Section 4521.100  Solicitation

 

a)         No HMO, or representative of the HMO, may cause or knowingly permit the use of advertising, solicitation, or any form of evidence of coverage that is untrue, misleading or deceptive.

 

1)         All information required to be disclosed pursuant to this Part shall set out conspicuously and in close conjunction with the statements to which the information relates under appropriate captions of the prominence that it shall not be minimized, rendered obscure or presented in an ambiguous fashion or intermingled with the context of the solicitation as to be confusing or misleading.

 

2)         The format and context of a solicitation of any HMO's plan or program shall be sufficiently complete and clear to avoid deception or the capacity or tendency to mislead or deceive.  Whether an advertisement has a capacity or tendency to mislead or deceive shall be determined by the Director from the overall impression that the advertisement may be reasonably expected to create upon a person of average education or intelligence within the segment of the public to which it is directed.

 

3)         Solicitations shall be truthful and not misleading in fact or implication.  Words or phrases, the meaning of which is clear only by employment or by familiarity with insurance, medical terminology or health care plans, shall not be used unless those words or phrases are otherwise explained in the solicitation.

 

4)         No solicitation shall omit information or use words, phrases, statements, references, or illustrations if an omission of the information or use of the words, phrases, statements, references or illustrations has the capacity, tendency or effect of misleading or deceiving prospective enrollees as to the nature or extent of any benefit payable, loss covered, premium payable or health care service provided.

 

b)         A detailed description of all training and educational programs provided to solicitors of the health care plan or to any person providing marketing activities shall be submitted to the Director upon application for a Certificate of Authority and any substantive changes in the programs shall be submitted to the Director 15 days prior to the intended effective date of the change.

 

c)         All brochures, media scripts, and any other marketing or advertising materials an HMO applying for Certificate of Authority plans to use must be filed with the Department.  The material must be filed before use and, in the event that the material can obviously not be filed, such as audiovisual presentations, a description of the solicitation activity must be filed.

 

d)         An advertisement or solicitation shall not directly or indirectly make unfair or incomplete comparisons of policies, plans, or benefits or comparisons of non-comparable plans or policies of other HMOs or insurers, and shall not disparage competitors, their policies or plans, services or business methods and shall not disparage or unfairly minimize a competing method of marketing insurance or health care services.

 

e)         No advertisement or marketing material of an HMO shall imply that certification by the Department is an endorsement of the HMO.

 

f)         An HMO shall provide its enrollees, no later than at the time of enrollment, or the time the individual contract or evidence of coverage is issued, lists of the names and locations of primary care physicians participating in the network applicable to the enrollee's benefit plan.  The lists shall disclose those providers who are not open for selection by the subscriber, as known to the HMO at the time the list is created.  The list shall also contain the following sentence in a prominent location:

 

NOTICE TO ENROLLEES:  While every provider listed in this document contracts with (the HMO) to provide primary care services, not every provider listed will be accepting new patients.  Although (the HMO) has identified those providers who were not accepting patients as known to (the HMO) at the time this (directory) was created, the status of any physician's practice may have changed.  For the most current information regarding the status of any physician's practice, please contact either the selected physician or (member services) at (phone number).

 

g)         If an HMO offers one or more health care plans that do not require enrollees to use a referral system to access covered health care services from participating providers, then, for individual or group HMO contracts or evidences of coverage delivered, issued, or renewed on or after July 1, 2026, the HMO must, in its marketing, solicitation, and advertising materials:

 

1)         if the materials refer to plans described in this subsection by name, use either the full plan name from Section 4521.110(y) or a shortened form of plan name that includes the word "open"; and

 

2)         for materials described in subsection (g)(1), and for any materials that describe terms of coverage under plans that do not require the use of a referral system for covered services from participating providers:

 

A)        disclose that an enrollee does not need a referral from the primary care physician to obtain covered services from a participating provider, but the enrollee will need a referral to see a nonparticipating provider except for emergency services and other limited circumstances provided by law; and

 

B)        if the materials also describe terms of coverage under plans that require referrals for participating specialists, distinguish those plans from the plans in subsection (g)(2)(A) by mentioning the requirement to obtain a referral from a primary care physician to see any other health care provider except for participating obstetrical or gynecological health care professionals, participating mental health or substance use disorder providers, emergency services from participating and nonparticipating providers, and other limited circumstances provided by law.

 

3)         Nothing in this subsection (g) prohibits an HMO from providing more disclosure or explanation than required.

 

4)         Except where inconsistent with subsections (a) or (g)(1), an HMO may use abbreviations or incomplete sentences to convey the minimum substantive information required by this subsection (g).

 

h)         Failure to comply with the requirements of this Section shall subject the HMO or its representative to corrective action the Director may order pursuant to Section 4-7 of the Act.

