SB0750eng 99TH GENERAL ASSEMBLY

SB0750 Engrossed LRB099 04042 MLM 24060 b

AN ACT concerning regulation.

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 355a as follows:

(215 ILCS 5/355a) (from Ch. 73, par. 967a)

Sec. 355a. Standardization of terms and coverage.

(1) The purpose of this Section shall be (a) to provide reasonable standardization and simplification of terms and coverages of individual accident and health insurance policies to facilitate public understanding and comparisons; (b) to eliminate provisions contained in individual accident and health insurance policies which may be misleading or unreasonably confusing in connection either with the purchase of such coverages or with the settlement of claims; and (c) to provide for reasonable disclosure in the sale of accident and health coverages.

(2) Definitions applicable to this Section are as follows:

(a) "Policy" means all or any part of the forms constituting the contract between the insurer and the insured, including the policy, certificate, subscriber contract, riders, endorsements, and the application if attached, which are subject to filing with and approval by the Director.

(b) "Service corporations" means voluntary health and dental corporations organized and operating respectively under the Voluntary Health Services Plans Act and the Dental Service Plan Act.

(c) "Accident and health insurance" means insurance written under Article XX of the Insurance Code, other than credit accident and health insurance, and coverages provided in subscriber contracts issued by service corporations. For purposes of this Section such service corporations shall be deemed to be insurers engaged in the business of insurance.

(3) The Director shall issue such rules as he shall deem necessary or desirable to establish specific standards, including standards of full and fair disclosure that set forth the form and content and required disclosure for sale, of individual policies of accident and health insurance, which rules and regulations shall be in addition to and in accordance with the applicable laws of this State, and which may cover but shall not be limited to: (a) terms of renewability; (b) initial and subsequent conditions of eligibility; (c) non-duplication of coverage provisions; (d) coverage of dependents; (e) pre-existing conditions; (f) termination of insurance; (g) probationary periods; (h) limitation, exceptions, and reductions; (i) elimination periods; (j) requirements regarding replacements; (k) recurrent conditions; and (l) the definition of terms including but not limited to the following: hospital, accident, sickness, injury, physician, accidental means, total disability, partial disability, nervous disorder, guaranteed renewable, and non-cancellable.

The Director may issue rules that specify prohibited policy provisions not otherwise specifically authorized by statute which in the opinion of the Director are unjust, unfair or unfairly discriminatory to the policyholder, any person insured under the policy, or beneficiary.

(4) The Director shall issue such rules as he shall deem necessary or desirable to establish minimum standards for benefits under each category of coverage in individual accident and health policies, other than conversion policies issued pursuant to a contractual conversion privilege under a group policy, including but not limited to the following categories: (a) basic hospital expense coverage; (b) basic medical-surgical expense coverage; (c) hospital confinement indemnity coverage; (d) major medical expense coverage; (e) disability income protection coverage; (f) accident only coverage; and (g) specified disease or specified accident coverage.

Nothing in this subsection (4) shall preclude the issuance of any policy which combines two or more of the categories of coverage enumerated in subparagraphs (a) through (f) of this subsection.

No policy shall be delivered or issued for delivery in this State which does not meet the prescribed minimum standards for the categories of coverage listed in this subsection unless the Director finds that such policy is necessary to meet specific needs of individuals or groups and such individuals or groups will be adequately informed that such policy does not meet the prescribed minimum standards, and such policy meets the requirement that the benefits provided therein are reasonable in relation to the premium charged. The standards and criteria to be used by the Director in approving such policies shall be included in the rules required under this Section with as much specificity as practicable.

The Director shall prescribe by rule the method of identification of policies based upon coverages provided.

(5) (a) In order to provide for full and fair disclosure in the sale of individual accident and health insurance policies, no such policy shall be delivered or issued for delivery in this State unless the outline of coverage described in paragraph (b) of this subsection either accompanies the policy, or is delivered to the applicant at the time the application is made, and an acknowledgment signed by the insured, of receipt of delivery of such outline, is provided to the insurer. In the event the policy is issued on a basis other than that applied for, the outline of coverage properly describing the policy must accompany the policy when it is delivered and such outline shall clearly state that the policy differs, and to what extent, from that for which application was originally made. All policies, except single premium nonrenewal policies, shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance, that the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if after examination of the policy the policyholder is not satisfied for any reason.

