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Public Act 91-0355
SB721 Enrolled LRB9105743JSpc
AN ACT concerning managed care dental benefit plans.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. Short title. This Act may be cited as the
Dental Care Patient Protection Act.
Section 5. Purpose; dental care patient rights.
(a) The purpose of this Act is to provide fairness and
choice to dental patients and dentists under managed care
dental benefit plans.
(b) Dental care patients have the following rights:
(1) A patient has the right to care consistent with
professional standards of practice to assure quality
dental care, to choose the participating dentist
responsible for providing his or her care, to receive
information concerning his or her condition and proposed
treatment, to refuse any treatment to the extent
permitted by law, and to privacy and confidentiality of
records except as otherwise provided by law.
(2) A patient has the right, regardless of source
of payment, to examine and to receive a reasonable
explanation of his or her total bill for services
rendered by his or her dentist. A dentist shall be
responsible only for a reasonable explanation of those
specific dental care services provided by the dentist.
(3) A patient has the right to timely prior notice
of the termination in the event a plan cancels or refuses
to renew an enrollee's participation in the plan except
when the termination is for non-payment of premium or
termination of the plan by the group.
(4) A patient has the right to privacy and
confidentiality. This right may be expressly waived in
writing by the patient or the patient's guardian.
(5) A patient has the right to purchase any dental
care services with that patient's own funds.
Section 10. Definitions. As used in this Act:
"Dental care services" means services permitted to be
performed by a licensed dentist or any person working under
the dentist's supervision as permitted by law.
"Dentist" means a person licensed to practice dentistry
in any state.
"Department" means the Department of Insurance.
"Director" means the Director of Insurance.
"Emergency dental services" means the provision of dental
care for a sudden, acute dental condition that would lead a
prudent layperson, who possesses an average knowledge of
dentistry, to reasonably expect the absence of immediate care
to result in serious impairment to the dentition or would
place the person's oral health in serious jeopardy.
"Enrollee" means an individual and his or her dependents
who are enrolled in a managed care dental plan.
"Managed care dental plan" or "plan" means a plan that
establishes, operates, or maintains a network of dentists
that have entered into agreements with the plan to provide
dental care services to enrollees to whom the plan has the
obligation to arrange for the provision of or payment for
services through organizational arrangements for ongoing
quality assurance, utilization review programs, or dispute
resolution.
For the purpose of this Act, "managed care dental plans"
do not include employee or employer self-insured dental
benefit plans under the federal ERISA Act of 1974.
"Point-of-service plan" means a plan or plans that
includes both in-plan covered services and out-of-plan
covered services as well as managed dental care plan
arrangements in which the risk for out-of-plan covered
services is borne through reinsurance. The term also
includes indemnity benefits that are underwritten in whole by
a licensed insurance carrier or a self-funded employer group.
For purposes of this Section, "out-of-plan services" means
those services which are obtained from providers who do not
have a contract, or any other arrangements, with a managed
care dental plan or services obtained without a referral from
providers who have contracted to provide services to the
enrollees on behalf of the managed care dental plan.
"Primary care provider (dentist)" means a dentist, having
an arrangement with a managed care dental plan, selected by
an enrollee or assigned to an enrollee by a plan to provide
dental care services under a managed care dental plan.
"Prospective enrollee" means an individual eligible for
enrollment in a managed care dental plan offered by that
individual's employer.
"Provider" means either a general dentist or a dentist
who is a licensed specialist.
Section 15. Rules. The Department may promulgate such
rules as it deems reasonably necessary to implement the terms
of this Act. The Department shall establish an advisory
committee made up of representatives from the dental
profession to provide clinical advice and counsel to the
Department regarding dental managed care issues for which a
dentist's professional training is relevant in the course of
administering this Act. The advisory committee shall be
comprised of dentists licensed to practice in Illinois,
appointed by the Director as follows: 2 dental directors or
their dentist designee from managed care dental plans which
are subject to this Act, 2 general dentists, and the dental
director of the Illinois Department of Public Health. The
advisory committee shall meet as reasonably determined by the
Director. Nothing in this Section shall be deemed as
authorizing or permitting the Department to delegate any
authority to enforce the provisions of this Act to the
advisory committee and any such delegation is expressly
prohibited hereunder.
Section 25. Provision of information.
(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:
(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
financial arrangements between providers and the plan.
(2) The service area.
(3) Covered benefits, exclusions, or limitations.
(4) Pre-certification requirements including any
requirements for referrals made by primary care dentists
to specialists, and other preauthorization requirements.
(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 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 service area.
(6) Emergency coverage and benefits.
(7) Out-of-area coverages and benefits, if any.
(8) The process about how participating dentists
are selected.
(9) The grievance process, including the telephone
number to call to receive information concerning
grievance procedures.
