Illinois Administrative Code › Title 50 - INSURANCE › Part 4540 - NETWORK ADEQUACY AND TRANSPARENCY › Section 4540.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
Terms used in this Part have the meanings ascribed in Section 5
				of the Act. In addition, the following definitions apply to this Part and the
				Act:
"2023 Letter" means the "2023 Letter to Issuers in the
				Federally-facilitated Exchanges" published by the Centers for Medicare &
				Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244 (January
				7, 2022) (no later editions or amendments), available online at
https://www.cms.gov/files/document/2023-draft-letter-issuers-508.pdf
.
"Act" means the Network Adequacy and Transparency Act
				[215 ILCS
				124 ].
"Acute inpatient hospital" means a hospital that provides
				emergency services 24 hours per day, every day of the year.
"CEAC" or "Counties with Extreme Access Considerations" means
				counties that satisfy the criteria for a CEAC county type designation provided
				in Section 3.1.1 of the MA Guidance.
"Contracted network group" means, for an insurer filing a
				network description under Section 10 of the Act, any group of providers with a
				direct or indirect contract or arrangement with a PPPA, MCO, other insurer,
				exempt HMO, or any other business entity by which beneficiaries are
				incentivized or required to use those providers' services, and which the filing
				insurer has directly or indirectly contracted or arranged with the business
				entity to include among the filing insurer's preferred providers at any tier of
				its own network plan. "Contracted network group" includes any group of
				providers the filing insurer has directly or indirectly contracted or arranged
				through another business entity to use for the filing insurer's network plan
				even when the group also is or has previously been contracted or arranged to
				provide services under Medicaid, Medicare, or any other public or private
				health benefits program not subject to the Act. "Contracted network group" does
				not include providers with which the filing insurer has directly contracted or
				arranged for services under its network plan. For purposes of this definition,
				a parent, subsidiary, or other affiliate of a filing insurer is not the same
				business entity as the filing insurer.
"County type" means Large Metro, Metro, Micro, Rural, or
				CEAC.
"Exempt HMO" means an HMO with respect to its Medicaid or
				Medicare Advantage health care plan.
"HMO" means a Health Maintenance Organization as defined in
				Section 1-2(9) of the Health Maintenance Organization Act [215 ILCS
				125 ].
"Individual or group policy for dental or vision insurance"
				means limited scope dental or vision benefits provided under a separate policy,
				certificate, or contract of insurance in compliance with
				45 CFR
				146.145(b)(3)(i) through
				(iii) (May 14, 2020) (no later editions or
				amendments) or 45 CFR
				148.220(b)(1) (Oct. 31,
				2016) (no later editions or amendments). The term includes, but is not limited
				to, a stand-alone dental plan.
"Large Metro" means a county that satisfies the criteria for a
				Large Metro county type designation provided in Section 3.1.1 of the MA
				Guidance.
"MA Guidance" means the "Medicare Advantage Network Adequacy
				Criteria Guidance" published by the Centers for Medicare & Medicaid
				Services, 7500 Security Boulevard, Baltimore, Maryland 21244 (January 10, 2017)
				(no later editions or amendments), available online at
https://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/Downloads/MA_Network_Adequacy_Criteria_Guidance_Document_1-10-17.pdf
.
"Material change" has the meaning ascribed in Section 5 of the
				Act and includes, but is not limited to:
a reduction of 10% or more
of a
provider
specialty
type
in the network as a
				whole;
the removal of a major health system that causes a
				network to be significantly different within one or more counties from the
				network when the beneficiary purchased the network plan;
when the network's provider ratio for any type of provider no
				longer satisfies the requirements of Section
				4540.40(e);
				and
when the network no longer satisfies the time and distance
				standards in any county for any type of provider described or incorporated
				under Section 4540.40(d).
				(Section 5 of the Act)
"MCO" has the meaning ascribed in 50 Ill. Adm. Code
				4521.20.
"Metro" means a county that satisfies the criteria for a Metro
				county type designation provided in Section 3.1.1 of the MA Guidance.
"Micro" means a county that satisfies the criteria for a Micro
				county type designation provided in Section 3.1.1 of the MA Guidance.
"Network" means the group or groups of preferred
				providers providing services to a network plan
. (Section 10 of the
				Act) Unless otherwise indicated, for purposes of the Act, a network consists of
				all preferred providers, and only those preferred providers, that service a
				network plan's beneficiaries, including all network tiers, if applicable,
				regardless of whether the filing insurer directly employs or contracts with
				those providers or has arranged access to them as members of one or more
				contracted network groups. Notwithstanding the existence of any contract
				between the insurer and the provider or the provider's contracted network
				group, a provider that is not a preferred provider with respect to a particular
				network plan is not part of the network for that plan. Nothing in this
				definition prevents more than one network plan from having the same network,
				nor shall it be interpreted in a manner inconsistent with Section 10(e) of the
				Act.
"Preferred provider" means any provider who has
				entered, either directly or indirectly, into an agreement with an employer or
				risk-bearing entity relating to health care services that may be rendered to
				beneficiaries under a network plan.
(Section 5 of the Act)
"Preferred Provider Program Administrator" has the meaning
				ascribed in 50 Ill. Adm. Code
				2051.220.
"Provider ratio" means the number of preferred providers of a
				given provider specialty type within the service area in relation to the number
				of network plan beneficiaries.
"Provider specialty type" or "type of provider" means a
				provider specialty type listed in
				215 ILCS
				124/10(c)(1) or in Table
				3.1 or
				3.2 of the 2023 Letter. A single
				facility may encompass more than one provider type.
"Rural" means a county that satisfies the criteria for a Rural
				county type designation provided in Section 3.1.1 of the MA Guidance.
"Qualified health plan" or "QHP" means a health plan that meets
				the criteria for a qualified health plan in
				42 U.S.C.
				18021.
"SERFF" means the System for Electronic Rate and Form Filing
				provided by the National Association of Insurance Commissioners (
https://www.serff.com
).
"Service area" means the approved county or total composition
				of counties where the network plan is available for purchase to
				consumers.
"Stand-alone dental plan" has the meaning ascribed in
				45 CFR
				153.400 (May 26, 2022) (no later editions or
				amendments).