Section 2026.30  Rates Subject to Review or Prior Approval

a)         All rates and classifications of risks in the individual or small group market, other than for grandfathered health plans, excepted benefits, or student health insurance coverage, on or after January 1, 2014, or effective on or after January 1, 2014 and taking effect no later than December 31, 2025, are subject to review under applicable law and Department rules, including, but not limited to, 50 Ill. Adm. Code 916, as well as:

1)         the public posting and public comment period described in Section 355(d) and (e) of the Code; and

2)         review for unreasonable rate increases through the implementation under Section 355 of the Code of an Effective Rate Review Program described in 45 CFR 154.301 (April 17, 2018) (no later editions or amendments) if:

A)        the rate represents a rate increase of 10 percent or more and applies to a 12-month period as calculated under subsection (a)(2)(B).

B)        a rate increase meets or exceeds the applicable threshold set forth in subsection (a)(2)(A) if the average increase for all enrollees weighted by premium volume meets or exceeds the applicable threshold.

C)        if a rate increase that does not otherwise meet or exceed the threshold under subsection (a)(2)(B) meets or exceeds the threshold when combined with a previous increase or increases during the 12-month period preceding the date on which the rate increase would become effective, then the rate increase must be considered to meet or exceed the threshold and is subject to review.  The review shall include a review of the aggregate rate increases during the applicable 12-month period.

b)         All rates and classifications of risks effective on or after January 1, 2026 in the individual and small group markets, other than for grandfathered health plans, excepted benefits, or student health insurance coverage, are subject to the Director's prior approval under the State's implementation of an Effective Rate Review Program described in 45 CFR 154.301 and State standards for inadequate rates in accordance with Section 355 of the Code. A health insurance issuer must submit the rates and all supporting documentation required under this Part by the rate filing deadline set by the Department in annual guidance as described in Section 355(d) of the Code.

c)         For large group market policies issued, delivered, amended, or renewed on or after January 1, 2026, other than for grandfathered health plans or excepted benefits, the premium rates and risk classifications, including any rate manuals and rules used to arrive at the rates, must be filed with the Department annually for prior approval at least 120 days before the rates are intended to take effect. (Section 355(j) of the Code) Nothing in this subsection requires a health insurance issuer to file a large group policy's final premium rates for prior approval if the health insurance issuer negotiates the final rates or rate adjustments with the plan sponsor or its administrator in accordance with the rate manual and rules of the currently approved rate filing for the policy. (Section 355(j)(4) of the Code)

d)         All rates, classifications of risks, and rate-setting methodologies not described in subsections (a) through (c) must be filed prior to use for the Director's review under applicable law and Department rules, including, but not limited to, 50 Ill. Adm. Code 916. The rates and classifications of risks are not subject to the Director's prior approval unless specifically provided by applicable law.

e)         For all rates described in subsection (a) or (b), and to the extent applicable to rate filings described in subsection (c) or (d):

1)         a rate sheet must be filed as a separate document and marked for public access in the System for Electronic Rates and Forms Filing (SERFF). For a rate filing described in subsection (c) or (d), this subsection (e)(1) applies if, and only if, the issuer does not intend the final rate for the product, policy, or contract to be subject to negotiation with a group or blanket policyholder, and public access need not be marked in SERFF unless provided otherwise under law or regulation applicable to the specific product. A rate sheet filed under this subsection (e)(1) must include either:

A)        all finally proposed rates; or

B)        all finally proposed base rates and all factors used to calculate the final rates; and

2)         the maximum, overall, and minimum rate changes, overall rate impact, written premium for the program, written premium change for the program, and number of affected policyholders must be specified in SERFF and marked for public access. This subsection (e)(2) applies to all rate filings.

(Source:  Amended at 49 Ill. Reg. 11309, effective August 28, 2025)