chapter 1: enrollment and eligibility information...dependent for income tax purposes. f child from...

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Your Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

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

Enrollment Opportunities Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Chapter 2: Health, Dental and Vision Coverage InformationHealth Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Managed Care Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22College Choice Health Plan (CCHP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Medical Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Prescription Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Dental Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Vision Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Chapter 3: Optional ProgramsCoordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Chapter 4: ReferenceGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Table of Contents

CIP Benefits HandbookMyBenefits.illinois.gov

Your Group Insurance BenefitsPlease read this handbook carefully as it contains vitalinformation about your benefits.The Bureau of Benefits within the Department of CentralManagement Services (Department) is the bureau thatadministers the College Insurance Program (CIP) as set forthin the State Employees Group Insurance Act of 1971 (Act).You have the opportunity to review your choices and changeyour coverage for each plan year during the annual BenefitChoice Period. If a qualifying change in status occurs, youmay be allowed to make a change to your coverage that isconsistent with the qualifying event. See the section‘Enrollment Periods’ for more information.

MyBenefits Service Center (MBSC)The MyBenefits Service Center (MBSC) is a custom benefitssolution service provider for the Department. The MBSC willmanage the detailed enrollment process of member benefitsthrough online technical support via theMyBenefits.illinois.gov website and telephonic support viathe MyBenefits Service Center 844-251-1777. The MBSC isnow the member's primary contact for answering generalquestions you may have about your eligibility for coverageand to assist you in enrolling or changing the benefits youhave selected.

Where To GetAdditional 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 MyBenefits.illinois.gov forinformation.

F Annual Benefit Choice Options booklet. This bookletcontains the most current information regarding changesfor the plan year. New benefits, changes in premiumamounts and changes in plan administrators are includedin the booklet. Review this booklet carefully as itcontains important eligibility and benefit informationthat may affect your coverage. VisitMyBenefits.illinois.gov to view the booklet.

F SURS continues to be a valuable resource concerningpolicies and rules regarding members' benefits andeligibility as well as ensuring the successful enrollment

process of the member. SURS can be reached at: State Universities Retirement System1901 Fox DriveP.O. Box 2710Champaign, IL 61825-2710800-275-7877TDD/TTY: 800-526-0844surs.org

F The Department will continue to assist members eligiblefor Medicare, with questions regarding eligibility policiesand rules as well as answer your benefit questions or referyou to the appropriate resource for assistance. The GroupInsurance Division can be reached at:

CMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208800-442-1300 or 217-782-2548TDD/TTY: 800-526-0844

F Each individual plan administrator can provide you withspecific information regarding plan coverageinclusions/exclusions.

ID CardsThe plan administrators produce ID cards at the time ofenrollment. Cards are mailed to the current address on filewith the Bureau of Benefits. To obtain additional cards,contact the plan administrator. Links to the planadministrators’ websites can be found atMyBenefits.illinois.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 security ofhealth 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.If you are enrolled in CIP, a copy of the Notice of PrivacyPractices will be sent to you on an annual basis. Additionalcopies are available on the MyBenefits.illinois.gov website.

Introduction

2 MyBenefits.illinois.govCIP Benefits Handbook

3 CIP Benefits HandbookMyBenefits.illinois.gov

It is your responsibility to know your benefits,including coverage limitations and exclusions,and to review the information in this publication.Referral and/or approval for treatment by a physiciandoes not ensure coverage under the plan.

You must notify MyBenefits Service Center (MBSC), or SURSimmediately when any of the following occurs:

F You and/or your dependents experience a change ofaddress. When you move, you must provide writtennotification to SURS. However, when your dependent(s)move, you must utilize the Self-Service Tools online atMyBenefits.illinois.gov to report your dependent(s)' newaddress. Changing your address with the retirement systemdoes not automatically change your health plan to a plan inthat geographic area.

F Your dependent loses eligibility. Dependents that areno longer eligible under CIP (including divorced spousesor partners of a dissolved civil union partnership) must bereported immediately by completing the online processusing the Self-Service Tools at MyBenefits.illinois.gov.Failure to report an ineligible dependent is considereda fraudulent act. Any premium payments you makeon behalf of the ineligible dependent which result inan overpayment will not be refunded. Additionally,the ineligible dependent may lose any rights to COBRAcontinuation coverage.

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

F You have a baby or adopt a child.F Your dependent’s employment status changes.F Your dependent dies.F You have or gain other coverage. If you have group

coverage provided by a plan other than CIP, or if you oryour dependents gain other coverage during the planyear, you must provide that information immediately bycompleting the online process using the Self-Service Toolsat MyBenefits.illinois.gov.

Contact MBSC or SURS if you are uncertain whether or not alife-changing event needs to be reported.

If you and/or your dependent experience a change inMedicare status or become eligible for Medicare benefits,a copy of the Medicare card must be provided to theDepartment's Medicare Coordination of Benefits (COB) Unit.Failure to notify the Medicare COB Unit of you and/or yourdependent’s Medicare eligibility may result in substantialfinancial liabilities. Refer to the ‘Medicare Section’ for theMedicare COB Unit’s contact information.

Benefit recipients should periodically review the following toensure all benefit information is accurate:

F Insurance Deductions. It is your responsibility to ensuredeductions are accurate for the insurance coverage you haveselected/enrolled. If your annuity check is insufficient tocover your premiums, you will be billed for the cost of yourcurrent coverage. Failure to pay the bill may result in aloss of coverage and/or withholding through the SURSannuity check.

If You Live or SpendTime Outside IllinoisBenefit recipients who move outside of Illinois or the countrywill most likely need to enroll in the College Choice HealthPlan (CCHP). For those in certain areas contiguous to the Stateof Illinois, some managed care health plan options may beavailable. Refer to MyBenefits.illinois.gov and login to youraccount to view your available options, or contact the managedcare health plan directly for information on plans available.Changing your address does not automatically change yourhealth plan.

Dependents Who Live Apart fromthe Benefit Recipient Eligible dependents who are enrolled in an HMO plan andlive apart from the benefit recipient’s residence and are out ofthe plan’s service area for any part of a plan year will belimited to coverage for emergency services only. It is crucialthat benefit recipients who have an out-of-area dependent(such as a college student) contact the HMO plan tounderstand the plan’s guidelines on this type of coverage.

Your Responsibilities

4

Power of AttorneyBenefit recipients may want to consider having a financialpower of attorney on file with both the retirement system andthe health plan to allow a representative to act on their behalf.For purposes of group insurance, a financial or propertypower of attorney is necessary; a healthcare power of attorneydoes not permit changes to health insurance coverage.

Penalty for FraudFalsifying information/documentation or failing to provide in-formation/documentation in order to obtain/continue cover-age under CIP is considered a fraudulent act. The State ofIllinois will impose a financial penalty, including, but notlimited to, repayment of all premiums the State made on be-half of the benefit recipient and/or the dependent beneficiary,as well as expenses incurred by CIP.

Your Responsibilities (cont.)

MyBenefits.illinois.govCIP Benefits Handbook

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

Enrollment Opportunities Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16


6CIP Benefits Handbook MyBenefits.illinois.gov

This section contains benefit eligibility information whichapplies to all CIP health, dental and vision plans.

Eligibility RequirementsEligibility is defined by the State Employees Group InsuranceAct of 1971 (5 ILCS 375/1 et seq.) or as hereafter amended(Act), and by such policies, rules and regulations as shall bepromulgated there under. If there is any change in eligibility(qualifying change in status, Medicare eligibility, residentialaddress) notify the MyBenefits Service Center immediately bycompleting the online process using the Self-Service Tools atMyBenefits.illinois.gov. Failure to notify MBSC of eligibilitychanges may result in loss of benefits and/or premiums.

Eligible as Benefit RecipientTo be eligible, benefit recipients must be receiving a monthlyretirement or survivor annuity benefit from SURS underArticle 15 (SURS) of the Illinois Pension Code; and either (I)have been a full-time employee of a community collegedistrict or an association of community college boards createdunder the Public Community College Act and was eligible toparticipate in a group health benefit plan as an employeeduring the time of employment with a community collegedistrict or an association of community college boards; or (II)be a survivor of an eligible CIP member.Benefit recipients enrolled in any of the CIP health plans arenot eligible for health, dental or vision coverage as a memberunder the State Employees Group Insurance Program.

Dependent ElgibilityEligible dependent beneficiaries of a benefit recipient mayparticipate in CIP. Dependent coverage is an additional costfor all members. Eligible dependents include the benefit recipient’s:F Spouse (does not include ex-spouses, common-law

spouses, persons not legally married or the new spouseof a survivor).

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

F Parent. Parent must be dependent upon the benefitrecipient for more than one-half of their support andeligible to be claimed by the benefit recipient as adependent for income tax purposes.

F Child from birth to age 26, limited to: – Natural child. – Adopted child.– Stepchild or child of a civil union partner.– Child for whom the benefit recipient has permanent

legal guardianship.– Adjudicated child for whom a U.S. court decree has

established a member’s financial responsibility for thechild’s medical, dental or other healthcare.

F Child age 26 and older, limited to:– Adult Veteran Child. Unmarried adult child age 26 up

to, but not including, age 30, an Illinois resident, hasserved as a member of the active or reservecomponents of any of the branches of the U.S. ArmedForces and received a release or discharge otherthan a dishonorable discharge.

– 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 benefit recipient.

NOTE: Survivors may add a dependent only if thatdependent was eligible for coverage as a dependentunder the original member.

Eligibility Requirements


Certification ofDependent CoverageIn addition to the following certification periods, SURS may askthe employee to certify their dependent either randomly orduring an audit anytime during the year.Birth Date Certification. Benefit recipients must verifycontinued eligibility for dependents turning ages 26 and 30.Members with dependents turning ages 26 and 30 willreceive a letter from MyBenefits Service Center (MBSC)several weeks prior to the birth month that containsinformation regarding continuation of coverage requirementsand options. The member must provide the requireddocumentation to MBSC prior to the dependent’s birth date.Failure to certify the dependent’s eligibility will result in thedependent’s coverage being terminated effective the end ofthe birth month.Annual Certification. Benefit recipients are required tocertify all IRS dependents in the following categories on anannual basis: Parent, Disabled and Adult Veteran Child (age26 and older).Reinstatement of Dependent Coverage. If coverage for adependent is terminated for failure to certify and the mem-ber provides the required documentation within 30 days fromthe date the termination was processed, coverage will be rein-stated retroactive to the date of termination. After 30 days the coverage will be reinstated only with a quali-fying change in status (see qualifying change in status reasonsin the ‘Enrollment Periods’ section later in this chapter). Termina-tion of coverage for failure to certify is not a qualifyingchange in status.

Contact the MyBenefits Service Center for questionsregarding certification of a dependent.

Eligibility Requirements (cont.)


Benefit recipients have several opportunities to initiallyenroll in CIP. After the initial enrollment, if the benefitrecipient terminates CIP coverage, re-enrollmentopportunities are limited.

Initial EnrollmentBenefit recipients may enroll in CIP during the annualBenefit Choice Period only if they have never previouslybeen enrolled in CIP. Benefit recipients who are eligiblefor, but have never enrolled in, one of the health plansunder CIP may do so during the annual Benefit ChoicePeriod. The coverage becomes effective July 1st.Outside the annual Benefit Choice Period, benefitrecipients may enroll in CIP when one of the followingoccurs, regardless of whether or not they have ever beenpreviously enrolled in the program:F Upon application of annuity benefits. An enrollment

application must be submitted to SURS no later than 30days after the effective date of the pension benefits.Coverage will be effective the first day of the first fullmonth of benefits or the first day of the month that theenrollment application is received, whichever is later.The effective date may be delayed up to 4 months afterthe effective date of the pension benefits; however,SURS must receive the enrollment form within 30 daysof the effective date of the pension benefits.

F The benefit recipient becomes eligible for Medicare.Benefit recipients who become eligible for Medicaremay apply for coverage. Benefit recipients must applywithin 6 months from the date they became Medicareeligible. If the benefit recipient is Medicare eligibledue to turning 65, and they wish to enroll in CIP, theyshould contact the Department's Medicare COB Unitprior to their 65th birthday. Coverage will be effectivethe first day of the month in which the benefit recipientbecomes Medicare eligible or the first day of the monthwhen the enrollment application is received by theDepartment's Medicare COB Unit, whichever is later.

F The benefit recipient has been determined to beineligible for Medicare. Benefit recipients who areMedicare ineligible have 30 days from their 65thbirthday to apply for coverage. Coverage will beeffective the first day of the month in which the benefitrecipient reaches age 65 or the first day of the month

when the enrollment application is received by theDepartment's Medicare COB Unit, whichever is later.

F Coverage is terminated by a former group plan.Benefit recipients who are eligible to enroll in CIP butinstead continue coverage with another plan, may enroll ifthe other plan terminates coverage. The benefit recipienthas 30 days following the loss of other coverage to submitthe enrollment application to SURS, along with a letterfrom the former plan stating the effective date oftermination. Termination of coverage must be initiated bythe former group plan. Termination for nonpayment ofpremium does not qualify as loss of coverage by the groupplan and therefore is not an eligible enrollment event. Theeffective date of the coverage is the first day of the monthfollowing cancellation of coverage with the other plan.

Annual Benefit Choice PeriodThe Benefit Choice Period is normally held annually May 1stthrough May 31st. During this 31-day period, benefitrecipients may change their health and dependent coverageelections. Coverage elected during the annual Benefit ChoicePeriod remains in effect throughout the entire plan yearunless the member experiences a qualifying change in statusor the Department institutes a special enrollment periodwhich would allow the member to change their coverageelections.

Benefit recipients may make the following electionsduring the annual Benefit Choice Period:

F Enroll in the College Insurance Program – applies tobenefit recipients and dependent beneficiaries who havenever been previously enrolled in CIP.

