Full Text of HB4789 103rd General Assembly
HB4789ham001 103RD GENERAL ASSEMBLY | Rep. Bob Morgan Filed: 4/1/2024 | | 10300HB4789ham001 | | LRB103 36280 RPS 71495 a |
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| 1 | | AMENDMENT TO HOUSE BILL 4789
| 2 | | AMENDMENT NO. ______. Amend House Bill 4789 by replacing | 3 | | everything after the enacting clause with the following: | 4 | | "Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 355.4 and by adding Section 355d as follows: | 6 | | (215 ILCS 5/355.4) | 7 | | Sec. 355.4. Provider notification of network plan changes. | 8 | | (a) As used in this Section: | 9 | | "Contracting entity" means any person or company that | 10 | | enters into direct contracts with providers for the delivery | 11 | | of dental services in the ordinary course of business, | 12 | | including a third-party administrator and a dental carrier. | 13 | | "Dental carrier" means a dental insurance company, dental | 14 | | service corporation, dental plan organization authorized to | 15 | | provide dental benefits, or a health insurance plan that | 16 | | includes coverage for dental services. |
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| 1 | | (b) No dental carrier may automatically enroll a provider | 2 | | in a leased network without allowing any provider that is part | 3 | | of the dental carrier's provider network to choose to not | 4 | | participate by opting out. | 5 | | (c) Any contract entered into or renewed on or after the | 6 | | effective date of this amendatory Act of the 103rd General | 7 | | Assembly that allows the rights and obligations of the | 8 | | contract to be assigned or leased to another insurer shall | 9 | | provide for notice that informs each provider in writing via | 10 | | certified mail 60 days before any scheduled assignment or | 11 | | lease of the network to which the provider is a contracted | 12 | | provider. To be in compliance with this Section, the | 13 | | notification must provide the specific URL address where the | 14 | | following are located: include all contract terms, a policy | 15 | | manual, a fee schedule, and a statement that the provider has | 16 | | the right to choose not to participate in third-party access. | 17 | | The notification must also provide instructions for how the | 18 | | provider may obtain a copy of those materials. | 19 | | (d) A dental carrier that leases or assigns its network | 20 | | shall not cancel a network participating dentist's contractual | 21 | | relationship or otherwise penalize a network participating | 22 | | dentist in any way based on whether or not the dentist accepts | 23 | | the terms of the assignment or lease. Before accepting the | 24 | | terms of an assignment or lease agreement as described in this | 25 | | Section, any provider who receives notification of an | 26 | | impending assignment or lease must be given the option to |
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| 1 | | contract directly with the entities proposing to gain access | 2 | | to the provider's network. | 3 | | (e) The provisions of this Section do not apply: | 4 | | (1) if access to a provider network contract is | 5 | | granted to a dental carrier or an entity operating in | 6 | | accordance with the same brand licensee program as the | 7 | | contracting entity; or | 8 | | (2) to a provider network contract for dental services | 9 | | provided to beneficiaries of the State employee group | 10 | | health insurance program or the medical assistance program | 11 | | under the Illinois Public Aid Code. | 12 | | (Source: P.A. 103-24, eff. 1-1-24 .) | 13 | | (215 ILCS 5/355d new) | 14 | | Sec. 355d. Denials of claims submitted after prior | 15 | | authorization. | 16 | | (a) In this Section: | 17 | | "Dental carrier" means an insurer, dental service | 18 | | corporation, insurance network leasing company, or any company | 19 | | that offers individual or group policies of accident and | 20 | | health insurance that provide coverage for dental services. | 21 | | "Prior authorization" means any written communication that | 22 | | is verifiable, whether through issuance or letter, facsimile, | 23 | | email, or similar means, indicating that a specific procedure | 24 | | is, or multiple procedures are, covered under the patient's | 25 | | dental plan and reimbursable at a specific amount, subject to |
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| 1 | | applicable coinsurance and deductibles, and issued in response | 2 | | to a request submitted by a dentist using a format prescribed | 3 | | by the dental carrier. | 4 | | (b) Beginning on the effective date of this amendatory Act | 5 | | of the 103rd General Assembly, a dental carrier shall not deny | 6 | | any claim subsequently submitted for procedures specifically | 7 | | included in a prior authorization unless at least one of the | 8 | | following circumstances applies for each procedure denied: | 9 | | (1) benefit limitations, such as annual maximums and | 10 | | frequency limitations, that were not applicable at the | 11 | | time of the prior authorization are reached due to | 12 | | utilization after issuance of the prior authorization; | 13 | | (2) the documentation for the claim provided by the | 14 | | person submitting the claim clearly fails to support the | 15 | | claim as originally authorized; | 16 | | (3) if, after the issuance of the prior authorization, | 17 | | new procedures are provided to the patient or a change in | 18 | | the condition of the patient occurs such that the prior | 19 | | authorized procedure would no longer be considered | 20 | | medically necessary based on the prevailing standard of | 21 | | care; | 22 | | (4) if, after the issuance of the prior authorization, | 23 | | new procedures are provided to the patient or a change in | 24 | | the condition of the patient occurs such that the prior | 25 | | authorized procedure would, at that time, require | 26 | | disapproval pursuant to the terms and conditions for |
