This installment brings the final, wide-ranging health insurance changes taking effect on January 1, 2026. Illinois lawmakers have passed a series of bills that collectively reshape the landscape of required medical coverage, providing relief and greater access to care for thousands of residents in areas often excluded or under-covered by insurance plans.
These mandates apply to fully insured group and individual health policies issued or renewed in the state.
Key Expansions to Health Insurance Coverage
The new laws create four major categories of mandatory coverage that insurers must adhere to:
1. Addressing Drug Shortages
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Brand-Name Coverage Required: If a generic drug or its therapeutic equivalent becomes unavailable due to a supply shortage (as listed by the FDA), insurers are now required to cover the brand-name version of the drug until the generic supply issue is resolved. This eliminates the burden on patients to pay high brand-name prices or face severe health risks when generic medications are out of stock.
2. Reproductive and Fertility Care
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Infertility Coverage Broadened: Mandatory coverage for infertility diagnosis and treatment is expanded. This includes required coverage for procedures necessary to screen or diagnose a fertilized egg before implantation, making fertility treatments more accessible.
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Menopause Visits: For individuals aged 45 and older, most insurance plans must now cover an annual menopause health visit without requiring the insured member to meet a cost-sharing requirement (i.e., no co-pay or deductible). Furthermore, coverage for medically necessary hormonal and non-hormonal therapy to treat menopausal symptoms must be provided.
3. Advanced and Diagnostic Imaging
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Breast MRI and MBI Coverage: Coverage for advanced diagnostic imaging, including Molecular Breast Imaging (MBI) or Magnetic Resonance Imaging (MRI) of the breast, must be provided without cost-sharing if a prior mammogram demonstrates heterogeneous or dense breast tissue, or when otherwise medically necessary as determined by a physician. This is a critical step for individuals whose dense tissue masks potential tumors on standard mammograms.
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Colonoscopies: Medically necessary colonoscopies must be covered by group and individual plans, removing a potential financial barrier to vital cancer screening.
4. Related Health Cost Caps
In addition to these mandates, the cost of an Epinephrine Auto-Injector (EpiPen) twin-pack will be capped at $60 (with a $25 individual injector cap for those 18 and under), ensuring emergency allergy medication is affordable.
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