 

(Source:  Amended at 49 Ill. Reg. 16042, effective December 4, 2025)

 

Section 4521.110  Requirements for Group Contracts, Evidences of Coverage and Individual Contracts

 

a)         Any group contract, evidence of coverage, individual contract, enrollee handbook, enrollment application, identification card or other form that affects the terms and conditions applicable to the subscriber or enrollee in the provision of health care services must be filed with and approved by the Director prior to use in accordance with the filing requirements of Section 4521.112 of this Part and Section 4-13 of the Act.  The HMO must issue to each subscriber or enrollee a group contract, evidence of coverage, or individual contract.  Any conflicting information between the valid current document referenced in this subsection (a) issued to the subscriber or enrollee and the current group contract must be interpreted according to whichever is most beneficial to the subscriber or enrollee.  Any group contract, evidence of coverage, or individual contract must provide for the rendering of health care services as defined in that document for either a specific period of not less than 12 months from the date of issuance or for another period mutually agreed to by the HMO and the group or individual contract holder except as prohibited by Section 352c of the Code.  The group contract, evidence of coverage, or individual contract must provide for renewal on a basis mutually agreed to by both parties, unless the HMO has given 31 days' written notice of nonrenewal prior to the renewal date of the contract and the nonrenewal is otherwise permitted under the Illinois Health Insurance Portability and Accountability Act [215 ILCS 97].

 

b)         A detailed statement of any exceptions, exclusions, or limitations must be set forth in the group contract, evidence of coverage, and individual contract for any type of health care service to be excepted.  Exception, exclusions, or limitations must appear with the same prominence in the group contract, evidence of coverage, and individual contract as any benefit.

 

c)         The group contract, evidence of coverage, and individual contract must set forth a detailed statement of the terms and conditions of maternity benefits and any related exceptions, exclusions, limitations, copayments, and deductibles.  Exceptions, exclusions, limitations, copayments, and deductibles applicable to prenatal and postnatal care must be covered no differently than any other covered health care services provided pursuant to the contract, with the exception of a limitation for coverage of routine prenatal care or delivery when the enrollee is outside the service area against medical advice (except when the enrollee is outside of the service area due to circumstances beyond the enrollee's control) may be included in the group contract and evidence of coverage.

 

d)         Entire Contract.  The group contract, evidence of coverage, and individual contract must contain a statement that the group contract evidence of coverage and individual contract, all applications, and any amendments shall constitute the entire agreement between the parties.  No portion of the charter, bylaws or other document of the HMO may be part of a contract or evidence of coverage unless set forth in full in the document or attached to it.

 

e)         Eligibility Requirements.  The group contract, evidence of coverage, and individual contract must contain eligibility requirements indicating the conditions that must be met to enroll in a health care plan, the limiting age for enrollees and eligible dependents including the effects of Medicare eligibility, and a clear statement regarding coverage of newborn children as set forth in Sections 4-8 and 4-9 of the Act.

 

f)         Benefits and Services Within the Service Area.  The group contract, evidence of coverage, and individual contract must contain a specific description of benefits and services available within the HMO's designated service area.

 

g)         Emergency Care Services.  The group contract, evidence of coverage, and individual contract must contain a specific description of benefits and services available for emergencies 24 hours per day, 7 days per week, including disclosure of any restrictions on emergency care services.  No group contract, evidence of coverage, or individual contract may limit the coverage of emergency services within the service area to those providers having a contract with the HMO.

 

h)         Out-of-area Benefits and Services.  The group contract, evidence of coverage, and individual contract must contain a specific description of benefits and services available out of the HMO's designated service area.

 

i)          Deductibles and Copayments 

 

1)         An HMO may require deductibles and copayments from enrollees as a condition for the receipt of specific health care services, including basic health care services.  Deductibles and copayments are the only allowable charge, other than premiums, assessed enrollees.  Nothing within this subsection (i) precludes the provider from charging reasonable administrative fees, such as service fees for checks returned for non-sufficient funds and missed appointments.

 

2)         Copayments and deductibles appearing in the policy must be for specific dollar amounts or for specific percentages of the cost of the health care services.

 

3)         No combination of deductibles and copayments for basic health care services may exceed the annual maximum out-of-pocket expenses of a high-deductible health plan as defined in 26 U.S.C. 223.

 

4)         Deductibles and copayments applicable to supplemental health care services or catastrophic-only plans as defined under the federal Patient Protection and Affordable Care Act (Pub. L. 111-148), are not subject to the annual limitations described in this Section.

 

5)         This subsection (i) applies to enrollees and does not limit the health care plan payment for services provided by non-participating providers.

 

j)          Cancellation.  The group contract, evidence of coverage, and individual contract must contain the conditions upon which they can be cancelled by the HMO or the enrollee as set forth in Section 4521.111.

 

k)         Reinstatement.  The group contract, evidence of coverage, and individual contract must contain the conditions of the enrollee's right to reinstatement.

