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91_HB0804
LRB9101215JSpc
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 Dental Care Patient Protection Act.
6 Section 5. Purpose. The purpose of this Act is to
7 provide fairness and choice to dental patients and dentists
8 under managed care dental benefit plans.
9 Section 10. Definitions. As used in this Act:
10 "Dental care services" means services permitted to be
11 performed by a licensed dentist.
12 "Dentist" means a person licensed to practice dentistry
13 under the Illinois Dental Practice Act.
14 "Department" means the Department of Insurance.
15 "Director" means the Director of Insurance.
16 "Emergency dental services" means the provision of dental
17 care for a sudden, acute dental condition that would lead a
18 prudent layperson, who possesses an average knowledge of
19 dentistry, to reasonably expect the absence of immediate care
20 to result in serious impairment to the dentition or would
21 place the person's oral health in serious jeopardy.
22 "Enrollee" means an individual and his or her dependents
23 who are enrolled in a managed care dental plan.
24 "Licensed dentist" means an individual licensed to
25 practice dentistry in any state.
26 "Managed care dental plan" or "plan" means a plan that
27 establishes, operates, or maintains a network of dentists
28 that have entered into agreements with the plan to provide
29 dental care services to enrollees to whom the plan has the
30 obligation to arrange for the provision of or payment for
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1 services through organizational arrangements for ongoing
2 quality assurance, utilization review programs, or dispute
3 resolution.
4 For the purpose of this Act, "managed care dental plans"
5 do not include the State of Illinois employees dental plan or
6 employee or employer self-insured dental benefit plans under
7 the federal ERISA Act of 1974.
8 "Point-of-service plan" means a plan provided through a
9 contractual arrangement under which indemnity benefits for
10 dental care services, other than emergency care services, are
11 provided in conjunction with corresponding benefits arranged
12 or provided by a managed care dental plan. An individual may
13 choose to obtain benefits or services under either the
14 indemnity plan or the managed care dental plan in accordance
15 with specific provisions of the point-of-service plan.
16 "Primary care provider (dentist)" means a dentist, having
17 an arrangement with a managed care dental plan, selected by
18 an enrollee or assigned to an enrollee by a plan to provide
19 dental care services under a managed care dental plan.
20 "Prospective enrollee" means an individual eligible for
21 enrollment in a managed care dental 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. The Illinois Department of Insurance
26 and the Illinois Department of Public Health may adopt rules
27 regarding standards ensuring compliance with this Act by
28 managed care dental plans that conduct business in this
29 State.
30 Section 20. Disclosure. A disclosure shall be made to
31 prospective enrollees that includes the following language:
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1 "Health Care Patient Rights
2 (1) A patient has the right to care consistent with
3 professional standards of practice to assure quality dental
4 care, to choose the participating dentist responsible for
5 providing his or her care, to receive information concerning
6 his or her condition and proposed treatment, to refuse any
7 treatment to the extent permitted by law, and to privacy and
8 confidentiality of records except as otherwise provided by
9 law.
10 (2) A patient has the right, regardless of source of
11 payment, to examine and to receive a reasonable explanation
12 of his or her total bill for services rendered by his or her
13 dentist. A dentist shall be responsible only for a
14 reasonable explanation of those specific health care services
15 provided by the dentist.
16 (3) A patient has the right to timely prior notice of
17 the termination in the event a plan cancels or refuses to
18 renew an enrollee's participation in the plan.
19 (4) A patient has the right to privacy and
20 confidentiality. This right may be expressly waived in
21 writing by the patient or the patient's guardian.
22 (5) An individual has the right to purchase any health
23 care services with that individual's own funds.".
24 Section 25. Provision of Information.
25 (a) A managed care dental plan shall provide to
26 enrollees and, upon request, prospective enrollees a list of
27 participating dentists in the plan's service area and an
28 evidence of coverage that contains a description of the
29 following terms of coverage:
30 (1) information about the dental plan, including
31 how the plan operates and what general types of financial
32 arrangements exist between dentists and the plan. Nothing
33 in this Section shall require disclosure of any specific
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1 financial arrangements between providers and the plan;
2 (2) the service area;
3 (3) covered benefits, exclusions, or limitations;
4 (4) pre-certification requirements;
5 (5) a description of the limitations on access to
6 specialists;
7 (6) emergency coverage and benefits;
8 (7) out-of-area coverages and benefits, if any;
9 (8) how participating dentists are selected; and
10 (9) the grievance process, including the telephone
11 number to call to receive information concerning
12 grievance procedures.