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.
(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.
(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.
(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:
(1) the plan application form includes a space in
which each enrollee selects a primary care provider
(dentist);
(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
(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.
(e) Nothing in this Act shall be deemed to require a
plan to assign an enrollee to a primary care provider
(dentist).
Section 35. Credentialing; utilization review; provider
input.
(a) Participating dentists shall be given an opportunity
to comment on the plan's policies affecting their services to
include the plan's dental policy, including coverage of a new
technology and procedures, utilization review criteria and
procedures, quality and credentialing criteria, and dental
management procedures provided, however, a plan shall not be
required to release any information which it deems
confidential or proprietary.
(b) Upon request, managed care dental plans shall
disclose to prospective purchasers the process about how
participating dentists are selected for the plan.
(c) A dentist under consideration for inclusion in a
managed care dental plan that requires the enrollee to select
a primary care provider (dentist) shall be subject to the
managed care dental plan's credentialing policy, which shall
be overseen by the dental director of the managed care dental
plan.
(d) Credentialing of dentists who will participate in a
managed care dental plan that requires its enrollees to
select a primary care provider (dentist) shall be based on
identified guidelines that have been adopted by the plan. The
managed care dental plan shall make the credentialing
guidelines available to applicants, upon request.
(e) A managed care dental plan shall have a dental
director who is a licensed dentist. The dental director shall
ultimately be responsible for the benefit coverage decisions
made by the plan which require professional dental training
and clinical judgement. Decisions made by the plan to deny
coverage for a procedure, based primarily upon clinical
judgment, or that a payment for an alternative procedure
should be considered must be made by the dental director or a
licensed dentist acting under the supervision of the dental
director. Nothing in this Section prohibits a benefit
coverage decision that does not require a dentist's
professional judgment from being denied without a dentist's
involvement.
A provider advocating on behalf of a patient who has had
a claim denied, the basis of which requires professional
dental training and judgment, or was offered an alternative
benefit for payment by the plan has an opportunity to appeal
to the dental director by submitting a written appeal and
providing information that is reasonably needed to consider
the appeal. The dental director or a licensed dentist acting
under the supervision of the dental director shall respond to
the provider's appeal. Enrollees shall be afforded appeal
rights as specified in the benefits contract or as otherwise
provided by law.
(h) A managed care dental plan may not exclude a
provider solely because of the anticipated characteristics of
the patients of that provider.
(i) Before terminating a contract with a provider for
cause, the managed care dental plan shall provide a written
explanation of the reasons for termination. The provider
shall be given an opportunity for discussion with the dental
director or his dentist designee. If a managed care dental
plan conducts or uses utilization profiling as the primary
basis for terminating the provider contract for cause, the
managed care dental plan shall make available the utilization
data relevant to that provider in advance of the termination.
(j) A communication relating to the subject matter
provided for under subsection (a) or (i) of this Section may
not be the basis for a cause of action for libel or slander,
except for disclosures or communications with parties other
than the plan or provider.
(k) The managed care dental plan shall establish
reasonable procedures for assuring a transition of enrollees
of the plan to new providers.
(l) This Act does not prohibit a managed care dental
plan from rejecting an application from a provider based on
the plan's determination that the plan has sufficient
qualified providers or if the plan reasonably determines that
inclusion of the provider is not in the best interest of the
managed care dental plan and its enrollees. Nothing in this
Act shall be construed as requiring a managed care dental
plan to contract with a dentist who has not agreed to the
terms of participation as specified by the plan.
(m) No contractual provision shall in any way prohibit a
dentist from discussing all clinical options for treatment
with a patient.
(n) A managed care dental plan shall submit for the
Director's approval, and thereafter maintain, a system for
the resolution of grievances concerning the provision of
dental care services or other matters concerning operation of
the managed care dental plan.
Section 40. Coverage; prior authorization. A managed
care dental plan shall:
(1) cover palliative treatment for emergency dental
services, as included in its certificate of coverage,
without regard to whether the provider furnishing the
services has a contractual or other arrangement with the
entity to provide items or services to covered
individuals, provided that the enrollee has made a
reasonable attempt to first obtain service through the
appropriate primary care dentist; and
(2) if an enrollee suffers trauma to the mouth,
teeth or oral cavity that results in a need for emergency
dental services, as included in the certificate of
coverage, provide that the prior authorization
requirement for emergency dental is waived.
Nothing in this Section shall be deemed as requiring
managed care dental plans to provide coverage for emergency
dental services in excess of that required in the Illinois
Insurance Code.
Section 45. Prior authorization; consent forms. A plan
for which prior authorization is a condition to coverage of a
service must clearly disclose this provision in the evidence
of coverage.
Section 50. Point-of-service plans.
