Section 4525.10  Purpose

The purpose of this Part is to implement the Dental Care Patient Protection Act.  This Part will set forth guidelines for the formation of an advisory committee; require the filing and approval of a summary description and grievance procedure for managed care dental plans; also identify the point of service plan filing requirements.

Section 4525.20  Applicability

This Part applies to all managed care dental plans as defined in Section 4525.30 of this Part.

Section 4525.30  Definitions  

            Act means the Dental Care Patient Protection Act [215 ILCS 109].

            Code means the Illinois Insurance Code [215 ILCS 5].

            Dental Director means the dental director of the Illinois Department of Public Health.

            Dentist means a person licensed to practice dentistry in any state.

            Department means the Illinois Department of Insurance.

            Director means the Director of the Illinois Department of Insurance.

            Enrollee means an individual and his or her dependents who are enrolled in a managed care dental plan.

            Grievance means a written notice relating to the managed care dental plan determinations, procedures, and administration primarily expressing a complaint to the managed care dental plan by, or on behalf of, the enrollee, or by the dental care provider.

            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.  Managed care dental plans do not include employee or employer self-insured dental benefit plans under the federal ERISA Act of 1974.

            Reasonable Travel Distance means a normal commute of no more than 30 miles or 30 minutes from the residence or place of employment of the enrollee.

(Source:  Amended at 33 Ill. Reg. 4967, effective March 23, 2009)

Section 4525.40  Dental Managed Care Advisory Committee

Pursuant to Section 15 of the Act [215 ILCS 109/15] the Director is authorized to convene an advisory committee for the purpose of providing counsel and gathering clinical advice concerning dental managed care issues.

a)         Such advisory committee shall be comprised as follows:

1)         There will be a total of 5 members all of whom shall be dentists licensed to practice dentistry in this State pursuant to Section 15 of the Act [215 ILCS 109/15]; and

2)         Two of the 5 members shall be dental directors from a managed care dental plan, or be a dentist designee on behalf of a plan, that is subject to the requirements of this Part and the Act; and

3)         Two of the remaining 3 members shall be general dentists; and

4)         The 1 remaining member shall be the dental director as defined in Section 4525.30 of  this Part.

b)         Each member of the advisory committee, except the dental director, shall be appointed by the Director as necessary to address arising issues.  When making appointments, the Director shall give due consideration to written recommendations submitted by professional dental organizations.  Appointments shall last only for the period of time necessary to address the issue for which the committee was convened.

(Source:  Amended at 31 Ill. Reg. 9445, effective June 20, 2007)

Section 4525.50  Filing and Approval of Summary Description  

Pursuant to Section 143 of the Code a managed care dental plan shall file a summary description of coverage for approval by the Department, prior to its use, for each plan it establishes, operates, or maintains.  The summary description shall contain all terms of coverage required by Section 25 of the Dental Care Patient Protection Act [215 ILCS 109/25].  In addition, each managed care dental plan is required to file a list of all participating dentists for informational purposes in accordance with the filing requirements of 50 Ill. Adm. Code 916.  Subsequent filings of the summary description will only be required pursuant to Section 4525.80 of this Part, if material modifications occur and are to be submitted to the Life, Accident and Health Compliance Unit of the Department in accordance with the filing requirements of 50 Ill. Adm. Code 916.

(Source:  Amended at 31 Ill. Reg. 9445, effective June 20, 2007)

Section 4525.60  Filing and Approval of Grievance Procedure

Every managed care dental plan shall submit for the Director's approval, and thereafter maintain, a system for the resolution of grievances pursuant to Section 35(n) of the Act [215 ILCS 109/35(n)].  The initial grievance procedure shall be filed with the annual financial statement by March 1 of the year after the managed care dental plan is formed.  Subsequent filings of the grievance procedure will only be required, pursuant to Section 4525.80 of this Part, if material modifications occur and are to be submitted to the Life, Accident and Health Compliance Unit of the Department in accordance with the filing requirements of 50 Ill. Adm. Code 916.

