a) Guaranteed Availability of Coverage in the
Individual and Group Market Subject to subsections (b) through (d), a health
insurance issuer that offers health insurance coverage in the individual or
group market in this State must offer to any individual or employer in this
State all products that are approved for sale in the applicable market, and
must accept any individual or employer that applies for any of those products.
(
45 CFR
147.106 )
b) Enrollment Periods
A health insurance issuer may restrict enrollment in health
insurance coverage to open or special enrollment periods.
1) Open Enrollment Periods
A) Group Market
A health insurance issuer in the group market must allow an
employer to purchase health insurance coverage for a group health plan at any
point during the year. In the case of health insurance coverage offered in the
small group market, a health insurance issuer may limit the availability of
coverage to an annual enrollment period that begins November 15 and extends
through December 15 of each year in the case of a plan sponsor that is unable
to comply with a material plan provision relating to employer contribution or
group participation rules as defined in
45 CFR
147.106(b)(3), pursuant to
215
ILCS 97/30(B)(3) and, in the case of
a QHP offered in the Small Business Health Option Program (SHOP), as permitted
by
45 CFR
156.285(c). With respect to
coverage in the small group market, and in the large group market if such
coverage is offered in a SHOP in a state, coverage must become effective
consistent with the dates described in
45 CFR
155.725(h).
B) Individual Market
A health insurance issuer in the individual market must allow
an individual to purchase health insurance coverage during the initial and
annual open enrollment periods described in
45 CFR
155.410(b) and (e). Coverage
must become effective consistent with the dates described in
45 CFR
155.410(c) and (f).
2) Limited Open
Enrollment Periods
A health insurance issuer in the individual market must
provide a limited open enrollment period for the events described in
45 CFR
155.420(d), excluding
paragraphs (d)(3) (concerning citizenship status), (d)(8) (concerning Indians),
and (d)(9) (concerning exceptional circumstances). In addition, a health
insurance issuer in the individual market must provide, with respect to
individuals enrolled in non-calendar year individual health insurance policies,
a limited open enrollment period beginning on the date that is 30 calendar days
prior to the date the policy year ends in 2014.
3) Special Enrollment Periods
A health insurance issuer in the group and individual market
must establish special enrollment periods for qualifying events as defined
under section 603 of ERISA. These special enrollment periods are in addition to
any other special enrollment periods that are required under federal and
Illinois law.
4) Length of
Enrollment Periods
With respect to the group market, enrollees must be provided
30 calendar days after the date of the qualifying event described in subsection
(b)(3) to elect coverage. With respect to the individual market, enrollees must
be provided 60 calendar days after the date of an event described in
subsections (b)(2) and (b)(3) to elect coverage.
5) Effective Date of Coverage for Limited
Open and Special Enrollment Periods
With respect to an election made under subsection (b)(2) or
(b)(3), coverage must become effective consistent with the dates described in
45 CFR
155.420(b). (
45 CFR
147.106 )
c) Special Rules for Network Plans
1) In the case of a health insurance issuer
that offers health insurance coverage in the group and individual market
through a network plan, the issuer may do the following:
A) Limit the employers that may apply for the
coverage to those with eligible individuals in the group market who live, work
or reside in the service area for the network plan, and limit the individuals
who may apply for the coverage in the individual market to those who live or
reside in the service area for the network plan.
B) Within the service area of the plan, deny
coverage to employers and individuals if the issuer has demonstrated to the
Director the following:
i) It will not have
the capacity to deliver services adequately to enrollees of any additional
groups or any additional individuals because of its obligations to existing
group contract holders and enrollees.
ii) It is applying this subsection (c)(1)
uniformly to all employers and individuals without regard to the claims
experience of those individuals, employers and their employees (and their
dependents) or any health status-related factor relating to such individuals,
employees, and dependents.
2) An issuer that denies health insurance
coverage to an individual or an employer in any service area, in accordance
with subsection (c)(1)(B), may not offer coverage in the individual or group
market, as applicable, within the service area to any individual or employer,
as applicable, for a period of 180 calendar days after the date the coverage is
denied. This subsection (c)(2) does not limit the issuer's ability to renew
coverage already in force or relieve the issuer of the responsibility to renew
that coverage.
3) Coverage offered
within a service area after the 180-day period specified in subsection (c)(2)
is subject to the requirements of this Section. (
45 CFR
147.106 )
d) Application of Financial Capacity Limits
1) A health insurance issuer may deny health
insurance coverage in the group or individual market if the issuer has
demonstrated to the Director the following:
A)
It does not have the financial reserves necessary to offer additional
coverage.
B) It is applying this
subsection (d)(1) uniformly to all employers or individuals in the group or
individual market, as applicable, in this State consistent with applicable
Illinois law and without regard to the claims experience of those individuals,
employers and their employees (and their dependents) or any health
status-related factor relating to those individuals, employees and
dependents.
2) An issuer
that denies health insurance coverage to any employer or individual in this
State under subsection (d)(1) may not offer coverage in the group or individual
market, as applicable, in this State before the later of either of the
following dates:
A) The
181st day after the date the issuer denies
coverage;
B) The date the issuer
demonstrates to the Director, if required under applicable Illinois law, that
the issuer has sufficient financial reserves to underwrite additional
coverage.
3) Subsection
(d)(2) does not limit the issuer's ability to renew coverage already in force
or relieve the issuer of the responsibility to renew that coverage.
4) Coverage offered after the 180-day period
specified in subsection (d)(2) is subject to the requirements of this
Section.