(b) The Director shall issue such rules as he shall deem necessary or desirable to prescribe the format and content of the outline of coverage required by paragraph (a) of this subsection. "Format" means style, arrangement, and overall appearance, including such items as the size, color, and prominence of type and the arrangement of text and captions. "Content" shall include without limitation thereto, statements relating to the particular policy as to the applicable category of coverage prescribed under subsection 4; principal benefits; exceptions, reductions and limitations; and renewal provisions, including any reservation by the insurer of a right to change premiums. Such outline of coverage shall clearly state that it constitutes a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

(c) Without limiting the generality of paragraph (b) of this subsection (5), no qualified health plans shall be offered for sale directly to consumers through the health insurance marketplace operating in the State in accordance with Sections 1311 and 1321 of the federal Patient Protection and Affordable Care Act of 2010 (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments thereto, or regulations or guidance issued thereunder (collectively, "the Federal Act"), unless the following information is made available to the consumer at the time he or she is comparing policies and their premiums:

(i) With respect to prescription drug benefits, the most recently published formulary where a consumer can view in one location covered prescription drugs; information on tiering and the cost-sharing structure for each tier; and information about how a consumer can obtain specific copayment amounts or coinsurance percentages for a specific qualified health plan before enrolling in that plan. This information shall clearly identify the qualified health plan to which it applies.

(ii) The most recently published provider directory where a consumer can view the provider network that applies to each qualified health plan and information about each provider, including location, contact information, specialty, medical group, if any, any institutional affiliation, and whether the provider is accepting new patients at each of the specific locations listing the provider. Providers shall notify qualified health plans electronically or in writing of any changes to their information as listed in the provider directory. Qualified health plans shall update their directories in a manner consistent with the information provided by the provider or dental management service organization within 10 business days after being notified of the change by the provider. Nothing in this paragraph (ii) shall void any contractual relationship between the provider and the plan. The information shall clearly identify the qualified health plan to which it applies.

(d) Each company that offers qualified health plans for sale directly to consumers through the health insurance marketplace operating in the State shall make the information in paragraph (c) of this subsection (5), for each qualified health plan that it offers, available and accessible to the general public on the company's Internet website and through other means for individuals without access to the Internet.

(e) The Department shall ensure that State-operated Internet websites, in addition to the Internet website for the health insurance marketplace established in this State in accordance with the Federal Act, prominently provide links to Internet-based materials and tools to help consumers be informed purchasers of health insurance.

(f) Nothing in this Section shall be interpreted or implemented in a manner not consistent with the Federal Act. This Section shall apply to all qualified health plans offered for sale directly to consumers through the health insurance marketplace operating in this State for any coverage year beginning on or after January 1, 2015.

(6) Prior to the issuance of rules pursuant to this Section, the Director shall afford the public, including the companies affected thereby, reasonable opportunity for comment. Such rulemaking is subject to the provisions of the Illinois Administrative Procedure Act.

(7) When a rule has been adopted, pursuant to this Section, all policies of insurance or subscriber contracts which are not in compliance with such rule shall, when so provided in such rule, be deemed to be disapproved as of a date specified in such rule not less than 120 days following its effective date, without any further or additional notice other than the adoption of the rule.

(8) When a rule adopted pursuant to this Section so provides, a policy of insurance or subscriber contract which does not comply with the rule shall not less than 120 days from the effective date of such rule, be construed, and the insurer or service corporation shall be liable, as if the policy or contract did comply with the rule.

(9) Violation of any rule adopted pursuant to this Section shall be a violation of the insurance law for purposes of Sections 370 and 446 of the Insurance Code.

(Source: P.A. 98-1035, eff. 8-25-14.)

Section 10. The Dental Care Patient Protection Act is amended by changing Section 25 as follows:

(215 ILCS 109/25)

Sec. 25. Provision of information.

