrogation and reimbursement provision shall begoverned by the laws of the State of Illinois.

F In the event that a covered person shall fail or refuse tohonor its obligations hereunder, the plan shall have aright to suspend the covered person’s eligibility and beentitled to offset the reimbursement obligation againstany entitlement for future medical benefits, regardless ofhow those medical benefits are incurred. The suspensionand offset shall continue until such time as the coveredperson has fully complied with his obligations hereunder.


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In general, most dental, medical and behavioral healthproviders file claims for reimbursement with the insurancecarrier. Out-of-network vision claims and pharmacyexpenses typically must be filed by the member. Insituations where a claim is not filed by the provider, themember must file the claim within a specific period of time.

All claims should be filed promptly. Nonsubmittedclaims for the dental and prescription plans, as well as theQuality Care Health Plan (QCHP) medical and behavioralhealth plans are required to be filed no later than one yearfrom the ending date of the plan year in which the chargewas incurred in order to be considered for reimbursement.Vision claims are required to be filed no later than one yearfrom the date of service in order to be considered forreimbursement. Claim forms are available on the planadministrators’ website and on the Benefits website.

F Effective August 1, 2011, in-network QCHP medicaland behavioral health claims must be filed within 90days from the date in which the charge was incurred.

F Effective January 1, 2012, out-of-network QCHPmedical and behavioral health claims must be filedwithin 180 days from the date in which the charge wasincurred.

Filing deadlines for managed care plans, includingbehavioral health services offered under the managed careplan, may be different. Contact the managed care plandirectly for deadlines and procedures.

Claim Filing ProceduresAll communication to the plan administrators must include theemployee’s social security number (SSN) and appropriategroup number as listed on the identification card. Thisinformation must be included on every page ofcorrespondence.

F Complete the claim form obtained from the appropriateplan administrator.

F Attach the itemized bill from the provider of services tothe claim form. The itemized bill must include name ofpatient, date of service, diagnosis, procedure code andthe provider’s name, address and telephone number.

F If the person for whom the claim is being submitted hasprimary coverage under another group plan or Medicare,the explanation of benefits (EOB) or the MedicareSummary Notice (MSN) from the other plan must alsobe attached to the claim.

F The plan administrator may communicate directly withthe plan participant or the provider of services regardingany additional information that may be needed to processa claim.

F The benefit check will be sent and made payable to theemployee (not to any dependents), unless benefits havebeen assigned directly to the provider of service.

F If benefits are assigned, the benefit check will bemade payable to the provider of service and maileddirectly to the provider. An EOB is sent to the planparticipant to verify the benefit determination.

F QCHP claims are adjudicated using industry standardclaim processing software and criteria. Claims arereviewed for possible bundling and unbundling of servicesand charges.

Claim Filing


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Under the State Employees Group Insurance Program(Program) there are formal procedures to follow in order tofile an appeal of an adverse benefit determination. Theappropriate plan administrator will provide moreinformation regarding the plan administrator’s internalappeal process.

Categories of AppealThere are two separate categories of appeals: medicaland administrative. The plan administrator determines thecategory of appeal and will send the plan participant writtennotification regarding the category of appeal, the planparticipant’s appeal rights and information regarding how toinitiate an appeal from the plan administrator.

F Medical Appeals. Medical appeals pertain to benefitdeterminations involving medical judgment, includingclaim denials determined by the plan administrator to bebased on lack of medical necessity, appropriateness,healthcare setting, level of care or effectiveness; denialspursuant to Section 6.4 of the State Employees GroupInsurance Act; and denials for services determined by theplan administrator to be experimental or investigational.Medical appeals also pertain to retroactive cancellationsor discontinuations of coverage, unless the cancellationor discontinuation relates to a failure to pay requiredpremiums or contributions.

F Administrative Appeals. Administrative appealspertain to benefit determinations based on plan designand/or contractual or legal interpretations of plan termsthat do not involve any use of medical judgment.

