Section 4515.20 Definitions

TITLE 50: INSURANCE

CHAPTER I: DEPARTMENT OF INSURANCE

SUBCHAPTER ww: HEALTH CARE SERVICE PLANS

PART 4515 NAVIGATOR, IN-PERSON COUNSELOR AND CERTIFIED APPLICATION COUNSELOR CERTIFICATION

SECTION 4515.20 DEFINITIONS

Section 4515.20

Definitions

"Act"

means the Navigator Certification Act [215 ILCS 121].

"Certification"

means the issuance by the Director of an authorization pursuant to this Part.

"Certified

Application Counselor" means any employee or volunteer of a Certified

Application Counselor Organization that enters into an agreement with the

Marketplace to have its employees or volunteers provide information to

individuals and employees about insurance affordability programs and qualified

health plan coverage options; assist individuals and employees to apply for

coverage in a qualified health plan through the Marketplace and for insurance

affordability programs; and help to facilitate enrollment of eligible

individuals in qualified health plans and insurance affordability programs.

"Certified

Application Counselor Organization" means any organization designated by

the Marketplace to certify its staff members or volunteers to act as certified

application counselors and includes those organizations described in 45 CFR

155.225 (Apr. 27, 2023) (no later editions or amendments).

"Code" means the Illinois Insurance Code

[215 ILCS 5].

"Course"

means any course of study certified to the Director that meets the requirements

of this Part, including, but not limited to, seminar, classroom, and self-study

formats.

"Department" means the Illinois Department

of Insurance.

"Director"

means the Director of the Department or anyone to whom the Director's responsibilities

and authority are lawfully delegated.

"Federal

training curriculum" means the curriculum implemented by the United States

Department of Health and Human Services under 45 C.F.R. 155.215(b) (Apr. 25,

2019) (no later editions or amendments)

"Department" means the Illinois Department

of Insurance.

"Director"

means the Director of the Department or anyone to whom the Director's responsibilities

and authority are lawfully delegated.

"Federal

training curriculum" means the curriculum implemented by the United States

Department of Health and Human Services under 45 C.F.R. 155.215(b) (Apr. 25,

2019) (no later editions or amendments).

"In-Person

Counselor" means any individual or entity who receives grant funds from

the State of Illinois to perform the activities and duties identified in 45 CFR

155.205 (Apr. 15, 2024) (no later editions or amendments) or is described or

designated by a Marketplace, the State, or the United States Department of

Health and Human Services, or could reasonably be described or designated as

"non-Navigator assistance personnel" as described in 45 CFR 155.215.

An In-Person Counselor would engage in the activities and meet the standards

described in 45 CFR 155.215, including, but not limited to:

conduct

public education activities to raise awareness of the availability of qualified

health plans;

distribute

fair and impartial information concerning enrollment in qualified health plans,

and the availability of premium tax credits under 26 U.S.C. 36B and

cost-sharing reductions under 42 U.S.C. 18071;

facilitate enrollment in qualified health plans;

provide

referrals to any applicable office of health insurance consumer assistance or

health insurance ombudsman established under section 2793 of the Public Health Services

Act (42 U.S.C. 300gg-93), or any other appropriate State agency or agencies,

for any enrollee with a grievance, complaint, or question regarding his or her

health plan, coverage, or a determination under a plan or coverage; and

provide

information in a manner that is culturally and linguistically appropriate to

the needs of the population being served by the Marketplace

Public Health Services

Act (42 U.S.C. 300gg-93), or any other appropriate State agency or agencies,

for any enrollee with a grievance, complaint, or question regarding his or her

health plan, coverage, or a determination under a plan or coverage; and

provide

information in a manner that is culturally and linguistically appropriate to

the needs of the population being served by the Marketplace.

"Marketplace"

means any health benefit exchange authorized under the federal Patient

Protection and Affordable Care Act and established or operating in this State,

including any exchange established or operated by the United States Department

of Health and Human Services.

"Navigator"

means any individual or entity who is certified as a "Navigator"

under the federal Patient Protection and Affordable Care Act, and means any

individual or entity, other than an insurance producer licensed by the

Department, who receives grant funds from the United States Department of

Health and Human Services to perform any of the activities and duties

identified in 42 U.S.C. 18031(i)(3) or is described or designated by a

Marketplace, the State, or the United States Department of Health and Human

Services, or could reasonably be described or designated, as Navigators, as

described in 45 CFR 155.210 (Apr. 27, 2023) (no later editions or amendments).

A Navigator would engage in the activities and meet the standards described in

45 CFR 155.210 and 45 CFR 155.215, including, but not limited to:

conduct

public education activities to raise awareness of the availability of qualified

health plans;

distribute

fair and impartial information concerning enrollment in qualified health plans,

and the availability of premium tax credits under 26 U.S.C. 36B and

cost-sharing reductions under 42 U.S.C

t the standards described in

45 CFR 155.210 and 45 CFR 155.215, including, but not limited to:

conduct

public education activities to raise awareness of the availability of qualified

health plans;

distribute

fair and impartial information concerning enrollment in qualified health plans,

and the availability of premium tax credits under 26 U.S.C. 36B and

cost-sharing reductions under 42 U.S.C. 18071;

facilitate enrollment in qualified health plans;

provide

referrals to any applicable office of health insurance consumer assistance or

health insurance ombudsman established under section 2793 of the Public Health

Services Act (42 U.S.C. 300gg-93), or any other appropriate State agency or

agencies, for any enrollee with a grievance, complaint, or question regarding his

or her health plan, coverage, or a determination under a plan or coverage; and

provide

information in a manner that is culturally and linguistically appropriate to

the needs of the population being served by the Marketplace.

"Qualified

health plan" or "QHP"

has

the meaning given that term in 42 U.S.C. 18021(a).

"Successful

completion" means passing an examination with a score of 80% or above in

no more than three attempts.