Section 4500.10  Purpose

 

This Part implements State and federal requirements for the operation of the Illinois Health Benefits Exchange as a State-based Exchange on the Federal Platform for plan year 2025 and as a State-based Exchange for plan year 2026 onward. Nothing in this Part incorporating a federal standard supersedes any more stringent or additional requirement provided under other State law or rule applicable to the same health plan, health insurance issuer, or person unless the federal standard requires the Exchange to enforce the federal standard without deviation.

 

Section 4500.20  Applicability

 

This Part applies to:

 

a)         health insurance issuers, including companies, health maintenance organizations, limited health service organizations, and dental service plan corporations;

 

b)         insurance producers;

 

c)         Navigators, Certified Application Counselors, Certified Application Counselor Organizations, and In-Person Counselors;

 

d)         employers;

 

e)         applicants, application filers, and enrollees;

 

f)         any other individual or entity seeking to participate in or facilitate enrollment through the Exchange; and

 

g)         where applicable, officers, directors, employees, authorized representatives, or others in an agency relationship with the persons listed in subsections (a) through (f).

 

Section 4500.30  Definitions

 

The following definitions apply to this Part:

 

"2023 Letter" means the "2023 Final Letter to Issuers in the Federally-facilitated Exchanges" published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244 (Apr. 28, 2022) (no later editions or amendments), available online at https://www.cms.gov/sites/default/files/2022-04/Final-2023-Letter-to-Issuers_0.pdf.

 

"Advance payments of the premium tax credit" or "APTCs" means payments of the tax credits specified in 26 U.S.C. 36B that are provided on an advance basis to an eligible individual enrolled in a QHP through the Exchange.

 

"Agent or broker" has the meaning ascribed in 45 CFR 155.20 (May 5, 2021) (no later editions or amendments).

 

"Annual open enrollment period" means the period each year when a qualified individual may enroll or change coverage in a QHP through the Exchange for an upcoming benefit year (see 45 CFR 155.20).

 

"Applicant" has the meaning ascribed in 45 CFR 155.20.

 

"Award" has the meaning ascribed in Section 15 of GATA.

 

"Benefit year" has the meaning ascribed in 45 CFR 155.20.

 

"Catalog of State Financial Assistance" has the meaning ascribed in Section 15 of GATA.

 

"Certified Application Counselor" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Certified Application Counselor Organization" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Company" has the meaning ascribed in Section 2(e) of the Code.

 

"Cost sharing" has the meaning ascribed in 45 CFR 155.20.

 

"Cost-sharing reductions" or "CSRs" has the meaning ascribed in 45 CFR 155.20.

 

"Dental service plan corporation" has the meaning ascribed in Section 3 of the Dental Service Plan Act [215 ILCS 110].

 

"Department" means the Illinois Department of Insurance.

 

"Dependent" means any individual who is or who may become eligible for coverage under the terms of a QHP because of a relationship to a qualified individual or enrollee.

 

"Director" means the Director of the Department.

 

"Employee" has the meaning ascribed in 29 U.S.C. 1002(6).

 

"Enrollee" has the meaning ascribed in 45 CFR 155.20.

 

"Essential community provider" has the meaning ascribed in 45 CFR 156.235(c) (Apr. 27, 2023) (no later editions or amendments).

 

"Exchange" or "Illinois Exchange" means the Illinois Health Benefits Exchange established under Section 5-5 of the IHBE Law and 42 U.S.C. 18031.

 

"Federal platform agreement" means an agreement between the Illinois Exchange, including the SHOP, and HHS under which the Illinois Exchange agrees to rely on the federal platform to carry out select Exchange functions (see 45 CFR 155.20).

 

"Full-time employee" has the meaning ascribed in 26 U.S.C. 4980H(c)(4) as implemented under 26 CFR 54.4980H-3 (Feb. 12, 2014) (no later editions or amendments). This definition applies in all instances where the term "full-time employee" appears in any provision incorporated by reference under this Part.

 

"GATA" means the Grant Accountability and Transparency Act [30 ILCS 708].

