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91_SB0721eng
SB721 Engrossed LRB9105743JSpc
1 AN ACT concerning managed care dental benefit plans.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Dental Care Patient Protection Act.
6 Section 5. Purpose; dental care patient rights.
7 (a) The purpose of this Act is to provide fairness and
8 choice to dental patients and dentists under managed care
9 dental benefit plans.
10 (b) Dental care patients have the following rights:
11 (1) A patient has the right to care consistent with
12 professional standards of practice to assure quality
13 dental care, to choose the participating dentist
14 responsible for providing his or her care, to receive
15 information concerning his or her condition and proposed
16 treatment, to refuse any treatment to the extent
17 permitted by law, and to privacy and confidentiality of
18 records except as otherwise provided by law.
19 (2) A patient has the right, regardless of source
20 of payment, to examine and to receive a reasonable
21 explanation of his or her total bill for services
22 rendered by his or her dentist. A dentist shall be
23 responsible only for a reasonable explanation of those
24 specific dental care services provided by the dentist.
25 (3) A patient has the right to timely prior notice
26 of the termination in the event a plan cancels or refuses
27 to renew an enrollee's participation in the plan except
28 when the termination is for non-payment of premium or
29 termination of the plan by the group.
30 (4) A patient has the right to privacy and
31 confidentiality. This right may be expressly waived in
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1 writing by the patient or the patient's guardian.
2 (5) A patient has the right to purchase any dental
3 care services with that patient's own funds.
4 Section 10. Definitions. As used in this Act:
5 "Dental care services" means services permitted to be
6 performed by a licensed dentist or any person working under
7 the dentist's supervision as permitted by law.
8 "Dentist" means a person licensed to practice dentistry
9 in any state.
10 "Department" means the Department of Insurance.
11 "Director" means the Director of Insurance.
12 "Emergency dental services" means the provision of dental
13 care for a sudden, acute dental condition that would lead a
14 prudent layperson, who possesses an average knowledge of
15 dentistry, to reasonably expect the absence of immediate care
16 to result in serious impairment to the dentition or would
17 place the person's oral health in serious jeopardy.
18 "Enrollee" means an individual and his or her dependents
19 who are enrolled in a managed care dental plan.
20 "Managed care dental plan" or "plan" means a plan that
21 establishes, operates, or maintains a network of dentists
22 that have entered into agreements with the plan to provide
23 dental care services to enrollees to whom the plan has the
24 obligation to arrange for the provision of or payment for
25 services through organizational arrangements for ongoing
26 quality assurance, utilization review programs, or dispute
27 resolution.
28 For the purpose of this Act, "managed care dental plans"
29 do not include employee or employer self-insured dental
30 benefit plans under the federal ERISA Act of 1974.
31 "Point-of-service plan" means a plan or plans that
32 includes both in-plan covered services and out-of-plan
33 covered services as well as managed dental care plan
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1 arrangements in which the risk for out-of-plan covered
2 services is borne through reinsurance. The term also
3 includes indemnity benefits that are underwritten in whole by
4 a licensed insurance carrier or a self-funded employer group.
5 For purposes of this Section, "out-of-plan services" means
6 those services which are obtained from providers who do not
7 have a contract, or any other arrangements, with a managed
8 care dental plan or services obtained without a referral from
9 providers who have contracted to provide services to the
10 enrollees on behalf of the managed care dental plan.
11 "Primary care provider (dentist)" means a dentist, having
12 an arrangement with a managed care dental plan, selected by
13 an enrollee or assigned to an enrollee by a plan to provide
14 dental care services under a managed care dental plan.
15 "Prospective enrollee" means an individual eligible for
16 enrollment in a managed care dental plan offered by that
17 individual's employer.
18 "Provider" means either a general dentist or a dentist
19 who is a licensed specialist.
20 Section 15. Rules. The Department may promulgate such
21 rules as it deems reasonably necessary to implement the terms
22 of this Act. The Department shall establish an advisory
23 committee made up of representatives from the dental
24 profession to provide clinical advice and counsel to the
25 Department regarding dental managed care issues for which a
26 dentist's professional training is relevant in the course of
27 administering this Act. The advisory committee shall be
28 comprised of dentists licensed to practice in Illinois,
29 appointed by the Director as follows: 2 dental directors or
30 their dentist designee from managed care dental plans which
31 are subject to this Act, 2 general dentists, and the dental
32 director of the Illinois Department of Public Health. The
33 advisory committee shall meet as reasonably determined by the
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1 Director. Nothing in this Section shall be deemed as
2 authorizing or permitting the Department to delegate any
3 authority to enforce the provisions of this Act to the
4 advisory committee and any such delegation is expressly
5 prohibited hereunder.
