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 onward. Nothing in this Part incorporating a federal standard supersedes any more stringent or additional requirement provided under other State law or rule applicable to the same health plan, health insurance issuer, or person unless the federal standard requires the Exchange to enforce the federal standard without deviation.

 

b)         Except where this Part specifies otherwise, a date in an incorporation by reference of a section of the Code of Federal Regulations ("CFR") refers to a date when the Federal Register published the adoption of or an amendment to any provision of the CFR section.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 Counselors, Certified Application Counselor Organizations, and In-Person Counselors;

 

d)         employers;

 

e)         applicants, application filers, and enrollees;

 

f)         any other individual or entity seeking to participate in or facilitate enrollment through the Exchange; and

 

g)         where applicable, officers, directors, employees, authorized representatives, or others in an agency relationship with the persons listed in subsections (a) through (f).

 

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 (Apr. 28, 2022) (no later editions or amendments), available online at https://www.cms.gov/sites/default/files/2022-04/Final-2023-Letter-to-Issuers_0.pdf.

 

"Advance payments of the premium tax credit" or "APTCs" means payments of the tax credits specified in 26 U.S.C. 36B that are provided on an advance basis to an eligible individual enrolled in a QHP through the Exchange.

 

"Agent or broker" has the meaning ascribed in 45 CFR 155.20 (Jun. 25, 2025) (no later editions or amendments).

 

"Annual open enrollment period" means the period each year when a qualified individual may enroll or change coverage in a QHP through the Exchange for an upcoming benefit year (see 45 CFR 155.20).

 

"Applicant" has the meaning ascribed in 45 CFR 155.20.

 

"Application filer" has the meaning ascribed in 45 CFR 155.20.

 

"Authorized representative" means an individual or organization that acts on behalf of an applicant or enrollee in applications, proceedings, or communications with the Exchange pursuant to a designation meeting the requirements of 45 CFR 155.227 (Jul. 15, 2013) (no later editions or amendments).

 

"Award" has the meaning ascribed in Section 15 of GATA.

 

"Benefit month" means a calendar month within a benefit year.

 

"Benefit year" has the meaning ascribed in 45 CFR 155.20.

 

"Catalog of State Financial Assistance" has the meaning ascribed in Section 15 of GATA.

 

"Certified Application Counselor" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Certified Application Counselor Organization" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Company" has the meaning ascribed in Section 2(e) of the Code.

 

"Continuation coverage" has the meaning ascribed in 45 CFR 144.103 (Apr. 3, 2024) (no later editions or amendments).

 

"Cost sharing" has the meaning ascribed in 45 CFR 155.20.

 

"Cost-sharing reductions" or "CSRs" has the meaning ascribed in 45 CFR 155.20.

 

"DSP Act" means the Dental Service Plan Act [215 ILCS 110].

 

"Dental service plan corporation" has the meaning ascribed in Section 3 of the DSP Act.

 

"Department" means the Illinois Department of Insurance.

 

"Dependent" means any individual who is or who may become eligible for coverage under the terms of a QHP because of a relationship to a qualified individual or enrollee.  "Dependent" may include an individual who is not a tax dependent of the qualified individual or enrollee, including, but not limited to, the qualified individual or enrollee's spouse, civil union partner, or domestic partner.

 

"Director" means the Director of the Department.

 

"Easy Enrollment Program" means the program established by Section 513 of the Illinois Income Tax Act [35 ILCS 5] under which the Department, the Department of Healthcare and Family Services, and the Department of Revenue to respond to requests from individual Illinois taxpayers to assess their potential eligibility for health insurance premium tax credits and Medicaid.

 

"Employee" has the meaning ascribed in 29 U.S.C. 1002(6).

 

"Enrollee" has the meaning ascribed in 45 CFR 155.20.

 

"Essential community provider" has the meaning ascribed in 45 CFR 156.235(c) (Apr. 27, 2023) (no later editions or amendments).

 

"Exchange" or "Illinois Exchange" means the Illinois Health Benefits Exchange established under Section 5-5 of the IHBE Law and 42 U.S.C. 18031.

 

"Federal platform agreement" means an agreement between the Illinois Exchange, including the SHOP, and HHS under which the Illinois Exchange agrees to rely on the federal platform to carry out select Exchange functions (see 45 CFR 155.20).

 

"Full-time employee" has the meaning ascribed in 26 U.S.C. 4980H(c)(4) as implemented under 26 CFR 54.4980H-3 (Feb. 12, 2014) (no later editions or amendments). This definition applies in all instances where the term "full-time employee" appears in any provision incorporated by reference under this Part.

 

"GATA" means the Grant Accountability and Transparency Act [30 ILCS 708].

 

"Health insurance coverage" has the meaning ascribed in 42 U.S.C. 300gg-91(b)(1).

 

"Health insurance issuer" has the meaning ascribed in 42 U.S.C. 300gg-91(b)(2).

 

"Health maintenance organization" has the meaning ascribed in Section 1-2(9) of the HMO Act.

 

"Health professional shortage area" has the meaning ascribed in 42 U.S.C. 254e.

 

"HHS" means the United States Department of Health and Human Services.

 

"Health plan" has the meaning ascribed in 42 U.S.C. 18021(b)(1).

 

"HMO Act" means the Health Maintenance Organization Act [215 ILCS 125].

 

"IHBE Law" means the Illinois Health Benefits Exchange Law [215 ILCS 122].

 

"In-Person Counselor" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Insurance producer" has the meaning ascribed in Section 500-10 of the Code.

 

"Lawfully present" has the meaning ascribed in 45 CFR 155.20.

 

"Limited health service organization" has the meaning ascribed in Section 1002 of the Limited Health Service Organization Act [215 ILCS 130].

 

"Medical QHP" means a QHP that is not an SADP. For purposes of this Part, a QHP that provides medical benefits is a "medical QHP" even if the plan also provides other types of benefits, including, but not limited to, dental or vision benefits.

 

"Metal level" means the level of coverage described in 42 U.S.C. 18022(d).

 

"Minimum essential coverage" has the meaning ascribed in 26 U.S.C. 5000A(f).

 

"NATA" means the Network Adequacy and Transparency Act [215 ILCS 124].

 

"Navigator" has the meaning ascribed in 50 Ill. Adm. Code 4515.20.

 

"Notice of Funding Opportunity" or "NOFO" has the meaning ascribed in 44 Ill. Adm. Code 7000.30.

 

"Person" has the meaning ascribed in Section 2(l) of the Code.

 

"Plain language" has the meaning ascribed in 42 U.S.C. 18031(e)(3)(B).

 

"Plan year" has the meaning ascribed in 45 CFR 155.20.

 

"Product" has the meaning ascribed in 45 CFR 144.103.

 

"Qualified employee" has the meaning ascribed in 45 CFR 155.20.

 

"Qualified employer" has the meaning ascribed in 45 CFR 155.20.

 

"Qualified health plan" or "QHP" has the meaning ascribed in 42 U.S.C. 18021(a).

 

"Qualified health plan issuer" or "QHP issuer" means a health insurance issuer that offers a QHP in accordance with a certification from the Exchange.

 

"Qualified health plan service area" or "QHP service area" means the entire geographic area of a county or group of counties where a QHP may be offered, unless the Exchange has approved a smaller geographic area for the QHP under the criteria provided in 45 CFR 155.1055 (Mar. 27, 2012) (no later editions or amendments).

 

"Qualified individual" means an individual who has been determined eligible to enroll through the Exchange in a QHP in the individual market.

 

"SHOP" or "Illinois SHOP" means the Small Business Health Options Program operated by the Exchange through which a qualified employer can provide its employees and their dependents with access to one or more QHPs.

 

"Small group market" has the meaning ascribed in 45 CFR 155.20.

 

"Special enrollment period" means a period during which a qualified individual or enrollee who experiences certain qualifying events may enroll in, or change enrollment in, a QHP through the Exchange outside of the annual open enrollment period (see 45 CFR 155.20).

 

"Stand-alone dental plan" or "SADP" has the meaning ascribed in 45 CFR 156.400 (Jun. 25, 2025) (no later editions or amendments) and is a type of "limited scope dental benefits" under 42 U.S.C. 300gg-91(c)(2)(A). A QHP that contains both medical and dental benefits is not an SADP.

 

"Standardized option" means, pursuant to 45 CFR 155.20, a QHP offered for sale through the Exchange in the individual market that either:

 

has a standardized cost-sharing structure specified in Table 1 of "Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2026; and Basic Health Program", 90 Fed. Reg. 4424, 4494 (Jan. 15, 2025) (no later editions or amendments), available online at https://www.govinfo.gov/content/pkg/FR-2025-01-15/pdf/2025-00640.pdf; or

 

has the standardized cost-sharing structure specified in Table 1 that is modified only to the extent necessary to align with high deductible health plan requirements under 26 U.S.C. 223 or the applicable annual limitation on cost-sharing and HHS actuarial value requirements.

 

"State award" has the meaning ascribed in Section 15 of GATA.

 

"Successful completion" means passing an examination with a score of 80% or above in no more than three attempts.

 

"Tax filer" has the meaning ascribed in 45 CFR 155.300 (Jul. 15, 2013) (no later editions or amendments).

