Rep. Bob Morgan

Filed: 4/1/2024

 

 


 

 


 
10300HB4789ham001LRB103 36280 RPS 71495 a

1
AMENDMENT TO HOUSE BILL 4789

2    AMENDMENT NO. ______. Amend House Bill 4789 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 355.4 and by adding Section 355d as follows:
 
6    (215 ILCS 5/355.4)
7    Sec. 355.4. Provider notification of network plan changes.
8    (a) As used in this Section:
9    "Contracting entity" means any person or company that
10enters into direct contracts with providers for the delivery
11of dental services in the ordinary course of business,
12including a third-party administrator and a dental carrier.
13    "Dental carrier" means a dental insurance company, dental
14service corporation, dental plan organization authorized to
15provide dental benefits, or a health insurance plan that
16includes coverage for dental services.

 

 

10300HB4789ham001- 2 -LRB103 36280 RPS 71495 a

1    (b) No dental carrier may automatically enroll a provider
2in a leased network without allowing any provider that is part
3of the dental carrier's provider network to choose to not
4participate by opting out.
5    (c) Any contract entered into or renewed on or after the
6effective date of this amendatory Act of the 103rd General
7Assembly that allows the rights and obligations of the
8contract to be assigned or leased to another insurer shall
9provide for notice that informs each provider in writing via
10certified mail 60 days before any scheduled assignment or
11lease of the network to which the provider is a contracted
12provider. To be in compliance with this Section, the
13notification must provide the specific URL address where the
14following are located: include all contract terms, a policy
15manual, a fee schedule, and a statement that the provider has
16the right to choose not to participate in third-party access.
17The notification must also provide instructions for how the
18provider may obtain a copy of those materials.
19    (d) A dental carrier that leases or assigns its network
20shall not cancel a network participating dentist's contractual
21relationship or otherwise penalize a network participating
22dentist in any way based on whether or not the dentist accepts
23the terms of the assignment or lease. Before accepting the
24terms of an assignment or lease agreement as described in this
25Section, any provider who receives notification of an
26impending assignment or lease must be given the option to

 

 

10300HB4789ham001- 3 -LRB103 36280 RPS 71495 a

1contract directly with the entities proposing to gain access
2to the provider's network.
3    (e) The provisions of this Section do not apply:
4        (1) if access to a provider network contract is
5    granted to a dental carrier or an entity operating in
6    accordance with the same brand licensee program as the
7    contracting entity; or
8        (2) to a provider network contract for dental services
9    provided to beneficiaries of the State employee group
10    health insurance program or the medical assistance program
11    under the Illinois Public Aid Code.
12(Source: P.A. 103-24, eff. 1-1-24.)
 
13    (215 ILCS 5/355d new)
14    Sec. 355d. Denials of claims submitted after prior
15authorization.
16    (a) In this Section:
17    "Dental carrier" means an insurer, dental service
18corporation, insurance network leasing company, or any company
19that offers individual or group policies of accident and
20health insurance that provide coverage for dental services.
21    "Prior authorization" means any written communication that
22is verifiable, whether through issuance or letter, facsimile,
23email, or similar means, indicating that a specific procedure
24is, or multiple procedures are, covered under the patient's
25dental plan and reimbursable at a specific amount, subject to

 

 

10300HB4789ham001- 4 -LRB103 36280 RPS 71495 a

1applicable coinsurance and deductibles, and issued in response
2to a request submitted by a dentist using a format prescribed
3by the dental carrier.
4    (b) Beginning on the effective date of this amendatory Act
5of the 103rd General Assembly, a dental carrier shall not deny
6any claim subsequently submitted for procedures specifically
7included in a prior authorization unless at least one of the
8following circumstances applies for each procedure denied:
9        (1) benefit limitations, such as annual maximums and
10    frequency limitations, that were not applicable at the
11    time of the prior authorization are reached due to
12    utilization after issuance of the prior authorization;
13        (2) the documentation for the claim provided by the
14    person submitting the claim clearly fails to support the
15    claim as originally authorized;
16        (3) if, after the issuance of the prior authorization,
17    new procedures are provided to the patient or a change in
18    the condition of the patient occurs such that the prior
19    authorized procedure would no longer be considered
20    medically necessary based on the prevailing standard of
21    care;
22        (4) if, after the issuance of the prior authorization,
23    new procedures are provided to the patient or a change in
24    the condition of the patient occurs such that the prior
25    authorized procedure would, at that time, require
26    disapproval pursuant to the terms and conditions for

 

 

10300HB4789ham001- 5 -LRB103 36280 RPS 71495 a

1    coverage under the plan for the patient in effect at the
2    time the prior authorization was used; or
3        (5) the claim was denied by a dental carrier due to one
4    of the following reasons:
5            (A) another payor is responsible for the payment;
6            (B) the dentist has already been paid for the
7        procedures identified on the claim;
8            (C) the claim was submitted fraudulently or the
9        prior authorization was based in whole or material
10        part on erroneous information provided to the dental
11        carrier; or
12            (D) the person receiving the procedure was not
13        eligible for the procedure on the date of service and
14        the dental carrier did not know, and with the exercise
15        of reasonable care could not have known, that person's
16        eligibility status.
17    A dental carrier shall not recoup a claim solely due to a
18loss of coverage of a patient or ineligibility if, at the time
19of treatment, the dental carrier erroneously confirmed
20coverage and eligibility, but had sufficient information
21available to the dental carrier indicating that the patient
22was no longer covered or was ineligible for coverage.
23    (c) The provisions of this Section may not be waived by
24contract. Any contractual arrangement in conflict with the
25provisions of this Section or that purports to waive any
26requirement of this Section is null and void.
 

 

 

10300HB4789ham001- 6 -LRB103 36280 RPS 71495 a

1    Section 10. The Limited Health Service Organization Act is
2amended by changing Section 4003 as follows:
 
3    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
4    Sec. 4003. Illinois Insurance Code provisions. Limited
5health service organizations shall be subject to the
6provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
7141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
8154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2,
9355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10,
10356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
11356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
12356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
13364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
14444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
15XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
16Nothing in this Section shall require a limited health care
17plan to cover any service that is not a limited health service.
18For purposes of the Illinois Insurance Code, except for
19Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
20health service organizations in the following categories are
21deemed to be domestic companies:
22        (1) a corporation under the laws of this State; or
23        (2) a corporation organized under the laws of another
24    state, 30% or more of the enrollees of which are residents

 

 

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1    of this State, except a corporation subject to
2    substantially the same requirements in its state of
3    organization as is a domestic company under Article VIII
4    1/2 of the Illinois Insurance Code.
5(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
6102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
71-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
8eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
9102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
101-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
11eff. 1-1-24; revised 8-29-23.)
 
12    Section 15. The Voluntary Health Services Plans Act is
13amended by changing Section 10 as follows:
 
14    (215 ILCS 165/10)  (from Ch. 32, par. 604)
15    Sec. 10. Application of Insurance Code provisions. Health
16services plan corporations and all persons interested therein
17or dealing therewith shall be subject to the provisions of
18Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
19143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
20355d, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
21356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
22356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
23356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
24356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,

 

 

10300HB4789ham001- 8 -LRB103 36280 RPS 71495 a

1356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
2356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
3356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
4401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
5and (15) of Section 367 of the Illinois Insurance Code.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
13102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff.
1410-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 102-804,
15eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
16102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, eff.
171-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
18eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
19103-551, eff. 8-11-23; revised 8-29-23.)".