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.

"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.).

"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.

"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.

(Source:  Amended at 50 Ill. Reg. 5346, effective April 1, 2026)