reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 50 - INSURANCE › Part 2019 - MINIMUM BENEFIT STANDARDS FOR DIABETES COVERAGE › Section 2019.20 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
This Part applies to all group accident and health insurance
				policies and health maintenance organization group contracts that are amended,
				delivered, issued or renewed in this State after the effective date of this
				Part. This Part also applies to group point-of-service contracts offered by a
				limited health service organization and group voluntary health services plans.
				This Part does not apply to agreements, contracts or policies that provide
				coverage for a specified diagnosis or other limited benefit
				coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2019 - MINIMUM BENEFIT STANDARDS FOR DIABETES COVERAGE › Section 2019.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
Durable Medical Equipment means blood glucose monitors, blood
				glucose monitors for the legally blind, cartridges for the legally blind and
				lancets and lancing devices.
Pharmaceuticals and Supplies means insulin, syringes, needles,
				test strips for glucose monitors, FDA approved oral agents used to control
				blood sugar and glucagon emergency kits.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2019 - MINIMUM BENEFIT STANDARDS FOR DIABETES COVERAGE › Section 2019.40 - Minimum Benefit Standards

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 Coverage for durable medical equipment shall be subject to the same deductible,
			 copayment, and coinsurance provisions provided for other durable medical
			 equipment, depending on whether the coverage is provided under the policy or a
			 durable medical equipment rider to the policy. The minimum benefit shall not
			 apply to a group policy of accident and health insurance that does not provide
			 durable medical equipment.
b)
			 Except as otherwise provided in Section 356z.41 of the Illinois Insurance Code
			 [215 ILCS 5], coverage for pharmaceuticals and supplies shall be subject to the
			 same coverage, deductible, co-payment, and co-insurance provisions provided for
			 other pharmaceuticals, depending on whether that coverage is provided under the
			 policy or a drug rider to the policy. The minimum benefit shall not apply to a
			 group policy of accident and health insurance that does not provide drug
			 coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2020 - REIMBURSEMENT AND SUBROGATION PROVISIONS CONTAINED IN INDIVIDUAL AND GROUP ACCIDENT AND HEALTH POLICIES › Section 2020.10 - Scope

Current through Register Vol. 48, No. 28, July 12, 2024
This Part shall apply to any insurance company licensed to do
				business in this State which is transacting the kind or kinds of business
				described as Class 1(b) or Class 2(a) of Section 4 of the Illinois Insurance
				Code [215 ILCS 5/4
				].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2020 - REIMBURSEMENT AND SUBROGATION PROVISIONS CONTAINED IN INDIVIDUAL AND GROUP ACCIDENT AND HEALTH POLICIES › Section 2020.20 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
The purpose of this Part is to clarify policy form language
				concerning the application of Sections 357.18 and 357.19 of the Illinois
				Insurance Code [215 ILCS 5/357.18 and 357.19] and the use of reimbursement and
				subrogation provisions in such policy forms. This Part is not intended to
				affect any equitable causes of action, if any, that may exist or develop in
				relation to the insurance contract.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2020 - REIMBURSEMENT AND SUBROGATION PROVISIONS CONTAINED IN INDIVIDUAL AND GROUP ACCIDENT AND HEALTH POLICIES › Section 2020.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
Code means the Illinois Insurance Code [215 ILCS 5 ].
Department means the Illinois Department of Financial and
				Professional Regulation.
Division means the Illinois Department of Financial and
				Professional Regulation-Division of Insurance.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2020 - REIMBURSEMENT AND SUBROGATION PROVISIONS CONTAINED IN INDIVIDUAL AND GROUP ACCIDENT AND HEALTH POLICIES › Section 2020.40 - Reimbursement Provision

Current through Register Vol. 48, No. 28, July 12, 2024
Right of Reimbursement: In addition to any other requirements
				set forth in the Code or Department regulations, if an insurer includes a
				reimbursement provision in its policy, that provision shall be in the form set
				forth in subsection (a)(1) if the insurer has the right to first reimbursement,
				or subsection (b) if the insurer does not have the right to first
				reimbursement:
a) "If a covered person
			 recovers expenses for sickness or injury that occurred due to the negligence of
			 a third party, we have the right to first reimbursement for all benefits we
			 paid from any and all damages collected from the negligent third party for
			 those same expenses whether by action at law, settlement, or compromise, by the
			 covered person, the covered person's parents if the covered person is a minor,
			 or the covered person's legal representative as a result of that sickness or
			 injury. You are required to furnish any information or assistance, or provide
			 any documents that we may reasonably require in order to exercise our rights
			 under this provision. This provision applies whether or not the third party
			 admits liability."
b) "If a covered
			 person recovers expenses for sickness or injury that occurred due to the
			 negligence of a third party, we have the right to reimbursement for all
			 benefits we paid from any and all damages collected from the negligent third
			 party for those same expenses whether by action at law, settlement, or
			 compromise, by the covered person, covered person's parents if the covered
			 person is a minor, or covered person's legal representative as a result of that
			 sickness or injury. You are required to furnish any information or assistance,
			 or provide any documents that we may reasonably require in order to exercise
			 our rights under this provision. This provision applies whether or not the
			 third party admits liability."
Illinois Administrative Code › Title 50 - INSURANCE › Part 2020 - REIMBURSEMENT AND SUBROGATION PROVISIONS CONTAINED IN INDIVIDUAL AND GROUP ACCIDENT AND HEALTH POLICIES › Section 2020.50 - Subrogation Provision

