Full Text of SB0750 99th General Assembly
SB0750 99TH GENERAL ASSEMBLY |
| | 99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016 SB0750 Introduced 2/3/2015, by Sen. Michael E. Hastings SYNOPSIS AS INTRODUCED: |
| 215 ILCS 5/355a | from Ch. 73, par. 967a | 215 ILCS 109/25 | | 215 ILCS 110/10 | from Ch. 32, par. 690.10 | 215 ILCS 110/25 | from Ch. 32, par. 690.25 |
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Amends the Illinois Insurance Code. Provides that health plan issuers offering health plans through the State health insurance marketplace update their provider directory on a monthly basis. Provides that the information in provider directories shall be offered in a manner that accommodates individuals with limited English proficiency and with disabilities. Provides that, with respect to dental plans, a dentist listed is considered an active network participant from the location published in the provider directory only if the dentist has filed a claim for a patient enrolled with the dental plan at least once in the previous 3-month period. Amends the Dental Care Patient Protection Act. Provides that managed care dental plans must only list participating dentists who have filed a claim for an enrolled patient within the past 3 months. Makes conforming changes in the Dental Service Plan Act.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 355a as follows:
| 6 | | (215 ILCS 5/355a) (from Ch. 73, par. 967a)
| 7 | | Sec. 355a. Standardization of terms and coverage.
| 8 | | (1) The purpose of this Section shall be (a) to provide
| 9 | | reasonable standardization and simplification of terms and | 10 | | coverages of
individual accident and health insurance policies | 11 | | to facilitate public
understanding and comparisons; (b) to | 12 | | eliminate provisions contained in
individual accident and | 13 | | health insurance policies which may be
misleading or | 14 | | unreasonably confusing in connection either with the
purchase | 15 | | of such coverages or with the settlement of claims; and (c) to
| 16 | | provide for reasonable disclosure in the sale of accident and | 17 | | health
coverages.
| 18 | | (2) Definitions applicable to this Section are as follows:
| 19 | | (a) "Policy" means all or any part of the forms | 20 | | constituting the
contract between the insurer and the | 21 | | insured, including the policy,
certificate, subscriber | 22 | | contract, riders, endorsements, and the
application if | 23 | | attached, which are subject to filing with and approval
by |
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| 1 | | the Director.
| 2 | | (b) "Service corporations" means
voluntary health and | 3 | | dental
corporations organized and operating respectively | 4 | | under
the Voluntary Health Services Plans Act and
the | 5 | | Dental Service Plan Act.
| 6 | | (c) "Accident and health insurance" means insurance | 7 | | written under
Article XX of the Insurance Code, other than | 8 | | credit accident and health
insurance, and coverages | 9 | | provided in subscriber contracts issued by
service | 10 | | corporations. For purposes of this Section such service
| 11 | | corporations shall be deemed to be insurers engaged in the | 12 | | business of
insurance.
| 13 | | (3) The Director shall issue such rules as he shall deem | 14 | | necessary
or desirable to establish specific standards, | 15 | | including standards of
full and fair disclosure that set forth | 16 | | the form and content and
required disclosure for sale, of | 17 | | individual policies of accident and
health insurance, which | 18 | | rules and regulations shall be in addition to
and in accordance | 19 | | with the applicable laws of this State, and which may
cover but | 20 | | shall not be limited to: (a) terms of renewability; (b)
initial | 21 | | and subsequent conditions of eligibility; (c) non-duplication | 22 | | of
coverage provisions; (d) coverage of dependents; (e) | 23 | | pre-existing
conditions; (f) termination of insurance; (g) | 24 | | probationary periods; (h)
limitation, exceptions, and | 25 | | reductions; (i) elimination periods; (j)
requirements | 26 | | regarding replacements; (k) recurrent conditions; and (l)
the |
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| 1 | | definition of terms including but not limited to the following:
| 2 | | hospital, accident, sickness, injury, physician, accidental | 3 | | means, total
disability, partial disability, nervous disorder, | 4 | | guaranteed renewable,
and non-cancellable.
| 5 | | The Director may issue rules that specify prohibited policy
| 6 | | provisions not otherwise specifically authorized by statute | 7 | | which in the
opinion of the Director are unjust, unfair or | 8 | | unfairly discriminatory to
the policyholder, any person | 9 | | insured under the policy, or beneficiary.
