Illinois Administrative Code

Section 4450.30 Definitions "Illinois Pension Code" or "Code" means 45 ILCS 5. "Department" means the Illinois Department of Insurance. "Lump Sum" means the one payment to the recipient by a pension fund when a benefit was mistakenly set too low. A lump sum payment shall consist …

Section 4450.40 Policy and Notification All Article 3 and Article 4 pension funds shall institute and maintain policies and procedures to discover and adjust any benefit that is set at an incorrect amount. Any pension fund that discovers and adjusts, if otherwise allowable by law…

Section 4451.10 Purpose This Part prescribes the procedure for breaking a tie vote in the ballot selection of a Board of Trustee for the Police Officers' Pension Investment Fund (Article 22B of the Code) or the Firefighters' Pension Investment Fund (Article 22C of the Code).

Section 4451.20 Definitions "Box" means a standard sized container in which confidential sealed envelopes are maintained. "Candidate" means a person nominated for election. "Code" means the Illinois Pension Code [40 ILCS 5]. "Department" means the Illinois Department of Insurance…

Section 4451.30 Prescribed Tie Breaker Procedure a) The prescribed procedure shall only apply when a tie vote occurs in a fund's Board of Trustee election process. After a review of the election count provided by the fund, the Department will, within 3 business days, set a date, …

Section 4451.40 Policy and Notification The fund shall submit a copy of the official election ballots to the Department prior to the election. At the completion of the election count, the fund shall notify the Department in writing of the results within 2 business days. The fund …

Section 4500.10 Purpose a) This Part implements State and federal requirements for the operation of the Illinois Health Benefits Exchange as a State-based Exchange on the Federal Platform, intended for plan year 2025, and as a State-based Exchange, intended for plan year 2026 onw…

Section 4500.100 Illinois SHOP a) This Section applies at any time the Exchange operates a SHOP for the small group market. The Exchange may delegate or defer functions of the Illinois SHOP to HHS through a federal platform agreement. b) The Exchange adopts the following provisio…

Section 4500.110 Compliance Reviews of QHP Issuers The Exchange adopts the requirements for compliance reviews of QHP issuers provided in 45 CFR 156.715 (Dec. 22, 2016) (no later editions or amendments), except that: a) references to "a Federally-facilitated Exchange" are substit…

Section 4500.120 Standards for QHP Issuers in Specific Types of Exchanges a) Until the Exchange operates as a State-based Exchange, a QHP issuer must comply with the requirements related to changes in ownership provided in 45 CFR 156.330 (Oct. 30, 2013) (no later editions or amen…

Section 4500.130 Casework Standards Until the Exchange operates as a State-based Exchange, a QHP issuer must comply with the casework standards provided in 45 CFR 156.1010 (Aug. 30, 2013) (no later editions or amendments). Nothing in this Section affects complaints subject to 50 …

Section 4500.140 State Awards for Navigators and In-Person Counselor Organizations, and Certifications for Certified Application Counselor Organizations and Certified Application Counselors a) The Exchange will offer State awards for Navigators and certifications to Certified App…

Section 4500.150 Agent and Broker Standards for Assisting with Enrollment in QHPs To enroll qualified individuals, qualified employers, or qualified employees in a manner that constitutes enrollment through the Illinois Exchange, or assists individual market consumers with submis…

Section 4500.160 Cultural, Linguistic, and Accessibility Standards a) A QHP issuer must comply with the accessibility standards provided in 45 CFR 155.205(c)(1), (c)(2)(i)(A), (c)(2)(ii), (c)(2)(iii)(A), (c)(2)(iv)(B), and (c)(3) (Apr. 15, 2024) (no later editions or amendments).…

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 f…

Section 4500.180 Annual Open Enrollment and Special Enrollment Periods a) During the annual open enrollment period, any qualified individual may enroll in a QHP, including an SADP, and any enrollee may change QHPs. 1) Unless provided otherwise under subsection (a)(2), the annual …