Current through Register Vol. 48, No. 28, July 12, 2024
In addition to any other requirements set forth in the Code or
				Division's regulations, if an insurer includes a subrogation provision in its
				policy, that provision shall be in the form as follows: "We are assigned the
				right to recover from the negligent third party, or his or her insurer, to the
				extent of the benefits we paid for that sickness or injury. You are required to
				furnish any information or assistance, or provide any documents that we may
				reasonably require in order to exercise our rights under this provision. This
				provision applies whether or not the third party admits
				liability."
Illinois Administrative Code › Title 50 - INSURANCE › Part 2020 - REIMBURSEMENT AND SUBROGATION PROVISIONS CONTAINED IN INDIVIDUAL AND GROUP ACCIDENT AND HEALTH POLICIES › Section 2020.100 - Effective Date for Existing Policies

Current through Register Vol. 48, No. 28, July 12, 2024
Any policy containing a reimbursement or subrogation provision
				that is in effect prior to November 1, 2007 shall comply with the provisions of
				this Part upon the renewal of that policy.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2021 - GROUP HEALTH POLICY MANDATE APPLICABILITY TO NONRESIDENT CERTIFICATEHOLDERS NOT EMPLOYED IN ILLINOIS › Section 2021.10 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
The purpose of this Part is to establish requirements for
				filing group policy forms with the Illinois Department of Financial and
				Professional Regulation-Division of Insurance pursuant to Section 352(c) of the
				Illinois Insurance Code [215 ILCS
				5/352(c) ], to be used for policies
				where the master contract has situs in this State and where certificates will
				be issued only to certificateholders who neither reside nor work in
				Illinois.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2021 - GROUP HEALTH POLICY MANDATE APPLICABILITY TO NONRESIDENT CERTIFICATEHOLDERS NOT EMPLOYED IN ILLINOIS › Section 2021.20 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
This Part applies to all group accident and health insurance
				policy forms, amendments, or certificate of insurance policy forms submitted
				pursuant to Section 352(c) of the Code on or after May 1,
				2005.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2021 - GROUP HEALTH POLICY MANDATE APPLICABILITY TO NONRESIDENT CERTIFICATEHOLDERS NOT EMPLOYED IN ILLINOIS › Section 2021.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
Code means the Illinois Insurance Code [215 ILCS 5 ].
Department means the Illinois Department of Financial and
				Professional Regulation.
Director means the Director of the Department of Financial and
				Professional Regulation-Division of Insurance of the State of Illinois or
				anyone to whom the Director's responsibilities and authority are lawfully
				delegated.
Division means the Illinois Department of Financial and
				Professional Regulation-Division of Insurance.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2021 - GROUP HEALTH POLICY MANDATE APPLICABILITY TO NONRESIDENT CERTIFICATEHOLDERS NOT EMPLOYED IN ILLINOIS › Section 2021.40 - Filing and Disclosure Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) Policies filed pursuant to Section 352(c)
			 of the Code must be accompanied by a statement that the policy does not need to
			 provide State required coverages or services pursuant to this Section for
			 nonresident certificateholders who are not employed in this State and:
1) File informationally, pursuant to 50 Ill.
			 Adm. Code
			 916.40, a
			 letter specifically listing each state in which certificates will be
			 issued.
2) If certificates are
			 issued in states not identified in subsection (a)(1), insurers must notify the
			 Division in writing within 30 days after issuing the certificate.
3) The letter must state and certify that the
			 certificateholders are being provided the coverages or services that meet
			 Illinois requirements or the applicable requirements of the state in which the
			 certificates will be issued.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2021 - GROUP HEALTH POLICY MANDATE APPLICABILITY TO NONRESIDENT CERTIFICATEHOLDERS NOT EMPLOYED IN ILLINOIS › Section 2021.50 - Out-of-State Certificate Policy Forms That Require Illinois Approval

