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90_HB0423
New Act
Creates the Managed Dental Care Patient Protection and
Reform Act. Provides for the regulation of dental managed
care plans by the Director of Insurance. Establishes
requirements for disclosure to enrollees. Establishes
credentialing and utilization review standards. Requires
plans to include a point-of-service option. Provides that
the Director of Insurance shall issue an annual report on the
performance of managed care entities.
LRB9001346JSgc
LRB9001346JSgc
1 AN ACT concerning managed care dental benefit plans.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Managed Dental Care Patient Protection and Reform Act.
6 Section 5. Purpose. The purpose of this Act is to
7 provide fairness and choice to dental patients and providers
8 under managed care dental benefit plans.
9 Section 10. Definitions. As used in this Act:
10 "Dentist" means a person licensed to practice dentistry
11 under the Illinois Dental Practice Act.
12 "Department" means the Illinois Department of Insurance.
13 "Director" means the Director of Insurance.
14 "Emergency care services" means dental services provided
15 for an emergency dental condition.
16 "Emergency dental condition" means a dental condition
17 manifesting itself by acute symptoms of sufficient severity,
18 including severe pain, so that the absence of immediate
19 dental attention could reasonably be expected to result in:
20 (1) placing the health of the individual in serious
21 jeopardy;
22 (2) serious impairment to a bodily function; or
23 (3) serious dysfunction of an organ or part of the
24 body.
25 "Managed care dental plan" or "plan" means a plan
26 operated by a managed care entity that provides for the
27 financing and delivery of dental care or dental services to
28 persons enrolled in the plan through:
29 (1) arrangements with selected providers to furnish
30 dental services;
31 (2) explicit standards for the selection of
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1 participating providers;
2 (3) organizational arrangements for ongoing quality
3 assurance, utilization review, and dispute resolution;
4 or
5 (4) differential coverages or payments or financial
6 incentives for a person enrolled in the plan to use the
7 participating providers and procedures provided by the
8 plan.
9 "Point-of-service plan" means a plan provided through a
10 contractual arrangement under which indemnity benefits for
11 the cost of dental care services, other than emergency care
12 services, are provided by an insurer or other corporation in
13 conjunction with corresponding benefits arranged or provided
14 by a health maintenance organization, including a single
15 service health maintenance organization. An individual may
16 choose to obtain benefits or services under either the
17 indemnity plan or the health maintenance organization plan in
18 accordance with specific provisions of a point-of-service
19 contract.
20 "Prospective enrollee" means an individual eligible for
21 enrollment in a managed care plan offered by that
22 individual's employer.
23 "Provider" means either a general dentist or a dentist
24 who is a licensed specialist.
25 Section 15. Rules; advisory committee. The Director may
26 adopt rules regarding standards ensuring compliance with this
27 Act by managed care entities that conduct business in this
28 State. The Director may appoint an advisory committee to
29 assist in the implementation of this Act.
30 Section 20. Disclosure.
31 (a) A managed care entity shall provide a prospective
32 enrollee a written plan description of the terms and
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1 conditions of the dental plan. The written dental plan
2 description must be in a readable and understandable format
3 and must include:
4 (1) coverage provisions;
5 (2) any prior authorization, including procedures
6 for and limitations or restrictions on referrals to
7 providers other than general dentists, or other review
8 requirements, including preauthorization review,
9 concurrent review, postservice review, and postpayment
10 review;
11 (3) an explanation of enrollee financial
12 responsibility for payment for coinsurance or other
13 noncovered or out-of-plan services; and
14 (4) a disclosure to prospective enrollees that
15 includes the following language:
16 "YOUR RIGHTS UNDER ILLINOIS LAW
17 You have the right to information about the dental
18 plan, including how the plan operates, what general types
19 of financial arrangements exist between providers and the
20 plan, names and locations of providers, the number of
21 enrollees and providers in the plan, the percentage of
22 premiums allocated for dental care, administrative costs,
23 and profit, and an explanation of the benefits to which
24 participants are entitled under the terms of the plan.";
25 and
26 (5) a phone number and address for the prospective
27 enrollee to obtain additional information concerning the
28 items described by paragraph (4) of this subsection.
29 (b) The managed care entity may provide the information
30 under paragraph (4) of subsection (a) of this Section
31 regarding the percentage of premiums allocated for dental
32 care, administrative costs, and profit by providing the
33 information in the entity's annual financial statement most
34 recently submitted to the Department.
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1 (c) The managed care entity shall demonstrate that each
2 covered enrollee has adequate access through the entity's
3 provider network to all items and dental services contained
4 in the package of benefits for which coverage is provided.
5 The access must be adequate considering the diverse needs of
6 enrollees.
