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91_SB0721sam001
SRS91SB0721MNsaam01
1 AMENDMENT TO SENATE BILL 721
2 AMENDMENT NO. . Amend Senate Bill 721 by replacing
3 everything after the enacting clause with the following:
4 "Section 1. Short title. This Act may be cited as the
5 Dental Care Patient Protection Act.
6 Section 5. Purpose; dental care patient rights.
7 (a) The purpose of this Act is to provide fairness and
8 choice to dental patients and dentists under managed care
9 dental benefit plans.
10 (b) Dental care patients have the following rights:
11 (1) A patient has the right to care consistent with
12 professional standards of practice to assure quality
13 dental care, to choose the participating dentist
14 responsible for providing his or her care, to receive
15 information concerning his or her condition and proposed
16 treatment, to refuse any treatment to the extent
17 permitted by law, and to privacy and confidentiality of
18 records except as otherwise provided by law.
19 (2) A patient has the right, regardless of source
20 of payment, to examine and to receive a reasonable
21 explanation of his or her total bill for services
22 rendered by his or her dentist. A dentist shall be
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1 responsible only for a reasonable explanation of those
2 specific dental care services provided by the dentist.
3 (3) A patient has the right to timely prior notice
4 of the termination in the event a plan cancels or refuses
5 to renew an enrollee's participation in the plan except
6 when the termination is for non-payment of premium or
7 termination of the plan by the group.
8 (4) A patient has the right to privacy and
9 confidentiality. This right may be expressly waived in
10 writing by the patient or the patient's guardian.
11 (5) A patient has the right to purchase any dental
12 care services with that patient's own funds.
13 Section 10. Definitions. As used in this Act:
14 "Dental care services" means services permitted to be
15 performed by a licensed dentist or any person working under
16 the dentist's supervision as permitted by law.
17 "Dentist" means a person licensed to practice dentistry
18 in any state.
19 "Department" means the Department of Insurance.
20 "Director" means the Director of Insurance.
21 "Emergency dental services" means the provision of dental
22 care for a sudden, acute dental condition that would lead a
23 prudent layperson, who possesses an average knowledge of
24 dentistry, to reasonably expect the absence of immediate care
25 to result in serious impairment to the dentition or would
26 place the person's oral health in serious jeopardy.
27 "Enrollee" means an individual and his or her dependents
28 who are enrolled in a managed care dental plan.
29 "Managed care dental plan" or "plan" means a plan that
30 establishes, operates, or maintains a network of dentists
31 that have entered into agreements with the plan to provide
32 dental care services to enrollees to whom the plan has the
33 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 employee or employer self-insured dental
6 benefit plans under the federal ERISA Act of 1974.
7 "Point-of-service plan" means a plan or plans that
8 includes both in-plan covered services and out-of-plan
9 covered services as well as managed dental care plan
10 arrangements in which the risk for out-of-plan covered
11 services is borne through reinsurance. The term also
12 includes indemnity benefits that are underwritten in whole by
13 a licensed insurance carrier or a self-funded employer group.
14 For purposes of this Section, "out-of-plan services" means
15 those services which are obtained from providers who do not
16 have a contract, or any other arrangements, with a managed
17 care dental plan or services obtained without a referral from
18 providers who have contracted to provide services to the
19 enrollees on behalf of the managed care dental plan.
20 "Primary care provider (dentist)" means a dentist, having
21 an arrangement with a managed care dental plan, selected by
22 an enrollee or assigned to an enrollee by a plan to provide
23 dental care services under a managed care dental plan.
24 "Prospective enrollee" means an individual eligible for
25 enrollment in a managed care dental plan offered by that
26 individual's employer.
27 "Provider" means either a general dentist or a dentist
28 who is a licensed specialist.
29 Section 15. Rules. The Department may promulgate such
30 rules as it deems reasonably necessary to implement the terms
31 of this Act. The Department shall establish an advisory
32 committee made up of representatives from the dental
33 profession to provide clinical advice and counsel to the
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1 Department regarding dental managed care issues for which a
2 dentist's professional training is relevant in the course of
3 administering this Act. The advisory committee shall be
4 comprised of dentists licensed to practice in Illinois,
5 appointed by the Director as follows: 2 dental directors or
6 their dentist designee from managed care dental plans which
7 are subject to this Act, 2 general dentists, and the dental
8 director of the Illinois Department of Public Health. The
9 advisory committee shall meet as reasonably determined by the
10 Director. Nothing in this Section shall be deemed as
11 authorizing or permitting the Department to delegate any
12 authority to enforce the provisions of this Act to the
13 advisory committee and any such delegation is expressly
14 prohibited hereunder.