| 10 | | (4) The Director shall issue such rules as he shall deem | 11 | | necessary
or desirable to establish minimum standards for | 12 | | benefits under each
category of coverage in individual accident | 13 | | and health policies, other
than conversion policies issued | 14 | | pursuant to a contractual conversion
privilege under a group | 15 | | policy, including but not limited to the
following categories: | 16 | | (a) basic hospital expense coverage; (b) basic
| 17 | | medical-surgical expense coverage; (c) hospital confinement | 18 | | indemnity
coverage; (d) major medical expense coverage; (e) | 19 | | disability income
protection coverage; (f) accident only | 20 | | coverage; and (g) specified
disease or specified accident | 21 | | coverage.
| 22 | | Nothing in this subsection (4) shall preclude the issuance | 23 | | of any
policy which combines two or more of the categories of | 24 | | coverage
enumerated in subparagraphs (a) through (f) of this | 25 | | subsection.
| 26 | | No policy shall be delivered or issued for delivery in this |
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| 1 | | State
which does not meet the prescribed minimum standards for | 2 | | the categories
of coverage listed in this subsection unless the | 3 | | Director finds that
such policy is necessary to meet specific | 4 | | needs of individuals or groups
and such individuals or groups | 5 | | will be adequately informed that such
policy does not meet the | 6 | | prescribed minimum standards, and such policy
meets the | 7 | | requirement that the benefits provided therein are reasonable
| 8 | | in relation to the premium charged. The standards and criteria | 9 | | to be
used by the Director in approving such policies shall be | 10 | | included in the
rules required under this Section with as much | 11 | | specificity as
practicable.
| 12 | | The Director shall prescribe by rule the method of | 13 | | identification of
policies based upon coverages provided.
| 14 | | (5) (a) In order to provide for full and fair disclosure in | 15 | | the
sale of individual accident and health insurance policies, | 16 | | no such
policy shall be delivered or issued for delivery in | 17 | | this State unless
the outline of coverage described in | 18 | | paragraph (b) of this subsection
either accompanies the policy, | 19 | | or is delivered to the applicant at the
time the application is | 20 | | made, and an acknowledgment signed by the
insured, of receipt | 21 | | of delivery of such outline, is provided to the
insurer. In the | 22 | | event the policy is issued on a basis other than that
applied | 23 | | for, the outline of coverage properly describing the policy | 24 | | must
accompany the policy when it is delivered and such outline | 25 | | shall clearly
state that the policy differs, and to what | 26 | | extent, from that for which
application was originally made. |
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| 1 | | All policies, except single premium
nonrenewal policies, shall | 2 | | have a notice prominently printed on the
first page of the | 3 | | policy or attached thereto stating in substance, that
the | 4 | | policyholder shall have the right to return the policy within | 5 | | 10 days of its delivery and to have the premium refunded if | 6 | | after
examination of the policy the policyholder is not | 7 | | satisfied for any
reason.
| 8 | | (b) The Director shall issue such rules as he shall deem | 9 | | necessary
or desirable to prescribe the format and content of | 10 | | the outline of
coverage required by paragraph (a) of this | 11 | | subsection. "Format" means
style, arrangement, and overall | 12 | | appearance, including such items as the
size, color, and | 13 | | prominence of type and the arrangement of text and
captions. | 14 | | "Content" shall include without limitation thereto,
statements | 15 | | relating to the particular policy as to the applicable
category | 16 | | of coverage prescribed under subsection 4; principal benefits;
| 17 | | exceptions, reductions and limitations; and renewal | 18 | | provisions,
including any reservation by the insurer of a right | 19 | | to change premiums.
Such outline of coverage shall clearly | 20 | | state that it constitutes a
summary of the policy issued or | 21 | | applied for and that the policy should
be consulted to | 22 | | determine governing contractual provisions.