Current through Register Vol. 48, No. 28, July 12, 2024
Where an exemption is not sought under Section 352(c) of the
				Code, and a master policy is issued in Illinois, policies and certificates
				issued to persons residing or working out-of-state must be submitted to the
				Division for approval and must demonstrate compliance with applicable Illinois
				laws and rules.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.10 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
The purpose of this Part is to set forth requirements the
				Director deems necessary to implement the Health Insurance Portability and
				Accountability Act. This Part will provide uniformity for the health insurance
				issuer by defining notice requirements, as well as requirements for
				modification, termination, discontinuance and rescission provisions to which
				all health insurance issuers must adhere. In addition, this Part also
				establishes penalty provisions for health insurance issuers who fail to comply
				with the certification requirements for creditable coverage found in Section
				2025.100 of
				this Part.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.20 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
This Part is applicable to all accident and health insurance
				policies and health maintenance organization contracts subject to the Illinois
				Health Insurance Portability and Accountability Act (IHIPAA) [215 ILCS 97 ],
				except those excluded by Section 45 of the Act that are issued, amended,
				delivered or renewed in this State on or after May 1, 2006.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Act" means the Illinois Health Insurance Portability and
				Accountability Act [215 ILCS 97].
"Anniversary Date" means the annually recurring date of the
				initial issuance of the policy.
"COBRA" means the federal Consolidated Omnibus Budget
				Reconciliation Act of 1985 (29 U.S. C. 1161 through
				1168 and 42 U.S.C. 300bb-1 through
				300bb-8).
"Code" means the Illinois Insurance Code [215 ILCS 5].
"Department" means the Department of Insurance.
"Director" means the Director of the Department of
				Insurance.
"Employee" means any individual employed by an
				employer
.
(29 U.S.C.
				1002(6))
"Employer" means any person acting directly as an employer, or
				indirectly in the interest of an employer, in relation to an employee benefit
				plan, and includes a group or association of employers acting for an employer
				in such capacity. Employer shall include only employers of 2 or more employees.
				(29 U.S.C.
				1002(5))
"Group Health Plan" means an employee welfare benefit
				plan (as defined in section 3(1) of the Employee Retirement Income Security Act
				of 1974
(29 U.S.C.
				1002))
to the extent that the plan
				provides medical care (as defined in paragraph (2) of that section and
				including items and services paid for as medical care) to employees or their
				dependents (as defined under the terms of the plan) directly or through
				insurance, reimbursement, or otherwise.
[215 ILCS 97/5
				]
"Health Insurance Issuer" means an insurance company,
				insurance service, or insurance organization (including a health maintenance
				organization) which is licensed to engage in the business of insurance in a
				state and which is subject to Illinois law that regulates insurance (within the
				meaning of section 514(b)(2) of the Employee Retirement Income Security Act of
				1974
(29 U.S.C.
				1144)).
This term does not include a
				group health plan.
[215 ILCS 97/5 ]
"Renewal Date" means each annual anniversary date unless
				otherwise specifically defined by the contract. A renewal date may not be
				defined to a period shorter than the underwriting and benefit time frames
				established by the contract.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.40 - Notice Requirement to the Division

Current through Register Vol. 48, No. 28, July 12, 2024
In any case where a health insurance issuer elects to uniformly
				modify coverage, uniformly terminate coverage, or discontinue coverage in a
				marketplace, the health insurance issuer shall provide notice to the Division
				prior to notifying the plan sponsors, participants, beneficiaries and covered
				individuals. The notice shall be sent by certified mail to the Division 90 days
				in advance of any notification of the company's actions. The notice shall
				include a complete description of the action to be taken, a specific
				description of the type of coverage affected, the total number of covered lives
				affected, a draft of the letter being sent to the plan sponsors and
				participants, beneficiaries or covered individuals, time frames for the actions
				being taken and any options the plan sponsors, participants, beneficiaries or
				covered individuals may have available to them under the Act.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.50 - Uniform Modification of Coverage

Current through Register Vol. 48, No. 28, July 12, 2024
Uniform modification to group or individual health insurance
				coverage may occur only at the time of coverage renewal. The modification of
				the health insurance coverage may include any changes to the health insurance
				coverage, including deductibles and copayments. Changes to the premium are not
				considered modifications of health insurance coverage. Any uniform
				modifications made to the health insurance coverage as provided by Sections
				30(D) and 50(D) of the Act that have not previously been approved by the
				Division as required by Section 143(1) of the Code and consistent with the
				requirements of 50 Ill. Adm. Code 916 must first be filed with the Division for
				approval as required by Section 143(1) of the Code [215 ILCS
				5/143(1) ].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.60 - Uniform Termination of Coverage

