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90_HB0558
New Act
Creates the Managed Dental Care Patient Protection and
Reform Act. Provides for the regulation of dental managed
care plans by the Director of Public Health. Establishes
requirements for disclosure to enrollees. Establishes
credentialing and utilization review standards. Requires
plans to include a point-of-service option. Provides that
the Director of Public Health shall issue an annual report on
the performance of managed care entities.
LRB9000645JSmgB
LRB9000645JSmgB
1 AN ACT concerning managed care dental benefit plans.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Managed Dental Care Patient Protection and Reform Act.
6 Section 5. Purpose. The purpose of this Act is to
7 provide fairness and choice to dental patients and providers
8 under managed care dental benefit plans.
9 Section 10. Definitions. As used in this Act:
10 "Dentist" means a person licensed to practice dentistry
11 under the Illinois Dental Practice Act.
12 "Department" means the Illinois Department of Public
13 Health.
14 "Director" means the Director of Public Health.
15 "Emergency care services" means dental services provided
16 for an emergency dental condition.
17 "Emergency dental condition" means a dental condition
18 manifesting itself by acute symptoms of sufficient severity,
19 including severe pain, so that the absence of immediate
20 dental attention could reasonably be expected to result in:
21 (1) placing the health of the individual in serious
22 jeopardy;
23 (2) serious impairment to a bodily function; or
24 (3) serious dysfunction of an organ or part of the
25 body.
26 "Managed care dental plan" or "plan" means a plan
27 operated by a managed care entity that provides for the
28 financing and delivery of dental care or dental services to
29 persons enrolled in the plan through:
30 (1) arrangements with selected providers to furnish
31 dental services;
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1 (2) explicit standards for the selection of
2 participating providers;
3 (3) organizational arrangements for ongoing quality
4 assurance, utilization review, and dispute resolution;
5 or
6 (4) differential coverages or payments or financial
7 incentives for a person enrolled in the plan to use the
8 participating providers and procedures provided by the
9 plan.
10 "Point-of-service plan" means a plan provided through a
11 contractual arrangement under which indemnity benefits for
12 the cost of dental care services, other than emergency care
13 services, are provided by an insurer or other corporation in
14 conjunction with corresponding benefits arranged or provided
15 by a health maintenance organization, including a single
16 service health maintenance organization. An individual may
17 choose to obtain benefits or services under either the
18 indemnity plan or the health maintenance organization plan in
19 accordance with specific provisions of a point-of-service
20 contract.
21 "Prospective enrollee" means an individual eligible for
22 enrollment in a managed care plan offered by that
23 individual's employer.
24 "Provider" means either a general dentist or a dentist
25 who is a licensed specialist.
26 Section 15. Rules; advisory committee. The Director may
27 adopt rules regarding standards ensuring compliance with this
28 Act by managed care entities that conduct business in this
29 State. The Director may appoint an advisory committee to
30 assist in the implementation of this Act.
31 Section 20. Disclosure.
32 (a) A managed care entity shall provide a prospective
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1 enrollee a written plan description of the terms and
2 conditions of the dental plan. The written dental plan
3 description must be in a readable and understandable format
4 and must include:
5 (1) coverage provisions;
6 (2) any prior authorization, including procedures
7 for and limitations or restrictions on referrals to
8 providers other than general dentists, or other review
9 requirements, including preauthorization review,
10 concurrent review, postservice review, and postpayment
11 review;
12 (3) an explanation of enrollee financial
13 responsibility for payment for coinsurance or other
14 noncovered or out-of-plan services; and
15 (4) a disclosure to prospective enrollees that
16 includes the following language:
17 "YOUR RIGHTS UNDER ILLINOIS LAW
18 You have the right to information about the dental
19 plan, including how the plan operates, what general types
20 of financial arrangements exist between providers and the
21 plan, names and locations of providers, the number of
22 enrollees and providers in the plan, the percentage of
23 premiums allocated for dental care, administrative costs,
24 and profit, and an explanation of the benefits to which
25 participants are entitled under the terms of the plan.";
26 and
27 (5) a phone number and address for the prospective
28 enrollee to obtain additional information concerning the
29 items described by paragraph (4) of this subsection.
30 (b) The managed care entity may provide the information
31 under paragraph (4) of subsection (a) of this Section
32 regarding the percentage of premiums allocated for dental
33 care, administrative costs, and profit by providing the
34 information in the entity's annual financial statement most
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1 recently submitted to the Department.
2 (c) The managed care entity shall demonstrate that each
3 covered enrollee has adequate access through the entity's
4 provider network to all items and dental services contained
5 in the package of benefits for which coverage is provided.
6 The access must be adequate considering the diverse needs of
7 enrollees.
8 (d) Nothing in subsection (c) of this Section may be
9 interpreted to circumvent the managed care plan's normal
10 referral and authorization processes.
