Health Rate Review Consumer Guide

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The Illinois Department of Insurance (“Department”) regulates all fully insured health insurance plans in Illinois, including health maintenance organizations (HMOs). The Department provides free, unbiased services for all Illinois consumers who have state-regulated health insurance. If a consumer is curious as to whether their health plan is regulated by the state, they can look for “DOI” to be listed on their insurance card.

If you encounter problems with your health insurance coverage, you may file a complaint with the Office of Consumer Health Insurance at the Department by visiting IDOI Help Center (Home) or calling 877-527-9431 to request that a complaint form be mailed to you. For more information about the Department and the products it regulates, visit its homepage at idoi.illinois.gov.

ACA is the Patient Protection and Affordable Care Act, referred to as the Affordable Care Act or “ACA” for short, the health care reform law enacted in March 2010. The ACA provides comprehensive, affordable health insurance to uninsured and underinsured consumers.

Fully insured health plans are plans where an employer or individual pays a premium to an insurance company in exchange for comprehensive coverage for the employees and dependents.

Individual health insurance is health insurance purchased directly by individuals - such as the ACA Marketplace - and not provided through employers. Consumers who purchase insurance via the Marketplace can receive a tax deduction for their health insurance, and self-employed individuals can buy Marketplace health insurance with additional tax benefits.

Large group insurance is health insurance for groups with 51 or more full-time employees.

Medical loss ratio (MLR) is a measure of the percentage of premium dollars that a health plan spends on medical claims and quality improvements versus administrative costs.

Premium is the amount of money a consumer must pay to receive a specific amount of insurance coverage. In this instance, a premium is the amount a consumer must pay for health insurance.

Rate is the base price for a health insurance plan that an issuer uses to calculate a premium for individual consumers. Rates are filed with and reviewed by the Department.

Small group insurance is health insurance for groups with 50 or fewer full-time employees.

Self-insured health plans are plans offered by an employer or association in which the employer or association pays for the medical claims of its employees and dependents. The employer assumes the financial risk of providing health benefits and may use an insurance company to administer the plan.

For plan year 2026 and thereafter, P.A. 103-0106 grants the Department the authority to review a health insurer’s rates in the individual and small group markets; determine whether rates are unreasonable or inadequate; and approve, disapprove, or modify rates. The Department also publicly posts rates and accepts public comments from interested parties and consumers.

The act does not apply to large group insurance, self-insured plans, or any government insurance program such as Medicare or Medicaid; however, the Healthcare Protection Act (“HPA”) (P.A. 103-0650) will require some large group insurers to file rates annually for approval with the Department. This requirement will begin on January 1, 2026.

How are rates developed?

Each year, health insurance companies determine future premiums based on a number of past factors.

These factors include, but are not limited to, hospital and prescription drug costs, enrollment figures, utilization trends, and inflation. Companies use these factors to project future consumer premium costs and ensure they can pay claims and remain financially stable. The ACA establishes an MLR which requires insurers to spend at least 80% of premiums collected in the individual and small group markets and requires insurers to spend at least 85% of premiums collected in the large group market.

Other factors that can impact consumer premium costs include age, location, the number of employees in an employer plan, and the type of plan a consumer chooses.

Under the ACA, a health insurance company may not use a consumer’s pre-existing conditions to deny coverage or determine a consumer’s premium rates.

What is the rate review process?

All individual and small group insurers are required to submit their rates to the Department annually by a deadline set by the Director of Insurance. Deadlines may change from year-to-year. After the rates are submitted, the Department is required to post the rates on its website within five (5) business days and then accept public comments for a period of 30 days. The Department must post all public comments within five (5) business days after the comment period ends.

The Director must then issue a decision approve, disapprove, or modify an insurer’s rates within 60 days. The Director must take public comments into account. If the Director does not issue a decision, the plan rates are automatically approved. The Department is required to notify the insurer of its decision and post the final rates on its website.

The Department uses credentialed actuaries and experts to determine whether rates are reasonable and adequate.

Where do I find the rate tables?

Individual and small group rates filed with the Department can be found here: Rate Filings. The Department posts an insurer’s initial average, maximum and minimum plan rate increases or decreases on the left-hand side of the table, and the Department posts an insurer’s final average, maximum and minimum plan rate increases or decreases on the right-hand side of the table. Links to the carrier’s rate filing or filings and the Department’s final decisions are posted on the far-right side of the table.

The initial rates filed by an insurer may vary from the final rates. The initial rates may also remain the same. After an insurer files their initial rates, the Director will determine whether the insurer’s rates are reasonable or adequate. If the insurer’s rates are found to be unreasonable or inadequate, the Director will adjust the final rates. If the insurer’s rates are found to be both reasonable and adequate, the Director will approve the rates without making any changes.

Beginning January 1, 2026, the Healthcare Protection Act (“HPA”) (P.A. 103-0650) requires some large group insurers to file rates annually for approval with the Department. The Department shall approve, disapprove, or modify rate filings within 60 days of receipt. The Department can disapprove or modify a rate filing it determines to be unreasonable.