il-v50i40-50-ill-adm-code-4521: 50 Ill. Adm. Code 4521 — Health Maintenance Organization

1) Heading of the Part: Health Maintenance Organization 2) Code Citation: 50 Ill. Adm. Code 4521 3) Section Number: Proposed Action: 4521.20 Amendment 4) Statutory Authority: Implementing and authorized by Sections 1-2, 2-1, 2-8, 2-9, 3-1, 4- 6.1, 4-7, 4-12, 4-13, 4-17, 4.5-1, 5-2 and 5-7 of the Health Maintenance Organization Act [215 ILCS 125]; 42 U.S.C. 300gg-22; and 45 CFR 150.101(b)(2) and 150.201. 5) A Complete Description of the Subjects and Issues Involved: This rulemaking is filed pursuant to Section 5-15 of the Illinois Administrative Procedure Act and is only changing the address of the Department's Springfield Office to reflect the fact that the office is moving on September 23, 2026. Section 5-15 of the Illinois Administrative Procedure Act requires agencies to include a statement of how the proposed rule made under this Section satisfies the criteria established by subsections (a) and (b). The Department's address is used by the public to obtain information from the Department and/or make submissions or requests of the Department. These members of the public may include insurance companies, persons licensed by the Department, and Illinois insurance consumers. The address provided in the rules should be accurate, otherwise such persons may go to or send correspondence to the wrong address. The decision to relocate the Springfield office was an internal management decision. The private rights of individuals are not affected by Department rules containing the accurate address, although having the incorrect address in rule will cause unnecessary confusion and delay for people seeking information from and/or making submissions to the Department in person or via mail. It is in the public interest to have the Department's office address published in the Illinois Administrative Code be correct. 6) Published studies or reports, and sources of underlying data, used to compose this rulemaking: Not required for Section 5-15 notices. 7) Will this proposed rulemaking replace an emergency rule currently in effect? Not required for Section 5-15 notices. 8) Does this rulemaking contain an automatic repeal date? Not required for Section 5-15 notices. 9) Does this proposed amendment contain incorporations by reference? Not required for Section 5-15 notices. 10) Are there any other proposed rulemakings pending on this Part? No 11) Statement of Statewide Policy Objectives: Not required for Section 5-15 notices. 12) Time, Place, and Manner in which interested persons may comment on this proposed rulemaking: Persons who wish to comment on this proposed rulemaking may submit written comments no later than 14 days after the publication of this Notice to: Kathryn Williams Department of Insurance 115 S. LaSalle Street, 13 Floor Chicago, IL 60603 (312) 814-8212 Kathryn.A.Williams@illinois.gov 13) Initial Regulatory Flexibility Analysis: Not required for Section 5-15 notices. A) Description of the type of small business, not for profit corporations or small municipalities subject to the proposed amendment: None B) Description of the proposed reporting, bookkeeping and other procedures required for compliance with the amendment: None C) Description of the types of professional skills necessary for compliance: None 14) Small Business Economic Impact Analysis: Not required for Section 5-15 notices. 15) Regulatory Agenda on which this rulemaking was summarized: Not required for Section 5-15 notices. 16) Any other information or justification for the proposed rule or amendment that the agency believes would be helpful to the public regarding the proposed rule or amendment. For example, a discussion or analysis of the benefits of the proposed rule or DEPARTMENT OF INSURANCE NOTICE OF PROPOSED AMENDMENT amendment is projected to have on the Illinois public, consumers, investors or other similar groups. Not required for Section 5-15 notices. The full text of the Proposed Amendment begins on the next page: DEPARTMENT OF INSURANCE NOTICE OF PROPOSED AMENDMENT TITLE 50: INSURANCE CHAPTER I: DEPARTMENT OF INSURANCE SUBCHAPTER ww: HEALTH CARE SERVICE PLANS PART 4521 HEALTH MAINTENANCE ORGANIZATION Section 4521.10 Scope 4521.20 Definitions 4521.30 Valuation of Investments 4521.40 Grievance Procedure 4521.50 Contracts, Administrative Arrangements and Material Modifications 4521.60 Rates (Repealed) 4521.70 Subordinated Indebtedness 4521.80 Financial Reporting (Repealed) 4521.90 Conflict of Interest and Required Disclosure 4521.100 Solicitation 4521.110 Requirements for Group Contracts, Evidences of Coverage and Individual Contracts 4521.111 Cancellation 4521.112 Form Filing Requirements 4521.113 Point of Service Plan Requirements 4521.120 Internal Security Standards and Fidelity Bonds 4521.130 Basic Health Care Services 4521.131 Basic