13 (b) An enrollee or prospective enrollee has the right to
14 the most current financial statement filed by the managed
15 care dental plan by contacting the Illinois Department of
16 Insurance.
17 (c) The managed care dental plan shall document that
18 each covered enrollee has adequate access, through the
19 managed care dental plan's provider network, to all items and
20 dental services contained in the package of benefits for
21 which coverage is provided. The access must be adequate
22 considering the diverse needs of enrollees.
23 (d) If the managed care dental plan uses a capitation
24 method of compensation to its primary care providers
25 (dentists), the plan must establish and follow procedures
26 that ensure that:
27 (1) the plan application form includes a space in
28 which each enrollee selects a primary care provider
29 (dentist);
30 (2) an enrollee who fails to select a primary care
31 provider (dentist) and is assigned a primary care
32 provider (dentist) is notified of the name and location
33 of that primary care provider (dentist); and
34 (3) a primary care provider (dentist) to whom an
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1 enrollee is assigned is physically located within a
2 reasonable travel distance, as established by rule
3 adopted by the Director, from the residence or place of
4 employment of the enrollee.
5 (e) A dentist participating in the plan shall provide
6 all of the following, where applicable, to enrollees upon
7 request:
8 (1) information related to the dentist's
9 educational background, experience, training, specialty
10 and board certification, if applicable;
11 (2) the names of licensed facilities on the
12 provider panel where the dentist presently has privileges
13 for the treatment, illness, or procedure that is the
14 subject of the request; and
15 (3) information regarding the dentist's
16 participation in continuing education programs and
17 compliance with any licensure, certification, or
18 registration requirements, if applicable.
19 Section 30. Financial incentives. Financial incentives
20 that limit services are prohibited. A managed care dental
21 plan may not use a financial incentive program that limits
22 medically necessary and appropriate services.
23 Section 35. Credentialing; utilization review; provider
24 input.
25 (a) Participating dentists shall be given an opportunity
26 to comment on the plan's policies affecting their services to
27 include the plan's dental policy, including coverage of a new
28 technology and procedures, utilization review criteria and
29 procedures, quality and credentialing criteria, and dental
30 management procedures. Upon request, a managed care dental
31 plan shall make available and disclose to dentists the
32 application process and qualification requirements for
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1 participation in the plan.
2 (b) Upon request, managed care dental plans shall
3 disclose to prospective purchasers the specific criteria used
4 in selecting dentists who participate in the plan.
5 (c) A dentist under consideration for inclusion in a
6 managed care dental plan that requires the enrollee to select
7 a primary care provider (dentist) shall be reviewed through
8 the managed care dental plan's credentialing process, which
9 shall be overseen by the dental director of the managed care
10 dental plan.
11 (d) Credentialing of dentists who will participate in a
12 managed care dental plan that requires its enrollees to
13 select a primary care provider (dentist) shall be based on
14 identified and commonly accepted standards that have been
15 adopted by the plan. The managed care dental plan shall make
16 the credentialing standards available to applicants.
17 (e) If economic considerations are part of the decision
18 to select a dentist or terminate a contract with a dentist,
19 the plan shall use identified criteria that shall be
20 available to applicants and participating dentists. If the
21 plan uses utilization profiling, the plan must consider the
22 specialty and location of the dentist.
23 (f) A managed care dental plan that conducts or uses
24 utilization profiling of providers within the plan shall make
25 the profile available to the provider profiled on a
26 reasonable, but at least semi-annual, basis determined by the
27 dental director.
28 (g) A managed care dental plan shall have a dental
29 director who is a licensed dentist. The dental director shall
30 be responsible for the dental decisions made by the plan and
31 provide assurance that the dental decisions and review
32 policies that are used by the plan are appropriate and based
33 on the commonly accepted standards of care.
