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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 at each of the specific locations listing the
25    provider. Dental providers shall notify qualified health
26    plans electronically or in writing of any changes to their

 

 

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1    information as listed in the provider directory. Qualified
2    health plans shall update their directories in a manner
3    consistent with the information provided by the provider or
4    dental management service organization within 10 business
5    days after being notified of the change by the provider.
6    Nothing in this paragraph (ii) shall void any contractual
7    relationship between the provider and the plan. The
8    information shall clearly identify the qualified health
9    plan to which it applies.
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, including whether the provider is accepting
5    new patients at each of the specific locations listing the
6    provider. Providers shall notify managed care dental plans
7    electronically or in writing of any changes to their
8    information as listed in the provider directory. Managed
9    care dental plans shall update their directories in a
10    manner consistent with the information provided by the
11    provider or dental management service organization within
12    10 business days after being notified of the change by the
13    provider.
14        Nothing in this paragraph (5) shall void any
15    contractual relationship between the provider and the
16    plan.
17        (6) Emergency coverage and benefits.
18        (7) Out-of-area coverages and benefits, if any.
19        (8) The process about how participating dentists are
20    selected.
21        (9) The grievance process, including the telephone
22    number to call to receive information concerning grievance
23    procedures.
24    An enrollee shall be provided with an evidence of coverage
25as required under the Illinois Insurance Code provisions
26applicable to the managed care dental plan.

 

 

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1    (b) An enrollee or prospective enrollee has the right to
2the most current financial statement filed by the managed care
3dental plan by contacting the Department of Insurance. The
4Department may charge a reasonable fee for providing such
5information.
6    (c) The managed care dental plan shall provide to the
7Department, on an annual basis, a list of all participating
8dentists. Nothing in this Section shall require a particular
9ratio for any type of provider.
10    (d) If the managed care dental plan uses a capitation
11method of compensation to its primary care providers
12(dentists), the plan must establish and follow procedures that
13ensure that:
14        (1) the plan application form includes a space in which
15    each enrollee selects a primary care provider (dentist);
16        (2) if an enrollee who fails to select a primary care
17    provider (dentist) is assigned a primary care provider
18    (dentist), the enrollee shall be notified of the name and
19    location of that primary care provider (dentist); and
20        (3) primary care provider (dentist) to whom an enrollee
21    is assigned, pursuant to item (2), is physically located
22    within a reasonable travel distance, as established by rule
23    adopted by the Director, from the residence or place of
24    employment of the enrollee.
25    (e) Nothing in this Act shall be deemed to require a plan
26to assign an enrollee to a primary care provider (dentist).

 

 

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1(Source: P.A. 91-355, eff. 1-1-00.)
 
2    Section 15. The Illinois Dental Practice Act is amended by
3changing Sections 44 and 45 as follows:
 
4    (225 ILCS 25/44)  (from Ch. 111, par. 2344)
5    (Section scheduled to be repealed on January 1, 2016)
6    Sec. 44. Practice by Corporations Prohibited. Exceptions.
7No corporation shall practice dentistry or engage therein, or
8hold itself out as being entitled to practice dentistry, or
9furnish dental services or dentists, or advertise under or
10assume the title of dentist or dental surgeon or equivalent
11title, or furnish dental advice for any compensation, or
12advertise or hold itself out with any other person or alone,
13that it has or owns a dental office or can furnish dental
14service or dentists, or solicit through itself, or its agents,
15officers, employees, directors or trustees, dental patronage
16for any dentist employed by any corporation.
17    Nothing contained in this Act, however, shall:
18        (a) prohibit a corporation from employing a dentist or
19    dentists to render dental services to its employees,
20    provided that such dental services shall be rendered at no
21    cost or charge to the employees;
22        (b) prohibit a corporation or association from
23    providing dental services upon a wholly charitable basis to
24    deserving recipients;

 

 

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1        (c) prohibit a corporation or association from
2    furnishing information or clerical services which can be
3    furnished by persons not licensed to practice dentistry, to
4    any dentist when such dentist assumes full responsibility
5    for such information or services;
6        (d) prohibit dental corporations as authorized by the
7    Professional Service Corporation Act, dental associations
8    as authorized by the Professional Association Act, or
9    dental limited liability companies as authorized by the
10    Limited Liability Company Act;
11        (e) prohibit dental limited liability partnerships as
12    authorized by the Uniform Partnership Act (1997);
13        (f) prohibit hospitals, public health clinics,
14    federally qualified health centers, or other entities
15    specified by rule of the Department from providing dental
16    services; or
17        (g) prohibit dental management service organizations
18    from providing non-clinical business services that do not
19    violate the provisions of this Act.
20    Any corporation violating the provisions of this Section is
21guilty of a Class A misdemeanor and each day that this Act is
22violated shall be considered a separate offense.
23    If a dental management service organization is responsible
24for enrolling the dentist as a provider in managed care plans
25provider networks, it shall provide verification to the managed
26care provider network regarding whether the provider is

 

 

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1accepting new patients at each of the specific locations
2listing the provider.
3    Nothing in this Section shall void any contractual
4relationship between the provider and the organization.
5(Source: P.A. 96-328, eff. 8-11-09.)
 