F Change health plans.F Add eligible dependents. Social security numbers are

required to add dependent coverage. Refer to the'Dependent Coverage' section for documentationrequirements.

Effective Date of Coverage Due to the AnnualBenefit Choice Period:

All Benefit Choice health and dependent coverage changesbecome effective July 1st.

Enrollment Periods


Qualifying Change in StatusThe Department’s administrative policy prohibits changes inthe benefit recipient’s elections during the plan year unlessthere is a qualifying change in status. Any request to changean election mid-year must be consistent with the qualifyingevent the benefit recipient or dependent has experienced.Qualifying change in status events may include, butare not limited to: F Events that change a benefit recipient’s legal relationship

status, including marriage, civil union partnership, death ofspouse or civil union partner, divorce, legal separation, civilunion dissolution or annulment.

F Events that change a benefit recipient’s number ofdependents, including birth, death, adoption or placement foradoption.

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

F A change of permanent residential county for the benefitrecipient or their dependent or, a move to a foreigncountry by an eligible dependent.

Benefit recipients experiencing a qualifying change in statushave 30 days to change their benefit selection by using theSelf-Service Tools online at MyBenefits.illinois.gov.Members must submit proper supporting documentation toMyBenefits Service Center (MBSC) within 30 days in order forthe change to become effective (31 days for a birth oradoption). Effective Date of Coverage Due to a QualifyingChange in Status:Coverage election changes made due to a qualifying eventare effective the first day of the month following the date ofthe event as long as the request is made within the requiredtime frame.Qualifying Change in Status Effective Date Exceptions:

F Newborns, natural or adopted. A child is considered anewborn if they are within 31 days of birth. If the requestto add the child is made within 31 days of the birth,coverage may be retroactive to the date of birth.

F Adopted children, other than newborn. Requests to addan adopted child who is 31 days old or older will beeffective the date of the placement of the child, the filing ofthe adoption petition or the entry of the adoption orderprovided that the request is received within 31 days of the

placement of the child, filing of the adoption petition or theentry of the adoption order.Dependent CoverageEnrolling DependentsDependent beneficiaries will be enrolled in the same healthplan as the benefit recipient. When both parents* arebenefit recipients, either may elect to cover the dependents.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. Benefit recipients must complete the online process using theSelf-Service Tools at MyBenefits.illinois.gov to adddependent coverage. * The term 'parent' includes a stepparent or a civil union

partner of the child's parent.Documentation RequirementsDocumentation, 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 the nextBenefit Choice Period (if never previously enrolled in CIP) orupon the benefit recipient experiencing a qualifying change instatus, as long as the documentation is provided in a timelymanner.A time period of 90 days is allotted to provide the SSN ofnewborns and adopted children; however, the election timeframes still apply to request the addition of the dependentcoverage. If the SSN is not provided within 90 days of thedependent’s date of birth or adoption date, coverage will beterminated. Refer to the ‘Documentation Requirements –Adding Dependent Coverage’ chart later in this chapter forspecific documentation requirements.Dependent Beneficiary Enrollment Opportunities

Dependent beneficiaries may be enrolled in CIP during theannual Benefit Choice Period only if they have never beenpreviously enrolled. The coverage becomes effective July 1st. Outside the annual Benefit Choice Period, dependentbeneficiaries who experience one of the following events maybe enrolled in CIP, regardless of whether or not they have everbeen previously enrolled:

Enrollment Periods (cont.)


F The dependent beneficiary becomes eligible forMedicare. Dependent beneficiaries who become eligiblefor Medicare are eligible for CIP coverage. The coveragemust be applied for within 6 months from the date thedependent beneficiary became Medicare eligible. If thedependent beneficiary is Medicare eligible due to turning65 and wishes to be enrolled in CIP, the benefit recipientshould contact the Department's Medicare COB prior totheir 65th birthday. Coverage will be effective the first dayof the month in which the dependent beneficiary becomesMedicare eligible or the first day of the month whenenrollment is completed online atMyBenefits.illinois.gov, whichever is later.

F The dependent beneficiary has been determined to beineligible for Medicare. Dependent beneficiaries whohave been determined by the Social SecurityAdministration to be ineligible for Medicare have 30 daysfrom their 65th birthday to apply for coverage. Coveragewill be effective the first day of the month in which thedependent reaches age 65 or the first day of the monthwhen the enrollment application is received by theDepartment's Medicare COB, whichever is later.

F Coverage is terminated by a former group plan.Dependent beneficiaries who are eligible to enroll in CIPbut instead continue coverage with another plan, mayenroll if the other plan terminates coverage. Thedependent has 30 days following the loss of othercoverage to submit an enrollment application to theDepartment's Medicare COB, along with a letter from theformer plan stating the effective date of termination.Termination of coverage must be initiated by the formergroup plan. Termination for nonpayment of premium doesnot qualify as loss of coverage by the group plan andtherefore is not an eligible enrollment event. The effectivedate of the coverage is the first day of the month followingcancellation of coverage with the other plan.

Enrollment Periods (cont.)


Reason

Upon application of annuity benefitsBenefit Recipient becomes eligible for Medicare (turning 65/ESRD/disability)Benefit Recipient determinedineligible for Medicare (turning 65)Benefit Recipient’s coverage is involuntarily terminated by a former group planAnnual Benefit Choice PeriodMarriage, civil union, adoption orbirthDependent Beneficiary becomes eligible for Medicare (turning 65/ESRD/disability)Dependent Beneficiary determinedineligible for Medicare (turning 65)Dependent Beneficiary’s coverage isinvoluntarily terminated by a former group plan

Benefit Recipient may

enroll in CIP forthe first time

X

X

X

X

X

Benefit Recipient may

enroll in CIP even if

previously enrolled

N/A

X

X

X

Dependent Beneficiary maybe enrolled inCIP for the first

time

X

X

X

X

X

X

X

X

X

Dependent Beneficiary maybe enrolled in

CIP even if previously enrolled

X

X

X

College Insurance Program Enrollment Opportunities


Type of DependentAdjudicated 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 26Natural ChildBirth up to, but not including, age 26Parent

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

benefit recipient must provide health insurance through the retirement system• 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 a• Copy of the tax return

• Birth Certificate required, and a• Statement from the Social Security Administration with the social security disability

determination or a Court Order, and a• Copy of the tax return

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

• Birth Certificate required

• Benefit Recipient’s Birth Certificate indicating the parent’s name, and • Copy of the tax return

• Marriage Certificate or tax return• Civil Union Partnership Certificate. • Birth Certificate required, and • Marriage or Civil Union Partnership Certificate indicating the member is married to,

or the partner of, the child’s parent.

Note: Birth Certificate from either the State or admitting hospital which indicates the benefit recipient 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 be added tothe benefit recipient’s coverage upon receipt of the birth certificate or adoption order without the SSN. The benefit recipient must provide the SSN within 90 days of the datethe coverage was requested in order to continue the dependent's coverage.

Documentation Requirements – Adding Dependent Coverage*


Qualifying EventDivorce, Dissolution of Civil Union Partnership or Annulment

Legal Separation

Loss of Court-Ordered Custody

Supporting Documentation RequiredDivorce 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 member no longer has custody of the dependent. Theorder must have judge’s signature with circuit clerk’s file stamp.

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 – 30 from the benefit begin date

During the Benefit Choice Period

Before, or the day of,the eventDay 1 – 30 after event

From birth up to 31 days after the birth

Within 31 days of theevent

And if the documentation is provided…Day 1 – 30 from the benefit begin date

Within 10 days of theBenefit Choice Periodending

1 – 30 days after theevent

From birth to 31 daysafter the birth

Within 31 days of theevent

Dependent coverage will be effective…On the date of commencementof retirement or annuity benefits,or the first of the month of theapplication for retirement,whichever is later

July 1st

The first day of the monthfollowing the date of the event

Date of birth

Date of placement of the child,filing of the petition or the entryof the adoption order

Documentation Time LimitsDependent coverage may be added with the corresponding effective date when documentation is provided to MyBenefits.illinois.gov orthe MyBenefits Service Center within the allowable time frame as indicated below. If documentation is provided outside the time frames,adding dependent coverage will not be allowed until the next annual Benefit Choice Period (as long as the dependent has never previouslybeen enrolled in CIP) or until the member experiences a qualifying change in status.

Penalty for FraudFalsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverageunder CIP is considered a fraudulent act. The State of Illinois will impose a financial penalty, including, but not limited to, re-payment of all premiums the State made on behalf of the benefit recipient and/or the dependent beneficiary, as well as expensesincurred by CIP.


The College Insurance Program (CIP) covers the majority of thecost of the benefit recipient’s health, dental and visioninsurance coverage. The amount a benefit recipient contributeseach month is based upon the coverage elections in effect onthe 1st of the month. Premiums will not be prorated when abenefit recipient changes their coverage elections or terminatesfrom CIP on a day other than the 1st. Benefit recipients whoseannuity check is insufficient to have premiums deducted will bedirect billed. It is your responsibility to verify the accuracyof premiums paid, whether deducted from the annuity ordirect billed, and to notify SURS of any errors.All benefit recipients are responsible for the entire cost ofelective dependent coverage. Premiums for dependentcoverage are established annually and reflected on theMyBenefits.illinois.gov website. Thesecontributions/premiums are subject to change each plan year.

Benefit RecipientsDirect BilledBilling Procedure and Time Frames

The law requires that the premium for coverage be deductedfrom the annuity received by the benefit recipient. If theannuity is insufficient to cover the premium, a direct billstatement will be sent which requires the benefit recipient tosubmit monthly payments. Premium payment is requiredthrough the month of cancellation or death.

Nonpayment of PremiumIf payment is not received by the final due date, coverage willbe terminated effective the last day of the current month.Failure to pay the bill may result in a loss of coverageand/or withholding through the SURS annuity check.Please be advised that benefit recipients and theirdependents who are terminated for nonpayment of premiumwill not be eligible to re-enroll in CIP, or be covered underanother member, nor are they eligible for continuation ofcoverage through COBRA.

COBRA ParticipantsWhile a plan participant is on COBRA, a monthly bill isgenerated by SURS for the premium amount due. Bills aremailed the first week of each month and must be paid by thedue date to ensure continuation of coverage. Planparticipants who do not receive a bill should contact SURS forassistance. Failure to submit payment will result intermination of coverage retroactive to midnight the last day ofthe month for which full payment was received.

Premium RefundsPremium refunds based on corrections to a benefit recipient’sinsurance elections may be processed retroactively up to sixmonths. Benefit recipients who fail to notify SURS within 30days of a dependent’s ineligibility will not receive a premiumrefund.

Premium UnderpaymentsUnderpaid premiums are the responsibility of the annuitantor survivor and must be paid in full, regardless of the timeperiod for which the underpayment occurred.

Premium Payment

Penalty for FraudFalsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverageunder CIP is considered a fraudulent act. The State of Illinois will impose a financial penalty, including, but not limited to, re-payment of all premiums the State made on behalf of the benefit recipient and/or the dependent beneficiary, as well as ex-penses incurred by CIP.


The coverage of a benefit recipient and any dependents willterminate upon the request of the benefit recipient, thebenefit ceasing, the benefit recipient’s death or upon thecoverage being terminated for nonpayment of premium.When a dependent experiences an event which terminatestheir coverage, such as a benefit recipient’s death, thedependent’s health, dental and vision coverage, in mostcases, can be continued under the Consolidated OmnibusBudget Reconciliation Act (COBRA). See the 'COBRACoverage' section for more information.

Termination of the BenefitRecipient’s CoverageA benefit recipient’s coverage terminates at midnight:

F On the date of benefit recipient’s death.

F On the last day of the month for which payment is notreceived following the issuance of a final notice ofpremium due from SURS (member and all dependentswill be ineligible for COBRA).

F On the last day of the month in which the benefitrecipient’s annuity benefit ceases.

F On the last day of the month in which the benefit recipientrequested the termination of coverage.

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

F Simultaneous with termination of the benefit recipient’scoverage.

F On the last day of the month in which the benefit recipientrequested termination of the dependent's coverage.

F On the last day of the month in which a dependent loseseligibility.

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

F On the last day of the month following receipt of thewritten request to terminate dependent coverage. Re-enrollment opportunities are limited – see theenrollment section for details (these dependents will beineligible for COBRA).

F On the date of dependent's death.

F On the last day of the month in which the benefit recipientfails to certify continued eligibility for coverage of thedependent child.

F On the day preceding the dependent's:

– enrollment in CIP as a benefit recipient.

– divorce or civil union partnership dissolution from thebenefit recipient. 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: Benefit recipients who fail to notify SURS within 30days of the dependent’s ineligibility will not receive apremium refund, nor will the dependent be eligible forCOBRA.

Termination


OverviewThe Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA) and Sections 367.2, 367e and 367e.1 of the IllinoisInsurance Code provides eligible covered benefit recipientsand their eligible dependents the opportunity to temporarilyextend their health coverage when coverage under the healthplan would otherwise end due to certain qualifying events.COBRA rights are restricted to certain conditions under whichcoverage is lost. The election to continue coverage must bemade within a specified election period. If elected, coveragewill be reinstated retroactive to the date following terminationof coverage. An initial notice is provided to all new members uponenrollment in CIP. This notice is to acquaint individualswith COBRA law, notification obligations and possiblerights to COBRA coverage if loss of group health coverageshould occur. If an initial notice is not received, benefitrecipients should contact SURS.

