Illinois Administrative Code › Title 50 - INSURANCE › Part 2001 - CONSTRUCTION AND FILING OF ACCIDENT AND HEALTH INSURANCE POLICY FORMS › Subpart A - PROVISIONS APPLICABLE TO INDIVIDUAL AND GROUP POLICIES › Section 2001.2 - Definitions and Cross-References

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				following definitions shall apply to this Part:
"ACA" means the Patient Protection and Affordable Care Act (
				  42
				  USC 18001 et seq.).
"Code" means the Illinois Insurance Code [215 ILCS 5
				  ].
"Director" means the Director of the Illinois Department of
				  Insurance.
"EHB" means essential health benefit or benefits.
"ERISA" means the Employee Retirement Income Security Act of
				  1974, as amended (
				  29 USC
				  1001 et seq.).
"Excepted benefits", as defined at
				  26
				  USC 9832, means benefits under one or more
				  (or any combination) of the following:
Benefits not subject to requirements:
Coverage only for accident, disability income insurance, or
				  any combination thereof;
Coverage issued as a supplement to liability
				  insurance;
Liability insurance, including general liability insurance
				  and automobile liability insurance;
Workers' compensation or similar insurance;
Automobile medical payment insurance;
Credit-only insurance;
Coverage for on-site medical clinics;
Other similar insurance coverage under which benefits for
				  medical care are secondary or incidental to other insurance benefits.
Benefits not subject to requirements if offered
				  separately:
Limited scope dental or vision benefits; and
Benefits for long-term care, nursing home care, home health
				  care, community-based care, or any combination thereof.
Benefits not subject to requirements if offered as
				  independent, noncoordinated benefits:
Coverage only for a specified disease or illness;
Hospital indemnity or other fixed indemnity insurance paid as
				  a fixed dollar amount per day or other period, paid per event or service, or
				  upon benefits paid upon a basis other than period of time, regardless of the
				  amount of expenses incurred.
Benefits not subject to requirements if offered as a separate
				  insurance policy: Medicare supplemental health insurance (as defined under
				  section 1882(g)(1) of the Social Security Act (
				  42 USC
				  1395 ss(g)(1)), coverage supplemental to the
				  coverage provided under 10 USC 55, and similar supplemental coverage provided
				  to coverage under a group health plan.
"Health Benefits Exchange" or "Exchange" means the Illinois
				  Health Benefits Exchange established pursuant to
				  42 USC
				  18031(b) and
				  215
				  ILCS 122/5-5, also known as the Illinois Health Insurance Marketplace.
"HHS" means the United States Department of Health and Human
				  Services.
"Network Plan" means health insurance coverage of a health
				  insurance issuer under which the financing and delivery of medical care
				  (including items and services paid for as medical care) are provided, in whole
				  or in part, through a defined set of providers under contract with the
				  issuer.
"PHS Act" means the Public Health Service Act (
				  42
				  USC 201 et seq.).
"Preexisting condition exclusion" means a limitation or
				  exclusion of benefits (including a denial of coverage) based on the fact that
				  the condition was present before the effective date of coverage (or if coverage
				  is denied, the date of the denial) under a group health plan or group or
				  individual health insurance coverage (or other coverage provided to federally
				  eligible individuals pursuant to 45 CFR 148 ), whether or not any medical
				  advice, diagnosis, care, or treatment was recommended or received before that
				  day. A preexisting condition exclusion includes any limitation or exclusion of
				  benefits (including a denial of coverage) applicable to an individual as a
				  result of information relating to an individual's health status before the
				  individual's effective date of coverage (or if coverage is denied, the date of
				  the denial) under a group health plan, or group or individual health insurance
				  coverage (or other coverage provided to federally eligible individuals pursuant
				  to 45 CFR 148 ), such as a condition identified as a result of a pre-enrollment
				  questionnaire or physical examination given to the individual, or review of
				  medical records relating to the pre-enrollment period. (See
				  45
				  CFR 144.103.)
"SBC" means summary of benefits and coverage.
"Secretary" means the Secretary of the United States
				  Department of Health and Human Services, except when specified otherwise within
				  this Part.
"Waiting period" means, with respect to a group health plan
				  and an individual who is a potential participant or beneficiary in the plan,
				  the period of time that must pass with respect to the individual before the
				  individual is eligible to be covered for benefits under the terms of the plan.
				  (See
				  42 USC
				  300 gg(b)(4).)
b) In this Part, parenthetical
				cross-references following rule text are to the federal statutes or regulations
				relating to that Illinois rule provision.