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Public Act 099-0329 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by | ||||
changing Section 355a as follows:
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(215 ILCS 5/355a) (from Ch. 73, par. 967a)
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Sec. 355a. Standardization of terms and coverage.
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(1) The purpose of this Section shall be (a) to provide
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reasonable standardization and simplification of terms and | ||||
coverages of
individual accident and health insurance policies | ||||
to facilitate public
understanding and comparisons; (b) to | ||||
eliminate provisions contained in
individual accident and | ||||
health insurance policies which may be
misleading or | ||||
unreasonably confusing in connection either with the
purchase | ||||
of such coverages or with the settlement of claims; and (c) to
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provide for reasonable disclosure in the sale of accident and | ||||
health
coverages.
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(2) Definitions applicable to this Section are as follows:
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(a) "Policy" means all or any part of the forms | ||||
constituting the
contract between the insurer and the | ||||
insured, including the policy,
certificate, subscriber | ||||
contract, riders, endorsements, and the
application if | ||||
attached, which are subject to filing with and approval
by |
the Director.
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(b) "Service corporations" means
voluntary health and | ||
dental
corporations organized and operating respectively | ||
under
the Voluntary Health Services Plans Act and
the | ||
Dental Service Plan Act.
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(c) "Accident and health insurance" means insurance | ||
written under
Article XX of the Insurance Code, other than | ||
credit accident and health
insurance, and coverages | ||
provided in subscriber contracts issued by
service | ||
corporations. For purposes of this Section such service
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corporations shall be deemed to be insurers engaged in the | ||
business of
insurance.
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(3) The Director shall issue such rules as he shall deem | ||
necessary
or desirable to establish specific standards, | ||
including standards of
full and fair disclosure that set forth | ||
the form and content and
required disclosure for sale, of | ||
individual policies of accident and
health insurance, which | ||
rules and regulations shall be in addition to
and in accordance | ||
with the applicable laws of this State, and which may
cover but | ||
shall not be limited to: (a) terms of renewability; (b)
initial | ||
and subsequent conditions of eligibility; (c) non-duplication | ||
of
coverage provisions; (d) coverage of dependents; (e) | ||
pre-existing
conditions; (f) termination of insurance; (g) | ||
probationary periods; (h)
limitation, exceptions, and | ||
reductions; (i) elimination periods; (j)
requirements | ||
regarding replacements; (k) recurrent conditions; and (l)
the |
definition of terms including but not limited to the following:
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hospital, accident, sickness, injury, physician, accidental | ||
means, total
disability, partial disability, nervous disorder, | ||
guaranteed renewable,
and non-cancellable.
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The Director may issue rules that specify prohibited policy
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provisions not otherwise specifically authorized by statute | ||
which in the
opinion of the Director are unjust, unfair or | ||
unfairly discriminatory to
the policyholder, any person | ||
insured under the policy, or beneficiary.
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(4) The Director shall issue such rules as he shall deem | ||
necessary
or desirable to establish minimum standards for | ||
benefits under each
category of coverage in individual accident | ||
and health policies, other
than conversion policies issued | ||
pursuant to a contractual conversion
privilege under a group | ||
policy, including but not limited to the
following categories: | ||
(a) basic hospital expense coverage; (b) basic
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medical-surgical expense coverage; (c) hospital confinement | ||
indemnity
coverage; (d) major medical expense coverage; (e) | ||
disability income
protection coverage; (f) accident only | ||
coverage; and (g) specified
disease or specified accident | ||
coverage.
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Nothing in this subsection (4) shall preclude the issuance | ||
of any
policy which combines two or more of the categories of | ||
coverage
enumerated in subparagraphs (a) through (f) of this | ||
subsection.
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No policy shall be delivered or issued for delivery in this |
State
which does not meet the prescribed minimum standards for | ||
the categories
of coverage listed in this subsection unless the | ||
Director finds that
such policy is necessary to meet specific | ||
needs of individuals or groups
and such individuals or groups | ||
will be adequately informed that such
policy does not meet the | ||
prescribed minimum standards, and such policy
meets the | ||
requirement that the benefits provided therein are reasonable
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in relation to the premium charged. The standards and criteria | ||
to be
used by the Director in approving such policies shall be | ||
included in the
rules required under this Section with as much | ||
specificity as
practicable.