Quality Care Health Plan (QCHP)and Open Access Managed CarePlans Appeal ProcessMembers enrolled in either the Quality Care Health Plan(QCHP) or one of the open access managed care plansmay utilize an internal appeal process which may befollowed by an external review, if needed. For urgent caresituations, the plan participant may bypass the internalappeal process and request an expedited external review(see “Expedited External Review- Medical Appeals Only”for urgent care situations in the box).

Expedited External Review - Medical AppealsOnly

For medical appeals involving urgent care situations, theplan participant may make a written or oral request forexpedited external review after the plan administratormakes an adverse benefit determination, even if the planadministrator’s internal appeal process has not beenexhausted. The external reviewer will review the requestto determine whether it qualifies for expedited review. Ifthe external reviewer determines that the requestqualifies for expedited review, the external reviewer willprovide a final external review decision within 72 hoursafter the receipt of the request. If the external reviewerdecides in favor of the plan participant, the decision shallbe final and binding on the plan administrator.

Step 1: Internal Appeal Process

The internal appeal process is available through the healthplan administrator. The plan administrator’s internal appealprocess must be followed before the plan participant mayseek an external review, except for urgent care situations.For urgent care situations, the plan participant may requestan expedited external review (see “Expedited ExternalReview- Medical Appeals Only” for urgent care situations).

First-Level Internal Appeals

First-level appeals must be initiated with the planadministrator within 180 days of the date of receipt of theinitial adverse benefit determination. All appeals will bereviewed and decided by an individual(s) who was notinvolved in the initial claim decision. Each case will bereviewed and considered on its own merits. If the appealinvolves a medical judgment, it will be reviewed andconsidered by a qualified healthcare professional. In somecases, additional information, such as test results, may berequired to determine if additional benefits are available.Once all required information has been received by theplan administrator, the plan administrator shall provide adecision within the applicable time frame: 15 days for pre-service authorizations, 30 days for post-service claims, or72 hours for urgent care claims.

Claim Appeal Process


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Step 2: External Review Process

After the completion of the plan administrator’s internalappeal process, the plan participant may request anexternal review of the plan administrator’s final internalbenefit determination. The process for external review willdepend on whether the appeal is an administrative appealor medical appeal.

Administrative Appeals

For administrative appeals, if, after exhausting every levelof review available through the plan administrator, the planparticipant still feels that the final benefit determination bythe plan administrator is not consistent with the publishedbenefit coverage, the plan participant may appeal the planadministrator’s decision to CMS’ Group Insurance Division.For an appeal to be considered by CMS’ Group InsuranceDivision, the plan participant must appeal in writing withinsixty (60) days of the date of receipt of the planadministrator’s final internal adverse benefit determination.All appeals must be accompanied by all documentationsupporting the request for reconsideration.

Submit Administrative Appeal Documentation to:

CMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

The decision of CMS’ Group Insurance Division shall befinal and binding on all parties.

Medical Appeals

I. External Review

For medical appeals, if, after exhausting every level of reviewavailable through the plan administrator, the plan participantstill feels that the final benefit determination is not consistentwith the published benefit coverage, the plan participant mayrequest an independent external review of the planadministrator’s decision. A request for an external reviewmust be filed in writing within four (4) months of the date ofreceipt of the plan administrator’s final internal adversebenefit determination. The plan administrator will providemore information regarding how to file a request for externalreview. The plan participant will be given the opportunity tosubmit additional written comments and supporting medicaldocumentation regarding the claim to the external reviewer.

The external reviewer will provide a final external reviewdecision within 45 days of the receipt of the request. If theexternal reviewer decides in favor of the plan participant, thedecision shall be final and binding on the plan administrator.

II. Final Review by CMS’ Appeal Committee

For medical appeals, if a plan participant does not agreewith the decision made by the external reviewer, the planparticipant may initiate a final level of the appeal process.Neither the plan administrator nor CMS shall be permittedto appeal a decision by the external reviewer. An appealcommittee appointed by the CMS Director will reviewwhether the external reviewer’s decision is consistent withthe requirements of the Group Insurance Act and all planguidelines.

