99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB0750

 

Introduced 2/3/2015, by Sen. Michael E. Hastings

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/355a  from Ch. 73, par. 967a
215 ILCS 109/25
215 ILCS 110/10  from Ch. 32, par. 690.10
215 ILCS 110/25  from Ch. 32, par. 690.25

    Amends the Illinois Insurance Code. Provides that health plan issuers offering health plans through the State health insurance marketplace update their provider directory on a monthly basis. Provides that the information in provider directories shall be offered in a manner that accommodates individuals with limited English proficiency and with disabilities. Provides that, with respect to dental plans, a dentist listed is considered an active network participant from the location published in the provider directory only if the dentist has filed a claim for a patient enrolled with the dental plan at least once in the previous 3-month period. Amends the Dental Care Patient Protection Act. Provides that managed care dental plans must only list participating dentists who have filed a claim for an enrolled patient within the past 3 months. Makes conforming changes in the Dental Service Plan Act.


LRB099 04042 MLM 24060 b

 

 

A BILL FOR

 

SB0750LRB099 04042 MLM 24060 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 355a as follows:
 
6    (215 ILCS 5/355a)  (from Ch. 73, par. 967a)
7    Sec. 355a. Standardization of terms and coverage.
8    (1) The purpose of this Section shall be (a) to provide
9reasonable standardization and simplification of terms and
10coverages of individual accident and health insurance policies
11to facilitate public understanding and comparisons; (b) to
12eliminate provisions contained in individual accident and
13health insurance policies which may be misleading or
14unreasonably confusing in connection either with the purchase
15of such coverages or with the settlement of claims; and (c) to
16provide for reasonable disclosure in the sale of accident and
17health coverages.
18    (2) Definitions applicable to this Section are as follows:
19        (a) "Policy" means all or any part of the forms
20    constituting the contract between the insurer and the
21    insured, including the policy, certificate, subscriber
22    contract, riders, endorsements, and the application if
23    attached, which are subject to filing with and approval by

 

 

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1    the Director.
2        (b) "Service corporations" means voluntary health and
3    dental corporations organized and operating respectively
4    under the Voluntary Health Services Plans Act and the
5    Dental Service Plan Act.
6        (c) "Accident and health insurance" means insurance
7    written under Article XX of the Insurance Code, other than
8    credit accident and health insurance, and coverages
9    provided in subscriber contracts issued by service
10    corporations. For purposes of this Section such service
11    corporations shall be deemed to be insurers engaged in the
12    business of insurance.
13    (3) The Director shall issue such rules as he shall deem
14necessary or desirable to establish specific standards,
15including standards of full and fair disclosure that set forth
16the form and content and required disclosure for sale, of
17individual policies of accident and health insurance, which
18rules and regulations shall be in addition to and in accordance
19with the applicable laws of this State, and which may cover but
20shall not be limited to: (a) terms of renewability; (b) initial
21and subsequent conditions of eligibility; (c) non-duplication
22of coverage provisions; (d) coverage of dependents; (e)
23pre-existing conditions; (f) termination of insurance; (g)
24probationary periods; (h) limitation, exceptions, and
25reductions; (i) elimination periods; (j) requirements
26regarding replacements; (k) recurrent conditions; and (l) the

 

 

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1definition of terms including but not limited to the following:
2hospital, accident, sickness, injury, physician, accidental
3means, total disability, partial disability, nervous disorder,
4guaranteed renewable, and non-cancellable.
5    The Director may issue rules that specify prohibited policy
6provisions not otherwise specifically authorized by statute
7which in the opinion of the Director are unjust, unfair or
8unfairly discriminatory to the policyholder, any person
9insured under the policy, or beneficiary.
10    (4) The Director shall issue such rules as he shall deem
11necessary or desirable to establish minimum standards for
12benefits under each category of coverage in individual accident
13and health policies, other than conversion policies issued
14pursuant to a contractual conversion privilege under a group
15policy, including but not limited to the following categories:
16(a) basic hospital expense coverage; (b) basic
17medical-surgical expense coverage; (c) hospital confinement
18indemnity coverage; (d) major medical expense coverage; (e)
19disability income protection coverage; (f) accident only
20coverage; and (g) specified disease or specified accident
21coverage.
22    Nothing in this subsection (4) shall preclude the issuance
23of any policy which combines two or more of the categories of
24coverage enumerated in subparagraphs (a) through (f) of this
25subsection.
26    No policy shall be delivered or issued for delivery in this

 

 

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1State which does not meet the prescribed minimum standards for
2the categories of coverage listed in this subsection unless the
3Director finds that such policy is necessary to meet specific
4needs of individuals or groups and such individuals or groups
5will be adequately informed that such policy does not meet the
6prescribed minimum standards, and such policy meets the
7requirement that the benefits provided therein are reasonable
8in relation to the premium charged. The standards and criteria
9to be used by the Director in approving such policies shall be
10included in the rules required under this Section with as much
11specificity as practicable.
12    The Director shall prescribe by rule the method of
13identification of policies based upon coverages provided.
14    (5) (a) In order to provide for full and fair disclosure in
15the sale of individual accident and health insurance policies,
16no such policy shall be delivered or issued for delivery in
17this State unless the outline of coverage described in
18paragraph (b) of this subsection either accompanies the policy,
19or is delivered to the applicant at the time the application is
20made, and an acknowledgment signed by the insured, of receipt
21of delivery of such outline, is provided to the insurer. In the
22event the policy is issued on a basis other than that applied
23for, the outline of coverage properly describing the policy
24must accompany the policy when it is delivered and such outline
25shall clearly state that the policy differs, and to what
26extent, from that for which application was originally made.

