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90_HB0558eng
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
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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 "Board" means the State Board of Health.
11 "Dentist" means a person licensed to practice dentistry
12 under the Illinois Dental Practice Act.
13 "Department" means the Department of Public 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 "Enrollee" means an individual and his or her dependents
27 who are enrolled in a managed care plan.
28 "Managed care dental plan" or "plan" means a plan
29 operated by a managed care entity that provides for the
30 financing and delivery of dental care or dental services to
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1 persons enrolled in the plan through:
2 (1) arrangements with selected providers to furnish
3 dental services;
4 (2) explicit standards for the selection of
5 participating providers;
6 (3) organizational arrangements for ongoing quality
7 assurance, utilization review, and dispute resolution;
8 and
9 (4) differential coverages or payments or financial
10 incentives for a person enrolled in the plan to use the
11 participating providers and procedures provided by the
12 plan.
13 A managed dental care plan does not include or attempt to
14 preempt federal ERISA plans or laws.
15 "Point-of-service plan" means a plan provided through a
16 contractual arrangement under which indemnity benefits for
17 dental care services, other than emergency care services, are
18 provided in conjunction with corresponding benefits arranged
19 or provided by a managed care dental plan. An individual may
20 choose to obtain benefits or services under either the
21 indemnity plan or the managed care dental plan in accordance
22 with specific provisions of a point-of-service contract.
23 "Primary care provider (dentist)" means a dentist, having
24 an arrangement with a managed care dental plan, selected by
25 an enrollee or assigned to an enrollee by a plan to provide
26 dental care benefits under a managed care dental plan.
27 "Prospective enrollee" means an individual eligible for
28 enrollment in a managed care plan offered by that
29 individual's employer.
30 "Provider" means either a general dentist or a dentist
31 who is a licensed specialist.
32 Section 15. Rules; advisory committee. The Director may
33 adopt rules regarding standards ensuring compliance with this
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1 Act by managed care entities that conduct business in this
2 State. The Director may appoint an advisory committee to
3 assist in the implementation of this Act.
4 Section 20. Disclosure.
5 (a) Plan purchasers shall provide a prospective
6 enrollee with a written plan description of the terms and
7 conditions of the dental plan. The written dental plan
8 description must be in a readable and understandable format
9 and must include:
10 (1) coverage provisions;
11 (2) any dental service review requirements on
12 referrals made by primary care providers (dentists),
13 including procedures for and limitations or restrictions
14 on referrals to providers other than general dentists, or
15 other review requirements, including preauthorization
16 review, concurrent review, postservice review, and
17 postpayment review;
18 (3) an explanation of enrollee financial
19 responsibility for payment for coinsurance or other
20 noncovered or out-of-plan services; and
21 (4) a disclosure to prospective enrollees that
22 includes the following language:
23 "YOUR RIGHTS UNDER ILLINOIS LAW
24 You have the right to information about the dental
25 plan, including how the plan operates, what general
26 types of financial arrangements exist between providers
27 and the plan, how providers are selected, names and
28 locations of providers, and an explanation of the
29 benefits to which participants are entitled under the
30 terms of the plan. You have the right to obtain
31 information from the Illinois Department of Insurance
32 about the managed care dental plan concerning the
33 percentage of premium that is allocated for dental care,
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1 administrative costs, and profit as it was disclosed in
2 an aggregate form in the most current financial statement
3 filed with the Illinois Department of Insurance."; and
4 (5) a phone number and address for the prospective
5 enrollee to obtain additional information concerning the
6 items described by paragraph (4) of this subsection.
7 (b) The managed care dental plan shall document that
8 each covered enrollee has adequate access through the
9 managed care dental plan's provider network to all items and
10 dental services contained in the package of benefits for
11 which coverage is provided. The access must be adequate
12 considering the diverse needs of enrollees.
13 (c) Nothing in subsection (b) of this Section may be
14 interpreted to circumvent the managed care plan's normal
15 referral and authorization processes.
16 (d) If the managed care dental plan uses a capitation
17 method of compensation to its primary care providers
18 (dentists), the plan must establish and follow procedures
19 that ensure that:
20 (1) the plan application form includes a space in
21 which each enrollee selects a primary care provider
22 (dentist);
23 (2) an enrollee who fails to select a primary care
24 provider (dentist) and is assigned a primary care
25 provider (dentist) is notified of the name and location
26 of that primary care provider (dentist); and
27 (3) a primary care provider (dentist) to whom an
28 enrollee is assigned is physically located within a
29 reasonable travel distance, as established by rule
30 adopted by the Director, from the residence or place of
31 employment of the enrollee.
