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90_HB0558ham001
LRB9000645JSgcam01
1 AMENDMENT TO HOUSE BILL 558
2 AMENDMENT NO. . Amend House Bill 558 by replacing
3 the title with the following:
4 "AN ACT concerning managed care dental benefit plans.";
5 and
6 by replacing everything after the enacting clause with the
7 following:
8 "Section 1. Short title. This Act may be cited as the
9 Managed Dental Care Patient Protection and Reform Act.
10 Section 5. Purpose. The purpose of this Act is to
11 provide fairness and choice to dental patients and providers
12 under managed care dental benefit plans.
13 Section 10. Definitions. As used in this Act:
14 "Board" means the State Board of Health.
15 "Dentist" means a person licensed to practice dentistry
16 under the Illinois Dental Practice Act.
17 "Department" means the Department of Public Health.
18 "Director" means the Director of Public Health.
19 "Emergency care services" means dental services provided
20 for an emergency dental condition.
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1 "Emergency dental condition" means a dental condition
2 manifesting itself by acute symptoms of sufficient severity,
3 including severe pain, so that the absence of immediate
4 dental attention could reasonably be expected to result in:
5 (1) placing the health of the individual in serious
6 jeopardy;
7 (2) serious impairment to a bodily function; or
8 (3) serious dysfunction of an organ or part of the
9 body.
10 "Enrollee" means an individual and his or her dependents
11 who are enrolled in a managed care plan.
12 "Managed care dental plan" or "plan" means a plan
13 operated by a managed care entity that provides for the
14 financing and delivery of dental care or dental services to
15 persons enrolled in the plan through:
16 (1) arrangements with selected providers to furnish
17 dental services;
18 (2) explicit standards for the selection of
19 participating providers;
20 (3) organizational arrangements for ongoing quality
21 assurance, utilization review, and dispute resolution;
22 and
23 (4) differential coverages or payments or financial
24 incentives for a person enrolled in the plan to use the
25 participating providers and procedures provided by the
26 plan.
27 A managed dental care plan does not include or attempt to
28 preempt federal ERISA plans or laws.
29 "Point-of-service plan" means a plan provided through a
30 contractual arrangement under which indemnity benefits for
31 dental care services, other than emergency care services, are
32 provided in conjunction with corresponding benefits arranged
33 or provided by a managed care dental plan. An individual may
34 choose to obtain benefits or services under either the
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1 indemnity plan or the managed care dental plan in accordance
2 with specific provisions of a point-of-service contract.
3 "Primary care provider (dentist)" means a dentist, having
4 an arrangement with a managed care dental plan, selected by
5 an enrollee or assigned to an enrollee by a plan to provide
6 dental care benefits under a managed care dental plan.
7 "Prospective enrollee" means an individual eligible for
8 enrollment in a managed care plan offered by that
9 individual's employer.
10 "Provider" means either a general dentist or a dentist
11 who is a licensed specialist.
12 Section 15. Rules; advisory committee. The Director may
13 adopt rules regarding standards ensuring compliance with this
14 Act by managed care entities that conduct business in this
15 State. The Director may appoint an advisory committee to
16 assist in the implementation of this Act.
17 Section 20. Disclosure.
18 (a) Plan purchasers shall provide a prospective
19 enrollee with a written plan description of the terms and
20 conditions of the dental plan. The written dental plan
21 description must be in a readable and understandable format
22 and must include:
23 (1) coverage provisions;
24 (2) any dental service review requirements on
25 referrals made by primary care providers (dentists) ,
26 including procedures for and limitations or restrictions
27 on referrals to providers other than general dentists, or
28 other review requirements, including preauthorization
29 review, concurrent review, postservice review, and
30 postpayment review;
31 (3) an explanation of enrollee financial
32 responsibility for payment for coinsurance or other
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1 noncovered or out-of-plan services; and
2 (4) a disclosure to prospective enrollees that
3 includes the following language:
4 "YOUR RIGHTS UNDER ILLINOIS LAW
5 You have the right to information about the dental
6 plan, including how the plan operates, what general
7 types of financial arrangements exist between providers
8 and the plan, how providers are selected, names and
9 locations of providers, and an explanation of the
10 benefits to which participants are entitled under the
11 terms of the plan. You have the right to obtain
12 information from the Illinois Department of Insurance
13 about the managed care dental plan concerning the
14 percentage of premium that is allocated for dental care,
15 administrative costs, and profit as it was disclosed in
16 an aggregate form in the most current financial statement
17 filed with the Illinois Department of Insurance."; and
18 (5) a phone number and address for the prospective
19 enrollee to obtain additional information concerning the
20 items described by paragraph (4) of this subsection.
21 (b) The managed care dental plan shall document that
22 each covered enrollee has adequate access through the
23 managed care dental plan's provider network to all items and
24 dental services contained in the package of benefits for
25 which coverage is provided. The access must be adequate
26 considering the diverse needs of enrollees.
27 (c) Nothing in subsection (b) of this Section may be
28 interpreted to circumvent the managed care plan's normal
29 referral and authorization processes.