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The Director shall prescribe by rule the method of | ||
identification of
policies based upon coverages provided.
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(5) (a) In order to provide for full and fair disclosure in | ||
the
sale of individual accident and health insurance policies, | ||
no such
policy shall be delivered or issued for delivery in | ||
this State unless
the outline of coverage described in | ||
paragraph (b) of this subsection
either accompanies the policy, | ||
or is delivered to the applicant at the
time the application is | ||
made, and an acknowledgment signed by the
insured, of receipt | ||
of delivery of such outline, is provided to the
insurer. In the | ||
event the policy is issued on a basis other than that
applied | ||
for, the outline of coverage properly describing the policy | ||
must
accompany the policy when it is delivered and such outline | ||
shall clearly
state that the policy differs, and to what | ||
extent, from that for which
application was originally made. |
All policies, except single premium
nonrenewal policies, shall | ||
have a notice prominently printed on the
first page of the | ||
policy or attached thereto stating in substance, that
the | ||
policyholder shall have the right to return the policy within | ||
10 days of its delivery and to have the premium refunded if | ||
after
examination of the policy the policyholder is not | ||
satisfied for any
reason.
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(b) The Director shall issue such rules as he shall deem | ||
necessary
or desirable to prescribe the format and content of | ||
the outline of
coverage required by paragraph (a) of this | ||
subsection. "Format" means
style, arrangement, and overall | ||
appearance, including such items as the
size, color, and | ||
prominence of type and the arrangement of text and
captions. | ||
"Content" shall include without limitation thereto,
statements | ||
relating to the particular policy as to the applicable
category | ||
of coverage prescribed under subsection 4; principal benefits;
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exceptions, reductions and limitations; and renewal | ||
provisions,
including any reservation by the insurer of a right | ||
to change premiums.
Such outline of coverage shall clearly | ||
state that it constitutes a
summary of the policy issued or | ||
applied for and that the policy should
be consulted to | ||
determine governing contractual provisions.
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(c) Without limiting the generality of paragraph (b) of | ||
this subsection (5), no qualified health plans shall be offered | ||
for sale directly to consumers through the health insurance | ||
marketplace operating in the State in accordance with Sections |
1311 and
1321 of the federal Patient Protection and Affordable | ||
Care Act of 2010 (Public Law 111-148), as amended by the | ||
federal Health Care and Education Reconciliation Act of 2010 | ||
(Public Law 111-152), and any amendments thereto, or | ||
regulations or guidance issued thereunder (collectively, "the | ||
Federal Act"), unless the following information is made | ||
available to the consumer at the time he or she is comparing | ||
policies and their premiums: | ||
(i) With respect to prescription drug benefits, the | ||
most recently published formulary where a consumer can view | ||
in one location covered prescription drugs; information on | ||
tiering and the cost-sharing structure for each tier; and | ||
information about how a consumer can obtain specific | ||
copayment amounts or coinsurance percentages for a | ||
specific qualified health plan before enrolling in that | ||
plan. This information shall clearly identify the | ||
qualified health plan to which it applies. | ||
(ii) The most recently published provider directory | ||
where a consumer can view the provider network that applies | ||
to each qualified health plan and information about each | ||
provider, including location, contact information, | ||
specialty, medical group, if any, any institutional | ||
affiliation, and whether the provider is accepting new | ||
patients at each of the specific locations listing the | ||
provider. Dental providers shall notify qualified health | ||
plans electronically or in writing of any changes to their |
information as listed in the provider directory. Qualified | ||
health plans shall update their directories in a manner | ||
consistent with the information provided by the provider or | ||
dental management service organization within 10 business | ||
days after being notified of the change by the provider. | ||
Nothing in this paragraph (ii) shall void any contractual | ||
relationship between the provider and the plan . The | ||
information shall clearly identify the qualified health | ||
plan to which it applies. | ||
(d) Each company that offers qualified health plans for | ||
sale directly to consumers through the health insurance | ||
marketplace operating in the State shall make the information | ||
in paragraph (c) of this subsection (5), for each qualified | ||
health plan that it offers, available and accessible to the | ||
general public on the company's Internet website and through | ||
other means for individuals without access to the Internet. | ||
(e) The Department shall ensure that State-operated | ||
Internet websites, in addition to the Internet website for the | ||
health insurance marketplace established in this State in | ||
accordance with the Federal Act, prominently provide links to | ||
Internet-based materials and tools to help consumers be | ||
informed purchasers of health insurance. | ||
(f) Nothing in this Section shall be interpreted or | ||
implemented in a manner not consistent with the Federal Act. | ||
This Section shall apply to all qualified health plans offered | ||
for sale directly to consumers through the health insurance |
marketplace operating in this State for any coverage year | ||
beginning on or after January 1, 2015. | ||
(6) Prior to the issuance of rules pursuant to this | ||
Section, the
Director shall afford the public, including the | ||
companies affected
thereby, reasonable opportunity for | ||
comment. Such rulemaking is subject
to the provisions of the | ||
Illinois Administrative Procedure Act.
