SB1545 97TH GENERAL ASSEMBLY

LRB097 05257 RPM 45309 b

97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB1545

Introduced 2/9/2011, by Sen. William R. Haine

SYNOPSIS AS INTRODUCED:

215 ILCS 5/355.3 new
215 ILCS 5/368d

Amends the Illinois Insurance Code. Provides that dental insurance plans must list in the fee schedule attached to the contract every Code on Dental Procedures and Nomenclature (CDT) code upon which the plan imposes a capped fee and the dollar amount of the capped fee. Provides that any CDT code not so listed shall not be subject to any fee cap, and the provider may balance bill the patient. Provides that dental insurance plans must highlight any changes in subsequent contract terms or conditions and shall have the original plan administrator notify the enrolled dentist and allow the dentist sufficient time to respond. Provides that no recoupment or offset may be requested or withheld from future payments 366 or more days after the original payment is made. Provides that no contract between an insurer and a health care professional or health care provider may provide for recoupments in violation of the provision concerning recoupment.

A BILL FOR

AN ACT concerning insurance.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by changing Section 368d and by adding Section 355.3 as follows:

(215 ILCS 5/355.3 new)

Sec. 355.3. Dental plans; contracting.

(a) Every company that issues, delivers, amends, or renews any individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 97th General Assembly that provides dental insurance must list in the fee schedule attached to the contract every American Dental Association's Code on Dental Procedures and Nomenclature (CDT) code upon which the plan imposes a capped fee and the specific dollar amount of the capped fee.

(b) Any CDT code not listed in the contract as prescribed in subsection (a) of this Section shall not be subject to any fee cap. In such cases, the provider may balance bill the patient.

(c) Every company that issues, delivers, amends, or renews any individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 97th General Assembly that provides dental insurance must highlight any changes in subsequent contract terms or conditions, including changes in reimbursement, and shall have the original plan administrator notify the enrolled dentist and allow the dentist sufficient time to review, renegotiate, or terminate the contract.

(215 ILCS 5/368d)

Sec. 368d. Recoupments.

(a) A health care professional or health care provider shall be provided a remittance advice, which must include an explanation of a recoupment or offset taken by an insurer, health maintenance organization, independent practice association, or physician hospital organization, if any. The recoupment explanation shall, at a minimum, include the name of the patient; the date of service; the service code or if no service code is available a service description; the recoupment amount; and the reason for the recoupment or offset. In addition, an insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide with the remittance advice a telephone number or mailing address to initiate an appeal of the recoupment or offset.

(b) It is not a recoupment when a health care professional or health care provider is paid an amount prospectively or concurrently under a contract with an insurer, health maintenance organization, independent practice association, or physician hospital organization that requires a retrospective reconciliation based upon specific conditions outlined in the contract.

(c) No recoupment or offset may be requested or withheld from future payments 366 or more days after the original payment is made. No contract between an insurer and a health care professional or health care provider may provide for recoupments in violation of this Section.

(Source: P.A. 93-261, eff. 1-1-04.)