1. a) A Member who is unsatisfied with a coverage decision made by a Plan Administrator may appeal such decision by complying with the appeals process established by the Plan Administrator.
2. b) Each Plan Administrator's appeals process shall comply with all applicable federal and state laws and regulations.
3. c) Unless a health plan is maintained on a self-insured basis, the Agency will have no direct involvement in appeals relating to coverage decisions made by a Plan Administrator, since non-self-insured plans are regulated by the Department of Insurance. For any health plan maintained on a self-insured basis, the Agency may permit a Member who has exhausted all available appeal levels through the Plan Administrator to submit a final appeal request to the Agency only if the appeal is based on an administrative denial, not on a medical denial. The final appeal request will be reviewed by the Agency and granted or denied based on the requirements of the Act or this Part.

(Source: Amended at 48 Ill. Reg. 9547, effective June 20, 2024)