DOI Pat Quinn Governor Andrew Boron, Director

Uninsured Ombudsman Program

Updated Feb 2011

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Note: This information was developed to provide consumers with general information and guidance about insurance coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy. For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact the Department.

The Uninsured Ombudsman Program was established by Public Act 92-331 on January 1, 2002.  The purpose of the program is to provide assistance and education to Illinois consumers who:

  • Have no health insurance
  • Are about to lose health insurance
  • Cannot afford to purchase health insurance

The Uninsured Ombudsman Program may be able to assist you by:

  • Explaining continuation rights under an existing health plan
  • Providing help on how to shop for health insurance
  • Providing information on state and federal programs that may be available including but not limited to:
    • Illinois Comprehensive Health Insurance Program (ICHIP)- A state funded health insurance program that provides coverage to eligible Illinois residents deemed as high-risk who can afford but are unable to purchase health insurance coverage in the private market because of chronic illness or disability.  www.chip.state.il.us or (866) 851-2751;
    • Illinois Pre-Existing Condition Insurance Plan (IPXP) - A federally-funded temporary high risk pool which provides insurance for uninsured Illinois residents.  Eligibility requirements include being a U.S. citizen, national, or legal resident; being uninsured for 6 months and having a pre-existing condition.  http://www.insurance.illinois.gov/ipxp/ or (877) 210-9167.
    • Illinois Department of Healthcare and Family Services – Medical Programs
      • AllKids: Birth to age 18 years
      • FamilyCare: Parents or caregivers living with their children
      • Pregnant  Women
      • Aged, Blind, Disabled (AABD)                 

      www.allkidscovered.com or (866) 255-5437

    • Illinois Healthcare Portal – The Healthcare Portal can help families sign up for affordable health insurance programs, prescription drug programs, and help women find free breast and cervical cancer screenings.  http://health.illinois./
    • Medicare
    • Seniors 65 years and older
    • Some disabled people under age 65
    • People with End-Stage Renal Disease (kidney failure)

            www.medicare.gov or (800) 633-4227

  • Illinois Cares Rx – Assistance for senior citizens and disabled adults for prescriptions. Contact the Illinois Department of Aging at www.state.il.us/aging or (800) 252-8966.
  • Hill-Burton Free Care Program – Uncompensated services program (no-fee or reduced-fee health care services at certain hospitals and other health care facilities).  Please contact the Health Resources & Services Administration www.hrsa.gov or (800) 638-0742.
  • Department of Specialized Care for Children - Provides coordination of care for families and children with special health care needs.   http://www.uic.edu/hsc/dscc/ or (800) 322-3722.
  • Health Care Services for HIV – Illinois Department of Public Health:  www.idph.state.il.us or (800) 825-3518.

Some Important Insurance Rights:

COBRA- (Consolidated Omnibus Budget Reconciliation Act of 1985) is a federal law, enforced by the U.S. Department of Labor, Employee Benefits Security Administration, which provides continuation of group health coveragethat otherwise might be terminated. The law contains provisions giving certain former employees, retirees, spouses and dependent children the right to temporary continuation of health coverage at group rates.  COBRA applies to group health plans maintained by employers who had 20 or more employees on more than 50% of the business days US Department of Labor at (866) 444-3272: http://www.dol.gov/ebsa.

Illinois Continuation Law- (Mini-COBRA) protects individuals who lose their group health insurance coverage with an employer group of any size due to termination of employment or reduction in hours. 215 ILCS 5/367(e) for insurance companies and 215 ILCS 125/4-9.2 for HMOs.

Illinois Spousal Continuation:  Protects a covered spouse and dependent children who lose group health insurance coverage due to death or retirement of the employee or divorce from the employee 215 ILCS 5/367.2.