6 Section 25. Provision of information.
7 (a) A managed care dental plan shall provide upon
8 request to prospective enrollees a written summary
9 description of all of the following terms of coverage:
10 (1) Information about the dental plan, including
11 how the plan operates and what general types of financial
12 arrangements exist between dentists and the plan. Nothing
13 in this Section shall require disclosure of any specific
14 financial arrangements between providers and the plan.
15 (2) The service area.
16 (3) Covered benefits, exclusions, or limitations.
17 (4) Pre-certification requirements including any
18 requirements for referrals made by primary care dentists
19 to specialists, and other preauthorization requirements.
20 (5) A list of participating primary care dentists
21 in the plan's service area, including provider address
22 and phone number, for an enrollee to evaluate the managed
23 care dental plan's network access, as well as a phone
24 number by which the prospective enrollee may obtain
25 additional information regarding the provider network
26 including participating specialists. However, a managed
27 care dental plan offering a preferred provider
28 organization ("PPO") product that does not require the
29 enrollee to select a primary care dentist shall only be
30 required to make available for inspection to enrollees
31 and prospective enrollees a list of participating
32 dentists in the plan's service area.
33 (6) Emergency coverage and benefits.
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1 (7) Out-of-area coverages and benefits, if any.
2 (8) The process about how participating dentists
3 are selected.
4 (9) The grievance process, including the telephone
5 number to call to receive information concerning
6 grievance procedures.
7 An enrollee shall be provided with an evidence of
8 coverage as required under the Illinois Insurance Code
9 provisions applicable to the managed care dental plan.
10 (b) An enrollee or prospective enrollee has the right to
11 the most current financial statement filed by the managed
12 care dental plan by contacting the Department of Insurance.
13 The Department may charge a reasonable fee for providing such
14 information.
15 (c) The managed care dental plan shall provide to the
16 Department, on an annual basis, a list of all participating
17 dentists. Nothing in this Section shall require a particular
18 ratio for any type of provider.
19 (d) If the managed care dental plan uses a capitation
20 method of compensation to its primary care providers
21 (dentists), the plan must establish and follow procedures
22 that ensure that:
23 (1) the plan application form includes a space in
24 which each enrollee selects a primary care provider
25 (dentist);
26 (2) if an enrollee who fails to select a primary
27 care provider (dentist) is assigned a primary care
28 provider (dentist), the enrollee shall be notified of the
29 name and location of that primary care provider
30 (dentist); and
31 (3) primary care provider (dentist) to whom an
32 enrollee is assigned, pursuant to item (2), is physically
33 located within a reasonable travel distance, as
34 established by rule adopted by the Director, from the
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1 residence or place of employment of the enrollee.
2 (e) Nothing in this Act shall be deemed to require a
3 plan to assign an enrollee to a primary care provider
4 (dentist).
5 Section 35. Credentialing; utilization review; provider
6 input.
7 (a) Participating dentists shall be given an opportunity
8 to comment on the plan's policies affecting their services to
9 include the plan's dental policy, including coverage of a new
10 technology and procedures, utilization review criteria and
11 procedures, quality and credentialing criteria, and dental
12 management procedures provided, however, a plan shall not be
13 required to release any information which it deems
14 confidential or proprietary.
15 (b) Upon request, managed care dental plans shall
16 disclose to prospective purchasers the process about how
17 participating dentists are selected for the plan.
18 (c) A dentist under consideration for inclusion in a
19 managed care dental plan that requires the enrollee to select
20 a primary care provider (dentist) shall be subject to the
21 managed care dental plan's credentialing policy, which shall
22 be overseen by the dental director of the managed care dental
23 plan.
24 (d) Credentialing of dentists who will participate in a
25 managed care dental plan that requires its enrollees to
26 select a primary care provider (dentist) shall be based on
27 identified guidelines that have been adopted by the plan. The
28 managed care dental plan shall make the credentialing
29 guidelines available to applicants, upon request.
30 (e) A managed care dental plan shall have a dental
31 director who is a licensed dentist. The dental director shall
32 ultimately be responsible for the benefit coverage decisions
33 made by the plan which require professional dental training
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1 and clinical judgement. Decisions made by the plan to deny
2 coverage for a procedure, based primarily upon clinical
3 judgment, or that a payment for an alternative procedure
4 should be considered must be made by the dental director or a
5 licensed dentist acting under the supervision of the dental
6 director. Nothing in this Section prohibits a benefit
7 coverage decision that does not require a dentist's
8 professional judgment from being denied without a dentist's
9 involvement.
