Sen. Michael E. Hastings

Filed: 4/17/2015

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 750

2    AMENDMENT NO. ______. Amend Senate Bill 750, AS AMENDED, by
3replacing everything after the enacting clause with:
 
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

 

 

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1health coverages.
2    (2) Definitions applicable to this Section are as follows:
3        (a) "Policy" means all or any part of the forms
4    constituting the contract between the insurer and the
5    insured, including the policy, certificate, subscriber
6    contract, riders, endorsements, and the application if
7    attached, which are subject to filing with and approval by
8    the Director.
9        (b) "Service corporations" means voluntary health and
10    dental corporations organized and operating respectively
11    under the Voluntary Health Services Plans Act and the
12    Dental Service Plan Act.
13        (c) "Accident and health insurance" means insurance
14    written under Article XX of the Insurance Code, other than
15    credit accident and health insurance, and coverages
16    provided in subscriber contracts issued by service
17    corporations. For purposes of this Section such service
18    corporations shall be deemed to be insurers engaged in the
19    business of insurance.
20    (3) The Director shall issue such rules as he shall deem
21necessary or desirable to establish specific standards,
22including standards of full and fair disclosure that set forth
23the form and content and required disclosure for sale, of
24individual policies of accident and health insurance, which
25rules and regulations shall be in addition to and in accordance
26with the applicable laws of this State, and which may cover but

 

 

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1shall not be limited to: (a) terms of renewability; (b) initial
2and subsequent conditions of eligibility; (c) non-duplication
3of coverage provisions; (d) coverage of dependents; (e)
4pre-existing conditions; (f) termination of insurance; (g)
5probationary periods; (h) limitation, exceptions, and
6reductions; (i) elimination periods; (j) requirements
7regarding replacements; (k) recurrent conditions; and (l) the
8definition of terms including but not limited to the following:
9hospital, accident, sickness, injury, physician, accidental
10means, total disability, partial disability, nervous disorder,
11guaranteed renewable, and non-cancellable.
12    The Director may issue rules that specify prohibited policy
13provisions not otherwise specifically authorized by statute
14which in the opinion of the Director are unjust, unfair or
15unfairly discriminatory to the policyholder, any person
16insured under the policy, or beneficiary.
17    (4) The Director shall issue such rules as he shall deem
18necessary or desirable to establish minimum standards for
19benefits under each category of coverage in individual accident
20and health policies, other than conversion policies issued
21pursuant to a contractual conversion privilege under a group
22policy, including but not limited to the following categories:
23(a) basic hospital expense coverage; (b) basic
24medical-surgical expense coverage; (c) hospital confinement
25indemnity coverage; (d) major medical expense coverage; (e)
26disability income protection coverage; (f) accident only

 

 

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1coverage; and (g) specified disease or specified accident
2coverage.
3    Nothing in this subsection (4) shall preclude the issuance
4of any policy which combines two or more of the categories of
5coverage enumerated in subparagraphs (a) through (f) of this
6subsection.
7    No policy shall be delivered or issued for delivery in this
8State which does not meet the prescribed minimum standards for
9the categories of coverage listed in this subsection unless the
10Director finds that such policy is necessary to meet specific
11needs of individuals or groups and such individuals or groups
12will be adequately informed that such policy does not meet the
13prescribed minimum standards, and such policy meets the
14requirement that the benefits provided therein are reasonable
15in relation to the premium charged. The standards and criteria
16to be used by the Director in approving such policies shall be
17included in the rules required under this Section with as much
18specificity as practicable.
19    The Director shall prescribe by rule the method of
20identification of policies based upon coverages provided.
21    (5) (a) In order to provide for full and fair disclosure in
22the sale of individual accident and health insurance policies,
23no such policy shall be delivered or issued for delivery in
24this State unless the outline of coverage described in
25paragraph (b) of this subsection either accompanies the policy,
26or is delivered to the applicant at the time the application is

 

 