EligibilityCovered benefit recipients and dependents who lose coveragedue to certain qualifying events (see the ‘COBRA QualifyingEvents’ chart at the end of this section) are considered qualifiedbeneficiaries and may be allowed to continue coverage under theprovisions of COBRA. A qualified beneficiary is an individual(including the member, spouse, civil union partner or child) wholoses employer-provided group health coverage and is entitled toelect COBRA coverage. The individual must have been covered bythe plan on the day before the qualifying event occurred andenrolled in COBRA effective the first day of eligibility or be anewborn or newly adopted child of the covered member. Anyvoluntary termination of coverage will render the benefitrecipients and any dependents ineligible for COBRAcoverage.Coverage available under COBRA for qualified beneficiaries isidentical to the health, dental and vision insurance coverageprovided to CIP members. Covered dependents retain COBRA eligibility rights even ifthe benefit recipient chooses not to enroll. Qualifiedbeneficiaries electing continuation of coverage under COBRAwill be enrolled as a member. NOTE: If the benefitrecipient’s spouse, civil union partner or dependentchild(ren) live at another address, SURS must be advisedimmediately so that notification can be sent to the properaddress(es).

Notification of COBRA EligibilityThe benefit recipient or qualified beneficiary must notify SURSwithin 60 days of the date of the termination event, or the dateon which coverage would end, whichever is earlier. Failure tonotify SURS within 60 days will result in disqualification ofCOBRA continuation coverage.

SURS will send a letter to the qualified beneficiary regardingCOBRA rights within 14 days of receiving notification of thetermination. Included with the letter will be an enrollmentform, premium payment information and important deadlines.If a letter is not received within 30 days and you notified SURSwithin the 60-day period, you should contact the retirementsystem immediately for information.

COBRA EnrollmentIndividuals have 60 days from the date of the COBRA eligibilityletter to elect enrollment in COBRA and 45 days from the date ofelection to pay all premiums. Failure to complete and return theenrollment form or to submit payment by the due dates willterminate COBRA rights. If the enrollment form and all requiredpayments are received by the due dates, coverage will bereinstated retroactive to the date of the qualifying event.

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 MBSC bycompleting the online process using the Self-Service Tools atMyBenefits.illinois.gov. These individuals are ineligible tocontinue COBRA coverage and will be terminated from theCOBRA program.

SURS reserves the right to retroactively terminate COBRAcoverage if an individual is deemed ineligible. Premiumswill not be refunded for coverage terminated retroactivelydue to ineligibility.

COBRA ExtensionsF Disability Extension

Qualified beneficiaries covered under COBRA who havebeen determined to be disabled by the Social Security

COBRA Coverage


Administration (SSA) may be eligible to extend coveragefrom 18 months to 29 months at an increased cost. Enrollednondisabled family members are also eligible for theextension. See ‘Premium Payment under COBRA’ later inthis 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) be 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 the SSAdetermination letter must be submitted to SURS within 60days of the date of the SSA determination letter or the firstday of COBRA coverage, whichever is later.

The affected qualified beneficiary must also notify SURS ofany SSA final determination of loss of disability status. Thisnotification must be provided within 30 days of the SSAdetermination letter.

F Second Qualifying Event ExtensionIf a member who experienced a qualifying event thatresulted in an 18-month maximum continuation periodexperiences a second qualifying event before the end ofthe original 18-month COBRA coverage period, thespouse, civil union partner and/or dependent child (mustbe a qualified beneficiary) may extend coverage anadditional 18 months for a maximum 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 waiver atany time before the end of the 60-day period. Coverage willbe retroactive to the qualifying event.

Premium Payment under COBRAThe qualified beneficiary has 45 days from the date coverage iselected to pay all premiums. Individuals electing COBRA areconsidered members and will be charged the member rate. Adivorced or widowed spouse (including a former civil unionpartner) who has a dependent child on their coverage would beconsidered the member and charged the member rate, with thechild being charged the applicable dependent rate. If only adependent child elects COBRA, then each child would beconsidered a member and charged the member rate.

Once the COBRA enrollment form is received and thepremium is paid, coverage will be reinstated retroactive to thedate coverage was terminated. Monthly billing statementswill be mailed to the member’s address on file on or aboutthe 5th of each month. Bills for the current month are due bythe 25th of the same month. Final notice bills (those with abalance from a previous month) are due by the 20th of thesame month. Failure to pay the premium by the final duedate will result in termination of coverage retroactive to thelast day of the month in which premiums were paid.

It is the member’s responsibility to promptly notify SURS inwriting of any address change or billing problem.

The College Insurance Program does not contribute to thepremium for COBRA coverage. Most COBRA members mustpay the applicable premium plus a 2% administrative fee forparticipation. COBRA members who extend coverage for 29months due to SSA’s determination of disability must pay theapplicable premium plus a 50% administrative fee for allmonths covered beyond the initial 18 months.

COBRA Coverage (cont.)


Adding Dependents - SecondQualifying Event LimitationsNewly-acquired dependents, including spouses, civil unionpartners, children of civil union partners and stepchildren,may be added to existing COBRA coverage. Even thoughthese dependents are eligible for COBRA coverage, unlessthey are a newborn child or a newly adopted child, they arenot considered “qualified beneficiaries” and therefore wouldbe ineligible for an extension if a second qualifying eventwould occur.

Existing dependents who are not enrolled on the first daythe benefit recipient becomes eligible for COBRAcontinuation coverage are not considered qualifiedbeneficiaries. These dependents may only be added duringthe annual Benefit Choice Period (if they have neverpreviously been enrolled in CIP) and are also not eligible forsecond qualifying 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 of thefollowing occurs:

F Maximum continuation period ends.

F Failure to make timely payment of premium.

F Covered member or dependent becomes a participant inanother 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 SURS for more information.

F Covered member or dependent reaches the qualifying agefor 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 loses eligibility.

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

Refer to the ‘COBRA Qualifying Events’ chart in this chapter formore information.

Conversion Privilege for HealthCoverageWhen COBRA coverage terminates, members may have theright to convert to an individual health plan. Members areeligible for this conversion unless group health coverageended because:

F the required premium was not paid, or

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

F the COBRA coverage was voluntarily terminated.

Approximately two months before COBRA coverage ends,SURS will send a letter providing instructions on how to applyfor conversion. To be eligible for conversion, members musthave been covered by the current COBRA health plan for atleast 3 months and requested conversion within 31 days ofexhaustion of COBRA coverage. The converted coverage, ifissued, will become effective the day after COBRA coverageended. Contact the appropriate health plan administratorfor information regarding conversion. SURS is notinvolved in the administration or premium rate structureof coverage obtained through conversion.




Qualifying EventsBENEFIT RECIPIENTBenefit Recipient’s loss of eligibilityDEPENDENT BENEFICIARYBenefit Recipient’s termination of benefitsLegal separation from Benefit Recipient*Loss of eligibility as a dependent childBenefit Recipient’s death

• Spouse under age 55• Spouse age 55 or older if already enrolled in Medicare• Spouse age 55 or older

• Dependent child 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 months36 months36 months

36 months36 months Until obtains Medicare or reaches the qualifying age for Medicare36 months

36 months36 monthsUntil obtains Medicare or reaches the qualifying age for Medicare36 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 partnerswhose partnership has been dissolved.

* Dropping a spouse’s coverage during the annual Benefit Choice Period in anticipation of a divorce, civil union partnership dissolution orlegal separation will result in the spouse losing coverage effective July 1st. The spouse will be eligible for COBRA only once the divorce,dissolution or legal separation actually occurs. Spouses whose coverage was terminated due to a divorce, dissolution or legal separationmust 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.



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

Qualifying EventsCOBRA MEMBERSSA Disability determination within the first 60 days of COBRA

COBRA DEPENDENTLoss of eligibility as a dependent child

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 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


Until obtains Medicare or reaches the qualifying age for Medicare



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 the member, spouse, civil union partner or child) who loses employer-providedgroup health coverage and is entitled to elect COBRA coverage. The individual must have been covered by the plan on the daybefore the qualifying event occurred and enrolled in COBRA effective the first day of eligibility or be a newborn or newly adoptedchild of the covered member.

Chapter 2Chapter 2: Health, Dental and Vision Coverage InformationHealth Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Managed Care Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22College Choice Health Plan (CCHP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Medical Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Prescription Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Dental Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Vision Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Benefits HandbookMyBenefits.illinois.gov 21


OverviewCollege Insurance Program (CIP) offers a variety of healthplans from which to choose. Each plan provides health,behavioral health and prescription drug benefits; however,the benefit levels, exclusions and limitations may differ.When making choices, benefit recipients should considerhealth status, coverage needs and service preferences.Dependents will have the same health and dental plan as thebenefit recipient under whom they are enrolled.The MyBenefits.illinois.gov website provides a listing of thehealth plans available and the Illinois counties in which theyprovide coverage.

Benefit recipients who change their health plan outsidethe Benefit Choice Period, regardless of the basis for thechange, will be responsible for any deductibles requiredby the new plan, even if the plan participant met alldeductibles while covered by the previous health plan.

Types of Health PlansThe types of health plans available are:F Managed Care Plans

• Health Maintenance Organizations (HMOs)• Open Access Plans (OAPs)

F College Choice Health Plan (CCHP)

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 from health riskassessments to educational materials and, in some cases,discounts on items such as gym memberships and weight lossprograms. These offerings are available to plan participants andare provided to help plan participants take control of theirpersonal health and well-being. Information about the variousofferings is available on the plan administrators’ websites.

Managed Care Health Plans Managed care is a method of delivering healthcare through asystem of network providers. Managed care plans providecomprehensive health benefits at lower out-of-pocket costs byutilizing network providers. Managed care health planscoordinate all aspects of a plan participant’s healthcareincluding medical, prescription drug and behavioral healthservices.There are two types of managed care plans, health maintenanceorganizations (HMOs) and open access plans (OAPs). Benefitrecipients who enroll in an HMO must select a primary carephysician/provider (PCP) from the health plan’s providerdirectory, which can be found on the plan’s website. Planparticipants should contact the physician’s office or the HMOplan administrator to find out if the PCP is accepting newpatients. Plan participants are required to use participatingphysicians and hospitals for maximum benefits. Benefitrecipients enrolled in an OAP do not need to select a PCP. Forcomplete information on specific plan coverage or providernetworks, contact the managed care health plan and review theSummary Plan Document (SPD).Like any health plan, managed care plans have planlimitations including geographic availability and limitedprovider networks. Managed care coverage is offered in certaincounties called service areas. Ordinarily, managed care plansonly cover members within the State; however, plans that havenetworks outside the State of Illinois may provide coverage.Members should contact the managed care plan administratorto ascertain if coverage is available outside their geographicarea. Eligible dependents that live apart from the benefitrecipient’s residence for any part of a plan year may be subjectto limited service coverage. It is critical that members whohave an out-of-area dependent (such as a college student)contact the managed care plan to understand the plan’sguidelines on out-of-area coverage.The open access care health plans are self insured, meaning allclaims are paid by CIP even though managed care health planbenefits apply. These plans are not regulated by the IllinoisDepartment of Insurance and are not governed by theEmployees Retirement Income Security Act (ERISA).In order to have the most detailed information regarding aparticular managed care health plan, benefit recipientsshould ask the plan administrator for its summary plandocument (SPD) which describes the covered services, benefitlevels, and exclusions and limitations of the plan’s coverage.The SPD may also be referred to as a certificate of coverage ora summary plan document.

Health Plan Options


Benefit recipients 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. Benefitrecipients deciding to enroll in a managed care healthplan should read the SPD before seeking medicalattention. It is the benefit recipient's responsibility tobecome familiar with all of the specific requirements ofthe health plan.Most managed care health plans impose benefit limitationson a plan year basis (July 1 through June 30); however, somemanaged care health plans impose benefit limitations on acalendar year basis (January 1 through December 31).

Refer to the MyBenefits.illinois.gov website for planadministrator information.

Health Maintenance Organization (HMO)HMO members must choose a primary care physician/ provider(PCP) who will coordinate the healthcare, hospitalizations andreferrals for specialty care. In most cases a referral for specialtycare will be restricted to those services and providers authorizedby the designated PCP. Additionally, referrals may also requireprior authorization from the HMO. To receive the maximumhospital benefit, your PCP or specialist must have admittingprivileges to a network hospital.

Like any health plan, HMOs have plan limitations includinggeographic availability and participating provider networks.HMO coverage is offered in certain counties called serviceareas. 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 the planadministrator. NOTE: When an HMO plan is the secondaryplan and the plan participant does not utilize the HMOnetwork of providers or does not obtain the required referral,the HMO plan is not required to pay for services. Refer to theplan’s description of coverage for additional information.

Preventive care is paid at 100 percent when services are obtainedthrough a network provider. HMO provider networks are subject to change. Benefit recipientswill be notified in writing by the plan administrator when a PCPnetwork change occurs. If the designated PCP leaves the HMOnetwork, you must choose another PCP within that plan.When an HMO member’s primary care physician (PCP) leavesthe plan’s network, the member will only be allowed to

change health plans if the HMO network experienced asignificant change in the number of medical providersoffered, as determined by CMS.

HMO Out-of-Pocket Maximum After the out-of-pocket maximum has been satisfied, the planwill pay 100 percent of covered expenses for the remainder ofthe plan year for eligible medical, behavioral health andprescription drug charges. Charges that apply toward the out-of-pocket maximum for HMOs are:F Medical and prescription copaymentsF Medical coinsurance.

Open Access Plans (OAPs) Open access plans combine similar benefits of an HMO withthe same type of coverage benefits as a traditional healthplan. Members who elect an OAP will have three tiers ofproviders from which to choose to obtain services. The benefitlevel is determined by the tier in which the healthcareprovider is contracted. Members enrolled in an OAP can mixand match providers and tiers.F Tier I offers a managed care network which provide

enhanced benefits and require copayments which mirrorHMO copayments, but do not require a plan yeardeductible.

F Tier II offers another managed care network, in addition tothe managed care network offered in Tier I, and alsoprovides enhanced benefits. Tier II requires copayments,coinsurance and is subject to an annual plan yeardeductible.