The plan participant must submit a written request to theappeal committee within 30 days of the decision by theexternal reviewer. The appeal committee will review thedocumentation presented in the appeal as well as thedecision of the external reviewer. The appeal committeewill consider the merits of each individual case.Information that was not presented to the planadministrator and/or the external reviewer will not beconsidered in the appeal committee’s review.

The appeal committee meets on a quarterly basis. Theappeal committee shall issue a written decision regardingany appeal within 30 days of the date of the meeting atwhich the appeal was considered. Whether or not theappeal committee decides in favor of the plan participant,the decision of the appeal committee shall be final andbinding on all parties.

NOTE: A bargaining unit employee covered underAFSCME has the option to request a designated unionrepresentative be a member of the appeal committee.AFSCME shall provide CMS with prior notification, ifapplicable, of the representative who will serve as amember of the committee.

Submit Medical Final Review Appeal Requests to:

CMS Benefits Deputy DirectorGroup Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

Claim Appeal Process (cont.)


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Appeal Process for Fully-InsuredManaged Care Health Plans

The Department of Central Management Services (CMS)does not have the authority to review or process fully-insured managed care health plan appeals. Fully-insuredmanaged care health plans must comply with the ManagedCare Reform and Patient Rights Act. In order to file aformal appeal, refer to the process outlined in the managedcare health plan’s summary plan document (SPD) orcertificate of coverage. Specific timetables and proceduresapply. Plan participants may call the customer servicenumber listed on their identification card to request a copyof such documents.

Assistance with the Appeal Process

For questions regarding appeal rights and/or assistancewith the appeal process, a plan participant may contactthe Employee Benefits Security Administration at1-866-444-EBSA (3272). A consumer assistanceprogram may also be able to assist the plan participant.Requests for assistance from the consumer assistanceprogram should be sent to:

Illinois Department of Insurance100 W. Randolph St, 9th FloorChicago, IL 60601(877) 527-9431

or

Illinois Department of Insurance320 W. Washington St, 4th FloorSpringfield, IL 62727

Claim Appeal Process (cont.)


Chapter 5Chapter 5: Reference

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86


Additional Deductible: Deductibles that are in addition tothe annual plan deductible.

Admission: Entry as an inpatient to an accredited facility,such as a hospital or skilled care facility, or entry to astructured outpatient, intensive outpatient or partialhospitalization program.

Adverse Claim Determination: A denial, reduction,termination of or failure to pay for a benefit, whether inwhole or in part. Adverse claim determinations includerescissions of coverage.

Allowable Charges: The maximum amount the plan willpay an out-of-network healthcare professional for billedservices.

Allowable Expense: A medically necessary service forwhich part of the cost is eligible for payment by this plan oranother plan(s).

Authorization: The result of a review that approvestreatment as meeting medical necessity criteria andappropriateness of care.

Auto Adjudication (as applies to the FSA Card): Theautomated process which allows certain MCAPtransactions that were paid for with the FSA card to notrequire follow-up documentation.

Auto Substitution (as applies to the FSA Card): Theprocess that the FSA plan administrator uses whendocumentation for an FSA card transaction requiringsubstantiation is not provided. Paper claim documentationwill be substituted for FSA card transaction documentationif card documentation is not provided within 60 days.

Benefit: The amount payable for services obtained by planparticipants and dependents.

Benefit Choice Period: A designated period when membersmay change benefit coverage elections, ordinarily held May 1through May 31.

Certificate of Coverage: A document containing adescription of benefits provided by licensed insuranceplans. Also known as a summary plan description (SPD).

Certificate of Creditable Coverage: A certificate thatprovides evidence of prior health coverage.

Civil Union: Civil union means a legal relationship betweentwo persons, of either the same or opposite sex, establishedpursuant to the Illinois Religious Freedom Protection andCivil Union Act.

Civil Union Partner: A party to a civil union.

Claim: A paper or electronic billing. This billing mustinclude full details of the service received, including name,age, sex, identification number, the name and address ofthe provider, an itemized statement of the service renderedor furnished, the date of service, the diagnosis and anyother information which a plan may request in connectionwith services rendered.