 

 

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1All policies, except single premium nonrenewal policies, shall
2have a notice prominently printed on the first page of the
3policy or attached thereto stating in substance, that the
4policyholder shall have the right to return the policy within
510 days of its delivery and to have the premium refunded if
6after examination of the policy the policyholder is not
7satisfied for any reason.
8    (b) The Director shall issue such rules as he shall deem
9necessary or desirable to prescribe the format and content of
10the outline of coverage required by paragraph (a) of this
11subsection. "Format" means style, arrangement, and overall
12appearance, including such items as the size, color, and
13prominence of type and the arrangement of text and captions.
14"Content" shall include without limitation thereto, statements
15relating to the particular policy as to the applicable category
16of coverage prescribed under subsection 4; principal benefits;
17exceptions, reductions and limitations; and renewal
18provisions, including any reservation by the insurer of a right
19to change premiums. Such outline of coverage shall clearly
20state that it constitutes a summary of the policy issued or
21applied for and that the policy should be consulted to
22determine governing contractual provisions.
23    (c) Without limiting the generality of paragraph (b) of
24this subsection (5), no qualified health plans shall be offered
25for sale directly to consumers through the health insurance
26marketplace operating in the State in accordance with Sections

 

 

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11311 and 1321 of the federal Patient Protection and Affordable
2Care Act of 2010 (Public Law 111-148), as amended by the
3federal Health Care and Education Reconciliation Act of 2010
4(Public Law 111-152), and any amendments thereto, or
5regulations or guidance issued thereunder (collectively, "the
6Federal Act"), unless the following information is made
7available to the consumer at the time he or she is comparing
8policies and their premiums:
9        (i) With respect to prescription drug benefits, the
10    most recently published formulary where a consumer can view
11    in one location covered prescription drugs; information on
12    tiering and the cost-sharing structure for each tier; and
13    information about how a consumer can obtain specific
14    copayment amounts or coinsurance percentages for a
15    specific qualified health plan before enrolling in that
16    plan. This information shall clearly identify the
17    qualified health plan to which it applies.
18        (ii) The most recently published provider directory
19    where a consumer can view the provider network that applies
20    to each qualified health plan and information about each
21    provider, including location, contact information,
22    specialty, medical group, if any, any institutional
23    affiliation, and whether the provider is accepting new
24    patients. The provider directory shall be updated on a
25    monthly basis. The information shall clearly identify the
26    qualified health plan to which it applies and be offered in

 

 

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1    a manner that accommodates individuals with limited
2    English proficiency and with disabilities.
3    With respect to dental plans, a dentist listed in a
4provider network is considered an active network participant
5from the location published in the provider directory only if
6the dentist has filed a claim for a patient enrolled with the
7dental plan at least once in the previous 3-month period. Any
8dentist not meeting this criterion must be removed from the
9published provider directory for that specific location.
10    (d) Each company that offers qualified health plans for
11sale directly to consumers through the health insurance
12marketplace operating in the State shall make the information
13in paragraph (c) of this subsection (5), for each qualified
14health plan that it offers, available and accessible to the
15general public on the company's Internet website and through
16other means for individuals without access to the Internet.
17    (e) The Department shall ensure that State-operated
18Internet websites, in addition to the Internet website for the
19health insurance marketplace established in this State in
20accordance with the Federal Act, prominently provide links to
21Internet-based materials and tools to help consumers be
22informed purchasers of health insurance.
23    (f) Nothing in this Section shall be interpreted or
24implemented in a manner not consistent with the Federal Act.
25This Section shall apply to all qualified health plans offered
26for sale directly to consumers through the health insurance

 

 

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1marketplace operating in this State for any coverage year
2beginning on or after January 1, 2015.
3    (6) Prior to the issuance of rules pursuant to this
4Section, the Director shall afford the public, including the
5companies affected thereby, reasonable opportunity for
6comment. Such rulemaking is subject to the provisions of the
7Illinois Administrative Procedure Act.
8    (7) When a rule has been adopted, pursuant to this Section,
9all policies of insurance or subscriber contracts which are not
10in compliance with such rule shall, when so provided in such
11rule, be deemed to be disapproved as of a date specified in
12such rule not less than 120 days following its effective date,
13without any further or additional notice other than the
14adoption of the rule.
15    (8) When a rule adopted pursuant to this Section so
16provides, a policy of insurance or subscriber contract which
17does not comply with the rule shall not less than 120 days from
18the effective date of such rule, be construed, and the insurer
19or service corporation shall be liable, as if the policy or
20contract did comply with the rule.
21    (9) Violation of any rule adopted pursuant to this Section
22shall be a violation of the insurance law for purposes of
23Sections 370 and 446 of the Insurance Code.
24(Source: P.A. 98-1035, eff. 8-25-14.)
 