F Tier III covers all providers which are not in the managedcare network of Tiers I or II (i.e., out of network providers)and does not have an out-of-pocket maximum. Using TierIII can offer members flexibility in selecting healthcareproviders, but involve higher out-of pocket costs. Tier IIIhas a higher plan year deductible and has a highercoinsurance amount than Tier II services. In addition,certain services, such as preventive/wellness care, are notcovered when obtained under Tier III. Furthermore, planparticipants who use out-of-network providers will beresponsible for any amount that is over and above thecharges allowed by the plan for services (i.e., allowablecharges, Usual and Customary charges (U&C), MaximumReimbursable Charges (MRC), Maximum AllowableCharges (MAC)), which could result in much higher out-of-pocket costs. When using out-of-network providers, it is

Health Plan Options


recommended that the participant obtain apreauthorization of benefits to ensure that medicalservices/stays will meet medical necessity criteria and beeligible for benefit coverage.

Members who use providers in Tiers II and III will beresponsible for the plan year deductible. In accordancewith the Affordable Care Act, these deductibles willaccumulate separately from each other and will not‘cross accumulate.' This means that amounts paid towardthe deductible in one tier will not apply toward the deductiblein the other tier.Preventive care is paid at 100 percent without having to meetthe annual deductible when services are obtained through aTier I or Tier II network provider.

OAP Out-of-Pocket Maximum Eligible medical, behavioral health and prescription drugcharges will be covered at 100 percent for the remainder ofthe plan year after the plan’s out-of-pocket maximum hasbeen satisfied. Charges that apply toward the out-of-pocketmaximum for an OAP plan (only applies to Tier I and Tier IIproviders) are:F Annual medical plan year deductible (Tier II).F Medical and prescription copaymentsF Medical coinsurance. Eligible charges from Tiers I and II will be added togetherwhen calculating the out-of-pocket maximum. Tier III doesnot have an out-of-pocket maximum.

College Choice Health Plan(CCHP) The College Choice Health Plan (CCHP) is a self-insured healthplan offering a comprehensive range of benefits. All claims andcosts are paid by the College Insurance Program (CIP) through athird-party administrator. For complete information regardingspecific plan coverage and the provider’s network, refer to thesummary plan document on the MyBenefits.illinois.govwebsite. Benefit enhancements are available by utilizing the:F Nationwide CCHP physician, hospital, ancillary services

and transplant network.F Pharmacy network.F Behavioral health network.Each of these three components is discussed separately in thissection. Each component has its own plan administrator.

Benefit Recipient ResponsibilitiesF The benefit recipient 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 notification

requirements.– Any charges NOT covered by the plan or determined by

the plan administrator to be not medically necessaryservices.

NOTE: Specific dollar amounts and percentages that apply todeductibles, “additional deductibles” and coinsurance areupdated each year on the MyBenefits.illinois.gov website.

Plan Requirements Plan Year DeductibleThe plan year deductible requirement applies to all medicaland behavioral health services, except preventive services.The plan year deductible for benefit recipients is a set amountthat may change each plan year. To verify individual andfamily plan year deductible, review theMyBenefits.illinois.gov website. The plan year runs fromJuly 1 through June 30.

Each individual plan year deductible accumulates toward theannual out-of-pocket maximum.

Additional DeductiblesBesides the plan year deductible, plan participants must payadditional deductibles for the following: F Each emergency room visit that does not result in a

hospital admissionF Hospital admission (CCHP and non-CCHP)F Transplant hospital admissionEven though these additional deductibles do not applytoward the plan year deductible, they do accumulate towardthe 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.

Health Plan Options


Health Plan Options CCHP Out-of-Pocket Maximum Eligible medical, behavioral health and prescription drugcharges will be covered at 100 percent for the remainder of theplan year after the plan’s out-of-pocket maximum has beensatisfied. There are two separate out-of-pocket maximums: in-network and out-of-network. After the out-of-pocket maximumhas been met, deductibles and coinsurance amounts are nolonger required and the plan pays 100% of eligible charges forthe remainder of the plan year.Coinsurance and deductiblesapply to one or the other, but not both. Charges that applytoward the out-of-pocket maximum for the CCHP plan are:

F Annual medical plan year deductibleF Prescription copaymentsF Medical coinsuranceF CCHP additional medical deductiblesThe following do not apply toward out-of-pocketmaximums:F Notification penalties.F Ineligible charges (i.e., amounts over the allowable

charge, charges for noncovered services and charges forservices deemed not to be medically necessary).

Medical NecessityF CCHP covers charges for services and supplies that are

medically necessary. Medically necessary services andsupplies are those which are:– provided by a hospital, medical facility or prescribed by a

physician or other provider and are required to identifyand/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 necessary andmeeting the standards for good medical practice for thediagnosis or treatment of the patient’s condition.

– the most appropriate supply or level of service which canbe 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 treatment

being rendered.

Predetermination of BenefitsPredetermination of benefits ensures that medicalservices/stays will meet medical necessity criteria and beeligible for benefit coverage. The plan participant’s physicianmust submit written detailed medical information to themedical 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 determined uponreceipt of the itemized bill and are subject to standard claimpayment policies including, but not limited to, multiple andincidental procedure reductions, allowable charges and claimbundling 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 by theplan and therefore cannot be applied to the plan yeardeductible nor the out-of-pocket maximum. The planparticipant will be responsible for the entire amount thatis 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 require

additional skill, time or experience.F Prevailing charge level in the geographic area where the

provider is located and other geographic areas havingsimilar medical-cost experience.

Allowable charges apply to medical services, procedures and/orsupplies.

IMPORTANT: The amount of the claim that will be paid isbased on the allowable charges amount or the actual chargemade by the provider, whichever is less, for out-of-networkservices.

College Choice Health Plan (CCHP) Network The College Choice Health Plan (CCHP) network includeshospitals, physicians and ancillary providers throughout


Illinois, 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 designed toassist plan participants requiring complex care in times ofserious or prolonged illness. There is no additional cost to theplan participant for this service.

The referral to the MCM Program is made through either theMCM administrator, the CCHP plan administrator or byrequest from a plan participant. Once referred, the planparticipant is assigned a case manager who serves as a liaisonand facilitator between the patient, family, physician andother healthcare providers. The case manager is a registerednurse or other healthcare professional with extensive clinicalbackground. The case manager can effectively minimize thefragmentation 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. Toreach the MCM plan administrator, call the toll-free numberlisted in the plan administrator section on theMyBenefits.illinois.gov website.Notification Requirements

Notification 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 CCHP networkprovider, the medical provider is responsible for contactingthe notification administrator on behalf of the planparticipant. If using a non-CCHP provider, the plan participant mayrequest that their non-CCHP medical provider contact thenotification administrator to provide specific medicalinformation, setting and anticipated length of stay to determinemedical appropriateness. The plan participant may also makenotification, after which a medically qualified reviewer willcontact the plan participant’s physician or provider to obtainspecific 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 a

financial 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 theMyBenefits.illinois.gov website. The toll-free number isalso printed on your identification card. You can call sevendays a week, twenty-four hours a day. F Notification is required for the following:

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

– Outpatient Surgery, Procedures, Therapies andSupplies/Equipment. Outpatient surgery andprocedures include, but are not limited to, items such asimaging (MRI, PET, SPECT and CAT scan), physical,occupational or speech therapy, foot orthotics, durablemedical equipment (DME) supplies, infertility surgery,cardiac or pulmonary rehabilitation, skin removal orenhancement (lipectomy, select injectable drug treatmentfor varicose veins, etc.).

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

– Skilled Nursing Facility, Extended Care Facility orNursing Home Admission. Notification must be madeat least seven days before admission. A review of thecare being rendered will be conducted to determine ifthe services are skilled in nature.

– Emergency or Urgent Admission. Notification must bemade within two business days after the admission.

– Hospice Admission. Notification must be made prior tothe admission.

– Potential Transplants. Notification must be made priorto beginning evaluation services. Benefits are onlyavailable through the CCHP transplant network ofhospitals/facilities.

F Notification is Not:– A final determination of medical necessity. If the

notification administrator should determine that thesetting and/or anticipated length of stay are no longermedically necessary and NOT eligible for coverage, thephysician will be informed immediately. The plan

Health Plan Options


participant will also receive written confirmation of thisdetermination.

– A guarantee of benefits. Regardless of notification of aprocedure or admission, there will be no benefitpayment if the plan participant is ineligible for coverage onthe date services were rendered or if the charges aredeemed ineligible.

– Enrollment of a newborn for coverage. Complete theonline process using the Self-Service Tools atMyBenefits.illinois.gov to enroll a newborn within 31days of birth.

– A determination of the amount which will be paid for acovered 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’ sectionlater in this chapter.Benefits for Services Received While Outside theUnited States

The plan covers eligible charges incurred outside of the UnitedStates for services that are generally accepted as medicallynecessary within the United States. All plan benefits aresubject to plan provisions and deductibles. The benefit forfacility and professional charges is paid at the non-CCHP rate.Notification is not required for medically necessary servicesrendered outside of the United States; however, medicalnecessity must be established prior to reimbursement.Payment for the services will most likely be required fromthe member at the time the services are rendered.Plan participants must file a claim with the plan administratorfor reimbursement. When filing a claim, enclose the itemizedbill with a description of the services translated to English andthe total amount of billed charges, along with the name of thepatient, date of service, diagnosis, procedure code and theprovider’s name, address and telephone number.Reimbursement in American dollars will be based on theconversion rate of the billed currency on the date serviceswere rendered.Generally, Medicare will not pay for healthcare obtainedoutside the United States and its territories. When Medicaredoes not pay, CCHP becomes the primary payer and standardbenefit levels will apply.

Hospital Bill Audit Program

The Hospital Bill Audit Program applies to CCHP and non-CCHP hospital charges. Under the program, a member ordependent who discovers an error or overcharge on a hospitalbill and obtains a corrected bill is eligible for 50% of theresulting 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 CCHP is the primary payer.Reimbursement documentation required:

– Original incorrect bill,– Corrected copy of the bill, and– Benefit recipient’s name, telephone number and last

four digits of the SSN.Submit Documentation to:

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

Health Plan Options


Ambulance (See Exclusion #5 and #41)F Transportation charges to the nearest hospital/facility for

emergency medically necessary services for a patientwhose condition warrants such service. The planadministrator should be notified as soon as possible for adetermination of coverage. Medically necessarytransportation charges (emergency ground or airambulance) will be paid at the 80% benefit level after theannual plan year deductible has been met. Services thatare determined not to be medically necessary will not becovered.

F Transportation services eligible for coverage: – From the site of the disabling illness, injury, accident or

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 the patient’sspecific injury, trauma or illness to the nearest hospitalequipped to treat the injury, trauma or illness.

Behavioral Health In an emergency or a life-threatening situation, call 911, or goto the nearest hospital emergency room. Plan participants mustcall the behavioral health plan administrator within 48 hours toavoid a financial penalty. Authorization requirements still applywhen plan participants have other coverage, such as Medicare.F Inpatient services must be authorized prior to admission

or 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 hours willresult in a financial penalty and risk incurring noncoveredcharges.

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 CCHP network provider. Mostroutine outpatient services (such as therapy sessions andmedication management) will be covered without theneed for prior authorization. Authorization requirementsfor certain specialty outpatient services are noted below.Outpatient services that are not consistent with usualtreatment practice for a plan participant’s condition will besubject to a medical necessity review. The behavioralhealth administrator will contact the plan participant’sprovider to discuss the treatment if a review will beapplied. Outpatient services received at the out-of-network benefit level must be provided by a licensedprofessional including licensed clinical social worker(LCSW), registered nurse, clinical nurse specialist (RNCNS), licensed clinical professional counselor (LCPC),licensed marriage and family therapist (LMFT),psychologist or psychiatrist to be eligible for coverage.

F Electroconvulsive therapy, psychological testing andapplied behavioral analysis must be authorized toreceive in-network or out-of-network benefits. Failure toobtain authorization will result in the risk of incurringnoncovered charges.

College Choice Health Plan – Medical Benefits SummaryIn-Network Benefit: Preventive services are paid at 100%. Unless otherwise indicated, a 80% benefit level will be applied to all other eligible services, supplies and therapies.Out-of-Network Benefit: Unless otherwise indicated, all eligible services, supplies and therapies,including preventive services, are paid at 60% of allowable charges after the plan year deductiblehas been met.

This document contains a brief overview of some of the benefits available under the College Choice Health Plan (CCHP). Contact the planadministrator for more information or coverage requirements and/or limitations. In order for any service, therapy or supply to beconsidered eligible for coverage, it must be medically necessary as determined by the plan administrator. The informationbelow indicates the requirements and benefit levels of the covered services, supplies and therapies for the standard benefitlevel (60% of allowable charges). There is a 80% enhanced benefit level for utilizing network providers.


F Residential services must be authorized prior toadmission to receive in-network or out-of-networkbenefits. Authorization is required with each newresidential admission. Failure to notify the behavioralhealth plan administrator of an admission to a residentialfacility will result in a financial penalty and risk incurringnoncovered charges.

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) on

which the mastectomy was performed.– Surgery and reconstruction on the other breast

(including implants) to produce a symmetricalappearance.

– Prosthesis and treatment for any physical complicationsat any stage of mastectomy, including post-surgicallymphedema (swelling associated with the removal oflymph nodes) rendered by a provider covered underthe 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 be

maintenance 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 a

Christian Science Journal at the time services are givenand who: (a) has completed nurses’ training at aChristian Science Benevolent Association Sanitarium; or(b) is a graduate of another School of Nursing; or (c) hadthree consecutive years of Christian Science Nursing,including two years of training.

– A Christian Science Practitioner is an individual who islisted as such in the Christian Science Journal at thetime the medical services are provided and whoprovides appropriate treatment in lieu of treatment by amedical doctor.

