HB2532 96TH GENERAL ASSEMBLY

LRB096 10098 RPM 20264 b

96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB2532

Introduced 2/20/2009, by Rep. Lisa M. Dugan

SYNOPSIS AS INTRODUCED:

215 ILCS 5/355.2

from Ch. 73, par. 967.2

Amends the Illinois Insurance Code in relation to reimbursement rates. Provides that a health insurer that bases payment for benefits upon a usual or customary charge or other similar reimbursement methodology must disclose certain information. Replaces references to "customary fee" with "customary charge or other similar methodology" throughout the provision. Provides that under no circumstances shall rates paid by Medicaid or Medicare, or rates negotiated or set by the insurer or any other insurer in conjunction with their contracted providers, be used to determine usual and customary charges. Makes other changes. Effective January 1, 2010.

A BILL FOR

AN ACT concerning insurance.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by changing Section 355.2 as follows:

(215 ILCS 5/355.2) (from Ch. 73, par. 967.2)

Sec. 355.2. Reimbursement Dental coverage reimbursement rates.

(a) A Every company that issues, delivers, amends, or renews any individual or group policy of accident and health insurance on or after the effective date of this amendatory Act of the 96th General Assembly 1991 that provides dental insurance and bases payment for those benefits upon a usual and customary charge or other similar reimbursement methodology fee charged by licensed dentists must disclose all of the following:

(1) The frequency of the determination of the usual and customary charge or other similar methodology fee.

(2) A general description of the methodology used to determine the usual and customary charge or other similar methodology fees.

(3) The percentile of the usual and customary charge or other similar methodology that determines the maximum allowable charge upon which the benefit is based benefit that the company will pay for any dental procedure, if the usual and customary fee is determined by taking a sample of fees submitted on actual claims from licensed dentists and then determining the benefit by selecting a percentile of those fees.

(b) The disclosure must be provided upon request to all group and individual policy holders and group certificate holders. All proposals for accident and health dental insurance must notify the prospective policy holder that information regarding the usual and customary charge or other similar methodology fee determinations is available from the insurer. All employee benefit descriptions or supplemental documents must notify the employee that information regarding reimbursement rates is available from the employer.

(c) Under no circumstances shall rates paid by Medicaid or Medicare, or rates negotiated or set by the insurer or any other insurer in conjunction with their contracted providers, be used to determine usual and customary charges.

(d) For purposes of this Section, the usual and customary charge is the charge for health care that is consistent with the average rate or charge for similar services furnished by similar providers in the geographic area in which services were provided.

(e) Under no circumstances shall the amount of reimbursement for covered expenses be less than 50% of the usual and customary charge, or similar reasonable charge when the usual and customary charge can not be calculated, for the services provided.

(f) Companies shall make their methodology for determining usual and customary charges available to the Department upon request. Such information shall be held confidential by the Department.

(Source: P.A. 87-587.)

Section 99. Effective date. This Act takes effect January 1, 2010.