Current through Register Vol. 48, No. 28, July 12, 2024
When a health insurance issuer decides to discontinue offering
				a particular type of health insurance coverage, the health insurance issuer
				must adhere to the following requirements:
a) The health insurance issuer may only
			 discontinue a particular type of health insurance coverage upon the renewal
			 date of the coverage. The statutory 90 day notice given to plan sponsors,
			 participants, beneficiaries and covered individuals must be 90 days prior to
			 the renewal date of the health insurance coverage.
b) The notice of discontinuance of coverage
			 must be sent to all the following: the plan sponsor, participant and
			 beneficiaries, or, if the coverage is an individual policy, the covered
			 individual.
c) The health insurance
			 issuer must offer to be purchased all products being marketed in that market.
			 The health insurance issuer may not limit which products are to be offered for
			 purchase.
d) The health insurance
			 issuer discontinuing the coverage must be the same company required to offer
			 other health insurance coverage in the market to the plan sponsor or covered
			 individual. It may not be an affiliated company unless approved by the
			 Director.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.70 - Discontinuance of a Market

Current through Register Vol. 48, No. 28, July 12, 2024
When a health insurance issuer elects to discontinue offering
				all health insurance coverage in the small group market, large group market or
				individual market, (see Section 5 of the Act), the health insurance issuer must
				adhere to the following requirements:
a) Provide notice to the Department of
			 Insurance as outlined in Section
			 2025.40 of this Part.
b) The notice of discontinuation of coverage
			 must be sent to all the following: the plan sponsor, participant, and
			 beneficiaries, or, if the coverage is an individual policy, the covered
			 individual.
c) The health insurance
			 issuer may only discontinue the health insurance coverage upon the renewal date
			 of the coverage. The 180-day notice given to plan sponsors, participants,
			 beneficiaries, and covered individuals must be 180 days prior to the renewal
			 date of the health insurance coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.80 - Rescission in the Small Group Market

Current through Register Vol. 48, No. 28, July 12, 2024
a) A health insurance issuer in the small
			 group market may not rescind an individual's health insurance coverage based on
			 health conditions. The health insurance issuer may adjust the premium if a
			 lower than appropriate premium resulted from the misrepresentation of health
			 conditions, by either the employer or employee. The premium may be adjusted to
			 reflect the current rating for the group.
b) The health insurance issuer may rescind a
			 small employer policy or employee certificate if fraud is proven in a court of
			 law.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.90 - Certificates of Creditable Coverage

Current through Register Vol. 48, No. 28, July 12, 2024
a) A health insurance issuer shall issue a
			 written certification, as required by Section 20(E) of the Act, that states:
1) The period of creditable coverage of the
			 individual, including the coverage (if any) under the COBRA continuation
			 provision; and
2) The waiting
			 period (if any) (and affiliation period, if applicable) imposed with respect to
			 the individual for any coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2025 - ILLINOIS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY STANDARDS › Section 2025.100 - Penalty Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
The Director may take any appropriate regulatory action
				authorized by Article XXIV of the Code [215 ILCS 5 /Art. XXIV] or any other
				provision of the Code or rule against a health insurance issuer if it fails to
				provide a certification of creditable coverage as required by Section
				2025.90
				of this Part.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.30 - Rates Subject to Review or Prior Approval

Current through Register Vol. 48, No. 28, July 12, 2024
a) All rates and classifications of risks in
			 the individual or small group market, other than for grandfathered health
			 plans, excepted benefits, student health insurance coverage, or short-term,
			 limited-duration health insurance coverage, on or after January 1, 2014, or
			 effective on or after January 1, 2014 and taking effect no later than December
			 31, 2025, are subject to review under applicable law and Department rules,
			 including, but not limited to, 50 Ill. Adm. Code 916, as well as:
1) the public posting and public comment
			 period described in Section 355(d) and (e) of the Code; and
2) review for unreasonable rate increases
			 through the implementation under Section 355 of the Code of an Effective Rate
			 Review Program described in 45 CFR 154.301 (April 17, 2018)
			 (no later editions or amendments) if:
A) the
			 rate represents a rate increase of 10 percent or more and applies to a 12-month
			 period as calculated under subsection (a)(2)(B).
B) a rate increase meets or exceeds the
			 applicable threshold set forth in subsection (a)(2)(A) if the average increase
			 for all enrollees weighted by premium volume meets or exceeds the applicable
			 threshold.
C) if a rate increase
			 that does not otherwise meet or exceed the threshold under subsection (a)(2)(B)
			 meets or exceeds the threshold when combined with a previous increase or
			 increases during the 12-month period preceding the date on which the rate
			 increase would become effective, then the rate increase must be considered to
			 meet or exceed the threshold and is subject to review. The review shall include
			 a review of the aggregate rate increases during the applicable 12-month
			 period.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.40 - Unreasonable Rate Increases