(a) A managed care dental plan shall provide upon request to prospective enrollees a written summary description of all of the following terms of coverage:

(1) Information about the dental plan, including how the plan operates and what general types of financial arrangements exist between dentists and the plan. Nothing in this Section shall require disclosure of any specific financial arrangements between providers and the plan.

(2) The service area.

(3) Covered benefits, exclusions, or limitations.

(4) Pre-certification requirements including any requirements for referrals made by primary care dentists to specialists, and other preauthorization requirements.

(5) A list of participating primary care dentists in the plan's service area, including provider address and phone number, for an enrollee to evaluate the managed care dental plan's network access, as well as a phone number by which the prospective enrollee may obtain additional information regarding the provider network including participating specialists. However, a managed care dental plan offering a preferred provider organization ("PPO") product that does not require the enrollee to select a primary care dentist shall only be required to make available for inspection to enrollees and prospective enrollees a list of participating dentists in the plan's service area, including whether the provider is accepting new patients at each of the specific locations listing the provider. Providers shall notify managed care dental plans electronically or in writing of any changes to their information as listed in the provider directory. Managed care dental plans shall update their directories in a manner consistent with the information provided by the provider or dental management service organization within 10 business days after being notified of the change by the provider.

Nothing in this paragraph (5) shall void any contractual relationship between the provider and the plan.

(6) Emergency coverage and benefits.

(7) Out-of-area coverages and benefits, if any.

(8) The process about how participating dentists are selected.

(9) The grievance process, including the telephone number to call to receive information concerning grievance procedures.

An enrollee shall be provided with an evidence of coverage as required under the Illinois Insurance Code provisions applicable to the managed care dental plan.

(b) An enrollee or prospective enrollee has the right to the most current financial statement filed by the managed care dental plan by contacting the Department of Insurance. The Department may charge a reasonable fee for providing such information.

(c) The managed care dental plan shall provide to the Department, on an annual basis, a list of all participating dentists. Nothing in this Section shall require a particular ratio for any type of provider.

(d) If the managed care dental plan uses a capitation method of compensation to its primary care providers (dentists), the plan must establish and follow procedures that ensure that:

(1) the plan application form includes a space in which each enrollee selects a primary care provider (dentist);

(2) if an enrollee who fails to select a primary care provider (dentist) is assigned a primary care provider (dentist), the enrollee shall be notified of the name and location of that primary care provider (dentist); and

(3) primary care provider (dentist) to whom an enrollee is assigned, pursuant to item (2), is physically located within a reasonable travel distance, as established by rule adopted by the Director, from the residence or place of employment of the enrollee.

(e) Nothing in this Act shall be deemed to require a plan to assign an enrollee to a primary care provider (dentist).

(Source: P.A. 91-355, eff. 1-1-00.)

Section 15. The Illinois Dental Practice Act is amended by changing Sections 44 and 45 as follows:

(225 ILCS 25/44) (from Ch. 111, par. 2344)

(Section scheduled to be repealed on January 1, 2016)

Sec. 44. Practice by Corporations Prohibited. Exceptions. No corporation shall practice dentistry or engage therein, or hold itself out as being entitled to practice dentistry, or furnish dental services or dentists, or advertise under or assume the title of dentist or dental surgeon or equivalent title, or furnish dental advice for any compensation, or advertise or hold itself out with any other person or alone, that it has or owns a dental office or can furnish dental service or dentists, or solicit through itself, or its agents, officers, employees, directors or trustees, dental patronage for any dentist employed by any corporation.

Nothing contained in this Act, however, shall:

(a) prohibit a corporation from employing a dentist or dentists to render dental services to its employees, provided that such dental services shall be rendered at no cost or charge to the employees;

(b) prohibit a corporation or association from providing dental services upon a wholly charitable basis to deserving recipients;

(c) prohibit a corporation or association from furnishing information or clerical services which can be furnished by persons not licensed to practice dentistry, to any dentist when such dentist assumes full responsibility for such information or services;

(d) prohibit dental corporations as authorized by the Professional Service Corporation Act, dental associations as authorized by the Professional Association Act, or dental limited liability companies as authorized by the Limited Liability Company Act;

(e) prohibit dental limited liability partnerships as authorized by the Uniform Partnership Act (1997);

(f) prohibit hospitals, public health clinics, federally qualified health centers, or other entities specified by rule of the Department from providing dental services; or

(g) prohibit dental management service organizations from providing non-clinical business services that do not violate the provisions of this Act.