Municipal Employee’s Health Insurance Continuation- Protects those who participate in the Illinois Municipal Retirement Fund (IMRF), and retire or become disabled.  215 ILCS 5/367j

Illinois Dependent Child Continuation Law: Protects dependent children who lose their group health insurance coverage with an employer group of any size due to attainment of the limiting age under the policy or death of the insured parent (and coverage is not available under the Spousal Continuation Law.)  215 ILCS 5/367.2-5  

Looking for Health Coverage?  Tips on Buying Individual Health Insurance

Finding an Agent – Look in the yellow pages or ask people you know and respect if they would recommend their agent. Find an agent who is reliable and helpful in answering any questions you have regarding your policy. You can check the licensing status and any Department of Insurance regulatory action against a producer on our website http://insurance.illinois.gov/producer/default.asp or by calling toll-free 1-877-527-9431.

Shop Carefully – Health insurance is expensive, so comparison shopping is worth the time it takes. Obtain more than one estimate or quote. Do not be rushed into buying a policy by high-pressure sales tactics. Do not be misled by advertising or buy a policy simply because it is endorsed on television, radio, in newspapers or other advertisements by famous people.

Fill Out Your Application Completely and Accurately – If you do not give correct and complete answers to medical questions, your claims may be denied or your policy rescinded. If someone else fills out the application for you, read it carefully before signing it. When you sign an application, you are agreeing that it is correct and complete.

Look for Exclusions and Pre-Existing Condition Language – Most health insurance policies contain a pre-existing condition benefit limitation. A pre-existing condition is a health condition you already have when you buy a policy. It may include a condition you have recovered from. Any condition, whether or not revealed on the application, for which symptoms existed prior to the effective date of coverage, causing an ordinarily prudent person to seek diagnosis, care or treatment, or one in which medical advice or treatment was recommended by or received from a physician may also be considered a pre-existing condition. One of the main reasons for claim denials or delayed payments is pre-existing condition exclusions in the policy. Even if health questions are not asked on the application, the policy may not cover conditions you already have. Make sure you understand the definition of pre-existing condition and how long such conditions will not be covered. Read the limitation and exclusion provisions of your policy very carefully.

Look for Limitations – Review limitations to the coverage such as dollar limitations ($500.00 for an emergency room visit or maximum of $200.00 for lab and x-ray per year) or number of visits limitations (2 covered physician office visits per year). Make sure you understand the policy and its limitations prior to incurring a claim.

Replacing a Policy – Replacing an old policy with a new one may not be a good idea. As stated above, a new policy may have waiting periods and pre-existing condition exclusions that could leave you without coverage for a period of time. The company may also attach riders to a new policy that completely exclude coverage for an existing health condition.

Know If and When a Company Can Refuse to Renew Your Policy – Read the renewal provision that is usually found on the first page of the policy.
Make Sure There is a “Free Look” Provision – Companies issuing individual health insurance in Illinois are required to give you a minimum period of ten days to review the policy and return it if you are not satisfied for any reason. The ten days begin the day you receive the policy either in the mail or by delivery from an agent. If during the ten-day period, you decide not to retain the policy, return it to the agent and obtain a receipt, or return it to the company by certified mail. Once the ten days have passed, the company is not required to refund the premium. Some companies, however, will take extenuating circumstances into consideration, so it is worth the effort to explain any unusual delay in returning the policy for a refund.

How to Pay Policy Premiums – It is best to pay by check, money order, or bank draft made directly to the insurance company. If you pay in cash, obtain a receipt for the payment. Keep in mind that when you pay an annual or semi-annual premium, the company considers the premium to be fully earned when they receive it and seldom will they refund any portion of the prepaid premium if you decide to change companies and drop the current policy.

Check with the Illinois Department of insurance to find out:

  • Whether or not the company is licensed and  the length of time the company has been licensed
  • The number of complaints filed against a company
  • A company’s A.M. Best rating

The Uninsured Ombudsman staff can answer questions about obtaining health insurance, and supply information on non-insurance resources for medical, dental, medication, vision and other services available.

The Uninsured Ombudsman Program is located within our Department’s Office of Consumer Health Insurance.  You may contact the Program by calling our Office of Consumer Health Toll Free at (877) 527-9431 or visit us on our website at http://www.insurance.illinois.gov/.

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