 

"Health insurance coverage" has the meaning ascribed in 42 U.S.C. 300gg-91(b)(1).

 

"Health insurance issuer" has the meaning ascribed in 42 U.S.C. 300gg-91(b)(2).

 

"Health maintenance organization" has the meaning ascribed in Section 1-2(9) of the Health Maintenance Organization Act [215 ILCS 125].

 

"Health professional shortage area" has the meaning ascribed in 42 U.S.C. 254e.

 

"HHS" means the United States Department of Health and Human Services.

 

"Health plan" has the meaning ascribed in 42 U.S.C. 18021(b)(1).

 

"IHBE Law" means the Illinois Health Benefits Exchange Law [215 ILCS 122].

 

"In-Person Counselor" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Insurance producer" has the meaning ascribed in Section 500-10 of the Code.

 

"Limited health service organization" has the meaning ascribed in Section 1002 of the Limited Health Service Organization Act [215 ILCS 130].

 

"Metal level" means the level of coverage described in 42 U.S.C. 18022(d).

 

"NATA" means the Network Adequacy and Transparency Act [215 ILCS 124].

 

"Navigator" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Notice of Funding Opportunity" or "NOFO" has the meaning ascribed in 44 Ill. Adm. Code 7000.30.

 

"Person" has the meaning ascribed in Section 2(l) of the Code.

 

"Plain language" has the meaning ascribed in 42 U.S.C. 18031(e)(3)(B).

 

"Plan year" has the meaning ascribed in 45 CFR 155.20.

 

"Product" has the meaning ascribed in 45 CFR 144.103 (May 6, 2022) (no later editions or amendments).

 

"Qualified employee" has the meaning ascribed in 45 CFR 155.20.

 

"Qualified employer" has the meaning ascribed in 45 CFR 155.20.

 

"Qualified health plan" or "QHP" has the meaning ascribed in 42 U.S.C. 18021(a).

 

"Qualified health plan issuer" or "QHP issuer" means a health insurance issuer that offers a QHP in accordance with a certification from the Exchange.

 

"Qualified health plan service area" or "QHP service area" means the entire geographic area of a county or group of counties where a QHP may be offered, unless the Exchange has approved a smaller geographic area for the QHP under the criteria provided in 45 CFR 155.1055 (Mar. 27, 2012) (no later editions or amendments).

 

"Qualified individual" means an individual who has been determined eligible to enroll through the Exchange in a QHP in the individual market.

 

"SHOP" or "Illinois SHOP" means the Small Business Health Options Program operated by the Exchange through which a qualified employer can provide its employees and their dependents with access to one or more QHPs.

 

"Small group market" has the meaning ascribed in 45 CFR 155.20.

 

"Special enrollment period" means a period during which a qualified individual or enrollee who experiences certain qualifying events may enroll in, or change enrollment in, a QHP through the Exchange outside of the annual open enrollment period (see 45 CFR 155.20).

 

"Stand-alone dental plan" or "SADP" has the meaning ascribed in 45 CFR 156.400 (May 6, 2022) (no later editions or amendments).

 

"Standardized option" means, pursuant to 45 CFR 155.20, a QHP offered for sale through the Exchange in the individual market that either:

 

has a standardized cost-sharing structure specified in Table 12 of "Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025; Updating Section 1332 Waiver Public Notice Procedures; Medicaid; Consumer Operated and Oriented Plan (CO–OP) Program; and Basic Health Program", 88 Fed. Reg. 82510, 82605 (Nov. 24, 2023) (no later editions or amendments), available online at https://www.govinfo.gov/content/pkg/FR-2023-11-24/pdf/2023-25576.pdf; or

 

has the standardized cost-sharing structure specified in Table 12 that is modified only to the extent necessary to align with high deductible health plan requirements under 26 U.S.C. 223 or the applicable annual limitation on cost-sharing and HHS actuarial value requirements.

 

"State award" has the meaning ascribed in Section 15 of GATA.

 

Section 4500.40  QHP Issuer Certification

 

a)         The Exchange will only offer health plans that have in effect a certification issued or that are recognized as plans deemed certified for participation in the Exchange as a QHP, unless specifically provided otherwise (see 45 CFR 155.1000(b) (Feb. 27, 2015) (no later editions or amendments)).