11 (e) If the managed care plan uses a capitation method of
12 compensation, the plan must establish and follow procedures
13 that ensure that:
14 (1) the plan application form includes a space in
15 which each enrollee selects a dentist;
16 (2) an enrollee who fails to select a dentist and
17 is assigned a dentist is notified of the name and
18 location of that dentist; and
19 (3) a dentist to whom an enrollee is assigned is
20 physically located within a reasonable travel distance,
21 as established by rule adopted by the Director, from the
22 residence or place of employment of the enrollee.
23 Section 25. Explanation of network configuration. The
24 managed care entity shall provide to the Director, for
25 information, an explanation of the targeted dentist, and, as
26 appropriate, other provider network configuration, including
27 geographic distribution of dentists by specialty. The
28 information required by this Section shall be updated at
29 least:
30 (1) on establishment of a new managed care dental
31 plan;
32 (2) on expansion of a service area; or
33 (3) when the network configuration targets are
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1 significantly modified.
2 Nothing in this Section shall require a particular ratio
3 for any type of provider. The information shall be made
4 available to the public by the Department on request. The
5 Department may charge a reasonable fee for providing the
6 information.
7 Section 30. Financial incentives that limit services
8 prohibited. A managed care dental plan may not use a
9 financial incentive program that limits medically necessary
10 and appropriate services.
11 Section 35. Credentialing; utilization review; provider
12 input.
13 (a) A managed care dental plan shall establish a
14 mechanism under which dentists participating in the plan
15 provide consultation and advice on the plan's dental policy,
16 including coverage of a new technology and procedures,
17 utilization review criteria and procedures, quality and
18 credentialing criteria, and dental management procedures.
19 Other participating providers shall be given an opportunity
20 to comment on the plan's policies affecting their services.
21 A managed care dental plan on request shall make available
22 and disclose to providers the application process and
23 qualification requirements for participation in the plan.
24 The plan must give a provider not selected on initial
25 application a reason why the initial application was denied.
26 (b) A dentist under consideration for inclusion in a
27 managed care dental plan shall be reviewed by a credentialing
28 committee composed primarily of network participating
29 dentists selected by the dental director of the managed care
30 entity. If there are no credentialed dentists in a newly
31 created plan, the committee shall be primarily composed of
32 dentists practicing in the same or similar settings. Other
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1 providers may be credentialed if appropriate, as determined
2 by the plan. When a provider, other than a general dentist,
3 is credentialed by the plan, the credentialing committee
4 shall include providers with the same license.
5 (c) Credentialing of providers shall be based on
6 identified standards developed after consultation with
7 providers credentialed in the plan. If there are no
8 credentialed providers in a newly created plan, the plan
9 shall develop credentialing standards after consulting with
10 area providers. The managed care dental plan shall make the
11 credentialing standards available to applicants.
12 (d) If economic considerations are part of the decision
13 to select a provider or terminate a contract with a provider,
14 the plan shall use identified criteria which shall be
15 available to applicants and participating providers. If the
16 plan uses an economic profile of a provider, the plan must
17 adjust the profile to recognize the characteristics of a
18 provider's practice that may account for variations from
19 expected costs.
20 (e) A managed care dental plan that conducts or uses
21 economic profiling of providers within the plan shall make
22 the profile available to the provider profiled on a periodic
23 basis.
24 (f) A managed care dental plan shall have a dental
25 director who is a licensed dentist. The dental director
26 shall be responsible for the clinical decisions made by the
27 plan and provide assurance that the dental decisions and
28 review policies that are used by the plan are clinically
29 appropriate and based on the commonly accepted standards of
30 care.
31 Decisions made by the plan to deny coverage for a
32 procedure, or that a payment for an alternative procedure
33 should be considered, must be made by the dental director or
34 a licensed dentist acting under the direct authority of the
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1 dental director. When claims are denied or an alternative
2 procedure is offered by the plan, the decisions must indicate
3 the name of the dentist who made the determination and a
4 telephone number and business hours where the dentist can be
5 contacted directly to discuss the clinical determination.
6 Upon request, enrollees or the provider may request the
7 credentials of the individual who has recommended a denial or
8 has offered an alternative procedure for payment for specific
9 claim. An enrollee or provider who has had a claim denied or
10 was offered an alternative benefit for payment by the plan
11 shall be provided the opportunity for a due process appeal to
12 a licensed dentist who was not involved in the initial
13 decision.
14 (g) Unless specifically required by this Act, a managed
15 care dental plan is not required to disclose proprietary
16 information regarding marketplace strategies.
17 (h) A managed care dental plan may not exclude a
18 provider solely because of the anticipated characteristics of
19 the patients of that provider.
20 (i) Before terminating a contract with a provider, the
21 managed care dental plan shall provide a written explanation
22 of the reasons for termination, an opportunity for
23 discussion, and an opportunity to enter into and complete a
24 corrective action plan, if appropriate, as determined by the
25 plan. Except in cases in which there is imminent harm to
26 patient health or an action by the Department of Professional
27 Regulation or other government agency that effectively
28 impairs the provider's ability to practice dentistry, or in
29 cases of fraud or malfeasance, on request and before the
30 effective date of the termination, the provider is entitled
31 to a review of the plan's proposed action by a plan advisory
32 panel. For a dentist, the plan advisory panel must be
33 primarily composed of the dentist's peers. The review may
34 include a review of the appropriateness and requirements of a
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1 corrective action plan. The decision of the advisory panel
2 must be considered but is not binding on the plan.
