Illinois Administrative Code

Section 4520.110 Emergency Services a) For purposes of determining compliance with Section 65 of the Act, timely determination shall mean a determination is made within 30 days after the health care plan receives a claim for emergency services if no additional information is need…

Section 4520.120 Post Stabilization Services For purposes of determining compliance with Section 70 of the Act, timely determination shall mean a determination is made within 30 days after the health care plan receives a claim for post stabilization services if no additional info…

Section 4520.130 Registration of Utilization Review Organizations a) Registration: On or after July 1, 2000, a URO may not conduct utilization review for persons subject to Section 85 of the Act unless the URO has registered with the Director. An application for registration shal…

Section 4520.140 Operational Requirements A URO shall comply with all URAC standards except when specifically addressed by Sections 45 and 50 of the Act for health care plans. The terms in Sections 45 and 50 of the Act shall have the meaning assigned by the Act. Utilization revie…

Section 4520.20 Applicability and Scope The requirements of this Part are applicable to: a) Policies and contracts amended, delivered, issued, or renewed by health care plans pursuant to the Act; and b) The program of health benefits under the State Employees Group Insurance Act,…

Section 4520.30 Definitions "Act" means the Managed Care Reform and Patient Rights Act [215 ILCS 134]. "Code" means the Illinois Insurance Code [215 ILCS 5]. "Department" means the Illinois Department of Insurance. "Director" means the Director of the Illinois Department of Insur…

Section 4520.40 Provision of Information Description of Coverage A written summary of benefits and coverage (SBC) in accordance with 50 Ill. Adm. Code 2001.10, must be provided to the enrollee by the health care plan. (Source: Amended at 38 Ill. Reg. 2253, effective January 2, 20…

Section 4520.50 Notice of Nonrenewal or Termination a) All provider agreements shall provide for at least 60 days notice by the provider for termination with cause, as defined in the provider agreement, and at least 90 days notice by the provider for termination without cause. Up…

Section 4520.60 Transition of Services a) Health care plans shall notify new enrollees and current enrollees of the availability of transitional services for conditions that require ongoing course of treatment. b) New enrollees must request the option of transitional services in …

Section 4520.70 Health Care Services, Appeals, Complaints and External Independent Reviews a) A plan shall implement an effective appeals process for appeals of coverage determinations and claims, under which the health care plan shall, at a minimum: 1) have in effect an internal…

Section 4520.80 Joint Resolution of Complaints – Department of Insurance and Department of Public Health − Notification and Resolution Process a) Complaints against health care plans participating in programs administered by the Department of Healthcare and Family Services (HFS) …

Section 4520.90 Record of Complaints a) Complaint, as used in this Section, means any communication primarily expressing a grievance to the health care plan by, or on behalf of, the enrollee, or by the health care provider. For purposes of this definition, "communication" shall i…

Section 4520.EXHIBIT A Complaint Record and Column Descriptions 1. Column A. Health Care Plan Identification Number – This is the identification number used by the health care plan to identify the complaint internally. The identification number must be unique for each complaint. …

Section 4521.10 Scope This Part shall apply to any Health Maintenance Organization (HMO) as defined in Section 1-2(9) of the Act. (Source: Amended at 30 Ill. Reg. 4732, effective March 2, 2006)

Section 4521.100 Solicitation a) No HMO, or representative of the HMO, may cause or knowingly permit the use of advertising, solicitation, or any form of evidence of coverage that is untrue, misleading or deceptive. 1) All information required to be disclosed pursuant to this Par…

Section 4521.110 Requirements for Group Contracts, Evidences of Coverage and Individual Contracts a) Any group contract, evidence of coverage, individual contract, enrollee handbook, enrollment application, identification card or other form that affects the terms and conditions a…

Section 4521.111 Cancellation a) No HMO shall cancel a group or individual contract or evidence of coverage except for one or more of the following reasons: 1) Failure of the enrollee to pay the amount due under the contract or evidence of coverage, for which the enrollee is lega…

Section 4521.112 Form Filing Requirements Group contracts, evidences of coverage, individual contracts, enrollment applications or other forms that affect the terms and conditions applicable to the enrollee in the provision of health care services must be filed with the Departmen…

Section 4521.113 Point of Service Plan Requirements a) The filing as described in this subsection shall be comprised of an HMO filing and an indemnity filing. The filing shall be coordinated by the HMO. The filing must contain reasonable financial incentives for point of service …

Section 4521.120 Internal Security Standards and Fidelity Bonds The standards and provisions set forth in 50 Ill. Adm. Code 904 (Internal Security Standard and Fidelity Bonds) shall apply to HMOs. (Source: Amended at 30 Ill. Reg. 4732, effective March 2, 2006)

Section 4521.130 Basic Health Care Services The provision of Basic Health Care Services must not discriminate against any class of physician. The following minimum standards describe the requirements for Basic Health Care Services, provided that services are medically necessary a…

Section 4521.131 Basic Outpatient Preventive and Primary Health Care Services for Children a) Eligibility. 1) A health maintenance organization may undertake to provide or arrange for and to pay for or reimburse the cost of basic outpatient preventive and primary health care serv…

Section 4521.132 Required Coverage for Reconstructive Surgery Following Mastectomies a) As required by the Federal Women's Health and Cancer Rights Act of 1998 (WHCRA) (42 USC 300gg-6, 300gg-52, incorporating 29 USC 1185(b)), every individual and group contract or evidence of cov…

Section 4521.140 General Provisions Every HMO, having been declared to be an entity to be regulated for the public good, shall take care to conduct all of its affairs within the declared Public Policy on Fair Employment. The Congress of the United States and the General Assembly …