 

b)         For certification in any given year, a QHP issuer must be validly accredited in accordance with the timeline set at 45 CFR 155.1045(b) (Feb. 25, 2013) (no later editions or amendments). An accreditation is valid if it complies with the requirements of 45 CFR 156.275 (Feb. 25, 2013) (no later editions or amendments). A QHP issuer's certification submission to the Department must include evidence of compliance with accreditation standards for its place on the timeline.

 

c)         The Exchange will allow a limited scope dental benefits plan to be offered through the Exchange under the conditions specified in 45 CFR 155.1065 (Mar. 27, 2012) (no later editions or amendments).

 

d)         The Exchange will certify a health plan as a QHP in the Exchange if (see 45 CFR 155.1000(c)):

 

1)         the health insurance issuer provides evidence during the certification process that it complies with the minimum certification requirements outlined in Section 4500.90, as applicable; and

 

2)         the Exchange determines that making the health plan available is in the interest of the qualified individuals and qualified employers, except that the Exchange will not exclude a health plan:

 

A)        on the basis that the plan is a fee-for-service plan;

 

B)        through the imposition of premium price controls; or

 

C)        on the basis that the health plan provides treatments necessary to prevent patients' deaths in circumstances the Exchange determines are inappropriate or too costly.

 

e)         QHP certifications will be issued on a calendar-year basis. However, for the SHOP, except when the Exchange has decertified the QHP pursuant to Section 4500.70, a certification will continue to remain in effect for the duration of any plan year beginning in the calendar year for which the QHP was certified, even if the plan year ends after the calendar year for which the QHP was certified (see 45 CFR 155.1000(d)).

 

f)         At least six months before the start of the annual open enrollment period, the Exchange will annually publish on its website a timeline of QHP certification deadlines and milestones, including, but not limited to, the date the application period will open, an initial application deadline, a final application deadline, a deadline for QHP issuers to sign QHP certification agreements, and the date the Exchange will release certification notices to issuers along with fully executed QHP certification agreements.  The certification notice and fully-executed QHP certification agreements will be released no later than 25 days before the start of the annual open enrollment period.

 

Section 4500.50  QHP Recertification

 

The criteria for initial certification apply to recertification, except that the Exchange will account for changes in applicable State and federal laws and rules as of the time of recertification. The Exchange will notify the QHP issuer of the recertification decision in the same manner as the initial certification no later than two weeks before the beginning of the annual open enrollment period.

 

Section 4500.60  Non-certification of QHPs

 

a)         If a QHP issuer elects not to seek certification for a subsequent, consecutive certification cycle within the Exchange, the QHP issuer, at a minimum, must:

 

1)         Notify the Exchange of its decision before the beginning of the recertification process, and no later than the deadline specified in 215 ILCS 97/60, and adhere to the procedures adopted by the Exchange under 45 CFR 155.1075 (Feb. 27, 2015) (no later editions or amendments);

 

2)         fulfill its obligation to cover benefits for each enrollee through the end of the plan or benefit year through the Exchange;

 

3)         fulfill data reporting obligations from the last plan or benefit year of the certification;

 

4)         provide notice to enrollees as described in subsection (b); and

 

5)         terminate the coverage or enrollment through the Exchange of enrollees in the QHP in accordance with 45 CFR 156.270 (Apr. 27, 2023) (no later editions or amendments), as applicable (see 45 CFR 156.290(a) (Dec. 22, 2016) (no later editions or amendments)).

 

b)         When, for a subsequent, consecutive certification cycle, a QHP issuer elects not to seek certification with the Exchange, or the Exchange denies certification of a QHP, the QHP issuer must provide written notice to each enrollee in the form and manner specified in 50 Ill. Adm. Code 2025 (see 45 CFR 156.290(b)).