| 23 | | (c) Without limiting the generality of paragraph (b) of | 24 | | this subsection (5), no qualified health plans shall be offered | 25 | | for sale directly to consumers through the health insurance | 26 | | marketplace operating in the State in accordance with Sections |
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| 1 | | 1311 and
1321 of the federal Patient Protection and Affordable | 2 | | Care Act of 2010 (Public Law 111-148), as amended by the | 3 | | federal Health Care and Education Reconciliation Act of 2010 | 4 | | (Public Law 111-152), and any amendments thereto, or | 5 | | regulations or guidance issued thereunder (collectively, "the | 6 | | Federal Act"), unless the following information is made | 7 | | available to the consumer at the time he or she is comparing | 8 | | policies and their premiums: | 9 | | (i) With respect to prescription drug benefits, the | 10 | | most recently published formulary where a consumer can view | 11 | | in one location covered prescription drugs; information on | 12 | | tiering and the cost-sharing structure for each tier; and | 13 | | information about how a consumer can obtain specific | 14 | | copayment amounts or coinsurance percentages for a | 15 | | specific qualified health plan before enrolling in that | 16 | | plan. This information shall clearly identify the | 17 | | qualified health plan to which it applies. | 18 | | (ii) The most recently published provider directory | 19 | | where a consumer can view the provider network that applies | 20 | | to each qualified health plan and information about each | 21 | | provider, including location, contact information, | 22 | | specialty, medical group, if any, any institutional | 23 | | affiliation, and whether the provider is accepting new | 24 | | patients. The provider directory shall be updated on a | 25 | | monthly basis. The information shall clearly identify the | 26 | | qualified health plan to which it applies and be offered in |
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| 1 | | a manner that accommodates individuals with limited | 2 | | English proficiency and with disabilities. | 3 | | With respect to dental plans, a dentist listed in a | 4 | | provider network is considered an active network participant | 5 | | from the location published in the provider directory only if | 6 | | the dentist has filed a claim for a patient enrolled with the | 7 | | dental plan at least once in the previous 3-month period. Any | 8 | | dentist not meeting this criterion must be removed from the | 9 | | published provider directory for that specific location. | 10 | | (d) Each company that offers qualified health plans for | 11 | | sale directly to consumers through the health insurance | 12 | | marketplace operating in the State shall make the information | 13 | | in paragraph (c) of this subsection (5), for each qualified | 14 | | health plan that it offers, available and accessible to the | 15 | | general public on the company's Internet website and through | 16 | | other means for individuals without access to the Internet. | 17 | | (e) The Department shall ensure that State-operated | 18 | | Internet websites, in addition to the Internet website for the | 19 | | health insurance marketplace established in this State in | 20 | | accordance with the Federal Act, prominently provide links to | 21 | | Internet-based materials and tools to help consumers be | 22 | | informed purchasers of health insurance. | 23 | | (f) Nothing in this Section shall be interpreted or | 24 | | implemented in a manner not consistent with the Federal Act. | 25 | | This Section shall apply to all qualified health plans offered | 26 | | for sale directly to consumers through the health insurance |
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| 1 | | marketplace operating in this State for any coverage year | 2 | | beginning on or after January 1, 2015. | 3 | | (6) Prior to the issuance of rules pursuant to this | 4 | | Section, the
Director shall afford the public, including the | 5 | | companies affected
thereby, reasonable opportunity for | 6 | | comment. Such rulemaking is subject
to the provisions of the | 7 | | Illinois Administrative Procedure Act.
| 8 | | (7) When a rule has been adopted, pursuant to this Section, | 9 | | all
policies of insurance or subscriber contracts which are not | 10 | | in
compliance with such rule shall, when so provided in such | 11 | | rule, be
deemed to be disapproved as of a date specified in | 12 | | such rule not less
than 120 days following its effective date, | 13 | | without any further or
additional notice other than the | 14 | | adoption of the rule.
| 15 | | (8) When a rule adopted pursuant to this Section so | 16 | | provides, a
policy of insurance or subscriber contract which | 17 | | does not comply with
the rule shall not less than 120 days from | 18 | | the effective date of such
rule, be construed, and the insurer | 19 | | or service corporation shall be
liable, as if the policy or | 20 | | contract did comply with the rule.
| 21 | | (9) Violation of any rule adopted pursuant to this Section | 22 | | shall be
a violation of the insurance law for purposes of | 23 | | Sections 370 and 446 of
the Insurance Code.
| 24 | | (Source: P.A. 98-1035, eff. 8-25-14.)
| 25 | | Section 10. The Dental Care Patient Protection Act is |
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| 1 | | amended by changing Section 25 as follows:
| 2 | | (215 ILCS 109/25)
| 3 | | Sec. 25. Provision of information.
| 4 | | (a) A managed care dental plan shall provide upon request | 5 | | to
prospective enrollees a written summary description of all | 6 | | of the following
terms of
coverage:
| 7 | | (1) Information about the dental plan, including how | 8 | | the plan operates and
what general types of financial | 9 | | arrangements exist between dentists and the
plan. Nothing | 10 | | in this Section shall require disclosure of any specific
| 11 | | financial arrangements between providers and the plan.
| 12 | | (2) The service area.
| 13 | | (3) Covered benefits, exclusions, or limitations.
| 14 | | (4) Pre-certification requirements including any | 15 | | requirements for
referrals
made by primary care dentists to | 16 | | specialists, and other preauthorization
requirements.
