(215 ILCS 109/5)
Sec. 5.
Purpose; dental care patient rights.
(a) The purpose of this Act is
to provide fairness and choice to dental patients and dentists under managed
care dental benefit plans.
(b) Dental care patients have the following rights:
(1) A patient has the right to care consistent with |
| professional standards of practice to assure quality dental care, to choose the participating dentist responsible for providing his or her care, to receive information concerning his or her condition and proposed treatment, to refuse any treatment to the extent permitted by law, and to privacy and confidentiality of records except as otherwise provided by law.
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(2) A patient has the right, regardless of source of
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| payment, to examine and to receive a reasonable explanation of his or her total bill for services rendered by his or her dentist. A dentist shall be responsible only for a reasonable explanation of those specific dental care services provided by the dentist.
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(3) A patient has the right to timely prior notice of
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| the termination in the event a plan cancels or refuses to renew an enrollee's participation in the plan except when the termination is for non-payment of premium or termination of the plan by the group.
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(4) A patient has the right to privacy and
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| confidentiality. This right may be expressly waived in writing by the patient or the patient's guardian.
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(5) A patient has the right to purchase any dental
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| care services with that patient's own funds.
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(Source: P.A. 91-355, eff. 1-1-00.)
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(215 ILCS 109/25)
Sec. 25. Provision of information.
(a) A managed care dental plan shall provide upon request to
prospective enrollees a written summary description of all of the following
terms of
coverage:
(1) Information about the dental plan, including how |
| the plan operates and what general types of financial arrangements exist between dentists and the plan. Nothing in this Section shall require disclosure of any specific financial arrangements between providers and the plan.
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(2) The service area.
(3) Covered benefits, exclusions, or limitations.
(4) Pre-certification requirements including any
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| requirements for referrals made by primary care dentists to specialists, and other preauthorization requirements.
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(5) A list of participating primary care dentists in
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| the plan's service area, including provider address and phone number, for an enrollee to evaluate the managed care dental plan's network access, as well as a phone number by which the prospective enrollee may obtain additional information regarding the provider network including participating specialists. However, a managed care dental plan offering a preferred provider organization ("PPO") product that does not require the enrollee to select a primary care dentist shall only be required to make available for inspection to enrollees and prospective enrollees a list of participating dentists in the plan's service area, including whether the provider is accepting new patients at each of the specific locations listing the provider. Providers shall notify managed care dental plans electronically or in writing of any changes to their information as listed in the provider directory. Managed care dental plans shall update their directories in a manner consistent with the information provided by the provider or dental management service organization within 10 business days after being notified of the change by the provider.
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Nothing in this paragraph (5) shall void any
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| contractual relationship between the provider and the plan.
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(6) Emergency coverage and benefits.
(7) Out-of-area coverages and benefits, if any.
(8) The process about how participating dentists are
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(9) The grievance process, including the telephone
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| number to call to receive information concerning grievance procedures.
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An enrollee shall be provided with an evidence of coverage as
required
under the Illinois Insurance Code provisions applicable to the managed care
dental plan.
(b) An enrollee or prospective enrollee has the right to the most current
financial statement filed by the managed care dental plan by contacting the
Department of Insurance. The Department may charge a reasonable fee
for providing such information.
(c) The managed care dental plan shall provide to the Department, on an
annual basis, a list of all participating dentists. Nothing in this Section
shall require a particular ratio for any type of provider.
(d) If the managed care dental plan uses a capitation method of
compensation to its primary care providers (dentists), the plan must
establish and follow procedures that ensure that:
(1) the plan application form includes a space in
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| which each enrollee selects a primary care provider (dentist);
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(2) if an enrollee who fails to select a primary care
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| provider (dentist) is assigned a primary care provider (dentist), the enrollee shall be notified of the name and location of that primary care provider (dentist); and
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(3) primary care provider (dentist) to whom an
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| enrollee is assigned, pursuant to item (2), is physically located within a reasonable travel distance, as established by rule adopted by the Director, from the residence or place of employment of the enrollee.
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(e) Nothing in this Act shall be deemed to require a plan to assign an
enrollee to a primary care provider (dentist).
(Source: P.A. 99-329, eff. 1-1-16.)
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(215 ILCS 109/35)
Sec. 35.
Credentialing; utilization review; provider input.