CircumcisionF Charges for professional services. F Charges for circumcision are considered to be covered

services when billed as a separate claim for the newbornas long as the newborn is enrolled in the plan and thesurgery is performed within the first thirty (30) daysfollowing birth.

Dental Services (See Exclusion #14 and # 15)F Accidental Injury:

– Coverage for professional services necessary as a resultof an accidental injury to sound natural teeth caused byan external force. Care must be rendered within threemonths of original accidental injury. The appropriatefacility benefit applies.

F Nonaccidental: Coverage limited to: – Anesthesia and facility charges for dependent children

age six and under. – A medical condition that requires anesthesia and facility

charges for dental care (not anxiety or behavioralrelated conditions). Professional services are notcovered under the medical plan.

Diabetic CoverageF Charges for dietitian services and consultation when

diagnosed with diabetes. No coverage unless ordered inconjunction 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.

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 during recovery.Examples include canes, crutches, walkers, hospitalbeds and wheelchairs.

F Purchase:– Charges to purchase the equipment. Equipment

should 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 of

the item. – Newer or more efficient models.

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

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

Emergency ServicesThe facility in which emergency treatment is rendered and thelevel of care determines the benefit level (hospital, urgentcare center, physician office). For emergency transportationservices, refer to the ‘Ambulance’ section.F Emergency Room:

– 80% of allowable charges at a CCHP or non-CCHPfacility. The special deductible applies to each visit toan emergency room which does not result in aninpatient admission.

F Physician’s Office: – 80% of allowable charges; no special emergency room

deductible applies. Treatment must be rendered within 72hours of an injury or illness and meet the definition ofemergency services presented above. Nonemergencymedically necessary care is covered at 60% of allowablecharges.

F Urgent Care or Similar Facility: – 80% of allowable charges; no special emergency room

deductible applies. Treatment must be rendered within72 hours of an injury or illness and meet the definitionof emergency services presented above. This benefitapplies to professional fees only. Facility charges notcovered when services are performed in a physician’soffice or urgent care center. Nonemergency medicallynecessary care is considered at 60% of allowablecharges.

Eye Care (See Exclusion #11 and #26)F Charges for treatment of injury or illness to eye.

Foot Orthotics Notification is required. Refer to ‘Notification Requirements’in the ‘College Choice Health Plan’ section of the BenefitsHandbook for more information. F Must be custom molded or fitted to the foot and ordered

by a physician or podiatrist.

Hearing Services F Professional service charges for the hearing exam associated

with the care and treatment of an injury or an illness.

Hospice F Written notification of the terminal condition is required

from the attending physician. F Inpatient hospice requires notification. Refer to ‘Notification

Requirements’ in the ‘College Choice Health Plan’ section ofthe Benefits Handbook for more information.

Inpatient Hospital/Facility Services(See Exclusions #3, #6, #8, #32)F Hospital/facility charges. CCHP

– In-network - 85% of allowable charges after the specialdeductible at a CCHP facility. the special deductibleapplies to each hospital stay.

– Out-of-network - 60% of allowable charges after thespecial deductible at a non-CCHP facility. The specialdeductible applies to each hospital stay.

NOTE: Failure to provide notification of an upcomingadmission or surgery will result in a financial penalty anddenial of coverage for services not deemed medicallynecessary. Refer to ‘Notification Requirements’ in the‘College Choice Health Plan’ section of the Benefits Handbookfor more information.

Infertility Treatment Benefits are provided for the diagnosis and treatment ofinfertility. Infertility is defined as the inability to conceiveafter one year of unprotected sexual intercourse, the inabilityto conceive after one year of attempts to produce conception,the inability to conceive after an individual is diagnosed with


a condition affecting fertility, or the inability to sustain asuccessful pregnancy. A woman shall be considered infertilewithout having to engage in one year of unprotected sexualintercourse if a physician determines that: 1) a medicalcondition exists that renders conception impossible throughunprotected sexual intercourse; or 2) efforts to conceive as aresult of one year of medically based and supervisedmethods of conception, including artificial insemination,have failed and are not likely to lead to a successfulpregnancy. 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 proposed planof treatment with physicians’ current proceduralterminology (CPT) codes.

F Infertility Benefits: – Coverage is provided only if the plan participant has

been unable to sustain a successful pregnancy throughreasonable, less costly, medically appropriate infertilitytreatment for which coverage is available under thisplan.

F Coverage for assisted reproductive procedures includes,but is not limited to: – Artificial insemination, in vitro fertilization (IVF) and

similar procedures which include but are not limited to:gamete intrafallopian tube transfer (GIFT), low tubeovum transfer (LTOT), zygote intrafallopian tube transfer(ZIFT), and uterine embryo lavage with a maximum offour (4) procedures per lifetime;

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

– If a live birth results from an in vitro 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 of adonor and retrieval of an egg for the purpose ofdonating to a covered individual.

F Infertility treatment exclusions include, but are not limitedto:– Nonmedical expenses of a sperm or egg donor

otherwise covered under the plan such as

transportation, shipping or mailing, administrative feessuch as donor processing, search for a donor or profilinga donor, cost of sperm or egg purchased from a donorbank, cryopreservation and storage of sperm or embryoor fees payable to a donor;

– Infertility treatment deemed experimental or unprovenin nature;

– Reversal of voluntary sterilization;– Payment for medical services rendered to a surrogate for

purposes of attempting or achieving pregnancy;– Pre-implantation genetic testing.

Lab and Radiology F Outpatient:

– Charges at a physician’s office, hospital, clinic or urgentcare center.

F Inpatient: – If billed by a hospital as part of a hospital confinement,

paid at the appropriate hospital benefit level.F Professional charges:

– Professional charges associated with the interpretationof the lab or radiology procedures.

Medical Supplies (See Exclusions #3, #5, #19)F Medical supplies include, but are not limited to ostomy

supplies, surgical dressings and surgical stockings.

Morbid Obesity Treatment (See Exclusion #12)F Charges for professional services.F Obesity surgery is eligible for covered dependents with a

showing of medical necessity and predetermination ofbenefits.

Newborn Care (See Exclusion #40)F Charges for professional services in an office or hospital

setting.F Benefits are available for newborn care only if the

dependent is enrolled no later than 31 days following thebirth.


Occupational Therapy/PhysicalTherapy (See Exclusion #10)Notification is required. Refer to ‘Notification Requirements’in the ‘College Choice Health Plan’ section of the BenefitsHandbook for more information.F Covered if administered under the supervision of and

billed 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 surgical treatment

center which is licensed by the Department of PublicHealth, or the equivalent agency in other states, toperform outpatient surgery.

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

Physician Services – Surgical (SeeExclusions #12, #13, #16)F Inpatient Surgery:

– Follow-up care by the surgeon is considered part of thecost of the surgical procedure and is NOT covered as aseparate charge.

F Outpatient Surgery: – If surgery is performed in a physician’s office, the

following 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 who assists

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 claims

when multiple surgical procedures are performedduring the same operative session.

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

Podiatry Services (See Exclusion #9)Notification is required. Refer to ‘Notification Requirements’in the ‘College Choice Health Plan’ section of the BenefitsHandbook 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 care facility

stay are payable by the health plan administrator.F Prescription drugs obtained as part of a hospital stay are

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 utilizing anetwork provider. Out-of-network preventive care is covered atthe out-of-network benefit level. Your doctor will determine thetests and frequency that are right for you based on your age,gender and family history. In-network preventive services arenot 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 growth or achange in the person’s medical condition.

– Repair of a prosthetic appliance due to normal wear andusage and no longer functional.

F No payment will be made if the appliance is damaged orlost due to negligence.

F Prosthetic appliances exclusions include, but are notlimited to: – Appliances not recommended or approved by a

physician.– Appliances to overcome sexual dysfunction, except when

the dysfunction is related to an injury or illness.– Items considered cosmetic in nature such as artificial

fingernails, toenails, eyelashes, wigs, toupees or breastimplants.

– Experimental or investigational appliances.

Skilled Nursing Service –Home SettingF Contact the Notification/Medical Case Management plan

administrator for a determination of benefits. F The benefit for skilled nursing service will be limited to the

lesser of the cost for care in a home setting or the averagecost in a skilled nursing facility, extended care facility ornursing home within the same geographic region.

F The continued coverage for skilled nursing service will bedetermined by the review of medical records and nursingnotes.

Skilled Nursing – In a SkilledNursing Facility, ExtendedCare Facility or Nursing Home(See Exclusions #3, #4, #6)F Benefits are subject to skilled care criteria and will be

allowed for the most cost-effective setting or the level ofcare required as determined by the Notification/MedicalCase Management plan administrator.

F 100 day limit per plan year.F Must be a licensed healthcare facility primarily engaged in

providing skilled care.F Notification is required at least seven days prior to admission or

at time of transfer from an inpatient hospital stay.F Benefits are limited to the average cost of available

facilities within the same geographic region.

F The service must be medically necessary.F The continued coverage for skilled nursing service will be

determined by the review of medical records and nursingnotes.

F Prescription drug charges must be submitted to the healthplan administrator.

NOTE: Extended care facilities are sometimes referred toas nursing homes. Most care in nursing homes is NOTskilled care and therefore is NOT covered. Many peoplepurchase long-term care insurance policies to cover thosenursing home services which are NOT covered by medicalinsurance or Medicare.

Speech TherapyNotification is required. Refer to ‘Notification Requirements’in the ‘College Choice Health Plan’ section of the BenefitsHandbook for more information.F Charges for medically necessary speech therapy ordered

by a physician. F Treatment must be for a speech disorder resulting from

injury or illness serious enough to significantly interferewith the ability to communicate at the appropriate agelevel.

F The therapy must be restorative in nature with the abilityto improve communication.

F The person must have the potential for communication.

Transplant Services In order for any organ, tissue or bone marrow transplantto be covered under the plan, one of the designatedprocedure specific transplant hospitals must be utilized.The transplant candidate must contact the Medical CaseManagement plan administrator of the potential transplant.Once notification occurs, the Medical Case Manager (MCM)will coordinate all treatments and further notification is notrequired. Those refusing to participate in the MCM programwill be notified that coverage may be terminated under theplan for treatment 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 80% ofthe contracted rate. In some cases, transplants may be considered nonviable forsome 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 experimental

procedures.– Charges related to the search for an unrelated bone

marrow donor.– A corneal transplant is not part of the transplant hospital

benefit; however, standard benefits apply under themedical 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 the plan,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 expenses incurred.

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

F When only the donor is covered, only the donor’s chargeswill be covered under the plan.

F When both donor and recipient are members of the samefamily and are both covered by the plan, no deductible orcoinsurance shall apply.

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

Transplant –Transportation/Lodging 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 and forup to one year following the transplant. This benefit isavailable only to those plan participants who have beenaccepted as a candidate for transplant services.

F Requests for reimbursement for transportation andlodging with accompanying receipts should be forwardedto:

Organ Transplant ReimbursementCMS 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 thanemergency care. Treatment may be rendered in facilitiessuch as a physician’s office, urgent care facility or prompt carefacility. This benefit applies to professional fees only. If afacility fee is billed, the emergency room deductible applies.NOTE: See Emergency Services for medically necessaryemergency care.


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 recognized bythe 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 in effectat the time the service was rendered. Excluded servicesand supplies include, but are not limited to: sports-related health checkups, employer-required checkups,wigs and hairpieces.

3. For care, treatment, services or supplies which are notmedically necessary for the diagnosed injury or illness,or for any charges for care, treatment, services orsupplies which are deemed unreasonable by the plan.

4. For charges for the services, room and board or suppliesthat exceed allowable charges.

5. For personal convenience items, including but notlimited to: telephone charges, television rental, guestmeals, wheelchair/van lifts, nonhospital type adjustablebeds, exercise equipment, special toilet seats, grab bars,ramps, transportation services or any other services oritems determined by the plan to be for personalconvenience.

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 such ashome 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 occupied bythe 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, exceptfor 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, except servicesfor morbid obesity, as approved by the planadministrator.

13. For sexual dysfunction, except when related to an injuryor 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 caused bybiting on a foreign object and outpatient services forroutine dental care.

16. For the expense of obtaining an abortion, inducedmiscarriage or induced premature birth, unless it is aphysician’s opinion that such procedures are necessaryfor the preservation of the life of the woman seekingsuch treatment, or except in an induced premature birthintended to produce a live viable child and suchprocedure is necessary for the health of the woman orher unborn child.

17. For cosmetic surgery or therapies, except for the repair ofaccidental injury, for congenital deformities evident ininfancy or for reconstructive mammoplasty after partialor total mastectomy when medically indicated.

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.

College Choice Health Plan (CCHP) Exclusions and LimitationsNo benefits are available:


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 out ofor 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, declaredor undeclared, or from participation in a riot, or incurredduring or as a result of a plan participant’s commissionor 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 or

completing any medical or dental reports/records.28. For services rendered while confined within any federal

hospital, 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-sponsoredhealth 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 health servicesincurred prior to July 1, 2014.

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, behavioraltraining, biofeedback, neuro feedback, hypnosis, sleeptherapy, employment counseling, back-to-school, returnto work services, work hardening programs, drivingsafety and services, training, educational therapy ornonmedical ancillary services for learning disabilities,developmental delays, autism (except as provided undercovered expenses) or intellectual disabilities.

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 transportation between healthcare facilities becauseof patient’s choice; transportation of patients who haveno other available means of transportation;transportation that is not medically necessary; orMedicar or similar type of transportation when used forpatient’s convenience.