30 (d) If the managed care dental plan uses a capitation
31 method of compensation to its primary care providers
32 (dentists), the plan must establish and follow procedures
33 that ensure that:
34 (1) the plan application form includes a space in
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1 which each enrollee selects a primary care provider
2 (dentist);
3 (2) an enrollee who fails to select a primary care
4 provider (dentist) and is assigned a primary care
5 provider (dentist) is notified of the name and location
6 of that primary care provider (dentist); and
7 (3) a primary care provider (dentist) to whom an
8 enrollee is assigned is physically located within a
9 reasonable travel distance, as established by rule
10 adopted by the Director, from the residence or place of
11 employment of the enrollee.
12 Section 25. Documentation of adequate access to care.
13 The managed care dental plan shall provide to the Director,
14 at intervals determined by the Director, a definition of its
15 service area documenting the degree to which covered
16 enrollees have access to the dental care from the provider
17 network including geographic distribution of dentists by
18 specialty within the service area. The information required
19 by this Section shall be updated:
20 (1) on establishment of a new managed care dental
21 plan;
22 (2) on expansion of a service area; or
23 (3) when the network is otherwise significantly
24 modified.
25 Nothing in this Section shall require a particular ratio
26 for any type of provider. The information shall be made
27 available to the public by the Department on request. The
28 Department may charge a reasonable fee for providing the
29 information.
30 Section 30. Financial incentives that limit services
31 prohibited. A managed care dental plan may not use a
32 financial incentive program that limits medically necessary
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1 and appropriate services.
2 Section 35. Credentialing; utilization review; provider
3 input.
4 (a) Participating providers shall be given an
5 opportunity to comment on the plan's policies affecting their
6 services to include the plan's dental policy, including
7 coverage of a new technology and procedures, utilization
8 review criteria and procedures, quality and credentialing
9 criteria, and dental management procedures. A managed care
10 dental plan on request shall make available and disclose to
11 providers the application process and qualification
12 requirements for participation in the plan. The plan must
13 give a provider not selected on initial application a reason
14 why the initial application was denied.
15 (b) Managed care dental plans shall disclose to
16 prospective purchasers, upon request, the specific criteria
17 used in selecting dentists who participate in the plan.
18 (c) A dentist under consideration for inclusion in a
19 managed care dental plan which requires the enrollee to
20 select a primary care provider (dentist), shall be reviewed
21 by a credentialing committee to include network
22 participating dentists selected by the dental director of the
23 managed care dental plan. If there are no credentialed
24 dentists in a newly created plan, the committee shall be
25 composed of dentists practicing in the same or similar
26 settings. Other providers may be credentialed, if
27 appropriate, as determined by the plan. When a provider,
28 other than a general dentist, is credentialed by the plan,
29 the credentialing committee shall include providers with the
30 same license.
31 (d) Credentialing of providers who will participate in a
32 managed care dental plan which requires its enrollees to
33 select a primary care provider (dentist) shall be based on
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1 identified standards developed after consultation with
2 providers credentialed in the plan. If there are no
3 credentialed providers in a newly created plan, the plan
4 shall develop credentialing standards after consulting with
5 area providers. The managed care dental plan shall make the
6 credentialing standards available to applicants.
7 (e) If economic considerations are part of the decision
8 to select a provider or terminate a contract with a provider,
9 the plan shall use identified criteria which shall be
10 available to applicants and participating providers. If the
11 plan uses utilization profiling, the plan must consider the
12 specialty and location of the provider.
13 (f) A managed care dental plan that conducts or uses
14 utilization profiling of providers within the plan shall
15 make the profile available to the provider profiled on a
16 reasonable, but at least semi-annual, basis determined by the
17 managed care dental director.
18 (g) A managed care dental plan shall have a dental
19 director who is a licensed dentist. The dental director shall
20 be responsible for the dental decisions made by the plan and
21 provide assurance that the dental decisions and review
22 policies that are used by the plan are appropriate and based
23 on the commonly accepted standards of care.
24 Decisions made by the plan to deny coverage for a
25 procedure, or that a payment for an alternative procedure
26 should be considered, must be made by the dental director or
27 a licensed dentist acting under the direct authority of the
28 dental director.
29 A provider who has had a claim denied or was offered an
30 alternative benefit for payment by the plan shall be provided
31 the opportunity for an appeal to the dental director and to
32 receive a written response from the dental director.
33 Enrollees shall be afforded appeal rights as specified in
34 the benefits contract or as otherwise provided by law.
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1 (h) Unless specifically required by this Act, a managed
2 care dental plan is not required to disclose proprietary
3 information regarding marketplace strategies.
4 (i) A managed care dental plan may not exclude a
5 provider solely because of the anticipated characteristics
6 of the patients of that provider.