Section 4521.141 HMO Producer Licensing Requirements a) HMO producer means an individual who solicits, negotiates, effects, procures, renews or continues enrollment in an HMO. The term HMO "producer" shall not include: 1) any regular salaried officer or employee of an HMO or of a…

Section 4521.142 Limited Insurance Representative Requirements − Public Aid and Medicare Enrollers a) No person may enroll recipients of Public Aid or Medicare in an HMO, either personally or by mail, unless the person is duly licensed by the Director pursuant to this Part. b) Th…

Section 4521.150 Severability If any Section, term or provision of this Part is adjudged invalid for any reason, that judgment shall not affect, impair or invalidate any other Section, term or provision of this Part and the remaining Sections, terms and provisions shall be and re…

Section 4521.20 Definitions "ACA" means the Patient Protection and Affordable Care Act (42 U.S.C. 18001 et seq.). "Act" means the Health Maintenance Organization Act [215 ILCS 125]. "Advertisement" has the meaning ascribed in Section 1-21(1) of the Act. "Base Rates" means the rat…

Section 4521.30 Valuation of Investments a) The "Purposes and Procedures Manual of the NAIC Investment Analysis Office", as of December 31, 2022 (National Association of Insurance Commissioners, One New York Plaza, Ste. 4210, New York NY 10004) (no later editions or amendments), …

Section 4521.40 Grievance Procedure a) Every HMO shall submit for the Director's approval, and maintain, a system for the resolution of grievances concerning the provision of health care services or other matters concerning operation of the HMO as follows. Each HMO shall: 1) Subm…

Section 4521.50 Contracts, Administrative Arrangements and Material Modifications a) Agreements or Contracts 1) All sample agreements or contracts, with variable language bracketed, under which any person is delegated management duties or control of the HMO or that transfer a sub…

Section 4521.60 Rates (Repealed) (Source: Repealed at 49 Ill. Reg. 16042, effective December 4, 2025)

Section 4521.70 Subordinated Indebtedness Subordinated indebtedness agreements (debenture) shall be submitted for the approval of the Director as required by Section 2-9 of the Act. a) The agreement must state that: 1) All payments of principal and/or interest may be made only af…

Section 4521.80 Financial Reporting (Repealed) (Source: Repealed at 43 Ill. Reg. 9386, effective August 26, 2019)

Section 4521.90 Conflict of Interest and Required Disclosure Each applicant for a Certificate of Authority shall file with the application, and shall immediately file any changes thereafter, disclosure of the following: a) Any contractual or financial arrangements between members…

Section 4525.10 Purpose The purpose of this Part is to implement the Dental Care Patient Protection Act. This Part will set forth guidelines for the formation of an advisory committee; require the filing and approval of a summary description and grievance procedure for managed ca…

Section 4525.20 Applicability This Part applies to all managed care dental plans as defined in Section 4525.30 of this Part.

Section 4525.30 Definitions Act means the Dental Care Patient Protection Act [215 ILCS 109]. Code means the Illinois Insurance Code [215 ILCS 5]. Dental Director means the dental director of the Illinois Department of Public Health. Dentist means a person licensed to practice den…

Section 4525.40 Dental Managed Care Advisory Committee Pursuant to Section 15 of the Act [215 ILCS 109/15] the Director is authorized to convene an advisory committee for the purpose of providing counsel and gathering clinical advice concerning dental managed care issues. a) Such…

Section 4525.50 Filing and Approval of Summary Description Pursuant to Section 143 of the Code a managed care dental plan shall file a summary description of coverage for approval by the Department, prior to its use, for each plan it establishes, operates, or maintains. The summa…

Section 4525.60 Filing and Approval of Grievance Procedure Every managed care dental plan shall submit for the Director's approval, and thereafter maintain, a system for the resolution of grievances pursuant to Section 35(n) of the Act [215 ILCS 109/35(n)]. The initial grievance …

Section 4525.70 Filing and Approval of Point of Service Plan Requirements Every managed care dental plan that is required to offer a point of service plan pursuant to the Act, except those plans that are licensed pursuant to Section 1001 of the Limited Health Service Organization…

Section 4525.80 Material Modifications to Summary Description, Grievance Procedure or Point of Service Plan A managed care dental plan shall file for approval with the Director, prior to use, any change in the summary description, grievance procedure, or point of service plan. In…

Section 4525.90 Enforcement and Penalties a) To enforce the provisions of this Part, the Director may issue a Cease and Desist Order and/or require a managed care dental plan to submit a plan of correction for violations of this Part or the Act. b) The Director may also impose an…

Section 4530.10 Purpose This Part will implement the Health Carrier External Review Act [215 ILCS 180] in order to assure uniform standards for the establishment and maintenance of external review procedures, to assure that covered persons have the opportunity for an independent …

Section 4530.20 Applicability and Scope a) Except as provided in subsection (b), the requirements of this Part are applicable to all health carriers. b) The provisions of this Part shall not apply to: 1) A policy or certificate that provides coverage only for a specified disease,…

Section 4530.30 Definitions "Act" means the Health Carrier External Review Act [215 ILCS 180]. "Adverse Determination" means: A determination by a health carrier or its designee utilization review organization that, based upon the information provided, a request for a benefit und…

Section 4530.40 Health Carrier Obligations a) Each health carrier shall maintain written records in the aggregate, by state, and for each type of health benefit plan offered by the health carrier on all requests for external review for which the health carrier received notice fro…

Section 4530.50 Independent Review Organization Obligations a) An independent review organization may not conduct external independent reviews of adverse determinations for persons subject to Section 15 of the Act unless the independent review organization has first registered wi…

Section 4530.60 Registration of Independent Review Organizations a) On or after July 1, 2010, an independent review organization may not conduct external reviews for persons subject to Section 15 of the Act unless the independent review organization has registered with the Direct…