42. For acupuncture.


OverviewPlan participants enrolled in any College Insurance Program(CIP) health plan have prescription drug benefits includedin the coverage. Regardless of the plan chosen, aprescription copayment applies to each plan participant.If the cost of the prescription is less than the plan’sprescription copayment, the plan participant will pay the costof the prescription. However, if a plan participant elects abrand name drug and a generic is available, the planparticipant must pay the cost difference between the brandproduct and the generic product, in addition to the brandcopayment. Prescription copayments paid by participants will applytoward the out-of-pocket maximum. Once the maximum hasbeen met, eligible medical, behavioral health andprescription drug charges will be covered at 100 percent forthe remainder of the plan year. The out-of-pocket maximumamount for each type of health plan varies and is outlined onthe MyBenefits.illinois.gov website. 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 diagnosis tothe prescription drug plan administrator for review. Once aprior authorization is in place, the prescriptions may be filleduntil the authorization expires, usually one year.Plan participants who have additional prescription drugcoverage, including Medicare, should contact their prescriptionplan administrator for coordination of benefits (COB)information.Formulary ListAll prescription medications are compiled on a formulary list (i.e.,drug list) maintained by each health plan's prescription benefitmanager (PBM). Formulary lists categorize drugs into levels: Eachlevel requires a different copayment amount. Formulary lists aresubject to change any time during the plan year. To compareformulary lists, cost-savings programs and to obtain a list ofnetwork pharmacies that participate in the various health plans,plan participants should visit the website of their health plan orPBM. Certain health plans or the PBM notify plan participants bymail when a prescribed medication they are currently taking isreclassified into a different formulary category. If a formularychange occurs, plan participants should consult with theirphysician to determine if a change in prescription is appropriate.

Health MaintenanceOrganizations (HMOs)Health maintenance organizations (HMOs) use a separateprescription benefit manager (PBM) to administer theirprescription drug benefits. Benefit recipients who elect one ofthese health plans must utilize a pharmacy participating in theplan’s pharmacy network or the full retail cost of the medicationwill be charged. If a plan participant uses a nonparticipatingpharmacy, partial reimbursement may be provided if the planparticipant files a claim with the health plan. It should benoted that most plans do not cover over-the-counter drugs ordrugs prescribed by medical professionals (includingdentists), other than the plan participant’s primary carephysician (PCP) or any specialist the plan participant wasreferred to by their PCP.

Open Access Managed CarePlans and the College ChoiceHealth Plan (CCHP) Open access managed care plans and the College ChoiceHealth Plan (CCHP) have prescription drug benefitsadministered through the self-funded insurance plans’prescription benefit manager (PBM). Prescription drugbenefits are independent of other medical services and arenot subject to the medical plan year deductible. Most drugspurchased with a prescription from a physician or a dentist arecovered; however,most over-the-counter drugs are notcovered, even if purchased with a prescription. Prescription Drug Step Therapy (PDST) is required formembers who have their prescription drug benefitsadministered through CCHP or one of the open accessmanaged care plans. PDST requires the member to first try oneor more specified drugs to treat a particular condition beforethe plan will cover another (usually more expensive) drug thattheir doctor may have prescribed. PDST is intended to reducecosts to both the member and the plan by encouraging the useof medications that are less expensive but can still treat themember’s condition effectively. Members taking a brand medication that requires PDST,which has not received prior authorization approval, willreceive a rejection at a retail or mail order pharmacy asthe plan requires a generic in that drug class be tried first.If the physician believes the original brand medication isneeded, he/she may request a review to override the steptherapy requirement.

Prescription Coverage


Prescription Coverage (cont.)Compound drugs are covered under the prescription drugplan. If the compound drug contains an ingredient not coveredby the plan, the entire compound drug will be denied.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 a 1 to30-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.Prescribed medical supplies are supplies necessary for theadministration of prescription drugs such as coveredhypodermic needles and syringes. Copayments may apply.Diabetic supplies and insulin that are purchased with aprescription are covered through the plan and are subject tothe appropriate copayment. Some diabetic supplies are also covered under MedicarePart B. If the plan participant is not Medicare Part B primary,the appropriate copayment must be paid at the time ofpurchase 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 first besubmitted to Medicare for reimbursement. Upon receipt ofthe Medicare Summary Notice (MSN), a claim may be filedwith the prescription drug plan administrator for anysecondary benefit due. If the diabetic supplies are billed by aphysician or medical supplier, the supplies would be paid bythe 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 on the MyBenefits.illinois.gov website.

Mail Order PrescriptionsThe mail order pharmacy option provides participants theopportunity to receive medications directly from the PBM. Bothmaintenance and nonmaintenance medications may beobtained through the mail order process. When plan participantsuse the mail order pharmacy for maintenance medications theywill receive a 90-day supply of medication (equivalent to 3fills) for only two copayments. To utilize the mail orderpharmacy, plan participants must submit an original prescriptionfrom the attending physician. For maintenance medication, the

prescription should be written for a 90-day supply and include upto three 90-day refills totaling one year of medication. Theoriginal prescription must be attached to a completed Mail Orderform and sent to the address indicated on the form. Order formscan be obtained by contacting the PBM or by accessing theMyBenefits.illinois.gov website.

Coordination of BenefitsCIP coordinates with Medicare and other group plans. Theappropriate copayment will be applied for each prescriptionfilled.

Exclusions and LimitationsCIP reserves the right to exclude or limit coverage of specificprescription drugs or supplies.


OverviewBehavioral health services are for the diagnosis and treatment ofmental health and/or substance abuse disorders. Eligiblecharges are for those covered services deemed medicallynecessary by the plan administrator. The coverage ofbehavioral health services (mental health and substanceabuse) complies with the federal Mental Health Parity andAddiction Equity Act of 2008. This federal law requires healthplans to cover behavioral health services at benefit levelsequal to those of the plan’s medical benefits. Coverage for behavioral health services is provided under allof the CIP plans. There are no restrictions regarding thenumber of visits and hospital days allowed per plan year. Thecharges for behavioral health services are included in a planparticipant’s annual plan deductible if applicable and annualout-of-pocket maximum. Covered services for behavioralhealth must still meet the plan administrator’s medicalnecessity criteria and will be paid in accordance with thebenefit schedule. Please contact the health plan for specificbenefit information.

College ChoiceHealth Plan (CCHP)Covered services for behavioral health which meet the planadministrator’s medical necessity criteria are paid inaccordance with the College Choice Health Plan (CCHP)benefit schedule for in-network and out-of-network providers.Please contact the behavioral health plan administrator forspecific benefit information and for a listing of in-networkhospital facilities and participating providers. Authorization Requirementsfor Behavioral Health ServicesIn an emergency or a life-threatening situation, call 911, or goto the nearest hospital emergency room. Plan participants mustcall the behavioral health plan administrator within 48 hours toavoid a financial penalty. Authorization requirements still applywhen plan participants have other coverage, such as Medicare.F Inpatient services must be authorized prior to admission

or 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 administrator

of an admission to an inpatient facility within 48 hours willresult in a financial penalty and risk incurring noncoveredcharges.

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 CCHP network provider. Mostroutine outpatient services (such as therapy sessions andmedication management) will be covered without theneed for prior authorization. Authorization requirementsfor certain specialty outpatient services are noted below.Outpatient services that are not consistent with usualtreatment practice for a plan participant’s condition will besubject to a medical necessity review. The behavioralhealth administrator will contact the plan participant’sprovider to discuss the treatment if a review will beapplied. Outpatient services received at the out-of-network benefit level must be provided by a licensedprofessional including licensed clinical social worker(LCSW), registered nurse, clinical nurse specialist (RNCNS), licensed clinical professional counselor (LCPC),licensed marriage and family therapist (LMFT),psychologist or psychiatrist to be eligible for coverage.

F Electroconvulsive therapy, psychological testing andapplied behavioral analysis must be authorized toreceive in-network or out-of-network benefits. Failure toobtain authorization will result in the risk of incurringnoncovered charges.

F Residential services must be authorized prior toadmission to receive in-network or out-of-networkbenefits. Authorization is required with each newresidential admission. Failure to notify the behavioralhealth plan administrator of an admission to a residentialfacility will result in a financial penalty and risk incurringnoncovered charges.

Behavioral Health


OverviewThe College Choice Dental Plan (CCDP) is designed to offerplan participants coverage for basic dental services regardlessof the health plan chosen. 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 theMyBenefits.illinois.gov website for the amount of themaximum benefit.F Plan participants may go to any dentist.F The maximum benefit amount paid for eligible services is

listed in the Dental Schedule of Benefits. Dentalprocedure codes that are not listed in the Dental Schedule ofBenefits are not covered by the plan and are not eligiblefor payment. Members are responsible for all chargesover the scheduled amount and/or over the annualmaximum benefit. The Dental Schedule of Benefits isavailable at MyBenefits.illinois.gov.

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

Choosing a Provider With CCDP, plan participants can choose any dental provider forservices; however, plan participants will receive enhancedbenefits, resulting in lower out-of-pocket costs, when theyreceive services from a network provider. There are twoseparate networks of providers that a plan participant mayutilize for dental services: the PPO network and the Premiernetwork.• PPO Network: If you receive services from a PPO dentist,

your out-of-pocket expenses will often be less becausethese providers accept a reduced PPO fee (less anydeductible). If the PPO fee is higher than the amount listedon the Schedule of Benefits, you will be required to pay thedifference.

• Premier Network: If you receive services from a Premierdentist, your out-of-pocket expenses may be less becausePremier providers accept the allowed Premier fee (less anydeductible). If the allowed fee is higher than the amountlisted on the Schedule of Benefits, you will be required topay the difference.

Out-of-Network ServicesIf you receive services from a dentist who does not participate ineither the PPO or Premier network, the amount paid by the planwill be in accordance with the Schedule of Benefits.

Preventive and Diagnostic ServicesPreventive and diagnostic services are not subject to theannual deductible and include, but are not limited to:

• Two periodic oral examinations per person per plan year. • Two adult or child prophylaxis (scaling and polishing of

teeth) per person per plan year. • Two bitewing radiographs per person per plan year. • One full mouth radiograph per person every three plan

years.

Prosthodontics Prosthodontics, which include crowns, bridges anddentures, are subject to the following limitations:

• Prosthodontics to replace missing teeth are covered onlyfor teeth that are lost while the person is coveredunder 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 thefollowing circumstances:

– Existing denture is at least 5 years old, or – Structural changes in the person's mouth require

new dentures.• Replacement crowns are covered only when the existing

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

bridge is at least 5 years old.

Dental Coverage


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 for otherdental 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 any orthodonticservices, not only the placement of braces. For example, achild may have a retaining device when they are 8 years oldand then have braces installed when they are 15. The benefitamount for the retainer plus the benefit amount for thebraces can not exceed the maximum lifetime benefit amountallowed.The benefit amount that will be paid for orthodontic treatmentdepends on the length of treatment plan as determined by theorthodontist. The length of treatment time frames and theassociated benefit amount allowed is listed on theMyBenefits.illinois.gov website.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 the dentistat the time of service (with the exception of applicabledeductibles, charges for noncovered services, charges over theamount listed on the Schedule of Benefits and/or amounts overthe annual maximum benefit). Network dentists willautomatically file the dental claim for their patients. Memberswho use a network provider and do not have any out-of-pocketcosts for their visit will not receive an explanation of benefits(EOB). The member may, however, view their EOB on the dentalplan administrator’s website. Participants who use an out-of-network dentist may haveto pay the entire bill at the time of service and/or filetheir own claim form depending on the paymentarrangements the plan participant has with their dentist.Out-of-network dentists can elect to accept assignment fromthe plan or may require other payment terms. Coordinationof benefits applies to any other dental coverage.

Pretreatment EstimateFor both prosthodontics and orthodontics, although notrequired, a pretreatment estimate is strongly encouraged toassist plan participants in determining the benefits available.To obtain a pretreatment estimate plan participants shouldcontact their dental provider.

Benefits for Services ReceivedWhile Outside the United StatesThe plan covers eligible charges incurred for services receivedoutside of the United States. All plan benefits are subject toplan 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, enclosethe itemized bill with a description of the service translated toEnglish and converted to U.S. currency along with the name ofthe patient, date of service, diagnosis, procedure code and theprovider’s name, address and telephone number.

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 effective

date of coverage or subsequent to the date of termination ofcoverage.

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

4. Services performed to correct congenital and /ordevelopmental conditions including but not limited tomalformations, retention of deciduous (baby) teeth,impaction or absence of permanent teeth, cleft palate,mandibular prognathism or retrognathism, enamelhypoplasia, amelogenesis imperfecta, fluorosis, andanodontia (i.e., the absence of teeth) are excluded fromcoverage.

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 diagnosis ortreatment 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’ Compensation Act

or Employer’s Liability Law.9. Procedures or surgeries undertaken for primarily cosmetic

reasons.10. Construction of duplicate dentures.11. Replacement of a fixed or removable prosthesis for

which benefits were paid under this plan for the sametooth/teeth, if the replacement occurs within five yearsfrom the date the expense was incurred, unless:– The prosthesis is a stayplate or a similar temporary

prosthesis 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 agency orunder any governmental program or law, except forcharges which the person is legally obligated to pay. Thisexception extends to any benefits provided under the U.S.Social Security Act and its amendments.

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

18. Fixed or removable prosthodontics for a patient underage 18.

19. Sealants for adults over age 18.20. Amalgam and resin-based composite fillings more than

once per surface in a 12-month interval.

Dental Coverage (cont.)


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 can detectand prevent ailments not only in the eyes, but throughoutthe body. The plan provides coverage when glasses orcontacts are required. For more information, contact thevision plan administrator.

EligibilityAll plan participants covered by any of the health plansoffered by the College Insurance Program are eligible forvision care benefits. Benefit levels are published on theMyBenefits.illinois.gov website.

Frequency of BenefitsEye exams, replacement lenses, including contacts arecovered once every 12 months from the last date of the exambenefit was used. Standard frames are covered every 24months from the last date used. Each service component isindependent 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 the timeof service. Eligible services or materials may be obtained fromany licensed optometrist, ophthalmologist or optician. Adirectory 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, sendan 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 on theMyBenefits.illinois.gov website. Out-of-network providerbenefits are paid directly to the covered member. Claimforms are available on the MyBenefits.illinois.gov websiteand through the plan administrator.

