Section 4500.230  Eligibility Appeals

 

a)         This Section provides the requirements for appeals of eligibility determinations issued by the Illinois Exchange. It incorporates all rights, requirements, and limitations applicable to the Exchange, an applicant, an authorized representative, a hearing officer, or any other participant in an appeals process that are provided in 45 CFR Part 155, Subpart F. Hearings under this Section are subject to the Illinois Administrative Procedure Act [5 ILCS 100], but unless otherwise specified, they are not subject to 50 Ill. Adm. Code 2402.

 

b)         Right to Appeal. An applicant has the right to appeal to the Illinois Exchange to contest the following actions by the Exchange, including with respect to their effective date:

 

1)         An initial eligibility determination, including the amount of advance payments of the premium tax credit (APTC) and level of cost-sharing reductions (CSRs);

 

2)         A redetermination of eligibility, including the amount of APTC and CSRs;

 

3)         An eligibility determination for an annual open enrollment period or special enrollment period;

 

4)         Failure of the Exchange to provide timely notice of an eligibility determination; and

 

5)         Unless the Exchange delegates the responsibility to HHS, an eligibility determination for an exemption to the individual mandate requiring insurance, if applicable, in accordance with 45 CFR 155.605.

 

c)         Filing an Appeal. An appeal is timely if the Exchange receives it within 90 days from the applicant's receipt of the notice of eligibility determination.

 

1)         An applicant is presumed to have received the notice of eligibility determination five business days after the date printed on the notice. An applicant may rebut the presumption by providing documentary evidence or testimony that the applicant actually received the notice of eligibility determination more than five business days after the date printed on the notice. If the Exchange determines that the evidence or testimony is not satisfactory, the Exchange will dismiss the appeal as untimely.

 

2)         With an untimely appeal, or in a later request to vacate a dismissal for failure to submit a valid appeal based on untimeliness, an applicant may submit a written explanation showing exceptional circumstances. For purposes of this subsection, "exceptional circumstances" includes situations in which an applicant demonstrates that, but for the occurrence of an unforeseen or uncontrollable event or condition, they would have timely filed or taken the required action.

 

d)         Representation. Applicants may represent themselves or be represented by an authorized representative, attorney, relative, friend, or another spokesperson. If an applicant designates a representative, the designation must be in writing or submitted through another legally binding format subject to applicable authentication and data security standards. An attorney representing an applicant must file a written notice of appearance. Unless the context requires otherwise, references in this Section to the "applicant" include persons designated under this subsection.

 

e)         Expedited Appeals. An applicant may request an expedited appeal when the applicant can show an immediate need for health care services because a standard appeal could jeopardize the applicant's life, health, or ability to attain, maintain, or regain maximum function.

 

1)         An expedited appeal must be requested in the same manner as a standard appeal.

 

2)         At the time the expedited appeal is requested, the applicant may submit evidence of the need for an expedited appeal and an explanation of why the applicant believes the eligibility determination is incorrect.

 

3)         If an expedited appeal is granted, the hearing will be scheduled as soon as practicable, but the Department will serve the notice of the hearing at least 10 days before the hearing, unless the parties agree to an earlier hearing date.

 

4)         If the request for an expedited appeal is denied solely with respect to the expedited basis, the Exchange will inform the applicant of the denial promptly and without undue delay, through electronic or oral notification, if possible. If notification is oral, the Exchange will follow up with the applicant by written notice. Written notice of the denial will include:

 

A)        The reason for the denial;

 

B)        An explanation that the appeal request will be transferred to the standard appeal process; and

 

C)        An explanation of the applicant's rights under the standard process.

 

5)         The informal resolution process may continue through the expedited appeal process before the hearing.

 

f)         Informal Resolution. Upon receipt of a valid appeals request, the Exchange may attempt to resolve the appeal through an informal resolution process before a hearing.

 

1)         Participation in the informal resolution process will not affect or waive the applicant's right to a hearing unless the Exchange and the applicant agree to a decision.

 

2)         The applicant may decline to participate in the informal resolution process at any time and proceed directly to a hearing.

 

3)         If the Exchange and the applicant resolve the appeal through informal resolution, the informal resolution decision must be final and binding. By agreeing to the decision, the applicant must waive the right to proceed to hearing. If a notice of hearing has been issued, the informal resolution decision will include the Director's Order terminating the hearing process.