7 (d) Nothing in subsection (c) of this Section may be
8 interpreted to circumvent the managed care plan's normal
9 referral and authorization processes.
10 (e) If the managed care plan uses a capitation method of
11 compensation, the plan must establish and follow procedures
12 that ensure that:
13 (1) the plan application form includes a space in
14 which each enrollee selects a dentist;
15 (2) an enrollee who fails to select a dentist and
16 is assigned a dentist is notified of the name and
17 location of that dentist; and
18 (3) a dentist to whom an enrollee is assigned is
19 physically located within a reasonable travel distance,
20 as established by rule adopted by the Director, from the
21 residence or place of employment of the enrollee.
22 Section 25. Explanation of network configuration. The
23 managed care entity shall provide to the Director, for
24 information, an explanation of the targeted dentist, and, as
25 appropriate, other provider network configuration, including
26 geographic distribution of dentists by specialty. The
27 information required by this Section shall be updated at
28 least:
29 (1) on establishment of a new managed care dental
30 plan;
31 (2) on expansion of a service area; or
32 (3) when the network configuration targets are
33 significantly modified.
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1 Nothing in this Section shall require a particular ratio
2 for any type of provider. The information shall be made
3 available to the public by the Department on request. The
4 Department may charge a reasonable fee for providing the
5 information.
6 Section 30. Financial incentives that limit services
7 prohibited. A managed care dental plan may not use a
8 financial incentive program that limits medically necessary
9 and appropriate services.
10 Section 35. Credentialing; utilization review; provider
11 input.
12 (a) A managed care dental plan shall establish a
13 mechanism under which dentists participating in the plan
14 provide consultation and advice on the plan's dental policy,
15 including coverage of a new technology and procedures,
16 utilization review criteria and procedures, quality and
17 credentialing criteria, and dental management procedures.
18 Other participating providers shall be given an opportunity
19 to comment on the plan's policies affecting their services.
20 A managed care dental plan on request shall make available
21 and disclose to providers the application process and
22 qualification requirements for participation in the plan.
23 The plan must give a provider not selected on initial
24 application a reason why the initial application was denied.
25 (b) A dentist under consideration for inclusion in a
26 managed care dental plan shall be reviewed by a credentialing
27 committee composed primarily of network participating
28 dentists selected by the dental director of the managed care
29 entity. If there are no credentialed dentists in a newly
30 created plan, the committee shall be primarily composed of
31 dentists practicing in the same or similar settings. Other
32 providers may be credentialed if appropriate, as determined
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1 by the plan. When a provider, other than a general dentist,
2 is credentialed by the plan, the credentialing committee
3 shall include providers with the same license.
4 (c) Credentialing of providers shall be based on
5 identified standards developed after consultation with
6 providers credentialed in the plan. If there are no
7 credentialed providers in a newly created plan, the plan
8 shall develop credentialing standards after consulting with
9 area providers. The managed care dental plan shall make the
10 credentialing standards available to applicants.
11 (d) If economic considerations are part of the decision
12 to select a provider or terminate a contract with a provider,
13 the plan shall use identified criteria which shall be
14 available to applicants and participating providers. If the
15 plan uses an economic profile of a provider, the plan must
16 adjust the profile to recognize the characteristics of a
17 provider's practice that may account for variations from
18 expected costs.
19 (e) A managed care dental plan that conducts or uses
20 economic profiling of providers within the plan shall make
21 the profile available to the provider profiled on a periodic
22 basis.
23 (f) Unless specifically required by this Act, a managed
24 care dental plan is not required to disclose proprietary
25 information regarding marketplace strategies.
26 (g) A managed care dental plan may not exclude a
27 provider solely because of the anticipated characteristics of
28 the patients of that provider.
29 (h) Before terminating a contract with a provider, the
30 managed care dental plan shall provide a written explanation
31 of the reasons for termination, an opportunity for
32 discussion, and an opportunity to enter into and complete a
33 corrective action plan, if appropriate, as determined by the
34 plan. Except in cases in which there is imminent harm to
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1 patient health or an action by the Department of Professional
2 Regulation or other government agency that effectively
3 impairs the provider's ability to practice dentistry, or in
4 cases of fraud or malfeasance, on request and before the
5 effective date of the termination, the provider is entitled
6 to a review of the plan's proposed action by a plan advisory
7 panel. For a dentist, the plan advisory panel must be
8 primarily composed of the dentist's peers. The review may
9 include a review of the appropriateness and requirements of a
10 corrective action plan. The decision of the advisory panel
11 must be considered but is not binding on the plan.
