Section 2040.10  Purpose

 

This Part is intended to help protect insured individuals' access during an epidemic or public health emergency to timely, affordable health care services by requiring temporary accommodations or exceptions to the terms of their health insurance coverage. As demonstrated during the COVID-19 outbreak, an epidemic or public health emergency that rises to the level of a statewide disaster is likely to result in significant economic impact, including loss of income, wages, and working hours, for Illinois residents and employers. These losses will temporarily reduce their ability either to pay for coverage or to qualify for their employment-based coverage under the terms of their health insurance coverage. A widespread loss of coverage combined with a loss in income is likely to undermine public health officials' efforts to contain the illness or health condition causing the public health emergency because affected individuals may delay seeking testing or treatment. Additionally, it is likely to place a financial strain on health care providers if increasing numbers of uninsured individuals use health care services, whether related or not to the illness or health condition causing the public health emergency.  Such an epidemic or emergency is also likely to place a strain on the ability of health care providers to deliver services quickly and efficiently to the increased number of patients who need them, particularly if those services are subject to utilization review. Such an epidemic or emergency could also cause shortages or disruptions to prescription drug supplies. This Part is intended to prevent or mitigate the impact of the above problems and to relieve insureds of policy restrictions or requirements that become unfair or unjust under extraordinary circumstances.

 

Section 2040.20  Applicability

 

a)         Except as provided in subsection (b), this Part applies regarding all policies, contracts, and certificates of health insurance coverage that are or will be in force, issued, delivered, amended, or renewed in this State and subject to the Director's authority under any insurance law.

 

b)         This Part does not apply to short-term, limited-duration health insurance coverage or policies of excepted benefits, except when specifically provided for dental benefits. This Part does not apply to any group health insurance coverage that is not provided by a health maintenance organization, except as specified in Section 2040.80.

 

c)         The provisions of this Part generally apply only while the Governor has a disaster proclamation in effect for all counties of the State pursuant to Section 7 of the Illinois Emergency Management Agency Act [20 ILCS 3305] that is predicated on an epidemic or public health emergency, and only if, pursuant to that proclamation, the Governor has generally ordered individuals to stay at their home or place of residence or has generally ordered the cessation of non-essential business and operations in this State. However, any provision of this Part that requires an action or period to last for a specific length of time shall apply as written even if that time goes beyond the disaster proclamation period, provided that the trigger for that requirement occurred while the disaster proclamation was in effect. Continuous renewals or extensions of a disaster proclamation shall be treated as creating a single disaster proclamation period.

 

Section 2040.30  Definitions

 

Except as provided in this Section, terms used in this Part have the meanings given in Section 5 of the Illinois Health Insurance Portability and Accountability Act [215 ILCS 97]. The following definitions also apply to this Part:

 

"CMMS' enforcement discretion" means the non-enforcement policy expressed by the federal Centers for Medicare & Medicaid Services in the FAQ document dated March 24, 2020, addressed to "All Qualified Health Plan and Stand-alone Dental Plan Issuers on the Federally-facilitated Exchanges and State-based Exchanges on the Federal Platform", which had the subject heading "Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency" (Department of Health & Human Services, Centers for Medicare & Medicaid Services, 7500 Security Blvd., Mail Stop C4-21-26, Baltimore MD  21244-1850) (no later editions or amendments included).

AGENCY NOTE: the FAQ document may be available online at https://www.cms.gov/files/document/faqs-payment-and-grace-period-covid-19.pdf.

 

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

 

"Cost-sharing" means any expenditure required by or on behalf of an enrollee related to health insurance coverage. Such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance billing amounts for non-network providers, and spending for non-covered services.

 

"COVID-19" means the respiratory disease recognized by the United States Centers for Disease Control and Prevention as "coronavirus disease 2019", or the novel coronavirus named "SARS-CoV-2" that causes this respiratory disease.

 

"Department" means the Illinois Department of Insurance.

 

"Employer" has the meaning ascribed in 29 USC 1003(5).

 

"Excepted benefits" has the meaning ascribed in the following federal regulations:

 

For individual health insurance coverage, the provisions in 45 CFR 148.220; and

 

For group health insurance coverage, the provisions in 45 CFR 146.145(b).

 

"Exchange" means the Illinois Health Benefits Exchange established pursuant to 42 USC 18031(b) and 215 ILCS 122/5-5, also known as the Illinois Health Insurance Marketplace.

 

"Health care provider" or "Provider" has the meaning ascribed in Section 10 of the Managed Care Reform and Patient Rights Act.

 

"Health care services" has the meaning ascribed in Section 10 of the Managed Care Reform and Patient Rights Act [215 ILCS 134].

 

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

 

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

 

"Insured" means a resident, employee, employer, or other natural or legal person that has a policy, contract, certificate, or other agreement with an issuer for health insurance coverage.

 

"Issuer" means a "health insurance issuer" as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act.

 

"Non-network provider" means any provider that has not entered into an agreement described in Section 370i of the Code or Section 2-8 of the HMO Act.

 

"Qualified health plan" has the meaning given in 45 CFR 155.20.

 

"Short-term, limited-duration health insurance coverage" has the meaning ascribed in Section 5 of the Short-Term, Limited Duration Health Insurance Coverage Act [215 ILCS 190].