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(7) When a rule has been adopted, pursuant to this Section, | ||
all
policies of insurance or subscriber contracts which are not | ||
in
compliance with such rule shall, when so provided in such | ||
rule, be
deemed to be disapproved as of a date specified in | ||
such rule not less
than 120 days following its effective date, | ||
without any further or
additional notice other than the | ||
adoption of the rule.
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(8) When a rule adopted pursuant to this Section so | ||
provides, a
policy of insurance or subscriber contract which | ||
does not comply with
the rule shall not less than 120 days from | ||
the effective date of such
rule, be construed, and the insurer | ||
or service corporation shall be
liable, as if the policy or | ||
contract did comply with the rule.
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(9) Violation of any rule adopted pursuant to this Section | ||
shall be
a violation of the insurance law for purposes of | ||
Sections 370 and 446 of
the Insurance Code.
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(Source: P.A. 98-1035, eff. 8-25-14.)
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Section 10. The Dental Care Patient Protection Act is |
amended by changing Section 25 as follows:
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(215 ILCS 109/25)
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Sec. 25. Provision of information.
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(a) A managed care dental plan shall provide upon request | ||
to
prospective enrollees a written summary description of all | ||
of the following
terms of
coverage:
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(1) Information about the dental plan, including how | ||
the plan operates and
what general types of financial | ||
arrangements exist between dentists and the
plan. Nothing | ||
in this Section shall require disclosure of any specific
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financial arrangements between providers and the plan.
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(2) The service area.
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(3) Covered benefits, exclusions, or limitations.
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(4) Pre-certification requirements including any | ||
requirements for
referrals
made by primary care dentists to | ||
specialists, and other preauthorization
requirements.
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(5) A list of participating primary care dentists in | ||
the plan's service
area, including provider address and | ||
phone number, for an enrollee to evaluate
the managed care | ||
dental plan's network access, as well as a phone number by
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which the prospective enrollee may obtain additional | ||
information regarding the
provider network including | ||
participating specialists. However,
a managed care
dental | ||
plan offering a preferred provider organization ("PPO") | ||
product
that does not require the enrollee to select a |
primary care dentist shall
only be required to make | ||
available for inspection to enrollees and
prospective | ||
enrollees a list of participating dentists in the plan's
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service area , including whether the provider is accepting | ||
new patients at each of the specific locations listing the | ||
provider. Providers shall notify managed care dental plans | ||
electronically or in writing of any changes to their | ||
information as listed in the provider directory. Managed | ||
care dental plans shall update their directories in a | ||
manner consistent with the information provided by the | ||
provider or dental management service organization within | ||
10 business days after being notified of the change by the | ||
provider . | ||
Nothing in this paragraph (5) shall void any | ||
contractual relationship between the provider and the | ||
plan.
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(6) Emergency coverage and benefits.
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(7) Out-of-area coverages and benefits, if any.
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(8) The process about how participating dentists are | ||
selected.
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(9) The grievance process, including the telephone | ||
number to call to
receive information concerning grievance | ||
procedures.