34 Decisions made by the plan to deny coverage for a
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1 procedure or that a payment for an alternative procedure
2 should be considered must be made by the dental director or a
3 licensed dentist acting under the direct authority of the
4 dental director.
5 A provider who has had a claim denied or was offered an
6 alternative benefit for payment by the plan shall be provided
7 the opportunity for an appeal to the dental director and to
8 receive a written response from the dental director or a
9 licensed dentist acting under the direct authority of the
10 dental director. Enrollees shall be afforded appeal rights as
11 specified in the benefits contract or as otherwise provided
12 by law.
13 (h) A managed care dental plan may not exclude a
14 provider solely because of the anticipated characteristics of
15 the patients of that provider.
16 (i) Before terminating a contract with a provider, the
17 managed care dental plan shall provide a written explanation
18 of the reasons for termination, an opportunity for
19 discussion, and an opportunity to enter into and complete a
20 corrective action plan, if appropriate, as determined by the
21 plan, except in cases in which there is imminent harm to
22 patient health or an action by the Department of Professional
23 Regulation or other government agency that effectively
24 impairs the provider's ability to practice dentistry, or in
25 cases of fraud or malfeasance, on request and before the
26 effective date of the termination. Upon request, the
27 provider is entitled to a review of the plan's proposed
28 action by a plan advisory panel. For a dentist, the plan
29 advisory panel must be composed of the dentist's peers. The
30 review may include a review of the appropriateness and
31 requirements of a corrective action plan. The decision of
32 the advisory panel must be considered, but is not binding on
33 the plan.
34 (j) A communication relating to the subject matter
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1 provided for under subsection (a) or (h) of this Section may
2 not be the basis for a cause of action for libel or slander,
3 except for disclosures or communications with parties other
4 than the plan or provider.
5 (k) The managed care dental plan shall establish
6 reasonable procedures for assuring a transition of enrollees
7 of the plan to new providers.
8 (l) This Act does not prohibit a managed care dental
9 plan from rejecting an application from a provider based on
10 the plan's determination that the plan has sufficient
11 qualified providers.
12 (m) No contractual provision shall in any way prohibit a
13 dentist from discussing all clinical options for treatment
14 with a patient.
15 (n) A managed care dental plan shall submit for the
16 Director's approval, and thereafter maintain, a system for
17 the resolution of grievances concerning the provision of
18 dental care services or other matters concerning operation of
19 the managed care dental plan.
20 Section 40. Coverage; prior authorization. A managed
21 care dental plan shall:
22 (1) cover emergency dental services, as included in its
23 certificate of coverage, without regard to whether the
24 provider furnishing the services has a contractual or other
25 arrangement with the entity to provide items or services to
26 covered individuals; and
27 (2) provide that the prior authorization requirement for
28 emergency dental is waived.
29 Section 45. Prior authorization; consent forms. A plan
30 for which prior authorization is a condition to coverage of a
31 service must ensure that enrollees are required to sign
32 dental information release consent forms on enrollment.
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1 Section 50. Point-of-service plans.
2 (a) When a managed care dental plan that requires its
3 enrollees to select a primary care provider (dentist) is the
4 only type of dental plan available to enrollees, the plan
5 must offer to all eligible enrollees the opportunity to
6 obtain coverage for out-of-network services through a
7 point-of-service plan.
8 (b) The premium for the point-of-service plan shall be
9 based on the actuarial value of that coverage.
10 (c) Any additional costs for the point-of-service plan
11 are the responsibility of the enrollee or the plan purchaser
12 at their discretion. The managed care dental plan may impose
13 a reasonable administrative cost for providing the point-of-
14 service option.
15 Section 55. Private cause of action; existing remedies.
16 This Act and rules adopted under this Act do not:
17 (1) provide a private cause of action for damages or
18 create a standard of care, obligation, or duty that provides
19 a basis for a private cause of action for damages; or
20 (2) abrogate a statutory or common law cause of action,
21 administrative remedy, or defense otherwise available and
22 existing before the effective date of this Act.