 

l)          Grace Period 

 

1)         A group contract or individual contract not involving the use of a premium tax credit must provide for a grace period for the payment of any premium, except the first, during which coverage must remain in effect if payment is made during the grace period.  The grace period for a group contract must not be less than 10 days.  The grace period for an individual contract must not be less than 31 days.  During the grace period, the HMO must remain liable for providing the services and benefits contracted for.  The subscriber must remain liable for the payment of the premium for the time coverage was in effect during the grace period and the enrollee must remain liable for the payment of any applicable share of the premium for the time coverage was in effect, as well as for any copayments owed.

 

2)         Termination of coverage for individuals receiving advance payments of premium tax credits must comply with the requirements of 45 CFR 155 and 45 CFR 156.270 (2020).

 

m)        No group contract, evidence of coverage, or individual contract may be delivered in this State unless the subscriber or enrollee is provided written notice required by Section 143c of the Illinois Insurance Code [215 ILCS 5/143c].

 

n)         Right to Examine Contract.  An individual contract, with the exception of an HMO Medicare contract entered into between the Health Care Financing Administration and the HMO under Title XVIII of the Social Security Act (42 U.S.C. 1395 through 1395lll), as amended from time to time, must contain a provision stating that an enrollee who has entered into an agreement with an HMO must be permitted to return the individual contract within ten days after receiving it and to receive a refund of the premium paid if the enrollee is not satisfied with the contract for any reason.  If the individual contract is returned to the HMO or to its representative through whom it was purchased, it is considered void from the beginning.  However, if services are rendered or claims are paid for the enrollee or dependent by the HMO during the 10-day examination period, the enrollee need not be permitted to return the contract and receive a refund of the premium paid.

 

o)         An HMO Medicare contract entered into between the Health Care Financing Administration and the HMO under Title XVIII of the Social Security Act, as amended from time to time, must be delivered to the enrollee at least 15 days prior to the effective date of the contract.  The enrollee must be permitted to return the HMO Medicare contract prior to the effective date and to receive a refund of the premium paid if the enrollee is not satisfied with the contract for any reason, provided the enrollee complies with the disenrollment procedures of Title XVIII of the Social Security Act, as amended from time to time.

 

p)         Every HMO must provide to every enrollee of the HMO information that generally describes the philosophy, functions, and organization of the HMO and related institutions, and specific information that describes the appropriate use of the HMO's services, including a general description of benefits and limitations.  The HMO must include in its enrollee information a description of the HMO's grievance procedure, directions for filing a grievance, and a Notice of Availability of the Department.

 

q)         Every HMO must provide enrollees with an identification card that must prominently display the following information:

 

1)         the words "Health Maintenance Organization" or "HMO" and, if the health care plan is described in subsection (y), the word "open";

 

2)         disclaimer language concerning an enrollee's unauthorized use of providers not selected by the HMO;

 

3)         a current telephone number for the enrollees to use when health care services are required outside of normal office hours; and

 

4)         the name of all enrollees entitled to coverage, along with all other mandated information, if the HMO does not issue a card to each enrollee who is entitled to coverage.  In these situations, at least two cards must be issued to the primary enrollee upon enrollment and the HMO must issue additional cards to all enrollees at the request of the enrollee for no additional charge.  Notification of the right to order additional cards for no additional charge must be included with information required to be disseminated to enrollees under subsection (p).

 

r)          Enrollment Application.  No individual contract may be issued except upon the signed enrollment application of the enrollee for whom coverage is being sought.  Any information or statement of the applicant must appear on the application in the form of interrogatories by the HMO and answers by the applicant.  The enrollee must not be bound by any statement made within an application for health care coverage unless a copy of the application is attached to the individual contract.  Group enrollment applications must be maintained on file by the HMO; otherwise, disputes arising from statements made within the applications will be resolved in the enrollee's favor.  Except for those instances involving fraud or material misrepresentation, an HMO's failure to investigate incomplete or conflicting answers on an enrollment application must estop the HMO from subsequently denying coverage on the basis of those responses.

 

s)         Coordination of Benefits

 

1)         HMOs are permitted, but not required, to adopt coordination of benefits provisions for group contracts, evidence of coverage, or individual contracts to avoid over insurance and to provide for the orderly payment of claims when a person is covered by two or more group health insurance or health care plans.

 

2)         If an HMO adopts coordination of benefits, the provision must be consistent with the coordination of benefits requirements set forth in 50 Ill. Adm. Code 2009.

 

3)         To the extent necessary for an HMO to meet its obligations as a secondary carrier under 50 Ill. Adm. Code 2009, and when an enrollee has established a credit within the reserve bank, the HMO must make payments for services that are:

 

A)        received from non-participating providers;

 

B)        provided outside its services areas; or

 

C)        not covered under the terms of health care plan.

