HB4789 EnrolledLRB103 36280 RPS 66377 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 355.4 and by adding Section 355d as follows:
 
6    (215 ILCS 5/355.4)
7    Sec. 355.4. Provider notification of network plan changes.
8    (a) As used in this Section:
9    "Contracting entity" means any person or company that
10enters into direct contracts with providers for the delivery
11of dental services in the ordinary course of business,
12including a third-party administrator and a dental carrier.
13    "Dental carrier" means a dental insurance company, dental
14service corporation, dental plan organization authorized to
15provide dental benefits, or a health insurance plan that
16includes coverage for dental services.
17    (b) No dental carrier may automatically enroll a provider
18in a leased network without allowing any provider that is part
19of the dental carrier's provider network to choose to not
20participate by opting out.
21    (c) Any contract entered into or renewed on or after the
22effective date of this amendatory Act of the 103rd General
23Assembly that allows the rights and obligations of the

 

 

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1contract to be assigned or leased to another insurer shall
2provide for notice that informs each provider in writing via
3certified mail 60 days before any scheduled assignment or
4lease of the network to which the provider is a contracted
5provider. To be in compliance with this Section, the
6notification must provide the specific URL address where the
7following are located: include all contract terms, a policy
8manual, a fee schedule, and a statement that the provider has
9the right to choose not to participate in third-party access.
10The notification must also provide instructions for how the
11provider may obtain a copy of those materials.
12    (d) A dental carrier that leases or assigns its network
13shall not cancel a network participating dentist's contractual
14relationship or otherwise penalize a network participating
15dentist in any way based on whether or not the dentist accepts
16the terms of the assignment or lease. Before accepting the
17terms of an assignment or lease agreement as described in this
18Section, any provider who receives notification of an
19impending assignment or lease must be given the option to
20contract directly with the entities proposing to gain access
21to the provider's network.
22    (e) The provisions of this Section do not apply:
23        (1) if access to a provider network contract is
24    granted to a dental carrier or an entity operating in
25    accordance with the same brand licensee program as the
26    contracting entity; or

 

 

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1        (2) to a provider network contract for dental services
2    provided to beneficiaries of the State employee group
3    health insurance program or the medical assistance program
4    under the Illinois Public Aid Code.
5(Source: P.A. 103-24, eff. 1-1-24.)
 
6    (215 ILCS 5/355d new)
7    Sec. 355d. Denials of claims submitted after prior
8authorization.
9    (a) In this Section:
10    "Dental carrier" means an insurer, dental service
11corporation, insurance network leasing company, or any company
12that offers individual or group policies of accident and
13health insurance that provide coverage for dental services.
14    "Prior authorization" means any written communication that
15is verifiable, whether through issuance or letter, facsimile,
16email, or similar means, indicating that a specific procedure
17is, or multiple procedures are, covered under the patient's
18dental plan and reimbursable at a specific amount, subject to
19applicable coinsurance and deductibles, and issued in response
20to a request submitted by a dentist using a format prescribed
21by the dental carrier.
22    (b) Beginning on the effective date of this amendatory Act
23of the 103rd General Assembly, a dental carrier shall not deny
24any claim subsequently submitted for procedures specifically
25included in a prior authorization unless at least one of the

 

 

HB4789 Enrolled- 4 -LRB103 36280 RPS 66377 b

1following circumstances applies for each procedure denied:
2        (1) benefit limitations, such as annual maximums and
3    frequency limitations, that were not applicable at the
4    time of the prior authorization are reached due to
5    utilization after issuance of the prior authorization;
6        (2) the documentation for the claim provided by the
7    person submitting the claim clearly fails to support the
8    claim as originally authorized;
9        (3) if, after the issuance of the prior authorization,
10    new procedures are provided to the patient or a change in
11    the condition of the patient occurs such that the prior
12    authorized procedure would no longer be considered
13    medically necessary based on the prevailing standard of
14    care;
15        (4) if, after the issuance of the prior authorization,
16    new procedures are provided to the patient or a change in
17    the condition of the patient occurs such that the prior
18    authorized procedure would, at that time, require
19    disapproval pursuant to the terms and conditions for
20    coverage under the plan for the patient in effect at the
21    time the prior authorization was used; or
22        (5) the claim was denied by a dental carrier due to one
23    of the following reasons:
24            (A) another payor is responsible for the payment;
25            (B) the dentist has already been paid for the
26        procedures identified on the claim;

 

 

HB4789 Enrolled- 5 -LRB103 36280 RPS 66377 b

1            (C) the claim was submitted fraudulently or the
2        prior authorization was based in whole or material
3        part on erroneous information provided to the dental
4        carrier; or
5            (D) the person receiving the procedure was not
6        eligible for the procedure on the date of service and
7        the dental carrier did not know, and with the exercise
8        of reasonable care could not have known, that person's
9        eligibility status.
10    A dental carrier shall not recoup a claim solely due to a
11loss of coverage of a patient or ineligibility if, at the time
12of treatment, the dental carrier erroneously confirmed
13coverage and eligibility, but had sufficient information
14available to the dental carrier indicating that the patient
15was no longer covered or was ineligible for coverage.
16    (c) The provisions of this Section may not be waived by
17contract. Any contractual agreement entered into or amended,
18delivered, issued, or renewed on or after the effective date
19of this amendatory Act of the 103rd General Assembly that is in
20conflict with this Section or that purports to waive any
21requirement of this Section is null and void.
 
22    Section 10. The Limited Health Service Organization Act is
23amended by changing Section 4003 as follows:
 
24    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)

 

 

HB4789 Enrolled- 6 -LRB103 36280 RPS 66377 b

1    Sec. 4003. Illinois Insurance Code provisions. Limited
2health service organizations shall be subject to the
3provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
4141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
5154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2,
6355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10,
7356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
8356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
9356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
10364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
11444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
12XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
13Nothing in this Section shall require a limited health care
14plan to cover any service that is not a limited health service.
15For purposes of the Illinois Insurance Code, except for
16Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
17health service organizations in the following categories are
18deemed to be domestic companies:
19        (1) a corporation under the laws of this State; or
20        (2) a corporation organized under the laws of another
21    state, 30% or more of the enrollees of which are residents
22    of this State, except a corporation subject to
23    substantially the same requirements in its state of
24    organization as is a domestic company under Article VIII
25    1/2 of the Illinois Insurance Code.
26(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;

 

 

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1102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
21-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
3eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
4102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
51-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
6eff. 1-1-24; revised 8-29-23.)
 
7    Section 15. The Voluntary Health Services Plans Act is
8amended by changing Section 10 as follows:
 
9    (215 ILCS 165/10)  (from Ch. 32, par. 604)
10    Sec. 10. Application of Insurance Code provisions. Health
11services plan corporations and all persons interested therein
12or dealing therewith shall be subject to the provisions of
13Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
14143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
15355d, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
16356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
17356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
18356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
19356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,
20356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
21356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
22356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
23401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
24and (15) of Section 367 of the Illinois Insurance Code.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
8102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
910-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
10eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
11102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
121-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
13eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
14103-551, eff. 8-11-23; revised 8-29-23.)