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 155.1000(b) (Jan. 15, 2025) (no later editions or amendments)).

 

b)         For certification in any given year, a QHP issuer must be validly accredited in accordance with the timeline set at 45 CFR 155.1045(b) (Feb. 25, 2013) (no later editions or amendments). An accreditation is valid if it complies with the requirements of 45 CFR 156.275 (Feb. 25, 2013) (no later editions or amendments). A QHP issuer's certification submission to the Department must include evidence of compliance with accreditation standards for its place on the timeline.

 

c)         The Exchange will allow a limited scope dental benefits plan to be offered through the Exchange under the conditions specified in 45 CFR 155.1065 (Mar. 27, 2012) (no later editions or amendments).

 

d)         The Exchange will certify a health plan as a QHP in the Exchange if (see 45 CFR 155.1000(c)):

 

1)         the health insurance issuer provides evidence during the certification process that it complies with the minimum certification requirements outlined in Section 4500.90, as applicable; and

 

2)         the Exchange determines that making the health plan available is in the interest of the qualified individuals and qualified employers, except that the Exchange will not exclude a health plan:

 

A)        on the basis that the plan is a fee-for-service plan;

 

B)        through the imposition of premium price controls; or

 

C)        on the basis that the health plan provides treatments necessary to prevent patients' deaths in circumstances the Exchange determines are inappropriate or too costly.

 

e)         QHP certifications will be issued on a calendar-year basis. However, for the SHOP, except when the Exchange has decertified the QHP pursuant to Section 4500.70, a certification will continue to remain in effect for the duration of any plan year beginning in the calendar year for which the QHP was certified, even if the plan year ends after the calendar year for which the QHP was certified (see 45 CFR 155.1000(d)).

 

f)         At least six months before the start of the annual open enrollment period, the Exchange will annually publish on its website a timeline of QHP certification deadlines and milestones, including, but not limited to, the date the application period will open, an initial application deadline, a final application deadline, a deadline for QHP issuers to sign QHP certification agreements, and the date the Exchange will release certification notices to issuers along with fully executed QHP certification agreements.  The certification notice and fully-executed QHP certification agreements will be released no later than 25 days before the start of the annual open enrollment period.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 recertification decision in the same manner as the initial certification no later than two weeks before the beginning of the annual open enrollment period.

 

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 recertification process, and no later than the deadline specified in 215 ILCS 97/60, and adhere to the procedures adopted by the Exchange under 45 CFR 155.1075 (Feb. 27, 2015) (no later editions or amendments);

 

2)         fulfill its obligation to cover benefits for each enrollee through the end of the plan or benefit year through the Exchange;

 

3)         fulfill data reporting obligations from the last plan or benefit year of the certification;

 

4)         provide notice to enrollees as described in subsection (b); and

 

5)         terminate the coverage or enrollment through the Exchange of enrollees in the QHP in accordance with 45 CFR 156.270 (Apr. 27, 2023) (no later editions or amendments), as applicable (see 45 CFR 156.290(a) (Dec. 22, 2016) (no later editions or amendments)).

 

b)         When, for a subsequent, consecutive certification cycle, a QHP issuer elects not to seek certification with the Exchange, or the Exchange denies certification of a QHP, the QHP issuer must provide written notice to each enrollee in the form and manner specified in 50 Ill. Adm. Code 2025 (see 45 CFR 156.290(b)).

 

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)). In particular, the Exchange may decertify a QHP on one or more of the following grounds (see 45 CFR 156.810(a) (Mar. 8, 2016) (no later editions or amendments)):

 

1)         the QHP issuer substantially fails to comply with federal or State laws and regulations applicable to QHP issuers participating in the Exchange;

 

2)         the QHP issuer substantially fails to comply with the standards related to the risk adjustment, reinsurance, or risk corridors programs as described in 45 CFR 156.810(a)(2);

 

3)         the QHP issuer substantially fails to comply with the transparency and marketing standards of 45 CFR 156.220 (Mar. 27, 2012) (no later editions or amendments) and 45 CFR 156.225 (Apr. 27, 2023) (no later editions or amendments);

 

4)         the QHP issuer substantially fails to comply with the health insurance issuer responsibilities for advance payments of the premium tax credit and cost-sharing in 45 CFR 156, Subpart E, as those provisions of the Code of Federal Regulations were in effect on July 1, 2025 (no later editions or amendments);

 

5)         the QHP issuer is operating in the Exchange in a manner that hinders the efficient and effective administration of the Exchange;

 

6)         the QHP no longer meets the applicable standards set forth under Section 4500.90;

 

7)         based on credible evidence, the QHP issuer has committed or participated in fraudulent or abusive activities, including submission of false or fraudulent data;

 

8)         the QHP issuer substantially fails to meet the requirements under Section 4500.90(k) related to network adequacy standards or Section 4500.90(l) related to inclusion of essential community providers;

 

9)         the QHP issuer substantially fails to comply with State or federal laws and regulations related to internal claims and appeals and external review processes, including, but not limited to, the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act;

 

10)       the Department's policy form compliance or premium rate review divisions recommend to the Exchange that the QHP should no longer be available in the Exchange;

 

11)       the QHP issuer substantially fails to comply with the privacy or security standards in 45 CFR 155.260 (Nov. 15, 2021) (no later editions or amendments);

 

12)       the QHP issuer substantially fails to meet the requirements related to the cases forwarded to QHP issuers under Section 4500.130;

 

13)       the QHP issuer substantially fails to meet the requirements related to the offering of a QHP under 45 CFR 156, Subpart M, as those provisions of the Code of Federal Regulations were in effect on July 1, 2025 (no later editions or amendments);

 

14)       the QHP issuer offering the QHP is the subject of a pending, ongoing, or final State regulatory or enforcement action or determination that relates to the issuer offering QHPs in the Exchange; or

 

15)       the Department or HHS reasonably believes that the QHP issuer lacks the financial viability to provide coverage under its QHPs until the end of the plan year.

 

b)         Sanctions and Determinations

 

1)         The Exchange may consider regulatory or enforcement actions taken by the Department or HHS against a QHP issuer as a factor in determining whether to decertify a QHP offered by that issuer.

 

2)         The Exchange may decertify a QHP offered by an issuer based on a determination or action by the Department as it relates to the issuer offering QHPs in the Exchange, including when the State places an issuer or its parent organization into receivership or when the Department's policy form compliance or rate review division recommends to the Exchange that the QHP no longer be available in the Exchange (see 45 CFR 156.810(b)).

 

c)         For standard decertifications on grounds other than those described in subsection (a)(7) through (a)(9), the Exchange will provide written notice to the QHP issuer and enrollees in the QHP, which will include the following (see 45 CFR 156.810(c)):

 

1)         the effective date of the decertification, which will be no earlier than 30 days after the date of issuance of the notice;

 

2)         the reason or reasons for the decertification, including the statute, statutes, regulation, or regulations that are the basis for the decertification;

 

3)         for the written notice to the QHP issuer, information about the effect of the decertification on the issuer's ability to offer the QHP in the Exchange, which will include information about the procedure for appealing the decertification by making a hearing request within 10 days after the QHP issuer's receipt of the notice; and

 

4)         for the written notice to the QHP enrollees, information about the effect of the decertification on enrollment in the QHP and about the availability of a special enrollment period, as described in 45 CFR 155.420 (Jun. 25, 2025) (no later editions or amendments).

 

d)         For expedited decertifications on grounds described in subsections (a)(6) through (a)(9), the Exchange will provide written notice to the QHP issuer and enrollees in the QHP, which will include the following (see 45 CFR 156.810(d)):

 

1)         the effective date of the decertification as determined by the Exchange; and

 

2)         the information required by subsection (c)(2) through (c)(4).

 

e)         An issuer may appeal the decertification of a QHP offered by that issuer under subsection (c) or (d), or the denial of certification of a health plan as a QHP, by filing a request for hearing before the Department within 10 days after the QHP issuer's receipt of the issuance notice. The hearing will be conducted under 50 Ill. Adm. Code 2402. If an issuer files a request for hearing on a decertification (see 45 CFR 156.810(e)):

 

1)         If the decertification is under subsection (b)(1), the decertification will not take effect before the issuance of the final administrative decision in the appeal, notwithstanding the effective date specified in subsection (b)(1); and

 

2)         If the decertification is under subsection (b)(2), the decertification will take effect on the date specified in the notice of decertification, but the certification of the QHP may be reinstated immediately upon issuance of a final administrative decision that the QHP should not be decertified.