 

Section 4500.70  QHP Decertification

 

a)         At any time, the Exchange may decertify a health plan if the Exchange determines that the QHP issuer no longer complies with the certification criteria in subsection (c) (see 45 CFR 155.1080(c) (May 29, 2012) (no later editions or amendments)). In particular, the Exchange may decertify a QHP on one or more of the following grounds (see 45 CFR 156.810(a) (Mar. 8, 2016) (no later editions or amendments)):

 

1)         the QHP issuer substantially fails to comply with federal or State laws and regulations applicable to QHP issuers participating in the Exchange;

 

2)         the QHP issuer substantially fails to comply with the standards related to the risk adjustment, reinsurance, or risk corridors programs as described in 45 CFR 156.810(a)(2);

 

3)         the QHP issuer substantially fails to comply with the transparency and marketing standards of 45 CFR 156.220 (Mar. 27, 2012) (no later editions or amendments) and 45 CFR 156.225 (Apr. 27, 2023) (no later editions or amendments);

 

4)         the QHP issuer substantially fails to comply with the health insurance issuer responsibilities for advance payments of the premium tax credit and cost-sharing in 45 CFR 156, Subpart E, as those provisions of the Code of Federal Regulations were in effect on January 12, 2024 (no later editions or amendments);

 

5)         the QHP issuer is operating in the Exchange in a manner that hinders the efficient and effective administration of the Exchange;

 

6)         the QHP no longer meets the applicable standards set forth under Section 4500.90;

 

7)         based on credible evidence, the QHP issuer has committed or participated in fraudulent or abusive activities, including submission of false or fraudulent data;

 

8)         the QHP issuer substantially fails to meet the requirements under Section 4500.90(k) related to network adequacy standards or Section 4500.90(l) related to inclusion of essential community providers;

 

9)         the QHP issuer substantially fails to comply with State or federal laws and regulations related to internal claims and appeals and external review processes, including, but not limited to, the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act;

 

10)       the Department's policy form compliance or premium rate review divisions recommend to the Exchange that the QHP should no longer be available in the Exchange;

 

11)       the QHP issuer substantially fails to comply with the privacy or security standards in 45 CFR 155.260 (Nov. 15, 2021) (no later editions or amendments);

 

12)       the QHP issuer substantially fails to meet the requirements related to the cases forwarded to QHP issuers under Section 4500.130;

 

13)       the QHP issuer substantially fails to meet the requirements related to the offering of a QHP under 45 CFR 156, Subpart M, as those provisions of the Code of Federal Regulations were in effect on June 4, 2024 (no later editions or amendments);

 

14)       the QHP issuer offering the QHP is the subject of a pending, ongoing, or final State regulatory or enforcement action or determination that relates to the issuer offering QHPs in the Exchange; or

 

15)       the Department or HHS reasonably believes that the QHP issuer lacks the financial viability to provide coverage under its QHPs until the end of the plan year.

 

b)         Sanctions and Determinations

 

1)         The Exchange may consider regulatory or enforcement actions taken by the Department or HHS against a QHP issuer as a factor in determining whether to decertify a QHP offered by that issuer.

 

2)         The Exchange may decertify a QHP offered by an issuer based on a determination or action by the Department as it relates to the issuer offering QHPs in the Exchange, including when the State places an issuer or its parent organization into receivership or when the Department's policy form compliance or rate review division recommends to the Exchange that the QHP no longer be available in the Exchange (see 45 CFR 156.810(b)).

 

c)         For standard decertifications on grounds other than those described in subsection (a)(7) through (a)(9), the Exchange will provide written notice to the QHP issuer and enrollees in the QHP, which will include the following (see 45 CFR 156.810(c)):

 

1)         the effective date of the decertification, which will be no earlier than 30 days after the date of issuance of the notice;

 

2)         the reason or reasons for the decertification, including the statute, statutes, regulation, or regulations that are the basis for the decertification;

 

3)         for the written notice to the QHP issuer, information about the effect of the decertification on the issuer's ability to offer the QHP in the Exchange, which will include information about the procedure for appealing the decertification by making a hearing request within 10 days after the QHP issuer's receipt of the notice; and

 

4)         for the written notice to the QHP enrollees, information about the effect of the decertification on enrollment in the QHP and about the availability of a special enrollment period, as described in 45 CFR 155.420.

