Illinois Individual Health Insurance Laws & Regulations

Eligibility: How Am I Evaluated by Health Insurance Companies?

Each private health insurance company has the flexibility to create their own rules regarding which applicants will be accepted for an individual health insurance policy in Illinois. Additionally, an applicant can be turned down by in insurance provider for any reason. The only exception to this is for newborns who are required to be covered under their parent’s policy for the first 30 days and disabled, dependent children whose parents have a policy that covers dependents.

Although private insurance in the state is not guarantee issue, to comply with HIPAA Group-to-Individual Portability Coverage regulations, the state does guarantee acceptance into the Illinois Comprehensive Health Insurance Plan (CHIP, the state’s high-risk insurance pool), for those who are HIPAA eligible but have been unable to obtain coverage through a private insurer.

What Benefits Are Individual Health Insurers Required to Cover in Illinois?

In Illinois, individual health insurers are not required to provide standardized health plans, but there are certain benefits that insurers are required to cover, such as diabetes care and mammogram screenings.

How are Health Insurance Companies Allowed to Treat Pre-Existing Conditions in Illinois?

In Illinois, private insurers are allowed to go as far back as 24-months in an applicant’s medical history to uncover a pre-existing condition. They can then either impose a 24-month exclusion period on the condition or add it to the policy’s elimination rider (which means that it will likely never be covered). Additionally, if you make a claim for treatment related to a specific condition within the first 2 years of your policy, the insurer can look back up to 24-months prior to your application to see if it was a condition that should have been listed as pre-existing. If so, then your claim can be denied.

How are Individual Health Insurance Premiums Calculated?

The state allows for private health insurers to set their premiums at whatever rate they see fit, hoping that market competition will help keep them at a reasonable cost. Your insurer will take many factors into consideration when determining your rate, including age, health, and plan type.

There are no laws or restrictions regarding what an individual can be charged for a policy or exclusions on the reasons for quoting a high premium. When it is time to renew your policy, your insurer also has the right to raise your premium for any reason. The good news for health insurance customers is that their provider cannot cancel their policy because they get sick, even at renewal. They can, however, raise your premium to compensate for this increased risk.