 

f)         If the Exchange decertifies a QHP, the QHP issuer must terminate the enrollment of enrollees through the Exchange only after (see 45 CFR 156.290(c) (Dec. 22, 2016) (no later editions or amendments)):

 

1)         the Exchange made notification as described in 45 CFR 155.1080; and

 

2)         enrollees have had an opportunity to enroll in other coverage, which means the earlier of:

 

A)        the effective date of the terminated enrollee's new minimum essential coverage; or

 

B)        the latest possible effective date of coverage under a terminated enrollee's special enrollment period triggered by a loss of minimum essential coverage under 45 CFR 155.420.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 editions or amendments)):

 

a)         The QHP issuer notifies the Exchange of its intent to withdraw the QHP from the Exchange when one of the exceptions to guaranteed renewability of coverage related to discontinuing a particular product or discontinuing all coverage applies under 45 CFR 147.106(c) or (d) (Apr. 25, 2019) (no later editions or amendments);

 

b)         Data submitted for the QHP is incomplete or inaccurate;

 

c)         The QHP is in the process of being decertified as described in Section 4500.70(c) or (d), or the QHP issuer is appealing a completed decertification through a hearing in accordance with 50 Ill. Adm. Code 2402;

 

d)         The QHP issuer offering the QHP is the subject of a pending, ongoing, or final State or HHS regulatory or enforcement action or determination that could affect the issuer's ability to enroll consumers or otherwise relates to the issuer offering QHPs in the Exchange; or

 

e)         One of the exceptions to guaranteed availability of coverage related to special rules for network plans or financial capacity limits under 45 CFR 147.104(c) or (d) (May 6, 2022) (no later editions or amendments) applies.

 

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 156.200(a) through (f) and (h) (Jun. 25, 2025) (no later editions or amendments).

 

a)         For the purpose of 45 CFR 156.200(b)(1), the Exchange establishes subsections (e) through (v) and Section 4500.80. The Exchange also adopts 45 CFR 156.200(b)(2) through (b)(7) and 156.200(c).  Beginning for Plan Year 2026, if an issuer offers a QHP, including an SADP, through the Exchange at the gold or silver metal level, the issuer must offer the same product at both the gold and silver metal levels.

 

b)         For the purpose of 45 CFR 156.200(d), the Department's approval pursuant to applicable State law of all policy forms and, beginning for Plan Year 2026, all rates to be used in connection with a QHP is among the conditions for participation in the Exchange.

 

c)         For the purpose of 45 CFR 156.200(e), in accordance with 50 Ill. Adm. Code 2603, a QHP issuer must not discriminate on the basis of gender identity or sexual orientation regardless of whether federal law continues to recognize them as discrimination on the basis of sex.

 

d)         For 45 CFR 156.200(f), the phrase "the Illinois Exchange" is substituted for "a Federally-facilitated Exchange".

 

e)         Except for plan years when the Exchange is a State-based Exchange, a QHP issuer must comply with the requirements related to standardized options and non-standardized options codified at 45 CFR 156.201(b) through (c) (Jan. 15, 2025) (no later editions or amendments) and 45 CFR 156.202(b) through (e) (Jan. 15, 2025) (no later editions or amendments).

 

f)         A QHP issuer must comply with the rate and benefit information requirements in 45 CFR 156.210 (Apr. 27, 2023) (no later editions or amendments). For purposes of 45 CFR 156.210(b) through (c), the rate submissions and justifications must comply with 50 Ill. Adm. Code 2026.

 

g)         In order for a health plan to be certified as a QHP initially and to maintain certification to be offered in the individual market in the Exchange, the issuer must meet the requirements related to the administration of cost-sharing reductions and advance payments of the premium tax credit set forth in 45 CFR 156, Subpart E (see 45 CFR 156.215 (Mar. 11, 2013) (no later editions or amendments).

 

h)         A QHP issuer must provide specified types of information to the Exchange, the Department, HHS, the public, and individuals in plain language as provided in 45 CFR 156.220 (Mar. 27, 2012) (no later editions or amendments).

 

i)          A QHP issuer must comply with the requirements for access to and exchange of health data and plan information provided in 45 CFR 156.221 (May 1, 2020) (no later editions or amendments), substituting "the Illinois Exchange" for "a Federally-facilitated Exchange."

 

j)          A QHP issuer and its officials, agents, employees, and representatives must comply with the marketing and benefit design requirements of 45 CFR 156.225 (Apr. 27, 2023) (no later editions or amendments).

 

k)         In addition to any other network adequacy and transparency requirements applicable under State law and administrative rule, for the purpose of implementing 45 CFR 156.230(a)(1)(ii), (a)(1)(iii), (a)(2)(i)(A), (a)(2)(ii), (a)(3), and (a)(4) (Apr. 27, 2023) (no later editions or amendments) for State-based Exchanges and State-based Exchanges on the Federal Platform, and subject to 42 U.S.C. 300gg-1(c):

 

1)         For a medical QHP, a QHP issuer must file with the Department a network adequacy and transparency description for each QHP in compliance with 50 Ill. Adm. Code 4540. However, pursuant to Section 10(d-5)(4) of the NATA for mental health and substance use disorder providers, the QHP issuer must demonstrate compliance with the time and distance standards in Tables 3.1 and 3.2 of the 2023 Letter in any county where those standards are more stringent than the standards in Section 10(d-5) (1) or (d-5)(2) of NATA. (see 45 CFR 156.230(a)(2)(i)(A)) Nothing in this subsection (k)(1) supersedes the requirement that, if the applicable time and distance standards under 215 ILCS 124/10(d-5) are not met within a county, the issuer shall provide the necessary exceptions to its network as described in 215 ILCS 124/10(d-5)(3).

 

2)         For an SADP, a QHP issuer must file with the Department a network adequacy and transparency description that satisfies the provisions of 50 Ill. Adm. Code 4540.30 and 50 Ill. Adm. Code 4540.40(a), (b)(3), (b)(4), (c), (d)(1), (g)(1), (g)(2), (h), (i), (j), (p), (q)(1), (q)(2), (q)(5), and (r). For 50 Ill. Adm. Code 4540.40(d)(1), Table 3.3 of the 2023 Letter applies instead of Tables 3.1 and Table 3.2 (see 45 CFR 156.230(a)(2)(i)(A)).

 

3)         Pursuant to Sections 10(d) and 10(d-5)(4) of NATA, notwithstanding 45 CFR 155.1050(a)(2) (Apr. 15, 2024) (no later editions or amendments), a QHP issuer of a medical QHP must demonstrate compliance with the appointment wait time standards in Table 3.4 of the 2023 Letter for both new and existing patients. Section 10(d-5)(4) of NATA incorporates the standard in Table 3.4 for behavioral health providers and facilities, which supersedes the less stringent standard in Section 10(d-5)(1) for repeat or follow-up appointments.

 

4)         For exception requests, a QHP issuer must include a completed QHP network adequacy justification form (see 45 CFR 156.230(a)(2)(ii)).

 

5)         In general, the Exchange may grant an exception to a time and distance standard or appointment wait time standard in Tables 3.1, 3.2, 3.3, or 3.4 of the 2023 Letter if the Exchange determines that making the QHP available through the Exchange is in the interests of qualified individuals in this State (see 45 CFR 156.230(a)(3)). However, under Section 10(g) of NATA, the Department cannot grant an exception to any time and distance or appointment wait time standard for mental health or substance use disorder providers specified in Section 10(d-5) of NATA, including the more stringent standards from the 2023 Letter that are incorporated by Section 10(d-5)(4). If a medical QHP does not comply with the time and distance or appointment wait time standards in Section 10(d-5) in a county, then the medical QHP must comply with the network exceptions provision in Section 10(d-5)(3).

 

6)         The provisions of 45 CFR 156.230(a)(4) apply to the Exchange only when at least 80 percent of counties in the State are classified as Counties with Extreme Access Considerations (CEAC) as defined in 50 Ill. Adm. Code 4540.30.

 

l)          For the purpose of implementing the federal requirement at 45 CFR 156.235(a)(1) that a QHP issuer must include in its provider network a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income individuals or individuals residing in Health Professional Shortage Areas within the QHP service area, in accordance with the network adequacy standards of the Exchange where the QHP is offered, the Illinois Exchange adopts the standards applicable in Federally-facilitated Exchanges as provided in 45 CFR 156.235.

 

m)        A QHP issuer must comply with the requirements for coverage through a direct primary care medical home provided in 45 CFR 156.245 (Mar. 27, 2012) (no later editions or amendments).

 

n)         A QHP issuer must provide all information that is critical for obtaining health insurance coverage or access to health care services through the QHP in the manner required under 45 CFR 156.250 (Feb. 27, 2015) (no later editions or amendments).

 

o)         A QHP issuer must comply with the limitations on rating variations provided in 45 CFR 156.255 (Mar. 27, 2012) (no later editions or amendments).

 

p)         In the individual market, a QHP issuer must (see 45 CFR 156.260 (Mar. 27, 2012) (no later editions or amendments)):

 

1)         Enroll a qualified individual during the annual open enrollment periods described in, and abide by the effective dates of coverage established at, Section 4500.180;

 

2)         Make available, at a minimum, special enrollment periods for QHPs described in, and abide by the effective dates of coverage established at, Section 4500.180; and

 

3)         notify a qualified individual of the qualified individual's effective date of coverage.

 

q)         A QHP issuer must comply with the enrollment process for qualified individuals provided in 45 CFR 156.265 (May 14, 2020) (no later editions or amendments). Until the Exchange becomes a State-based Exchange, the Exchange will enforce 45 CFR 156.265(d) regarding binder payments and premium payment deadlines in the manner required under 45 CFR 156.350(a)(4) (Apr. 17, 2018) (no later editions or amendments).  When the Exchange operates a State-based Exchange, binder payments and premium payment deadlines must comply with Sections 4500.170 and 4500.200.