 

d)         For expedited decertifications on grounds described in subsections (a)(6) through (a)(9), the Exchange will provide written notice to the QHP issuer and enrollees in the QHP, which will include the following (see 45 CFR 156.810(d)):

 

1)         the effective date of the decertification as determined by the Exchange; and

 

2)         the information required by subsection (c)(2) through (c)(4).

 

e)         An issuer may appeal the decertification of a QHP offered by that issuer under subsection (c) or (d), or the denial of certification of a health plan as a QHP, by filing a request for hearing before the Department within 10 days after the QHP issuer's receipt of the issuance notice. The hearing will be conducted under 50 Ill. Adm. Code 2402. If an issuer files a request for hearing on a decertification (see 45 CFR 156.810(e)):

 

1)         If the decertification is under subsection (b)(1), the decertification will not take effect before the issuance of the final administrative decision in the appeal, notwithstanding the effective date specified in subsection (b)(1); and

 

2)         If the decertification is under subsection (b)(2), the decertification will take effect on the date specified in the notice of decertification, but the certification of the QHP may be reinstated immediately upon issuance of a final administrative decision that the QHP should not be decertified.

 

f)         If the Exchange decertifies a QHP, the QHP issuer must terminate the enrollment of enrollees through the Exchange only after (see 45 CFR 156.290(c) (Dec. 22, 2016) (no later editions or amendments)):

 

1)         the Exchange made notification as described in 45 CFR 155.1080; and

 

2)         enrollees have had an opportunity to enroll in other coverage, which means the earlier of:

 

A)        the effective date of the terminated enrollee's new minimum essential coverage; or

 

B)        the latest possible effective date of coverage under a terminated enrollee's special enrollment period triggered by a loss of minimum essential coverage under 45 CFR 155.420.

 

Section 4500.80  Plan Suppression

 

The Exchange may temporarily make a QHP certified to be offered through the Exchange temporarily unavailable for enrollment through the Exchange on one or more of the following grounds (see 45 CFR 156.815(a) through (b) (Feb. 27, 2015) (no later editions or amendments)):

 

a)         The QHP issuer notifies the Exchange of its intent to withdraw the QHP from the Exchange when one of the exceptions to guaranteed renewability of coverage related to discontinuing a particular product or discontinuing all coverage applies under 45 CFR 147.106(c) or (d) (Apr. 25, 2019) (no later editions or amendments);

 

b)         Data submitted for the QHP is incomplete or inaccurate;

 

c)         The QHP is in the process of being decertified as described in Section 4500.70(c) or (d), or the QHP issuer is appealing a completed decertification through a hearing in accordance with 50 Ill. Adm. Code 2402;

 

d)         The QHP issuer offering the QHP is the subject of a pending, ongoing, or final State or HHS regulatory or enforcement action or determination that could affect the issuer's ability to enroll consumers or otherwise relates to the issuer offering QHPs in the Exchange; or

 

e)         One of the exceptions to guaranteed availability of coverage related to special rules for network plans or financial capacity limits under 45 CFR 147.104(c) or (d) (May 6, 2022) (no later editions or amendments) applies.

 

Section 4500.90  Minimum QHP Certification Standards

 

To participate in the Exchange, a health insurance issuer must have in effect a certification issued or recognized by the Exchange to demonstrate that each health plan it offers in the Exchange is a QHP in accordance with 45 CFR 156.200(a) through (f) and (h) (May 6, 2022) (no later editions or amendments).

 

a)         For the purpose of 45 CFR 156.200(b)(1), the Exchange establishes subsections (e) through (v) and Section 4500.80. The Exchange also adopts 45 CFR 156.200(b)(2) through (b)(7) and 156.200(c).

 

b)         For the purpose of 45 CFR 156.200(d), the Department's approval pursuant to applicable State law of all policy forms and, beginning for Plan Year 2026, all rates to be used in connection with a QHP is among the conditions for participation in the Exchange.

