Section 4500.180  Annual Open Enrollment and Special Enrollment Periods

a)         During the annual open enrollment period, any qualified individual may enroll in a QHP, including an SADP, and any enrollee may change QHPs.

1)         Unless provided otherwise under subsection (a)(2), the annual open enrollment period begins November 1 of the calendar year before the benefit year and extends through January 15 of the benefit year. (see 45 CFR 155.410(e)(4) (Apr. 15, 2024) (no later editions or amendments))

2)         For plan years when the Exchange operates as a State-based Exchange, the Illinois Exchange may provide a longer annual enrollment period that begins on November 1 of the calendar year before the benefit year and extends through a date later than January 15 of the benefit year if the Illinois Exchange provides advance public notice on its website at least 120 days before the first day of the period.

b)         For QHP selections that the Exchange receives during the annual open enrollment period, coverage must be effective as provided in 45 CFR 155.410(f)(3)(i).

c)         If the qualified individual or enrollee experiences a triggering event for a special enrollment period, the qualified individual may enroll in a QHP and an enrollee may change QHPs as provided in 45 CFR 155.420. References to "dependent" in 45 CFR 155.420 are deemed to incorporate the definition of the term in Section 4500.30. Additionally, for plan years when the Exchange operates as a State-based Exchange:

1)         The Illinois Exchange expressly adopts the triggering event for the death of the enrollee or the enrollee's dependent in 45 CFR 155.420(d)(2)(ii).

2)         The triggering events based on other exceptional circumstances under 45 CFR 155.420(d)(9) include, but are not limited to:

A)        when a qualified individual receives a certification of pregnancy from a qualified health care professional, including a licensed certified professional midwife, who is licensed or certified under the laws of this State or any other state to provide pregnancy-related health care services. The special enrollment period lasts through the 60th day after the date the qualified individual received the certification of pregnancy.  The special enrollment period includes the qualified individual's dependents; and

B)        when a qualified individual is an uninsured taxpayer who requested health insurance benefit information through the Easy Enrollment Program. If the uninsured taxpayer is a qualified individual, the special enrollment period includes the uninsured taxpayer's dependents. As used in this subsection, "dependent" has the meaning ascribed in Section 4500.30. The special enrollment period lasts through the 60^th day after the date of the letter from the Illinois Exchange under Section 513(d) of the Illinois Income Tax Act.

3)         A qualified individual or a qualified individual's dependent who has a loss of Medicaid coverage described in 45 CFR 155.420(d)(1)(i) has 90 days after the triggering event to select a QHP.

d)         For QHP selections received during a special enrollment period, coverage must be effective as provided in 45 CFR 155.420(b)(1), (b)(2), (b)(4), and (b)(5) , subject to the following provisions for plan years when the Exchange operates as a State-based Exchange:

1)         For the special enrollment periods described in 45 CFR 155.420(b)(2)(iv), except as provided in subsection (d)(4) below, if the plan selection is made after the date of the triggering event, coverage must become effective on the first day of the month after plan selection.

2)         For the special enrollment period in subsection (c)(1) triggered by the death of an enrollee or the enrollee's dependent, coverage must become effective on the first day of the month after plan selection.

3)         For the special enrollment period in subsection (c)(2)(A) triggered by a certification of pregnancy, the pregnant individual may elect to have coverage become effective on:

A)        the first day of the month of the pregnancy certification;

B)        the first day of the month after the pregnancy certification; or

C)        the first day of the month after the pregnant individual makes the plan selection.

4)         For the special enrollment period in subsection (c)(2)(B) triggered by the Easy Enrollment Program, coverage must be effective the first day of the month after plan selection.

5)         For a qualified individual or a qualified individual's dependent who has a loss of minimum essential coverage described in 45 CFR 155.420(d)(1)(i) that occurs in the middle of a month, if the qualified individual or dependent makes the plan selection during the month before the triggering event, the qualified individual or dependent may elect to have coverage become effective on the first day of either the month of the triggering event or the month after the triggering event.

6)         For the special enrollment periods described in 45 CFR 155.420(d)(2)(i) triggered by a qualified individual gaining or becoming a dependent through birth, adoption, placement for adoption, placement in foster care, or child support or other court order, the qualified individual or enrollee may elect to have coverage effective either on the date of the triggering event or on the first day of the month after plan selection.

A)        For medical QHPs or SADPs, nothing in subsection (d)(5) waives the Illinois requirement that the policy must cover a newborn child from the moment of birth under the circumstances described in Section 356c of the Code, Section 4-8 of the HMO Act, or Section 30.1 of the DSP Act, as applicable to the product network type. If an issuer elects under Section 356c of the Code, Section 4-8 of the HMO Act, or Section 30.1 of the DSP Act to require timely payment of a specific premium to extend the dependent newborn's coverage beyond the first 31 days, or to effectuate coverage for the newborn from the moment of birth in the case of a qualified individual who had no other dependents on the policy at the moment of birth, the qualified individual's failure to timely pay premiums for those purposes will not prevent the qualified individual from electing to make coverage effective on the first day of the month after plan selection.

B)        For an SADP offered by a limited health service organization, the general requirements of subsection (d)(5) apply without regard for subsection (d)(5)(A).

C)        Nothing in subsection (d)(5) affects the requirement described in 45 CFR 155.420(d)(2)(i) triggered by a qualified individual gaining or becoming a dependent through marriage that coverage must be effective for the qualified individual or enrollee on the first day of the month after plan selection.

e)         An applicant has the right to appeal a determination related to eligibility for an enrollment period as provided in 45 CFR Part 155, Subpart F.

f)         For plan years when Illinois operates a State-based Exchange on the Federal Platform, the Illinois Exchange will rely on HHS to perform all eligibility and enrollment functions, including related appeals.

g)         For plan years when Illinois operates a State-based Exchange, the Illinois Exchange will perform eligibility and enrollment functions provided or incorporated under this Section, including related appeals under Section 4500.230.

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