Current through Register Vol. 48, No. 28, July 12, 2024
a) When
			 the Director reviews a rate increase for any rate described in Section
			 2026.30(a)(2) or
			 (b), the Director will determine that the
			 rate increase is an unreasonable rate increase if the increase is an excessive
			 rate increase, an unjustified rate increase, or an unfairly discriminatory rate
			 increase, as required and defined by
			 45 CFR
			 154.205.
b) The rate increase is an excessive rate
			 increase if the increase causes the premium charged for the health insurance
			 coverage to be unreasonably high in relation to the benefits provided under the
			 coverage (see 45 CFR
			 154.205(b)). In determining
			 whether the rate increase causes the premium charged to be unreasonably high in
			 relationship to the benefits provided, the Director will consider:
1) Whether the rate increase results in a
			 projected medical loss ratio below the federal medical loss ratio standard in
			 the applicable market to which the rate increase applies, after accounting for
			 any adjustments allowable under federal law;
2) Whether one or more of the assumptions on
			 which the rate increase is based is not supported by substantial evidence;
			 and
3) Whether the choice of
			 assumptions or combination of assumptions on which the rate increase is based
			 is unreasonable.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.50 - Submission of Rate Filing Justification

Current through Register Vol. 48, No. 28, July 12, 2024
a) For all rates described in Section
			 2026.30(a) and
			 (b), a health insurance issuer must submit a
			 Rate Filing Justification for all products in the single risk pool, including
			 new or discontinuing products, to the Director on a form and in a manner
			 prescribed by the Secretary in
			 45 CFR
			 154.215(a) (April 17, 2018)
			 (no later editions or amendments) and as further provided in this
			 Section.
b) The Rate Filing
			 Justification must consist of the following Parts (as required in
			 45 CFR
			 154.205(b) and pursuant to
			 Section 355 of the Code):
1) Unified rate
			 review template (Part I), as described in subsection (d).
2) Written description justifying the rate
			 increase (Part II), as described in subsection (e).
3) Rating filing documentation (Part III), as
			 described in subsection (f).
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.60 - Determination of an Unreasonable Rate Increase or Inadequate Rate

Current through Register Vol. 48, No. 28, July 12, 2024
a) When the
			 Director receives a Rate Filing Justification for a rate subject to review
			 under Section 2026.30(a)(2) or (b)
			  and the Director reviews the rate, the
			 Director will make a timely determination whether:
1) for any rate increase subject to review
			 under Section 2026.30(a)(2)
			 or prior approval under Section
			 2026.30(b), the
			 rate increase is an unreasonable rate increase in accordance with Section
			 2026.40, and submit that
			 decision to CMMS within 5 business days following the final determination as
			 required by 45 CFR
			 154.210(b)(2) (May 23, 2011)
			 (no later editions or amendments); and
2) for rates described in Section
			 2026.30(b), the
			 rate is an inadequate rate as defined in Section
			 2026.20.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.70 - Public Comment

Current through Register Vol. 48, No. 28, July 12, 2024
All rate filings and summaries in the individual or small group
				markets that will be effective on or after January 1, 2025, other than
				grandfathered health plans, excepted benefits, student health insurance
				coverage, or short-term, limited-duration health insurance coverage, will be
				posted to the Department's website within 5 business days after the rate filing
				deadline set by the Department in annual guidance as described in Section
				355(d) of the Code, which will be in the form of a company bulletin posted to
				the Department's website. The rate filings and summaries will be open to a
				30-day public comment period under Section 355(e) of the Code even if the rates
				are not subject to review for an unreasonable rate increase or inadequate
				rates. Information not subject to public disclosure when the health insurance
				issuer meets the criteria in Section 7(1)(g) of the Freedom of Information Act
				[5 ILCS 140], and health insurance issuer information deemed confidential under
				any other applicable law or regulation, will not be posted to the Department's
				public website.
The Department
will
post all of the
				comments received to the Department's website within 5 business days after the
				comment period ends.
(Section 355(e) of the Code)
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.80 - Prior Approval, Disapproval, or Modification of Rates

Current through Register Vol. 48, No. 28, July 12, 2024
When the Director approves, disapproves, or modifies a rate
				described in Section 2026.30(b), the
				Director, within 60 days after the close of the public comment period, will
notify the health insurance issuer of the decision, make the decision
				available to the public by posting it on the Department's website, and include
				an explanation of the findings, actuarial justifications, and rationale that
				are the basis for the decision.
Any notice of modification or
				disapproval will state that the
health insurance issuer whose rate has
				been modified or disapproved may request a hearing within 10 days
				after
the Department issues the notice to the health insurance issuer.
				(Section 355(f) of the Code) Hearings will be conducted in accordance with 50
				Ill. Adm. Code 2402, and costs of the hearing may be assessed against the
				health insurance issuer in accordance with Section 408(5) of the Code and 50
				Ill. Adm. Code 2402.270.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.90 - Material Changes to the Director's Decision After Approving Rates