 

c)         For the purpose of 45 CFR 156.200(e), in accordance with 50 Ill. Adm. Code 2603, a QHP issuer must not discriminate on the basis of gender identity or sexual orientation regardless of whether federal law continues to recognize them as discrimination on the basis of sex.

 

d)         For 45 CFR 156.200(f), the phrase "the Illinois Exchange" is substituted for "a Federally-facilitated Exchange".

 

e)         A QHP issuer must comply with the requirements related to standardized options and non-standardized options codified at 45 CFR 156.201(b) (Apr. 27, 2023) (no later editions or amendments) and 45 CFR 156.202(b) through (e) (Apr. 15, 2024) (no later editions or amendments).

 

f)         A QHP issuer must comply with the rate and benefit information requirements in 45 CFR 156.210 (Apr. 27, 2023) (no later editions or amendments). For purposes of 45 CFR 156.210(b) through (c), the rate submissions and justifications must comply with 50 Ill. Adm. Code 2026.

 

g)         In order for a health plan to be certified as a QHP initially and to maintain certification to be offered in the individual market in the Exchange, the issuer must meet the requirements related to the administration of cost-sharing reductions and advance payments of the premium tax credit set forth in 45 CFR 156, Subpart E (see 45 CFR 156.215 (Mar. 11, 2013) (no later editions or amendments).

 

h)         A QHP issuer must provide specified types of information to the Exchange, the Department, HHS, the public, and individuals in plain language as provided in 45 CFR 156.220 (Mar. 27, 2012) (no later editions or amendments).

 

i)          A QHP issuer must comply with the requirements for access to and exchange of health data and plan information provided in 45 CFR 156.221 (May 1, 2020) (no later editions or amendments), substituting "the Illinois Exchange" for "a Federally-facilitated Exchange."

 

j)          A QHP issuer and its officials, agents, employees, and representatives must comply with the marketing and benefit design requirements of 45 CFR 156.225 (Apr. 27, 2023) (no later editions or amendments).

 

k)         In addition to any other network adequacy and transparency requirements applicable under State law and administrative rule, for the purpose of implementing 45 CFR 156.230(a)(1)(ii), (a)(1)(iii), (a)(2)(i)(A), (a)(2)(ii), (a)(3), and (a)(4) (Apr. 27, 2023) (no later editions or amendments) for State-based Exchanges and State-based Exchanges on the Federal Platform, and subject to 42 U.S.C. 300gg-1(c):

 

1)         For a medical QHP, a QHP issuer must file with the Department a network adequacy and transparency description for each QHP in compliance with 50 Ill. Adm. Code 4540. However, for mental health and substance use disorder providers, the QHP issuer must demonstrate compliance with the time and distance standards in Tables 3.1 and 3.2 of the 2023 Letter in any county where those standards are more stringent than the standards in Section 10(d-5) of NATA. (see 45 CFR 156.230(a)(2)(i)(A)) Nothing in this subsection (k)(1) supersedes the requirement that, if the applicable time and distance standards under 215 ILCS 124/10(d-5) are not met within a county, the issuer shall provide the necessary exceptions to its network as described in 215 ILCS 124/10(d-5)(3).

 

2)         For an SADP, a QHP issuer must file with the Department a network adequacy and transparency description that satisfies the provisions of 50 Ill. Adm. Code 4540.30 and 50 Ill. Adm. Code 4540.40(a), (b)(3), (b)(4), (c), (d)(1), (g)(1), (g)(2), (h), (i), (j), (p), (q)(1), (q)(2), (q)(5), and (r). For 50 Ill. Adm. Code 4540.40(d)(1), Table 3.3 of the 2023 Letter applies instead of Tables 3.1 and Table 3.2 (see 45 CFR 156.230(a)(2)(i)(A)).

 

3)         For exception requests, a QHP issuer must include a completed QHP network adequacy justification form (see 45 CFR 156.230(a)(2)(ii)).