 

r)          A QHP issuer must comply with the termination of coverage or enrollment for qualified individuals provided in 45 CFR 156.270.

 

s)         A QHP issuer must comply with the provisions for issuer participation for the full plan year specified in 45 CFR 156.272 (Dec. 22, 2016) (no later editions or amendments), except that:

 

1)         references within that rule to 45 CFR 156.815 instead will refer to Section 4500.80 of this Part; and

 

2)         references to a "Federally-facilitated Exchange" or "Federally-facilitated SHOP" refer to the Illinois Exchange's individual market or the Illinois SHOP, respectively.

 

t)          For the abortion care and abortifacient coverages required under Sections 356z.4a and 356z.60 of the Code, a QHP issuer must comply with 45 CFR 156.280(d) through (i) (Sep. 27, 2021) (no later editions or amendments).

 

u)         A QHP issuer offering a QHP through the SHOP must comply with 45 CFR 156.286 (Apr. 17, 2018) (no later editions or amendments).

 

v)         A QHP issuer must comply with the prescription drug distribution and cost reporting requirements of 45 CFR 156.295 (May 5, 2021) (no later editions or amendments).

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 provisions for the SHOP and related standards for individuals and entities to participate in the SHOP or in QHPs offered through the SHOP, except that references to the "Federally-facilitated SHOP" or "FF-SHOP" are substituted with "Illinois SHOP" unless the applicable section of the Code of Federal Regulations contains a conflicting or additional requirement for the type of Exchange operating in Illinois (see 45 CFR 155.706(a) (Apr. 17, 2018) (no later editions or amendments)):

 

1)         Sections 4500.40 through 4500.90;

 

2)         the functions of an Exchange provided in 45 CFR Part 155, Subparts E, K, and M as those provisions of the Code of Federal Regulations were in effect on July 1, 2025 (no later editions or amendments), as modified by this Part; and

 

3)         45 CFR Part 155, Subpart H as those provisions of the Code of Federal Regulations were in effect on July 1, 2025 (no later editions or amendments), as modified by this Part.

 

c)         The following provisions do not apply to the Illinois SHOP (see 45 CFR 155.706(a)):

 

1)         Requirements related to individual eligibility determinations in 45 CFR Part 155, Subpart D as those provisions of the Code of Federal Regulations were in effect on July 1, 2025 (no later editions or amendments);

 

2)         Requirements related to enrollment of qualified individuals described in 45 CFR Part 155, Subpart E;

 

3)         The requirement to issue certificates of exemption in accordance with 45 CFR 155.200(b) (Dec. 27, 2019) (no later editions or amendments); and

 

4)         Requirements related to the payment of premiums by individuals, Indian tribes, tribal organizations, and urban Indian organizations under 45 CFR 155.240 (May 27, 2014) (no later editions or amendments).

 

d)         A QHP issuer must not change its rates in the SHOP more frequently than quarterly and must not vary rates for a qualified employer during the employer's plan year. In addition to the Department's filing and approval requirements under Section 355 of the Code and 50 Ill. Adm. Code 2026, updated rates must be submitted to the SHOP at least 60 days before their effective date, which must be January 1, April 1, July 1, or October 1 of the calendar year (see 45 CFR 155.706(b)(6)).

 

e)         The uniform group participation rate requirements for Federally-facilitated Exchanges in 45 CFR 155.706(b)(10)(i) also apply while Illinois has a State-based Exchange on the Federal Platform.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 substituted with "the Illinois Exchange";

 

b)         references to "HHS" are substituted with "the Department";

 

c)         the reference to "subpart I of this part" is substituted with "this Part"; and

 

d)         until the Exchange operates as a State-based Exchange, the Exchange will enforce 45 CFR 156.715 in the manner required under 45 CFR 156.350(a)(3).  When the Exchange operates as a State-based Exchange, the limitation in 45 CFR 156.350(a)(3) does not apply. Nothing in this Section affects the Department's authority, scope, or procedures available for market analysis or market conduct actions performed under Section 132 of the Code.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 amendments). When the Exchange operates as a State-based Exchange, this Section incorporates 45 CFR 156.330 with "State-based Exchange" substituted for "Federally-facilitated Exchange" and "Illinois Exchange" substituted for "HHS."

 

b)         A QHP issuer must comply with the requirements related to downstream and delegated entities depending on the type of Exchange in operation as provided in 45 CFR 156.340 (May 6, 2022) (no later editions or amendments).

 

c)         Until the Exchange operates as a State-based Exchange, a QHP issuer must comply with the requirements related to eligibility and enrollment standards in the manner provided in 45 CFR 156.350.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 Ill. Adm. Code 926.

 

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 Application Counselor Organizations. The Exchange may elect to offer State awards for In-Person Counselors. The Exchange may delegate the administration of its agreements, certifications, or State awards under this Section to an eligible entity as allowed under 45 CFR 155.110(a) through (b) (Mar. 27, 2012) (no later editions or amendments).

 

b)         As required by Section 50 of GATA, for all State awards under this Part, the Exchange hereby incorporates by reference 2 CFR 200, Subparts A through F and Appendices I through XII as those provisions of the Code of Federal Regulations were in effect on July 1, 2025 (no later editions or amendments).

 

1)         The terminology equivalences listed at 44 Ill. Adm. Code 7000.200(b)(1) apply to the incorporation of 2 CFR 200.

 

2)         Copies of the materials incorporated by reference are available for inspection at the Illinois Department of Insurance, 320 West Washington Street, Floor 4, Springfield, Illinois 62767 and online via the U.S. Government Publishing Office at http://www.ecfr.gov.

 

3)         The Exchange or its designee may submit a request for specific exceptions or exemptions from GATA. Those exceptions or exemptions granted by the Grant Accountability and Transparency Unit within the Illinois Governor's Office of Management and Budget will be recorded in the Catalog of State Financial Assistance. This subsection (b)(3) does not apply when different provisions are required by State or federal law.

 

c)         To receive, renew, or maintain a State award as a Navigator or In-Person Counselor, an entity or individual must:

 

1)         for Navigators, meet the criteria in 45 CFR 155.210(c)(1) (Apr. 27, 2023) (no later editions or amendments), including having an active certification from the Department under 50 Ill. Adm. Code 4515;

 

2)         for In-Person Counselors, have an active certification from the Department under 50 Ill. Adm. Code 4515;

 

3)         comply with the applicable conflict-of-interest standards in 45 CFR 155.215(a) (Apr. 25, 2019) (no later editions or amendments);

 

4)         not engage in any conduct or hold any status prohibited under 45 CFR 155.210(d);

 

5)         comply with the applicable cultural, linguistic, and accessibility standards in Section 4500.160(b);

 

6)         enter an agreement to perform and in fact perform the duties described in 45 CFR 155.210(e);

 

7)         comply with any other requirements or standards specified in the NOFO, grant agreement, or cooperative agreement, as applicable; and

 

8)         for new and renewed grants, satisfactorily complete the following application process:

 

A)        pursuant to 44 Ill. Adm. Code 7000.320, registration with the State of Illinois, prequalification, and being determined "qualified" as described in 44 Ill. Adm. Code 7000.70;

 

B)        pursuant to 44 Ill. Adm. Code 7000.330, submission of the uniform grant application and uniform budget template;

 

C)        pursuant to 44 Ill. Adm. Code 7000.350, receipt of a successful determination under the merit review process; and

 

D)        any other applicable requirements under the GATA and 44 Ill. Adm. Code 7000.

 

d)         To receive, renew, or maintain certification by the Exchange as a Certified Application Counselor Organization, an entity must:

 

1)         comply with 45 CFR 155.225(b)(1) (Apr. 27, 2023) (no later editions or amendments);

 

2)         enforce the standards of certification for its own Certified Application Counselors specified in 45 CFR 155.225(d), including the requirement that the Certified Application Counselor have an active certification from the Department under 50 Ill. Adm. Code 4515;

 

3)         comply with the availability of information and authorization requirements in 45 CFR 155.225(f);

 

4)         comply with the applicable accessibility standards in Section 4500.160(b);

 

5)         meet the terms and conditions of the agreement entered with the Exchange or its designee;

 

6)         not engage in the conduct described in 45 CFR 155.225(g). The Illinois Exchange adopts the provisions applicable to Federally-facilitated Exchanges; and

 

7)         for new and renewal certifications, successfully make an application on a form prescribed by the Exchange addressing the requirements of this subsection (d).

 

e)         To receive, renew, or maintain certification to perform the duties in 45 CFR 155.225(c) as a Certified Application Counselor, an individual must:

 

1)         meet the standards provided in 45 CFR 155.225(d), including the requirement that the Certified Application Counselor have an active certification from the Department under 50 Ill. Adm. Code 4515;

 

2)         comply with the availability of information and authorization requirements in 45 CFR 155.225(f);

 

3)         meet the terms and conditions of the agreement entered with the Certified Application Counselor Organization; and

 

4)         not engage in the conduct described in 45 CFR 155.225(g). The Illinois Exchange adopts the provisions applicable to Federally-facilitated Exchanges.

