Full Text of SB1289 103rd General Assembly
SB1289ham001 103RD GENERAL ASSEMBLY | Rep. Jennifer Gong-Gershowitz Filed: 4/20/2023
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| 1 | | AMENDMENT TO SENATE BILL 1289
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1289 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Short title. This Act may be referred to as the | 5 | | Dental Loss Ratio Act. | 6 | | Section 5. Definitions. As used in this Act: | 7 | | "Dental care provider" means a dentist who bills for | 8 | | services in Illinois. | 9 | | "Dental loss ratio" means the ratio of incurred claims to | 10 | | earned premiums as calculated using the formula under Section | 11 | | 10 of this Act. | 12 | | "Dental plan carrier" means an entity subject to the | 13 | | insurance laws, rules, and regulations of this State or | 14 | | subject to the jurisdiction of the Director that contracts or | 15 | | offers to contract to provide, deliver, arrange for, pay for, | 16 | | or reimburse any of the costs of dental care services, |
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| 1 | | including an accident and health insurance company, a health | 2 | | maintenance organization, a limited health service | 3 | | organization, a dental service plan corporation, a health | 4 | | services plan corporation, a voluntary health services plan, | 5 | | or any other entity providing a plan of dental insurance, | 6 | | dental benefits, or dental health care services. | 7 | | "Department" means the Department of Insurance. | 8 | | "Director" means the Director of Insurance. | 9 | | "Earned premiums" means the portion of the premium paid in | 10 | | the reporting year that is intended to provide coverage during | 11 | | that reporting period. | 12 | | "Incurred claims" means the claims for which services were | 13 | | provided in that reporting year. "Incurred claims" includes | 14 | | claims that were paid in the reporting year plus unpaid claim | 15 | | reserves for claims paid after the reporting year. | 16 | | Section 10. Dental loss ratio reporting. | 17 | | (a) A health insurer or dental plan carrier that issues, | 18 | | sells, renews, or offers a specialized health insurance policy | 19 | | covering dental services shall, beginning January 1, 2024, | 20 | | annually submit to the Department the dental loss ratio | 21 | | calculated in accordance with subsection (c). The annual | 22 | | filing shall, at a minimum, include rates, rating schedules, | 23 | | and supporting documentation, including ratios of incurred | 24 | | claims to earned premiums for each calendar year since the | 25 | | plan's issuance. The required information shall be in the form |
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| 1 | | established by the Department and shall demonstrate that each | 2 | | plan complies with the minimum dental loss ratio standards. | 3 | | (b) The annual filing shall be made publicly available on | 4 | | the Department's website. | 5 | | (c) The dental loss ratio for a dental plan or dental | 6 | | coverage of a health benefit plan shall be determined by | 7 | | dividing the numerator by the denominator as follows: | 8 | | (1) The numerator is the amount spent on dental care. | 9 | | The amount spent on dental care shall include: | 10 | | (A) the amount expended for clinical dental | 11 | | services that are services within the Code on Dental | 12 | | Procedures and Nomenclature, provided to enrollees | 13 | | that includes payments under capitation contracts with | 14 | | dental providers, and covered by the contract for | 15 | | dental clinical services or supplies covered by the | 16 | | contract; | 17 | | (B) reserves and liabilities established to | 18 | | account for claims that were incurred during the | 19 | | reporting year but were not paid within 3 months of the | 20 | | end of the reporting year; and | 21 | | (C) any claim payment recovered by insurers from | 22 | | providers or enrollees using utilization management | 23 | | efforts, but which shall be deducted from incurred | 24 | | claims amounts. | 25 | | (2) The calculation of the numerator does not include: | 26 | | (A) any overpayment that has already been received |
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| 1 | | from providers that should not be reported as a paid | 2 | | claim; overpayment recoveries received from providers | 3 | | must be deducted from incurred claims amounts; | 4 | | (B) all administrative costs, including, but not | 5 | | limited to, infrastructure, personnel costs, or broker | 6 | | payments; | 7 | | (C) amounts paid to third-party vendors for | 8 | | secondary network savings; | 9 | | (D) amounts paid to third-party vendors for | 10 | | network development, administrative fees, claims | 11 | | processing, and utilization management; or | 12 | | (E) amounts paid to providers for professional or | 13 | | administrative services that do not represent | 14 | | compensation or reimbursement for covered services | 15 | | provided to an enrollee, including, but not limited | 16 | | to, dental record copying costs, attorney's fees, | 17 | | subrogation vendor fees, compensation to | 18 | | paraprofessionals, janitors, quality assurance | 19 | | analysts, administrative supervisors, secretaries to | 20 | | dental personnel, and dental record clerks. | 21 | | (3) The denominator is the total amount of the earned | 22 | | premium revenues, excluding federal and State taxes and | 23 | | licensing and regulatory fees paid after accounting for | 24 | | any payments pursuant to federal law. In this paragraph, | 25 | | "earned premium revenues" means all moneys paid by a | 26 | | policyholder or subscriber as a condition of receiving |