10 A provider advocating on behalf of a patient who has had
11 a claim denied, the basis of which requires professional
12 dental training and judgment, or was offered an alternative
13 benefit for payment by the plan has an opportunity to appeal
14 to the dental director by submitting a written appeal and
15 providing information that is reasonably needed to consider
16 the appeal. The dental director or a licensed dentist acting
17 under the supervision of the dental director shall respond to
18 the provider's appeal. Enrollees shall be afforded appeal
19 rights as specified in the benefits contract or as otherwise
20 provided by law.
21 (h) A managed care dental plan may not exclude a
22 provider solely because of the anticipated characteristics of
23 the patients of that provider.
24 (i) Before terminating a contract with a provider for
25 cause, the managed care dental plan shall provide a written
26 explanation of the reasons for termination. The provider
27 shall be given an opportunity for discussion with the dental
28 director or his dentist designee. If a managed care dental
29 plan conducts or uses utilization profiling as the primary
30 basis for terminating the provider contract for cause, the
31 managed care dental plan shall make available the utilization
32 data relevant to that provider in advance of the termination.
33 (j) A communication relating to the subject matter
34 provided for under subsection (a) or (i) of this Section may
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1 not be the basis for a cause of action for libel or slander,
2 except for disclosures or communications with parties other
3 than the plan or provider.
4 (k) The managed care dental plan shall establish
5 reasonable procedures for assuring a transition of enrollees
6 of the plan to new providers.
7 (l) This Act does not prohibit a managed care dental
8 plan from rejecting an application from a provider based on
9 the plan's determination that the plan has sufficient
10 qualified providers or if the plan reasonably determines that
11 inclusion of the provider is not in the best interest of the
12 managed care dental plan and its enrollees. Nothing in this
13 Act shall be construed as requiring a managed care dental
14 plan to contract with a dentist who has not agreed to the
15 terms of participation as specified by the plan.
16 (m) No contractual provision shall in any way prohibit a
17 dentist from discussing all clinical options for treatment
18 with a patient.
19 (n) A managed care dental plan shall submit for the
20 Director's approval, and thereafter maintain, a system for
21 the resolution of grievances concerning the provision of
22 dental care services or other matters concerning operation of
23 the managed care dental plan.
24 Section 40. Coverage; prior authorization. A managed
25 care dental plan shall:
26 (1) cover palliative treatment for emergency dental
27 services, as included in its certificate of coverage,
28 without regard to whether the provider furnishing the
29 services has a contractual or other arrangement with the
30 entity to provide items or services to covered
31 individuals, provided that the enrollee has made a
32 reasonable attempt to first obtain service through the
33 appropriate primary care dentist; and
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1 (2) if an enrollee suffers trauma to the mouth,
2 teeth or oral cavity that results in a need for emergency
3 dental services, as included in the certificate of
4 coverage, provide that the prior authorization
5 requirement for emergency dental is waived.
6 Nothing in this Section shall be deemed as requiring
7 managed care dental plans to provide coverage for emergency
8 dental services in excess of that required in the Illinois
9 Insurance Code.
10 Section 45. Prior authorization; consent forms. A plan
11 for which prior authorization is a condition to coverage of a
12 service must clearly disclose this provision in the evidence
13 of coverage.
14 Section 50. Point-of-service plans.
15 (a) If an employer who has 25 or more employees and
16 contributes 25% or more to the cost of the dental benefit
17 plan coverage to employees and the only dental plan coverage
18 being offered requires enrollees to select a primary care
19 provider (dentist) and has no out-of-plan covered services
20 option, the managed care dental plan with which the employer
21 is contracting for the coverage shall offer a dental
22 point-of-service ("POS") option to the employee.
23 (b) An employer may require an employee who accepts the
24 POS option to be responsible for the payment of a premium
25 over the amount of the premium for the coverage provided to
26 employees under the dental benefit plan offered which
27 requires enrollees to select a primary care provider
28 (dentist) and has no out-of-plan covered services option.
29 The enrollee may pay any additional premium either directly
30 or by payroll deduction in the same manner in which the other
31 premium is paid. The premium for the POS option shall be as
32 established by the managed care dental plan using its
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1 underwriting guidelines for establishing rates to be charged
2 for products which it offers.