 

f)         Denials, suspensions, terminations, withdrawals, and appeals

 

1)         For Navigator and In-Person Counselor award applications, nothing in this subsection (f) supersedes the requirements for the merit review and appeals process described in 44 Ill. Adm. Code 7700.350.

 

2)         The Exchange may deny, suspend, or terminate a Navigator or In-Person Counselor award, or deny, suspend, or withdraw a Certified Application Counselor Organization certification, if the applicant, certificate holder, or recipient:

 

A)        provides incorrect, misleading, incomplete, or materially untrue information in the award or certificate application;

 

B)        violates any insurance law, or violates any rule, subpoena, or order of the Director or of another state's insurance Director;

 

C)        obtains or attempts to obtain an award or certificate through misrepresentation or fraud;

 

D)        obtains or attempts to obtain any monies or property from Illinois consumers while conducting business under this Section;

 

E)        intentionally misrepresents the terms of an actual or proposed insurance contract;

 

F)         has been convicted of a felony, unless the applicant, certificate holder, or recipient demonstrates to the Director sufficient rehabilitation to warrant the public trust in accordance with Section 4515.140;

 

G)        has admitted or been found to have committed any insurance unfair trade practice or fraud;

 

H)        uses fraudulent, coercive, or dishonest practices, or demonstrating incompetence, untrustworthiness or financial irresponsibility in the conduct of business in this State or elsewhere;

 

I)         has a Navigator or In-Person Counselor award or Certified Application Counselor Organization certificate, or its equivalent, denied, suspended, terminated, or withdrawn by HHS or by the American Health Benefit Exchange for any other state, province, district, or territory;

 

J)         forges a name to an application for insurance or a document related to an insurance transaction;

 

K)        fails to comply with an administrative or court order imposing a child support obligation;

 

L)        fails to pay Illinois State income tax or penalty or interest, or to comply with any administrative or court order directing payment of Illinois state income tax, or fails to file a return or to pay any final assessment of any tax due to the Illinois Department of Revenue; or

 

M)       fails to make satisfactory repayment to the Illinois Student Assistance Commission for a delinquent or defaulted student loan.

 

3)         If the Exchange determines that any of the grounds listed in subsection (f)(2) exists, the Exchange or its designee will send a written notice to the entity or individual identifying the nature of the disciplinary action to be taken, the specific reasons for the action, an effective date 10 days from the date the notice is issued, and information about how to request a hearing on the decision. The entity or individual may appeal by submitting a request for hearing to the Department within 10 days. The appeal will stay the effective date of the disciplinary action pending the outcome of the hearing and any further administrative review. The hearing will be conducted in accordance with 50 Ill. Adm. Code 2402. An entity or individual may reapply for certification or an award one calendar year after certification has been withdrawn or the award has been terminated.

 

4)         A Certified Application Counselor Organization must have procedures to withdraw a certification it has issued to a Certified Application Counselor when the individual does not comply with the requirements of this Section.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 submission of applications for APTCs and CSRs through the Illinois Exchange, an agent or broker must comply with:

 

a)         45 CFR 155.220 (Jun. 25, 2025) (no later editions or amendments), including the provisions referencing Federally-facilitated Exchanges. When the Exchange operates as a State-based Exchange, this Section incorporates the provisions referencing agents and brokers in 45 CFR 155.220 with "State-based Exchange" substituted for "Federally-facilitated Exchange" and "Illinois Exchange" substituted for "HHS";

 

b)         45 CFR 155.260(b);

 

c)         State insurance producer licensing requirements under Article XXXI of the Code; and

 

d)         when the Exchange operates as a State-based Exchange, the following requirements to receive and maintain an annual certification from the Exchange:

 

1)         The agent or broker must complete an initial or renewal application on a form developed or accepted by the Exchange and must declare under penalty of refusal, suspension, or revocation of the Exchange certification that the statements made in the application are true, correct, and complete to the best of the agent or broker's knowledge and belief.  Before approving the application, the Exchange must find that the agent or broker:

 

A)        complies with subsection (c);

 

B)        is not disqualified for having committed any act that would be a ground for denial, suspension, or revocation of an Exchange certification;

 

C)        has not had an insurance producer license, Navigator certification, In-Person Counselor certification, or Certified Application Counselor certification, or equivalent license or certification denied, suspended, or revoked in any state, province, district, or territory or by the United States Department of Health and Human Services; and

 

D)        for individual insurance producers, the agent or broker demonstrates successful completion of the applicable training curriculum for agents or brokers described in subsection (d)(4).

 

2)         The agent or broker must maintain and provide documentation required by the Exchange to verify the information contained in an Exchange certification application. The agent or broker must retain the certificate of completion from each course or training curriculum completed under subsection (d)(4) for 3 years from the date of successful completion.

 

3)         An Exchange certification will be valid through October 31 of the plan year for which the certificate holder successfully completed the applicable training curriculum. The agent or broker may file an application for renewal 60 days before the end of the certification period.

 

4)         An individual agent or broker seeking to obtain or renew an Exchange certification must register for the Get Covered Illinois Learning Management System (GCILMS) application at https://getcovered.illinois.gov and must successfully complete the Director-approved training modules prescribed in GCILMS.

 

A)        The courses will be designed to increase the agent or broker's knowledge and understanding of private and public insurance principles, QHP options, applicable laws and regulations governing insurance affordability programs, eligibility, and benefits, Marketplace and Medicaid policies and operations, and outreach and education skills. The curriculum may contain modules covering topics that include, but are not limited to:

 

i)          the needs of underserved and vulnerable populations;

 

ii)         eligibility and enrollment rules and procedures;

 

iii)        the range of QHP options and affordability programs; and

 

iv)        privacy and security of personally identifiable information applicable under 45 CFR 155.260.

 

B)        Each course in GCILMS will:

 

i)          require an examination at its end;

 

ii)         allow the student to go back and review any unit at any time before, but not during, the examination; and

 

iii)        require each student to affirm that the student, and only that same student, completed the course.

 

C)        No credit will be given for a course if the student does not demonstrate successful completion of the examination.

 

5)         The Exchange may deny, suspend, or revoke an Exchange certification for cause.

 

A)        "Cause" means any of the reasons specified in Section 500-70 of the Code, including violations of any applicable rules the Director has adopted under this Part or failure to demonstrate successful completion of the applicable training curriculum. Additionally, the Exchange may deny, suspend, or revoke an Exchange certification for providing incorrect, misleading, incomplete, or materially untrue information in an application for Exchange certification, or for obtaining or attempting to obtain an Exchange certification through misrepresentation or fraud.

 

B)        If the Exchange determines that cause for denial, suspension, or revocation exists, the Exchange or its designee will send a written notice to the agent or broker identifying the nature of the disciplinary action to be taken, the specific reasons for the action, an effective date 10 days from the date the notice is issued, and information about how to request a hearing on the decision. The agent or broker may appeal by submitting a request for hearing to the Department within 10 days. The appeal will stay the effective date of the disciplinary action pending the outcome of the hearing and any further administrative review. The hearing will be conducted in accordance with 50 Ill. Adm. Code 2402.

 

C)        Action against an agent or broker's Exchange certification or application for certification does not, by itself, affect the status of an agent or broker's insurance producer license under the Code. Nothing in this subsection prevents the Exchange from cooperating with the Department's regulatory divisions on enforcement actions under the Code.

 

D)        Notwithstanding any other provision of this subsection, an agent or broker's Exchange certification will terminate no later than the actual effective date of termination of the agent or broker's insurance producer license under Article XXXI of the Code.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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).

 

b)         Navigators and In-Person Counselors must comply with the standards for providing culturally and linguistically appropriate services under 45 CFR 155.215(c) and the standards to ensure access for persons with disabilities under 45 CFR 155.215(d). A Certified Application Counselor Organization must comply with 45 CFR 155.215(d) unless it provides an appropriate referral to a Navigator, In-Person Counselor, or the Exchange call center.

 

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 following:

 

1)         The applicant is a citizen or national of the United States, or is a non-citizen who is lawfully present in the United States, and is reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought;

 

2)         The applicant is not incarcerated, other than incarceration pending the disposition of charges; and

 

3)         The applicant meets the applicable residency standard identified in 45 CFR 155.305(a)(3).

 

b)         For a QHP that is a catastrophic plan, an applicant will be eligible for enrollment if the applicant meets the requirements of subsection (a) and either (see 45 CFR 155.305(h)):

 

1)         has not attained the age of 30 before the beginning of the plan year; or

 

2)         has a certification in effect for any plan year that the applicant is exempt from the requirement to maintain minimum essential coverage under 26 U.S.C. 5000A by reason of:

 

A)        26 U.S.C. 5000A(e)(1) relating to individuals without affordable coverage; or

 

B)        26 U.S.C. 5000A(e)(5) relating to individuals with hardships.

 

c)         Upon receipt of an application, the Exchange will determine whether an applicant is eligible for Medicaid or CHIP as provided in 45 CFR 155.305(c) and (d).

 

d)         The Exchange will accept a QHP selection from an applicant determined eligible for enrollment in a QHP. The Exchange will notify the QHP issuer of the applicant's selected QHP and transmit the information necessary to enable the issuer to enroll the applicant.