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1made, and an acknowledgment signed by the insured, of receipt
2of delivery of such outline, is provided to the insurer. In the
3event the policy is issued on a basis other than that applied
4for, the outline of coverage properly describing the policy
5must accompany the policy when it is delivered and such outline
6shall clearly state that the policy differs, and to what
7extent, from that for which application was originally made.
8All policies, except single premium nonrenewal policies, shall
9have a notice prominently printed on the first page of the
10policy or attached thereto stating in substance, that the
11policyholder shall have the right to return the policy within
1210 days of its delivery and to have the premium refunded if
13after examination of the policy the policyholder is not
14satisfied for any reason.
15    (b) The Director shall issue such rules as he shall deem
16necessary or desirable to prescribe the format and content of
17the outline of coverage required by paragraph (a) of this
18subsection. "Format" means style, arrangement, and overall
19appearance, including such items as the size, color, and
20prominence of type and the arrangement of text and captions.
21"Content" shall include without limitation thereto, statements
22relating to the particular policy as to the applicable category
23of coverage prescribed under subsection 4; principal benefits;
24exceptions, reductions and limitations; and renewal
25provisions, including any reservation by the insurer of a right
26to change premiums. Such outline of coverage shall clearly

 

 

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1state that it constitutes a summary of the policy issued or
2applied for and that the policy should be consulted to
3determine governing contractual provisions.
4    (c) Without limiting the generality of paragraph (b) of
5this subsection (5), no qualified health plans shall be offered
6for sale directly to consumers through the health insurance
7marketplace operating in the State in accordance with Sections
81311 and 1321 of the federal Patient Protection and Affordable
9Care Act of 2010 (Public Law 111-148), as amended by the
10federal Health Care and Education Reconciliation Act of 2010
11(Public Law 111-152), and any amendments thereto, or
12regulations or guidance issued thereunder (collectively, "the
13Federal Act"), unless the following information is made
14available to the consumer at the time he or she is comparing
15policies and their premiums:
16        (i) With respect to prescription drug benefits, the
17    most recently published formulary where a consumer can view
18    in one location covered prescription drugs; information on
19    tiering and the cost-sharing structure for each tier; and
20    information about how a consumer can obtain specific
21    copayment amounts or coinsurance percentages for a
22    specific qualified health plan before enrolling in that
23    plan. This information shall clearly identify the
24    qualified health plan to which it applies.
25        (ii) The most recently published provider directory
26    where a consumer can view the provider network that applies

 

 

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1    to each qualified health plan and information about each
2    provider, including location, contact information,
3    specialty, medical group, if any, any institutional
4    affiliation, and whether the provider is accepting new
5    patients at each of the specific locations listing the
6    provider. Providers shall notify qualified health plans
7    electronically or in writing of any changes to their
8    information as listed in the provider directory. Qualified
9    health plans shall update their directories in a manner
10    consistent with the information provided by the provider
11    within 10 business days after being notified of the change
12    by the provider. Nothing in this paragraph (ii) shall void
13    any contractual relationship between the provider and the
14    plan. The information shall clearly identify the qualified
15    health plan to which it applies.
16    (d) Each company that offers qualified health plans for
17sale directly to consumers through the health insurance
18marketplace operating in the State shall make the information
19in paragraph (c) of this subsection (5), for each qualified
20health plan that it offers, available and accessible to the
21general public on the company's Internet website and through
22other means for individuals without access to the Internet.
23    (e) The Department shall ensure that State-operated
24Internet websites, in addition to the Internet website for the
25health insurance marketplace established in this State in
26accordance with the Federal Act, prominently provide links to

 

 

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1Internet-based materials and tools to help consumers be
2informed purchasers of health insurance.
3    (f) Nothing in this Section shall be interpreted or
4implemented in a manner not consistent with the Federal Act.
5This Section shall apply to all qualified health plans offered
6for sale directly to consumers through the health insurance
7marketplace operating in this State for any coverage year
8beginning on or after January 1, 2015.
9    (6) Prior to the issuance of rules pursuant to this
10Section, the Director shall afford the public, including the
11companies affected thereby, reasonable opportunity for
12comment. Such rulemaking is subject to the provisions of the
13Illinois Administrative Procedure Act.
14    (7) When a rule has been adopted, pursuant to this Section,
15all policies of insurance or subscriber contracts which are not
16in compliance with such rule shall, when so provided in such
17rule, be deemed to be disapproved as of a date specified in
18such rule not less than 120 days following its effective date,
19without any further or additional notice other than the
20adoption of the rule.
21    (8) When a rule adopted pursuant to this Section so
22provides, a policy of insurance or subscriber contract which
23does not comply with the rule shall not less than 120 days from
24the effective date of such rule, be construed, and the insurer
25or service corporation shall be liable, as if the policy or
26contract did comply with the rule.