15 Section 25. Provision of information.
16 (a) A managed care dental plan shall provide upon
17 request to prospective enrollees a written summary
18 description of all of the following terms of coverage:
19 (1) Information about the dental plan, including
20 how the plan operates and what general types of financial
21 arrangements exist between dentists and the plan. Nothing
22 in this Section shall require disclosure of any specific
23 financial arrangements between providers and the plan.
24 (2) The service area.
25 (3) Covered benefits, exclusions, or limitations.
26 (4) Pre-certification requirements including any
27 requirements for referrals made by primary care dentists
28 to specialists, and other preauthorization requirements.
29 (5) A list of participating primary care dentists
30 in the plan's service area, including provider address
31 and phone number, for an enrollee to evaluate the managed
32 care dental plan's network access, as well as a phone
33 number by which the prospective enrollee may obtain
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1 additional information regarding the provider network
2 including participating specialists. However, a managed
3 care dental plan offering a preferred provider
4 organization ("PPO") product that does not require the
5 enrollee to select a primary care dentist shall only be
6 required to make available for inspection to enrollees
7 and prospective enrollees a list of participating
8 dentists in the plan's service area.
9 (6) Emergency coverage and benefits.
10 (7) Out-of-area coverages and benefits, if any.
11 (8) The process about how participating dentists
12 are selected.
13 (9) The grievance process, including the telephone
14 number to call to receive information concerning
15 grievance procedures.
16 An enrollee shall be provided with an evidence of
17 coverage as required under the Illinois Insurance Code
18 provisions applicable to the managed care dental plan.
19 (b) An enrollee or prospective enrollee has the right to
20 the most current financial statement filed by the managed
21 care dental plan by contacting the Department of Insurance.
22 The Department may charge a reasonable fee for providing such
23 information.
24 (c) The managed care dental plan shall provide to the
25 Department, on an annual basis, a list of all participating
26 dentists. Nothing in this Section shall require a particular
27 ratio for any type of provider.
28 (d) If the managed care dental plan uses a capitation
29 method of compensation to its primary care providers
30 (dentists), the plan must establish and follow procedures
31 that ensure that:
32 (1) the plan application form includes a space in
33 which each enrollee selects a primary care provider
34 (dentist);
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1 (2) if an enrollee who fails to select a primary
2 care provider (dentist) is assigned a primary care
3 provider (dentist), the enrollee shall be notified of the
4 name and location of that primary care provider
5 (dentist); and
6 (3) primary care provider (dentist) to whom an
7 enrollee is assigned, pursuant to item (2), is physically
8 located within a reasonable travel distance, as
9 established by rule adopted by the Director, from the
10 residence or place of employment of the enrollee.
11 (e) Nothing in this Act shall be deemed to require a
12 plan to assign an enrollee to a primary care provider
13 (dentist).
14 Section 35. Credentialing; utilization review; provider
15 input.
16 (a) Participating dentists shall be given an opportunity
17 to comment on the plan's policies affecting their services to
18 include the plan's dental policy, including coverage of a new
19 technology and procedures, utilization review criteria and
20 procedures, quality and credentialing criteria, and dental
21 management procedures provided, however, a plan shall not be
22 required to release any information which it deems
23 confidential or proprietary.
24 (b) Upon request, managed care dental plans shall
25 disclose to prospective purchasers the process about how
26 participating dentists are selected for the plan.
27 (c) A dentist under consideration for inclusion in a
28 managed care dental plan that requires the enrollee to select
29 a primary care provider (dentist) shall be subject to the
30 managed care dental plan's credentialing policy, which shall
31 be overseen by the dental director of the managed care dental
32 plan.
33 (d) Credentialing of dentists who will participate in a
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1 managed care dental plan that requires its enrollees to
2 select a primary care provider (dentist) shall be based on
3 identified guidelines that have been adopted by the plan. The
4 managed care dental plan shall make the credentialing
5 guidelines available to applicants, upon request.
6 (e) A managed care dental plan shall have a dental
7 director who is a licensed dentist. The dental director shall
8 ultimately be responsible for the benefit coverage decisions
9 made by the plan which require professional dental training
10 and clinical judgement. Decisions made by the plan to deny
11 coverage for a procedure, based primarily upon clinical
12 judgment, or that a payment for an alternative procedure
13 should be considered must be made by the dental director or a
14 licensed dentist acting under the supervision of the dental
15 director. Nothing in this Section prohibits a benefit
16 coverage decision that does not require a dentist's
17 professional judgment from being denied without a dentist's
18 involvement.