Current through Register Vol. 48, No. 28, July 12, 2024
If, following the issuance of a decision but before the
				effective date of the premium rates approved by the decision, an event occurs
				that materially affects the Director's decision to approve, deny, or modify the
				rates
described in Section
				2026.30(b)
, the Director may consider supplemental facts or data reasonably
				related to the event.
(Section 355(g) of the Code) The Director will
				issue a new decision rescinding the prior decision and notifying the health
				insurance issuer of the disapproval or modification of rates in accordance with
				Section 2026.80. After approval has been expressly given or automatically
				deemed by law, the Director will not disapprove or modify rates based solely on
				analysis or reconsideration of information already submitted to the Director by
				the health insurance issuer or in public comments before the approval decision
				was finalized.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2026 - HEALTH INSURANCE RATE REVIEW › Section 2026.100 - Review of Rates Not Subject to the Effective Rate Review Program

Current through Register Vol. 48, No. 28, July 12, 2024
The Director's review of any rate or classification of risks
				described in Section 2026.30(c) is
				subject to Section 355(i) of the Code in addition to any other law or rule
				applicable to the type of coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2028 - CONFIDENTIALITY PROTOCOLS FOR REQUEST AND RECEIPT OF CLAIM INFORMATION BY ALTERNATIVE MEANS › Section 2028.5 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
People experiencing actual or threatened violence frequently
				establish new addresses and telephone numbers to protect their health and
				safety. Section 355b of the Code requires the Director to adopt rules to guide
				companies in guarding against disclosure of information protected pursuant to
				that Section. This Part establishes requirements for health companies so that
				they effectively respond to reasonable requests for receipt of claim-related
				information by alternative means and keep that information confidential in
				conformance with Section 355b of the Code.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2028 - CONFIDENTIALITY PROTOCOLS FOR REQUEST AND RECEIPT OF CLAIM INFORMATION BY ALTERNATIVE MEANS › Section 2028.10 - Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Part shall
			 apply to a company that issues, delivers, amends or renews an individual or
			 group policy of accident and health insurance in this State on or after January
			 1, 2014.
b) With respect to a
			 company authorized to write other kinds of insurance in addition to accident
			 and health insurance, this Part shall apply only with respect to accident and
			 health insurance coverage.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2028 - CONFIDENTIALITY PROTOCOLS FOR REQUEST AND RECEIPT OF CLAIM INFORMATION BY ALTERNATIVE MEANS › Section 2028.20 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
As used in this Part:
"Accident and health insurance" shall have the meaning set
				forth in Section 4 Class 1(b) and Class 2(a) of the Code and includes those
				coverages authorized by the Health Maintenance Organization Act [215 ILCS 125
				], the Limited Health Service Organization Act [215 ILCS 130 ], and the
				Voluntary Health Services Plan Act [215 ILCS 165 ]. With regard to a fraternal
				benefit society, the term includes coverages authorized by Section 297.1(4) and
				(5) of the Code.
"Address" means a street address, mailing address or e-mail
				address.
"Claim related information" means all claim or billing
				information relating specifically to an insured, subscriber or person covered
				by an individual or group policy of accident and health insurance issued,
				delivered, amended or renewed by a company doing business in this State.
"Code" means the Illinois Insurance Code [215 ILCS 5 ].
"Company" means a company, as defined in Section 2 of the Code,
				that issues, delivers, amends or renews an individual or group policy of
				accident and health insurance or other insurance providing accident and health
				insurance benefits.
"Director" means the Director of the Illinois Department of
				Insurance.
"Fraternal benefit society" shall have the meaning set forth in
				Section 282.1 of the Code.
"Insured" means a natural person who is, has been or will be
				covered under an individual or group accident and health policy or a policy
				including accident and health coverage.
"Person" means a natural person or legal entity, including a
				partnership, limited liability company, association, trust or
				corporation.
"Policy" means a policy, contract or certificate of accident
				and health insurance.
"Policyholder" means a person to whom a policy has been
				issued.
"Reasonable request" means:
a statement that disclosure of all or part of the claim related
				information to which the request pertains could endanger an individual;
				or
a copy of a valid protective order from a court of competent
				jurisdiction.
The request shall specify an alternative address, telephone
				number or other method of contact.
"Requestor" means an insured making a request to receive
				claim-related information by alternative means, or the insured's legal
				representative, or, with regard to an insured who is a child, the child's
				parent or guardian.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2028 - CONFIDENTIALITY PROTOCOLS FOR REQUEST AND RECEIPT OF CLAIM INFORMATION BY ALTERNATIVE MEANS › Section 2028.30 - Confidentiality Protocol