23 Section 60. Record of complaints.
24 (a) The Department of Insurance and the Department of
25 Public Health shall coordinate the complaint review and
26 investigation process. The Department of Insurance and the
27 Department of Public Health shall jointly establish rules
28 under the Illinois Administrative Procedure Act implementing
29 this complaint process.
30 (b) The Department shall maintain records concerning the
31 complaints filed against the plans and shall require them to
32 annually report complaints made to and resolutions by the
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1 plans in a manner determined by rule. The Department shall
2 make a summary of all data collected available upon request
3 and publish the summary on the World Wide Web.
4 (c) The Department shall maintain records on the number
5 of complaints filed against each plan.
6 (d) The Department shall maintain records classifying
7 each complaint by whether the complaint was filed by:
8 (1) a consumer or enrollee;
9 (2) a provider; or
10 (3) any other individual.
11 (e) The Department shall maintain records classifying
12 each complaint according to the nature of the complaint as it
13 pertains to a specific function of the plan. The complaints
14 shall be classified under the following categories:
15 (1) denial of care or treatment;
16 (2) denial of a diagnostic procedure;
17 (3) denial of a referral request;
18 (4) sufficient choice and accessibility of
19 dentists;
20 (5) underwriting;
21 (6) marketing and sales;
22 (7) claims and utilization review;
23 (8) member services;
24 (9) provider relations; and
25 (10) miscellaneous.
26 (f) The Department shall maintain records classifying
27 the disposition of each complaint. The disposition of the
28 complaint shall be classified in one of the following
29 categories:
30 (1) complaint referred to the plan and no further
31 action necessary by the Department;
32 (2) no corrective action deemed necessary by the
33 Department; or
34 (3) corrective action taken by the Department.
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1 (g) No Department publication or release of information
2 shall identify any enrollee, dentist, or individual
3 complainant.
4 Section 65. Administration of Act.
5 (a) The Director shall take enforcement action under
6 this Act including, but not limited to, the assessment of
7 civil fines and injunctive relief for any failure to comply
8 with this Act or any violation of the Act or rules by a
9 managed care dental plan.
10 (b) The Department shall have the authority to impose
11 fines on any managed care dental plan. The Department shall
12 adopt rules pursuant to this Act that establish a system of
13 fines related to the type and level of violation or repeat
14 violation, including but not limited to:
15 (1) a fine not exceeding $5000 for a violation that
16 created a condition or occurrence presenting a
17 substantial probability that death or serious harm to an
18 individual will or did result therefrom; and
19 (2) a fine not exceeding $1000 for a violation that
20 creates or created a condition or occurrence that
21 threatens the health, safety, or welfare of an
22 individual.
23 Each day a violation continues shall constitute a
24 separate offense. These rules shall include an opportunity
25 for a hearing in accordance with the Illinois Administrative
26 Procedure Act. All final decisions of the Department shall be
27 reviewable under the Administrative Review Law.
28 (c) Notwithstanding the existence or pursuit of any
29 other remedy, the Director may, through the Attorney General,
30 seek an injunction to restrain or prevent any person, company
31 or plan from functioning or operating in violation of this
32 Act or rule.
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1 Section 70. Retaliation prohibited. A managed care
2 dental plan may not take any retaliatory actions, including
3 cancellation or refusal to renew a policy, against an
4 employer or enrollee solely because the employer or enrollee
5 has filed complaints with the plan or appealed a decision of
6 the plan.
7 Section 75. Application of other law.
8 (a) All provisions of this Act and other applicable law
9 that are not in conflict with this Act shall apply to managed
10 care dental plans and other persons subject to this Act.
11 (b) Solicitation of enrollees by a managed care entity
12 granted a certificate of authority or its representatives
13 shall not be construed to violate any provision of law
14 relating to solicitation or advertising by health
15 professionals.
16 Section 80. Prohibited activity. No plan by contract,
17 written policy, or procedure shall contain any clause
18 attempting to transfer or transferring to a dentist by
19 indemnification or otherwise, any liability relating to
20 activities, actions, or omissions of the plan or its
21 officers, employees, or agents as opposed to those of the
22 dentist.
23 Section 85. Severability. The provisions of this Act
24 are severable under Section 1.31 of the Statute on Statutes.