Section 2001.8  Coverage of Preventive Health Services

a)         A group health plan, or a health insurance issuer offering group or individual health insurance coverage, must cover preventive services without cost-sharing as described in Sections 356z.62 and 356z.77 of the Code.

1)         For the purposes of Section 356z.62(a)(2) of the Code, a plan or issuer must cover an immunization if it is for routine use in children, adolescents, or adults and it has a recommendation in effect from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved.

2)         A limited health care plan or a policy of accident and health insurance that is designed to coordinate with other group or individual health insurance coverage or a group health plan to cover preventive services must cover the preventive services and related administration without cost-sharing to the same extent as the coordinating plan or policy.

3)         A group health plan or health insurance issuer offering group or individual health insurance coverage must ensure that neither it nor any utilization review program conducted for its plan or coverage renders an adverse determination about the medical necessity of a preventive service or related administration contrary to the recommendations and guidance applicable to the plan or coverage under subsection (a), as established by Sections 356z.62 and 356z.77 of the Code. Nothing in this subsection (a)(3) prevents a plan, issuer, or utilization review program from rendering an adverse determination when a preventive service is contraindicated for the covered individual.

4)         The examples at 45 CFR 147.130(a)(2) (Nov. 6, 2020) (no later editions or amendments) illustrate the requirements of Section 356z.62(c) of the Code.

b)         Specific Requirements for Immunization Coverage

1)         An ACIP recommendation is considered in effect after it has been adopted by the Director of CDC.  An immunization is considered to be "for routine use" if it is listed on the Immunization Schedules of the CDC.

2)         State Guidelines are considered "in effect" when the Department of Public Health publishes them under Section 1.2(d) of the Communicable Disease Prevention Act or the Immunization Advisory Committee republishes them after an override vote under Section 8.4(e) of the Department of Public Health Act.

3)         A group health plan or a health insurance issuer offering group or individual health insurance coverage must implement Section 356z.77 of the Code consistent with the requirements of Section 356z.62(c) through (g), (i), and (j) of the Code.

c)         Shared clinical decision-making

When a recommendation or guideline under Sections 356z.62 or 356z.77 of the Code does not require a specific set of considerations or decision points in the shared clinical decision-making process, a group health plan or a health insurance issuer offering group or individual health insurance coverage, or its designee utilization review program, must not deny or exclude coverage based on any of the following:

1)         The health care provider or covered individual did not follow a specific set of considerations or decision points that the plan, issuer, or utilization review program prescribed for the shared clinical decision-making process.

2)         The health care provider relied on a patient questionnaire or patient disclosure form given to the covered individual before the administration of the immunization to share or receive information relevant to the provider's shared clinical decision-making process with the covered individual.

3)         To the maximum extent allowed by the standards of practice in the State where the covered individual received the preventive service, the health care provider with whom the covered individual directly engaged in shared clinical decision-making was not the covered individual's primary care physician or attending physician. Nothing in this subsection (c)(3) prohibits a health maintenance organization health care plan from applying referral requirements it generally applies to a preventive service.

d)         Applicability

1)         If differing State and federal recommendations or guidelines apply to the same preventive service, coverage must be provided consistent with the recommendation or guideline that provides the greater scope of coverage for the covered individual.

2)         Nothing in this Section may be construed to extend the requirements of Section 356z.62 of the Code to grandfathered health plans.

3)         The provisions of this Section that implement coverage for immunizations under Section 356z.77 of the Code apply to grandfathered health plans. This includes subsections (a)(2), (a)(3), (a)(4), (b), (c), and (d)(1).

(Source:  Amended at 50 Ill. Reg. 5346, effective April 1, 2026)