Vision Coverage


Chapter 3Chapter 3: MiscellaneousCoordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53


If a plan participant enrolled in the College InsuranceProgram (CIP) is entitled to primary benefits under anothergroup plan, the amount of benefits payable under CIP maybe reduced. The reduction may be to the extent that thetotal payment provided by all plans does not exceed thetotal allowable expense incurred for the service. Allowableexpense is defined as a medically necessary service forwhich part of the cost is eligible for payment by this plan oranother plan(s). Under coordination of benefits (COB) rules, CIP’s plan firstcalculates what the benefit would have been for the claim ifthere was no other plan involved. The CIP plan then considersthe amount paid by the primary plan and pays the claim up to100% 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 managed carehealth plan is not required to pay. Refer to the managedcare plan’s summary plan document for additionalinformation.CIP 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 a

motor vehicle plan which is required by law and providesmedical or dental care payments which are made, in wholeor in part, without regard to fault. A person who has notcomplied with the law will be deemed to have received thebenefits required by the law.

CIP does not coordinate benefits with the following:F Private individual insurance plans.F Any student insurance policy (elementary, high school

and college).F Medicaid or any other State-sponsored health insurance

program.F TRICARE. It is the member’s responsibility to provide otherinsurance information (including Medicare) to theDepartment's Medicare Coordination of Benefits (COB)Unit. Any changes to other insurance coverage mustbe reported promptly to the Department's MedicareCOB Unit.

Order of Benefit DeterminationCIP’s medical and dental plans follow the National Associationof Insurance Commissioners (NAIC) model regulations. Theseregulations dictate the order of benefit determination, exceptfor members who are eligible for Medicare due to End-StageRenal Disease (ESRD). Refer to the ‘Medicare’ section for detailsregarding coordination of benefits for plan participants eligiblefor Medicare. The rules below are applied in sequence. Ifthe first rule does not apply, the sequence is followed until theappropriate rule that applies is found. Special rules apply foradult children and children of civil union partners. Contact theDepartment's Medicare Coordination of Benefits Unit at 800-442-1300 or 217-782-7007 for more information.MemberThe plan that covers the plan participant as an active memberis primary:

1. Over the plan that covers the plan participant as adependent.

2. Over the plan that covers the plan participant as aretiree.

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 or notthe insurance company has changed over the course ofcoverage.

Dependent Children of Parents Not Separated or DivorcedThe following “Birthday Rule” is used if a child is covered bymore than one group plan. The plans must pay in thefollowing order:

1. The plan covering the parent whose birthday* falls earlierin the calendar year is the primary plan.

2. If both parents have the same birthday, the plan that hasprovided 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 DivorcedParentsIf a child is covered by more than one group plan and theparents are separated or divorced, the plans must pay in thefollowing order:

1. The plan of the parent with custody of the child; 2. The plan of the spouse of the parent with custody of the

child; 3. The plan of the parent not having custody of the child.

NOTE: If the terms of a court order state that one parent isresponsible for the healthcare expenses of the child andthe health plan has been advised of the responsibility, thatplan is primary payer over the plan of the other parent.

Dependent Children of Parents with Joint CustodyThe Birthday Rule applies to dependent children of parentswith joint custody.

Coordination of Benefits (cont.)


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). If you do not enroll in Parts A and B, you will beresponsible for the portion of your healthcare costs thatMedicare would have covered. The Social Security Administration (SSA) or the RailroadRetirement Board (RRB)** determines Medicare eligibility uponapplication and enrolls eligible plan participants into theMedicare Program. The Medicare Program is administered bythe Centers for Medicare and Medicaid Services (also known asthe federal CMS).

Medicare has the following parts:F Part A is insurance that helps pay for inpatient hospital

facility charges, skilled nursing facility charges, hospicecare and some home healthcare services. Medicare Part Adoes not require a monthly premium contribution fromplan participants with enough earned work credits. Planparticipants without enough earned work credits have theoption to enroll in Medicare Part A and pay a monthlypremium 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 insurance thathelps pay for a combination of the coverage provided inMedicare Parts A, B and sometimes D. An individual mustalready be enrolled in Medicare Parts A and B in order toenroll in a Medicare Part C plan. Medicare Part C requires amonthly 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 olderCIP requires all plan participants to contact the SSA andapply for Medicare benefits three months prior to turningage 65.

Medicare Part AEligibility for premium-free Medicare Part A occurs when anindividual is age 65 or older and has earned at least 40 workcredits from paying into Medicare through Social Security. Anindividual who is not eligible for premium-free Medicare PartA benefits based on his/her own work credits may qualify forpremium-free Medicare Part A benefits based on the workhistory of a current, former or deceased spouse. All planparticipants that are determined to be ineligible for MedicarePart A based on their own work history are required to applyfor premium-free Medicare Part A on the basis of a spouse(when applicable).

If the SSA determines that a plan participant is eligible forpremium-free Medicare Part A, CIP requires that the planparticipant accept the Medicare Part A coverage andsubmit a copy of the Medicare identification card to theDepartment's Medicare COB Unit upon receipt.

If the SSA determines that a plan participant is not eligible forMedicare Part A benefits at a premium-free rate, CIP does notrequire the plan participant to purchase Medicare Part Acoverage; however, CIP does require the plan participant toprovide a written statement from the SSA advising of his/herMedicare Part A ineligibility. The plan participant is requiredto submit a copy of the SSA statement to the Medicare COBUnit.

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 Social SecurityAdministration (SSA) office or call the SSA at 800-772-1213. Plan participants may enroll in Medicareon the SSA website at ssa.gov/Medicare.

** Railroad Retirement Board (RRB) participants should contact their local RRB office or callthe RRB at 877-772-5772 to apply for Medicare.


CIP requires plan participants to enroll in Medicare Part Bif they are eligible for Medicare Part A benefits at apremium-free rate. Refer to the ‘Medicare Part B Reduction’section for more information.

Medicare Due to DisabilityPlan Participants Age 64 and UnderPlan 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 A coverageand submit a copy of the Medicare identification card to theDepartment's Medicare COB Unit upon receipt.

Medicare Part B

Plan participants who become eligible for Medicare disabilitybenefits are required to accept the Medicare Part B coverage.Refer to the 'Failure to Enroll in Medicare' section for moreinformation.

Medicare Due to End-Stage RenalDisease (ESRD)All CIP participants who are receiving regular dialysistreatments or who have had a kidney transplant on thebasis of ESRD are required to apply for Medicarebenefits. Plan participants eligible for Medicare on the basis of ESRD,must contact the Department's Medicare Coordination ofBenefits (COB) Unit at 800-442-1300. The Department'sMedicare COB Unit calculates the 30-month coordinationperiod in order for plan participants to sign up for Medicarebenefits on time and avoid additional out-of-pocketexpenditures.

Medicare Part A

Plan participants who become eligible for Medicare benefitson the basis of ESRD are required to accept the Medicare PartA coverage and submit a copy of the Medicare identificationcard to the Department's Medicare COB Unit upon receipt.

Medicare Part B

CIP requires plan participants to enroll in Medicare Part Bif they are eligible for Medicare Part A benefits at apremium-free rate. Plan participants who becomeeligible for Medicare benefits on the basis of ESRD arerequired to accept the Medicare Part B coverage whenMedicare is determined to be the primary payer. Refer tothe 'Failure to Enroll in Medicare' section for moreinformation.

Medicare Coordination with theCollege Choice Health Plan (CCHP)When Medicare is the primary payer, CCHP will coordinatebenefits with Medicare as follows:

Medicare Part A - Hospital Insurance

In-Network Provider: After Medicare Part A pays, CCHP pays80% of the Medicare Part A deductible after the CCHP annualplan deductible has been met.

Out-of-Network Provider: After Medicare Part A pays, CCHPpays 60% of the Medicare Part A deductible after the CCHPannual plan deductible has been met.

Medicare Part B - Medical Insurance

In-Network Provider: After Medicare Part B pays, CCHP pays80% of the balance after the CCHP annual plan deductiblehas been met.

Out-of-Network Provider: After Medicare Part B pays, CCHPpays 60% of the balance after the CCHP annual plandeductible has been met.

Failure to Enroll in Medicare(Medicare Parts A and B Reduction)Members who do not enroll in Parts A and B, are responsiblefor the portion of healthcare costs that Medicare would havecovered. Failure to enroll or remain enrolled in Medicarewhen Medicare is determined to be the primary payer willresult in a reduction of eligible benefit payments.

Medicare (cont.)


Services and Supplies Not Coveredby MedicareServices and supplies that are not covered by Medicare will bepaid in the same manner (i.e., same benefit levels anddeductibles) as if the plan participant did not have Medicare(provided the services and supplies meet medical necessityand benefit criteria and would normally be eligible forcoverage).

Medicare Crossover -CCHP MembersMedicare Crossover is an electronic transmittal of claim datafrom Medicare (after Medicare has processed their portion ofthe claim) to the CCHP plan administrator for secondarybenefit determination.

In order to set up Medicare Crossover, plan participants mustcontact the CCHP plan administrator and provide theMedicare Health Insurance Claim Number (HICN) located onthe front side of the 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 that theplan participant is responsible for the cost of the medicalservices rendered. Neither providers nor plan participants areallowed to bill Medicare. Therefore, Medicare will not pay for theservice (even if it would normally qualify as being Medicareeligible) or provide a Medicare Summary Notice to the planparticipant. If the service(s) would have normally been coveredby Medicare, the CCHP plan administrator will estimate theportion of the claim that Medicare Part B would have paid. TheCCHP plan administrator will then pay 80% of the 20% claimbalance (after the annual plan year deductible has beensatisfied) for services rendered by in-network CCHP providers.For out-of-network CCHP provider claims, CCHP will pay 60% ofthe 20% (after the CCHP plan year deductible has beensatisfied). The difference between the total charge and whatCCHP pays is the plan participant’s responsibility.

Medicare (cont.)

Medicare COB Unit Contact InformationDepartment of Central Management ServicesMedicare Coordination of Benefits Unit801 S. 7th Street, P.O. Box 19208Springfield, Illinois 62794-9208Phone: 800-442-1300 or 217-782-7007Fax: 217-557-3973


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 not providebenefits to the extent that there is other coverage undernongroup medical payments (including automobile liability)or medical expense type coverage to the extent of thatcoverage. 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, the

plan shall be subrogated to all of the covered person’s rightsof recovery against any person or entity. The coveredperson shall execute and deliver instruments anddocuments and do whatever else is necessary to securesuch rights. The covered person shall do nothing after lossto prejudice such rights. The covered person shallcooperate with the plan and/or any representatives of theplan in completing such documents and in providing suchinformation relating to any accident as the plan by itsrepresentatives may deem necessary to fully investigatethe incident. The plan reserves the right to withhold ordelay payment of any benefits otherwise payable until allexecuted documents required by this provision have beenreceived 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 of anysettlement, 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, consents tosaid lien and shall take whatever steps are necessary tohelp 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 behalf ofa 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 designed orintended 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 understand and

agree that the State’s plan does not pay for expensesincurred for injuries received as a result of an accident orincident for which a third party is liable. Any benefits paidon behalf of a minor covered person are conditional uponthe plan’s express right of reimbursement. No adultcovered person hereunder may assign any rights that suchperson may have to recover medical expenses from anytortfeasor or other person or entity to any minor child orchildren of the adult covered person without the expressprior written consent of the plan. In the event any minorcovered child is injured as a result of the acts or omissionsof any third party, the adult covered persons/parentsagree to promptly notify the plan of the existence of anyclaim on behalf of the minor child against the third partytortfeasor responsible for the injuries. Further, the adultcovered persons/parents agree, prior to thecommencement of any claim against the third partytortfeasors responsible for the injuries to the minor child,to either assign any right to collect medical expenses fromany tortfeasor or other person or entity to the plan, or attheir election, to prosecute a claim for medical expenseson behalf of the plan.


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 which

specifically 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, which rightshall not be defeated nor reduced by the application of anyso-called “Made-Whole Doctrine,” “Rimes Doctrine” or anyother such doctrine purporting to defeat the plan’srecovery rights by allocating the proceeds exclusively tononmedical 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 from theplan’s recovery without the prior express written consentof the plan. This right shall not be defeated by any 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 the partof 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.


In general, most dental, medical and behavioral healthproviders file claims for reimbursement with the insurancecarrier. Out-of-network vision claims and pharmacy expensestypically must be filed by the member. In situations where aclaim is not filed by the provider, the member must file theclaim within a specific period of time. All claims should be filed promptly. Claim forms areavailable on the plan administrators’ website and on theMyBenefits.illinois.gov website. F In-network CCHP medical and behavioral health claims

must be filed within 90 days from the date in which thecharge was incurred.

F Out-of-network CCHP medical and behavioral healthclaims must be filed within 180 days from the date inwhich the charge was incurred.

F Out-of-network dental claims must be filed no later thanone-year from the ending date of the plan year in whichthe charge was incurred.

F Out-of-network pharmacy claims for the open accessplans (OAPs) and CCHP must be filed no later thanone-year from the ending date of the plan year in whichthe charge was incurred.

F Out-of-network vision claims are required to be filed nolater than one year from the date of service in order to beconsidered for reimbursement.

Filing deadlines for managed care plans, including behavioralhealth services offered under the managed care plan, may bedifferent. Contact the managed care plan directly fordeadlines and procedures.

Claim Filing ProceduresAll communication to the plan administrators must include thebenefit recipient's social security number (SSN) andappropriate group number as listed on the identification card.This information must be included on every page ofcorrespondence.F Complete the claim form obtained from the appropriate

plan administrator.F Attach the itemized bill from the provider of services to

the claim form. The itemized bill must include name ofpatient, date of service, diagnosis, procedure code and theprovider’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 Medicare SummaryNotice (MSN) from the other plan must also be attachedto 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 process aclaim.