6    (225 ILCS 25/45)  (from Ch. 111, par. 2345)
7    (Section scheduled to be repealed on January 1, 2016)
8    Sec. 45. Advertising. The purpose of this Section is to
9authorize and regulate the advertisement by dentists of
10information which is intended to provide the public with a
11sufficient basis upon which to make an informed selection of
12dentists while protecting the public from false or misleading
13advertisements which would detract from the fair and rational
14selection process.
15    Any dentist may advertise the availability of dental
16services in the public media or on the premises where such
17dental services are rendered. Such advertising shall be limited
18to the following information:
19        (a) The dental services available;
20        (b) Publication of the dentist's name, title, office
21    hours, address and telephone;
22        (c) Information pertaining to his or her area of
23    specialization, including appropriate board certification
24    or limitation of professional practice;
25        (d) Information on usual and customary fees for routine

 

 

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1    dental services offered, which information shall include
2    notification that fees may be adjusted due to complications
3    or unforeseen circumstances;
4        (e) Announcement of the opening of, change of, absence
5    from, or return to business;
6        (f) Announcement of additions to or deletions from
7    professional dental staff;
8        (g) The issuance of business or appointment cards;
9        (h) Other information about the dentist, dentist's
10    practice or the types of dental services which the dentist
11    offers to perform which a reasonable person might regard as
12    relevant in determining whether to seek the dentist's
13    services. However, any advertisement which announces the
14    availability of endodontics, pediatric dentistry,
15    periodontics, prosthodontics, orthodontics and dentofacial
16    orthopedics, oral and maxillofacial surgery, or oral and
17    maxillofacial radiology by a general dentist or by a
18    licensed specialist who is not licensed in that specialty
19    shall include a disclaimer stating that the dentist does
20    not hold a license in that specialty.
21    Any dental practice with more than one location that
22enrolls its dentist as a participating provider in a managed
23care plan's network must verify electronically or in writing to
24the managed care plan whether the provider is accepting new
25patients at each of the specific locations listing the
26provider. The health plan shall remove the provider from the

 

 

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1directory in accordance with standard practices within 10
2business days after being notified of the changes by the
3provider. Nothing in this paragraph shall void any contractual
4relationship between the provider and the plan.
5    It is unlawful for any dentist licensed under this Act to
6do any of the following:
7        (1) Use claims of superior quality of care to entice
8    the public.
9        (2) Advertise in any way to practice dentistry without
10    causing pain.
11        (3) Pay a fee to any dental referral service or other
12    third party who advertises a dental referral service,
13    unless all advertising of the dental referral service makes
14    it clear that dentists are paying a fee for that referral
15    service.
16        (4) Advertise or offer gifts as an inducement to secure
17    dental patronage. Dentists may advertise or offer free
18    examinations or free dental services; it shall be unlawful,
19    however, for any dentist to charge a fee to any new patient
20    for any dental service provided at the time that such free
21    examination or free dental services are provided.
22        (5) Use the term "sedation dentistry" or similar terms
23    in advertising unless the advertising dentist holds a valid
24    and current permit issued by the Department to administer
25    either general anesthesia, deep sedation, or conscious
26    sedation as required under Section 8.1 of this Act.

 

 

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1    This Act does not authorize the advertising of dental
2services when the offeror of such services is not a dentist.
3Nor shall the dentist use statements which contain false,
4fraudulent, deceptive or misleading material or guarantees of
5success, statements which play upon the vanity or fears of the
6public, or statements which promote or produce unfair
7competition.
8    A dentist shall be required to keep a copy of all
9advertisements for a period of 3 years. All advertisements in
10the dentist's possession shall indicate the accurate date and
11place of publication.
12    The Department shall adopt rules to carry out the intent of
13this Section.
14(Source: P.A. 97-1013, eff. 8-17-12.)
 
15    Section 99. Effective date. This Act takes effect January
161, 2016.