96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB2532

 

Introduced 2/20/2009, by Rep. Lisa M. Dugan

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/355.2   from Ch. 73, par. 967.2

    Amends the Illinois Insurance Code in relation to reimbursement rates. Provides that a health insurer that bases payment for benefits upon a usual or customary charge or other similar reimbursement methodology must disclose certain information. Replaces references to "customary fee" with "customary charge or other similar methodology" throughout the provision. Provides that under no circumstances shall rates paid by Medicaid or Medicare, or rates negotiated or set by the insurer or any other insurer in conjunction with their contracted providers, be used to determine usual and customary charges. Makes other changes. Effective January 1, 2010.


LRB096 10098 RPM 20264 b

 

 

A BILL FOR

 

HB2532 LRB096 10098 RPM 20264 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 355.2 as follows:
 
6     (215 ILCS 5/355.2)  (from Ch. 73, par. 967.2)
7     Sec. 355.2. Reimbursement Dental coverage reimbursement
8 rates.
9     (a) A Every company that issues, delivers, amends, or
10 renews any individual or group policy of accident and health
11 insurance on or after the effective date of this amendatory Act
12 of the 96th General Assembly 1991 that provides dental
13 insurance and bases payment for those benefits upon a usual and
14 customary charge or other similar reimbursement methodology
15 fee charged by licensed dentists must disclose all of the
16 following:
17         (1) The frequency of the determination of the usual and
18     customary charge or other similar methodology fee.
19         (2) A general description of the methodology used to
20     determine the usual and customary charge or other similar
21     methodology fees.
22         (3) The percentile of the usual and customary charge or
23     other similar methodology that determines the maximum

 

 

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1     allowable charge upon which the benefit is based benefit
2     that the company will pay for any dental procedure, if the
3     usual and customary fee is determined by taking a sample of
4     fees submitted on actual claims from licensed dentists and
5     then determining the benefit by selecting a percentile of
6     those fees.
7     (b) The disclosure must be provided upon request to all
8 group and individual policy holders and group certificate
9 holders. All proposals for accident and health dental insurance
10 must notify the prospective policy holder that information
11 regarding the usual and customary charge or other similar
12 methodology fee determinations is available from the insurer.
13 All employee benefit descriptions or supplemental documents
14 must notify the employee that information regarding
15 reimbursement rates is available from the employer.
16     (c) Under no circumstances shall rates paid by Medicaid or
17 Medicare, or rates negotiated or set by the insurer or any
18 other insurer in conjunction with their contracted providers,
19 be used to determine usual and customary charges.
20     (d) For purposes of this Section, the usual and customary
21 charge is the charge for health care that is consistent with
22 the average rate or charge for similar services furnished by
23 similar providers in the geographic area in which services were
24 provided.
25     (e) Under no circumstances shall the amount of
26 reimbursement for covered expenses be less than 50% of the

 

 

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1 usual and customary charge, or similar reasonable charge when
2 the usual and customary charge can not be calculated, for the
3 services provided.
4     (f) Companies shall make their methodology for determining
5 usual and customary charges available to the Department upon
6 request. Such information shall be held confidential by the
7 Department.
8 (Source: P.A. 87-587.)
 
9     Section 99. Effective date. This Act takes effect January
10 1, 2010.