SB2355 99TH GENERAL ASSEMBLY

LRB099 16016 MLM 40334 b

99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB2355

Introduced 1/28/2016, by Sen. Linda Holmes

SYNOPSIS AS INTRODUCED:

215 ILCS 5/355.4 new

Amends the Illinois Insurance Code. Provides that a contracting entity may not sell, lease, rent, or otherwise grant access to the dental services of a participating provider under a dental services contract unless expressly authorized by the dental services contract. Requires a contracting entity to make certain disclosures to the participating provider. Provides that any contract entered into or renewed on or after the effective date of the amendatory Act shall require that any time a contracting entity leases, rents, or otherwise grants access to the dental services of a participating provider it must allow the participating provider the option to refuse to continue to provide services to third-parties entities that have bought, leased, rented, or otherwise been granted access to the health care services of a participating provider by the contracting entity. Requires contracting entities to timely update their provider directories to reflect participating providers who have refused to continue to provide services. Requires third parties who contract with contracting entities to provide certain information to participating providers.

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by adding Section 355.4 as follows:

(215 ILCS 5/355.4 new)

Sec. 355.4. Provider notification of network plan changes.

(a) As used in this Section:

"Contracting entity" means any person or entity that is engaged in the act of contracting with participating providers and has a direct contract with a participating provider for the delivery of dental services or the selling or assigning of dental network plans to other health care entities.

"Identify" means to provide, in writing, by e-mail, or otherwise, to the participating provider the name, address, telephone number, and website link.

"Network plan" means health insurance coverage offered by a health insurance issuer under which the financing and delivery of dental care, including items and services paid for as dental care, are provided, in whole or in part, through a defined set of participating providers under contract with the issuer.

"Participating provider" any person licensed to practice dentistry under the Illinois Dental Practice Act.

(b) A contracting entity may not sell, lease, rent, or otherwise grant access to the dental services of a participating provider under a dental services contract unless expressly authorized by the dental services contract. The dental service contract must specifically provide that one purpose of the contract is the selling, renting, or giving the contracting entity rights to the services of the participating provider, including network plans. At the time a dental service contract is entered into with a participating provider, the contracting entity shall, to the extent possible, identify any third party to which the contracting entity has granted access to the dental services of the participating provider.

(c) Upon a request by a participating provider, a contracting entity must properly identify any third party that has been granted access to the dental services of the participating provider.

(d) Any contracts entered into or renewed on or after the effective date of this amendatory Act of the 99th General Assembly shall require that any time a contracting entity leases, rents, or otherwise grants access to the dental services of a participating provider it must allow the participating provider the option to refuse to continue to provide services to third-parties entities that have bought, leased, rented, or otherwise been granted access to the health care services of a participating provider by the contracting entity. Contracting entities must timely update their provider directories of any participating providers who have refused to continue to provide services to the new contracting entity as required under item (ii) of paragraph (c) of subsection (5) of Section 355a of this Code, paragraph (5) of subsection (a) of Section 25 of the Dental Care Patient Protection Act, and Sections 44 and 45 of the Illinois Dental Practice Act.

(e) Any third-party entity, within 30 days of leasing, renting, or otherwise accessing the dental services of a participating provider, must provide to the participating provider a listing of the 100 most frequently reimbursed American Dental Association Current Dental Terminology (CDT) codes by the third-party entity and the amount by which the third-party entity reimburses a participating provider.

(f) A contracting entity that leases, rents, or otherwise grants access to a participating provider's dental services must ensure that an explanation of benefits or remittance advice furnished to the participating provider that delivers dental services under the dental services contract identifies the contractual source of any applicable discount.

(g) All third parties that have contracted with a contracting entity to purchase, rent, assign, or otherwise have been granted access to the participating provider's discounted rate shall comply with the dentist's contract, including all requirements to encourage access to the participating provider and pay the participating provider pursuant to the rates of payment and methodology set forth in that contract, unless otherwise agreed to by a participating provider.

(h) A contracting entity is deemed in compliance with this Section when the insured's identification card provides information that identifies the insurance carrier to be used to reimburse the participating provider for covered services.