 

4)         Except as provided in subsection (e)(5), if the informal resolution process concludes without a resolution, the matter will proceed to a hearing.

 

5)         The documentation provided and produced during the informal resolution process will become part of the appeal record. If the appeal advances to hearing, the applicant will not be asked to provide duplicative information or documentation that the applicant previously provided during the application or informal resolution process.

 

g)         Notice of Hearing. When a hearing is scheduled, the Department will send written notice to the applicant and the applicant's authorized representative, if any, of the date, time, legal authority, a short and plain statement of the matters asserted, the consequences of a failure to respond, and the location or format of the hearing. The Notice of Hearing will be served no later than 15 days before the hearing date unless the Department, in its sole discretion, grants a request from the applicant for an earlier hearing date; or for an expedited hearing as described in subsection (e)(3).

 

h)         Conduct of the Hearing. A hearing officer appointed by the Director will conduct the hearing. The hearing officer and the Exchange's representative must ensure that the applicant is afforded the right to review the appeal record, including all documents and records to be used at the hearing, at a reasonable time before the hearing date and during the hearing. The hearing must be conducted as an evidentiary hearing and must include the opportunity for both parties to:

 

1)         present their case to establish all relevant facts and circumstances;

 

2)         present an argument without undue interference; and

 

3)         question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses.

 

i)          Hearing officer. The hearing officer has the authority to conduct a hearing, take all necessary action to avoid delay, maintain order, and ensure the development of clear and complete record.

 

1)         The authority of the hearing officer includes, but is not limited to, authority to:

 

A)        administer oaths and affirmations;

 

B)        regulate the course of hearings, set the time and place for continued hearings, fix the time for the filing of documents, and otherwise conduct the proceeding according to generally recognized administrative law;

 

C)        examine witnesses and direct witnesses to testify, limit the number of times any witness may testify, limit repetitious or cumulative testimony, and set reasonable limits on the amount of time each witness may testify;

 

D)        rule upon offers of proof and receive relevant evidence;

 

E)        sign and issue subpoenas that require attendance, giving testimony and the production of books, papers, and other documentary evidence;

 

F)         direct parties to appear and confer for the settlement or simplification of issues, and to otherwise conduct prehearing conferences;

 

G)        dispose of procedural matters or similar requests;

 

H)        issue the report described in subsection (l)(1); and

 

I)         enter any order that further carries out the purpose of this Section.

 

2)         Except as provided in subsection (n), the hearing officer has no authority to dismiss a hearing and must afford all parties the right to be heard and to establish a record.

 

3)         Disqualification of hearing officer. At any time before the issuance of a ruling directly related to the merits of the hearing, either party may move to disqualify the hearing officer on the grounds of bias or conflict of interest.  The motion must be made in writing to the Director with a copy to the hearing officer and the opposing party and must set forth the specific instances of bias or conflict of interest. A hearing officer may at any time voluntarily disqualify themselves, subject to the Director's approval.

 

A)        A hearing officer must be disqualified if the hearing officer was directly involved in the eligibility determination or any prior Exchange appeal decisions in the same matter.

 

B)        An adverse decision or ruling, in itself, is not grounds for disqualification.

 

C)        The hearing officer's employment or contract with the Department is not, in itself, a conflict of interest.

 

j)          Rescheduling the Hearing. A hearing may be postponed or continued at the discretion of the hearing officer upon request.

 

k)         Transcription of Proceedings. The hearing will be recorded either by a certified court reporter or a recording device. If an applicant would like the oral proceedings of the hearing transcribed, the applicant must notify the hearing officer at least 5 days before the scheduled hearing. The applicant must pay for the transcription except as otherwise provided by the Department or by law.

 

l)          Appeals Decisions after a Hearing. Unless the applicant or applicant's representative fails to appear at a hearing without good cause or the appeal is withdrawn before a decision is issued, this subsection will govern the rendering of an appeals decision after a hearing.

 

1)         After the hearing, the hearing officer must compile the record and submit a written report to the Director that contains separately stated findings of fact, conclusions of law, and recommendations for a decision. Findings of fact must be based exclusively on the evidence presented at the hearing or known to all parties, including matters officially noticed.