Claim Payment: The benefit payment calculated by a plan,after submission of a claim, in accordance with the benefitsdescribed in this handbook and the annual Benefit ChoiceOptions booklet.

Coinsurance: The percentage of the charges for eligibleservices for which the plan participant is responsible afterany applicable deductible has been met.

Coordination of Benefits: A method of integrating benefitspayable under more than one group insurance plan.

Copayment: A specific dollar amount the plan participantis required to pay for certain services covered by a plan.

Covered Services: Services that are eligible for benefitsunder a plan.

Creditable Coverage: The amount of time a plan participanthad continuous coverage under a previous health plan.

Current Employment Status (CES): The status of a currentor active employee. An employee is considered to be withCES if he/she is an actively working individual that performshis/her job duties on a regular basis and is receiving financialcompensation for the job duties performed.

Custodial Care: Room and board or other institutional ornursing services which are provided for a patient due to ageor mental or physical condition mainly to aid in daily living; or,medical services which are given merely as care to maintainpresent state of health and which cannot be expected toimprove a medical condition.

Deductible: The amount of eligible charges plan participantsmust pay before insurance payments begin.

Glossary

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Department: The Department of Central ManagementServices, also referred to as DCMS.

Dependent: An employee’s spouse, civil union partner, childor other person as defined by the State Employees GroupInsurance Act of 1971, as amended (5 ILCS 375/1 et seq.).For purposes of the health plan only, the term dependentalso includes a domestic partner.

Diagnostic Service: Tests performed to diagnose a conditiondue to symptoms or to determine the progress of an illness orinjury. Examples of these types of tests are x-rays, pathologyservices, clinical laboratory tests, pulmonary function studies,electrocardiograms (ECG), electroencephalograms (EEG),radioisotope tests and electromyograms.

Domestic Partner: An unrelated, same-sex individual, age19 or older, who resides in the same household and has afinancial and emotional interdependence consistent with thatof a married couple for a period of not less than one year.

Eligible Charges: Charges for covered services andsupplies which are medically necessary and based oncharges as determined by a plan administrator.

Emergency Services: Services provided to alleviatesevere pain or for immediate diagnosis and/or treatment ofconditions or injuries such that in the opinion of the prudentlayperson might result in permanent disability or death ifnot treated immediately.

Employee: A person presently employed by the State ofIllinois as defined by the State Employees Group InsuranceAct of 1971, as amended (5 ILCS 375/1 et seq.).

Evidence of Insurability: Documentation that an individual’shealth condition is satisfactory for coverage. May requireproof of age or a statement of health status from thephysician. Evidence of insurability is generally required toadd Child Life or Spouse Life insurance and to increaseMember Optional Life insurance.

Exclusions and Limitations: Services not covered underthe State Employees Group Insurance Program, or servicesthat are provided only with certain qualifications, conditionsor limits.

Experimental: Medical services or supplies in which newtreatments or products are tested for safety and effect onhumans.

Explanation of Benefits (EOB): A statement from a planadministrator explaining benefit determination for servicesrendered.

Final Internal Determination: The final benefitdetermination made by a plan administrator after a planparticipant has exhausted all appeals available through theplan administrator’s formal internal appeals process.

Follow-up Documentation (as applies to the FSA Card):Acceptable documentation includes itemized bills andexplanation of benefits (EOBs).

Fiscal Year (FY): Begins on July 1 and ends on June 30.

Formulary (Prescription Drugs): A list of drugs andancillary supplies approved by the prescription drug planadministrator for inclusion in the prescription drug plan.The formulary list is subject to change.

Fully Insured: All claims and costs are paid by theinsurance company.

Generic Drug: Therapeutic equivalent of a brand namedrug and must be approved by the U.S. Food and DrugAdministration for safety and effectiveness.

Group Insurance Representative (GIR): An individualwho provides information and/or materials and processesenrollment changes related to benefits.

Hospice: A program of palliative and supportive servicesfor terminally ill patients that must be approved by a planadministrator as meeting standards including any legallicensing requirements.

Hospital: A legally constituted and licensed institutionhaving on the premises organized facilities (includingorganized diagnostic and surgical facilities) for the care andtreatment of sick and injured persons by or under thesupervision of a staff of physicians and registered nurseson duty or on call at all times.