 

 

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1    (9) Violation of any rule adopted pursuant to this Section
2shall be a violation of the insurance law for purposes of
3Sections 370 and 446 of the Insurance Code.
4(Source: P.A. 98-1035, eff. 8-25-14.)
 
5    Section 10. The Dental Care Patient Protection Act is
6amended by changing Section 25 as follows:
 
7    (215 ILCS 109/25)
8    Sec. 25. Provision of information.
9    (a) A managed care dental plan shall provide upon request
10to prospective enrollees a written summary description of all
11of the following terms of coverage:
12        (1) Information about the dental plan, including how
13    the plan operates and what general types of financial
14    arrangements exist between dentists and the plan. Nothing
15    in this Section shall require disclosure of any specific
16    financial arrangements between providers and the plan.
17        (2) The service area.
18        (3) Covered benefits, exclusions, or limitations.
19        (4) Pre-certification requirements including any
20    requirements for referrals made by primary care dentists to
21    specialists, and other preauthorization requirements.
22        (5) A list of participating primary care dentists in
23    the plan's service area, including provider address and
24    phone number, for an enrollee to evaluate the managed care

 

 

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1    dental plan's network access, as well as a phone number by
2    which the prospective enrollee may obtain additional
3    information regarding the provider network including
4    participating specialists. However, a managed care dental
5    plan offering a preferred provider organization ("PPO")
6    product that does not require the enrollee to select a
7    primary care dentist shall only be required to make
8    available for inspection to enrollees and prospective
9    enrollees a list of participating dentists in the plan's
10    service area, including whether the provider is accepting
11    new patients at each of the specific locations listing the
12    provider. Providers shall notify managed care dental plans
13    electronically or in writing of any changes to their
14    information as listed in the provider directory. Managed
15    care dental plans shall update their directories in a
16    manner consistent with the information provided by the
17    provider within 10 business days after being notified of
18    the change by the provider.
19        Nothing in this paragraph (5) shall void any
20    contractual relationship between the provider and the
21    plan.
22        (6) Emergency coverage and benefits.
23        (7) Out-of-area coverages and benefits, if any.
24        (8) The process about how participating dentists are
25    selected.
26        (9) The grievance process, including the telephone

 

 

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

 

 

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1    within a reasonable travel distance, as established by rule
2    adopted by the Director, from the residence or place of
3    employment of the enrollee.
4    (e) Nothing in this Act shall be deemed to require a plan
5to assign an enrollee to a primary care provider (dentist).
6(Source: P.A. 91-355, eff. 1-1-00.)
 
7    Section 15. The Illinois Dental Practice Act is amended by
8changing Sections 44 and 45 as follows:
 
9    (225 ILCS 25/44)  (from Ch. 111, par. 2344)
10    (Section scheduled to be repealed on January 1, 2016)
11    Sec. 44. Practice by Corporations Prohibited. Exceptions.
12No corporation shall practice dentistry or engage therein, or
13hold itself out as being entitled to practice dentistry, or
14furnish dental services or dentists, or advertise under or
15assume the title of dentist or dental surgeon or equivalent
16title, or furnish dental advice for any compensation, or
17advertise or hold itself out with any other person or alone,
18that it has or owns a dental office or can furnish dental
19service or dentists, or solicit through itself, or its agents,
20officers, employees, directors or trustees, dental patronage
21for any dentist employed by any corporation.
22    Nothing contained in this Act, however, shall:
23        (a) prohibit a corporation from employing a dentist or
24    dentists to render dental services to its employees,

 

 

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1    provided that such dental services shall be rendered at no
2    cost or charge to the employees;
3        (b) prohibit a corporation or association from
4    providing dental services upon a wholly charitable basis to
5    deserving recipients;
6        (c) prohibit a corporation or association from
7    furnishing information or clerical services which can be
8    furnished by persons not licensed to practice dentistry, to
9    any dentist when such dentist assumes full responsibility
10    for such information or services;
11        (d) prohibit dental corporations as authorized by the
12    Professional Service Corporation Act, dental associations
13    as authorized by the Professional Association Act, or
14    dental limited liability companies as authorized by the
15    Limited Liability Company Act;
16        (e) prohibit dental limited liability partnerships as
17    authorized by the Uniform Partnership Act (1997);
18        (f) prohibit hospitals, public health clinics,
19    federally qualified health centers, or other entities
20    specified by rule of the Department from providing dental
21    services; or
22        (g) prohibit dental management service organizations
23    from providing non-clinical business services that do not
24    violate the provisions of this Act.
25    Any corporation violating the provisions of this Section is
26guilty of a Class A misdemeanor and each day that this Act is

 

 

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1violated shall be considered a separate offense.
2    If a dental management service organization is responsible
3for enrolling the dentist as a provider in managed care plans
4provider networks, it shall provide verification to the managed
5care provider network regarding whether the provider is
6accepting new patients at each of the specific locations
7listing the provider.
8    Nothing in this Section shall void any contractual
9relationship between the provider and the organization.
10(Source: P.A. 96-328, eff. 8-11-09.)
 
