Section 4500.170  QHP Eligibility and Enrollment

a)         An applicant will be eligible for enrollment in a QHP through the Exchange, including an SADP, if the applicant meets the requirements in 45 CFR 155.305(a) (Apr. 15, 2024) (no later editions or amendments), including all of the following:

1)         The applicant is a citizen or national of the United States, or is a non-citizen who is lawfully present in the United States, and is reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought;

2)         The applicant is not incarcerated, other than incarceration pending the disposition of charges; and

3)         The applicant meets the applicable residency standard identified in 45 CFR 155.305(a)(3).

b)         For a QHP that is a catastrophic plan, an applicant will be eligible for enrollment if the applicant meets the requirements of subsection (a) and either (see 45 CFR 155.305(h)):

1)         has not attained the age of 30 before the beginning of the plan year; or

2)         has a certification in effect for any plan year that the applicant is exempt from the requirement to maintain minimum essential coverage under 26 U.S.C. 5000A by reason of:

A)        26 U.S.C. 5000A(e)(1) relating to individuals without affordable coverage; or

B)        26 U.S.C. 5000A(e)(5) relating to individuals with hardships.

c)         Upon receipt of an application, the Exchange will determine whether an applicant is eligible for Medicaid or CHIP as provided in 45 CFR 155.305(c) and (d).

d)         The Exchange will accept a QHP selection from an applicant determined eligible for enrollment in a QHP. The Exchange will notify the QHP issuer of the applicant's selected QHP and transmit the information necessary to enable the issuer to enroll the applicant.

e)         The Exchange will accept enrollment of a qualified individual in a QHP only during the annual open enrollment period or a special enrollment period as described in Section 4500.180.

f)         An applicant has the right to appeal an eligibility determination as provided in 45 CFR 155, Subpart F (as those provisions of the Code of Federal Regulations were in effect on August 1, 2024) (no later editions or amendments).

g)         For plan years when the Illinois Exchange is a State-based Exchange on the Federal Platform, the Illinois Exchange will rely on HHS to perform all eligibility and enrollment functions, including related appeals.

(Source:  Added at 49 Ill. Reg. 420, effective December 26, 2024)