(a) If an employer who has 25 or more employees and
contributes 25% or more to the cost of the dental benefit
plan coverage to employees and the only dental plan coverage
being offered requires enrollees to select a primary care
provider (dentist) and has no out-of-plan covered services
option, the managed care dental plan with which the employer
is contracting for the coverage shall offer a dental
point-of-service ("POS") option to the employee.
(b) An employer may require an employee who accepts the
POS option to be responsible for the payment of a premium
over the amount of the premium for the coverage provided to
employees under the dental benefit plan offered which
requires enrollees to select a primary care provider
(dentist) and has no out-of-plan covered services option.
The enrollee may pay any additional premium either directly
or by payroll deduction in the same manner in which the other
premium is paid. The premium for the POS option shall be as
established by the managed care dental plan using its
underwriting guidelines for establishing rates to be charged
for products which it offers.
(c) Different cost-sharing provisions may be imposed for
the POS option.
(d) An employer may charge an employee who accepts the
POS option a reasonable administrative fee for costs
associated with the employer's reasonable administration of
the POS option.
(e) The POS option to be offered pursuant to this
Section may be satisfied by the plan by allowing prospective
enrollees to elect the POS option during the employer's
enrollment period, and remaining in the POS option until the
next open enrollment period, or any other basis reasonably
determined by the plan to satisfy the requirements of this
Section.
(f) A managed care dental plan required to offer a POS
option pursuant to this Act shall be subject to those rules
for POS products as set by the Department.
Section 55. Private cause of action; existing remedies.
This Act and rules adopted under this Act do not:
(1) provide a private cause of action for damages
or create a standard of care, obligation, or duty that
provides a basis for a private cause of action for
damages; or
(2) abrogate a statutory or common law cause of
action, administrative remedy, or defense otherwise
available and existing before the effective date of this
Act.
Section 60. Record of complaints.
(a) The Department shall maintain records concerning the
complaints filed against the plan with the Department. The
Department shall make a summary of all data collected
available upon request and publish the summary on the World
Wide Web.
(b) The Department shall maintain records on the number
of complaints filed against each plan.
(c) The Department shall maintain records classifying
each complaint by whether the complaint was filed by:
(1) a consumer or enrollee;
(2) a provider; or
(3) any other individual.
(e) The Department shall maintain records classifying
each complaint according to the nature of the complaint as it
pertains to a specific function of the plan. The complaints
shall be classified under the following categories:
(1) denial of care or treatment;
(2) denial of a diagnostic procedure;
(3) denial of a referral request;
(4) sufficient choice and accessibility of
dentists;
(5) underwriting;
(6) marketing and sales;
(7) claims and utilization review;
(8) member services;
(9) provider relations; and
(10) miscellaneous.
(f) The Department shall maintain records classifying
the disposition of each complaint. The disposition of the
complaint shall be classified in one of the following
categories:
(1) complaint referred to the plan and no further
action necessary by the Department;
(2) no corrective action deemed necessary by the
Department; or
(3) corrective action taken by the Department.
(g) No Department publication or release of information
shall identify any enrollee, dentist, or individual
complainant.
Section 65. Administration of Act. The Director may
adopt rules necessary to implement the Department's
responsibility under this Act. To enforce the provisions of
this Act, the director may issue a cease and desist order or
require a managed care dental plan to submit a plan of
correction for violations of this Act, or both. Subject to
the provisions of the Illinois Administrative Procedure Act,
the Director may impose an administrative fine, not to exceed
$1,000, for failure to submit a requested plan of correction,
failure to comply with its plan of correction, or repeated
violations of the Act. All final decisions regarding the
imposition of a fine shall be subject to review under the
Illinois Administrative Review Law.
Section 70. Retaliation prohibited. A managed care
dental plan may not take any retaliatory actions, including
cancellation or refusal to renew a policy, against an
employer or enrollee solely because the employer or enrollee
has filed complaints with the plan or appealed a decision of
the plan.
Section 75. Application of other law.
(a) All provisions of this Act and other applicable law
that are not in conflict with this Act shall apply to managed
care dental plans and other persons subject to this Act.
(b) Solicitation of enrollees by a managed care entity
granted a certificate of authority or its representatives
shall not be construed to violate any provision of law
relating to solicitation or advertising by health
professionals.
Section 80. Limitations on indemnification provisions.
No contract between a managed care dental plan and a provider
may require that the provider indemnify the managed care
dental plan for the Plan's, or its officers, employees, or
agents, negligence, willful misconduct, or breach of
contract, if any, provided nothing herein shall relieve the
provider for such obligations that have been delegated to the
provider pursuant to written agreement. The delegation of
functions agreed to between the plan and the provider shall
be identified in the written agreement.
Section 85. Severability. The provisions of this Act are
severable under Section 1.31 of the Statute on Statutes.
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