3 (c) Different cost-sharing provisions may be imposed for
4 the POS option.
5 (d) An employer may charge an employee who accepts the
6 POS option a reasonable administrative fee for costs
7 associated with the employer's reasonable administration of
8 the POS option.
9 (e) The POS option to be offered pursuant to this
10 Section may be satisfied by the plan by allowing prospective
11 enrollees to elect the POS option during the employer's
12 enrollment period, and remaining in the POS option until the
13 next open enrollment period, or any other basis reasonably
14 determined by the plan to satisfy the requirements of this
15 Section.
16 (f) A managed care dental plan required to offer a POS
17 option pursuant to this Act shall be subject to those rules
18 for POS products as set by the Department.
19 Section 55. Private cause of action; existing remedies.
20 This Act and rules adopted under this Act do not:
21 (1) provide a private cause of action for damages
22 or create a standard of care, obligation, or duty that
23 provides a basis for a private cause of action for
24 damages; or
25 (2) abrogate a statutory or common law cause of
26 action, administrative remedy, or defense otherwise
27 available and existing before the effective date of this
28 Act.
29 Section 60. Record of complaints.
30 (a) The Department shall maintain records concerning the
31 complaints filed against the plan with the Department. The
32 Department shall make a summary of all data collected
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1 available upon request and publish the summary on the World
2 Wide Web.
3 (b) The Department shall maintain records on the number
4 of complaints filed against each plan.
5 (c) The Department shall maintain records classifying
6 each complaint by whether the complaint was filed by:
7 (1) a consumer or enrollee;
8 (2) a provider; or
9 (3) any other individual.
10 (e) The Department shall maintain records classifying
11 each complaint according to the nature of the complaint as it
12 pertains to a specific function of the plan. The complaints
13 shall be classified under the following categories:
14 (1) denial of care or treatment;
15 (2) denial of a diagnostic procedure;
16 (3) denial of a referral request;
17 (4) sufficient choice and accessibility of
18 dentists;
19 (5) underwriting;
20 (6) marketing and sales;
21 (7) claims and utilization review;
22 (8) member services;
23 (9) provider relations; and
24 (10) miscellaneous.
25 (f) The Department shall maintain records classifying
26 the disposition of each complaint. The disposition of the
27 complaint shall be classified in one of the following
28 categories:
29 (1) complaint referred to the plan and no further
30 action necessary by the Department;
31 (2) no corrective action deemed necessary by the
32 Department; or
33 (3) corrective action taken by the Department.
34 (g) No Department publication or release of information
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1 shall identify any enrollee, dentist, or individual
2 complainant.
3 Section 65. Administration of Act. The Director may
4 adopt rules necessary to implement the Department's
5 responsibility under this Act. To enforce the provisions of
6 this Act, the director may issue a cease and desist order or
7 require a managed care dental plan to submit a plan of
8 correction for violations of this Act, or both. Subject to
9 the provisions of the Illinois Administrative Procedure Act,
10 the Director may impose an administrative fine, not to exceed
11 $1,000, for failure to submit a requested plan of correction,
12 failure to comply with its plan of correction, or repeated
13 violations of the Act. All final decisions regarding the
14 imposition of a fine shall be subject to review under the
15 Illinois Administrative Review Law.
16 Section 70. Retaliation prohibited. A managed care
17 dental plan may not take any retaliatory actions, including
18 cancellation or refusal to renew a policy, against an
19 employer or enrollee solely because the employer or enrollee
20 has filed complaints with the plan or appealed a decision of
21 the plan.
22 Section 75. Application of other law.
23 (a) All provisions of this Act and other applicable law
24 that are not in conflict with this Act shall apply to managed
25 care dental plans and other persons subject to this Act.
26 (b) Solicitation of enrollees by a managed care entity
27 granted a certificate of authority or its representatives
28 shall not be construed to violate any provision of law
29 relating to solicitation or advertising by health
30 professionals.
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1 Section 80. Limitations on indemnification provisions.
2 No contract between a managed care dental plan and a provider
3 may require that the provider indemnify the managed care
4 dental plan for the Plan's, or its officers, employees, or
5 agents, negligence, willful misconduct, or breach of
6 contract, if any, provided nothing herein shall relieve the
7 provider for such obligations that have been delegated to the
8 provider pursuant to written agreement. The delegation of
9 functions agreed to between the plan and the provider shall
10 be identified in the written agreement.
11 Section 85. Severability. The provisions of this Act are
12 severable under Section 1.31 of the Statute on Statutes.