The national guide covers medical plan design:

• plan types: HMOs, PPOs and POS plans;
• cost sharing: deductibles, coinsurance, copays and out-of-pocket maximums;
• HSAs and the ACA.

Illinois's state questions on medical plans focus on dependent coverage, mandated benefits, external review (the Health Carrier External Review Act, 215 ILCS 180), and the HMO Act (215 ILCS 125). Group continuation is covered in the Group Health Insurance guide.

National concepts in brief

• An HSA must be paired with a qualified high-deductible health plan (26 U.S.C. 223).
• HMOs provide network care through a primary care physician. PPOs cover out-of-network care at a higher cost.

Illinois coverage rules

• Dependents to 26: coverage for an unmarried dependent can't end because of age before the 26th birthday. Illinois-resident military veterans may stay eligible to 30 (215 ILCS 5/356z.12).
• Mammography: a baseline mammogram at 35–39 and an annual mammogram from 40 (215 ILCS 5/356g).
• Clinical trials: a policy can't be cancelled or nonrenewed because the insured is in a qualified clinical cancer trial (215 ILCS 5/364.01).
• Dentists as physicians: where a policy covers services a dentist may perform, "physician" includes a licensed dentist. Discrimination solely because of disability is barred unless actuarially sound (215 ILCS 5/364).
• Form approval: life, accident and health policy forms must be filed and approved before use (215 ILCS 5/143(1)).
• Prompt payment: clean claims must be paid on time or earn interest. Under individual policies, claims are paid within 30 days of proof, with 9% interest after that (215 ILCS 5/357.9).

External review (215 ILCS 180)

• Insureds may have an adverse determination reviewed by an independent reviewer.
• A standard review is requested within four months of the adverse or final adverse determination (215 ILCS 180/35).

HMOs (215 ILCS 125)

• Evidence of coverage: delivered within 30 days after the later of the coverage effective date or the HMO's receipt of the enrollment (215 ILCS 125/4-1).
• Adopted children can't be excluded or limited because they are adopted (215 ILCS 125/4-9).
• Emergency ambulance transportation can't be excluded (215 ILCS 125/4-15).
• Medical necessity disputes: the review is done by an unaffiliated physician of the same license class, chosen jointly by the patient, the primary care physician and the HMO (215 ILCS 125/4-10).
• Complaints: an HMO responds to a Department complaint notice within 21 days (215 ILCS 125/4-6).
• Medicaid enrollers: people enrolling Medicaid recipients in HMOs must be licensed as limited insurance representatives, with no written exam (215 ILCS 125/4-11).

Limited health service organizations

• What they provide: dental, vision, pharmaceutical, podiatric and similar limited services, generally not hospital or medical care (215 ILCS 130/1002).
• Renewal: contracts renew year to year unless 31 days' written notice of termination is given (215 ILCS 130/3001).
• Who may sell: sellers need a limited insurance representative license or a producer license (215 ILCS 130/3005).

Common exam traps

• Illinois dependent coverage runs to 26, or 30 for qualifying veterans.
• Mammograms: baseline at 35–39, then annual from 40.
• External review must be requested within 4 months.
• An HMO can't exclude emergency ambulance coverage.
• Late individual health claims earn 9% interest.