Section 4500.90  Minimum QHP Certification Standards

To participate in the Exchange, a health insurance issuer must have in effect a certification issued or recognized by the Exchange to demonstrate that each health plan it offers in the Exchange is a QHP in accordance with 45 CFR 156.200(a) through (f) and (h) (May 6, 2022) (no later editions or amendments).

a)         For the purpose of 45 CFR 156.200(b)(1), the Exchange establishes subsections (e) through (v) and Section 4500.80. The Exchange also adopts 45 CFR 156.200(b)(2) through (b)(7) and 156.200(c).

b)         For the purpose of 45 CFR 156.200(d), the Department's approval pursuant to applicable State law of all policy forms and, beginning for Plan Year 2026, all rates to be used in connection with a QHP is among the conditions for participation in the Exchange.

c)         For the purpose of 45 CFR 156.200(e), in accordance with 50 Ill. Adm. Code 2603, a QHP issuer must not discriminate on the basis of gender identity or sexual orientation regardless of whether federal law continues to recognize them as discrimination on the basis of sex.

d)         For 45 CFR 156.200(f), the phrase "the Illinois Exchange" is substituted for "a Federally-facilitated Exchange".

e)         A QHP issuer must comply with the requirements related to standardized options and non-standardized options codified at 45 CFR 156.201(b) (Apr. 27, 2023) (no later editions or amendments) and 45 CFR 156.202(b) through (e) (Apr. 15, 2024) (no later editions or amendments).

f)         A QHP issuer must comply with the rate and benefit information requirements in 45 CFR 156.210 (Apr. 27, 2023) (no later editions or amendments). For purposes of 45 CFR 156.210(b) through (c), the rate submissions and justifications must comply with 50 Ill. Adm. Code 2026.

g)         In order for a health plan to be certified as a QHP initially and to maintain certification to be offered in the individual market in the Exchange, the issuer must meet the requirements related to the administration of cost-sharing reductions and advance payments of the premium tax credit set forth in 45 CFR 156, Subpart E (see 45 CFR 156.215 (Mar. 11, 2013) (no later editions or amendments).

h)         A QHP issuer must provide specified types of information to the Exchange, the Department, HHS, the public, and individuals in plain language as provided in 45 CFR 156.220 (Mar. 27, 2012) (no later editions or amendments).

i)          A QHP issuer must comply with the requirements for access to and exchange of health data and plan information provided in 45 CFR 156.221 (May 1, 2020) (no later editions or amendments), substituting "the Illinois Exchange" for "a Federally-facilitated Exchange."

j)          A QHP issuer and its officials, agents, employees, and representatives must comply with the marketing and benefit design requirements of 45 CFR 156.225 (Apr. 27, 2023) (no later editions or amendments).

k)         In addition to any other network adequacy and transparency requirements applicable under State law and administrative rule, for the purpose of implementing 45 CFR 156.230(a)(1)(ii), (a)(1)(iii), (a)(2)(i)(A), (a)(2)(ii), (a)(3), and (a)(4) (Apr. 27, 2023) (no later editions or amendments) for State-based Exchanges and State-based Exchanges on the Federal Platform, and subject to 42 U.S.C. 300gg-1(c):

1)         For a medical QHP, a QHP issuer must file with the Department a network adequacy and transparency description for each QHP in compliance with 50 Ill. Adm. Code 4540. However, for mental health and substance use disorder providers, the QHP issuer must demonstrate compliance with the time and distance standards in Tables 3.1 and 3.2 of the 2023 Letter in any county where those standards are more stringent than the standards in Section 10(d-5) of NATA. (see 45 CFR 156.230(a)(2)(i)(A)) Nothing in this subsection (k)(1) supersedes the requirement that, if the applicable time and distance standards under 215 ILCS 124/10(d-5) are not met within a county, the issuer shall provide the necessary exceptions to its network as described in 215 ILCS 124/10(d-5)(3).

2)         For an SADP, a QHP issuer must file with the Department a network adequacy and transparency description that satisfies the provisions of 50 Ill. Adm. Code 4540.30 and 50 Ill. Adm. Code 4540.40(a), (b)(3), (b)(4), (c), (d)(1), (g)(1), (g)(2), (h), (i), (j), (p), (q)(1), (q)(2), (q)(5), and (r). For 50 Ill. Adm. Code 4540.40(d)(1), Table 3.3 of the 2023 Letter applies instead of Tables 3.1 and Table 3.2 (see 45 CFR 156.230(a)(2)(i)(A)).

