Illinois Administrative Code

Section 2020.50 Subrogation Provision In addition to any other requirements set forth in the Code or Department'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 …

Section 2021.10 Purpose The purpose of this Part is to establish requirements for filing group policy forms with the Illinois Department 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 h…

Section 2021.20 Applicability and Scope 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.

Section 2021.30 Definitions Code means the Illinois Insurance Code [215 ILCS 5]. Department means the Illinois Department of Insurance. Director means the Director of the Department of Insurance of the State of Illinois or anyone to whom the Director's responsibilities and author…

Section 2021.40 Filing and Disclosure Requirements 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…

Section 2021.50 Out-of-State Certificate Policy Forms That Require Illinois Approval 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 …

Section 2025.10 Purpose 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 w…

Section 2025.100 Penalty Provisions 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 credita…

Section 2025.20 Applicability and Scope 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 2025.30 Definitions "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…

Section 2025.40 Notice Requirement to the Department 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 Department prior t…

Section 2025.50 Uniform Modification of Coverage 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, inclu…

Section 2025.60 Uniform Termination of Coverage 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 discontinu…

Section 2025.70 Discontinuance of a Market 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 fo…

Section 2025.80 Rescission in the Small Group Market 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…

Section 2025.90 Certificates of Creditable Coverage 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 cont…

Section 2026.10 Definitions "Administrator" has the meaning ascribed in 29 U.S.C. 1002(16). "Affordable Care Act" or "ACA" means the Patient Protection and Affordable Care Act (42 U.S.C. 18001 et seq.). "Code" means the Illinois Insurance Code [215 ILCS 5]. "Department" means the…

Section 2026.100 Review of Rates Not Subject to the Effective Rate Review Program a) The Director's review of any rate, classification of risks, or rate-setting methodology described in Section 2026.30(d) is subject to Section 355(i) of the Code in addition to any other law or ru…

Section 2026.20 Applicability The requirements of this Part apply to health insurance issuers offering health insurance coverage that is subject to Section 355 of the Code. (Source: Amended at 48 Ill. Reg. 7239, effective April 30, 2024)

Section 2026.30 Rates Subject to Review or Prior Approval a) All rates and classifications of risks in the individual or small group market, other than for grandfathered health plans, excepted benefits, or student health insurance coverage, on or after January 1, 2014, or effecti…

Section 2026.40 Unreasonable Rate Increases a) When the Director reviews a rate increase for any individual or small group market 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…

Section 2026.5 Purpose This Part describes the Director's authority and timelines to review, approve, modify, or disapprove rate filings pursuant to Section 355 of the Code. (Source: Amended at 48 Ill. Reg. 7239, effective April 30, 2024)

Section 2026.50 Submission of Rate Filing Justification a) For all individual and small group market 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 discont…

Section 2026.60 Determination of an Unreasonable Rate Increase or Inadequate Rate a) When the Director receives a Rate Filing Justification for an individual or small group market rate subject to review under Section 2026.30(a)(2) or (b) and the Director reviews the rate, the Dir…

Section 2026.70 Public Comment 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, or student health insurance coverage, will be posted to the Departm…

Section 2026.80 Prior Approval, Disapproval, or Modification of Rates a) When the Director approves, disapproves, or modifies an individual or small group market rate described in Section 2026.30(b), the Director, within 60 days after the close of the public comment period, will …

Section 2026.90 Material Changes to the Director's Decision After Approving Rates 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…

Section 2028.10 Applicability 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 in…

Section 2028.20 Definitions 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 Hea…

Section 2028.30 Confidentiality Protocol 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…

Section 2028.40 Notice 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 …

Section 2028.5 Purpose 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…

Section 2030.10 Purpose The purpose of this Part is to prescribe the standard template for drug formularies, which health insurance issuers must post on their public websites for health products that they offer in this State. Nothing in this Part requires a health product to use …

Section 2030.20 Applicability a) This Part applies to health products that both: 1) use a formulary; and 2) are in force, issued, delivered, amended, or renewed in this State on or after October 1, 2025. b) This Part does not apply to Medicare supplement insurance, fraternal bene…

Section 2030.30 Definitions "Accident and health insurance" has the meaning ascribed in Section 4, Class 1(b) and 2(a) of the Code. "Biological product" has the meaning ascribed in Section 19.5 of the Pharmacy Practice Act [225 ILCS 85]. "Brand name drug" means a drug that has be…

Section 2030.40 Standard Drug Formulary Template The following standards are minimum standards, and unless otherwise noted, apply to all health product formularies subject to Section 155.37 of the Code. A health insurance issuer or its designee may implement additional provisions…

Section 2030.50 Filing Requirement a) By October 1, 2025, a health insurance issuer that maintains drug formularies must submit all drug formularies for health products in which it has enrolled a covered individual for review for compliance with this Part. The filing must be subm…

Section 2035.10 Applicability and Scope 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) …

Section 2035.20 Definitions "Assertive Community Treatment" or "ACT" means a bundle of health care services delivered through a multidisciplinary team of mental health professionals to individuals who are experiencing severe and persistent symptoms from a serious mental illness. …

Section 2035.30 Medical Necessity Criteria for Utilization Review of Treatment Models for Serious Mental Illnesses for Individuals Under Age 26 Any medical necessity criteria that an issuer, nonfederal governmental payor, or utilization review organization prescribes or uses for …

Section 2040.10 Purpose 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. …

Section 2040.20 Applicability 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…

Section 2040.30 Definitions Except as provided in this Section, terms used in this Part have the meanings given in Section 5 of the Illinois Health Insurance Portability and Accountability Act [215 ILCS 97]. The following definitions also apply to this Part: "CMMS' enforcement di…

Section 2040.40 Grace Periods and Terminations for Nonpayment of Premium 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…

Section 2040.50 Employee Eligibility for Existing Group Coverage 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 th…

Section 2040.60 Minimum Employment Required for Statutory Continuation Coverages a) For an employer that employs 20 or more employees, as long as one person remains actively employed, an issuer shall not directly or indirectly prohibit an eligible employee from electing to contin…

Section 2040.70 Special Enrollment Effective Date for Off-Exchange Coverage a) For health insurance coverage that is not issued through the Exchange, an issuer shall waive the normal special enrollment procedures for an employee or former employee who has lost coverage under thei…

Section 2040.80 Access to Covered Prescription Drugs This Section applies to health insurance coverage that covers prescription drugs. a) An issuer shall cover off-formulary prescription drugs if there is not a formulary drug available to treat the insured. The issuer shall do so…

Section 2051.210 Purpose a) The purpose of this Part is to implement Article XX½ of the Illinois Insurance Code, which, in part, provides for the regulation of preferred provider programs for health care benefit plans and for the provision of workers' compensation medical benefit…

Section 2051.220 Definitions "Act" means the Health Care Reimbursement Reform Act of 1985 [215 ILCS 5/Art. XX½]. "Administrator", "Preferred Provider Program Administrator" or "PPP Administrator" means any person, partnership or corporation, other than a risk-bearing entity that …