April 19, 2017

Clarification on the 2016 Illinois Contraceptive Mandate

As previously reported, Illinois enacted several new laws during 2016 that impact insurance coverage, including PA 99-0672 (HB 5576), the Illinois Contraceptive Mandate. This mandate impacts benefit changes for all insured groups, including grandfathered, grandmothered, and ACA-exempt plans. Self-insured medical groups are not impacted by the mandate.

These changes are effective upon renewal on or after Jan. 2, 2017. Plans renewing on Jan. 1, 2017, won't receive the benefit changes listed below until their Jan. 1, 2018, renewal. If there are no off-cycle renewals, benefit changes won't be applied until 2018.

For fully insured plans, the following medical benefits will be paid at no cost-share as a result of the mandate:

Contraceptive Mandate – Requirements

Provide coverage for all contraceptive drugs, devices and other products approved by the USFDA, including all over-the-counter contraceptive drugs, devices and products approved by the USFDA, but excluding male condoms.

Policy only required to cover one therapeutic equivalent version of a contraceptive drug, device or product without cost sharing.

For drugs, devices or products not covered, issuer must have expedient process to ensure coverage without cost sharing.

If a provider recommends a specific service or item approved by USFDA, Policy must defer to attending provider for medical necessity and cover without cost sharing.

Must provide for the dispensing of 12 months' worth of contraception at one time.

Provide coverage for voluntary sterilization procedures (male).

Provide coverage for voluntary sterilization procedures (female).

Provide coverage for contraceptive services, patient education and counseling on contraception.

Provide coverage for follow-up services related to the drugs, devices, products and procedures; including, but not limited to, management of side effects, counseling for continued adherence, and device insertion and removal.

This communication is intended for informational purposes only. It is not intended to provide, does not constitute, and cannot be relied upon as legal, tax or compliance advice. The information contained in this communication is subject to change based on future regulation and guidance.