Identification Card: Document identifying eligibility forbenefits under a plan.

Independent External Review: An external review,conducted by an independent third party of a planadministrator’s adverse claim determination or final internaldetermination.

Initial Enrollment Period: The 10-day period beginningwith the date of hire.

Injury: Damage inflicted to the body by external force.

In Loco Parentis: An individual who has day-to-dayresponsibilities to care for and financially support a childunder 18 years of age. A biological or legal relationship isnot necessary or required.

Glossary (cont.)


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Inpatient Services: A hospital stay of 24 or more hours.

Intensive Outpatient Program (Behavioral HealthServices): Services offered to address treatment of mentalhealth or substance abuse and could include individual,group or family psychotherapy and adjunctive servicessuch as medical monitoring.

Inventory Information Approval System (IIAS) (as appliesto the FSA Card): The IIAS automatically processeseligible over-the-counter and prescription items by readingthe item’s barcode. Follow-up documentation is not requiredfor eligible FSA items when the card is used at a locationthat has this system. Most major discount and pharmacystores have implemented IIAS.

Investigational: Procedures, drugs, devices, servicesand/or supplies which (a) are provided or performed inspecial settings for research purposes or under a controlledenvironment and which are being studied for safety, efficiencyand effectiveness, and/or (b) are awaiting endorsement bythe appropriate National Medical Specialty College or FederalGovernment agency for general use by the medical communityat the time they are rendered to a covered person, and (c)with respect to drugs, combination of drugs and/or devices,which have not received final approval by the Food andDrug Administration at the time used or administered to thecovered person.

Itemized Bill: A form submitted for claim purposes; musthave the name of the patient, description, diagnosis, dateand cost of services provided.

Medical Documentation: Additional medical informationrequired to substantiate the necessity of proceduresperformed. This could include daily nursing and doctor notes,additional x-rays, treatment plans, operative reports, etc.

Medicare: A federally operated insurance program providingbenefits for eligible persons.

Medicare Summary Notice (MSN): A quarterly statementfrom Medicare explaining benefit determination for servicesrendered.

Member: Employee, annuitant, retired employee, survivoror COBRA participant.

Non-IRS: Any dependent who is not considered aqualifying child or a qualifying relative, as defined by theIRS, and cannot be claimed as a dependent for income taxpurposes.

Nonpreferred Brand Drug: Prescription drugs availableat the highest copayment. Many high cost specialty drugsfall under the nonpreferred drug category.

Out-of-Pocket Maximum: The maximum dollar amountpaid out of pocket for covered expenses in any given planyear. After the out-of-pocket maximum has been met theplan begins paying at the 100% of allowable charges foreligible covered expenses.

Outpatient Services (Behavioral Health Services): Carerendered for the treatment of mental health or substanceabuse when not confined to an inpatient hospital setting.

Outpatient Services (Medical/Surgical): Services providedin a hospital emergency room or outpatient clinic, at anambulatory surgical center or in a doctor’s office.

Partial Hospitalization (Behavioral Health Services):Services offered to address treatment of mental health orsubstance abuse and could include individual, group orfamily psychotherapy. Services are medically supervisedand essentially the same intensity as would be provided ina hospital setting except that the patient is in the programless than 24 hours per day.

Physician/Doctor: A person licensed to practice under theIllinois Medical Practice Act or under similar laws of Illinoisor other states or countries; a Christian Science Practitionerlisted in the Christian Science Journal at the time themedical services are provided.

Plan: A specifically designed program of benefits.

Plan Administrator: An organization, company or otherentity contracted to review and approve benefit payments,pay claims, and perform other duties related to theadministration of a specific plan.

Plan Participant: An eligible person enrolled and participatingin the Program.

Plan Year: July 1 through the following June 30.

Preexisting Condition: Any disease, condition, (excludingmaternity) or injury for which the individual was diagnosed,received treatment/services, or took prescribed drugs duringthe three months immediately preceding the effective date ofcoverage.

Glossary (cont.)


