Section 4500.170  QHP Eligibility and Enrollment

a)         An applicant will be eligible for enrollment in a QHP through the Exchange, including an SADP, if the applicant meets the requirements in 45 CFR 155.305(a) (Jun. 25, 2025) (no later editions or amendments), including all of the following:

1)         The applicant is a citizen or national of the United States, or is a non-citizen who is lawfully present in the United States, and is reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought;

2)         The applicant is not incarcerated, other than incarceration pending the disposition of charges; and

3)         The applicant meets the applicable residency standard identified in 45 CFR 155.305(a)(3).

b)         For a QHP that is a catastrophic plan, an applicant will be eligible for enrollment if the applicant meets the requirements of subsection (a) and either (see 45 CFR 155.305(h)):

1)         has not attained the age of 30 before the beginning of the plan year; or

2)         has a certification in effect for any plan year that the applicant is exempt from the requirement to maintain minimum essential coverage under 26 U.S.C. 5000A by reason of:

A)        26 U.S.C. 5000A(e)(1) relating to individuals without affordable coverage; or

B)        26 U.S.C. 5000A(e)(5) relating to individuals with hardships.

c)         Upon receipt of an application, the Exchange will determine whether an applicant is eligible for Medicaid or CHIP as provided in 45 CFR 155.305(c) and (d).

d)         The Exchange will accept a QHP selection from an applicant determined eligible for enrollment in a QHP. The Exchange will notify the QHP issuer of the applicant's selected QHP and transmit the information necessary to enable the issuer to enroll the applicant.

e)         The Exchange will accept enrollment of a qualified individual in a QHP only during the annual open enrollment period or a special enrollment period as described in Section 4500.180.

f)         An applicant has the right to appeal an eligibility determination as provided in 45 CFR Part 155, Subpart F (as those provisions of the Code of Federal Regulations were in effect on July 1, 2025) (no later editions or amendments).

g)         For plan years when the Illinois Exchange is a State-based Exchange on the Federal Platform, the Illinois Exchange will rely on HHS to perform all eligibility and enrollment functions, including related appeals.

h)         For plan years when Illinois operates a State-based Exchange, the Illinois Exchange will perform eligibility and enrollment functions provided or incorporated under this Section, including related appeals under Section 4500.230. The Exchange may continue to defer to HHS to handle eligibility determinations and related appeals not provided or incorporated under this Section.

1)         The Exchange will make annual eligibility redeterminations and reenrollments in accordance with 45 CFR 155.335 (Jun. 25, 2025) (no later editions or amendments). If no QHPs from the same issuer are available through the Exchange for the next plan year at the time of an enrollee's annual redetermination, the Illinois Exchange may enroll the enrollee in a similar QHP from a different issuer, as determined by the Exchange. This paragraph does not apply if the enrollee terminates coverage in accordance with Section 4500.200, including termination of coverage in connection with voluntarily selecting a different QHP.

2)         Notwithstanding an affirmative eligibility determination from the Exchange, an applicant or enrollee must pay a binder payment for an issuer to effectuate an enrollment or add coverage retroactively to an already effectuated enrollment. An issuer must establish binder payment deadlines subject to the following:

A)        For coverage to be effectuated under a prospective effective date, the binder payment must consist of the first month's premium. For coverage to be effectuated under a retroactive effective date, the binder payment must consist of the premium due for all months of retroactive coverage through the first prospective month of coverage. An issuer may establish binder payment thresholds to the extent allowed by 45 CFR 155.400(g) (Jan. 15, 2025) (no later editions or amendments).

B)        An issuer's binder payment deadlines must fall within the following range:

i)          no earlier than the later of:

•           the coverage effective date; or

•           14 calendar days from the date the premium invoice is sent; and

ii)         no later than the later of 30 calendar days from:

•           the date the issuer receives the enrollment transaction; or

•           the coverage effective date.

C)        When an issuer experiences billing or enrollment problems due to high volume or technical errors, the issuer may implement a reasonable extension of its binder payment deadlines.

3)         For any plan year for which the Illinois Exchange operates a SHOP, Section 4500.100 will govern the eligibility and enrollment procedures for QHPs offered through the SHOP.

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)