 

2)         The Director will issue an order in writing that constitutes the final decision in the appeal, which contains the Director's findings of fact and conclusions of law based on the record of the hearing. The Director may adopt, partially adopt, or reject the hearing officer's findings, conclusions, and recommendations. The order will be issued electronically, unless otherwise agreed upon. The order will be issued within 90 days of the date the Exchange received the appeal, as administratively feasible, unless a shorter time is required by law.

 

3)         A rehearing before the Department is not available for appeals decisions issued under this Section.

 

m)        Implementation of Appeals Decisions. The decision after a hearing, administrative review, or as agreed in the informal resolution process will be implemented either:

 

1)         Prospectively on the first day of the month following the notice of appeal decision; or

 

2)         Retroactively, to the coverage effective date the applicant did receive or would have received if the applicant had enrolled in coverage under the incorrect eligibility determination that is the subject of the appeal, at the option of the applicant.

 

n)         Dismissal. If the Exchange dismisses an appeal, the Exchange will provide timely written notice to the applicant that includes the reason for the dismissal; how the dismissal affects the applicant's eligibility; and how an applicant may show good cause why the dismissal should be vacated.

 

1)         The Exchange will dismiss an appeal when an applicant:

 

A)        Fails to submit a valid appeal. An appeal is not valid if it is untimely or if the applicant does not have a right to appeal to the Exchange under subsection (b);

 

B)        Dies before the appeal is concluded;

 

C)        Withdraws the appeal as described in subsection (o). If the withdrawal occurs after a Notice of Hearing has been issued, the hearing officer or the Director will issue an Order of Dismissal to terminate the proceedings without receiving evidence on the record or considering the pleadings; or

 

D)        Fails to appear at the hearing without good cause. The hearing officer or the Director will issue an Order of Dismissal to terminate the proceedings without receiving evidence on the record or considering the pleadings.

 

2)         Vacating a dismissal.  The Exchange will vacate a dismissal if the applicant submits a written request showing good cause. To vacate a dismissal:

 

A)        The applicant must make the written request within 30 days of the notice of the dismissal; and

 

B)        The request must state the reason for good cause to vacate the dismissal.

 

i)          For a dismissal that was based on the applicant's failure to timely file an appeal, the Exchange may recognize good cause to vacate if the applicant demonstrates exceptional circumstances as defined in subsection (c)(2).

 

ii)         For dismissals based on other reasons, the Exchange may recognize good cause to vacate in situations including, but not limited to:

 

•           a death or serious illness in the person's family;

 

•           a personal injury or physical or mental illness that reasonably prevents an applicant from attending the hearing;

 

•           an emergency, crisis, including a mental health crisis, or unforeseen event that reasonably prevents an applicant from attending the hearing;

 

•           lack of or failure to receive timely notice of the hearing in the preferred language of an applicant involved in the hearing;

 

•           excusable neglect, excusable inadvertence, or excusable mistake as determined by the Exchange;

 

•           where an interpreter, translator, or other service necessary to accommodate a person with a disability is needed but not available; or

 

•           any other compelling reason beyond the applicant's control as determined by the Exchange in relation to its prior basis for dismissal.

 

3)         If the Exchange denies a request to vacate a dismissal, the Exchange will provide timely written notice of the denial and include a description of the applicant's right to administrative review under subsection (p)(3).

 

o)         Withdrawal. An applicant may withdraw an appeal request for any reason at any time during the appeal process. The withdrawal request must be made in writing or by telephone. If the withdrawal request is made by telephone, the Exchange will record it in full and will provide a written confirmation to the applicant documenting the telephonic withdrawal.

 

p)         Administrative Review. An applicant may seek administrative review of an appeal decision through one of the following ways:

 

1)         File a complaint for administrative review in Illinois court within 35 days of the date of the appeal decision under 735 ILCS 5/3-103;

 

2)         Request review of the decision by the Centers for Medicare & Medicaid Services (CMS) Administrator within 14 calendar days of the date of the appeal decision; or

 

3)         File an appeal request of the decision or the denial of request to vacate dismissal to the US Department of Health and Human Services (HHS) within 30 days of the date of the decision. This method is the only avenue for review of the Exchange's denial of a request to vacate a dismissal.

 

q)         The provisions of 50 Ill. Adm. Code 2402.290 govern the restrictions on ex parte communications related to hearings under this Section.

 

(Source:  Added at 49 Ill. Reg. 14672, effective October 28, 2025)