(Source:  Amended at 31 Ill. Reg. 9445, effective June 20, 2007)

Section 4525.70  Filing and Approval of Point of Service Plan Requirements

Every managed care dental plan that is required to offer a point of service plan pursuant to the Act, except those plans that are licensed pursuant to Section 1001 of the Limited Health Service Organization Act [215 ILCS 130/1001], shall be required to file a description of its point of service plan for approval to the Life, Accident and Health Compliance Unit of the Department in accordance with the filing requirements of 50 Ill. Adm. Code 916.

a)         The filing shall be comprised of:

1)         A managed care dental plan filing and an indemnity filing.  Such filing shall be coordinated by the managed care dental plan.  The filing must contain reasonable financial incentives for the point of service member to utilize dental services provided or arranged by the designated managed care dental plan primary care provider and shall include:

A)        Copies of all policy forms necessary to implement the point of service plan, including the member handbook used to integrate the services provided by the managed care dental plan and the benefits provided by the indemnity carrier; and

B)        Enrollment application and member identification card disclosing the name of both the managed care dental plan and the indemnity carrier; and

C)        Solicitation material; and

D)        Copies of all administrative service contracts between the managed care dental plan and indemnity carrier detailing their respective responsibilities and obligations in offering a point of service plan; and

E)        The managed care dental plan shall include in its rate filing the rate level justification and a demonstration of how the out-of-network indemnity benefits to be provided by the indemnity carrier will impact on the managed care dental plan's rates and underlying utilization assumptions.  Such documentation shall be deemed confidential by the Department unless specific authorization for disclosure is given by the managed care dental plan; and

F)         Written descriptions and illustrative flow charts of how the premium is received and distributed in a timely fashion and how claims will be handled for payment; and

G)        A comparison of benefits offered by the managed care dental plan and the indemnity carrier.

2)         Out-of-network claims shall be filed with the managed care dental plan.  The managed care dental plan is responsible for coordinating payment of all claims.

3)         Covered services rendered by a participating provider without proper authorization shall be covered at the out-of-network benefit level.

4)         For purposes of coordination of benefits, the two policies comprising the point of service plan shall be considered one policy.

5)         For purposes of conversion and State continuation, when by statute the managed care dental plan must provide these provisions, they shall provide each enrollee who has a point of service plan the right to convert to either a managed care dental plan option or indemnity option.  The managed care dental plan may, but is not required to, offer the enrollee the right to continue under a point of service plan option.  Once the enrollee has chosen an option, the other plan's options will no longer be available.  Should the enrollee choose to continue or convert coverage under a point of service plan, the plan shall meet applicable standards for Illinois conversion or continuation requirements.  In the event of any inconsistency between these standards, then the most favorable to the enrollee shall apply.

b)         Subsequent filings of the point of service plan procedure will only be required, pursuant to Section 4525.80 of this Part, if material modifications occur and are to be submitted to the Life, Accident and Health Compliance Unit of the Department in accordance with the filing requirements of 50 Ill. Adm. Code 916.

c)         A managed care dental plan licensed pursuant to Section 1001 of the Limited Health Service Organization Act [215 ILCS 130/1001] shall be subject to the point of service requirements contained in Section 3009 of the Limited Health Service Organization Act [215 ILCS 130/3009].

(Source:  Amended at 31 Ill. Reg. 9445, effective June 20, 2007)

Section 4525.80  Material Modifications to Summary Description, Grievance Procedure or Point of Service Plan

A managed care dental plan shall file for approval with the Director, prior to use, any change in the summary description, grievance procedure, or point of service plan.  In addition, each managed care dental plan shall keep current the list of participating dentists required to be filed pursuant to Section 4525.50 of this Part.  Any changes or additions to the list shall be filed with the Department for informational purposes within 30 days after such change.

(Source:  Amended at 31 Ill. Reg. 9445, effective June 20, 2007)

Section 4525.90  Enforcement and Penalties

a)         To enforce the provisions of this Part, the Director may issue a Cease and Desist Order and/or require a managed care dental plan to submit a plan of correction for violations of this Part or the Act.

b)         The Director may also impose an administrative fine, pursuant to Section 65 of the Act [215 ILCS 109/65], not to exceed $1000, for failure to submit a requested plan of correction, failure to comply with its plan of correction, or repeated violations of this Part or the Act.