 

t)          Dependents-termination of coverage-disability and dependency, proof-application.  Every group contract, evidence of coverage, or individual contract providing that coverage of a dependent person of an enrollee terminates upon attainment of the limiting age for dependent persons must comply with the requirements of Section 4-9.1 of the Act.

 

u)         Conversion of Coverage

 

1)         The group contract and evidence of coverage shall contain a conversion provision that provides that each enrollee has the right to convert coverage to an individual or group HMO contract in the following circumstances:

 

A)        upon cancellation of eligibility for coverage under a group contract;

 

B)        upon cancellation of the group contract; or

 

C)        upon non-renewal of the group contract.

 

2)         The conversion contract must cover the enrollee and the enrollee's eligible dependents who were covered by the group contract on the date of cancellation or non-renewal of coverage.  To obtain the conversion contract, an enrollee must submit a written application, along with the application premium payment, within 31 days after the date the enrollee's coverage is cancelled.

 

3)         The HMO may require copayments and deductibles under a conversion contract that differ from the group contract.

 

4)         A conversion contract is not required to be made available if:

 

A)        The cancellation of the enrollee's coverage occurred for any of the reasons listed in Section 4521.111(a);

 

B)        The enrollee is covered by or is eligible for benefits under Title XVIII of the Social Security Act (42 U.S.C. 1395-1395lll);

 

C)        The enrollee is covered by similar hospital, medical, or surgical benefits under State or federal law;

 

D)        The enrollee is covered by similar hospital, medical, or surgical benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis;

 

E)        The enrollee is covered for similar benefits through individual coverage;

 

F)         The enrollee has not been continuously covered during the three-month period immediately preceding cancellation of that person's coverage;

 

G)        The enrollee has moved outside of the service area of the health maintenance organization;

 

H)        The cancellation of the enrollee's coverage occurred in relation to the HMO being placed in rehabilitation or liquidation proceedings pursuant to Section 5-6 of the Act; or

 

I)         The group contract has been discontinued in its entirety and there is a succeeding carrier providing coverage to the group in its entirety.

 

5)         Benefits or coverage must be considered "similar" if coverage is provided for at least 12 months under comprehensive type medical coverage.

 

6)         At a minimum, the conversion contract must provide basic health care services.

 

7)         The conversion contract shall begin coverage of the enrollee and any dependents formerly covered under the group contract on the date of termination from the group or the former individual contract.

 

8)         Coverage must be provided without requiring evidence of insurability and must not impose any pre-existing condition limitations or exclusions.

 

v)         Discrimination between individuals of the same class in the terms and conditions of the health care plan, or in the amount charged for coverage under a health care plan except when the rate differential is based on sound actuarial principles, or in any other manner whatsoever, is prohibited.

 

w)        Grievance Procedure

The group contract, evidence of coverage, and individual contract must set forth a full description of the HMO grievance procedure required by Section 4521.40.

 

x)         The provisions of 50 Ill. Adm. Code 2001, Subparts A and C, apply to this Part.

 

y)         For any group or individual HMO contract or evidence of coverage delivered, issued, or renewed on or after July 1, 2026, a health care plan that does not require enrollees to use a referral system to access covered health care services from participating providers must include the word "open" in its plan name as shown on the contract or evidence of coverage.

 

(Source:  Amended at 49 Ill. Reg. 16042, effective December 4, 2025)

 

Section 4521.111  Cancellation

 

a)         No HMO shall cancel a group or individual contract or evidence of coverage except for one or more of the following reasons:

 

1)         Failure of the enrollee to pay the amount due under the contract or evidence of coverage, for which the enrollee is legally responsible;

 

2)         Fraud or material misrepresentation in enrollment or in the use of services or facilities;

 

3)         Material violation of the terms of the contract or evidence of coverage;

 

4)         Failure of the enrollee and the primary care physician to establish a satisfactory patient-physician relationship if the enrollee has repeatedly refused to follow the plan of treatment ordered by the physician; it is shown that the HMO has in good faith provided the enrollee with the opportunity to select an alternative primary care physician; and the enrollee has been notified in writing at least 31 days in advance that the HMO considers such patient-physician relationship to be unsatisfactory;

 

5)         Under the Basic Outpatient Preventive and Primary Care Services for Children Program, failure to meet or continue to meet eligibility requirements as required by Section 4521.131 of this Part; or

 

6)         Other good cause agreed upon in the contract and approved by the Director pursuant to Section 4-13 of the Act.

 

b)         A group contract, evidence of coverage or individual contract may not be cancelled for any of the following reasons:

 

1)         The status of the enrollee's health;

 

2)         The enrollee has exercised his or her rights under the HMO's grievance system.

 

(Source:  Amended at 30 Ill. Reg. 4732, effective March 2, 2006)