Section 4500.70  QHP Decertification

a)         At any time, the Exchange may decertify a health plan if the Exchange determines that the QHP issuer no longer complies with the certification criteria in subsection (c) (see 45 CFR 155.1080(c) (May 29, 2012) (no later editions or amendments)). In particular, the Exchange may decertify a QHP on one or more of the following grounds (see 45 CFR 156.810(a) (Mar. 8, 2016) (no later editions or amendments)):

1)         the QHP issuer substantially fails to comply with federal or State laws and regulations applicable to QHP issuers participating in the Exchange;

2)         the QHP issuer substantially fails to comply with the standards related to the risk adjustment, reinsurance, or risk corridors programs as described in 45 CFR 156.810(a)(2);

3)         the QHP issuer substantially fails to comply with the transparency and marketing standards of 45 CFR 156.220 (Mar. 27, 2012) (no later editions or amendments) and 45 CFR 156.225 (Apr. 27, 2023) (no later editions or amendments);

4)         the QHP issuer substantially fails to comply with the health insurance issuer responsibilities for advance payments of the premium tax credit and cost-sharing in 45 CFR 156, Subpart E, as those provisions of the Code of Federal Regulations were in effect on January 12, 2024 (no later editions or amendments);

5)         the QHP issuer is operating in the Exchange in a manner that hinders the efficient and effective administration of the Exchange;

6)         the QHP no longer meets the applicable standards set forth under Section 4500.90;

7)         based on credible evidence, the QHP issuer has committed or participated in fraudulent or abusive activities, including submission of false or fraudulent data;

8)         the QHP issuer substantially fails to meet the requirements under Section 4500.90(k) related to network adequacy standards or Section 4500.90(l) related to inclusion of essential community providers;

9)         the QHP issuer substantially fails to comply with State or federal laws and regulations related to internal claims and appeals and external review processes, including, but not limited to, the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act;

10)       the Department's policy form compliance or premium rate review divisions recommend to the Exchange that the QHP should no longer be available in the Exchange;

11)       the QHP issuer substantially fails to comply with the privacy or security standards in 45 CFR 155.260 (Nov. 15, 2021) (no later editions or amendments);

12)       the QHP issuer substantially fails to meet the requirements related to the cases forwarded to QHP issuers under Section 4500.130;

13)       the QHP issuer substantially fails to meet the requirements related to the offering of a QHP under 45 CFR 156, Subpart M, as those provisions of the Code of Federal Regulations were in effect on June 4, 2024 (no later editions or amendments);

14)       the QHP issuer offering the QHP is the subject of a pending, ongoing, or final State regulatory or enforcement action or determination that relates to the issuer offering QHPs in the Exchange; or

15)       the Department or HHS reasonably believes that the QHP issuer lacks the financial viability to provide coverage under its QHPs until the end of the plan year.

b)         Sanctions and Determinations

1)         The Exchange may consider regulatory or enforcement actions taken by the Department or HHS against a QHP issuer as a factor in determining whether to decertify a QHP offered by that issuer.

2)         The Exchange may decertify a QHP offered by an issuer based on a determination or action by the Department as it relates to the issuer offering QHPs in the Exchange, including when the State places an issuer or its parent organization into receivership or when the Department's policy form compliance or rate review division recommends to the Exchange that the QHP no longer be available in the Exchange (see 45 CFR 156.810(b)).

c)         For standard decertifications on grounds other than those described in subsection (a)(7) through (a)(9), the Exchange will provide written notice to the QHP issuer and enrollees in the QHP, which will include the following (see 45 CFR 156.810(c)):

1)         the effective date of the decertification, which will be no earlier than 30 days after the date of issuance of the notice;

2)         the reason or reasons for the decertification, including the statute, statutes, regulation, or regulations that are the basis for the decertification;

3)         for the written notice to the QHP issuer, information about the effect of the decertification on the issuer's ability to offer the QHP in the Exchange, which will include information about the procedure for appealing the decertification by making a hearing request within 10 days after the QHP issuer's receipt of the notice; and

4)         for the written notice to the QHP enrollees, information about the effect of the decertification on enrollment in the QHP and about the availability of a special enrollment period, as described in 45 CFR 155.420.

d)         For expedited decertifications on grounds described in subsections (a)(6) through (a)(9), the Exchange will provide written notice to the QHP issuer and enrollees in the QHP, which will include the following (see 45 CFR 156.810(d)):

1)         the effective date of the decertification as determined by the Exchange; and

2)         the information required by subsection (c)(2) through (c)(4).

e)         An issuer may appeal the decertification of a QHP offered by that issuer under subsection (c) or (d), or the denial of certification of a health plan as a QHP, by filing a request for hearing before the Department within 10 days after the QHP issuer's receipt of the issuance notice. The hearing will be conducted under 50 Ill. Adm. Code 2402. If an issuer files a request for hearing on a decertification (see 45 CFR 156.810(e)):

1)         If the decertification is under subsection (b)(1), the decertification will not take effect before the issuance of the final administrative decision in the appeal, notwithstanding the effective date specified in subsection (b)(1); and

2)         If the decertification is under subsection (b)(2), the decertification will take effect on the date specified in the notice of decertification, but the certification of the QHP may be reinstated immediately upon issuance of a final administrative decision that the QHP should not be decertified.

f)         If the Exchange decertifies a QHP, the QHP issuer must terminate the enrollment of enrollees through the Exchange only after (see 45 CFR 156.290(c) (Dec. 22, 2016) (no later editions or amendments)):

1)         the Exchange made notification as described in 45 CFR 155.1080; and

2)         enrollees have had an opportunity to enroll in other coverage, which means the earlier of:

A)        the effective date of the terminated enrollee's new minimum essential coverage; or

B)        the latest possible effective date of coverage under a terminated enrollee's special enrollment period triggered by a loss of minimum essential coverage under 45 CFR 155.420.