5) The Director may
provide for the application of this subsection (d) on a service-area-specific
basis. (
45 CFR
147.106 )
e) Marketing
A health insurance issuer and its officials, employees,
agents and representatives must comply with Illinois law regarding marketing by
health insurance issuers and cannot employ marketing practices or benefit
designs that will have the effect of discouraging the enrollment of individuals
with significant health needs in health insurance coverage or discriminate
based on an individual's race, color, national origin, present or predicted
disability, age, sex, gender identity, sexual orientation, expected length of
life, degree of medical dependency, quality of life, or other health
conditions. (
45 CFR
147.106 )
f) Guaranteed Renewability of Coverage
General Rule.
Subject to subsections (g) through (i), a health insurance
issuer offering health insurance coverage in the individual or group market is
required to renew or continue in force the coverage at the option of the plan
sponsor or the individual, as applicable. (
45 CFR
147.106 )
g) Exceptions
An issuer may nonrenew or discontinue health insurance
coverage offered in the group or individual market based only on one or more of
the following:
1) Nonpayment of
Premiums
The plan sponsor or individual, as applicable, has failed to
pay premiums or contributions in accordance with the terms of the health
insurance coverage, including any timeliness requirements.
2) Fraud
The plan sponsor or individual, as applicable, has performed
an act or practice that constitutes fraud or made an intentional
misrepresentation of material fact in connection with the coverage.
3) Violation of Participation or
Contribution Rules
In the case of group health insurance coverage, the plan
sponsor has failed to comply with a material plan provision relating to
employer contribution or group participation rules, pursuant to applicable
Illinois law. For purposes of this subsection (g)(13), the following
apply:
A) The term "employer
contribution rule" means a requirement relating to the minimum level or amount
of employer contribution toward the premium for enrollment of participants and
beneficiaries.
B) The term "group
participation rule" means a requirement relating to the minimum number of
participants or beneficiaries that must be enrolled in relation to a specified
percentage or number of eligible individuals or employees of an
employer.
4) Termination
of Plan
The issuer is ceasing to offer coverage in the market in
accordance with subsection (h) or (i) and applicable Illinois law.
5) Enrollees' Movement Outside
Service Area
For network plans, there is no longer any enrollee under the
plan who lives, resides or works in the service area of the issuer (or in the
area for which the issuer is authorized to do business) and, in the case of the
small group market, the issuer applies the same criteria it would apply in
denying enrollment in the plan under
45 CFR
147.104(c)(1)(i).
6) Association Membership Ceases
For coverage made available in the small or large group
market only through one or more bona fide associations, if the employer's
membership in the bona fide association ceases, but only if the coverage is
terminated uniformly without regard to any health status-related factor
relating to any covered individual. (
45 CFR
147.106 )
h) Discontinuing a Particular Product
In any case in which an issuer decides to discontinue
offering a particular product offered in the group or individual market, that
product may be discontinued by the issuer in accordance with applicable
Illinois law in the applicable market only if the following occurs:
1) The issuer provides notice in writing to
each plan sponsor or individual, as applicable, provided that particular
product in that market (and to all participants and beneficiaries covered under
such coverage) of the discontinuation at least 90 calendar days before the date
the coverage will be discontinued.
2) The issuer offers to each plan sponsor or
individual, as applicable, provided that particular product the option, on a
guaranteed availability basis, to purchase all (or, in the case of the large
group market, any) other health insurance coverage currently being offered by
the issuer to a group health plan or individual health insurance coverage in
that market.
3) In exercising the
option to discontinue that product and in offering the option of coverage under
subsection (h)(2), the issuer acts uniformly without regard to the claims
experience of those sponsors or individuals, as applicable, or any health
status-related factor relating to any participants or beneficiaries covered or
new participants or beneficiaries who may become eligible for such coverage. (
45 CFR
147.106 )
i) Discontinuing All Coverage
1) An issuer may elect to discontinue
offering all health insurance coverage in the individual or group market, or
all markets, in this State in accordance with applicable Illinois law only if:
A) The issuer provides notice in writing to
the Director and to each plan sponsor or individual, as applicable, (and all
participants and beneficiaries covered under the coverage) of the
discontinuation at least 180 calendar days prior to the date the coverage will
be discontinued; and
B) All health
insurance policies issued or delivered for issuance in this State in the
applicable market (or markets) are discontinued and not renewed.
2) An issuer that elects to
discontinue offering all health insurance coverage in a market (or markets) in
this State as described in this subsection (i) may not issue coverage in the
applicable market (or markets) in this State during the 5-year period beginning
on the date of discontinuation of the last coverage not renewed. (
45 CFR
147.106 )
j) Exception for Uniform Modification of
Coverage
Only at the time of coverage renewal may issuers modify the
health insurance coverage for a product offered to a group health plan in the
following:
1) Large group
market;
2) Small group market if,
for coverage available in this market (other than only through one or more bona
fide associations), the modification is consistent with Illinois law and is
effective uniformly among group health plans with that product. (
45 CFR
147.106 )
k) Application to Coverage Offered Only
Through Associations
In the case of health insurance coverage that is made
available by a health insurance issuer in the small or large group market to
employers only through one or more associations, the reference to "plan
sponsor" is deemed, with respect to coverage provided to an employer member of
the association, to include a reference to the employer. (
45 CFR
147.106 )
l) Applicability Date
The provisions of this Section apply for plan years (in the
individual market, policy years) beginning on or after January 1, 2014. (
45 CFR
147.106 )
m) Grandfathered Health Plans
This Section does not apply to grandfathered health plans in
accordance with
45 CFR
147.140. (
45 CFR
147.106 )