11    (225 ILCS 25/45)  (from Ch. 111, par. 2345)
12    (Section scheduled to be repealed on January 1, 2016)
13    Sec. 45. Advertising. The purpose of this Section is to
14authorize and regulate the advertisement by dentists of
15information which is intended to provide the public with a
16sufficient basis upon which to make an informed selection of
17dentists while protecting the public from false or misleading
18advertisements which would detract from the fair and rational
19selection process.
20    Any dentist may advertise the availability of dental
21services in the public media or on the premises where such
22dental services are rendered. Such advertising shall be limited
23to the following information:
24        (a) The dental services available;
25        (b) Publication of the dentist's name, title, office

 

 

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1    hours, address and telephone;
2        (c) Information pertaining to his or her area of
3    specialization, including appropriate board certification
4    or limitation of professional practice;
5        (d) Information on usual and customary fees for routine
6    dental services offered, which information shall include
7    notification that fees may be adjusted due to complications
8    or unforeseen circumstances;
9        (e) Announcement of the opening of, change of, absence
10    from, or return to business;
11        (f) Announcement of additions to or deletions from
12    professional dental staff;
13        (g) The issuance of business or appointment cards;
14        (h) Other information about the dentist, dentist's
15    practice or the types of dental services which the dentist
16    offers to perform which a reasonable person might regard as
17    relevant in determining whether to seek the dentist's
18    services. However, any advertisement which announces the
19    availability of endodontics, pediatric dentistry,
20    periodontics, prosthodontics, orthodontics and dentofacial
21    orthopedics, oral and maxillofacial surgery, or oral and
22    maxillofacial radiology by a general dentist or by a
23    licensed specialist who is not licensed in that specialty
24    shall include a disclaimer stating that the dentist does
25    not hold a license in that specialty.
26    Any dental practice with more than one location that

 

 

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1enrolls its dentist as a participating provider in a managed
2care plan's network must verify electronically or in writing to
3the managed care plan whether the provider is accepting new
4patients at each of the specific locations listing the
5provider. The health plan shall remove the provider from the
6directory in accordance with standard practices within 10
7business days after being notified of the changes by the
8provider. Nothing in this paragraph shall void any contractual
9relationship between the provider and the plan.
10    It is unlawful for any dentist licensed under this Act to
11do any of the following:
12        (1) Use claims of superior quality of care to entice
13    the public.
14        (2) Advertise in any way to practice dentistry without
15    causing pain.
16        (3) Pay a fee to any dental referral service or other
17    third party who advertises a dental referral service,
18    unless all advertising of the dental referral service makes
19    it clear that dentists are paying a fee for that referral
20    service.
21        (4) Advertise or offer gifts as an inducement to secure
22    dental patronage. Dentists may advertise or offer free
23    examinations or free dental services; it shall be unlawful,
24    however, for any dentist to charge a fee to any new patient
25    for any dental service provided at the time that such free
26    examination or free dental services are provided.

 

 

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1        (5) Use the term "sedation dentistry" or similar terms
2    in advertising unless the advertising dentist holds a valid
3    and current permit issued by the Department to administer
4    either general anesthesia, deep sedation, or conscious
5    sedation as required under Section 8.1 of this Act.
6    This Act does not authorize the advertising of dental
7services when the offeror of such services is not a dentist.
8Nor shall the dentist use statements which contain false,
9fraudulent, deceptive or misleading material or guarantees of
10success, statements which play upon the vanity or fears of the
11public, or statements which promote or produce unfair
12competition.
13    A dentist shall be required to keep a copy of all
14advertisements for a period of 3 years. All advertisements in
15the dentist's possession shall indicate the accurate date and
16place of publication.
17    The Department shall adopt rules to carry out the intent of
18this Section.
19(Source: P.A. 97-1013, eff. 8-17-12.)
 
20    Section 99. Effective date. This Act takes effect January
211, 2016.".