19 A provider advocating on behalf of a patient who has had
20 a claim denied, the basis of which requires professional
21 dental training and judgment, or was offered an alternative
22 benefit for payment by the plan has an opportunity to appeal
23 to the dental director by submitting a written appeal and
24 providing information that is reasonably needed to consider
25 the appeal. The dental director or a licensed dentist acting
26 under the supervision of the dental director shall respond to
27 the provider's appeal. Enrollees shall be afforded appeal
28 rights as specified in the benefits contract or as otherwise
29 provided by law.
30 (h) A managed care dental plan may not exclude a
31 provider solely because of the anticipated characteristics of
32 the patients of that provider.
33 (i) Before terminating a contract with a provider for
34 cause, the managed care dental plan shall provide a written
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1 explanation of the reasons for termination. The provider
2 shall be given an opportunity for discussion with the dental
3 director or his dentist designee. If a managed care dental
4 plan conducts or uses utilization profiling as the primary
5 basis for terminating the provider contract for cause, the
6 managed care dental plan shall make available the utilization
7 data relevant to that provider in advance of the termination.
8 (j) A communication relating to the subject matter
9 provided for under subsection (a) or (i ) of this Section may
10 not be the basis for a cause of action for libel or slander,
11 except for disclosures or communications with parties other
12 than the plan or provider.
13 (k) The managed care dental plan shall establish
14 reasonable procedures for assuring a transition of enrollees
15 of the plan to new providers.
16 (l) This Act does not prohibit a managed care dental
17 plan from rejecting an application from a provider based on
18 the plan's determination that the plan has sufficient
19 qualified providers or if the plan reasonably determines that
20 inclusion of the provider is not in the best interest of the
21 managed care dental plan and its enrollees. Nothing in this
22 Act shall be construed as requiring a managed care dental
23 plan to contract with a dentist who has not agreed to the
24 terms of participation as specified by the plan.
25 (m) No contractual provision shall in any way prohibit a
26 dentist from discussing all clinical options for treatment
27 with a patient.
28 (n) A managed care dental plan shall submit for the
29 Director's approval, and thereafter maintain, a system for
30 the resolution of grievances concerning the provision of
31 dental care services or other matters concerning operation of
32 the managed care dental plan.
33 Section 40. Coverage; prior authorization. A managed
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1 care dental plan shall:
2 (1) cover palliative treatment for emergency dental
3 services, as included in its certificate of coverage,
4 without regard to whether the provider furnishing the
5 services has a contractual or other arrangement with the
6 entity to provide items or services to covered
7 individuals, provided that the enrollee has made a
8 reasonable attempt to first obtain service through the
9 appropriate primary care dentist; and
10 (2) if an enrollee suffers trauma to the mouth,
11 teeth or oral cavity that results in a need for emergency
12 dental services, as included in the certificate of
13 coverage, provide that the prior authorization
14 requirement for emergency dental is waived.
15 Nothing in this Section shall be deemed as requiring
16 managed care dental plans to provide coverage for emergency
17 dental services in excess of that required in the Illinois
18 Insurance Code.
19 Section 45. Prior authorization; consent forms. A plan
20 for which prior authorization is a condition to coverage of a
21 service must clearly disclose this provision in the evidence
22 of coverage.
23 Section 50. Point-of-service plans.
24 (a) If an employer who has 25 or more employees and
25 contributes 25% or more to the cost of the dental benefit
26 plan coverage to employees and the only dental plan coverage
27 being offered requires enrollees to select a primary care
28 provider (dentist) and has no out-of-plan covered services
29 option, the managed care dental plan with which the employer
30 is contracting for the coverage shall offer a dental
31 point-of-service ("POS") option to the employee.
32 (b) An employer may require an employee who accepts the
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1 POS option to be responsible for the payment of a premium
2 over the amount of the premium for the coverage provided to
3 employees under the dental benefit plan offered which
4 requires enrollees to select a primary care provider
5 (dentist) and has no out-of-plan covered services option.
6 The enrollee may pay any additional premium either directly
7 or by payroll deduction in the same manner in which the other
8 premium is paid. The premium for the POS option shall be as
9 established by the managed care dental plan using its
10 underwriting guidelines for establishing rates to be charged
11 for products which it offers.