Current through Register Vol. 48, No. 28, July 12, 2024
a) A company
			 shall develop and implement a confidentiality protocol to accommodate a
			 reasonable request by a requestor to receive communications of claim-related
			 information from the company by alternative means or at alternative locations
			 if the requestor clearly states that disclosure of all or part of the
			 information could endanger the insured. The confidentiality protocol shall
			 provide that, except with the express consent of the requestor, the company
			 shall not disclose to the policyholder:
1) the
			 address, telephone number or any other personally identifying information of
			 the insured or child for whose benefit a request was made;
2) the nature of the health care services
			 provided;
3) the name or address of
			 the provider of the health care services; or
4) any other information from which there is
			 a reasonable basis to believe the foregoing information could be
			 obtained.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2028 - CONFIDENTIALITY PROTOCOLS FOR REQUEST AND RECEIPT OF CLAIM INFORMATION BY ALTERNATIVE MEANS › Section 2028.40 - Notice

Current through Register Vol. 48, No. 28, July 12, 2024
a) A company shall
			 post conspicuously on its website and annually provide all its participating
			 health service providers with:
1) a
			 description of Section 355b of the Code;
2) the information required by Section
			 2028.30(c)(1), (2) and
			 (6); and
3) the phone number for the State of Illinois
			 Domestic Violence Helpline.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2035 - MEDICAL NECESSITY CRITERIA FOR SERIOUS MENTAL ILLNESSES FOR INDIVIDUALS UNDER THE AGE OF 26 › Section 2035.10 - Applicability and Scope

Current through Register Vol. 48, No. 28, July 12, 2024
a) This Part
			 applies to any issuer, nonfederal governmental payor, or utilization review
			 organization regarding their requirements for or use of utilization review for
			 any of the following types of coverage, excluding excepted benefits:
1) any group or individual policy,
			 certificate, or evidence of coverage of accident and health insurance subject
			 to the Code;
2) any group or
			 individual health care plan contract, certificate, or evidence of coverage
			 subject to the HMO Act; or
3) any
			 coverage for health benefits under a nonfederal governmental plan provided
			 under the State Employees Group Insurance Act of 1971 [5 ILCS 375], the
			 Counties Code [55 ILCS 5], the Illinois Municipal Code [65 ILCS 5], or the
			 School Code [105 ILCS 5].
Illinois Administrative Code › Title 50 - INSURANCE › Part 2035 - MEDICAL NECESSITY CRITERIA FOR SERIOUS MENTAL ILLNESSES FOR INDIVIDUALS UNDER THE AGE OF 26 › Section 2035.30 - Medical Necessity Criteria for Utilization Review of Treatment Models for Serious Mental Illnesses for Individuals Under Age 26

Current through Register Vol. 48, No. 28, July 12, 2024
Any medical necessity criteria that an issuer, nonfederal
				governmental payor, or utilization review organization prescribes or uses for
				utilization review on any of the following interdisciplinary, team-based
				treatment models for serious mental illnesses in individuals under the age of
				26 shall conform to the criteria in this Section. The services are delivered
				through the appropriate interdisciplinary team of mental health professionals
				to enable early treatment and recovery, improved functioning, improved and/or
				managed mental health symptoms, medication adherence, and the prevention of any
				further functional impairment. For individuals with Medicaid coverage, the
				medical necessity criteria will continue to be governed by the criteria
				established by the Illinois Department of Healthcare and Family
				Services.
a) Coordinated Specialty
			 Care (CSC) for First Episode Psychosis Treatment
1) Service Initiation Criteria. An individual
			 meets the medical necessity criteria for initiating CSC services if they meet
			 all of the following:
A) The individual is 14
			 through 25 years of age;
B) The
			 individual experienced significant symptoms of psychosis or a psychotic
			 episode, as defined in DSM, for the first time in the last 18 months;
			 and
C) The individual (and parent
			 or legal guardian when appropriate and with consent) is willing to accept CSC
			 services.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2040 - TEMPORARY HEALTH COVERAGE REQUIREMENTS DURING AN EPIDEMIC OR PUBLIC HEALTH EMERGENCY › Section 2040.10 - Purpose