 

4)         In general, the Exchange may grant an exception to a time and standard in Tables 3.1, 3.2, or 3.3 of the 2023 Letter if the Exchange determines that making the QHP available through the Exchange is in the interests of qualified individuals in this State (see 45 CFR 156.230(a)(3)). However, under Section 10(g) of NATA, the Department cannot grant an exception to any time and distance standard for mental health or substance use disorder providers specified in Section 10(d-5) of NATA. In any county where the time and distance standard in the 2023 Letter is more stringent than the standard in Section 10(d-5), the Exchange may grant an exception only to the extent that the QHP still complies with the time and distance standards in Section 10(d-5). If the QHP does not comply with the time and distance standards in Section 10(d-5) in a county, then the QHP must comply with the network exceptions provision in Section 10(d-5)(3).

 

5)         The provisions of 45 CFR 156.230(a)(4) apply to the Exchange only when at least 80 percent of counties in the State are classified as Counties with Extreme Access Considerations (CEAC) as defined in 50 Ill. Adm. Code 4540.30.

 

l)          For the purpose of implementing the federal requirement at 45 CFR 156.235(a)(1) that a QHP issuer must include in its provider network a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income individuals or individuals residing in Health Professional Shortage Areas within the QHP service area, in accordance with the network adequacy standards of the Exchange where the QHP is offered, the Illinois Exchange adopts the standards applicable in Federally-facilitated Exchanges as provided in 45 CFR 156.235.

 

m)        A QHP issuer must comply with the requirements for coverage through a direct primary care medical home provided in 45 CFR 156.245 (Mar. 27, 2012) (no later editions or amendments).

 

n)         A QHP issuer must provide all information that is critical for obtaining health insurance coverage or access to health care services through the QHP in the manner required under 45 CFR 156.250 (Feb. 27, 2015) (no later editions or amendments).

 

o)         A QHP issuer must comply with the limitations on rating variations provided in 45 CFR 156.255 (Mar. 27, 2012) (no later editions or amendments).

 

p)         In the individual market, a QHP issuer must (see 45 CFR 156.260 (Mar. 27, 2012) (no later editions or amendments)):

 

1)         Enroll a qualified individual during the annual open enrollment periods described in 45 CFR 155.410(e)(4) (Apr. 15, 2024) (no later editions or amendments), and abide by the effective dates of coverage established at 45 CFR 155.410(f)(3);

 

2)         Make available, at a minimum, special enrollment periods for QHPs described in 45 CFR 155.420(d) (Apr. 15, 2024) (no later editions or amendments) and abide by the effective dates of coverage established at 45 CFR 155.420(b); and

 

3)         notify a qualified individual of the qualified individual's effective date of coverage.

 

q)         A QHP issuer must comply with the enrollment process for qualified individuals provided in 45 CFR 156.265 (May 14, 2020) (no later editions or amendments). Until the Exchange becomes a State-based Exchange, the Exchange will enforce 45 CFR 156.265(d) regarding binder payments and premium payment deadlines in the manner required under 45 CFR 156.350(a)(4) (Apr. 17, 2018) (no later editions or amendments).

 

r)          A QHP issuer must comply with the termination of coverage or enrollment for qualified individuals provided in 45 CFR 156.270.

 

s)         A QHP issuer must comply with the provisions for issuer participation for the full plan year specified in 45 CFR 156.272 (Dec. 22, 2016) (no later editions or amendments), except that:

 

1)         references within that rule to 45 CFR 156.815 instead will refer to Section 4500.80 of this Part; and

 

2)         references to a "Federally-facilitated Exchange" or "Federally-facilitated SHOP" refer to the Illinois Exchange's individual market or the Illinois SHOP, respectively.

 

t)          For the abortion care and abortifacient coverages required under Sections 356z.4a and 356z.60 of the Code, a QHP issuer must comply with 45 CFR 156.280(d) through (i) (Sep. 27, 2021) (no later editions or amendments).

 

u)         A QHP issuer offering a QHP through the SHOP must comply with 45 CFR 156.286 (Apr. 17, 2018) (no later editions or amendments).

 

v)         A QHP issuer must comply with the prescription drug distribution and cost reporting requirements of 45 CFR 156.295 (May 5, 2021) (no later editions or amendments).