GL

OS

SA

RY

Preferred Brand Drug: A list of drugs, biologicals anddevices approved by the pharmacy benefit manager forinclusion in the prescription drug plan. These drugs areproven to be both clinically and cost effective. The preferredbrand drug list is subject to change.

Prescription Drugs: Medications which are lawfully obtainedwith a prescription from a physician/doctor or dentist.

Pretreatment Estimate (Dental): A provider’s statement,including diagnostic x-rays and laboratory reports describingplanned treatment and expected charges which is reviewed bythe dental plan administrator for verification of eligible benefits.

Preventive Service: Routine services which do not requirea diagnosis or treatment of an illness or injury.

Primary Care Physician/Primary Care Provider (PCP): Thephysician or other medical provider a plan participant selectsunder a managed care plan to manage all healthcare needs.

Professional Services: Eligible services provided by alicensed medical professional, including but not limited to aphysician, radiologist, anesthesiologist, surgeon, physicaltherapist, etc.

Program: The State Employees Group Insurance Programas defined by the State Employees Group Insurance Act of1971, as amended (5 ILCS 375/1 et seq.).

Provider: Any organization or individual which providesservices or supplies to plan participants. This may includesuch entities as hospitals, pharmacies, physicians, laboratoriesor home health companies.

quality Care Health Plan (qCHP) Hospital: A hospital orfacility with which the Quality Care Health Plan plan hasnegotiated favorable rates.

qualified Beneficiary: A qualified beneficiary is anindividual (including member, spouse, civil union partner,domestic partner and child) who loses employer-providedgroup health coverage and is entitled to elect COBRAcoverage. The individual must have been covered by theplan on the day before the qualifying event occurred andenrolled in COBRA effective the first day of eligibility or bea newborn or newly adopted child of the covered member.

Schedule of Benefits: A listing of specific services coveredby the Quality Care Dental Plan and the vision plan.

Second Opinion: An opinion rendered by a secondphysician prior to the performance of certain nonemergency,elective surgical procedures or medical treatments.

Self Insured: All claims and costs are paid by the State ofIllinois.

Skilled Nursing Service: Noncustodial professionalservices provided by a registered nurse (RN) or licensedpractical nurse (LPN) which require the technical skills andprofessional training of such a licensed professional actingwithin the scope of their licensure.

Spouse: A person who is legally married to the member asdefined under Illinois law and pursuant to the InternalRevenue Service Code.

Spouse Life: Term life insurance coverage that covers theemployee's spouse or civil union partner, but does not coverdomestic partners.

State Employees Group Insurance Act: The statutoryauthority for benefits offered by the Department (5 ILCS375/1 et seq.).

Statement of Health: A form which a plan participantcompletes and submits to the life insurance plan administratorto have a determination made of health status for lifeinsurance coverage.

Substantiation (applies to FSA Card): Follow-updocumentation that must be submitted for FSA items orservices paid for with the FSA card that are not automaticallyadjudicated.

Survivor: Spouse, civil union partner, dependentchild(ren) or dependent parent(s) of a deceased memberas determined by the appropriate state retirement system.

Surgery: The performance of any medically recognized,noninvestigational surgical procedure including specializedinstrumentation and the correction of fractures or completedislocations and any other procedures as reasonablyapproved by a plan.

Urgent Care Claim: Any claim for medical care ortreatment with respect to the application of the time periodsfor making nonurgent care determinations could:1) seriously jeopardize the life or health of the claimant orthe ability of the claimant to regain maximum function; or2) in the opinion of the physician with knowledge of theclaimant's medical condition, would subject the claimant tosevere pain that cannot be adequately managed withoutthe care or treatment that is the subject of the claim.

Glossary (cont.)