12 (i) If the action that is under consideration is of a
13 type that must be reported to the National Practitioner Data
14 Bank or the Department of Professional Regulation under
15 federal or State law, the dentist's procedural rights must
16 meet the standards set forth in the federal Health Care
17 Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
18 (j) A communication relating to the subject matter
19 provided for under subsection (a) or (h) of this Section may
20 not be the basis for a cause of action for libel or slander
21 except for disclosures or communications with parties other
22 than the plan or provider.
23 (k) The managed care dental plan shall establish
24 reasonable procedures for assuring a transition of enrollees
25 of the plan to new providers.
26 (l) If a contract with a provider is terminated by a
27 managed care dental plan, the plan shall reimburse the
28 provider the reasonable cost for copies of medical or dental
29 records that are furnished to another provider at the
30 patient's request. If a provider terminates the contract
31 with the plan, the provider shall bear the reasonable cost of
32 providing copies of dental records that are furnished to
33 another provider at the patient's request.
34 (m) This Act does not prohibit a managed care dental
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1 plan from rejecting an application from a provider based on
2 the determination that the plan has sufficient qualified
3 providers.
4 Section 40. Coverage; prior authorization. A managed
5 care dental plan shall:
6 (1) cover emergency dental care services provided to
7 covered individuals, without regard to whether the provider
8 furnishing the services has a contractual or other
9 arrangement with the entity to provide items or services to
10 covered individuals, including the treatment and
11 stabilization of an emergency dental condition; and
12 (2) provide that the prior authorization requirement for
13 medically necessary services provided or originating in a
14 hospital emergency department following treatment or
15 stabilization of an emergency dental condition is approved
16 unless denied in the time appropriate to the circumstances
17 relating to the delivery of the services and the condition of
18 the patient, as determined by the treating provider and
19 communicated to the plan.
20 Section 45. Prior authorization; consent forms. A plan
21 for which prior authorization is a condition to coverage of a
22 service must ensure that enrollees are required to sign
23 dental information release consent forms on enrollment.
24 Section 50. Point-of-service plans.
25 (a) When a health maintenance organization offers a
26 point-of-service plan in its service area and is the only
27 entity providing services under a dental benefit plan, it
28 must offer to all eligible enrollees the opportunity to
29 obtain coverage for out-of-network services through the
30 point-of-service plan as defined by subsection (b) of this
31 Section at the time of enrollment and at least annually.
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1 (b) The premium for the point-of-service plan shall be
2 based on the actuarial value of that coverage.
3 (c) Any additional costs for the point-of-service plan
4 are the responsibility of the enrollee, and the employer may
5 impose a reasonable administrative cost for providing the
6 point-of-service option.
7 (d) When 5% or less of the group's eligible employees
8 elect to purchase the point-of-service option, the plan is
9 not required to offer the point-of-service option during
10 subsequent open enrollment periods.
11 Section 55. Private cause of action; existing remedies.
12 This Act and rules adopted under this Act do not:
13 (1) provide a private cause of action for damages
14 or create a standard of care, obligation, or duty that
15 provides a basis for a private cause of action for
16 damages; or
17 (2) abrogate a statutory or common law cause of
18 action, administrative remedy, or defense otherwise
19 available and existing before the effective date of this
20 Act.
21 Section 60. Director's report.
22 (a) The Director shall issue an annual report to
23 consumers on the performance of managed care entities.
24 (b) The Director shall have access to:
25 (1) information provided under Section 25 of this
26 Act;
27 (2) information contained in complaints relating to
28 managed care entities made to the Department provided
29 that the Director shall maintain as confidential any
30 information in the complaint that relates to a patient or
31 that is made confidential by another law; and
32 (3) any statistical information relating to
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1 utilization, quality assurance, and complaints that a
2 health maintenance organization is required to maintain
3 under rules adopted by the Department.
4 (c) The Director shall provide a copy of the report to a
5 person on request on payment of a reasonable fee. The
6 Director shall set the fee in the amount necessary to defray
7 the cost of producing the report.
8 Section 65. Retaliation prohibited. A managed care
9 dental plan may not take any retaliatory actions, including
10 cancellation or refusal to renew a policy, against an
11 employer or enrollee solely because the enrollee has filed
12 complaints with the plan or appealed a decision of the plan.
13 Section 70. Application of other law.
14 (a) All provisions of this Act and other applicable law
15 which are not in conflict with this Act shall apply to
16 managed care entities and other persons subject to this Act.
17 (b) Solicitation of enrollees by a managed care entity
18 granted a certificate of authority or its representatives
19 shall not be construed to violate any provision of law
20 relating to solicitation or advertising by health
21 professionals.
22 Section 75. Severability. The provisions of this Act
23 are severable under Section 1.31 of the Statute on Statutes.