3)         For exception requests, a QHP issuer must include a completed QHP network adequacy justification form (see 45 CFR 156.230(a)(2)(ii)).

4)         In general, the Exchange may grant an exception to a time and standard in Tables 3.1, 3.2, or 3.3 of the 2023 Letter if the Exchange determines that making the QHP available through the Exchange is in the interests of qualified individuals in this State (see 45 CFR 156.230(a)(3)). However, under Section 10(g) of NATA, the Department cannot grant an exception to any time and distance standard for mental health or substance use disorder providers specified in Section 10(d-5) of NATA. In any county where the time and distance standard in the 2023 Letter is more stringent than the standard in Section 10(d-5), the Exchange may grant an exception only to the extent that the QHP still complies with the time and distance standards in Section 10(d-5). If the QHP does not comply with the time and distance standards in Section 10(d-5) in a county, then the QHP must comply with the network exceptions provision in Section 10(d-5)(3).

5)         The provisions of 45 CFR 156.230(a)(4) apply to the Exchange only when at least 80 percent of counties in the State are classified as Counties with Extreme Access Considerations (CEAC) as defined in 50 Ill. Adm. Code 4540.30.

l)          For the purpose of implementing the federal requirement at 45 CFR 156.235(a)(1) that a QHP issuer must include in its provider network a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income individuals or individuals residing in Health Professional Shortage Areas within the QHP service area, in accordance with the network adequacy standards of the Exchange where the QHP is offered, the Illinois Exchange adopts the standards applicable in Federally-facilitated Exchanges as provided in 45 CFR 156.235.

m)        A QHP issuer must comply with the requirements for coverage through a direct primary care medical home provided in 45 CFR 156.245 (Mar. 27, 2012) (no later editions or amendments).

n)         A QHP issuer must provide all information that is critical for obtaining health insurance coverage or access to health care services through the QHP in the manner required under 45 CFR 156.250 (Feb. 27, 2015) (no later editions or amendments).

o)         A QHP issuer must comply with the limitations on rating variations provided in 45 CFR 156.255 (Mar. 27, 2012) (no later editions or amendments).

p)         In the individual market, a QHP issuer must (see 45 CFR 156.260 (Mar. 27, 2012) (no later editions or amendments)):

1)         Enroll a qualified individual during the annual open enrollment periods described in 45 CFR 155.410(e)(4) (Apr. 15, 2024) (no later editions or amendments), and abide by the effective dates of coverage established at 45 CFR 155.410(f)(3);

2)         Make available, at a minimum, special enrollment periods for QHPs described in 45 CFR 155.420(d) (Apr. 15, 2024) (no later editions or amendments) and abide by the effective dates of coverage established at 45 CFR 155.420(b); and

3)         notify a qualified individual of the qualified individual's effective date of coverage.

q)         A QHP issuer must comply with the enrollment process for qualified individuals provided in 45 CFR 156.265 (May 14, 2020) (no later editions or amendments). Until the Exchange becomes a State-based Exchange, the Exchange will enforce 45 CFR 156.265(d) regarding binder payments and premium payment deadlines in the manner required under 45 CFR 156.350(a)(4) (Apr. 17, 2018) (no later editions or amendments).

r)          A QHP issuer must comply with the termination of coverage or enrollment for qualified individuals provided in 45 CFR 156.270.

s)         A QHP issuer must comply with the provisions for issuer participation for the full plan year specified in 45 CFR 156.272 (Dec. 22, 2016) (no later editions or amendments), except that:

1)         references within that rule to 45 CFR 156.815 instead will refer to Section 4500.80 of this Part; and

2)         references to a "Federally-facilitated Exchange" or "Federally-facilitated SHOP" refer to the Illinois Exchange's individual market or the Illinois SHOP, respectively.

t)          For the abortion care and abortifacient coverages required under Sections 356z.4a and 356z.60 of the Code, a QHP issuer must comply with 45 CFR 156.280(d) through (i) (Sep. 27, 2021) (no later editions or amendments).

u)         A QHP issuer offering a QHP through the SHOP must comply with 45 CFR 156.286 (Apr. 17, 2018) (no later editions or amendments).

v)         A QHP issuer must comply with the prescription drug distribution and cost reporting requirements of 45 CFR 156.295 (May 5, 2021) (no later editions or amendments).