32 Section 25. Documentation of adequate access to care.
33 The managed care dental plan shall provide to the Director,
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1 at intervals determined by the Director, a definition of its
2 service area documenting the degree to which covered
3 enrollees have access to the dental care from the provider
4 network including geographic distribution of dentists by
5 specialty within the service area. The information required
6 by this Section shall be updated:
7 (1) on establishment of a new managed care dental
8 plan;
9 (2) on expansion of a service area; or
10 (3) when the network is otherwise significantly
11 modified.
12 Nothing in this Section shall require a particular ratio
13 for any type of provider. The information shall be made
14 available to the public by the Department on request. The
15 Department may charge a reasonable fee for providing the
16 information.
17 Section 30. Financial incentives that limit services
18 prohibited. A managed care dental plan may not use a
19 financial incentive program that limits medically necessary
20 and appropriate services.
21 Section 35. Credentialing; utilization review; provider
22 input.
23 (a) Participating providers shall be given an
24 opportunity to comment on the plan's policies affecting their
25 services to include the plan's dental policy, including
26 coverage of a new technology and procedures, utilization
27 review criteria and procedures, quality and credentialing
28 criteria, and dental management procedures. A managed care
29 dental plan on request shall make available and disclose to
30 providers the application process and qualification
31 requirements for participation in the plan. The plan must
32 give a provider not selected on initial application a reason
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1 why the initial application was denied.
2 (b) Managed care dental plans shall disclose to
3 prospective purchasers, upon request, the specific criteria
4 used in selecting dentists who participate in the plan.
5 (c) A dentist under consideration for inclusion in a
6 managed care dental plan which requires the enrollee to
7 select a primary care provider (dentist), shall be reviewed
8 by a credentialing committee to include network
9 participating dentists selected by the dental director of the
10 managed care dental plan. If there are no credentialed
11 dentists in a newly created plan, the committee shall be
12 composed of dentists practicing in the same or similar
13 settings. Other providers may be credentialed, if
14 appropriate, as determined by the plan. When a provider,
15 other than a general dentist, is credentialed by the plan,
16 the credentialing committee shall include providers with the
17 same license.
18 (d) Credentialing of providers who will participate in a
19 managed care dental plan which requires its enrollees to
20 select a primary care provider (dentist) shall be based on
21 identified standards developed after consultation with
22 providers credentialed in the plan. If there are no
23 credentialed providers in a newly created plan, the plan
24 shall develop credentialing standards after consulting with
25 area providers. The managed care dental plan shall make the
26 credentialing standards available to applicants.
27 (e) If economic considerations are part of the decision
28 to select a provider or terminate a contract with a provider,
29 the plan shall use identified criteria which shall be
30 available to applicants and participating providers. If the
31 plan uses utilization profiling, the plan must consider the
32 specialty and location of the provider.
33 (f) A managed care dental plan that conducts or uses
34 utilization profiling of providers within the plan shall
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1 make the profile available to the provider profiled on a
2 reasonable, but at least semi-annual, basis determined by the
3 managed care dental director.
4 (g) A managed care dental plan shall have a dental
5 director who is a licensed dentist. The dental director shall
6 be responsible for the dental decisions made by the plan and
7 provide assurance that the dental decisions and review
8 policies that are used by the plan are appropriate and based
9 on the commonly accepted standards of care.
10 Decisions made by the plan to deny coverage for a
11 procedure, or that a payment for an alternative procedure
12 should be considered, must be made by the dental director or
13 a licensed dentist acting under the direct authority of the
14 dental director.
15 A provider who has had a claim denied or was offered an
16 alternative benefit for payment by the plan shall be provided
17 the opportunity for an appeal to the dental director and to
18 receive a written response from the dental director.
19 Enrollees shall be afforded appeal rights as specified in
20 the benefits contract or as otherwise provided by law.
21 (h) Unless specifically required by this Act, a managed
22 care dental plan is not required to disclose proprietary
23 information regarding marketplace strategies.
24 (i) A managed care dental plan may not exclude a
25 provider solely because of the anticipated characteristics
26 of the patients of that provider.
27 (j) Before terminating a contract with a provider, the
28 managed care dental plan shall provide a written explanation
29 of the reasons for termination, an opportunity for
30 discussion, and an opportunity to enter into and complete a
31 corrective action plan, if appropriate, as determined by the
32 plan. Except in cases in which there is imminent harm to
33 patient health or an action by the Department of Professional
34 Regulation or other government agency that effectively
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1 impairs the provider's ability to practice dentistry, or in
2 cases of fraud or malfeasance, on request and before the
3 effective date of the termination, the provider is entitled
4 to a review of the plan's proposed action by a plan advisory
5 panel. For a dentist, the plan advisory panel must be
6 composed of the dentist's peers. The review may include a
7 review of the appropriateness and requirements of a
8 corrective action plan. The decision of the advisory panel
9 must be considered but is not binding on the plan.