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| 1 | | coverage under the plan for the patient in effect at the | 2 | | time the prior authorization was used; or | 3 | | (5) the claim was denied by a dental carrier due to one | 4 | | of the following reasons: | 5 | | (A) another payor is responsible for the payment; | 6 | | (B) the dentist has already been paid for the | 7 | | procedures identified on the claim; | 8 | | (C) the claim was submitted fraudulently or the | 9 | | prior authorization was based in whole or material | 10 | | part on erroneous information provided to the dental | 11 | | carrier; or | 12 | | (D) the person receiving the procedure was not | 13 | | eligible for the procedure on the date of service and | 14 | | the dental carrier did not know, and with the exercise | 15 | | of reasonable care could not have known, that person's | 16 | | eligibility status. | 17 | | A dental carrier shall not recoup a claim solely due to a | 18 | | loss of coverage of a patient or ineligibility if, at the time | 19 | | of treatment, the dental carrier erroneously confirmed | 20 | | coverage and eligibility, but had sufficient information | 21 | | available to the dental carrier indicating that the patient | 22 | | was no longer covered or was ineligible for coverage. | 23 | | (c) The provisions of this Section may not be waived by | 24 | | contract. Any contractual arrangement in conflict with the | 25 | | provisions of this Section or that purports to waive any | 26 | | requirement of this Section is null and void. |
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| 1 | | Section 10. The Limited Health Service Organization Act is | 2 | | amended by changing Section 4003 as follows: | 3 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3) | 4 | | Sec. 4003. Illinois Insurance Code provisions. Limited | 5 | | health service organizations shall be subject to the | 6 | | provisions of Sections 133, 134, 136, 137, 139, 140, 141.1, | 7 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, | 8 | | 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2, | 9 | | 355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10, | 10 | | 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, | 11 | | 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | 12 | | 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68, | 13 | | 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, | 14 | | 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, | 15 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code. | 16 | | Nothing in this Section shall require a limited health care | 17 | | plan to cover any service that is not a limited health service. | 18 | | For purposes of the Illinois Insurance Code, except for | 19 | | Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited | 20 | | health service organizations in the following categories are | 21 | | deemed to be domestic companies: | 22 | | (1) a corporation under the laws of this State; or | 23 | | (2) a corporation organized under the laws of another | 24 | | state, 30% or more of the enrollees of which are residents |
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| 1 | | of this State, except a corporation subject to | 2 | | substantially the same requirements in its state of | 3 | | organization as is a domestic company under Article VIII | 4 | | 1/2 of the Illinois Insurance Code. | 5 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | 6 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff. | 7 | | 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816, | 8 | | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | 9 | | 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. | 10 | | 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, | 11 | | eff. 1-1-24; revised 8-29-23.) | 12 | | Section 15. The Voluntary Health Services Plans Act is | 13 | | amended by changing Section 10 as follows: | 14 | | (215 ILCS 165/10) (from Ch. 32, par. 604) | 15 | | Sec. 10. Application of Insurance Code provisions. Health | 16 | | services plan corporations and all persons interested therein | 17 | | or dealing therewith shall be subject to the provisions of | 18 | | Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140, | 19 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, | 20 | | 355d, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, | 21 | | 356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a, | 22 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 23 | | 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22, | 24 | | 356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, |
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| 1 | | 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53, | 2 | | 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, | 3 | | 356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401, | 4 | | 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) | 5 | | and (15) of Section 367 of the Illinois Insurance Code. | 6 | | Rulemaking authority to implement Public Act 95-1045, if | 7 | | any, is conditioned on the rules being adopted in accordance | 8 | | with all provisions of the Illinois Administrative Procedure | 9 | | Act and all rules and procedures of the Joint Committee on | 10 | | Administrative Rules; any purported rule not so adopted, for | 11 | | whatever reason, is unauthorized. | 12 | | (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; | 13 | | 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. | 14 | | 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804, | 15 | | eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; | 16 | | 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff. | 17 | | 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, | 18 | | eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; | 19 | | 103-551, eff. 8-11-23; revised 8-29-23.)". |
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