7 (j) Before terminating a contract with a provider, the
8 managed care dental plan shall provide a written explanation
9 of the reasons for termination, an opportunity for
10 discussion, and an opportunity to enter into and complete a
11 corrective action plan, if appropriate, as determined by the
12 plan. Except in cases in which there is imminent harm to
13 patient health or an action by the Department of Professional
14 Regulation or other government agency that effectively
15 impairs the provider's ability to practice dentistry, or in
16 cases of fraud or malfeasance, on request and before the
17 effective date of the termination, the provider is entitled
18 to a review of the plan's proposed action by a plan advisory
19 panel. For a dentist, the plan advisory panel must be
20 composed of the dentist's peers. The review may include a
21 review of the appropriateness and requirements of a
22 corrective action plan. The decision of the advisory panel
23 must be considered but is not binding on the plan.
24 (k) If the action that is under consideration is of a
25 type that must be reported to the National Practitioner Data
26 Bank or the Department of Professional Regulation under
27 federal or State law, the dentist's procedural rights must
28 meet the standards set forth in the federal Health Care
29 Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
30 (l) A communication relating to the subject matter
31 provided for under subsection (a) or (i) of this Section may
32 not be the basis for a cause of action for libel or slander
33 except for disclosures or communications with parties other
34 than the plan or provider.
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1 (m) The managed care dental plan shall establish
2 reasonable procedures for assuring a transition of enrollees
3 of the plan to new providers.
4 (n) This Act does not prohibit a managed care dental
5 plan from rejecting an application from a provider based on
6 the determination that the plan has sufficient qualified
7 providers.
8 (o) No contractual provision shall in any way prohibit a
9 dentist from discussing all clinical options for treatment
10 with a patient.
11 Section 40. Coverage; prior authorization.
12 (a) A managed care dental plan shall:
13 (1) cover emergency dental care services provided
14 to covered individuals, without regard to whether the
15 provider furnishing the services has a contractual or
16 other arrangement with the entity to provide items or
17 services to covered individuals, including the treatment
18 and stabilization of an emergency dental condition; and
19 (2) provide that the prior authorization
20 requirement for medically necessary services provided or
21 originating in a hospital emergency department for
22 treatment or stabilization of an emergency dental
23 condition is waived.
24 (b) Services provided not related to the emergency
25 condition are subject to established review or prior
26 authorization requirements.
27 Section 45. Prior authorization; consent forms. A plan for
28 which prior authorization is a condition to coverage of a
29 service must ensure that enrollees are required to sign
30 dental information release consent forms on enrollment.
31 Section 50. Point-of-service plans.
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1 (a) When a managed care dental plan which requires its
2 enrollees to select a primary care provider (dentist) is the
3 only entity providing benefits under a dental benefit plan,
4 it must offer to all eligible enrollees the opportunity to
5 obtain coverage for out-of-network services through a
6 point-of-service plan as defined in Section 10.
7 (b) The premium for the point-of-service plan shall be
8 based on the actuarial value of that coverage.
9 (c) Any additional costs for the point-of-service plan
10 are the responsibility of the enrollee or the plan purchaser
11 at their discretion. The managed care dental plan may impose
12 a reasonable administrative cost for providing the
13 point-of-service option.
14 Section 55. Private cause of action; existing remedies.
15 This Act and rules adopted under this Act do not:
16 (1) provide a private cause of action for damages or
17 create a standard of care, obligation, or duty that provides
18 a basis for a private cause of action for damages; or
19 (2) abrogate a statutory or common law cause of action,
20 administrative remedy, or defense otherwise available and
21 existing before the effective date of this Act.
22 Section 60. Director's report.
23 (a) The Director shall issue an annual report to
24 consumers on the performance of managed care dental plans.
25 (b) The Director shall have access to:
26 (1) information provided under Section 25 of this
27 Act;
28 (2) information contained in complaints relating to
29 managed care entities made to the Department provided
30 that the Director shall maintain as confidential any
31 information in the complaint that relates to a patient or
32 that is made confidential by another law; and
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1 (3) any statistical information relating to
2 utilization, quality assurance, and complaints that a
3 health maintenance organization is required to maintain
4 under rules adopted by the Department.
5 (c) The managed care dental plans shall be provided such
6 report and be afforded the opportunity to submit comments
7 prior to the release of such report.
8 (d) The Director shall provide a copy of the report to a
9 person on request on payment of a reasonable fee. The
10 Director shall set the fee in the amount necessary to defray
11 the cost of producing the report.
12 Section 65. Retaliation prohibited. A managed care
13 dental plan may not take any retaliatory actions, including
14 cancellation or refusal to renew a policy, against an
15 employer or enrollee solely because the enrollee has filed
16 complaints with the plan or appealed a decision of the plan.
17 Section 70. Application of other law.
18 (a) All provisions of this Act and other applicable laws
19 which are not in conflict with this Act shall apply to
20 managed care entities and other persons subject to this Act.
21 (b) Solicitation of enrollees by a managed care entity
22 granted a certificate of authority or its representatives
23 shall not be construed to violate any provision of law
24 relating to solicitation or advertising by health
25 professionals.
26 Section 75. Severability. The provisions of this Act
27 are severable under Section 1.31 of the Statute on
28 Statutes.".