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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by | |||||||||||||||||||
5 | changing Section 355.2 as follows:
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6 | (215 ILCS 5/355.2) (from Ch. 73, par. 967.2)
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7 | Sec. 355.2. Reimbursement Dental coverage reimbursement | |||||||||||||||||||
8 | rates.
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9 | (a) A Every company that issues, delivers, amends, or | |||||||||||||||||||
10 | renews any
individual or group policy of accident and health | |||||||||||||||||||
11 | insurance on or after the
effective date of this amendatory Act | |||||||||||||||||||
12 | of the 96th General Assembly 1991 that provides
dental | |||||||||||||||||||
13 | insurance and bases payment for those benefits upon a
usual and | |||||||||||||||||||
14 | customary charge or other similar reimbursement methodology | |||||||||||||||||||
15 | fee charged by licensed dentists
must disclose all of the | |||||||||||||||||||
16 | following:
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17 | (1) The frequency of the determination of the usual and | |||||||||||||||||||
18 | customary charge or other similar methodology fee .
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19 | (2) A general description of the methodology used to | |||||||||||||||||||
20 | determine
the usual and customary charge or other similar | |||||||||||||||||||
21 | methodology fees .
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22 | (3) The percentile of the usual and customary charge or | |||||||||||||||||||
23 | other similar methodology that determines the maximum |
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1 | allowable charge upon which the benefit is based benefit | ||||||
2 | that the
company will pay for any dental procedure, if the | ||||||
3 | usual and customary
fee is determined by taking a sample of | ||||||
4 | fees submitted on actual claims
from licensed dentists and | ||||||
5 | then determining the benefit by selecting a
percentile of | ||||||
6 | those fees .
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7 | (b) The disclosure must be provided upon request to all | ||||||
8 | group and
individual policy holders and group certificate | ||||||
9 | holders. All proposals for
accident and health dental insurance | ||||||
10 | must notify the prospective policy holder that information
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11 | regarding the usual and customary charge or other similar | ||||||
12 | methodology fee determinations is available from the
insurer. | ||||||
13 | All employee benefit descriptions or supplemental documents | ||||||
14 | must
notify the employee that information regarding | ||||||
15 | reimbursement rates is
available from the employer.
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16 | (c) Under no circumstances shall rates paid by Medicaid or | ||||||
17 | Medicare, or rates negotiated or set by the insurer or any | ||||||
18 | other insurer in conjunction with their contracted providers, | ||||||
19 | be used to determine usual and customary charges. | ||||||
20 | (d) For purposes of this Section, the usual and customary | ||||||
21 | charge is the charge for health care that is consistent with | ||||||
22 | the average rate or charge for similar services furnished by | ||||||
23 | similar providers in the geographic area in which services were | ||||||
24 | provided. | ||||||
25 | (e) Under no circumstances shall the amount of | ||||||
26 | reimbursement for covered expenses be less than 50% of the |
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1 | usual and customary charge, or similar reasonable charge when | ||||||
2 | the usual and customary charge can not be calculated, for the | ||||||
3 | services provided. | ||||||
4 | (f) Companies shall make their methodology for determining | ||||||
5 | usual and customary charges available to the Department upon | ||||||
6 | request. Such information shall be held confidential by the | ||||||
7 | Department. | ||||||
8 | (Source: P.A. 87-587.)
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9 | Section 99. Effective date. This Act takes effect January | ||||||
10 | 1, 2010.
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