97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB1545

 

Introduced 2/9/2011, by Sen. William R. Haine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/355.3 new
215 ILCS 5/368d

    Amends the Illinois Insurance Code. Provides that dental insurance plans must list in the fee schedule attached to the contract every Code on Dental Procedures and Nomenclature (CDT) code upon which the plan imposes a capped fee and the dollar amount of the capped fee. Provides that any CDT code not so listed shall not be subject to any fee cap, and the provider may balance bill the patient. Provides that dental insurance plans must highlight any changes in subsequent contract terms or conditions and shall have the original plan administrator notify the enrolled dentist and allow the dentist sufficient time to respond. Provides that no recoupment or offset may be requested or withheld from future payments 366 or more days after the original payment is made. Provides that no contract between an insurer and a health care professional or health care provider may provide for recoupments in violation of the provision concerning recoupment.


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A BILL FOR

 

SB1545LRB097 05257 RPM 45309 b

1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 368d and by adding Section 355.3 as follows:
 
6    (215 ILCS 5/355.3 new)
7    Sec. 355.3. Dental plans; contracting.
8    (a) Every company that issues, delivers, amends, or renews
9any individual or group policy of accident and health insurance
10on or after the effective date of this amendatory Act of the
1197th General Assembly that provides dental insurance must list
12in the fee schedule attached to the contract every American
13Dental Association's Code on Dental Procedures and
14Nomenclature (CDT) code upon which the plan imposes a capped
15fee and the specific dollar amount of the capped fee.
16    (b) Any CDT code not listed in the contract as prescribed
17in subsection (a) of this Section shall not be subject to any
18fee cap. In such cases, the provider may balance bill the
19patient.
20    (c) Every company that issues, delivers, amends, or renews
21any individual or group policy of accident and health insurance
22on or after the effective date of this amendatory Act of the
2397th General Assembly that provides dental insurance must

 

 

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1highlight any changes in subsequent contract terms or
2conditions, including changes in reimbursement, and shall have
3the original plan administrator notify the enrolled dentist and
4allow the dentist sufficient time to review, renegotiate, or
5terminate the contract.
 
6    (215 ILCS 5/368d)
7    Sec. 368d. Recoupments.
8    (a) A health care professional or health care provider
9shall be provided a remittance advice, which must include an
10explanation of a recoupment or offset taken by an insurer,
11health maintenance organization, independent practice
12association, or physician hospital organization, if any. The
13recoupment explanation shall, at a minimum, include the name of
14the patient; the date of service; the service code or if no
15service code is available a service description; the recoupment
16amount; and the reason for the recoupment or offset. In
17addition, an insurer, health maintenance organization,
18independent practice association, or physician hospital
19organization shall provide with the remittance advice a
20telephone number or mailing address to initiate an appeal of
21the recoupment or offset.
22    (b) It is not a recoupment when a health care professional
23or health care provider is paid an amount prospectively or
24concurrently under a contract with an insurer, health
25maintenance organization, independent practice association, or

 

 

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1physician hospital organization that requires a retrospective
2reconciliation based upon specific conditions outlined in the
3contract.
4    (c) No recoupment or offset may be requested or withheld
5from future payments 366 or more days after the original
6payment is made. No contract between an insurer and a health
7care professional or health care provider may provide for
8recoupments in violation of this Section.
9(Source: P.A. 93-261, eff. 1-1-04.)