25    Section 10. The Dental Care Patient Protection Act is

 

 

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1amended by changing Section 25 as follows:
 
2    (215 ILCS 109/25)
3    Sec. 25. Provision of information.
4    (a) A managed care dental plan shall provide upon request
5to prospective enrollees a written summary description of all
6of the following terms of coverage:
7        (1) Information about the dental plan, including how
8    the plan operates and what general types of financial
9    arrangements exist between dentists and the plan. Nothing
10    in this Section shall require disclosure of any specific
11    financial arrangements between providers and the plan.
12        (2) The service area.
13        (3) Covered benefits, exclusions, or limitations.
14        (4) Pre-certification requirements including any
15    requirements for referrals made by primary care dentists to
16    specialists, and other preauthorization requirements.
17        (5) A list of participating primary care dentists in
18    the plan's service area, including provider address and
19    phone number, for an enrollee to evaluate the managed care
20    dental plan's network access, as well as a phone number by
21    which the prospective enrollee may obtain additional
22    information regarding the provider network including
23    participating specialists. However, a managed care dental
24    plan offering a preferred provider organization ("PPO")
25    product that does not require the enrollee to select a

 

 

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1    primary care dentist shall only be required to make
2    available for inspection to enrollees and prospective
3    enrollees a list of participating dentists in the plan's
4    service area in which participating dentist has filed a
5    claim for an enrollee with the managed care dental plan
6    within the previous 3-month period for the address listed.
7    Any dentist not meeting this criterion must be removed from
8    the managed care provider network directory (written or
9    electronic) for the address listed.
10        (6) Emergency coverage and benefits.
11        (7) Out-of-area coverages and benefits, if any.
12        (8) The process about how participating dentists are
13    selected.
14        (9) The grievance process, including the telephone
15    number to call to receive information concerning grievance
16    procedures.
17    An enrollee shall be provided with an evidence of coverage
18as required under the Illinois Insurance Code provisions
19applicable to the managed care dental plan.
20    (b) An enrollee or prospective enrollee has the right to
21the most current financial statement filed by the managed care
22dental plan by contacting the Department of Insurance. The
23Department may charge a reasonable fee for providing such
24information.
25    (c) The managed care dental plan shall provide to the
26Department, on an annual basis, a list of all participating

 

 

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1dentists meeting the criteria listed in subsection (a) of this
2Section. Nothing in this Section shall require a particular
3ratio for any type of provider.
4    (d) If the managed care dental plan uses a capitation
5method of compensation to its primary care providers
6(dentists), the plan must establish and follow procedures that
7ensure that:
8        (1) the plan application form includes a space in which
9    each enrollee selects a primary care provider (dentist);
10        (2) if an enrollee who fails to select a primary care
11    provider (dentist) is assigned a primary care provider
12    (dentist), the enrollee shall be notified of the name and
13    location of that primary care provider (dentist); and
14        (3) primary care provider (dentist) to whom an enrollee
15    is assigned, pursuant to item (2), is physically located
16    within a reasonable travel distance, as established by rule
17    adopted by the Director, from the residence or place of
18    employment of the enrollee.
19    (e) Nothing in this Act shall be deemed to require a plan
20to assign an enrollee to a primary care provider (dentist).
21(Source: P.A. 91-355, eff. 1-1-00.)
 
22    Section 15. The Dental Service Plan Act is amended by
23changing Sections 10 and 25 as follows:
 
24    (215 ILCS 110/10)  (from Ch. 32, par. 690.10)

 

 

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1    Sec. 10. "Participating dentist" means a dentist licensed
2in Illinois to practice dentistry, and who, by written
3agreement with a dental service plan corporation undertakes to
4furnish dental service to the plan's subscribers and their
5covered dependents at least once every 3-month period and to
6abide by its by-laws, rules and regulations.
7(Source: Laws 1965, p. 2179.)
 
8    (215 ILCS 110/25)  (from Ch. 32, par. 690.25)
9    Sec. 25. Application of Insurance Code provisions. Dental
10service plan corporations and all persons interested therein or
11dealing therewith shall be subject to the provisions of
12Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
13143, 143c, 149, 355.2, 355.3, 367.2, 401, 401.1, 402, 403,
14403A, 408, 408.2, and 412, paragraph (c) of subsection (5) of
15Section 355a, and subsection (15) of Section 367 of the
16Illinois Insurance Code.
17(Source: P.A. 97-486, eff. 1-1-12; 97-805, eff. 1-1-13.)