F The benefit check will be sent and made payable to themember (not to any dependents), unless otherwiseindicated by law, or benefits have been assigned directlyto the provider of service.

F If benefits are assigned, the benefit check will be madepayable to the provider of service and mailed directly tothe provider. An EOB is sent to the plan participant toverify the benefit determination.

F CCHP claims are adjudicated using industry standardclaim processing software and criteria. Claims arereviewed for possible bundling and unbundling of servicesand charges.

Claim Filing


Under the College Insurance Program there are formalprocedures to follow in order to file an appeal of an adversebenefit determination. The appropriate plan administratorwill provide more information regarding the planadministrator’s internal appeal process.

Categories of AppealThere are two separate categories of appeals: medical andadministrative. 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 benefit

determinations 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 cancellations ordiscontinuations of coverage, unless the cancellation ordiscontinuation relates to a failure to pay requiredpremiums or contributions.

F Administrative Appeals. Administrative appeals pertainto benefit determinations based on plan design and/orcontractual or legal interpretations of plan terms that donot involve any use of medical judgment.

College Choice Health Plan (CCHP)and Open Access Managed CarePlans Appeal ProcessMembers enrolled in either the CCHP or one of open accessmanaged care plans may utilize an internal appeal processwhich may be followed by an external review, if needed. Forurgent care situations, the plan participant may bypass theinternal appeal process and request an expedited externalreview (see “Expedited External Review- Medical AppealsOnly” for urgent care situations in the box).

Expedited External Review - Medical Appeals Only 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 request todetermine whether it qualifies for expedited review. If theexternal reviewer determines that the request qualifies forexpedited review, the external reviewer will provide a finalexternal review decision within 72 hours after the receipt ofthe request. If the external reviewer decides in favor of theplan participant, the decision shall be final and binding onthe 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. Forurgent care situations, the plan participant may request anexpedited external review (see “Expedited External Review-Medical Appeals Only” for urgent care situations).

First-Level Internal AppealsFirst-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 the planadministrator, the plan administrator shall provide a decisionwithin the applicable time frame:15 days for pre-serviceauthorizations, 30 days for post-service claims, or 72 hours forurgent care claims.

Claim Appeal Process


Step 2: External Review Process

After the completion of the plan administrator’s internalappeal process, the plan participant may request an externalreview of the plan administrator’s final internal benefitdetermination. The process for external review will dependon whether the appeal is an administrative appeal or medicalappeal.

Administrative AppealsFor administrative appeals, if, after exhausting every level ofreview 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 be finaland binding on all parties.Medical AppealsExternal ReviewFor 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 review

decision 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.

Appeal Process for Fully-InsuredManaged Care Health PlansThe Department of Central Management Services (CMS) doesnot have the authority to review or process fully-insuredmanaged care health plan appeals. Fully-insured managedcare health plans must comply with the Managed CareReform and Patient Rights Act. In order to file a formalappeal, refer to the process outlined in the managed carehealth plan’s summary plan document (SPD) or certificate ofcoverage. Specific timetables and procedures apply. Planparticipants may call the customer service number listed ontheir identification card to request a copy of such documents.

Assistance with the Appeal Process For questions regarding appeal rights and/or assistancewith the appeal process, a plan participant may contact theEmployee Benefits Security Administration at 866-444-EBSA (3272). A consumer assistance program may alsobe able to assist the plan participant. Requests forassistance from the consumer assistance program shouldbe sent to:

Office of Consumer Health InsuranceConsumer Services Section122 S. Michigan Ave., 19th FLChicago, IL 60603insurance.illinois.gov877-527-9431Email: [email protected] or

Illinois Department of Insurance320 W. Washington St, 4th FloorSpringfield, IL 62727

Claim Appeal Process (cont.)


Chapter 4Chapter 4: ReferenceGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60


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 in wholeor in part. Adverse claim determinations include rescissionsof coverage.

Allowable Charges: The maximum amount the plan willpay an out-of-network healthcare professional for billedservices.

Allowable Expense: A medically necessary service for whichpart of the cost is eligible for payment by this plan or anotherplan(s).

Authorization: The result of a review that approves treatment asmeeting medical necessity criteria and appropriateness ofcare.

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.

Benefit Recipient: An annuitant or survivor enrolled in theCollege Insurance Program.

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 and CivilUnion Act.

Civil Union Partner: A party to a civil union.

Claim: A paper or electronic billing. This billing must include fulldetails of the service received, including name, age, sex,identification number, the name and address of the provider, anitemized statement of the service rendered or furnished, the dateof service, the diagnosis and any other information which a planmay request in connection with 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 on theMyBenefits.illinois.gov website.

Coinsurance: The percentage of the charges for eligibleservices for which the plan participant is responsible after anyapplicable deductible has been met.

College Choice Health Plan (CCHP) Hospital: A hospital orfacility with which the College Choice Health Plan plan hasnegotiated favorable rates.

Coordination of Benefits: A method of integrating benefitspayable under more than one group insurance plan.

Copayment: A specific dollar amount the plan participant isrequired 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.

Custodial Care: Room and board or other institutional ornursing services which are provided for a patient due to age ormental 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 to improvea medical condition.

Deductible: The amount of eligible charges plan participantsmust pay before insurance payments begin.

Department: The Department of Central ManagementServices, also referred to as CMS.

Glossary


Dependent Beneficiary/Dependent: A benefit recipient’sspouse, civil union partner, child, parent or other person asdefined by the State Employees Group Insurance Act of 1971,as amended (5 ILCS 375/1 et seq.).

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.

Eligible Charges: Charges for covered services and supplieswhich are medically necessary and based on usual andcustomary charges as determined by a plan administrator.

Emergency Services: Services provided to alleviate severepain 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 if nottreated immediately.

Exclusions and Limitations: Services not covered under theCollege Insurance Program, or services that are provided onlywith certain qualifications, conditions or 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.

Fiscal Year (FY): Begins on July 1 and ends on June 30.

Formulary (Prescription Drugs): A list of drugs and ancillarysupplies approved by the prescription drug planadministrator for inclusion in the prescription drug plan. Theformulary list is subject to change.

Fully Insured: All claims and costs are paid by the insurancecompany.

Generic Drug: Therapeutic equivalent of a brand name drugand must be approved by the U.S. Food and DrugAdministration for safety and effectiveness.

Hospice: A program of palliative and supportive services forterminally 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 nurses onduty 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.

Injury: Damage inflicted to the body by external force.

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 services suchas medical monitoring.

Investigational: Procedures, drugs, devices, services and/orsupplies which (a) are provided or performed in specialsettings for research purposes or under a controlledenvironment and which are being studied for safety, efficiencyand effectiveness, and/or (b) are awaiting endorsement by theappropriate National Medical Specialty College or FederalGovernment agency for general use by the medical community atthe time they are rendered to a covered person, and (c) withrespect to drugs, combination of drugs and/or devices, whichhave not received final approval by the Food and DrugAdministration at the time used or administered to thecovered person.

Glossary (cont.)


Itemized Bill: A form submitted for claim purposes; musthave the name of the patient, description, diagnosis, date andcost 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: Benefit recipient or COBRA participant.

MyBenefits Service Center (MBSC): The MyBenefits ServiceCenter (MBSC) is a custom benefits solution service providerfor the Department. The MBSC will manage the detailedenrollment process of member benefits through onlinetechnical support via the MyBenefits.illinois.gov website andtelephonic support via the MyBenefits Service Center 844-251-1777. The MBSC is now the member's primary contactfor answering questions you may have about your eligibilityfor coverage and to assist you in enrolling or changing thebenefits you have selected.

Nonpreferred Brand Drug: Prescription drugs available atthe highest copayment. Many high cost specialty drugs fallunder 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 the planbegins paying at the 100% of allowable charges for eligiblecovered 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 provided ina 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 supervised andessentially the same intensity as would be provided in ahospital setting except that the patient is in the program lessthan 24 hours per day.

Physician/Doctor: A person licensed to practice under theIllinois Medical Practice Act or under similar laws of Illinois orother states or countries; a Christian Science Practitioner listedin the Christian Science Journal at the time the medicalservices 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 College Insurance Program.

Plan Year: July 1 through the following June 30.

Preferred Brand Drug: A list of drugs, biologicals and devicesapproved by the pharmacy benefit manager for inclusion in theprescription drug plan. These drugs are proven to be bothclinically and cost effective. The preferred brand drug list issubject 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 reviewedby the dental plan administrator for verification of eligiblebenefits.

Preventive Service: Routine services which do not require adiagnosis 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.

Glossary (cont.)


Professional Services: Eligible services provided by alicensed medical professional, including but not limited to aphysician, radiologist, anesthesiologist, surgeon, physicaltherapist, etc.

Program: The College Insurance Program as defined by theState Employees Group Insurance Act of 1971, as amended (5ILCS 375/1 et seq.).

Provider: Any organization or individual which providesservices or supplies to plan participants. This may includesuch entities as hospitals, pharmacies, physicians, laboratories orhome health companies.

Qualified Beneficiary: A qualified beneficiary is an individual(including member, spouse, civil union partner or child)who loses employer-provided group health coverage and isentitled to elect COBRA coverage. The individual must havebeen covered by the plan on the day before the qualifyingevent occurred and enrolled in COBRA effective the first day ofeligibility or be a newborn or newly adopted child of thecovered member.

Schedule of Benefits: A listing of specific services covered bythe College Choice Dental Plan and the vision plan.

Second Opinion: An opinion rendered by a second physicianprior to the performance of certain nonemergency, electivesurgical procedures or medical treatments.

Self Insured: All claims and costs are paid by the CollegeInsurance Program.

Self-Service Tools: Using the Self-Service tools online allowsthe member to create a life event (such as getting married,adding a child etc) online as the electronic version ofsubmitting a paper form to the Department.

Skilled Nursing Service: Noncustodial professional servicesprovided by a registered nurse (RN) or licensed practical nurse(LPN) which require the technical skills and professionaltraining of such a licensed professional acting within thescope of their licensure.

Spouse: A person who is legally married to the benefitrecipient as defined under Illinois law and pursuant to theInternal Revenue Service Code.

State Employees Group Insurance Act: The statutoryauthority for benefits offered by the Department (5 ILCS 375/1et seq.).

Survivor: Spouse, civil union partner, dependent child(ren)or dependent parent(s) of a deceased member as determinedby the State University 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 or treatmentwith respect to the application of the time periods for makingnonurgent care determinations could: 1) seriously jeopardizethe life or health of the claimant or the ability of the claimantto regain maximum function; or 2) in the opinion of thephysician with knowledge of the claimant's medicalcondition, would subject the claimant to severe pain thatcannot be adequately managed without the care or treatmentthat is the subject of the claim.

Glossary (cont.)


– A –Annual Benefit Choice Period ...................................8

– B –Behavioral Health Coverage ...................................40

– C –Certification of Dependent Coverage........................7Claim Appeal Process..............................................54Claim Filing.............................................................53COBRA.....................................................................16College Choice Dental Plan ....................................41

Deductible ..........................................................41Exclusions...........................................................43General Information ...........................................41

College Choice Health Plan ....................................24Additional Deductibles .......................................24Allowable Charges..............................................25CCHP Network ....................................................25Coinsurance........................................................24Emergency Admission ........................................26Exclusions and Limitations .................................36Medical Benefit Summary..................................28Medical Case Management................................25Medical Necessity...............................................25Notification Requirements .................................26Out-of-Pocket Maximum.....................................24Plan Year Deductible ..........................................24Predetermination of Benefits .............................25Transplant Notification........................................26

Contributions..........................................................14Conversion Privilege Health Coverage ...................18Coordination of Benefits.........................................46

– D –Dependent Coverage ................................................9Dental Coverage .....................................................41Dental Exclusions....................................................43Direct Billing ...........................................................14Documentation Requirements

Adding Dependent Coverage .............................12Terminating Dependent Coverage .....................13

Documentation Time Limits....................................13

– E –Eligibility

Eligible as Benefit Recipient.................................6Eligible as Dependents.........................................6

Enrolling Dependents...............................................9Enrollment Opportunities Chart .............................11Enrollment Periods ...................................................8

– F –Formulary................................................................38

– G-H –Group Insurance Division..........................................2Health Maintenance Organizations (HMOs)...........23Health Plan Options................................................22HIPAA ........................................................................2Hospital Bill Audit Program ....................................27

– I –ID Cards.....................................................................2Initial Enrollment ......................................................8

– J-K-L –

Index


– M –Managed Care Health Plans ...................................22Medicare.................................................................48MyBenefits Service Center (MBSC) ...........................2

– N –Nonpayment of Premium.......................................14

– O –Open Access Plan....................................................23Orthodontic Services (child)....................................42

– P –Premium Payment ..................................................14Premium Refunds...................................................14Premium Underpayments ......................................14Prescription Coverage.............................................38Prescription Drug Step Therapy ..............................38Pretreatment Estimate (Dental) ..............................42Prior Authorization (Prescription Drugs) .................38Prosthodontics ........................................................41

– Q –Qualifying Change in Status .....................................9

– R-S –Self-Service Tools.......................................................3Subrogation and Reimbursement ..........................51

– T –Termination of Dependent Beneficiary

Coverage............................................................ 15Termination of Benefit Recipient Coverage ............15Termination of Coverage under COBRA..................18

– U-V –Vision Coverage ......................................................44

– W-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 on the MyBenefits.illinois.govwebsite and the annual Benefit Choice Options Booklet. If there is a discrepancy between this Handbook or any otherDepartment publications, and state or federal law, the law will control.

Printed by the Authority of the State of Illinois. 9/16 IOCI 17-167

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