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Claim Payment Delay

Eligible university employees are offered health insurance coverage through the State Employees Group Insurance Program that is administered by the State’s Department of Central Management Services (CMS).  The State of Illinois offers both self-insured and fully-insured health plans.  Funding for these plans are provided through legislative appropriations, state revenues, and employee contributions.  Although the plan administrators continue to process claims, payment can only be made when funds are available.  Human Resource Services continues to monitor the impact of the State budget impasse on employee health and dental insurance, and would like to provide you with the following information regarding delays in claim payments.

Payments to Health and Dental Plan Providers

Fully-Insured Health Plans

Under a fully-insured health plan arrangement, the State of Illinois pays plan administrators a fixed amount regardless of claims incurred.  The State of Illinois’ fully-insured health plans are making timely payments to health plan providers.  However, there is no indication of how long these timely payments will continue. 

The following are fully-insured health plans:

  • BlueAdvantage HMO
  • Coventry HMO
  • Health Alliance HMO
  • HMO Illinois 

Self-Insured Health and Dental Plans

Under a self-insured health/dental plan arrangement, the State of Illinois pays plan administrators based on claims incurred.  At this time, state funds are insufficient to pay claims on a normal schedule.  As a result, claim payments are being released as funding becomes available.  At this time, there is no estimate of when a timely payment schedule will resume.  

The following are self-insured health and dental plans:

  • Quality Care Health Plan (administered by Cigna)
  • Coventry OAP
  • HealthLink OAP
  • Quality Care Dental Plan (administered by Delta Dental of Illinois) 

Employees are encouraged to go to the Latest News item on the CMS website for details on claim payment dates for self-insured health/dental plans.  

Self-Insured Providers Requiring Payment at the Time of Service 

Health Care Providers 

In-network Providers

  • In-network providers should only charge the patient the plan’s negotiated amount for their deductible, copayment, or coinsurance. They may request this payment at the time of service.  However, the provider should not require payment above what the employee may owe for the service.
  • If full payment is requested at the time of service, employees should contact their health plan administrator (Cigna, Coventry OAP, HealthLink OAP) and ask that it assist them in claim payment resolution.

Out-of-network Providers

  • Out-of-network providers may require full payment up front. Additionally, out-of-network services are reimbursed at a lower rate.  If you are referred to or choose to see an out-of-network provider, you should contact your health plan prior to receiving services.  Your prior contact will help to ensure the services meet the medical necessity criteria, to receive prior authorization, and to obtain a cost estimate.
  • If full payment is made at the time of service, the employee should receive interest from the State when reimbursement is processed. If the provider submits the claim on the employee’s behalf, the employee may need to work with the provider on the reimbursement as the plan administrator is likely to send payment to the provider. 

Dental Providers

In-network Providers

  • Delta Dental of Illinois has a network dentist policy that allows network dentists to charge patients up front only for deductibles, services not covered by the plan, amounts greater than the member’s Schedule of Benefits but up to the dentist’s contracted network amount, and any amounts that exceed the annual benefit maximum.
  • If full payment is requested at the time of service, employees should contact Delta Dental and ask that they assist them in claim payment resolution.

Out-of-network Providers

  • If full payment is made at the time of service, the employee should receive interest from the State when reimbursement is processed. 

Claims Payment Delay is Not a Qualifying Event

The claims payment delay is not a qualifying event that would allow employees to change their health plan elections.  As a covered plan participant, your health and dental coverage has not been stopped or reduced as payment will eventually be made.  However, the Benefit Choice period will begin on May 1, 2017.  During this period, employees have the option to make health plan changes with their new coverage becoming effective on July 1, 2017. 

Recommendations 

Call Ahead of Scheduled Procedures

If you will be receiving scheduled care or treatment, call your provider’s billing office to learn what its policy is regarding the State’s claim payment delay.  The provider’s office should be able to confirm expectations for payment in advance of your appointment. 

Central Management Services (CMS) – Member Services

For assistance with your personal situation, you are encouraged to first call your health or dental plan provider at the number listed on your ID card.  If your issue is not resolved, then contact CMS Member Services at (800) 442-1300 and select the number 1 at the first three prompts for additional assistance. 

More Information

Please go to the following links for more information on this topic:

Human Resource Services will continue to monitor the State budget situation and its impact on payments of health and dental claims.  More information will be provided as it is received.  Questions regarding this announcement can be directed to the Insurance and Employee Benefits office by contacting Renee Bechtel at 753-8230 or Maya Wilk-Siuba at 753-6036.


DISCLAIMER: Every effort will be made to present current information without inaccuracies; however, errors, additions, deletions, and changes in the budget may occur and could make the information out of date or inaccurate. Therefore, users of this website are advised of their responsibility to check the CMS "Latest News" web page to confirm the accuracy and completeness of the posted information.

Need More Information?

For assistance with your personal situation, you are encouraged to first call your health or dental plan provider at the number listed on your ID card.  If your issue is not resolved, then contact CMS Member Services at (800) 442-1300 and select the number "1" at the first three prompts for additional assistance. 

Call the HRS Service Center at 815-753-6000 and ask to be connected to one of our HR associates.