IND

EX

– A –Adoption Benefit Program...................................66

Allowable Mid-year Changes ..............................10

Annual Benefit Choice Period ...............................8

– B –Behavioral Health Coverage ...............................53

– C –Certification of Dependent Coverage....................7

Claim Appeal Process.........................................78

Claim Filing .........................................................77

COBRA ...............................................................27

Commuter Savings Program (CSP) ....................65

Contributions.......................................................17

Converting Life Coverage ...................................59

Conversion Privilege Health Coverage ...............29

Coordination of Benefits......................................70

– D –Dental Coverage .................................................54

Dental Exclusions ...............................................56

Direct Billing ........................................................18

Documentation Requirements

Adding Dependent Coverage.........................13

Terminating Dependent Coverage .................14

Documentation Time Limits.................................14

– E –Eligibility

Eligible as Dependents ....................................7

Eligible as Employees......................................6

Employee Assistance Program ...........................52

Enrolling Dependents..........................................10

Enrollment Periods................................................8

– F –Family Leaves of Absence ..................................22

Family Medical Leave Act (FMLA) ......................20

Flexible Spending Accounts................................61

Formulary............................................................49

– G-H –Group Insurance Division......................................2

Group Insurance Representative ..........................2

Health Maintenance Organizations (HMOs) .......34

Health Plan Options ............................................33

HIPAA....................................................................2

Hospital Bill Audit Program..................................38

– I –ID Cards................................................................2

Initial Enrollment ...................................................8

– J-k-L –Leaves of Absence..............................................20

Life Insurance Coverage.....................................58

– M –Mail Order Pharmacy ..........................................51

Maintenance Medication .....................................51

Maintenance Pharmacy Network ........................51

Managed Care Health Plans...............................33

Medicare .............................................................72

– N –Nonmaintenance Medication ..............................50

Nonpayment of Premium ....................................18

Index


IND

EX

– O –Open Access Plan...............................................34

Opt Out ...............................................................15

Orthodontic Services (child) ................................55

– P –Payroll Premium Refund .....................................19

Porting Life Coverage .........................................59

Premium Payment ..............................................17

Premium Underpayment .....................................19

Prescription Coverage ........................................49

Prescription Drug Step Therapy..........................49

Pretreatment Estimate (Dental)...........................55

Prior Authorization (Prescription Drugs)..............49

Prosthodontics ....................................................54

– q –Qualifying Change in Status .................................9

Qualifying Change in Status Chart ......................11

Quality Care Dental Plan ....................................54

Quality Care Health Plan ....................................35

Additional Deductibles....................................35

Allowable Charges .........................................36

Coinsurance...................................................35

Emergency Admission ...................................37

Exclusions and Limitations.............................47

Medical Benefit Summary ..............................39

Medical Case Management ...........................37

Medical Necessity ..........................................36

Notification Requirements..............................37

Out-of-Pocket Maximum ................................35

Plan Year Deductible......................................35

Predetermination of Benefits..........................36

QCHP Network...............................................37

Transplant Notification ...................................37

– R-S –Smoking Cessation Program ..............................68

Subrogation and Reimbursement .......................75

– T –Termination of Dependent Coverage ................. 26

Termination of Employee Coverage....................26

Termination of Coverage under COBRA.............29

Time Away from Work Chart ...............................25

– U-V –Vision Coverage..................................................57

– W –Waiving Coverage...............................................15

– X-Y-Z –

Index (cont.)

The State of Illinois intends that the terms of this plan are legally enforceable and that the plan is maintained for the exclusivebenefit of Members. The State reserves the right to change any of the benefits, program requirements and contributionsdescribed in this Handbook. Changes will be communicated through addenda as needed and the annual Benefit ChoiceOptions Booklet. If there is a discrepancy between this Handbook or any other Department publications, and state or federallaw, the law will control.*

* Note: The original version of the October 1, 2011, Benefits Handbook inadvertently omitted the above reservation of rights due to an oversight during the graphicdesign process. This omission in no way represents and should not be construed as a lapse of, suspension of or exception to this reservation of rights. The State ofIllinois has continuously maintained this reservation of rights since at least 1994 through the present. The State of Illinois continues to apply this reservation of rightson an ongoing basis, effective until such time as the State expressly waives or terminates this reservation of rights in writing.

Printed by the Authority of the State of Illinois. 500 2/12 IOCI 0260-11

state of illinois department of central management services bureau of benefits · 2020. 2. 13. ·...

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