Section 4540.30 Definitions

Section 4540.30  Definitions

Terms used in this Part have

the meanings ascribed in Section 5 of the Act. In addition, the following

definitions apply to this Part and the Act:

"2023

Letter" means the "2023 Letter to Issuers in the

Federally-facilitated Exchanges"

published by

the Centers for Medicare & Medicaid Services, 7500 Security Boulevard,

Baltimore, Maryland  21244

(January 7, 2022) (no later editions or

amendments), available online at

https://www.cms.gov/files/document/2023-draft-letter-issuers-508.pdf.

"Act"

means the Network Adequacy and Transparency Act [215 ILCS 124].

"Acute

inpatient hospital" means a hospital that provides emergency services 24

hours per day, every day of the year.

"CEAC"

or "Counties with Extreme Access Considerations" means counties that

satisfy the criteria for a CEAC county type designation provided in Section

3.1.1 of the MA Guidance.

"Contracted

network group" means, for an insurer filing a network description under

Section 10 of the Act, any group of providers with a direct or indirect

contract or arrangement with a PPPA, MCO, other insurer, exempt HMO, or any

other business entity by which beneficiaries are incentivized or required to

use those providers' services, and which the filing insurer has directly or

indirectly contracted or arranged with the business entity to include among the

filing insurer's preferred providers at any tier of its own network plan.  "Contracted

network group" includes any group of providers the filing insurer has

directly or indirectly contracted or arranged through another business entity

to use for the filing insurer's network plan even when the group also is or has

previously been contracted or arranged to provide services under Medicaid, Medicare,

or any other public or private health benefits program not subject to the Act.

"Contracted network group" does not include providers with which the

filing insurer has directly contracted or arranged for services under its network

plan

e for the filing insurer's network plan even when the group also is or has

previously been contracted or arranged to provide services under Medicaid, Medicare,

or any other public or private health benefits program not subject to the Act.

"Contracted network group" does not include providers with which the

filing insurer has directly contracted or arranged for services under its network

plan.  For purposes of this definition, a parent, subsidiary, or other

affiliate of a filing insurer is not the same business entity as the filing

insurer.

"County

type" means Large Metro, Metro, Micro, Rural, or CEAC.

"Exempt

HMO" means an HMO with respect to its Medicaid or Medicare Advantage

health care plan.

"HMO"

means a Health Maintenance Organization as defined in Section 1-2(9) of the

Health Maintenance Organization Act [215 ILCS 125].

"Individual

or group policy for dental or vision insurance" means limited scope dental

or vision benefits provided under a separate policy, certificate, or contract

of insurance in compliance with 45 CFR 146.145(b)(3)(i) through (iii) (May 14,

2020) (no later editions or amendments) or 45 CFR 148.220(b)(1) (Oct. 31, 2016)

(no later editions or amendments).  The term includes, but is not limited to, a

stand-alone dental plan.

"Large

Metro" means a county that satisfies the criteria for a Large Metro county

type designation provided in Section 3.1.1 of the MA Guidance.

"MA

Guidance" means the "Medicare Advantage Network Adequacy Criteria

Guidance"

published by the Centers for Medicare

& Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland  21244

(January 10, 2017) (no later editions or amendments), available online at https://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/Downloads/MA_Network_Adequacy_Criteria_Guidance_Document_1-10-17.pdf

uidance" means the "Medicare Advantage Network Adequacy Criteria

Guidance"

published by the Centers for Medicare

& Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland  21244

(January 10, 2017) (no later editions or amendments), available online at https://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/Downloads/MA_Network_Adequacy_Criteria_Guidance_Document_1-10-17.pdf.

"Material change" has

the meaning ascribed in Section 5 of the Act and includes, but is not limited

to:

a reduction of 10% or more

of a

provider

specialty

type

in the network as a whole;

the removal of a major health

system that causes a network to be significantly different within one or more

counties from the network when the beneficiary purchased the network plan;

when the network's provider ratio

for any type of provider no longer satisfies the requirements of Section

4540.40(e); and

when the network no longer

satisfies the time and distance standards in any county for any type of

provider described or incorporated under Section 4540.40(d). (Section 5 of the

Act)

"MCO"

has the meaning ascribed in 50 Ill. Adm. Code 4521.20.

"Metro"

means a county that satisfies the criteria for a Metro county type designation

provided in Section 3.1.1 of the MA Guidance.

"Micro"

means a county that satisfies the criteria for a Micro county type designation

provided in Section 3.1.1 of the MA Guidance.

"Network"

means the group or groups of preferred providers providing services to a

network plan

. (Section 10 of the Act) Unless otherwise indicated, for

purposes of the Act, a network consists of all preferred providers, and only

those preferred providers, that service a network plan's beneficiaries,

including all network tiers, if applicable, regardless of whether the filing

insurer directly employs or contracts with those providers or has arranged

access to them as members of one or more contracted network groups

ss otherwise indicated, for

purposes of the Act, a network consists of all preferred providers, and only

those preferred providers, that service a network plan's beneficiaries,

including all network tiers, if applicable, regardless of whether the filing

insurer directly employs or contracts with those providers or has arranged

access to them as members of one or more contracted network groups.

Notwithstanding the existence of any contract between the insurer and the

provider or the provider's contracted network group, a provider that is not a

preferred provider with respect to a particular network plan is not part of the

network for that plan.  Nothing in this definition prevents more than one

network plan from having the same network, nor shall it be interpreted in a

manner inconsistent with Section 10(e) of the Act.

"Preferred

provider" means any provider who has entered, either directly or

indirectly, into an agreement with an employer or risk-bearing entity relating

to health care services that may be rendered to beneficiaries under a network

plan.

(Section 5 of the Act)

"Preferred

Provider Program Administrator" has the meaning ascribed in 50 Ill. Adm.

Code 2051.220.

"Provider

ratio" means the number of preferred providers of a given provider

specialty type within the service area in relation to the number of network

plan beneficiaries.

"Provider

specialty type" or "type of provider" means a provider specialty

type listed in 215 ILCS 124/10(c)(1) or in Table 3.1 or 3.2 of the 2023 Letter.

A single facility may encompass more than one provider type.

"Rural"

means a county that satisfies the criteria for a Rural county type designation

provided in Section 3.1.1 of the MA Guidance.

"Qualified

health plan" or "QHP" means a health plan that meets the

criteria for a qualified health plan in 42 U.S.C. 18021.

"SERFF"

means the

System for Electronic Rate and Form Filing

provided by the National Association of Insurance Commissioners (https://www.serff.com)

ns a county that satisfies the criteria for a Rural county type designation

provided in Section 3.1.1 of the MA Guidance.

"Qualified

health plan" or "QHP" means a health plan that meets the

criteria for a qualified health plan in 42 U.S.C. 18021.

"SERFF"

means the

System for Electronic Rate and Form Filing

provided by the National Association of Insurance Commissioners (https://www.serff.com).

"Service area" means the

approved county or total composition of counties where the network plan is

available for purchase to consumers.

"Stand-alone dental

plan" has the meaning ascribed in 45 CFR 153.400 (May 26, 2022) (no later

editions or amendments).