 

e)         The Exchange will accept enrollment of a qualified individual in a QHP only during the annual open enrollment period or a special enrollment period as described in Section 4500.180.

 

f)         An applicant has the right to appeal an eligibility determination as provided in 45 CFR Part 155, Subpart F (as those provisions of the Code of Federal Regulations were in effect on July 1, 2025) (no later editions or amendments).

 

g)         For plan years when the Illinois Exchange is a State-based Exchange on the Federal Platform, the Illinois Exchange will rely on HHS to perform all eligibility and enrollment functions, including related appeals.

 

h)         For plan years when Illinois operates a State-based Exchange, the Illinois Exchange will perform eligibility and enrollment functions provided or incorporated under this Section, including related appeals under Section 4500.230. The Exchange may continue to defer to HHS to handle eligibility determinations and related appeals not provided or incorporated under this Section.

 

1)         The Exchange will make annual eligibility redeterminations and reenrollments in accordance with 45 CFR 155.335 (Jun. 25, 2025) (no later editions or amendments). If no QHPs from the same issuer are available through the Exchange for the next plan year at the time of an enrollee's annual redetermination, the Illinois Exchange may enroll the enrollee in a similar QHP from a different issuer, as determined by the Exchange. This paragraph does not apply if the enrollee terminates coverage in accordance with Section 4500.200, including termination of coverage in connection with voluntarily selecting a different QHP.

 

2)         Notwithstanding an affirmative eligibility determination from the Exchange, an applicant or enrollee must pay a binder payment for an issuer to effectuate an enrollment or add coverage retroactively to an already effectuated enrollment. An issuer must establish binder payment deadlines subject to the following:

 

A)        For coverage to be effectuated under a prospective effective date, the binder payment must consist of the first month's premium. For coverage to be effectuated under a retroactive effective date, the binder payment must consist of the premium due for all months of retroactive coverage through the first prospective month of coverage. An issuer may establish binder payment thresholds to the extent allowed by 45 CFR 155.400(g) (Jan. 15, 2025) (no later editions or amendments).

 

B)        An issuer's binder payment deadlines must fall within the following range:

 

i)          no earlier than the later of:

 

•           the coverage effective date; or

 

•           14 calendar days from the date the premium invoice is sent; and

 

ii)         no later than the later of 30 calendar days from:

 

•           the date the issuer receives the enrollment transaction; or

 

•           the coverage effective date.

 

C)        When an issuer experiences billing or enrollment problems due to high volume or technical errors, the issuer may implement a reasonable extension of its binder payment deadlines.

 

3)         For any plan year for which the Illinois Exchange operates a SHOP, Section 4500.100 will govern the eligibility and enrollment procedures for QHPs offered through the SHOP.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 open enrollment period begins November 1 of the calendar year before the benefit year and extends through January 15 of the benefit year. (see 45 CFR 155.410(e)(4) (Apr. 15, 2024) (no later editions or amendments))

 

2)         For plan years when the Exchange operates as a State-based Exchange, the Illinois Exchange may provide a longer annual enrollment period that begins on November 1 of the calendar year before the benefit year and extends through a date later than January 15 of the benefit year if the Illinois Exchange provides advance public notice on its website at least 120 days before the first day of the period.

 

b)         For QHP selections that the Exchange receives during the annual open enrollment period, coverage must be effective as provided in 45 CFR 155.410(f)(3)(i).

 

c)         If the qualified individual or enrollee experiences a triggering event for a special enrollment period, the qualified individual may enroll in a QHP and an enrollee may change QHPs as provided in 45 CFR 155.420. References to "dependent" in 45 CFR 155.420 are deemed to incorporate the definition of the term in Section 4500.30. Additionally, for plan years when the Exchange operates as a State-based Exchange:

 

1)         The Illinois Exchange expressly adopts the triggering event for the death of the enrollee or the enrollee's dependent in 45 CFR 155.420(d)(2)(ii).

 

2)         The triggering events based on other exceptional circumstances under 45 CFR 155.420(d)(9) include, but are not limited to:

 

A)        when a qualified individual receives a certification of pregnancy from a qualified health care professional, including a licensed certified professional midwife, who is licensed or certified under the laws of this State or any other state to provide pregnancy-related health care services. The special enrollment period lasts through the 60th day after the date the qualified individual received the certification of pregnancy.  The special enrollment period includes the qualified individual's dependents; and

 

B)        when a qualified individual is an uninsured taxpayer who requested health insurance benefit information through the Easy Enrollment Program. If the uninsured taxpayer is a qualified individual, the special enrollment period includes the uninsured taxpayer's dependents. As used in this subsection, "dependent" has the meaning ascribed in Section 4500.30. The special enrollment period lasts through the 60^th day after the date of the letter from the Illinois Exchange under Section 513(d) of the Illinois Income Tax Act.

 

3)         A qualified individual or a qualified individual's dependent who has a loss of Medicaid coverage described in 45 CFR 155.420(d)(1)(i) has 90 days after the triggering event to select a QHP.

 

d)         For QHP selections received during a special enrollment period, coverage must be effective as provided in 45 CFR 155.420(b)(1), (b)(2), (b)(4), and (b)(5) , subject to the following provisions for plan years when the Exchange operates as a State-based Exchange:

 

1)         For the special enrollment periods described in 45 CFR 155.420(b)(2)(iv), except as provided in subsection (d)(4) below, if the plan selection is made after the date of the triggering event, coverage must become effective on the first day of the month after plan selection.

 

2)         For the special enrollment period in subsection (c)(1) triggered by the death of an enrollee or the enrollee's dependent, coverage must become effective on the first day of the month after plan selection.

 

3)         For the special enrollment period in subsection (c)(2)(A) triggered by a certification of pregnancy, the pregnant individual may elect to have coverage become effective on:

 

A)        the first day of the month of the pregnancy certification;

 

B)        the first day of the month after the pregnancy certification; or

 

C)        the first day of the month after the pregnant individual makes the plan selection.

 

4)         For the special enrollment period in subsection (c)(2)(B) triggered by the Easy Enrollment Program, coverage must be effective the first day of the month after plan selection.

 

5)         For a qualified individual or a qualified individual's dependent who has a loss of minimum essential coverage described in 45 CFR 155.420(d)(1)(i) that occurs in the middle of a month, if the qualified individual or dependent makes the plan selection during the month before the triggering event, the qualified individual or dependent may elect to have coverage become effective on the first day of either the month of the triggering event or the month after the triggering event.

 

6)         For the special enrollment periods described in 45 CFR 155.420(d)(2)(i) triggered by a qualified individual gaining or becoming a dependent through birth, adoption, placement for adoption, placement in foster care, or child support or other court order, the qualified individual or enrollee may elect to have coverage effective either on the date of the triggering event or on the first day of the month after plan selection.

 

A)        For medical QHPs or SADPs, nothing in subsection (d)(5) waives the Illinois requirement that the policy must cover a newborn child from the moment of birth under the circumstances described in Section 356c of the Code, Section 4-8 of the HMO Act, or Section 30.1 of the DSP Act, as applicable to the product network type. If an issuer elects under Section 356c of the Code, Section 4-8 of the HMO Act, or Section 30.1 of the DSP Act to require timely payment of a specific premium to extend the dependent newborn's coverage beyond the first 31 days, or to effectuate coverage for the newborn from the moment of birth in the case of a qualified individual who had no other dependents on the policy at the moment of birth, the qualified individual's failure to timely pay premiums for those purposes will not prevent the qualified individual from electing to make coverage effective on the first day of the month after plan selection.

 

B)        For an SADP offered by a limited health service organization, the general requirements of subsection (d)(5) apply without regard for subsection (d)(5)(A).

 

C)        Nothing in subsection (d)(5) affects the requirement described in 45 CFR 155.420(d)(2)(i) triggered by a qualified individual gaining or becoming a dependent through marriage that coverage must be effective for the qualified individual or enrollee on the first day of the month after plan selection.

 

e)         An applicant has the right to appeal a determination related to eligibility for an enrollment period as provided in 45 CFR Part 155, Subpart F.

 

f)         For plan years when Illinois operates a State-based Exchange on the Federal Platform, the Illinois Exchange will rely on HHS to perform all eligibility and enrollment functions, including related appeals.

 

g)         For plan years when Illinois operates a State-based Exchange, the Illinois Exchange will perform eligibility and enrollment functions provided or incorporated under this Section, including related appeals under Section 4500.230.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 criteria in 45 CFR 155.305(g).

 

c)         An applicant has the right to appeal an eligibility determination regarding APTCs and CSRs, including the amount calculated, as provided in 45 CFR Part 155, Subpart F.

 

d)         For plan years when Illinois operates a State-based Exchange on the Federal Platform, the Illinois Exchange will rely on HHS to determine eligibility for, calculate, and provide APTCs and CSRs and to conduct all related appeals.