12 (c) Different cost-sharing provisions may be imposed for
13 the POS option.
14 (d) An employer may charge an employee who accepts the
15 POS option a reasonable administrative fee for costs
16 associated with the employer's reasonable administration of
17 the POS option.
18 (e) The POS option to be offered pursuant to this
19 Section may be satisfied by the plan by allowing prospective
20 enrollees to elect the POS option during the employer's
21 enrollment period, and remaining in the POS option until the
22 next open enrollment period, or any other basis reasonably
23 determined by the plan to satisfy the requirements of this
24 Section.
25 (f) A managed care dental plan required to offer a POS
26 option pursuant to this Act shall be subject to those rules
27 for POS products as set by the Department.
28 Section 55. Private cause of action; existing remedies.
29 This Act and rules adopted under this Act do not:
30 (1) provide a private cause of action for damages
31 or create a standard of care, obligation, or duty that
32 provides a basis for a private cause of action for
33 damages; or
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1 (2) abrogate a statutory or common law cause of
2 action, administrative remedy, or defense otherwise
3 available and existing before the effective date of this
4 Act.
5 Section 60. Record of complaints.
6 (a) The Department shall maintain records concerning the
7 complaints filed against the plan with the Department. The
8 Department shall make a summary of all data collected
9 available upon request and publish the summary on the World
10 Wide Web.
11 (b) The Department shall maintain records on the number
12 of complaints filed against each plan.
13 (c) The Department shall maintain records classifying
14 each complaint by whether the complaint was filed by:
15 (1) a consumer or enrollee;
16 (2) a provider; or
17 (3) any other individual.
18 (e) The Department shall maintain records classifying
19 each complaint according to the nature of the complaint as it
20 pertains to a specific function of the plan. The complaints
21 shall be classified under the following categories:
22 (1) denial of care or treatment;
23 (2) denial of a diagnostic procedure;
24 (3) denial of a referral request;
25 (4) sufficient choice and accessibility of
26 dentists;
27 (5) underwriting;
28 (6) marketing and sales
29 (7) claims and utilization review;
30 (8) member services;
31 (9) provider relations; and
32 (10) miscellaneous.
33 (f) The Department shall maintain records classifying
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1 the disposition of each complaint. The disposition of the
2 complaint shall be classified in one of the following
3 categories:
4 (1) complaint referred to the plan and no further
5 action necessary by the Department;
6 (2) no corrective action deemed necessary by the
7 Department; or
8 (3) corrective action taken by the Department.
9 (g) No Department publication or release of information
10 shall identify any enrollee, dentist, or individual
11 complainant.
12 Section 65. Administration of Act. The Director may
13 adopt rules necessary to implement the Department's
14 responsibility under this Act. To enforce the provisions of
15 this Act, the director may issue a cease and desist order or
16 require a managed care dental plan to submit a plan of
17 correction for violations of this Act, or both. Subject to
18 the provisions of the Illinois Administrative Procedure Act,
19 the Director may impose an administrative fine, not to exceed
20 $1,000, for failure to submit a requested plan of correction,
21 failure to comply with its plan of correction, or repeated
22 violations of the Act. All final decisions regarding the
23 imposition of a fine shall be subject to review under the
24 Illinois Administrative Review Law.
25 Section 70. Retaliation prohibited. A managed care
26 dental plan may not take any retaliatory actions, including
27 cancellation or refusal to renew a policy, against an
28 employer or enrollee solely because the employer or enrollee
29 has filed complaints with the plan or appealed a decision of
30 the plan.
31 Section 75. Application of other law.
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1 (a) All provisions of this Act and other applicable law
2 that are not in conflict with this Act shall apply to managed
3 care dental plans and other persons subject to this Act.
4 (b) Solicitation of enrollees by a managed care entity
5 granted a certificate of authority or its representatives
6 shall not be construed to violate any provision of law
7 relating to solicitation or advertising by health
8 professionals.
9 Section 80. Limitations on indemnification provisions.
10 No contract between a managed care dental plan and a provider
11 may require that the provider indemnify the managed care
12 dental plan for the Plan's, or its officers, employees, or
13 agents, negligence, willful misconduct, or breach of
14 contract, if any, provided nothing herein shall relieve the
15 provider for such obligations that have been delegated to the
16 provider pursuant to written agreement. The delegation of
17 functions agreed to between the plan and the provider shall
18 be identified in the written agreement.
19 Section 85. Severability. The provisions of this Act are
20 severable under Section 1.31 of the Statute on Statutes.".