Outpatient Preventive and Primary Health Care Services for Children 4521.132 Required Coverage for Reconstructive Surgery Following Mastectomies 4521.140 General Provisions 4521.141 HMO Producer Licensing Requirements 4521.142 Limited Insurance Representative Requirements − Public Aid and Medicare Enrollers 4521.150 Severability AUTHORITY: Implementing and authorized by Sections 1-2, 2-1, 2-8, 2-9, 3-1, 4-6.1, 4-7, 4- 12, 4-13, 4-17, 4.5-1, 5-2 and 5-7 of the Health Maintenance Organization Act [215 ILCS 125]; 42 U.S.C. 300gg-22; and 45 CFR 150.101(b)(2) and 150.201. SOURCE: Filed June 16, 1976, effective July 1, 1976; codified at 7 Ill. Reg. 3016; amended at 15 Ill. Reg. 199, effective December 28, 1990; amended at 20 Ill. Reg. 10639, effective July 25, DEPARTMENT OF INSURANCE NOTICE OF PROPOSED AMENDMENT 1996; recodified at 21 Ill. Reg. 1729; emergency amendment at 21 Ill. Reg. 15262, effective November 18, 1997, for a maximum of 150 days; amended at 22 Ill. Reg. 6671, effective March 31, 1998; amended at 23 Ill. Reg. 5690, effective May 3, 1999; emergency amendment at 26 Ill. Reg. 5146, effective March 25, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 13088, effective August 19, 2002; transferred from the Department of Insurance to the Department of Financial and Professional Regulation pursuant to Executive Order 2004-6 on July 1, 2004; amended at 28 Ill. Reg. 14412, effective October 19, 2004; amended at 30 Ill. Reg. 4732, effective March 2, 2006; transferred from the Department of Financial and Professional Regulation to the Department of Insurance pursuant to Executive Order 2009-4 on June 1, 2009; amended at 37 Ill. Reg. 14032, effective August 26, 2013; amended at 38 Ill. Reg. 2272, effective January 2, 2014; amended at 38 Ill. Reg. 23437, effective November 25, 2014; amended at 39 Ill. Reg. 6505, effective April 24, 2015; recodified from 50 Ill. Adm. Code 5421 to 50 Ill. Adm. Code 4521 at 41 Ill. Reg. 4985; amended at 43 Ill. Reg. 9386, effective August 26, 2019; amended at 48 Ill. Reg. 7266, effective April 30, 2024; amended at 49 Ill. Reg. 1287, effective January 17, 2025; amended at 49 Ill. Reg. 16042, effective December 4, 2025; amended at 50 Ill. Reg. ______, effective ____________. Section 4521.20 Definitions "ACA" means the Patient Protection and Affordable Care Act (42 U.S.C. 18001 et seq.). "Act" means the Health Maintenance Organization Act [215 ILCS 125]. "Advertisement" has the meaning ascribed in Section 1-21(1) of the Act. "Base Rates" means the rate generated before any classification deviations are applied. "Basic Health Care Services" means emergency care, and inpatient hospital and physician care, outpatient medical services, mental health services and care for alcohol and drug abuse, infertility treatment, prenatal and postnatal care, delivery and inpatient services for maternity care, and preventative services required pursuant to 42 U.S.C. 300gg-13, all of which are subject to limitations set forth in this Part (see Section 1-2(3) of the Act). "Cancellation" means the termination of a group contract, evidence of coverage, or individual contract by an HMO prior to the expiration date of the group contract, evidence of coverage, or individual contract. DEPARTMENT OF INSURANCE NOTICE OF PROPOSED AMENDMENT "Code" means the Illinois Insurance Code [215 ILCS 5]. "Consumer" means any enrollee, provided that the individual is not or has not been in the previous two years an employee (including the employee's spouse or dependent) of the HMO or affiliate of the HMO or a provider furnishing health care services to the HMO or affiliate of the HMO. "Copayment" means the amount an enrollee must pay in order to receive a specific covered service that is not fully prepaid. "Deductible" means the amount an enrollee is responsible to pay out of pocket before the HMO begins to pay the costs associated with treatment. "Director" means the Director of the Illinois Department of Insurance. "Department" means the Illinois Department of Insurance. "Department of Insurance Complaint" means a written complaint filed by or on behalf of an enrollee, with the Department pursuant to Section 4-6 of the Act, excluding complaints filed by Illinois Department of Healthcare and Family Services HMO members under Section 5-11 of the Public Aid Code [305 ILCS 5/5-11] and complaints subject to handling by the Centers for Medicare and Medicaid Services (CMMS) pursuant to a contract entered into between CMMS and the HMO. "Enrollee" has the meaning ascribed in Section 1-2(4) of the Act. "Evidence of Coverage" has the meaning ascribed in Section 1-2(5) of the Act. "Governing Body" means the board of trustees, or directors, or, if otherwise designated in the basic organizational document bylaws, those individuals vested with the ultimate responsibility for the management of any organization that has been