| 17 | | (5) A list of participating primary care dentists in | 18 | | the plan's service
area, including provider address and | 19 | | phone number, for an enrollee to evaluate
the managed care | 20 | | dental plan's network access, as well as a phone number by
| 21 | | which the prospective enrollee may obtain additional | 22 | | information regarding the
provider network including | 23 | | participating specialists. However,
a managed care
dental | 24 | | plan offering a preferred provider organization ("PPO") | 25 | | product
that does not require the enrollee to select a |
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| 1 | | primary care dentist shall
only be required to make | 2 | | available for inspection to enrollees and
prospective | 3 | | enrollees a list of participating dentists in the plan's
| 4 | | service area in which participating dentist has filed a | 5 | | claim for an enrollee with the managed care dental plan | 6 | | within the previous 3-month period for the address listed. | 7 | | Any dentist not meeting this criterion must be removed from | 8 | | the managed care provider network directory (written or | 9 | | electronic) for the address listed .
| 10 | | (6) Emergency coverage and benefits.
| 11 | | (7) Out-of-area coverages and benefits, if any.
| 12 | | (8) The process about how participating dentists are | 13 | | selected.
| 14 | | (9) The grievance process, including the telephone | 15 | | number to call to
receive information concerning grievance | 16 | | procedures.
| 17 | | An enrollee shall be provided with an evidence of coverage | 18 | | as
required
under the Illinois Insurance Code provisions | 19 | | applicable to the managed care
dental plan.
| 20 | | (b) An enrollee or prospective enrollee has the right to | 21 | | the most current
financial statement filed by the managed care | 22 | | dental plan by contacting the
Department of Insurance. The | 23 | | Department may charge a reasonable fee
for providing such | 24 | | information.
| 25 | | (c) The managed care dental plan shall provide to the | 26 | | Department, on an
annual basis, a list of all participating |
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| 1 | | dentists meeting the criteria listed in subsection (a) of this | 2 | | Section . Nothing in this Section
shall require a particular | 3 | | ratio for any type of provider.
| 4 | | (d) If the managed care dental plan uses a capitation | 5 | | method of
compensation to its primary care providers | 6 | | (dentists), the plan must
establish and follow procedures that | 7 | | ensure that:
| 8 | | (1) the plan application form includes a space in which | 9 | | each enrollee
selects a primary care provider (dentist);
| 10 | | (2) if an enrollee who fails to select a primary care | 11 | | provider (dentist)
is assigned a primary care provider | 12 | | (dentist), the enrollee shall be notified
of
the name and | 13 | | location of that primary care provider (dentist); and
| 14 | | (3) primary care provider (dentist) to whom an enrollee | 15 | | is assigned,
pursuant to item (2), is physically located | 16 | | within a reasonable travel
distance, as established by rule | 17 | | adopted by the Director, from the residence or
place of | 18 | | employment of the enrollee.
| 19 | | (e) Nothing in this Act shall be deemed to require a plan | 20 | | to assign an
enrollee to a primary care provider (dentist).
| 21 | | (Source: P.A. 91-355, eff. 1-1-00.)
| 22 | | Section 15. The Dental Service Plan Act is amended by | 23 | | changing Sections 10 and 25 as follows:
| 24 | | (215 ILCS 110/10) (from Ch. 32, par. 690.10)
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| 1 | | Sec. 10.
"Participating dentist" means a dentist licensed | 2 | | in Illinois to
practice dentistry, and who, by written | 3 | | agreement with a dental service
plan corporation undertakes to | 4 | | furnish dental service to the plan's
subscribers and their | 5 | | covered dependents at least once every 3-month period and to | 6 | | abide by its by-laws, rules
and regulations.
| 7 | | (Source: Laws 1965, p. 2179.)
| 8 | | (215 ILCS 110/25) (from Ch. 32, par. 690.25)
| 9 | | Sec. 25. Application of Insurance Code provisions. Dental | 10 | | service
plan corporations and all persons interested therein or | 11 | | dealing therewith
shall be subject to the provisions of | 12 | | Articles IIA and XII 1/2
and
Sections 3.1,
133, 136, 139, 140, | 13 | | 143, 143c, 149, 355.2, 355.3, 367.2, 401, 401.1, 402, 403, | 14 | | 403A, 408,
408.2, and 412, paragraph (c) of subsection (5) of | 15 | | Section 355a, and subsection (15) of Section 367 of the | 16 | | Illinois Insurance
Code.
| 17 | | (Source: P.A. 97-486, eff. 1-1-12; 97-805, eff. 1-1-13.)
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