3 (j) If the action that is under consideration is of a
4 type that must be reported to the National Practitioner Data
5 Bank or the Department of Professional Regulation under
6 federal or State law, the dentist's procedural rights must
7 meet the standards set forth in the federal Health Care
8 Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
9 (k) A communication relating to the subject matter
10 provided for under subsection (a) or (i) of this Section may
11 not be the basis for a cause of action for libel or slander
12 except for disclosures or communications with parties other
13 than the plan or provider.
14 (l) The managed care dental plan shall establish
15 reasonable procedures for assuring a transition of enrollees
16 of the plan to new providers.
17 (m) If a contract with a provider is terminated by a
18 managed care dental plan, the plan shall reimburse the
19 provider the reasonable cost for copies of medical or dental
20 records that are furnished to another provider at the
21 patient's request. If a provider terminates the contract
22 with the plan, the provider shall bear the reasonable cost of
23 providing copies of dental records that are furnished to
24 another provider at the patient's request.
25 (n) This Act does not prohibit a managed care dental
26 plan from rejecting an application from a provider based on
27 the determination that the plan has sufficient qualified
28 providers.
29 Section 40. Coverage; prior authorization. A managed
30 care dental plan shall:
31 (1) cover emergency dental care services provided to
32 covered individuals, without regard to whether the provider
33 furnishing the services has a contractual or other
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1 arrangement with the entity to provide items or services to
2 covered individuals, including the treatment and
3 stabilization of an emergency dental condition; and
4 (2) provide that the prior authorization requirement for
5 medically necessary services provided or originating in a
6 hospital emergency department following treatment or
7 stabilization of an emergency dental condition is approved
8 unless denied in the time appropriate to the circumstances
9 relating to the delivery of the services and the condition of
10 the patient, as determined by the treating provider and
11 communicated to the plan.
12 Section 45. Prior authorization; consent forms. A plan
13 for which prior authorization is a condition to coverage of a
14 service must ensure that enrollees are required to sign
15 dental information release consent forms on enrollment.
16 Section 50. Point-of-service plans.
17 (a) When a health maintenance organization offers a
18 managed care dental plan in its service area and is the only
19 entity providing services under a dental benefit plan, it
20 must offer to all eligible enrollees the opportunity to
21 obtain coverage for out-of-network services through the
22 point-of-service plan as defined by subsection (b) of this
23 Section at the time of enrollment and at least annually.
24 (b) The premium for the point-of-service plan shall be
25 based on the actuarial value of that coverage.
26 (c) Any additional costs for the point-of-service plan
27 are the responsibility of the enrollee, and the employer may
28 impose a reasonable administrative cost for providing the
29 point-of-service option.
30 (d) When 5% or less of the group's eligible employees
31 elect to purchase the point-of-service option, the plan is
32 not required to offer the point-of-service option during
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1 subsequent open enrollment periods.
2 Section 55. Private cause of action; existing remedies.
3 This Act and rules adopted under this Act do not:
4 (1) provide a private cause of action for damages
5 or create a standard of care, obligation, or duty that
6 provides a basis for a private cause of action for
7 damages; or
8 (2) abrogate a statutory or common law cause of
9 action, administrative remedy, or defense otherwise
10 available and existing before the effective date of this
11 Act.
12 Section 60. Director's report.
13 (a) The Director shall issue an annual report to
14 consumers on the performance of managed care entities.
15 (b) The Director shall have access to:
16 (1) information provided under Section 25 of this
17 Act;
18 (2) information contained in complaints relating to
19 managed care entities made to the Department provided
20 that the Director shall maintain as confidential any
21 information in the complaint that relates to a patient or
22 that is made confidential by another law; and
23 (3) any statistical information relating to
24 utilization, quality assurance, and complaints that a
25 health maintenance organization is required to maintain
26 under rules adopted by the Department.
27 (c) The Director shall provide a copy of the report to a
28 person on request on payment of a reasonable fee. The
29 Director shall set the fee in the amount necessary to defray
30 the cost of producing the report.
31 Section 65. Retaliation prohibited. A managed care
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1 dental plan may not take any retaliatory actions, including
2 cancellation or refusal to renew a policy, against an
3 employer or enrollee solely because the enrollee has filed
4 complaints with the plan or appealed a decision of the plan.
5 Section 70. Application of other law.
6 (a) All provisions of this Act and other applicable law
7 which are not in conflict with this Act shall apply to
8 managed care entities and other persons subject to this Act.
9 (b) Solicitation of enrollees by a managed care entity
10 granted a certificate of authority or its representatives
11 shall not be construed to violate any provision of law
12 relating to solicitation or advertising by health
13 professionals.
14 Section 75. Severability. The provisions of this Act
15 are severable under Section 1.31 of the Statute on Statutes.