issued or is applying for a certificate of authority as an HMO. "Grievance" means any written complaint submitted to the HMO by or on behalf of an enrollee regarding any aspect of the HMO relative to the enrollee, but shall not include any complaint by or on behalf of a provider. DEPARTMENT OF INSURANCE NOTICE OF PROPOSED AMENDMENT "Grievance Committee" means individuals who have been appointed by the HMO to respond to grievances that have been filed on appeal from the HMO's simplified complaint process established pursuant to Section 4521.40(d). At least 50% of the individuals on this committee shall be enrollees who are consumers. "Group Contract" has the meaning ascribed in Section 1-2(6) of the Act. "Health Care Plan" has the meaning ascribed in Section 1-2(7) of the Act. "Health Care Services" has the meaning ascribed in Section 1-2(8) of the Act. "HMO" means Health Maintenance Organization. "Individual Contract" means a contract for health care services issued to and covering an individual. The individual contract may include dependents of the subscriber. "Limited Insurance Representative" means an individual appointed by an HMO to represent the HMO in the enrollment of recipients of Medicaid or Medicare in the HMO. "Managed Care Organization" or "MCO" means a partnership, association, corporation, or other legal entity, including but not limited to individual practice associations (IPAs) and Physician Hospital Organizations (PHOs), that delivers or arranges for the delivery of health care services through providers it has contracted with or otherwise made arrangements with to furnish those health care services. "Notice of Availability of the Department", as required by this Part, shall be no less informative than the following: The regulations of the Illinois Department of Insurance (50 Ill. Adm. Code 4521.110(p)) require that we advise you that if you wish to take this matter up with the Illinois Department of Insurance it maintains a Consumer Division in Chicago at 115 S. LaSalle Street, 13 Floor, Chicago, Illinois 60603 and in Springfield at 4800 Wabash Ave.320 West Washington Street, Springfield, Illinois 6271162767-0001. The Department can also be contacted by phone at (217) 782-4515 or its website at: https://idoi.illinois.gov. DEPARTMENT OF INSURANCE NOTICE OF PROPOSED AMENDMENT "Nursing Home" means a skilled nursing care facility that is subject to licensure by the Illinois Department of Public Health under the Nursing Home Care Act [210 ILCS 45]. "Point of Service Plan" means a plan in which an eligible enrollee is covered under both an HMO evidence of coverage and an indemnity insurance policy or certificate and may select, on a point-of-service basis, between using the HMO or the indemnity benefit program. "Primary Care Physician" means a provider who has contracted with an HMO to provide primary care services as defined by the contract and who is: a physician licensed to practice medicine in all of its branches who spends a majority of clinical time engaged in general practice or in the practice of internal medicine, pediatrics, gynecology, obstetrics, or family practice; a chiropractic physician licensed to treat human ailments without the use of drugs or operative surgery. "Producer" means a person directly or indirectly associated with a health care plan who engages in solicitation or enrollment (see Section 1-2(13) of the Act). "Provider" has the meaning ascribed in Section 1-2(12) of the Act. "Renewal" means the issuance and delivery by an HMO of a group contract or individual contract superseding at the end of the contract period a contract previously issued and delivered by the same HMO or the issuance and delivery of a certificate or notice extending the term of the group or individual contract beyond its contract term. "Solicitation" means any method by which information relative to an HMO is made known to the public for the purpose of informing or influencing potential enrollees to enroll in a Health Care Plan, regardless of the media or technique used. "State" means any governing body, department or agency of the State of Illinois that has regulatory authority under the Act. DEPARTMENT OF INSURANCE NOTICE OF PROPOSED AMENDMENT "Subscriber" has the meaning ascribed in Section 1-2(16) of the Act. "Supplemental Health Care Services" means any health care service other than basic health care services. "Usual and Customary Fee" means the fee, as reasonably determined by the HMO, that is based on the fee the provider who renders the service usually charges its patients for the same service. The fee shall be within the range of usual fees other providers of similar type, training, and experience in a similar geographic area charge their patients for the same service, under similar or comparable circumstances. (Source: Amended at 50 Ill. Reg. ______, effective ____________)