Section 4500.190 Eligibility and Special Rules on Advanced Payments of the Premium Tax Credit and Cost-Sharing Reductions a) A tax filer is eligible for APTCs if the tax filer meets the criteria in 45 CFR 155.305(f). b) A tax filer is eligible for CSRs if the tax filer meets the …

Section 4500.20 Applicability This Part applies to: a) health insurance issuers, including companies, health maintenance organizations, limited health service organizations, and dental service plan corporations; b) insurance producers; c) Navigators, Certified Application Counsel…

Section 4500.200 Termination of Coverage and Grace Periods a) At any time upon request, an enrollee may voluntarily terminate coverage or enrollment in a QHP through the Exchange, including an SADP, including as a result of the enrollee obtaining other minimum essential coverage.…

Section 4500.210 Plan Formulary Information A health insurance issuer must publish an up-to-date, accurate, and complete list of all covered drugs on its QHP's formulary drug list in compliance with 45 CFR 156.122(d)(1) (April 15, 2024) (no later editions or amendments). Until Il…

Section 4500.220 Illinois Exchange User Fee a) Pursuant to Section 5-21 of the IHBE Law, a health insurance issuer offering a QHP, including an SADP, through the Illinois Exchange must remit a monthly user fee directly to the Department that equals the product of: 1) the total of…

Section 4500.230 Eligibility Appeals a) This Section provides the requirements for appeals of eligibility determinations issued by the Illinois Exchange. It incorporates all rights, requirements, and limitations applicable to the Exchange, an applicant, an authorized representati…

Section 4500.30 Definitions The following definitions apply to this Part: "2023 Letter" means the "2023 Final Letter to Issuers in the Federally-facilitated Exchanges" published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244 (A…

Section 4500.40 QHP Issuer Certification a) The Exchange will only offer health plans that have in effect a certification issued or that are recognized as plans deemed certified for participation in the Exchange as a QHP, unless specifically provided otherwise (see 45 CFR 155.100…

Section 4500.50 QHP Recertification The criteria for initial certification apply to recertification, except that the Exchange will account for changes in applicable State and federal laws and rules as of the time of recertification. The Exchange will notify the QHP issuer of the …

Section 4500.60 Non-certification of QHPs a) If a QHP issuer elects not to seek certification for a subsequent, consecutive certification cycle within the Exchange, the QHP issuer, at a minimum, must: 1) Notify the Exchange of its decision before the beginning of the recertificat…

Section 4500.70 QHP Decertification a) At any time, the Exchange may decertify a health plan if the Exchange determines that the QHP issuer no longer complies with the certification criteria in subsection (c) (see 45 CFR 155.1080(c) (May 29, 2012) (no later editions or amendments…

Section 4500.80 Plan Suppression The Exchange may temporarily make a QHP certified to be offered through the Exchange temporarily unavailable for enrollment through the Exchange on one or more of the following grounds (see 45 CFR 156.815(a) through (b) (Feb. 27, 2015) (no later e…

Section 4500.90 Minimum QHP Certification Standards To participate in the Exchange, a health insurance issuer must have in effect a certification issued or recognized by the Exchange to demonstrate that each health plan it offers in the Exchange is a QHP in accordance with 45 CFR…

Section 4510.10 Scope and Purpose The purpose of this Part is to facilitate the implementation of certain provisions of the Patient Protection and Affordable Care Act of 2010, PL 111-148, 124 Stat. 119 (2010), and the Health Care and Education Reconciliation Act of 2010, PL 111-1…

Section 4510.20 Applicability This Part applies to all carriers that issue Child Only coverage in the individual health insurance market with an effective date on or after September 23, 2010.