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An enrollee shall be provided with an evidence of coverage | ||
as
required
under the Illinois Insurance Code provisions | ||
applicable to the managed care
dental plan.
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(b) An enrollee or prospective enrollee has the right to | ||
the most current
financial statement filed by the managed care | ||
dental plan by contacting the
Department of Insurance. The | ||
Department may charge a reasonable fee
for providing such | ||
information.
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(c) The managed care dental plan shall provide to the | ||
Department, on an
annual basis, a list of all participating | ||
dentists. Nothing in this Section
shall require a particular | ||
ratio for any type of provider.
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(d) If the managed care dental plan uses a capitation | ||
method of
compensation to its primary care providers | ||
(dentists), the plan must
establish and follow procedures that | ||
ensure that:
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(1) the plan application form includes a space in which | ||
each enrollee
selects a primary care provider (dentist);
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(2) if an enrollee who fails to select a primary care | ||
provider (dentist)
is assigned a primary care provider | ||
(dentist), the enrollee shall be notified
of
the name and | ||
location of that primary care provider (dentist); and
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(3) primary care provider (dentist) to whom an enrollee | ||
is assigned,
pursuant to item (2), is physically located | ||
within a reasonable travel
distance, as established by rule | ||
adopted by the Director, from the residence or
place of | ||
employment of the enrollee.
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(e) Nothing in this Act shall be deemed to require a plan | ||
to assign an
enrollee to a primary care provider (dentist).
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(Source: P.A. 91-355, eff. 1-1-00.)
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Section 15. The Illinois Dental Practice Act is amended by | ||
changing Sections 44 and 45 as follows:
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(225 ILCS 25/44) (from Ch. 111, par. 2344)
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(Section scheduled to be repealed on January 1, 2016)
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Sec. 44. Practice by Corporations Prohibited. Exceptions. | ||
No corporation
shall practice dentistry or engage therein, or | ||
hold itself out as being
entitled to practice dentistry, or | ||
furnish dental services or dentists, or
advertise under or | ||
assume the title of dentist or dental surgeon or equivalent
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title, or furnish dental advice for any compensation, or | ||
advertise or hold
itself out with any other person or alone, | ||
that it has or owns a dental office
or can furnish dental | ||
service or dentists, or solicit through itself, or its
agents, | ||
officers, employees, directors or trustees, dental patronage | ||
for any
dentist employed by any corporation.
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Nothing contained in this Act, however, shall:
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(a) prohibit a corporation from employing a dentist or | ||
dentists to render
dental services to its employees, | ||
provided that such dental services shall
be rendered at no | ||
cost or charge to the employees;
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(b) prohibit a corporation or association from | ||
providing dental services
upon a wholly charitable basis to | ||
deserving recipients;
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(c) prohibit a corporation or association from | ||
furnishing information or
clerical services which can be | ||
furnished by persons not licensed to practice
dentistry, to | ||
any dentist when such dentist assumes full responsibility | ||
for
such information or services;
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(d) prohibit dental corporations as authorized by the
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Professional Service Corporation Act, dental associations | ||
as authorized by
the Professional Association Act, or | ||
dental limited liability companies as
authorized by the | ||
Limited Liability Company Act;
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(e) prohibit dental limited liability partnerships as | ||
authorized by the
Uniform Partnership Act (1997);
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(f) prohibit hospitals, public health clinics, | ||
federally qualified
health centers, or other entities | ||
specified by rule of the Department from
providing dental | ||
services; or
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(g) prohibit dental management service organizations | ||
from providing
non-clinical business services that do not | ||
violate the provisions of this
Act.
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Any corporation violating the provisions of this Section is | ||
guilty of a
Class A misdemeanor and each day that this Act is | ||
violated shall be
considered a separate offense.
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If a dental management service organization is responsible | ||
for enrolling the dentist as a provider in managed care plans | ||
provider networks, it shall provide verification to the managed | ||
care provider network regarding whether the provider is |
accepting new patients at each of the specific locations | ||
listing the provider. | ||
Nothing in this Section shall void any contractual | ||
relationship between the provider and the organization. | ||
(Source: P.A. 96-328, eff. 8-11-09.)