 

e)         For plan years when Illinois operates a State-based Exchange, the Illinois Exchange will determine eligibility for, calculate, and provide information on APTCs and CSRs under this Section, and the Illinois Exchange will conduct related appeals under Section 4500.230. HHS will continue to make actual payments of the APTCs and, if applicable, CSRs.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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. (see 45 CFR 155.430(b)(1) (April 15, 2024) (no later editions or amendments))

 

1)         At the time of plan selection, an enrollee may remain enrolled in a QHP even if the enrollee becomes eligible for other minimum essential coverage. If the enrollee does not actively elect to remain enrolled in a QHP, the Exchange must terminate enrollment in the QHP upon completion of the process specified in 45 CFR 155.330(e)(2) (April 15, 2024) (no later editions or amendments).

 

2)         An individual, including an enrollee's authorized representative, may report the death of an enrollee to initiate termination of the enrollee's Exchange enrollment.

 

3)         An enrollee may retroactively terminate or cancel coverage within 10 days of receipt of the QHP contract for the plan year and receive a full refund of the premium paid for the same plan year to the extent provided by 50 Ill. Adm. Code 2007.80(a)(7) or 50 Ill. Adm. Code 4521.110(n), as applicable.

 

4)         An enrollee may retroactively terminate or cancel the enrollee's coverage or enrollment in a QHP under the circumstances described in 45 CFR 155.430(b)(1)(iv).

 

b)         The Exchange will involuntarily terminate an enrollee's enrollment in a QHP through the Exchange and will permit a QHP issuer to terminate the coverage or enrollment under 45 CFR 155.430(b)(2) in any of the following circumstances:

 

1)         The enrollee is no longer eligible for coverage in a QHP through the Exchange;

 

2)         Premiums have not been paid for the enrollee's coverage and all applicable grace periods have been exhausted, including, but not limited to, the three-month grace period in 45 CFR 156.270(d) and (g), as well as the grace period in Section 357.4 of the Code or 50 Ill. Adm. Code 4521.110(l);

 

3)         The QHP issuer demonstrates to the Exchange that rescission of the enrollee's coverage is appropriate under 45 CFR 147.128 (November 18, 2015) (no later editions or amendments). A rescission also must comply with Section 154 of the Code;

 

4)         The QHP terminates or is decertified as described in Section 4500.70;

 

5)         The enrollee changes from one QHP to another during an annual open enrollment period or special enrollment period as permitted under Section 4500.180;

 

6)         The enrollee had been enrolled in a QHP without the enrollee's knowledge or consent by a third party, including by a third party with no connection with the Exchange; or

 

7)         Any other reason for termination of coverage described in 45 CFR 147.106.

 

c)         An issuer must not involuntarily terminate dependent coverage of a child before the end of the plan year in which the child attains age 26 on the basis of the child's age, unless otherwise permitted by this Section. (see 45 CFR 155.430(b)(3))

 

d)         Coverage or enrollment must be terminated or cancelled consistent with the effective dates in 45 CFR 155.430(d).

 

e)         For plan years when Illinois operates a State-based Exchange on the Federal Platform, the Illinois Exchange will rely on HHS to permit or initiate terminations of coverage or enrollment and to conduct all appeals related to terminations arising from ineligibility for coverage in a QHP through the Exchange.

 

f)         For plan years when Illinois operates a State-based Exchange, the Illinois Exchange will permit or initiate terminations of coverage or enrollment provided or incorporated under this Section and will conduct related appeals under Section 4500.230.

 

g)         To the extent allowed by 45 CFR 155.400(g), an issuer may establish premium payment thresholds at or above which non-payment of premium will not trigger a grace period or termination of enrollment. Additionally, when an issuer experiences billing or enrollment problems due to high volume or technical errors, the issuer may implement a reasonable extension of premium payment deadlines.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 Illinois operates a State-based Exchange, the health insurance issuer must submit this information to HHS as provided in 45 CFR 156.122(d)(2). When Illinois operates a State-based Exchange, the issuer must submit this information to the Illinois Exchange in a format and at times specified by the Exchange.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 monthly premiums charged by the issuer for every policy under every QHP to the extent that enrollment is through the Illinois Exchange; and

 

2)         the user fee rate, which is:

 

A)        for benefit months in any calendar year when Illinois operates a State-based Exchange on the Federal Platform in January of the same year, 0.5%; and

 

B)        for benefit months in any calendar year when Illinois operates a State-based Exchange in January of the same year, 2.75%.

 

b)         The total of monthly premiums charged in subsection (a) must be calculated before the application of any APTCs, CSRs, rebates, or other subsidies or reductions in premiums filed with the Exchange that affect the amount the issuer actually bills to, or is directly owed by, any of its enrollees or qualified employers.

 

c)         The Department will issue a monthly invoice to each issuer for the user fee in subsection (a) based on:

 

1)         effectuated enrollment in the issuer's plans through the Exchange as of the end of the current month; and

 

2)         adjustments to one or more prior months' invoices due to changes or errors in effectuated enrollment.

 

d)         A QHP issuer must pay the invoice within 30 days of the date the Department issues the invoice.

 

e)         A QHP issuer may report an overpayment and request an adjustment or other refund under Section 412 of the Code as implemented by 50 Ill. Adm. Code 2500.120 if the issuer believes it has made an overpayment of its monthly user fee and either:

 

1)         the following month's invoice does not adjust for the overpayment; or

 

2)         the Department does not issue an invoice for the following month.

 

f)         The Department will not collect any portion of a user fee that HHS assesses under 45 CFR 156.50(c) and (d) (May 6, 2022) (no later editions or amendments). A QHP issuer must remit directly to HHS any user fee that HHS assesses separately from the user fee collected by the Department under Section 5-21 of the IHBE Law.

 

AGENCY NOTE:  The user fee rate of 0.5% in subsection (a)(2)(A) does not include any of the Federal Platform User Fee rate of 1.2% owed to the Federal Government under 89 Fed. Reg. 26218 (April 15, 2024), which HHS will collect directly from the issuer.

 

(Source:  Amended at 49 Ill. Reg. 14672, effective October 28, 2025)

 

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 representative, a hearing officer, or any other participant in an appeals process that are provided in 45 CFR Part 155, Subpart F. Hearings under this Section are subject to the Illinois Administrative Procedure Act [5 ILCS 100], but unless otherwise specified, they are not subject to 50 Ill. Adm. Code 2402.

 

b)         Right to Appeal. An applicant has the right to appeal to the Illinois Exchange to contest the following actions by the Exchange, including with respect to their effective date:

 

1)         An initial eligibility determination, including the amount of advance payments of the premium tax credit (APTC) and level of cost-sharing reductions (CSRs);

 

2)         A redetermination of eligibility, including the amount of APTC and CSRs;

 

3)         An eligibility determination for an annual open enrollment period or special enrollment period;

 

4)         Failure of the Exchange to provide timely notice of an eligibility determination; and

 

5)         Unless the Exchange delegates the responsibility to HHS, an eligibility determination for an exemption to the individual mandate requiring insurance, if applicable, in accordance with 45 CFR 155.605.

 

c)         Filing an Appeal. An appeal is timely if the Exchange receives it within 90 days from the applicant's receipt of the notice of eligibility determination.

 

1)         An applicant is presumed to have received the notice of eligibility determination five business days after the date printed on the notice. An applicant may rebut the presumption by providing documentary evidence or testimony that the applicant actually received the notice of eligibility determination more than five business days after the date printed on the notice. If the Exchange determines that the evidence or testimony is not satisfactory, the Exchange will dismiss the appeal as untimely.

 

2)         With an untimely appeal, or in a later request to vacate a dismissal for failure to submit a valid appeal based on untimeliness, an applicant may submit a written explanation showing exceptional circumstances. For purposes of this subsection, "exceptional circumstances" includes situations in which an applicant demonstrates that, but for the occurrence of an unforeseen or uncontrollable event or condition, they would have timely filed or taken the required action.

 

d)         Representation. Applicants may represent themselves or be represented by an authorized representative, attorney, relative, friend, or another spokesperson. If an applicant designates a representative, the designation must be in writing or submitted through another legally binding format subject to applicable authentication and data security standards. An attorney representing an applicant must file a written notice of appearance. Unless the context requires otherwise, references in this Section to the "applicant" include persons designated under this subsection.

 

e)         Expedited Appeals. An applicant may request an expedited appeal when the applicant can show an immediate need for health care services because a standard appeal could jeopardize the applicant's life, health, or ability to attain, maintain, or regain maximum function.

 

1)         An expedited appeal must be requested in the same manner as a standard appeal.

 

2)         At the time the expedited appeal is requested, the applicant may submit evidence of the need for an expedited appeal and an explanation of why the applicant believes the eligibility determination is incorrect.

 

3)         If an expedited appeal is granted, the hearing will be scheduled as soon as practicable, but the Department will serve the notice of the hearing at least 10 days before the hearing, unless the parties agree to an earlier hearing date.

 

4)         If the request for an expedited appeal is denied solely with respect to the expedited basis, the Exchange will inform the applicant of the denial promptly and without undue delay, through electronic or oral notification, if possible. If notification is oral, the Exchange will follow up with the applicant by written notice. Written notice of the denial will include:

 

A)        The reason for the denial;

 

B)        An explanation that the appeal request will be transferred to the standard appeal process; and

 

C)        An explanation of the applicant's rights under the standard process.

 

5)         The informal resolution process may continue through the expedited appeal process before the hearing.

