TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051 PREFERRED PROVIDER PROGRAMS
SECTION 2051.330 INSURER REQUIREMENTS


 

Section 2051.330  Insurer Requirements

 

a)         As required by Section 143(1) of the Code and consistent with the requirements of 50 Ill. Adm. Code 916, insurers must file the following compliance documents in the format prescribed in Appendix C each time a policy incorporating a preferred provider arrangement is filed, or when the insurer markets, leases, sells or otherwise issues DHCSPs to beneficiaries, either directly or indirectly, independent of insurance coverage:

 

1)         Sample copies of all payor agreements as required by Section 2051.280, when applicable, and provider agreements as required by Section 2051.290. If the terms and conditions in the agreements include significant, substantial or material changes or additions, the filing of one complete sample of each type of agreement, together with a description of all variable terms and conditions, will satisfy this requirement;

 

2)         Valid and current signed administrator agreements pursuant to Section 2051.300;

 

3)         Network availability and adequacy requirements pursuant to Section 2051.310; and

 

4)         DHCSPs' requirements pursuant to Section 2051.320, if applicable.

 

b)         When incorporated in a policy filing, the filing requirements of subsection (a) may be waived if the preferred provider arrangement information had previously been filed and is identified in the subsequent filing.

 

c)         Any material changes or additions to the preferred provider program filed in accordance with subsection (a) must be reported to the Director within 30 days after the end of the month of each change or addition. The change or addition shall be filed informationally in accordance with Section 143(1) of the Code and consistent with the requirements of 50 Ill. Adm. Code 916. A material change or addition includes any modification of the information required by this Part that has significant effect on the operation of the administrator or DHCSP administrator or on the availability and accessibility of health care.

 

d)         All advertising and solicitation by an insurer regarding a DHCSP must comply with the requirements established by Section 2051.360.

 

e)         Insurers may not market EPO plans in this State, except when such an arrangement is shown to be in the best interest of the beneficiaries and has been expressly approved by the Director in writing.

 

f)         Insurers offering a DHCSP as part of a policy of insurance must set off the DHCSP provisions from the insurance coverage and disclose information as required by Section 2051.320(d)(3) through (5).

 

(Source:  Amended at 37 Ill. Reg. 2895, effective March 4, 2013)