Any corporation violating the provisions of this Section is guilty of a Class A misdemeanor and each day that this Act is violated shall be considered a separate offense.

If a dental management service organization is responsible for enrolling the dentist as a provider in managed care plans provider networks, it shall provide verification to the managed care provider network regarding whether the provider is accepting new patients at each of the specific locations listing the provider.

Nothing in this Section shall void any contractual relationship between the provider and the organization.

(Source: P.A. 96-328, eff. 8-11-09.)

(225 ILCS 25/45) (from Ch. 111, par. 2345)

(Section scheduled to be repealed on January 1, 2016)

Sec. 45. Advertising. The purpose of this Section is to authorize and regulate the advertisement by dentists of information which is intended to provide the public with a sufficient basis upon which to make an informed selection of dentists while protecting the public from false or misleading advertisements which would detract from the fair and rational selection process.

Any dentist may advertise the availability of dental services in the public media or on the premises where such dental services are rendered. Such advertising shall be limited to the following information:

(a) The dental services available;

(b) Publication of the dentist's name, title, office hours, address and telephone;

(c) Information pertaining to his or her area of specialization, including appropriate board certification or limitation of professional practice;

(d) Information on usual and customary fees for routine dental services offered, which information shall include notification that fees may be adjusted due to complications or unforeseen circumstances;

(e) Announcement of the opening of, change of, absence from, or return to business;

(f) Announcement of additions to or deletions from professional dental staff;

(g) The issuance of business or appointment cards;

(h) Other information about the dentist, dentist's practice or the types of dental services which the dentist offers to perform which a reasonable person might regard as relevant in determining whether to seek the dentist's services. However, any advertisement which announces the availability of endodontics, pediatric dentistry, periodontics, prosthodontics, orthodontics and dentofacial orthopedics, oral and maxillofacial surgery, or oral and maxillofacial radiology by a general dentist or by a licensed specialist who is not licensed in that specialty shall include a disclaimer stating that the dentist does not hold a license in that specialty.

Any dental practice with more than one location that enrolls its dentist as a participating provider in a managed care plan's network must verify electronically or in writing to the managed care plan whether the provider is accepting new patients at each of the specific locations listing the provider. The health plan shall remove the provider from the directory in accordance with standard practices within 10 business days after being notified of the changes by the provider. Nothing in this paragraph shall void any contractual relationship between the provider and the plan.

It is unlawful for any dentist licensed under this Act to do any of the following:

(1) Use claims of superior quality of care to entice the public.

(2) Advertise in any way to practice dentistry without causing pain.

(3) Pay a fee to any dental referral service or other third party who advertises a dental referral service, unless all advertising of the dental referral service makes it clear that dentists are paying a fee for that referral service.

(4) Advertise or offer gifts as an inducement to secure dental patronage. Dentists may advertise or offer free examinations or free dental services; it shall be unlawful, however, for any dentist to charge a fee to any new patient for any dental service provided at the time that such free examination or free dental services are provided.

(5) Use the term "sedation dentistry" or similar terms in advertising unless the advertising dentist holds a valid and current permit issued by the Department to administer either general anesthesia, deep sedation, or conscious sedation as required under Section 8.1 of this Act.

This Act does not authorize the advertising of dental services when the offeror of such services is not a dentist. Nor shall the dentist use statements which contain false, fraudulent, deceptive or misleading material or guarantees of success, statements which play upon the vanity or fears of the public, or statements which promote or produce unfair competition.

A dentist shall be required to keep a copy of all advertisements for a period of 3 years. All advertisements in the dentist's possession shall indicate the accurate date and place of publication.

The Department shall adopt rules to carry out the intent of this Section.

(Source: P.A. 97-1013, eff. 8-17-12.)

Section 99. Effective date. This Act takes effect January 1, 2016.