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(225 ILCS 25/45) (from Ch. 111, par. 2345)
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(Section scheduled to be repealed on January 1, 2016)
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Sec. 45. Advertising. The purpose of this Section is to | ||
authorize and
regulate the advertisement by dentists of | ||
information which is intended to
provide the public with a | ||
sufficient basis upon which to make an informed
selection of | ||
dentists while protecting the public from false or misleading
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advertisements which would detract from the fair and rational | ||
selection
process.
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Any dentist may advertise the availability of dental | ||
services in the
public media or on the premises where such | ||
dental services are rendered.
Such advertising shall be limited | ||
to the following information:
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(a) The dental services available;
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(b) Publication of the dentist's name, title, office | ||
hours, address
and telephone;
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(c) Information pertaining to his or her area of | ||
specialization, including
appropriate board certification | ||
or limitation of professional practice;
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(d) Information on usual and customary fees for routine |
dental services
offered, which information shall include | ||
notification that fees may be
adjusted due to complications | ||
or unforeseen circumstances;
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(e) Announcement of the opening of, change of, absence | ||
from, or return
to business;
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(f) Announcement of additions to or deletions from | ||
professional
dental staff;
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(g) The issuance of business or appointment cards;
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(h) Other information about the dentist, dentist's | ||
practice or the types
of dental services which the dentist | ||
offers to perform which a reasonable
person might regard as | ||
relevant in determining whether to seek the
dentist's | ||
services. However, any advertisement which announces the
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availability of endodontics, pediatric dentistry,
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periodontics, prosthodontics, orthodontics and dentofacial | ||
orthopedics,
oral and maxillofacial
surgery, or oral and | ||
maxillofacial radiology by a general dentist or by a
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licensed specialist who is not
licensed in that specialty | ||
shall include a disclaimer stating that the
dentist does | ||
not hold a license in that specialty.
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Any dental practice with more than one location that | ||
enrolls its dentist as a participating provider in a managed | ||
care plan's network must verify electronically or in writing to | ||
the managed care plan whether the provider is accepting new | ||
patients at each of the specific locations listing the | ||
provider. The health plan shall remove the provider from the |
directory in accordance with standard practices within 10 | ||
business days after being notified of the changes by the | ||
provider. Nothing in this paragraph shall void any contractual | ||
relationship between the provider and the plan. | ||
It is unlawful for any dentist licensed under this Act to | ||
do any of the following:
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(1) Use claims of superior quality of care to
entice | ||
the public.
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(2) Advertise in any way to practice dentistry without | ||
causing pain.
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(3) Pay a fee to any dental referral service or other | ||
third party who
advertises a dental referral service, | ||
unless all advertising of the dental
referral service makes | ||
it clear that dentists are paying a fee for that
referral | ||
service.
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(4) Advertise or offer gifts as an inducement to secure
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dental
patronage.
Dentists may advertise or offer free | ||
examinations or free dental services;
it shall be unlawful, | ||
however, for any dentist to charge a fee to any new
patient | ||
for any dental service provided at the time that such free
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examination or free dental services are provided. | ||
(5) Use the term "sedation dentistry" or similar terms | ||
in advertising unless the advertising dentist holds a valid | ||
and current permit issued by the Department to administer | ||
either general anesthesia, deep sedation, or conscious | ||
sedation as required under Section 8.1 of this Act.
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This Act does not authorize the advertising of dental | ||
services when the
offeror of such services is not a dentist. | ||
Nor shall the dentist use
statements which contain false, | ||
fraudulent, deceptive or misleading
material or guarantees of | ||
success, statements which play upon the vanity or
fears of the | ||
public, or statements which promote or produce unfair | ||
competition.
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A dentist shall be required to keep a copy of all | ||
advertisements for a
period of 3 years. All advertisements in | ||
the dentist's possession shall
indicate the accurate date and | ||
place of publication.
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The Department shall adopt rules to carry out the intent of | ||
this Section.
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(Source: P.A. 97-1013, eff. 8-17-12.)
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Section 99. Effective date. This Act takes effect January | ||
1, 2016. |