 

f)         Informal Resolution. Upon receipt of a valid appeals request, the Exchange may attempt to resolve the appeal through an informal resolution process before a hearing.

 

1)         Participation in the informal resolution process will not affect or waive the applicant's right to a hearing unless the Exchange and the applicant agree to a decision.

 

2)         The applicant may decline to participate in the informal resolution process at any time and proceed directly to a hearing.

 

3)         If the Exchange and the applicant resolve the appeal through informal resolution, the informal resolution decision must be final and binding. By agreeing to the decision, the applicant must waive the right to proceed to hearing. If a notice of hearing has been issued, the informal resolution decision will include the Director's Order terminating the hearing process.

 

4)         Except as provided in subsection (e)(5), if the informal resolution process concludes without a resolution, the matter will proceed to a hearing.

 

5)         The documentation provided and produced during the informal resolution process will become part of the appeal record. If the appeal advances to hearing, the applicant will not be asked to provide duplicative information or documentation that the applicant previously provided during the application or informal resolution process.

 

g)         Notice of Hearing. When a hearing is scheduled, the Department will send written notice to the applicant and the applicant's authorized representative, if any, of the date, time, legal authority, a short and plain statement of the matters asserted, the consequences of a failure to respond, and the location or format of the hearing. The Notice of Hearing will be served no later than 15 days before the hearing date unless the Department, in its sole discretion, grants a request from the applicant for an earlier hearing date; or for an expedited hearing as described in subsection (e)(3).

 

h)         Conduct of the Hearing. A hearing officer appointed by the Director will conduct the hearing. The hearing officer and the Exchange's representative must ensure that the applicant is afforded the right to review the appeal record, including all documents and records to be used at the hearing, at a reasonable time before the hearing date and during the hearing. The hearing must be conducted as an evidentiary hearing and must include the opportunity for both parties to:

 

1)         present their case to establish all relevant facts and circumstances;

 

2)         present an argument without undue interference; and

 

3)         question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses.

 

i)          Hearing officer. The hearing officer has the authority to conduct a hearing, take all necessary action to avoid delay, maintain order, and ensure the development of clear and complete record.

 

1)         The authority of the hearing officer includes, but is not limited to, authority to:

 

A)        administer oaths and affirmations;

 

B)        regulate the course of hearings, set the time and place for continued hearings, fix the time for the filing of documents, and otherwise conduct the proceeding according to generally recognized administrative law;

 

C)        examine witnesses and direct witnesses to testify, limit the number of times any witness may testify, limit repetitious or cumulative testimony, and set reasonable limits on the amount of time each witness may testify;

 

D)        rule upon offers of proof and receive relevant evidence;

 

E)        sign and issue subpoenas that require attendance, giving testimony and the production of books, papers, and other documentary evidence;

 

F)         direct parties to appear and confer for the settlement or simplification of issues, and to otherwise conduct prehearing conferences;

 

G)        dispose of procedural matters or similar requests;

 

H)        issue the report described in subsection (l)(1); and

 

I)         enter any order that further carries out the purpose of this Section.

 

2)         Except as provided in subsection (n), the hearing officer has no authority to dismiss a hearing and must afford all parties the right to be heard and to establish a record.

 

3)         Disqualification of hearing officer. At any time before the issuance of a ruling directly related to the merits of the hearing, either party may move to disqualify the hearing officer on the grounds of bias or conflict of interest.  The motion must be made in writing to the Director with a copy to the hearing officer and the opposing party and must set forth the specific instances of bias or conflict of interest. A hearing officer may at any time voluntarily disqualify themselves, subject to the Director's approval.

 

A)        A hearing officer must be disqualified if the hearing officer was directly involved in the eligibility determination or any prior Exchange appeal decisions in the same matter.

 

B)        An adverse decision or ruling, in itself, is not grounds for disqualification.

 

C)        The hearing officer's employment or contract with the Department is not, in itself, a conflict of interest.

 

j)          Rescheduling the Hearing. A hearing may be postponed or continued at the discretion of the hearing officer upon request.

 

k)         Transcription of Proceedings. The hearing will be recorded either by a certified court reporter or a recording device. If an applicant would like the oral proceedings of the hearing transcribed, the applicant must notify the hearing officer at least 5 days before the scheduled hearing. The applicant must pay for the transcription except as otherwise provided by the Department or by law.

 

l)          Appeals Decisions after a Hearing. Unless the applicant or applicant's representative fails to appear at a hearing without good cause or the appeal is withdrawn before a decision is issued, this subsection will govern the rendering of an appeals decision after a hearing.

 

1)         After the hearing, the hearing officer must compile the record and submit a written report to the Director that contains separately stated findings of fact, conclusions of law, and recommendations for a decision. Findings of fact must be based exclusively on the evidence presented at the hearing or known to all parties, including matters officially noticed.

 

2)         The Director will issue an order in writing that constitutes the final decision in the appeal, which contains the Director's findings of fact and conclusions of law based on the record of the hearing. The Director may adopt, partially adopt, or reject the hearing officer's findings, conclusions, and recommendations. The order will be issued electronically, unless otherwise agreed upon. The order will be issued within 90 days of the date the Exchange received the appeal, as administratively feasible, unless a shorter time is required by law.

 

3)         A rehearing before the Department is not available for appeals decisions issued under this Section.

 

m)        Implementation of Appeals Decisions. The decision after a hearing, administrative review, or as agreed in the informal resolution process will be implemented either:

 

1)         Prospectively on the first day of the month following the notice of appeal decision; or

 

2)         Retroactively, to the coverage effective date the applicant did receive or would have received if the applicant had enrolled in coverage under the incorrect eligibility determination that is the subject of the appeal, at the option of the applicant.

 

n)         Dismissal. If the Exchange dismisses an appeal, the Exchange will provide timely written notice to the applicant that includes the reason for the dismissal; how the dismissal affects the applicant's eligibility; and how an applicant may show good cause why the dismissal should be vacated.

 

1)         The Exchange will dismiss an appeal when an applicant:

 

A)        Fails to submit a valid appeal. An appeal is not valid if it is untimely or if the applicant does not have a right to appeal to the Exchange under subsection (b);

 

B)        Dies before the appeal is concluded;

 

C)        Withdraws the appeal as described in subsection (o). If the withdrawal occurs after a Notice of Hearing has been issued, the hearing officer or the Director will issue an Order of Dismissal to terminate the proceedings without receiving evidence on the record or considering the pleadings; or

 

D)        Fails to appear at the hearing without good cause. The hearing officer or the Director will issue an Order of Dismissal to terminate the proceedings without receiving evidence on the record or considering the pleadings.

 

2)         Vacating a dismissal.  The Exchange will vacate a dismissal if the applicant submits a written request showing good cause. To vacate a dismissal:

 

A)        The applicant must make the written request within 30 days of the notice of the dismissal; and

 

B)        The request must state the reason for good cause to vacate the dismissal.

 

i)          For a dismissal that was based on the applicant's failure to timely file an appeal, the Exchange may recognize good cause to vacate if the applicant demonstrates exceptional circumstances as defined in subsection (c)(2).

 

ii)         For dismissals based on other reasons, the Exchange may recognize good cause to vacate in situations including, but not limited to:

 

•           a death or serious illness in the person's family;

 

•           a personal injury or physical or mental illness that reasonably prevents an applicant from attending the hearing;

 

•           an emergency, crisis, including a mental health crisis, or unforeseen event that reasonably prevents an applicant from attending the hearing;

 

•           lack of or failure to receive timely notice of the hearing in the preferred language of an applicant involved in the hearing;

 

•           excusable neglect, excusable inadvertence, or excusable mistake as determined by the Exchange;

 

•           where an interpreter, translator, or other service necessary to accommodate a person with a disability is needed but not available; or

 

•           any other compelling reason beyond the applicant's control as determined by the Exchange in relation to its prior basis for dismissal.

 

3)         If the Exchange denies a request to vacate a dismissal, the Exchange will provide timely written notice of the denial and include a description of the applicant's right to administrative review under subsection (p)(3).

 

o)         Withdrawal. An applicant may withdraw an appeal request for any reason at any time during the appeal process. The withdrawal request must be made in writing or by telephone. If the withdrawal request is made by telephone, the Exchange will record it in full and will provide a written confirmation to the applicant documenting the telephonic withdrawal.

 

p)         Administrative Review. An applicant may seek administrative review of an appeal decision through one of the following ways:

 

1)         File a complaint for administrative review in Illinois court within 35 days of the date of the appeal decision under 735 ILCS 5/3-103;

 

2)         Request review of the decision by the Centers for Medicare & Medicaid Services (CMS) Administrator within 14 calendar days of the date of the appeal decision; or

 

3)         File an appeal request of the decision or the denial of request to vacate dismissal to the US Department of Health and Human Services (HHS) within 30 days of the date of the decision. This method is the only avenue for review of the Exchange's denial of a request to vacate a dismissal.

 

q)         The provisions of 50 Ill. Adm. Code 2402.290 govern the restrictions on ex parte communications related to hearings under this Section.

 

(Source:  Added at 49 Ill. Reg. 14672, effective October 28, 2025)