(a) Participating dentists shall be given an opportunity to comment on the
plan's policies affecting their services to include the plan's dental policy,
including coverage of a new technology and procedures, utilization review
criteria and procedures, quality and credentialing criteria, and dental
management procedures provided, however, a plan shall not be required to
release any information which it deems confidential or proprietary.
(b) Upon request, managed care dental plans shall disclose to prospective
purchasers the process about how participating dentists are selected for the
plan.
(c) A dentist under consideration for inclusion in a managed care dental
plan that requires the enrollee to select a primary care provider (dentist)
shall be subject to the managed care dental plan's credentialing policy, which
shall be overseen by the dental director of the managed care dental plan.
(d) Credentialing of dentists who will participate in a managed care
dental plan that requires its enrollees to select a primary care provider
(dentist) shall be based on identified guidelines that have been adopted by the
plan. The managed care dental plan shall make the credentialing guidelines
available to applicants, upon request.
(e) A managed care dental plan shall have a dental director who is a
licensed dentist. The dental director shall ultimately be responsible for the
benefit coverage decisions made by the plan which require professional dental
training and clinical judgement. Decisions made by the plan to deny coverage
for
a procedure, based primarily upon clinical judgment, or that a payment for an
alternative procedure should be considered must be made by the dental director
or a licensed dentist acting under the supervision of the dental director.
Nothing in this Section prohibits a benefit coverage decision that does not
require a dentist's professional judgment from being denied without a dentist's
involvement.
A provider advocating on behalf of a patient who has had a claim denied, the
basis of which requires professional dental training and judgment, or was
offered an alternative benefit for payment by the plan has an opportunity to
appeal to the dental director by submitting a written appeal and providing
information that is reasonably needed to consider the appeal. The dental
director or a licensed dentist acting under the supervision of the dental
director shall respond to the provider's appeal. Enrollees shall be afforded
appeal rights as specified in the benefits contract or as otherwise provided by
law.
(h) A managed care dental plan may not exclude a provider solely because
of the anticipated characteristics of the patients of that provider.
(i) Before terminating a contract with a provider for cause, the managed
care dental plan shall provide a written explanation of the reasons for
termination. The provider shall be given an opportunity for discussion with
the
dental director or his dentist designee.
If a managed care dental plan conducts or uses utilization profiling as the
primary basis for terminating the provider contract for cause, the managed care
dental plan shall make available the utilization data relevant to that provider
in advance of the termination.
(j) A communication relating to the subject matter provided for under
subsection (a) or (i) of this Section may not be the basis for a cause of
action for libel or slander, except for disclosures or communications with
parties other than the plan or provider.
(k) The managed care dental plan shall establish reasonable procedures for
assuring a transition of enrollees of the plan to new providers.
(l) This Act does not prohibit a managed care dental plan from rejecting
an application from a provider based on the plan's determination that the
plan has sufficient qualified providers or if the plan reasonably determines
that inclusion of the provider is not in the best interest of the managed care
dental plan and its enrollees. Nothing in this Act shall be construed as
requiring a managed care dental plan to contract with a dentist who has not
agreed to the terms of participation as specified by the plan.
(m) No contractual provision shall in any way prohibit a dentist from
discussing all clinical options for treatment with a patient.
(n) A managed care dental plan shall submit for the Director's approval,
and thereafter maintain, a system for the resolution of grievances concerning
the provision of dental care services or other matters concerning operation
of the managed care dental plan.
(Source: P.A. 91-355, eff. 1-1-00.)
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(215 ILCS 109/40)
Sec. 40.
Coverage; prior authorization.
A managed care dental plan
shall:
(1) cover palliative treatment for emergency dental |
| services, as included in its certificate of coverage, without regard to whether the provider furnishing the services has a contractual or other arrangement with the entity to provide items or services to covered individuals, provided that the enrollee has made a reasonable attempt to first obtain service through the appropriate primary care dentist; and
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(2) if an enrollee suffers trauma to the mouth, teeth
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| or oral cavity that results in a need for emergency dental services, as included in the certificate of coverage, provide that the prior authorization requirement for emergency dental is waived.
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Nothing in this Section shall be deemed as requiring managed care
dental plans to provide coverage for emergency dental services in excess of
that
required in the Illinois Insurance Code.
(Source: P.A. 91-355, eff. 1-1-00.)
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