Current through Register Vol. 48, No. 28, July 12, 2024
This Part is intended to help protect insured individuals'
				access during an epidemic or public health emergency to timely, affordable
				health care services by requiring temporary accommodations or exceptions to the
				terms of their health insurance coverage. As demonstrated during the COVID-19
				outbreak, an epidemic or public health emergency that rises to the level of a
				statewide disaster is likely to result in significant economic impact,
				including loss of income, wages, and working hours, for Illinois residents and
				employers. These losses will temporarily reduce their ability either to pay for
				coverage or to qualify for their employment-based coverage under the terms of
				their health insurance coverage. A widespread loss of coverage combined with a
				loss in income is likely to undermine public health officials' efforts to
				contain the illness or health condition causing the public health emergency
				because affected individuals may delay seeking testing or treatment.
				Additionally, it is likely to place a financial strain on health care providers
				if increasing numbers of uninsured individuals use health care services,
				whether related or not to the illness or health condition causing the public
				health emergency. Such an epidemic or emergency is also likely to place a
				strain on the ability of health care providers to deliver services quickly and
				efficiently to the increased number of patients who need them, particularly if
				those services are subject to utilization review. Such an epidemic or emergency
				could also cause shortages or disruptions to prescription drug supplies. This
				Part is intended to prevent or mitigate the impact of the above problems and to
				relieve insureds of policy restrictions or requirements that become unfair or
				unjust under extraordinary circumstances.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2040 - TEMPORARY HEALTH COVERAGE REQUIREMENTS DURING AN EPIDEMIC OR PUBLIC HEALTH EMERGENCY › Section 2040.20 - Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
a) Except as
			 provided in subsection (b), this Part applies regarding all policies,
			 contracts, and certificates of health insurance coverage that are or will be in
			 force, issued, delivered, amended, or renewed in this State and subject to the
			 Director's authority under any insurance law.
b) This Part does not apply to short-term,
			 limited-duration health insurance coverage or policies of excepted benefits,
			 except when specifically provided for dental benefits. This Part does not apply
			 to any group health insurance coverage that is not provided by a health
			 maintenance organization, except as specified in Section 2040.80.
c) The provisions of this Part generally
			 apply only while the Governor has a disaster proclamation in effect for all
			 counties of the State pursuant to Section 7 of the Illinois Emergency
			 Management Agency Act [20 ILCS 3305] that is predicated on an epidemic or
			 public health emergency, and only if, pursuant to that proclamation, the
			 Governor has generally ordered individuals to stay at their home or place of
			 residence or has generally ordered the cessation of non-essential business and
			 operations in this State. However, any provision of this Part that requires an
			 action or period to last for a specific length of time shall apply as written
			 even if that time goes beyond the disaster proclamation period, provided that
			 the trigger for that requirement occurred while the disaster proclamation was
			 in effect. Continuous renewals or extensions of a disaster proclamation shall
			 be treated as creating a single disaster proclamation period.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2040 - TEMPORARY HEALTH COVERAGE REQUIREMENTS DURING AN EPIDEMIC OR PUBLIC HEALTH EMERGENCY › Section 2040.40 - Grace Periods and Terminations for Nonpayment of Premium

Current through Register Vol. 48, No. 28, July 12, 2024
Except as otherwise provided in this Section, an issuer shall
				allow an insured, upon request, to defer premium payments without interest for
				health insurance coverage, including limited-scope dental benefits, for at
				least 60 calendar days from each original premium due date.
a) For an insured who, as of April 20, 2020,
			 has already failed to make a sufficient premium payment by the due date but
			 whose effective date of coverage termination has not yet occurred, an issuer
			 shall, to the extent permitted by CMMS' enforcement discretion under federal
			 law, refrain from cancelling or nonrenewing the insured's health insurance
			 coverage or enrollment under that coverage based on nonpayment of premium until
			 after June 18, 2020.
b) For an
			 insured who receives advance payments of premium tax credits for a qualified
			 health plan or stand-alone dental plan under
			 42
			 USC 18082, an issuer shall delay the
			 initiation of the federally mandated 3-month grace period in
			 45
			 CFR 156.270, without pending any claims or
			 imposing interest, for at least 30 calendar days after the missed payment
			 date.
c) Binder Payments
1) An issuer of any qualified health plan or
			 stand-alone dental plan in the individual market shall, to the extent permitted
			 by CMMS' enforcement discretion under federal law, extend all existing
			 deadlines to make a binder payment, interest free, until at least 30 calendar
			 days after the latest permissible deadline applicable to the circumstances
			 under
			 45 CFR
			 155.400(e).
2) An issuer shall extend its existing
			 deadlines to make a binder payment for all other health insurance coverage in
			 the individual market, including limited-scope dental benefits, by 30 calendar
			 days without interest.
Illinois Administrative Code › Title 50 - INSURANCE › Part 2040 - TEMPORARY HEALTH COVERAGE REQUIREMENTS DURING AN EPIDEMIC OR PUBLIC HEALTH EMERGENCY › Section 2040.50 - Employee Eligibility for Existing Group Coverage

Current through Register Vol. 48, No. 28, July 12, 2024
a) An issuer of group health insurance
			 coverage under the HMO Act shall allow an employer to continue covering an
			 employee even if the employee would otherwise become ineligible under the terms
			 of the coverage or the group health plan due to a reduction in hours worked or
			 temporary lay-off. This requirement to allow an employer to continue coverage
			 does not mean coverage under a COBRA continuation provision or Section 4-9.2 of
			 the HMO Act. An issuer may not prevent an employer from continuing to cover an
			 employee at the employer's discretion as provided in this Section regardless of
			 any "actively at work" or similar eligibility requirements in any group health
			 insurance coverage or group health plan.
b) An issuer may not discriminate among
			 similarly situated individuals as provided in 50 Ill. Adm. Code
			 2001.9
			 when making the allowances required by this Section.