Illinois Health Study Guide

The Illinois Accident & Health State paper is the largest state-specific exam the state sets — thirty-nine scored questions — and it earns the size. Illinois writes its required policy provisions, its claim clocks and its continuation rules into statute in unusual detail, and it runs three different continuation regimes where most states run one. Work through the clocks in the order a policy actually lives through them and the material organises itself.

The required provisions — and the grace period that is tiered

The grace period is where Illinois splits from itself. Individual accident and health is tiered by premium mode under § 357.4: “not less than ‘7’ for weekly premium policies, ‘10’ for monthly premium policies and ‘31’ for all other policies.” Individual life, under § 224, is a flat 30 days regardless of mode. Same state, two rules, and the exam sets the same fact pattern on both papers.

The time limit on certain defenses is 2 years: after two years “no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy.”

That section carries a second rule most candidates never notice, and it is a good one. After two years a claim may not be reduced or denied on the ground that a disease or physical condition pre-existed the coverage — unless that condition was excluded from coverage by name or specific description on the effective date. A generic pre-existing-conditions clause runs out at two years. A named exclusion does not.

The free look is 10 days from delivery, with the notice printed prominently on the first page or attached — except on single premium nonrenewal policies. Medicare supplement and long-term care each get 30 days instead.

The claim chain — and the section that rewards the insurer’s delay

Four sections run in order, and one of them does something unusual.

Notice of claim, § 357.6 — 20 days. “Written notice of claim must be given to the company within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible.” For disabilities lasting at least two years, the insurer may require notice of continuance every six months.

Claim forms, § 357.7 — 15 days. The insurer must furnish claim forms after notice. If it does not, “within 15 days after the giving of such notice the claimant shall be deemed to have complied” with the proof-of-loss requirement by simply submitting written proof of the occurrence, character and extent of the loss. The insurer’s delay converts a formal requirement into an informal one — which is exactly the kind of consequence examiners like.

Proofs of loss, § 357.8 — 90 days, and an outside limit: “in no event, except in the absence of legal capacity, later than one year.”

Time of payment, § 357.9. Indemnities other than periodic payments are “paid immediately upon receipt of due written proof of such loss,” and periodic payments “not less frequently than monthly.”

One more section belongs to this cluster and is commonly mis-cited: § 357.5 is reinstatement. Candidates reach for it expecting notice of claim and find something else.

Prompt pay — § 368a

Layered on top of “immediately” sits a hard clock. Clean claims — Illinois says “due written proof of such loss,” not “clean claim” — must be paid within 30 days. There is no separate deadline for paper versus electronic claims; the words do not appear in the section. A different clock, 60 days, covers periodic and capitation payments to a selected provider.

Late payment carries 9% a year — and note when it starts. Interest runs “from the 30th day after receipt of such proof of loss to the date of the late payment,” so it accrues from day thirty-one, not from receipt. Interest amounting to less than $1 need not be paid. The payor must also notify the claimant of any failure to provide sufficient documentation within 30 days of receiving the claim.

The same rule reaches HMOs, which are made subject to § 368a by incorporation.

Continuation — three regimes, not one

Ordinary continuation, § 367e: up to 12 months after coverage would otherwise have ended. There is no employer-size threshold — but there is a precondition the summaries omit: the employee must have been continuously insured under the group policy, and any policy it replaced, for the entire 3 months before termination. The employer must present or mail written notice within 10 days of the termination, with a copy to the insurer, and the insurer may not deny coverage because the employer failed to do so. The employee elects within 30 days, and “in no event…more than 60 days after the date of such termination.” The premium is the full group amount including the employer’s share, “but not more than the group rate” — no percentage cap.

Spousal continuation, § 367.2: triggered by divorce, the employee’s death, or retirement. It runs 2 years — except that a spouse aged 55 or older continues until Medicare eligibility. And unlike ordinary continuation it permits “an additional amount, not to exceed 20% … for costs of administration.”

Dependent child continuation, § 367.2-5: 2 years, elected within 30 days.

Appeals, the exchange, and long-term care

External review under 215 ILCS 180 must be requested within 4 months of the final adverse determination. “The health carrier shall be solely responsible for paying the cost.” The decision “is binding on the health carrier” and on the covered person, except where other federal or state remedies exist. Standard decisions come within 45 days, expedited within 72 hours.

Illinois runs its own exchange, Get Covered Illinois, and the statute set the path in two steps: a state-based exchange using the federal platform for plan year 2025, then a fully state-based exchange for plan year 2026. The platform went live 1 November 2025 for coverage beginning 1 January 2026.

And if you intend to sell long-term care, there is a further training gate: 8 hours one time and 4 hours before each subsequent renewal, with a 12-month grace period after renewal to complete the ongoing hours without repeating the eight (50 Ill. Adm. Code 2012.121). Those hours may also count toward the 24-hour CE requirement.

A wording difference here is worth knowing, because the two Illinois sources describe the gate differently. The rule imposes the requirement on anyone who sells, solicits or negotiates long-term care insurance, and treats qualified state Partnership programs as one of its mandated topics. IDOI’s own producer page describes the operational requirement as holding the Health line of authority and completing the Long Term Care (Partnership) certification course. The hours are the same either way; the framing is not.