10 (k) If the action that is under consideration is of a
11 type that must be reported to the National Practitioner Data
12 Bank or the Department of Professional Regulation under
13 federal or State law, the dentist's procedural rights must
14 meet the standards set forth in the federal Health Care
15 Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
16 (l) A communication relating to the subject matter
17 provided for under subsection (a) or (i) of this Section may
18 not be the basis for a cause of action for libel or slander
19 except for disclosures or communications with parties other
20 than the plan or provider.
21 (m) The managed care dental plan shall establish
22 reasonable procedures for assuring a transition of enrollees
23 of the plan to new providers.
24 (n) This Act does not prohibit a managed care dental
25 plan from rejecting an application from a provider based on
26 the determination that the plan has sufficient qualified
27 providers.
28 (o) No contractual provision shall in any way prohibit a
29 dentist from discussing all clinical options for treatment
30 with a patient.
31 Section 40. Coverage; prior authorization.
32 (a) A managed care dental plan shall:
33 (1) cover emergency dental care services provided
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1 to covered individuals, without regard to whether the
2 provider furnishing the services has a contractual or
3 other arrangement with the entity to provide items or
4 services to covered individuals, including the treatment
5 and stabilization of an emergency dental condition; and
6 (2) provide that the prior authorization
7 requirement for medically necessary services provided or
8 originating in a hospital emergency department for
9 treatment or stabilization of an emergency dental
10 condition is waived.
11 (b) Services provided not related to the emergency
12 condition are subject to established review or prior
13 authorization requirements.
14 Section 45. Prior authorization; consent forms. A plan
15 for which prior authorization is a condition to coverage of a
16 service must ensure that enrollees are required to sign
17 dental information release consent forms on enrollment.
18 Section 50. Point-of-service plans.
19 (a) When a managed care dental plan which requires its
20 enrollees to select a primary care provider (dentist) is the
21 only entity providing benefits under a dental benefit plan,
22 it must offer to all eligible enrollees the opportunity to
23 obtain coverage for out-of-network services through a
24 point-of-service plan as defined in Section 10.
25 (b) The premium for the point-of-service plan shall be
26 based on the actuarial value of that coverage.
27 (c) Any additional costs for the point-of-service plan
28 are the responsibility of the enrollee or the plan purchaser
29 at their discretion. The managed care dental plan may impose
30 a reasonable administrative cost for providing the
31 point-of-service option.
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1 Section 55. Private cause of action; existing remedies.
2 This Act and rules adopted under this Act do not:
3 (1) provide a private cause of action for damages or
4 create a standard of care, obligation, or duty that provides
5 a basis for a private cause of action for damages; or
6 (2) abrogate a statutory or common law cause of action,
7 administrative remedy, or defense otherwise available and
8 existing before the effective date of this Act.
9 Section 60. Director's report.
10 (a) The Director shall issue an annual report to
11 consumers on the performance of managed care dental plans.
12 (b) The Director shall have access to:
13 (1) information provided under Section 25 of this
14 Act;
15 (2) information contained in complaints relating to
16 managed care entities made to the Department provided
17 that the Director shall maintain as confidential any
18 information in the complaint that relates to a patient or
19 that is made confidential by another law; and
20 (3) any statistical information relating to
21 utilization, quality assurance, and complaints that a
22 health maintenance organization is required to maintain
23 under rules adopted by the Department.
24 (c) The managed care dental plans shall be provided such
25 report and be afforded the opportunity to submit comments
26 prior to the release of such report.
27 (d) 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
32 dental plan may not take any retaliatory actions, including
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1 cancellation or refusal to renew a policy, against an
2 employer or enrollee solely because the enrollee has filed
3 complaints with the plan or appealed a decision of the plan.
4 Section 70. Application of other law.
5 (a) All provisions of this Act and other applicable laws
6 which are not in conflict with this Act shall apply to
7 managed care entities and other persons subject to this Act.
8 (b) Solicitation of enrollees by a managed care entity
9 granted a certificate of authority or its representatives
10 shall not be construed to violate any provision of law
11 relating to solicitation or advertising by health
12 professionals.
13 Section 75. Severability. The provisions of this Act
14 are severable under Section 1.31 of the Statute on Statutes.