Section 4540.30  Definitions

Terms used in this Part have the meanings ascribed in Section 5 of the Act. In addition, the following definitions apply to this Part and the Act:

"2023 Letter" means the "2023 Letter to Issuers in the Federally-facilitated Exchanges" published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland  21244 (January 7, 2022) (no later editions or amendments), available online at https://www.cms.gov/files/document/2023-draft-letter-issuers-508.pdf.

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

"Acute inpatient hospital" means a hospital that provides emergency services 24 hours per day, every day of the year.

"CEAC" or "Counties with Extreme Access Considerations" means counties that satisfy the criteria for a CEAC county type designation provided in Section 3.1.1 of the MA Guidance.

"Contracted network group" means, for an insurer filing a network description under Section 10 of the Act, any group of providers with a direct or indirect contract or arrangement with a PPPA, MCO, other insurer, exempt HMO, or any other business entity by which beneficiaries are incentivized or required to use those providers' services, and which the filing insurer has directly or indirectly contracted or arranged with the business entity to include among the filing insurer's preferred providers at any tier of its own network plan.  "Contracted network group" includes any group of providers the filing insurer has directly or indirectly contracted or arranged through another business entity to use for the filing insurer's network plan even when the group also is or has previously been contracted or arranged to provide services under Medicaid, Medicare, or any other public or private health benefits program not subject to the Act.  "Contracted network group" does not include providers with which the filing insurer has directly contracted or arranged for services under its network plan.  For purposes of this definition, a parent, subsidiary, or other affiliate of a filing insurer is not the same business entity as the filing insurer.

"County type" means Large Metro, Metro, Micro, Rural, or CEAC.

"Exempt HMO" means an HMO with respect to its Medicaid or Medicare Advantage health care plan.

"HMO" means a Health Maintenance Organization as defined in Section 1-2(9) of the Health Maintenance Organization Act [215 ILCS 125].

"Individual or group policy for dental or vision insurance" means limited scope dental or vision benefits provided under a separate policy, certificate, or contract of insurance in compliance with 45 CFR 146.145(b)(3)(i) through (iii) (May 14, 2020) (no later editions or amendments) or 45 CFR 148.220(b)(1) (Oct. 31, 2016) (no later editions or amendments).  The term includes, but is not limited to, a stand-alone dental plan.

"Large Metro" means a county that satisfies the criteria for a Large Metro county type designation provided in Section 3.1.1 of the MA Guidance.

"MA Guidance" means the "Medicare Advantage Network Adequacy Criteria Guidance" published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland  21244 (January 10, 2017) (no later editions or amendments), available online at https://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/Downloads/MA_Network_Adequacy_Criteria_Guidance_Document_1-10-17.pdf.

"Material change" has the meaning ascribed in Section 5 of the Act and includes, but is not limited to:

a reduction of 10% or more of a provider specialty type in the network as a whole;

the removal of a major health system that causes a network to be significantly different within one or more counties from the network when the beneficiary purchased the network plan;

when the network's provider ratio for any type of provider no longer satisfies the requirements of Section 4540.40(e); and

when the network no longer satisfies the time and distance standards in any county for any type of provider described or incorporated under Section 4540.40(d). (Section 5 of the Act)

"MCO" has the meaning ascribed in 50 Ill. Adm. Code 4521.20.

"Metro" means a county that satisfies the criteria for a Metro county type designation provided in Section 3.1.1 of the MA Guidance.

"Micro" means a county that satisfies the criteria for a Micro county type designation provided in Section 3.1.1 of the MA Guidance.

"Network" means the group or groups of preferred providers providing services to a network plan. (Section 10 of the Act) Unless otherwise indicated, for purposes of the Act, a network consists of all preferred providers, and only those preferred providers, that service a network plan's beneficiaries, including all network tiers, if applicable, regardless of whether the filing insurer directly employs or contracts with those providers or has arranged access to them as members of one or more contracted network groups.  Notwithstanding the existence of any contract between the insurer and the provider or the provider's contracted network group, a provider that is not a preferred provider with respect to a particular network plan is not part of the network for that plan.  Nothing in this definition prevents more than one network plan from having the same network, nor shall it be interpreted in a manner inconsistent with Section 10(e) of the Act.

"Preferred provider" means any provider who has entered, either directly or indirectly, into an agreement with an employer or risk-bearing entity relating to health care services that may be rendered to beneficiaries under a network plan. (Section 5 of the Act)

"Preferred Provider Program Administrator" has the meaning ascribed in 50 Ill. Adm. Code 2051.220.

"Provider ratio" means the number of preferred providers of a given provider specialty type within the service area in relation to the number of network plan beneficiaries. 

"Provider specialty type" or "type of provider" means a provider specialty type listed in 215 ILCS 124/10(c)(1) or in Table 3.1 or 3.2 of the 2023 Letter. A single facility may encompass more than one provider type.

"Rural" means a county that satisfies the criteria for a Rural county type designation provided in Section 3.1.1 of the MA Guidance.

"Qualified health plan" or "QHP" means a health plan that meets the criteria for a qualified health plan in 42 U.S.C. 18021.

"SERFF" means the System for Electronic Rate and Form Filing provided by the National Association of Insurance Commissioners (https://www.serff.com).

"Service area" means the approved county or total composition of counties where the network plan is available for purchase to consumers.

"Stand-alone dental plan" has the meaning ascribed in 45 CFR 153.400 (May 26, 2022) (no later editions or amendments).