 

Section 4500.100  Illinois SHOP

 

a)         This Section applies at any time the Exchange operates a SHOP for the small group market. The Exchange may delegate or defer functions of the Illinois SHOP to HHS through a federal platform agreement.

 

b)         The Exchange adopts the following provisions for the SHOP and related standards for individuals and entities to participate in the SHOP or in QHPs offered through the SHOP, except that references to the "Federally-facilitated SHOP" or "FF-SHOP" are substituted with "Illinois SHOP" unless the applicable section of the Code of Federal Regulations contains a conflicting or additional requirement for the type of Exchange operating in Illinois (see 45 CFR 155.706(a) (Apr. 17, 2018) (no later editions or amendments)):

 

1)         Sections 4500.40 through 4500.90;

 

2)         the functions of an Exchange provided in 45 CFR 155, Subparts E, K, and M as those provisions of the Code of Federal Regulations were in effect on June 4, 2024 (no later editions or amendments), as modified by this Part; and

 

3)         45 CFR 155, Subpart H as those provisions of the Code of Federal Regulations were in effect on June 4, 2024 (no later editions or amendments), as modified by this Part.

 

c)         The following provisions do not apply to the Illinois SHOP (see 45 CFR 155.706(a)):

 

1)         Requirements related to individual eligibility determinations in 45 CFR 155, Subpart D as those provisions of the Code of Federal Regulations were in effect on June 4, 2024 (no later editions or amendments);

 

2)         Requirements related to enrollment of qualified individuals described in 45 CFR 155, Subpart E;

 

3)         The requirement to issue certificates of exemption in accordance with 45 CFR 155.200(b) (Dec. 27, 2019) (no later editions or amendments); and

 

4)         Requirements related to the payment of premiums by individuals, Indian tribes, tribal organizations, and urban Indian organizations under 45 CFR 155.240 (May 27, 2014) (no later editions or amendments).

 

d)         A QHP issuer must not change its rates in the SHOP more frequently than quarterly and must not vary rates for a qualified employer during the employer's plan year. In addition to the Department's filing and approval requirements under Section 355 of the Code and 50 Ill. Adm. Code 2026, updated rates must be submitted to the SHOP at least 60 days before their effective date, which must be January 1, April 1, July 1, or October 1 of the calendar year (see 45 CFR 155.706(b)(6)).

 

e)         The uniform group participation rate requirements for Federally-facilitated Exchanges in 45 CFR 155.706(b)(10)(i) also apply while Illinois has a State-based Exchange on the Federal Platform.

 

Section 4500.110  Compliance Reviews of QHP Issuers

 

The Exchange adopts the requirements for compliance reviews of QHP issuers provided in 45 CFR 156.715 (Dec. 22, 2016) (no later editions or amendments), except that:

 

a)         references to "a Federally-facilitated Exchange" are substituted with "the Illinois Exchange";

 

b)         references to "HHS" are substituted with "the Department";

 

c)         the reference to "subpart I of this part" is substituted with "this Part"; and

 

d)         until the Exchange operates as a State-based Exchange, the Exchange will enforce 45 CFR 156.715 in the manner required under 45 CFR 156.350(a)(3).

 

Section 4500.120  Standards for QHP Issuers in Specific Types of Exchanges

 

a)         Until the Exchange operates as a State-based Exchange, a QHP issuer must comply with the requirements related to changes in ownership provided in 45 CFR 156.330 (Oct. 30, 2013) (no later editions or amendments).

 

b)         A QHP issuer must comply with the requirements related to downstream and delegated entities depending on the type of Exchange in operation as provided in 45 CFR 156.340 (May 6, 2022) (no later editions or amendments).

 

c)         Until the Exchange operates as a State-based Exchange, a QHP issuer must comply with the requirements related to eligibility and enrollment standards in the manner provided in 45 CFR 156.350.

 

Section 4500.130  Casework Standards

 

Until the Exchange operates as a State-based Exchange, a QHP issuer must comply with the casework standards provided in 45 CFR 156.1010 (Aug. 30, 2013) (no later editions or amendments). Nothing in this Section affects complaints subject to 50 Ill. Adm. Code 926.