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)