 

"Stand-alone dental plan" has the meaning ascribed in 45 CFR 156.400.

 

Section 2040.40  Grace Periods and Terminations for Nonpayment of Premium

 

Except as otherwise provided in this Section, an issuer shall allow an insured, upon request, to defer premium payments without interest for health insurance coverage, including limited-scope dental benefits, for at least 60 calendar days from each original premium due date.

 

a)         For an insured who, as of April 20, 2020, has already failed to make a sufficient premium payment by the due date but whose effective date of coverage termination has not yet occurred, an issuer shall, to the extent permitted by CMMS' enforcement discretion under federal law, refrain from cancelling or nonrenewing the insured's health insurance coverage or enrollment under that coverage based on nonpayment of premium until after June 18, 2020.

 

b)         For an insured who receives advance payments of premium tax credits for a qualified health plan or stand-alone dental plan under 42 USC 18082, an issuer shall delay the initiation of the federally mandated 3-month grace period in 45 CFR 156.270, without pending any claims or imposing interest, for at least 30 calendar days after the missed payment date.

 

c)         Binder Payments

 

1)         An issuer of any qualified health plan or stand-alone dental plan in the individual market shall, to the extent permitted by CMMS' enforcement discretion under federal law, extend all existing deadlines to make a binder payment, interest free, until at least 30 calendar days after the latest permissible deadline applicable to the circumstances under 45 CFR 155.400(e).

 

2)         An issuer shall extend its existing deadlines to make a binder payment for all other health insurance coverage in the individual market, including limited-scope dental benefits, by 30 calendar days without interest.

 

d)         Any communication from an issuer addressed to an insured regarding the payment extensions in this Section must clearly state the insured's obligation to pay back premiums or potentially be subject to billing from the issuer for paid claims or from health care providers for unpaid claims, and must clearly state the issuer's obligations during the payment extension period in light of this Section.

 

Section 2040.50  Employee Eligibility for Existing Group Coverage

 

a)         An issuer of group health insurance coverage under the HMO Act shall allow an employer to continue covering an employee even if the employee would otherwise become ineligible under the terms of the coverage or the group health plan due to a reduction in hours worked or temporary lay-off. This requirement to allow an employer to continue coverage does not mean coverage under a COBRA continuation provision or Section 4-9.2 of the HMO Act. An issuer may not prevent an employer from continuing to cover an employee at the employer's discretion as provided in this Section regardless of any "actively at work" or similar eligibility requirements in any group health insurance coverage or group health plan.

 

b)         An issuer may not discriminate among similarly situated individuals as provided in 50 Ill. Adm. Code 2001.9 when making the allowances required by this Section.

 

Section 2040.60  Minimum Employment Required for Statutory Continuation Coverages

 

a)         For an employer that employs 20 or more employees, as long as one person remains actively employed, an issuer shall not directly or indirectly prohibit an eligible employee from electing to continue coverage under a COBRA continuation provision using the normal notice and election procedures provided under the Employee Retirement Income Security Act of 1974 (29 USC 1001 et seq.).

 

b)         For any employer with group health insurance coverage, as long as at least one person remains actively employed and enrolled in the coverage, an issuer shall not directly or indirectly prohibit an eligible employee from electing to continue coverage under the State continuation coverage required by Section 4-9.2 of the HMO Act.

 

Section 2040.70  Special Enrollment Effective Date for Off-Exchange Coverage

 

a)         For health insurance coverage that is not issued through the Exchange, an issuer shall waive the normal special enrollment procedures for an employee or former employee who has lost coverage under their employer or former employer's group health plan or group health insurance coverage to the extent necessary to allow the employee or former employee to obtain or enroll under health insurance coverage effective the day after his or her prior coverage terminated. This requirement applies even if the employee or former employee previously had the opportunity to enroll under the new health insurance coverage. Otherwise, existing requirements for limited and special enrollment periods contained in Title 45 of the Code of Federal Regulations and 50 Ill. Adm. Code 2001.4 continue to apply.

 

b)         An issuer may make the retroactive extension of coverage optional to the applicant rather than automatic.

 

c)         An issuer shall notify the applicant of the amount of premiums due and the due date based on the effective coverage date, accounting for the availability of an extension on the due dates under Section 2040.40.

 

d)         This Section applies with respect to employees or former employees whose coverage terminates on or after the Governor declares a disaster in all counties of the State. However, existing requirements for the length of the enrollment period in 50 Ill. Adm. Code 2001.4 continue to apply to each applicant.

 

Section 2040.80  Access to Covered Prescription Drugs

 

This Section applies to health insurance coverage that covers prescription drugs.

 

a)         An issuer shall cover off-formulary prescription drugs if there is not a formulary drug available to treat the insured. The issuer shall do so without any prior authorization or step-therapy requirements that are separate from or redundant to any requirements already satisfied for the unavailable formulary drug. No greater cost-sharing shall be imposed than would apply to the formulary drug. Group health insurance coverage is subject to this subsection even if it is not provided by a health maintenance organization.

 

b)         To the extent consistent with clinical guidelines, an issuer shall cover an insured to obtain at least a 90-day supply upon refill of a covered maintenance medication, though exceptions may be made for drug classes that are prone to misuse, such as opioids, benzodiazepines, and stimulants. Group health insurance coverage is subject to this subsection only if it is provided by a health maintenance organization.