Section 2001.2 Definitions and Cross-References

TITLE 50: INSURANCE

CHAPTER I: DEPARTMENT OF INSURANCE

SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE

PART 2001 CONSTRUCTION AND FILING OF ACCIDENT AND HEALTH INSURANCE POLICY FORMS

SECTION 2001.2 DEFINITIONS AND CROSS-REFERENCES

Section 2001.2  Definitions and Cross-References

a)         The

following definitions apply to this Part:

"ACA" means the

Patient Protection and Affordable Care Act

(

42 U.S.C.

18001 et seq.).

"Accident

and Health Insurance" means insurance transacted under Class 1(b) or 2(a)

of Section 4 of the Code.

"Adverse

Determination" has the meaning ascribed in Section 10 of the Managed Care

Reform and Patient Rights Act [215 ILCS 134].

"Code"

means the Illinois Insurance Code [215 ILCS 5].

"Covered

Individual" means an individual insured, enrollee, subscriber,

participant, beneficiary, dependent, or other individual member under a policy

or certificate of health insurance coverage or a group health plan.

"Dental

Service Plan" has the meaning ascribed in Section 4 of the DSP Act.

"Department"

means the Illinois Department of Insurance.

"Director" means the

Director of the Department.

"DSP

Act" means the Dental Service Plan Act [215 ILCS 110].

"EHB" means essential

health benefit or benefits.

"ERISA" means the

Employee Retirement Income Security Act of 1974, as amended (29 U.S.C. 1001 et

seq.).

"Excepted

benefits"

has the meaning ascribed in 42 U.S.C.

300gg-91(c).

"Grandfathered

Health Plan" has the meaning ascribed in 45 CFR 147.140 (Dec. 15, 2020)

(no later editions or amendments).

"Health Benefits

Exchange" or "Exchange" means the Illinois Health Benefits

Exchange established pursuant to 42 U.S.C. 18031(b) and 215 ILCS 122/5-5, also

known as the Illinois Health Insurance Marketplace.

"Health

Care Plan" has the meaning ascribed in Section 1-2(7) of the HMO Act.

"Health Care Provider" means an individual or

entity duly licensed, certified, or otherwise legally authorized to perform or

recommend health care services

s the Illinois Health Benefits

Exchange established pursuant to 42 U.S.C. 18031(b) and 215 ILCS 122/5-5, also

known as the Illinois Health Insurance Marketplace.

"Health

Care Plan" has the meaning ascribed in Section 1-2(7) of the HMO Act.

"Health Care Provider" means an individual or

entity duly licensed, certified, or otherwise legally authorized to perform or

recommend health care services.

"Health

Care Service" means a service or item for the diagnosis, prevention,

treatment, cure, or relief of a health condition, illness, injury, or disease.

The term includes, but is not limited to, hospital, medical, surgical, mental

health, substance use disorder, home health, nursing, dental, vision,

transportation, and pharmaceutical services or products.

"Health

Insurance Coverage" has the meaning ascribed in Section 5 of Illinois

HIPAA.

"Health

Insurance Issuer" has the meaning ascribed in Section 5 of Illinois HIPAA.

"HHS" means the United

States Department of Health and Human Services.

"HMO

Act" means the Health Maintenance Organization Act [215 ILCS 125].

"HMO

Point of Service Plan" means a "point of service plan" as

defined at 50 Ill. Adm. Code 4521.20 that is offered under Article IV.5 of the

HMO Act.

"Illinois

HIPAA" means the Illinois Health Insurance Portability and Accountability

Act [215 ILCS 97].

"LHSO

Act" means the Limited Health Service Organization Act [215 ILCS 130].

"Limited

Health Care Plan" has the meaning ascribed at Section 1002 of the LHSO

Act.

"Limited

Point of Service Product" means a "point-of-service product" as

defined in Section 1002 of the LHSO Act that is offered under Section 3009 of

the LHSO Act.

"Network Plan" means

health insurance coverage of a health insurance issuer under which the

financing and delivery of medical care (including items and services paid for

as medical care) are provided, in whole or in part, through a defined set of

providers under contract with the issuer.

"PHS Act" means the

Public Health Service Act (42 U.S.C. 201 et seq.)

under Section 3009 of

the LHSO Act.

"Network Plan" means

health insurance coverage of a health insurance issuer under which the

financing and delivery of medical care (including items and services paid for

as medical care) are provided, in whole or in part, through a defined set of

providers under contract with the issuer.

"PHS Act" means the

Public Health Service Act (42 U.S.C. 201 et seq.).

"Preexisting

condition exclusion"

means a limitation or exclusion

of benefits (including a denial of coverage) based on the fact that the

condition was present before the effective date of coverage (or if coverage is

denied, the date of the denial) under a group health plan or group or individual

health insurance coverage (or other coverage provided to federally eligible

individuals pursuant to 45 CFR

148

), whether or not any

medical advice, diagnosis, care, or treatment was recommended or received

before that day. A preexisting condition exclusion includes any limitation or

exclusion of benefits (including a denial of coverage) applicable to an

individual as a result of information relating to an individual's health status

before the individual's effective date of coverage (or if coverage is denied,

the date of the denial) under a group health plan, or group or individual

health insurance coverage (or other coverage provided to federally eligible

individuals pursuant to 45 CFR

148

), such as a condition

identified as a result of a pre-enrollment questionnaire or physical

examination given to the individual, or review of medical records relating to

the pre-enrollment period. (See 45 CFR 144.103.)

"SBC" means summary of

benefits and coverage.

"Secretary" means the

Secretary of the United States Department of Health and Human Services, except

when specified otherwise within this Part.

"Shared

Clinical Decision-making" means a collaborative process where a healthcare

provider and patient together make a healthcare choice. It is also known as shared

decision-making or individual decision-making

eans summary of

benefits and coverage.

"Secretary" means the

Secretary of the United States Department of Health and Human Services, except

when specified otherwise within this Part.

"Shared

Clinical Decision-making" means a collaborative process where a healthcare

provider and patient together make a healthcare choice. It is also known as shared

decision-making or individual decision-making.

"State

Guidelines" means immunization recommendations issued by the Illinois

Department of Public Health pursuant to Section 1.2 of the Communicable Disease

Prevention Act [410 ILCS 315].

"Utilization

Review Program" has the meaning ascribed in Section 10 of the Managed Care

Reform and Patient Rights Act.

"VHSP

Act" means the Voluntary Health Services Plans Act [215 ILCS 165].

"Voluntary

Health Services Plan" has the meaning ascribed at Section 2(b) of the VHSP

Act.

"Waiting Period" means,

with respect to a group health plan and an individual who is a potential

participant or beneficiary in the plan, the period of time that must pass with

respect to the individual before the individual is eligible to be covered for

benefits under the terms of the plan.  (See 42 U.S.C. 300gg(b)(4).)

b)         In

this Part, parenthetical cross-references following rule text are to the

federal statutes or regulations relating to that Illinois rule provision.