Section 4510.30 Definitions "Carrier" means an insurer or health maintenance organization issuing Child Only Plans. "Child Only Plan" means renewable individual health insurance coverage (as defined in 42 USC 300gg-91) issued with an effective date on or after September 23, 2010 …

Section 4510.40 Rules a) Enrollment Required During Certain Periods 1) Carriers shall accept applications from eligible persons for Child Only Plan coverage during the open enrollment periods outlined in subsections (b), (c) and (d). 2) Carriers shall also accept applications fro…

Section 4510.50 Enforcement Pursuant to Article XXIV of the Illinois Insurance Code [215 ILCS 5/Art. XXIV], noncompliance with this Part may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Illinois statutes pertaining to th…

Section 4515.10 Purpose The purpose of this Part is to establish certification criteria for Navigator, In-Person Counselor or Certified Application Counselor certification; establish pre-certification education requirements for applicants for Navigators, In-Person Counselors or C…

Section 4515.100 Education Responsibilities of the Applicant for the Navigator, In-Person Counselor or Certified Application Counselor Certification or Renewal a) Before receiving approval for a Navigator, In-Person Counselor or Certified Application Counselor certification, the …

Section 4515.110 State-Provided Education Course Curriculum a) Applicants and certificate holders seeking to satisfy initial or continuing education requirements for the applicable certification through GCILMS must demonstrate successful completion of Director-prescribed courses …

Section 4515.120 Certification Denial, Suspension, Nonrenewal, Probation, or Revocation a) The Director may place on probation, suspend, revoke, or refuse to issue or renew a Navigator, In-Person Counselor or Certified Application Counselor's certificate or may levy a civil penal…

Section 4515.130 Regulatory Examinations a) The Director may examine any applicant for or holder of a Navigator, In-person Counselor or Certified Application Counselor certificate or Navigator or In-Person Counselor entity certificate. b) All Navigators, In-Person Counselors or C…

Section 4515.140 Felony Offense Review a) The Director and the Department will not require applicants or certificate holders to report the following information and will not collect and consider the following criminal history records in connection with a certificate under this Pa…

Section 4515.20 Definitions "Act" means the Navigator Certification Act [215 ILCS 121]. "Certification" means the issuance by the Director of an authorization pursuant to this Part. "Certified Application Counselor" means any employee or volunteer of a Certified Application Couns…

Section 4515.30 Certification Required a) No individual or entity may act as, offer to act as, or advertise any service as a Navigator, In-Person Counselor, Certified Application Counselor or Certified Application Counselor Organization in this State unless the individual or enti…

Section 4515.40 Exemption from Certification a) Government employees and their agents performing activities related to the Marketplace are exempt from certification. Those individuals and entities may not engage in Navigator, In-Person Counselor and Certified Application Counselo…

Section 4515.50 Application for Certification a) An individual applying for a Navigator, In-Person Counselor or Certified Application Counselor certification must make an application to the Department on a form developed or accepted by the Director and declare under penalty of re…

Section 4515.60 Certification Renewal a) A Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization certification shall be valid through October 31 of the plan year for which the certificate holder successfully completed the…

Section 4515.70 Navigator, In-Person Counselor and Certified Application Counselor Prohibited Conduct a) A Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization may not: 1) sell, solicit, or negotiate, as these terms are …

Section 4515.80 Reporting to the Director a) Each certified Navigator, In-Person Counselor, Certified Application Counselor and Certified Application Counselor Organization shall report to the Director any administrative action taken by a governmental agency against that person i…

Section 4515.90 Training Provider Responsibilities (Repealed) (Source: Repealed at 43 Ill. Reg. 422, effective December 21, 2018)

Section 4520.10 Purpose This Part will implement the Managed Care Reform and Patient Rights Act [215 ILCS 134] in order to assure: the proper provision of information to enrollees by health care plans; the proper treatment of enrollees by health care plans; the proper treatment o…

Section 4520.100 Access and Quality of Care from Providers Without Primary Care Physician Referral or Authorization a) Health care plans that allow enrollees to access health care services from contractual providers without a referral or authorization from the primary care physic…