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| 1 | | coverage from the issuer, including any fees or other | 2 | | contributions associated with the dental plan. | 3 | | (d) If the Director decides to conduct an examination | 4 | | because the Director finds it necessary to verify a health | 5 | | insurer's or dental plan carrier's representation in a dental | 6 | | loss ratio report, then the Department shall provide the | 7 | | health insurer or dental plan carrier with a notification 30 | 8 | | days before the commencement of the examination. | 9 | | (e) The health insurer or dental plan carrier shall have | 10 | | 30 days after the date of notification to electronically | 11 | | submit to the Department all requested records specified by | 12 | | the Department. The Director may extend the time for a health | 13 | | insurer or dental plan carrier to comply with this examination | 14 | | upon a finding of good cause. | 15 | | Section 15. Dental loss ratio requirement. | 16 | | (a) A health insurer or dental plan carrier that issues, | 17 | | sells, renews, or offers a specialized health insurance policy | 18 | | covering dental services shall meet a minimum dental loss | 19 | | ratio requirement of 80%. | 20 | | (b) If the minimum dental loss ratio is not met, then the | 21 | | Department shall require a corrective action plan from the | 22 | | carrier to return excess premiums. | 23 | | Section 20. Rulemaking. The Department may adopt rules to | 24 | | implement this Act. |
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| 1 | | Section 25. Exemptions. This Act does not apply to an | 2 | | insurance policy issued, sold, renewed, or offered for health | 3 | | care services or coverage provided as a function of the State | 4 | | of Illinois Medicaid coverage for children or adults or | 5 | | disability insurance for covered benefits in the single | 6 | | specialized area of dental-only health care that pays benefits | 7 | | on a fixed benefit, cash payment-only basis. | 8 | | Section 90. The Illinois Insurance Code is amended by | 9 | | adding Section 355.5 as follows: | 10 | | (215 ILCS 5/355.5 new) | 11 | | Sec. 355.5. Dental coverage reimbursement; prohibitions. | 12 | | No insurer, dental service plan corporation, professional | 13 | | service corporation, insurance network leasing company, or any | 14 | | company that amends, delivers, issues, or renews an individual | 15 | | or group policy of accident and health insurance on or after | 16 | | the effective date of this amendatory Act of the 103rd General | 17 | | Assembly shall require a dental care provider to incur a fee to | 18 | | access and obtain payment or reimbursement for services | 19 | | provided. A dental plan carrier shall provide a dental care | 20 | | provider with 100% of the contracted amount of the payment or | 21 | | reimbursement. Fees incurred directly by a dental care | 22 | | provider from third parties related to transmitting an | 23 | | automated clearinghouse network claim, transaction management, |
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| 1 | | data management, or portal services and other fees charged by | 2 | | third parties that are not in the control of the dental plan | 3 | | carrier shall not be prohibited by this Section. | 4 | | Section 95. The Dental Service Plan Act is amended by | 5 | | changing Sections 25 and 34 as follows:
| 6 | | (215 ILCS 110/25) (from Ch. 32, par. 690.25)
| 7 | | Sec. 25. Application of Insurance Code provisions. Dental | 8 | | service
plan corporations and all persons interested therein | 9 | | or dealing therewith
shall be subject to the provisions of | 10 | | Articles IIA, VIII 1/2, XI, and XII 1/2
and
Sections 3.1,
133, | 11 | | 136, 139, 140, 143, 143c, 149, 355.2, 355.3, 367.2, 401, | 12 | | 401.1, 402, 403, 403A, 408,
408.2, and 412, and subsection | 13 | | (15) of Section 367 of the Illinois Insurance
Code.
| 14 | | (Source: P.A. 99-151, eff. 7-28-15.)
| 15 | | (215 ILCS 110/34) (from Ch. 32, par. 690.34)
| 16 | | Sec. 34.
No such corporation shall disburse during any one | 17 | | year , except
upon the approval of the Director, a sum greater | 18 | | than 20% of payments
received from subscribers during that | 19 | | year, as administrative expenses.
| 20 | | The term "administrative expense" as used in this Section | 21 | | section includes all
expenditures for nonprofessional services | 22 | | and in general all expenses not
directly connected with the | 23 | | payment for dental services, but does not
include expenses of |
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| 1 | | soliciting subscriptions.
| 2 | | (Source: Laws 1965, p. 2179.)
| 3 | | Section 99. Effective date. This Act takes effect January | 4 | | 1, 2024.".
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